Kerri Wachter

Major Finding: Moderate and severe physical abuse in childhood and adolescence was associated with 26%-54% higher risk of diabetes in women. Women who had experienced forced sex once or repeatedly before adulthood had 34%-69% higher risk of diabetes than did women who were not sexually abused as girls.

Data Source: Epidemiologic analysis of data from a cohort of 68,376 women.

Disclosures: The authors reported no financial disclosures.

Physical and sexual abuse in childhood and adolescence appear to increase the risk of type 2 diabetes in adult women in a dose-response fashion, based on the results of an epidemiologic study involving almost 70,000 women.

Moderate and severe physical abuse in childhood and adolescence was associated with 26%-54% higher risk of diabetes in women. Those who had experienced forced sex once had a 34% higher risk of diabetes than were women who were not sexually abused as girls and a 69% higher risk when sexual abuse occurred more frequently.

Even after accounting for adult body mass index, there remained a 10%-30% increased risk of diabetes among women who had experienced moderate physical abuse or the most severe forms of physical or sexual abuse (Am. J. Prev. Med. [doi:10.1016/j.amepre.2010.09.007]).

“The PAR [population attributable risk] percent derived from this model indicates that child/adolescent abuse accounted for 14% (7%-21%) of type 2 diabetes in this cohort. Applying the hazard ratio from this study to the 43% prevalence of any child or adolescent abuse reported by women in the National Violence Against Women Survey, an estimated 9% of diabetes in U.S. women may be attributed to early abuse,” wrote Janet W. Rich-Edwards, Sc.D., and her colleagues.

An association consistently has been reported between child abuse and adult obesity. Studies indicate “that early trauma may cause lasting dysregulated responsivity, which may link child abuse with diabetes through physiologic pathways independent of adiposity,” wrote Dr. Rich-Edwards, director of developmental epidemiology at the Connors Center for Women's Health and Gender Biology at Brigham and Women's Hospital, Boston, and her colleagues.

However, the association between childhood abuse and adult diabetes has not been studied before in a large population.

The new findings highlight the importance of recognizing abuse in children and adolescents and asking adults about a history of abuse, according to Dr. Lawrence S. Phillips, a professor of endocrinology at Emory University, Atlanta.

Physicians need to be aware that “there are not only emotional and behavioral consequences of abuse in childhood and adolescence; there are physical consequences as well,” he said in an interview. “We need to be much more sensitive to issues of abuse and in the history, because they demonstrably now have mental and physical downstream impacts.”

For this study, the researchers used data from the Nurses Health Study II (NHSII), a cohort of 116,430 registered nurses, who were aged 25-42 years when the cohort was established in 1989. The cohort has been followed by biennial mailed questionnaires, which inquire about risk factors and disease incidence.

In 2001, a violence questionnaire was added to this large longitudinal cohort study of women. Participants returned 68,376 violence questionnaires; 67,853 were included in this analysis.

A total of 2,074 cases of type 2 diabetes were accrued from 1989 to 2005, and 759 incident cases occurred after the violence questionnaire was administered in 2001. All of the cases (2,833) were included in the analysis to maximize power. Data were analyzed in 2009, after diagnoses of diabetes reported on the 2005 questionnaire were reviewed and coded.

The Violence Questionnaire covers three periods: childhood (up to age 11 years), adolescence (11-17 years), and adulthood. Childhood and adolescent physical abuse was assessed through an adaptation of the Revised Conflict Tactics Scale. Physical abuse during childhood was categorized into four groups: no physical abuse (none); being “pushed, grabbed, or shoved” at any frequency or being “kicked, bitten, or punched” once or “hit with something” once (mild); being “hit with something” more than once or “physically attacked” once (moderate); being “kicked, bitten, or punched” or “physically attacked” more than once or ever “choked or burned” (severe). Spanking was not included.

Child and adolescent sexual abuse was measured by questions about unwanted sexual touching and forced sexual activity. Exposure was categorized into four groups: no sexual abuse; unwanted sexual touching only; forced sexual activity once; and forced sexual activity more than once. Adult experiences of abuse were measured on the violence questionnaire with questions adapted from the McFarlane Abuse Assessment Screen.

In this cohort, 65% of participants reported any degree of physical or sexual abuse in childhood or adolescence, which was associated with a 24% increased risk of type 2 diabetes in adulthood, even after adjustment for age, race/ethnicity, body type at 5 years, and maternal/paternal education and history of diabetes.

A dose-response association was found between physical abuse and risk of diabetes. However, this was somewhat attenuated by adjustment for race, maternal and paternal education, maternal and paternal diabetes, and somatotype at age 5.

Physical and sexual abuse interacted on an additive scale but not on a multiplicative scale, indicating that the absolute risk of diabetes was greater among women who had experienced both forms of abuse than would be expected from the risk of sexual or physical abuse alone, according to Dr. Rich-Edwards and her coauthors.

At age 5 years, little difference was found between the somatotypes of girls who did and did not report later abuse. By the age of 18 years, however, the BMI trajectories of abused girls had begun to diverge.

By ages 25-42 years, a marked trend was found of increasing BMI with more severe abuse history.

Adjustment for adult smoking, alcohol use, and BMI weakened, but did not eliminate, the dose-response associations of child and teen abuse with risk of adult diabetes. The attenuation was attributable almost entirely to adjustment for adult BMI, which accounted for 60% and 64% of the associations of physical and sexual abuse, respectively, with diabetes.

Despite adjustment, moderate physical abuse, severe physical abuse, and repeated forced sex remained independently associated with significantly increased risks of diabetes of 12%, 21%, and 28%, respectively.

Moderate and severe physical abuse were associated with 26%-54% higher risks of diabetes in maturity. Unwanted sexual touching was associated with 16% higher risk of diabetes, and forced sexual activity before adulthood carried a 34% greater risk when it occurred once and a 69% greater risk when it occurred more frequently. Child and teen abuse predicted later diabetes even among women who reported no adult physical or sexual abuse.

Major Finding: Moderate and severe physical abuse in childhood and adolescence was associated with 26%-54% higher risk of diabetes in women. Women who had experienced forced sex once or repeatedly before adulthood had 34%-69% higher risk of diabetes than did women who were not sexually abused as girls.

Data Source: Epidemiologic analysis of data from a cohort of 68,376 women.

Disclosures: The authors reported no financial disclosures.

Physical and sexual abuse in childhood and adolescence appear to increase the risk of type 2 diabetes in adult women in a dose-response fashion, based on the results of an epidemiologic study involving almost 70,000 women.

Moderate and severe physical abuse in childhood and adolescence was associated with 26%-54% higher risk of diabetes in women. Those who had experienced forced sex once had a 34% higher risk of diabetes than were women who were not sexually abused as girls and a 69% higher risk when sexual abuse occurred more frequently.

Even after accounting for adult body mass index, there remained a 10%-30% increased risk of diabetes among women who had experienced moderate physical abuse or the most severe forms of physical or sexual abuse (Am. J. Prev. Med. [doi:10.1016/j.amepre.2010.09.007]).

“The PAR [population attributable risk] percent derived from this model indicates that child/adolescent abuse accounted for 14% (7%-21%) of type 2 diabetes in this cohort. Applying the hazard ratio from this study to the 43% prevalence of any child or adolescent abuse reported by women in the National Violence Against Women Survey, an estimated 9% of diabetes in U.S. women may be attributed to early abuse,” wrote Janet W. Rich-Edwards, Sc.D., and her colleagues.

An association consistently has been reported between child abuse and adult obesity. Studies indicate “that early trauma may cause lasting dysregulated responsivity, which may link child abuse with diabetes through physiologic pathways independent of adiposity,” wrote Dr. Rich-Edwards, director of developmental epidemiology at the Connors Center for Women's Health and Gender Biology at Brigham and Women's Hospital, Boston, and her colleagues.

However, the association between childhood abuse and adult diabetes has not been studied before in a large population.

The new findings highlight the importance of recognizing abuse in children and adolescents and asking adults about a history of abuse, according to Dr. Lawrence S. Phillips, a professor of endocrinology at Emory University, Atlanta.

Physicians need to be aware that “there are not only emotional and behavioral consequences of abuse in childhood and adolescence; there are physical consequences as well,” he said in an interview. “We need to be much more sensitive to issues of abuse and in the history, because they demonstrably now have mental and physical downstream impacts.”

For this study, the researchers used data from the Nurses Health Study II (NHSII), a cohort of 116,430 registered nurses, who were aged 25-42 years when the cohort was established in 1989. The cohort has been followed by biennial mailed questionnaires, which inquire about risk factors and disease incidence.

In 2001, a violence questionnaire was added to this large longitudinal cohort study of women. Participants returned 68,376 violence questionnaires; 67,853 were included in this analysis.

A total of 2,074 cases of type 2 diabetes were accrued from 1989 to 2005, and 759 incident cases occurred after the violence questionnaire was administered in 2001. All of the cases (2,833) were included in the analysis to maximize power. Data were analyzed in 2009, after diagnoses of diabetes reported on the 2005 questionnaire were reviewed and coded.

The Violence Questionnaire covers three periods: childhood (up to age 11 years), adolescence (11-17 years), and adulthood. Childhood and adolescent physical abuse was assessed through an adaptation of the Revised Conflict Tactics Scale. Physical abuse during childhood was categorized into four groups: no physical abuse (none); being “pushed, grabbed, or shoved” at any frequency or being “kicked, bitten, or punched” once or “hit with something” once (mild); being “hit with something” more than once or “physically attacked” once (moderate); being “kicked, bitten, or punched” or “physically attacked” more than once or ever “choked or burned” (severe). Spanking was not included.

Child and adolescent sexual abuse was measured by questions about unwanted sexual touching and forced sexual activity. Exposure was categorized into four groups: no sexual abuse; unwanted sexual touching only; forced sexual activity once; and forced sexual activity more than once. Adult experiences of abuse were measured on the violence questionnaire with questions adapted from the McFarlane Abuse Assessment Screen.

In this cohort, 65% of participants reported any degree of physical or sexual abuse in childhood or adolescence, which was associated with a 24% increased risk of type 2 diabetes in adulthood, even after adjustment for age, race/ethnicity, body type at 5 years, and maternal/paternal education and history of diabetes.

A dose-response association was found between physical abuse and risk of diabetes. However, this was somewhat attenuated by adjustment for race, maternal and paternal education, maternal and paternal diabetes, and somatotype at age 5.

Physical and sexual abuse interacted on an additive scale but not on a multiplicative scale, indicating that the absolute risk of diabetes was greater among women who had experienced both forms of abuse than would be expected from the risk of sexual or physical abuse alone, according to Dr. Rich-Edwards and her coauthors.

At age 5 years, little difference was found between the somatotypes of girls who did and did not report later abuse. By the age of 18 years, however, the BMI trajectories of abused girls had begun to diverge.

By ages 25-42 years, a marked trend was found of increasing BMI with more severe abuse history.

Adjustment for adult smoking, alcohol use, and BMI weakened, but did not eliminate, the dose-response associations of child and teen abuse with risk of adult diabetes. The attenuation was attributable almost entirely to adjustment for adult BMI, which accounted for 60% and 64% of the associations of physical and sexual abuse, respectively, with diabetes.

Despite adjustment, moderate physical abuse, severe physical abuse, and repeated forced sex remained independently associated with significantly increased risks of diabetes of 12%, 21%, and 28%, respectively.

Moderate and severe physical abuse were associated with 26%-54% higher risks of diabetes in maturity. Unwanted sexual touching was associated with 16% higher risk of diabetes, and forced sexual activity before adulthood carried a 34% greater risk when it occurred once and a 69% greater risk when it occurred more frequently. Child and teen abuse predicted later diabetes even among women who reported no adult physical or sexual abuse.

Major Finding: Moderate and severe physical abuse in childhood and adolescence was associated with 26%-54% higher risk of diabetes in women. Women who had experienced forced sex once or repeatedly before adulthood had 34%-69% higher risk of diabetes than did women who were not sexually abused as girls.

Data Source: Epidemiologic analysis of data from a cohort of 68,376 women.

Disclosures: The authors reported no financial disclosures.

Physical and sexual abuse in childhood and adolescence appear to increase the risk of type 2 diabetes in adult women in a dose-response fashion, based on the results of an epidemiologic study involving almost 70,000 women.

Moderate and severe physical abuse in childhood and adolescence was associated with 26%-54% higher risk of diabetes in women. Those who had experienced forced sex once had a 34% higher risk of diabetes than were women who were not sexually abused as girls and a 69% higher risk when sexual abuse occurred more frequently.

Even after accounting for adult body mass index, there remained a 10%-30% increased risk of diabetes among women who had experienced moderate physical abuse or the most severe forms of physical or sexual abuse (Am. J. Prev. Med. [doi:10.1016/j.amepre.2010.09.007]).

“The PAR [population attributable risk] percent derived from this model indicates that child/adolescent abuse accounted for 14% (7%-21%) of type 2 diabetes in this cohort. Applying the hazard ratio from this study to the 43% prevalence of any child or adolescent abuse reported by women in the National Violence Against Women Survey, an estimated 9% of diabetes in U.S. women may be attributed to early abuse,” wrote Janet W. Rich-Edwards, Sc.D., and her colleagues.

An association consistently has been reported between child abuse and adult obesity. Studies indicate “that early trauma may cause lasting dysregulated responsivity, which may link child abuse with diabetes through physiologic pathways independent of adiposity,” wrote Dr. Rich-Edwards, director of developmental epidemiology at the Connors Center for Women's Health and Gender Biology at Brigham and Women's Hospital, Boston, and her colleagues.

However, the association between childhood abuse and adult diabetes has not been studied before in a large population.

The new findings highlight the importance of recognizing abuse in children and adolescents and asking adults about a history of abuse, according to Dr. Lawrence S. Phillips, a professor of endocrinology at Emory University, Atlanta.

Physicians need to be aware that “there are not only emotional and behavioral consequences of abuse in childhood and adolescence; there are physical consequences as well,” he said in an interview. “We need to be much more sensitive to issues of abuse and in the history, because they demonstrably now have mental and physical downstream impacts.”

For this study, the researchers used data from the Nurses Health Study II (NHSII), a cohort of 116,430 registered nurses, who were aged 25-42 years when the cohort was established in 1989. The cohort has been followed by biennial mailed questionnaires, which inquire about risk factors and disease incidence.

In 2001, a violence questionnaire was added to this large longitudinal cohort study of women. Participants returned 68,376 violence questionnaires; 67,853 were included in this analysis.

A total of 2,074 cases of type 2 diabetes were accrued from 1989 to 2005, and 759 incident cases occurred after the violence questionnaire was administered in 2001. All of the cases (2,833) were included in the analysis to maximize power. Data were analyzed in 2009, after diagnoses of diabetes reported on the 2005 questionnaire were reviewed and coded.

The Violence Questionnaire covers three periods: childhood (up to age 11 years), adolescence (11-17 years), and adulthood. Childhood and adolescent physical abuse was assessed through an adaptation of the Revised Conflict Tactics Scale. Physical abuse during childhood was categorized into four groups: no physical abuse (none); being “pushed, grabbed, or shoved” at any frequency or being “kicked, bitten, or punched” once or “hit with something” once (mild); being “hit with something” more than once or “physically attacked” once (moderate); being “kicked, bitten, or punched” or “physically attacked” more than once or ever “choked or burned” (severe). Spanking was not included.

Child and adolescent sexual abuse was measured by questions about unwanted sexual touching and forced sexual activity. Exposure was categorized into four groups: no sexual abuse; unwanted sexual touching only; forced sexual activity once; and forced sexual activity more than once. Adult experiences of abuse were measured on the violence questionnaire with questions adapted from the McFarlane Abuse Assessment Screen.

In this cohort, 65% of participants reported any degree of physical or sexual abuse in childhood or adolescence, which was associated with a 24% increased risk of type 2 diabetes in adulthood, even after adjustment for age, race/ethnicity, body type at 5 years, and maternal/paternal education and history of diabetes.

A dose-response association was found between physical abuse and risk of diabetes. However, this was somewhat attenuated by adjustment for race, maternal and paternal education, maternal and paternal diabetes, and somatotype at age 5.

Physical and sexual abuse interacted on an additive scale but not on a multiplicative scale, indicating that the absolute risk of diabetes was greater among women who had experienced both forms of abuse than would be expected from the risk of sexual or physical abuse alone, according to Dr. Rich-Edwards and her coauthors.

At age 5 years, little difference was found between the somatotypes of girls who did and did not report later abuse. By the age of 18 years, however, the BMI trajectories of abused girls had begun to diverge.

By ages 25-42 years, a marked trend was found of increasing BMI with more severe abuse history.

Adjustment for adult smoking, alcohol use, and BMI weakened, but did not eliminate, the dose-response associations of child and teen abuse with risk of adult diabetes. The attenuation was attributable almost entirely to adjustment for adult BMI, which accounted for 60% and 64% of the associations of physical and sexual abuse, respectively, with diabetes.

Despite adjustment, moderate physical abuse, severe physical abuse, and repeated forced sex remained independently associated with significantly increased risks of diabetes of 12%, 21%, and 28%, respectively.

Moderate and severe physical abuse were associated with 26%-54% higher risks of diabetes in maturity. Unwanted sexual touching was associated with 16% higher risk of diabetes, and forced sexual activity before adulthood carried a 34% greater risk when it occurred once and a 69% greater risk when it occurred more frequently. Child and teen abuse predicted later diabetes even among women who reported no adult physical or sexual abuse.

Certain infectious diseases can concentrate in impoverished areas and disproportionately affect minorities, women, and other disadvantaged groups, according to Dr. Paul T. Cantey.

Clinicians often receive little training on infectious diseases seen in these areas, which include tribal lands and border regions in the southwestern United States, the Mississippi Delta, the Cotton Belt, Appalachia, and some dense urban areas.

Dr. Cantey outlined the diagnosis and treatment of three of these diseases – Chagas disease, toxocariasis, and trichomoniasis – during the teleconference.

Dr. Cantey is a medical officer in the Centers for Disease Control and Prevention's division of parasitic diseases and malaria.

Chagas disease

Chagas disease is caused by the protozoan parasite Trypanosoma cruzi. The primary mode of transmission is through infected triatomine bugs. Other modes of transmission include blood transfusion, organ and tissue transplantation, congenital infection, laboratory accidents, and food.

Chagas disease is endemic in much of Latin America. However, both the parasite and the triatomine bug are found in the United States. It's estimated that there are at least 300,000 infected Latin American immigrants living in the United States. California, Florida, and Texas are disproportionately affected. Other geographic concentrations include Arizona, Georgia, Illinois, New York, North Carolina, and Virginia.

Blood donor screening for T. cruzi started in early 2007. Since then 1,267 infected donors have been identified. More than 40 of these individuals had no recognized risk factors.

The acute phase of the disease lasts 4-8 weeks. Patients are usually asymptomatic during this period. An estimated 10%-20% of infected individuals may have nonspecific febrile illness. Romaña's sign (chagoma) occurs less frequently.

The chronic phase is lifelong and may be asymptomatic and indeterminate in form. Approximately 20%-30% of infected individuals will manifest symptomatic disease – heart failure, sudden death, stroke, or organomegaly.

Testing for Chagas disease is available through the CDC, Dr. Cantey said. For acute infection, a blood smear, hemoculture, and polymerase chain reaction (PCR) tests are useful. For chronic infection, serologic tests are useful. However, there is no preferred test.

Tests for acute infection are sensitive, but the acute phase often is not recognized. Tests for chronic infection have issues with sensitivity and specificity, and usually positive results from two different tests are needed for diagnosis.

Nifurtimox or benznidazole are used for treatment, although neither drug is approved by the Food and Drug Administration. Both are available through CDC's investigational new drug protocol for compassionate use. Data on the efficacy of these two drugs for the treatment of chronic infection are still evolving.

Side effects are frequent, especially in adults, and require monitoring. These effects include anorexia and weight loss, nausea and vomiting, insomnia, convulsions, headache, myalgias and arthralgias, mucosal edema, hepatic intolerance, and skin manifestations. Yearly physicals should be performed, along with an ECG with a rhythm strip.

Treatment should always be offered for acute infections, congenital disease, and for children and adolescents 18 years and younger with chronic infection, and immunocompromised patients with reactivation, said Dr. Cantey. Treatment generally should be offered to women of reproductive age, adults aged 50 years and younger with indeterminate form disease or with mild to moderate cardiomyopathy, and patients in whom immunosuppression is anticipated.

Treatment generally should not be offered to patients with advanced cardiomyopathy with congestive heart failure and patients with impairment of swallowing. Treatment should almost never be offered during pregnancy or to patients with severe renal or hepatic insufficiency, Dr. Cantey said.

Toxocariasis

Toxocariasis in humans is caused by infection with larval stages of dog/cat roundworm. Toxocara eggs are shed in dog and cat feces, and humans become infected through ingestion. Larvae migrate and encyst in humans but do not develop into adults or reproduce in humans.

According to data from the National Health and Nutrition Examination Survey (NHANES), approximately 14% of the U.S. population is infected. The highest prevalence is in the southern United States (less than 17%). Toxocariasis affects non-Hispanic blacks more than other groups and is associated with poverty, low education level, and dog ownership.

Many infected individuals are asymptomatic, said Dr. Cantey. In children, symptoms include fever, headache, behavioral and sleep disturbances, cough, anorexia, abdominal pain, hepatomegaly, nausea, and vomiting. Eosinophils may or may not be present. In adults, symptoms include chronic dyspnea, weakness, rash, pruritus, and abdominal pain. Eosinophilia is often present in adults.

Visceral toxocariasis typically occurs in children aged 2-7 years. Symptoms include fever, lower respiratory symptoms, hepatomegaly, abdominal pain, and anorexia. Other symptoms are specific to the organ involved and include hepatic granulomas, chronic prurigo, pruritus, urticaria, eczema, vasculitis, eosinophilic meningitis or encephalitis, myelitis, optic neuritis, radiculitis, cranial nerve palsy, and, less commonly, myocarditis, nephrotic syndrome, and arthritis. Laboratory test results show marked eosinophilia, anemia, hypergammaglobulinemia, and increased titers to A and B blood group antigens.

Ocular toxocariasis typically occurs in 5- to 10-year-olds. Usually a single eye is affected. Symptoms include strabismus, unilateral decreased vision, and leukokoria.

Enzyme-linked immunosorbent assay (ELISA) is 78% sensitive and 92% specific for the diagnosis of visceral toxocariasis. However, the sensitivity is lower for ocular toxocariasis. The disease cannot be diagnosed from stool, as the eggs are not excreted by humans, said Dr. Cantey.

Mild toxocariasis often does not need treatment. Visceral disease is treated with 5 days of albendazole; corticosteroids may be used for allergic symptoms. Ocular toxocariasis is treated with 2-4 weeks of albendazole, along with aggressive anti-inflammatory treatment with corticosteroids, and surgery. Albendazole is not approved by the FDA for this indication.

Trichomoniasis

Trichomonas vaginalis is a parasite that is spread through sexual contact. It's estimated that there are 5-7 million cases yearly in the United States. However, the prevalence may be as great as 20 million. The rate is 10-fold greater among black women, compared with non-Hispanic white women (13.3% vs. 1.3% respectively).

Patients with trichomoniasis can be asymptomatic. In women, symptoms include vaginal discharge, pruritus, and dysuria; in men, symptoms include urethral discharge and dysuria.

Physical examination may reveal mucopurulent discharge, “strawberry cervix” (colpitis macularis), cervical erythema, or cervical friability.

T. vaginalis infection can cause premature rupture of membranes in pregnant women, preterm birth, low birth weight, pelvic inflammatory diseases, and increased susceptibility to HIV transmission.

In terms of diagnosis, wet preparation examination is only 60%-70% sensitive in women. Two point-of-care tests (OSOM Trichomonas Rapid Test and Affirm VP III) are available. These tests, performed on vaginal secretions, are more than 83% sensitive and more than 97% specific. Pap smears are not recommended for Trichomonas screening. In men, wet preparation of urethral discharge, prostatic secretions, or urethral scrapings is of uncertain sensitivity. Instead, PCR or culture on special media should be used.

Trichomoniasis is treated with metronidazole or tinidazole. If treatment with 2 g metronidazole given once fails (and reinfection is excluded), then patients should be treated with 500 g metronidazole twice daily for 7 days or with 2 g tinidazole once. If either therapy fails, then treat with 2 g metronidazole or 2 g tinidazole daily for 5 days. If this treatment fails, consult the CDC for testing and management (404-718-4141 or

www.cdc.gov/std)

Metronidazole is pregnancy category B and tinidazole is pregnancy category C. Asymptomatic pregnant women should be counseled about the risks and benefits of treatment, Dr. Cantey noted.

The assassin bug, also known as the kissing bug, is a blood-sucking triatomine insect that carries Trypanosoma cruzi.

Source ©Travfotos/Flickr.com

Certain infectious diseases can concentrate in impoverished areas and disproportionately affect minorities, women, and other disadvantaged groups, according to Dr. Paul T. Cantey.

Clinicians often receive little training on infectious diseases seen in these areas, which include tribal lands and border regions in the southwestern United States, the Mississippi Delta, the Cotton Belt, Appalachia, and some dense urban areas.

Dr. Cantey outlined the diagnosis and treatment of three of these diseases – Chagas disease, toxocariasis, and trichomoniasis – during the teleconference.

Dr. Cantey is a medical officer in the Centers for Disease Control and Prevention's division of parasitic diseases and malaria.

Chagas disease

Chagas disease is caused by the protozoan parasite Trypanosoma cruzi. The primary mode of transmission is through infected triatomine bugs. Other modes of transmission include blood transfusion, organ and tissue transplantation, congenital infection, laboratory accidents, and food.

Chagas disease is endemic in much of Latin America. However, both the parasite and the triatomine bug are found in the United States. It's estimated that there are at least 300,000 infected Latin American immigrants living in the United States. California, Florida, and Texas are disproportionately affected. Other geographic concentrations include Arizona, Georgia, Illinois, New York, North Carolina, and Virginia.

Blood donor screening for T. cruzi started in early 2007. Since then 1,267 infected donors have been identified. More than 40 of these individuals had no recognized risk factors.

The acute phase of the disease lasts 4-8 weeks. Patients are usually asymptomatic during this period. An estimated 10%-20% of infected individuals may have nonspecific febrile illness. Romaña's sign (chagoma) occurs less frequently.

The chronic phase is lifelong and may be asymptomatic and indeterminate in form. Approximately 20%-30% of infected individuals will manifest symptomatic disease – heart failure, sudden death, stroke, or organomegaly.

Testing for Chagas disease is available through the CDC, Dr. Cantey said. For acute infection, a blood smear, hemoculture, and polymerase chain reaction (PCR) tests are useful. For chronic infection, serologic tests are useful. However, there is no preferred test.

Tests for acute infection are sensitive, but the acute phase often is not recognized. Tests for chronic infection have issues with sensitivity and specificity, and usually positive results from two different tests are needed for diagnosis.

Nifurtimox or benznidazole are used for treatment, although neither drug is approved by the Food and Drug Administration. Both are available through CDC's investigational new drug protocol for compassionate use. Data on the efficacy of these two drugs for the treatment of chronic infection are still evolving.

Side effects are frequent, especially in adults, and require monitoring. These effects include anorexia and weight loss, nausea and vomiting, insomnia, convulsions, headache, myalgias and arthralgias, mucosal edema, hepatic intolerance, and skin manifestations. Yearly physicals should be performed, along with an ECG with a rhythm strip.

Treatment should always be offered for acute infections, congenital disease, and for children and adolescents 18 years and younger with chronic infection, and immunocompromised patients with reactivation, said Dr. Cantey. Treatment generally should be offered to women of reproductive age, adults aged 50 years and younger with indeterminate form disease or with mild to moderate cardiomyopathy, and patients in whom immunosuppression is anticipated.

Treatment generally should not be offered to patients with advanced cardiomyopathy with congestive heart failure and patients with impairment of swallowing. Treatment should almost never be offered during pregnancy or to patients with severe renal or hepatic insufficiency, Dr. Cantey said.

Toxocariasis

Toxocariasis in humans is caused by infection with larval stages of dog/cat roundworm. Toxocara eggs are shed in dog and cat feces, and humans become infected through ingestion. Larvae migrate and encyst in humans but do not develop into adults or reproduce in humans.

According to data from the National Health and Nutrition Examination Survey (NHANES), approximately 14% of the U.S. population is infected. The highest prevalence is in the southern United States (less than 17%). Toxocariasis affects non-Hispanic blacks more than other groups and is associated with poverty, low education level, and dog ownership.

Many infected individuals are asymptomatic, said Dr. Cantey. In children, symptoms include fever, headache, behavioral and sleep disturbances, cough, anorexia, abdominal pain, hepatomegaly, nausea, and vomiting. Eosinophils may or may not be present. In adults, symptoms include chronic dyspnea, weakness, rash, pruritus, and abdominal pain. Eosinophilia is often present in adults.

Visceral toxocariasis typically occurs in children aged 2-7 years. Symptoms include fever, lower respiratory symptoms, hepatomegaly, abdominal pain, and anorexia. Other symptoms are specific to the organ involved and include hepatic granulomas, chronic prurigo, pruritus, urticaria, eczema, vasculitis, eosinophilic meningitis or encephalitis, myelitis, optic neuritis, radiculitis, cranial nerve palsy, and, less commonly, myocarditis, nephrotic syndrome, and arthritis. Laboratory test results show marked eosinophilia, anemia, hypergammaglobulinemia, and increased titers to A and B blood group antigens.

Ocular toxocariasis typically occurs in 5- to 10-year-olds. Usually a single eye is affected. Symptoms include strabismus, unilateral decreased vision, and leukokoria.

Enzyme-linked immunosorbent assay (ELISA) is 78% sensitive and 92% specific for the diagnosis of visceral toxocariasis. However, the sensitivity is lower for ocular toxocariasis. The disease cannot be diagnosed from stool, as the eggs are not excreted by humans, said Dr. Cantey.

Mild toxocariasis often does not need treatment. Visceral disease is treated with 5 days of albendazole; corticosteroids may be used for allergic symptoms. Ocular toxocariasis is treated with 2-4 weeks of albendazole, along with aggressive anti-inflammatory treatment with corticosteroids, and surgery. Albendazole is not approved by the FDA for this indication.

Trichomoniasis

Trichomonas vaginalis is a parasite that is spread through sexual contact. It's estimated that there are 5-7 million cases yearly in the United States. However, the prevalence may be as great as 20 million. The rate is 10-fold greater among black women, compared with non-Hispanic white women (13.3% vs. 1.3% respectively).

Patients with trichomoniasis can be asymptomatic. In women, symptoms include vaginal discharge, pruritus, and dysuria; in men, symptoms include urethral discharge and dysuria.

Physical examination may reveal mucopurulent discharge, “strawberry cervix” (colpitis macularis), cervical erythema, or cervical friability.

T. vaginalis infection can cause premature rupture of membranes in pregnant women, preterm birth, low birth weight, pelvic inflammatory diseases, and increased susceptibility to HIV transmission.

In terms of diagnosis, wet preparation examination is only 60%-70% sensitive in women. Two point-of-care tests (OSOM Trichomonas Rapid Test and Affirm VP III) are available. These tests, performed on vaginal secretions, are more than 83% sensitive and more than 97% specific. Pap smears are not recommended for Trichomonas screening. In men, wet preparation of urethral discharge, prostatic secretions, or urethral scrapings is of uncertain sensitivity. Instead, PCR or culture on special media should be used.

Trichomoniasis is treated with metronidazole or tinidazole. If treatment with 2 g metronidazole given once fails (and reinfection is excluded), then patients should be treated with 500 g metronidazole twice daily for 7 days or with 2 g tinidazole once. If either therapy fails, then treat with 2 g metronidazole or 2 g tinidazole daily for 5 days. If this treatment fails, consult the CDC for testing and management (404-718-4141 or

www.cdc.gov/std)

Metronidazole is pregnancy category B and tinidazole is pregnancy category C. Asymptomatic pregnant women should be counseled about the risks and benefits of treatment, Dr. Cantey noted.

The assassin bug, also known as the kissing bug, is a blood-sucking triatomine insect that carries Trypanosoma cruzi.

Source ©Travfotos/Flickr.com

Certain infectious diseases can concentrate in impoverished areas and disproportionately affect minorities, women, and other disadvantaged groups, according to Dr. Paul T. Cantey.

Clinicians often receive little training on infectious diseases seen in these areas, which include tribal lands and border regions in the southwestern United States, the Mississippi Delta, the Cotton Belt, Appalachia, and some dense urban areas.

Dr. Cantey outlined the diagnosis and treatment of three of these diseases – Chagas disease, toxocariasis, and trichomoniasis – during the teleconference.

Dr. Cantey is a medical officer in the Centers for Disease Control and Prevention's division of parasitic diseases and malaria.

Chagas disease

Chagas disease is caused by the protozoan parasite Trypanosoma cruzi. The primary mode of transmission is through infected triatomine bugs. Other modes of transmission include blood transfusion, organ and tissue transplantation, congenital infection, laboratory accidents, and food.

Chagas disease is endemic in much of Latin America. However, both the parasite and the triatomine bug are found in the United States. It's estimated that there are at least 300,000 infected Latin American immigrants living in the United States. California, Florida, and Texas are disproportionately affected. Other geographic concentrations include Arizona, Georgia, Illinois, New York, North Carolina, and Virginia.

Blood donor screening for T. cruzi started in early 2007. Since then 1,267 infected donors have been identified. More than 40 of these individuals had no recognized risk factors.

The acute phase of the disease lasts 4-8 weeks. Patients are usually asymptomatic during this period. An estimated 10%-20% of infected individuals may have nonspecific febrile illness. Romaña's sign (chagoma) occurs less frequently.

The chronic phase is lifelong and may be asymptomatic and indeterminate in form. Approximately 20%-30% of infected individuals will manifest symptomatic disease – heart failure, sudden death, stroke, or organomegaly.

Testing for Chagas disease is available through the CDC, Dr. Cantey said. For acute infection, a blood smear, hemoculture, and polymerase chain reaction (PCR) tests are useful. For chronic infection, serologic tests are useful. However, there is no preferred test.

Tests for acute infection are sensitive, but the acute phase often is not recognized. Tests for chronic infection have issues with sensitivity and specificity, and usually positive results from two different tests are needed for diagnosis.

Nifurtimox or benznidazole are used for treatment, although neither drug is approved by the Food and Drug Administration. Both are available through CDC's investigational new drug protocol for compassionate use. Data on the efficacy of these two drugs for the treatment of chronic infection are still evolving.

Side effects are frequent, especially in adults, and require monitoring. These effects include anorexia and weight loss, nausea and vomiting, insomnia, convulsions, headache, myalgias and arthralgias, mucosal edema, hepatic intolerance, and skin manifestations. Yearly physicals should be performed, along with an ECG with a rhythm strip.

Treatment should always be offered for acute infections, congenital disease, and for children and adolescents 18 years and younger with chronic infection, and immunocompromised patients with reactivation, said Dr. Cantey. Treatment generally should be offered to women of reproductive age, adults aged 50 years and younger with indeterminate form disease or with mild to moderate cardiomyopathy, and patients in whom immunosuppression is anticipated.

Treatment generally should not be offered to patients with advanced cardiomyopathy with congestive heart failure and patients with impairment of swallowing. Treatment should almost never be offered during pregnancy or to patients with severe renal or hepatic insufficiency, Dr. Cantey said.

Toxocariasis

Toxocariasis in humans is caused by infection with larval stages of dog/cat roundworm. Toxocara eggs are shed in dog and cat feces, and humans become infected through ingestion. Larvae migrate and encyst in humans but do not develop into adults or reproduce in humans.

According to data from the National Health and Nutrition Examination Survey (NHANES), approximately 14% of the U.S. population is infected. The highest prevalence is in the southern United States (less than 17%). Toxocariasis affects non-Hispanic blacks more than other groups and is associated with poverty, low education level, and dog ownership.

Many infected individuals are asymptomatic, said Dr. Cantey. In children, symptoms include fever, headache, behavioral and sleep disturbances, cough, anorexia, abdominal pain, hepatomegaly, nausea, and vomiting. Eosinophils may or may not be present. In adults, symptoms include chronic dyspnea, weakness, rash, pruritus, and abdominal pain. Eosinophilia is often present in adults.

Visceral toxocariasis typically occurs in children aged 2-7 years. Symptoms include fever, lower respiratory symptoms, hepatomegaly, abdominal pain, and anorexia. Other symptoms are specific to the organ involved and include hepatic granulomas, chronic prurigo, pruritus, urticaria, eczema, vasculitis, eosinophilic meningitis or encephalitis, myelitis, optic neuritis, radiculitis, cranial nerve palsy, and, less commonly, myocarditis, nephrotic syndrome, and arthritis. Laboratory test results show marked eosinophilia, anemia, hypergammaglobulinemia, and increased titers to A and B blood group antigens.

Ocular toxocariasis typically occurs in 5- to 10-year-olds. Usually a single eye is affected. Symptoms include strabismus, unilateral decreased vision, and leukokoria.

Enzyme-linked immunosorbent assay (ELISA) is 78% sensitive and 92% specific for the diagnosis of visceral toxocariasis. However, the sensitivity is lower for ocular toxocariasis. The disease cannot be diagnosed from stool, as the eggs are not excreted by humans, said Dr. Cantey.

Mild toxocariasis often does not need treatment. Visceral disease is treated with 5 days of albendazole; corticosteroids may be used for allergic symptoms. Ocular toxocariasis is treated with 2-4 weeks of albendazole, along with aggressive anti-inflammatory treatment with corticosteroids, and surgery. Albendazole is not approved by the FDA for this indication.

Trichomoniasis

Trichomonas vaginalis is a parasite that is spread through sexual contact. It's estimated that there are 5-7 million cases yearly in the United States. However, the prevalence may be as great as 20 million. The rate is 10-fold greater among black women, compared with non-Hispanic white women (13.3% vs. 1.3% respectively).

Patients with trichomoniasis can be asymptomatic. In women, symptoms include vaginal discharge, pruritus, and dysuria; in men, symptoms include urethral discharge and dysuria.

Physical examination may reveal mucopurulent discharge, “strawberry cervix” (colpitis macularis), cervical erythema, or cervical friability.

T. vaginalis infection can cause premature rupture of membranes in pregnant women, preterm birth, low birth weight, pelvic inflammatory diseases, and increased susceptibility to HIV transmission.

In terms of diagnosis, wet preparation examination is only 60%-70% sensitive in women. Two point-of-care tests (OSOM Trichomonas Rapid Test and Affirm VP III) are available. These tests, performed on vaginal secretions, are more than 83% sensitive and more than 97% specific. Pap smears are not recommended for Trichomonas screening. In men, wet preparation of urethral discharge, prostatic secretions, or urethral scrapings is of uncertain sensitivity. Instead, PCR or culture on special media should be used.

Trichomoniasis is treated with metronidazole or tinidazole. If treatment with 2 g metronidazole given once fails (and reinfection is excluded), then patients should be treated with 500 g metronidazole twice daily for 7 days or with 2 g tinidazole once. If either therapy fails, then treat with 2 g metronidazole or 2 g tinidazole daily for 5 days. If this treatment fails, consult the CDC for testing and management (404-718-4141 or

www.cdc.gov/std)

Metronidazole is pregnancy category B and tinidazole is pregnancy category C. Asymptomatic pregnant women should be counseled about the risks and benefits of treatment, Dr. Cantey noted.

The assassin bug, also known as the kissing bug, is a blood-sucking triatomine insect that carries Trypanosoma cruzi.

Source ©Travfotos/Flickr.com

Physical and sexual abuse in childhood and adolescence appear to increase the risk of type 2 diabetes in adult women in a dose-response fashion, based on the results of an epidemiologic study involving almost 70,000 women.

Moderate and severe physical abuse in childhood and adolescence were associated with 26%-54% higher risks of diabetes in women. Those who had experienced forced sex once had a 34% higher risk of diabetes than were women who were not sexually abused as girls and a 69% higher risk when sexual abuse occurred more frequently. Even after accounting for adult body mass index, there remained a 10%-30% increased risk of diabetes among women who had experienced moderate physical abuse or the most severe forms of physical or sexual abuse (Am. J. Prev. Med. [doi:10.1016/j.amepre.2010.09.007]).

"The PAR [population attributable risk] percent derived from this model indicates that child/adolescent abuse accounted for 14% (7%-21%) of type 2 diabetes in this cohort. Applying the hazard ratio from this study to the 43% prevalence of any child or adolescent abuse reported by women in the National Violence Against Women Survey, an estimated 9% of diabetes in U.S. women may be attributed to early abuse," wrote Janet W. Rich-Edwards, Sc.D., and her colleagues.

An association consistently has been reported between child abuse and adult obesity. Studies indicate "that early trauma may cause lasting dysregulated responsivity, which may link child abuse with diabetes through physiologic pathways independent of adiposity," wrote Dr. Rich-Edwards, director of developmental epidemiology at the Connors Center for Women’s Health and Gender Biology at Brigham and Women’s Hospital, Boston, and her colleagues. However, the association between childhood abuse and adult diabetes has not been studied before in a large population.

The new findings highlight the importance of recognizing abuse in children and adolescents and asking adults about a history of abuse, according to Dr. Lawrence S. Phillips, a professor of endocrinology at Emory University, Atlanta.

Physicians need to be aware that "there are not only emotional and behavioral consequences of abuse in childhood and adolescence; there are physical consequences as well," he said in an interview. "We need to be much more sensitive to issues of abuse and in the history, because they demonstrably now have mental and physical downstream impacts."

For this study, the researchers used data from the Nurses Health Study II (NHSII), a cohort of 116,430 registered nurses, who were aged 25-42 years when the cohort was established in 1989. The cohort has been followed by biennial mailed questionnaires, which inquire about risk factors and disease incidence.

In 2001, a violence questionnaire was added to this large longitudinal cohort study of women. Participants returned 68,376 violence questionnaires; 67,853 were included in this analysis.

A total of 2,074 cases of type 2 diabetes were accrued from 1989 to 2005, and 759 incident cases occurred after the violence questionnaire was administered in 2001. All of the cases (2,833) were included in the analysis to maximize power. Data were analyzed in 2009, after diagnoses of diabetes reported on the 2005 questionnaire were reviewed and coded.

The Violence Questionnaire covers three periods: childhood (up to age 11 years), adolescence (11-17 years), and adulthood. Childhood and adolescent physical abuse was assessed through an adaptation of the Revised Conflict Tactics Scale. Physical abuse during childhood was categorized into four groups: no physical abuse (none); being "pushed, grabbed, or shoved" at any frequency or being "kicked, bitten, or punched" once or "hit with something" once (mild); being "hit with something" more than once or "physically attacked" once (moderate); being "kicked, bitten, or punched" or "physically attacked" more than once or ever "choked or burned" (severe). Spanking was not included.

Child and adolescent sexual abuse was measured by questions about unwanted sexual touching and forced sexual activity. Exposure was categorized into four groups: no sexual abuse; unwanted sexual touching only; forced sexual activity once; and forced sexual activity more than once. Adult experiences of abuse were measured on the violence questionnaire with questions adapted from the McFarlane Abuse Assessment Screen.

In this cohort, 65% of participants reported any degree of physical or sexual abuse in childhood or adolescence, which was associated with a 24% increased risk of type 2 diabetes in adulthood, even after adjustment for age, race/ethnicity, body type at 5 years, and maternal/paternal education and history of diabetes.

A dose-response association was found between physical abuse and risk of diabetes. However, this was somewhat attenuated by adjustment for race, maternal and paternal education, maternal and paternal diabetes, and somatotype at age 5.

Physical and sexual abuse interacted on an additive scale but not on a multiplicative scale, indicating that the absolute risk of diabetes was greater among women who had experienced both forms of abuse than would be expected from the risk of sexual or physical abuse alone, according to Dr. Rich-Edwards and her coauthors.

At age 5 years, little difference was found between the somatotypes of girls who did and did not report later abuse. By the age of 18 years, however, the BMI trajectories of abused girls had begun to diverge. By ages 25-42 years, a marked trend was found of increasing BMI with more severe abuse history.

Adjustment for adult smoking, alcohol use, and BMI weakened, but did not eliminate the dose-response associations of child and teen abuse with risk of adult diabetes. The attenuation was attributable almost entirely to adjustment for adult BMI, which accounted for 60% and 64% of the associations of physical and sexual abuse respectively with diabetes.

Despite adjustment, moderate physical abuse, severe physical abuse, and repeated forced sex remained independently associated with significantly increased risks of diabetes of 12%, 21%, and 28%, respectively.

Moderate and severe physical abuse were associated with 26%-54% higher risks of diabetes in maturity. Unwanted sexual touching was associated with 16% higher risk of diabetes, and forced sexual activity before adulthood carried a 34% greater risk when it occurred once and a 69% greater risk when it occurred more frequently. Child and teen abuse predicted later diabetes even among women who reported no adult physical or sexual abuse.

"The high prevalence of child abuse suggests that it is an important, if overlooked, contributor to type 2 diabetes ... A more precise description of the physiologic and psychological mechanisms through which abuse leads to overweight and obesity would help to focus prevention efforts. Weight-control interventions designed specifically for survivors of abuse may help to reduce the risk of diabetes," the investigators concluded.

Dr. Phillips agreed. "If an individual [with a history of abuse] is heavy or is gaining weight or is physically inactive, we need to try to intervene – recognizing that those kinds of changes in these individuals will predispose them to the development of diabetes more than perhaps the general population."

The authors reported no financial disclosures.

Physical and sexual abuse in childhood and adolescence appear to increase the risk of type 2 diabetes in adult women in a dose-response fashion, based on the results of an epidemiologic study involving almost 70,000 women.

Moderate and severe physical abuse in childhood and adolescence were associated with 26%-54% higher risks of diabetes in women. Those who had experienced forced sex once had a 34% higher risk of diabetes than were women who were not sexually abused as girls and a 69% higher risk when sexual abuse occurred more frequently. Even after accounting for adult body mass index, there remained a 10%-30% increased risk of diabetes among women who had experienced moderate physical abuse or the most severe forms of physical or sexual abuse (Am. J. Prev. Med. [doi:10.1016/j.amepre.2010.09.007]).

"The PAR [population attributable risk] percent derived from this model indicates that child/adolescent abuse accounted for 14% (7%-21%) of type 2 diabetes in this cohort. Applying the hazard ratio from this study to the 43% prevalence of any child or adolescent abuse reported by women in the National Violence Against Women Survey, an estimated 9% of diabetes in U.S. women may be attributed to early abuse," wrote Janet W. Rich-Edwards, Sc.D., and her colleagues.

An association consistently has been reported between child abuse and adult obesity. Studies indicate "that early trauma may cause lasting dysregulated responsivity, which may link child abuse with diabetes through physiologic pathways independent of adiposity," wrote Dr. Rich-Edwards, director of developmental epidemiology at the Connors Center for Women’s Health and Gender Biology at Brigham and Women’s Hospital, Boston, and her colleagues. However, the association between childhood abuse and adult diabetes has not been studied before in a large population.

The new findings highlight the importance of recognizing abuse in children and adolescents and asking adults about a history of abuse, according to Dr. Lawrence S. Phillips, a professor of endocrinology at Emory University, Atlanta.

Physicians need to be aware that "there are not only emotional and behavioral consequences of abuse in childhood and adolescence; there are physical consequences as well," he said in an interview. "We need to be much more sensitive to issues of abuse and in the history, because they demonstrably now have mental and physical downstream impacts."

For this study, the researchers used data from the Nurses Health Study II (NHSII), a cohort of 116,430 registered nurses, who were aged 25-42 years when the cohort was established in 1989. The cohort has been followed by biennial mailed questionnaires, which inquire about risk factors and disease incidence.

In 2001, a violence questionnaire was added to this large longitudinal cohort study of women. Participants returned 68,376 violence questionnaires; 67,853 were included in this analysis.

A total of 2,074 cases of type 2 diabetes were accrued from 1989 to 2005, and 759 incident cases occurred after the violence questionnaire was administered in 2001. All of the cases (2,833) were included in the analysis to maximize power. Data were analyzed in 2009, after diagnoses of diabetes reported on the 2005 questionnaire were reviewed and coded.

The Violence Questionnaire covers three periods: childhood (up to age 11 years), adolescence (11-17 years), and adulthood. Childhood and adolescent physical abuse was assessed through an adaptation of the Revised Conflict Tactics Scale. Physical abuse during childhood was categorized into four groups: no physical abuse (none); being "pushed, grabbed, or shoved" at any frequency or being "kicked, bitten, or punched" once or "hit with something" once (mild); being "hit with something" more than once or "physically attacked" once (moderate); being "kicked, bitten, or punched" or "physically attacked" more than once or ever "choked or burned" (severe). Spanking was not included.

Child and adolescent sexual abuse was measured by questions about unwanted sexual touching and forced sexual activity. Exposure was categorized into four groups: no sexual abuse; unwanted sexual touching only; forced sexual activity once; and forced sexual activity more than once. Adult experiences of abuse were measured on the violence questionnaire with questions adapted from the McFarlane Abuse Assessment Screen.

In this cohort, 65% of participants reported any degree of physical or sexual abuse in childhood or adolescence, which was associated with a 24% increased risk of type 2 diabetes in adulthood, even after adjustment for age, race/ethnicity, body type at 5 years, and maternal/paternal education and history of diabetes.

A dose-response association was found between physical abuse and risk of diabetes. However, this was somewhat attenuated by adjustment for race, maternal and paternal education, maternal and paternal diabetes, and somatotype at age 5.

Physical and sexual abuse interacted on an additive scale but not on a multiplicative scale, indicating that the absolute risk of diabetes was greater among women who had experienced both forms of abuse than would be expected from the risk of sexual or physical abuse alone, according to Dr. Rich-Edwards and her coauthors.

At age 5 years, little difference was found between the somatotypes of girls who did and did not report later abuse. By the age of 18 years, however, the BMI trajectories of abused girls had begun to diverge. By ages 25-42 years, a marked trend was found of increasing BMI with more severe abuse history.

Adjustment for adult smoking, alcohol use, and BMI weakened, but did not eliminate the dose-response associations of child and teen abuse with risk of adult diabetes. The attenuation was attributable almost entirely to adjustment for adult BMI, which accounted for 60% and 64% of the associations of physical and sexual abuse respectively with diabetes.

Despite adjustment, moderate physical abuse, severe physical abuse, and repeated forced sex remained independently associated with significantly increased risks of diabetes of 12%, 21%, and 28%, respectively.

Moderate and severe physical abuse were associated with 26%-54% higher risks of diabetes in maturity. Unwanted sexual touching was associated with 16% higher risk of diabetes, and forced sexual activity before adulthood carried a 34% greater risk when it occurred once and a 69% greater risk when it occurred more frequently. Child and teen abuse predicted later diabetes even among women who reported no adult physical or sexual abuse.

"The high prevalence of child abuse suggests that it is an important, if overlooked, contributor to type 2 diabetes ... A more precise description of the physiologic and psychological mechanisms through which abuse leads to overweight and obesity would help to focus prevention efforts. Weight-control interventions designed specifically for survivors of abuse may help to reduce the risk of diabetes," the investigators concluded.

Dr. Phillips agreed. "If an individual [with a history of abuse] is heavy or is gaining weight or is physically inactive, we need to try to intervene – recognizing that those kinds of changes in these individuals will predispose them to the development of diabetes more than perhaps the general population."

The authors reported no financial disclosures.

Physical and sexual abuse in childhood and adolescence appear to increase the risk of type 2 diabetes in adult women in a dose-response fashion, based on the results of an epidemiologic study involving almost 70,000 women.

Moderate and severe physical abuse in childhood and adolescence were associated with 26%-54% higher risks of diabetes in women. Those who had experienced forced sex once had a 34% higher risk of diabetes than were women who were not sexually abused as girls and a 69% higher risk when sexual abuse occurred more frequently. Even after accounting for adult body mass index, there remained a 10%-30% increased risk of diabetes among women who had experienced moderate physical abuse or the most severe forms of physical or sexual abuse (Am. J. Prev. Med. [doi:10.1016/j.amepre.2010.09.007]).

"The PAR [population attributable risk] percent derived from this model indicates that child/adolescent abuse accounted for 14% (7%-21%) of type 2 diabetes in this cohort. Applying the hazard ratio from this study to the 43% prevalence of any child or adolescent abuse reported by women in the National Violence Against Women Survey, an estimated 9% of diabetes in U.S. women may be attributed to early abuse," wrote Janet W. Rich-Edwards, Sc.D., and her colleagues.

An association consistently has been reported between child abuse and adult obesity. Studies indicate "that early trauma may cause lasting dysregulated responsivity, which may link child abuse with diabetes through physiologic pathways independent of adiposity," wrote Dr. Rich-Edwards, director of developmental epidemiology at the Connors Center for Women’s Health and Gender Biology at Brigham and Women’s Hospital, Boston, and her colleagues. However, the association between childhood abuse and adult diabetes has not been studied before in a large population.

The new findings highlight the importance of recognizing abuse in children and adolescents and asking adults about a history of abuse, according to Dr. Lawrence S. Phillips, a professor of endocrinology at Emory University, Atlanta.

Physicians need to be aware that "there are not only emotional and behavioral consequences of abuse in childhood and adolescence; there are physical consequences as well," he said in an interview. "We need to be much more sensitive to issues of abuse and in the history, because they demonstrably now have mental and physical downstream impacts."

For this study, the researchers used data from the Nurses Health Study II (NHSII), a cohort of 116,430 registered nurses, who were aged 25-42 years when the cohort was established in 1989. The cohort has been followed by biennial mailed questionnaires, which inquire about risk factors and disease incidence.

In 2001, a violence questionnaire was added to this large longitudinal cohort study of women. Participants returned 68,376 violence questionnaires; 67,853 were included in this analysis.

A total of 2,074 cases of type 2 diabetes were accrued from 1989 to 2005, and 759 incident cases occurred after the violence questionnaire was administered in 2001. All of the cases (2,833) were included in the analysis to maximize power. Data were analyzed in 2009, after diagnoses of diabetes reported on the 2005 questionnaire were reviewed and coded.

The Violence Questionnaire covers three periods: childhood (up to age 11 years), adolescence (11-17 years), and adulthood. Childhood and adolescent physical abuse was assessed through an adaptation of the Revised Conflict Tactics Scale. Physical abuse during childhood was categorized into four groups: no physical abuse (none); being "pushed, grabbed, or shoved" at any frequency or being "kicked, bitten, or punched" once or "hit with something" once (mild); being "hit with something" more than once or "physically attacked" once (moderate); being "kicked, bitten, or punched" or "physically attacked" more than once or ever "choked or burned" (severe). Spanking was not included.

Child and adolescent sexual abuse was measured by questions about unwanted sexual touching and forced sexual activity. Exposure was categorized into four groups: no sexual abuse; unwanted sexual touching only; forced sexual activity once; and forced sexual activity more than once. Adult experiences of abuse were measured on the violence questionnaire with questions adapted from the McFarlane Abuse Assessment Screen.

In this cohort, 65% of participants reported any degree of physical or sexual abuse in childhood or adolescence, which was associated with a 24% increased risk of type 2 diabetes in adulthood, even after adjustment for age, race/ethnicity, body type at 5 years, and maternal/paternal education and history of diabetes.

A dose-response association was found between physical abuse and risk of diabetes. However, this was somewhat attenuated by adjustment for race, maternal and paternal education, maternal and paternal diabetes, and somatotype at age 5.

Physical and sexual abuse interacted on an additive scale but not on a multiplicative scale, indicating that the absolute risk of diabetes was greater among women who had experienced both forms of abuse than would be expected from the risk of sexual or physical abuse alone, according to Dr. Rich-Edwards and her coauthors.

At age 5 years, little difference was found between the somatotypes of girls who did and did not report later abuse. By the age of 18 years, however, the BMI trajectories of abused girls had begun to diverge. By ages 25-42 years, a marked trend was found of increasing BMI with more severe abuse history.

Adjustment for adult smoking, alcohol use, and BMI weakened, but did not eliminate the dose-response associations of child and teen abuse with risk of adult diabetes. The attenuation was attributable almost entirely to adjustment for adult BMI, which accounted for 60% and 64% of the associations of physical and sexual abuse respectively with diabetes.

Despite adjustment, moderate physical abuse, severe physical abuse, and repeated forced sex remained independently associated with significantly increased risks of diabetes of 12%, 21%, and 28%, respectively.

Moderate and severe physical abuse were associated with 26%-54% higher risks of diabetes in maturity. Unwanted sexual touching was associated with 16% higher risk of diabetes, and forced sexual activity before adulthood carried a 34% greater risk when it occurred once and a 69% greater risk when it occurred more frequently. Child and teen abuse predicted later diabetes even among women who reported no adult physical or sexual abuse.

"The high prevalence of child abuse suggests that it is an important, if overlooked, contributor to type 2 diabetes ... A more precise description of the physiologic and psychological mechanisms through which abuse leads to overweight and obesity would help to focus prevention efforts. Weight-control interventions designed specifically for survivors of abuse may help to reduce the risk of diabetes," the investigators concluded.

Dr. Phillips agreed. "If an individual [with a history of abuse] is heavy or is gaining weight or is physically inactive, we need to try to intervene – recognizing that those kinds of changes in these individuals will predispose them to the development of diabetes more than perhaps the general population."

The authors reported no financial disclosures.

Physical and sexual abuse in childhood and adolescence appear to increase the risk of type 2 diabetes in adult women in a dose-response fashion, based on the results of an epidemiologic study involving almost 70,000 women.

Moderate and severe physical abuse in childhood and adolescence were associated with 26%-54% higher risks of diabetes in women. Those who had experienced forced sex once had a 34% higher risk of diabetes than were women who were not sexually abused as girls and a 69% higher risk when sexual abuse occurred more frequently. Even after accounting for adult body mass index, there remained a 10%-30% increased risk of diabetes among women who had experienced moderate physical abuse or the most severe forms of physical or sexual abuse (Am. J. Prev. Med. [doi:10.1016/j.amepre.2010.09.007]).

"The PAR [population attributable risk] percent derived from this model indicates that child/adolescent abuse accounted for 14% (7%-21%) of type 2 diabetes in this cohort. Applying the hazard ratio from this study to the 43% prevalence of any child or adolescent abuse reported by women in the National Violence Against Women Survey, an estimated 9% of diabetes in U.S. women may be attributed to early abuse," wrote Janet W. Rich-Edwards, Sc.D., and her colleagues.

An association consistently has been reported between child abuse and adult obesity. Studies indicate "that early trauma may cause lasting dysregulated responsivity, which may link child abuse with diabetes through physiologic pathways independent of adiposity," wrote Dr. Rich-Edwards, director of developmental epidemiology at the Connors Center for Women’s Health and Gender Biology at Brigham and Women’s Hospital, Boston, and her colleagues. However, the association between childhood abuse and adult diabetes has not been studied before in a large population.

The new findings highlight the importance of recognizing abuse in children and adolescents and asking adults about a history of abuse, according to Dr. Lawrence S. Phillips, a professor of endocrinology at Emory University, Atlanta.

Physicians need to be aware that "there are not only emotional and behavioral consequences of abuse in childhood and adolescence; there are physical consequences as well," he said in an interview. "We need to be much more sensitive to issues of abuse and in the history, because they demonstrably now have mental and physical downstream impacts."

For this study, the researchers used data from the Nurses Health Study II (NHSII), a cohort of 116,430 registered nurses, who were aged 25-42 years when the cohort was established in 1989. The cohort has been followed by biennial mailed questionnaires, which inquire about risk factors and disease incidence.

In 2001, a violence questionnaire was added to this large longitudinal cohort study of women. Participants returned 68,376 violence questionnaires; 67,853 were included in this analysis.

A total of 2,074 cases of type 2 diabetes were accrued from 1989 to 2005, and 759 incident cases occurred after the violence questionnaire was administered in 2001. All of the cases (2,833) were included in the analysis to maximize power. Data were analyzed in 2009, after diagnoses of diabetes reported on the 2005 questionnaire were reviewed and coded.

The Violence Questionnaire covers three periods: childhood (up to age 11 years), adolescence (11-17 years), and adulthood. Childhood and adolescent physical abuse was assessed through an adaptation of the Revised Conflict Tactics Scale. Physical abuse during childhood was categorized into four groups: no physical abuse (none); being "pushed, grabbed, or shoved" at any frequency or being "kicked, bitten, or punched" once or "hit with something" once (mild); being "hit with something" more than once or "physically attacked" once (moderate); being "kicked, bitten, or punched" or "physically attacked" more than once or ever "choked or burned" (severe). Spanking was not included.

Child and adolescent sexual abuse was measured by questions about unwanted sexual touching and forced sexual activity. Exposure was categorized into four groups: no sexual abuse; unwanted sexual touching only; forced sexual activity once; and forced sexual activity more than once. Adult experiences of abuse were measured on the violence questionnaire with questions adapted from the McFarlane Abuse Assessment Screen.

In this cohort, 65% of participants reported any degree of physical or sexual abuse in childhood or adolescence, which was associated with a 24% increased risk of type 2 diabetes in adulthood, even after adjustment for age, race/ethnicity, body type at 5 years, and maternal/paternal education and history of diabetes.

A dose-response association was found between physical abuse and risk of diabetes. However, this was somewhat attenuated by adjustment for race, maternal and paternal education, maternal and paternal diabetes, and somatotype at age 5.

Physical and sexual abuse interacted on an additive scale but not on a multiplicative scale, indicating that the absolute risk of diabetes was greater among women who had experienced both forms of abuse than would be expected from the risk of sexual or physical abuse alone, according to Dr. Rich-Edwards and her coauthors.

At age 5 years, little difference was found between the somatotypes of girls who did and did not report later abuse. By the age of 18 years, however, the BMI trajectories of abused girls had begun to diverge. By ages 25-42 years, a marked trend was found of increasing BMI with more severe abuse history.

Adjustment for adult smoking, alcohol use, and BMI weakened, but did not eliminate the dose-response associations of child and teen abuse with risk of adult diabetes. The attenuation was attributable almost entirely to adjustment for adult BMI, which accounted for 60% and 64% of the associations of physical and sexual abuse respectively with diabetes.

Despite adjustment, moderate physical abuse, severe physical abuse, and repeated forced sex remained independently associated with significantly increased risks of diabetes of 12%, 21%, and 28%, respectively.

Moderate and severe physical abuse were associated with 26%-54% higher risks of diabetes in maturity. Unwanted sexual touching was associated with 16% higher risk of diabetes, and forced sexual activity before adulthood carried a 34% greater risk when it occurred once and a 69% greater risk when it occurred more frequently. Child and teen abuse predicted later diabetes even among women who reported no adult physical or sexual abuse.

"The high prevalence of child abuse suggests that it is an important, if overlooked, contributor to type 2 diabetes ... A more precise description of the physiologic and psychological mechanisms through which abuse leads to overweight and obesity would help to focus prevention efforts. Weight-control interventions designed specifically for survivors of abuse may help to reduce the risk of diabetes," the investigators concluded.

Dr. Phillips agreed. "If an individual [with a history of abuse] is heavy or is gaining weight or is physically inactive, we need to try to intervene – recognizing that those kinds of changes in these individuals will predispose them to the development of diabetes more than perhaps the general population."

The authors reported no financial disclosures.

Physical and sexual abuse in childhood and adolescence appear to increase the risk of type 2 diabetes in adult women in a dose-response fashion, based on the results of an epidemiologic study involving almost 70,000 women.

Moderate and severe physical abuse in childhood and adolescence were associated with 26%-54% higher risks of diabetes in women. Those who had experienced forced sex once had a 34% higher risk of diabetes than were women who were not sexually abused as girls and a 69% higher risk when sexual abuse occurred more frequently. Even after accounting for adult body mass index, there remained a 10%-30% increased risk of diabetes among women who had experienced moderate physical abuse or the most severe forms of physical or sexual abuse (Am. J. Prev. Med. [doi:10.1016/j.amepre.2010.09.007]).

"The PAR [population attributable risk] percent derived from this model indicates that child/adolescent abuse accounted for 14% (7%-21%) of type 2 diabetes in this cohort. Applying the hazard ratio from this study to the 43% prevalence of any child or adolescent abuse reported by women in the National Violence Against Women Survey, an estimated 9% of diabetes in U.S. women may be attributed to early abuse," wrote Janet W. Rich-Edwards, Sc.D., and her colleagues.

An association consistently has been reported between child abuse and adult obesity. Studies indicate "that early trauma may cause lasting dysregulated responsivity, which may link child abuse with diabetes through physiologic pathways independent of adiposity," wrote Dr. Rich-Edwards, director of developmental epidemiology at the Connors Center for Women’s Health and Gender Biology at Brigham and Women’s Hospital, Boston, and her colleagues. However, the association between childhood abuse and adult diabetes has not been studied before in a large population.

The new findings highlight the importance of recognizing abuse in children and adolescents and asking adults about a history of abuse, according to Dr. Lawrence S. Phillips, a professor of endocrinology at Emory University, Atlanta.

Physicians need to be aware that "there are not only emotional and behavioral consequences of abuse in childhood and adolescence; there are physical consequences as well," he said in an interview. "We need to be much more sensitive to issues of abuse and in the history, because they demonstrably now have mental and physical downstream impacts."

For this study, the researchers used data from the Nurses Health Study II (NHSII), a cohort of 116,430 registered nurses, who were aged 25-42 years when the cohort was established in 1989. The cohort has been followed by biennial mailed questionnaires, which inquire about risk factors and disease incidence.

In 2001, a violence questionnaire was added to this large longitudinal cohort study of women. Participants returned 68,376 violence questionnaires; 67,853 were included in this analysis.

A total of 2,074 cases of type 2 diabetes were accrued from 1989 to 2005, and 759 incident cases occurred after the violence questionnaire was administered in 2001. All of the cases (2,833) were included in the analysis to maximize power. Data were analyzed in 2009, after diagnoses of diabetes reported on the 2005 questionnaire were reviewed and coded.

The Violence Questionnaire covers three periods: childhood (up to age 11 years), adolescence (11-17 years), and adulthood. Childhood and adolescent physical abuse was assessed through an adaptation of the Revised Conflict Tactics Scale. Physical abuse during childhood was categorized into four groups: no physical abuse (none); being "pushed, grabbed, or shoved" at any frequency or being "kicked, bitten, or punched" once or "hit with something" once (mild); being "hit with something" more than once or "physically attacked" once (moderate); being "kicked, bitten, or punched" or "physically attacked" more than once or ever "choked or burned" (severe). Spanking was not included.

Child and adolescent sexual abuse was measured by questions about unwanted sexual touching and forced sexual activity. Exposure was categorized into four groups: no sexual abuse; unwanted sexual touching only; forced sexual activity once; and forced sexual activity more than once. Adult experiences of abuse were measured on the violence questionnaire with questions adapted from the McFarlane Abuse Assessment Screen.

In this cohort, 65% of participants reported any degree of physical or sexual abuse in childhood or adolescence, which was associated with a 24% increased risk of type 2 diabetes in adulthood, even after adjustment for age, race/ethnicity, body type at 5 years, and maternal/paternal education and history of diabetes.

A dose-response association was found between physical abuse and risk of diabetes. However, this was somewhat attenuated by adjustment for race, maternal and paternal education, maternal and paternal diabetes, and somatotype at age 5.

Physical and sexual abuse interacted on an additive scale but not on a multiplicative scale, indicating that the absolute risk of diabetes was greater among women who had experienced both forms of abuse than would be expected from the risk of sexual or physical abuse alone, according to Dr. Rich-Edwards and her coauthors.

At age 5 years, little difference was found between the somatotypes of girls who did and did not report later abuse. By the age of 18 years, however, the BMI trajectories of abused girls had begun to diverge. By ages 25-42 years, a marked trend was found of increasing BMI with more severe abuse history.

Adjustment for adult smoking, alcohol use, and BMI weakened, but did not eliminate the dose-response associations of child and teen abuse with risk of adult diabetes. The attenuation was attributable almost entirely to adjustment for adult BMI, which accounted for 60% and 64% of the associations of physical and sexual abuse respectively with diabetes.

Despite adjustment, moderate physical abuse, severe physical abuse, and repeated forced sex remained independently associated with significantly increased risks of diabetes of 12%, 21%, and 28%, respectively.

Moderate and severe physical abuse were associated with 26%-54% higher risks of diabetes in maturity. Unwanted sexual touching was associated with 16% higher risk of diabetes, and forced sexual activity before adulthood carried a 34% greater risk when it occurred once and a 69% greater risk when it occurred more frequently. Child and teen abuse predicted later diabetes even among women who reported no adult physical or sexual abuse.

"The high prevalence of child abuse suggests that it is an important, if overlooked, contributor to type 2 diabetes ... A more precise description of the physiologic and psychological mechanisms through which abuse leads to overweight and obesity would help to focus prevention efforts. Weight-control interventions designed specifically for survivors of abuse may help to reduce the risk of diabetes," the investigators concluded.

Dr. Phillips agreed. "If an individual [with a history of abuse] is heavy or is gaining weight or is physically inactive, we need to try to intervene – recognizing that those kinds of changes in these individuals will predispose them to the development of diabetes more than perhaps the general population."

The authors reported no financial disclosures.

Physical and sexual abuse in childhood and adolescence appear to increase the risk of type 2 diabetes in adult women in a dose-response fashion, based on the results of an epidemiologic study involving almost 70,000 women.

Moderate and severe physical abuse in childhood and adolescence were associated with 26%-54% higher risks of diabetes in women. Those who had experienced forced sex once had a 34% higher risk of diabetes than were women who were not sexually abused as girls and a 69% higher risk when sexual abuse occurred more frequently. Even after accounting for adult body mass index, there remained a 10%-30% increased risk of diabetes among women who had experienced moderate physical abuse or the most severe forms of physical or sexual abuse (Am. J. Prev. Med. [doi:10.1016/j.amepre.2010.09.007]).

"The PAR [population attributable risk] percent derived from this model indicates that child/adolescent abuse accounted for 14% (7%-21%) of type 2 diabetes in this cohort. Applying the hazard ratio from this study to the 43% prevalence of any child or adolescent abuse reported by women in the National Violence Against Women Survey, an estimated 9% of diabetes in U.S. women may be attributed to early abuse," wrote Janet W. Rich-Edwards, Sc.D., and her colleagues.

An association consistently has been reported between child abuse and adult obesity. Studies indicate "that early trauma may cause lasting dysregulated responsivity, which may link child abuse with diabetes through physiologic pathways independent of adiposity," wrote Dr. Rich-Edwards, director of developmental epidemiology at the Connors Center for Women’s Health and Gender Biology at Brigham and Women’s Hospital, Boston, and her colleagues. However, the association between childhood abuse and adult diabetes has not been studied before in a large population.

The new findings highlight the importance of recognizing abuse in children and adolescents and asking adults about a history of abuse, according to Dr. Lawrence S. Phillips, a professor of endocrinology at Emory University, Atlanta.

Physicians need to be aware that "there are not only emotional and behavioral consequences of abuse in childhood and adolescence; there are physical consequences as well," he said in an interview. "We need to be much more sensitive to issues of abuse and in the history, because they demonstrably now have mental and physical downstream impacts."

For this study, the researchers used data from the Nurses Health Study II (NHSII), a cohort of 116,430 registered nurses, who were aged 25-42 years when the cohort was established in 1989. The cohort has been followed by biennial mailed questionnaires, which inquire about risk factors and disease incidence.

In 2001, a violence questionnaire was added to this large longitudinal cohort study of women. Participants returned 68,376 violence questionnaires; 67,853 were included in this analysis.

A total of 2,074 cases of type 2 diabetes were accrued from 1989 to 2005, and 759 incident cases occurred after the violence questionnaire was administered in 2001. All of the cases (2,833) were included in the analysis to maximize power. Data were analyzed in 2009, after diagnoses of diabetes reported on the 2005 questionnaire were reviewed and coded.

The Violence Questionnaire covers three periods: childhood (up to age 11 years), adolescence (11-17 years), and adulthood. Childhood and adolescent physical abuse was assessed through an adaptation of the Revised Conflict Tactics Scale. Physical abuse during childhood was categorized into four groups: no physical abuse (none); being "pushed, grabbed, or shoved" at any frequency or being "kicked, bitten, or punched" once or "hit with something" once (mild); being "hit with something" more than once or "physically attacked" once (moderate); being "kicked, bitten, or punched" or "physically attacked" more than once or ever "choked or burned" (severe). Spanking was not included.

Child and adolescent sexual abuse was measured by questions about unwanted sexual touching and forced sexual activity. Exposure was categorized into four groups: no sexual abuse; unwanted sexual touching only; forced sexual activity once; and forced sexual activity more than once. Adult experiences of abuse were measured on the violence questionnaire with questions adapted from the McFarlane Abuse Assessment Screen.

In this cohort, 65% of participants reported any degree of physical or sexual abuse in childhood or adolescence, which was associated with a 24% increased risk of type 2 diabetes in adulthood, even after adjustment for age, race/ethnicity, body type at 5 years, and maternal/paternal education and history of diabetes.

A dose-response association was found between physical abuse and risk of diabetes. However, this was somewhat attenuated by adjustment for race, maternal and paternal education, maternal and paternal diabetes, and somatotype at age 5.

Physical and sexual abuse interacted on an additive scale but not on a multiplicative scale, indicating that the absolute risk of diabetes was greater among women who had experienced both forms of abuse than would be expected from the risk of sexual or physical abuse alone, according to Dr. Rich-Edwards and her coauthors.

At age 5 years, little difference was found between the somatotypes of girls who did and did not report later abuse. By the age of 18 years, however, the BMI trajectories of abused girls had begun to diverge. By ages 25-42 years, a marked trend was found of increasing BMI with more severe abuse history.

Adjustment for adult smoking, alcohol use, and BMI weakened, but did not eliminate the dose-response associations of child and teen abuse with risk of adult diabetes. The attenuation was attributable almost entirely to adjustment for adult BMI, which accounted for 60% and 64% of the associations of physical and sexual abuse respectively with diabetes.

Despite adjustment, moderate physical abuse, severe physical abuse, and repeated forced sex remained independently associated with significantly increased risks of diabetes of 12%, 21%, and 28%, respectively.

Moderate and severe physical abuse were associated with 26%-54% higher risks of diabetes in maturity. Unwanted sexual touching was associated with 16% higher risk of diabetes, and forced sexual activity before adulthood carried a 34% greater risk when it occurred once and a 69% greater risk when it occurred more frequently. Child and teen abuse predicted later diabetes even among women who reported no adult physical or sexual abuse.

"The high prevalence of child abuse suggests that it is an important, if overlooked, contributor to type 2 diabetes ... A more precise description of the physiologic and psychological mechanisms through which abuse leads to overweight and obesity would help to focus prevention efforts. Weight-control interventions designed specifically for survivors of abuse may help to reduce the risk of diabetes," the investigators concluded.

Dr. Phillips agreed. "If an individual [with a history of abuse] is heavy or is gaining weight or is physically inactive, we need to try to intervene – recognizing that those kinds of changes in these individuals will predispose them to the development of diabetes more than perhaps the general population."

The authors reported no financial disclosures.

Certain infectious diseases can concentrate in impoverished areas and disproportionately affect minorities, women, and other disadvantaged groups, according to Dr. Paul T. Cantey.

Clinicians often receive little training on infectious diseases seen in these areas, which include tribal lands and border regions in the southwestern United States, the Mississippi delta, the cotton belt, Appalachia, and some dense urban areas.

Dr. Cantey outlined the diagnosis and treatment of three of these diseases – Chagas disease, toxocariasis, and trichomoniasis – during a teleconference sponsored by the Centers for Disease Control and Prevention. Dr. Cantey is a medical officer in the CDC's division of parasitic diseases and malaria.

Chagas disease

Photo credit: travfotos/flickr (Creative Commons)

Chagas disease is caused by the protozoan parasite Trypanosoma cruzi. The primary mode of transmission is through infected triatomine bugs. Other modes of transmission include blood transfusion, organ and tissue transplantation, congenital infection, laboratory accidents, and food.

Chagas disease is endemic in much of Latin America. However, both the parasite and the triatomine bug are found in the United States. It's estimated that there are at least 300,000 infected Latin American immigrants living in the United States. California, Florida, and Texas are disproportionately affected. Other geographic concentrations include Arizona, Georgia, Illinois, North Carolina, New York, and Virginia.

Blood donor screening for T. cruzi started in early 2007. Since then 1,267 infected donors have been identified. More than 40 of these individuals had no recognized risk factors.

The acute phase of the disease lasts 4-8 weeks. Patients are usually asymptomatic during this period. An estimated 10%-20% of infected individuals may have nonspecific febrile illness. Romana’s sign (chagoma) occurs less frequently.

The chronic phase is lifelong and may be asymptomatic and indeterminate in form. Approximately 20%-30% of infected individuals will manifest symptomatic disease – heart failure, sudden death, stroke, or organomegaly.

Testing for Chagas disease is available through the CDC, Dr. Cantey said. For acute infection, a blood smear, hemoculture, and polymerase chain reaction (PCR) tests are useful. For chronic infection, serologic tests are useful. However, there is no preferred test.

Tests for acute infection are sensitive, but the acute phase often is not recognized. Tests for chronic infection have issues with sensitivity and specificity, and usually positive results from two different tests are needed for diagnosis.

Nifurtimox or benznidazole are used for treatment, although neither drug is approved by the Food and Drug Administration. Both are available through CDC's investigational new drug protocol for compassionate use. Data on the efficacy of these two drugs for the treatment of chronic infection are still evolving. Side effects are frequent, especially in adults, and require monitoring. Side effects include anorexia and weight loss, nausea and vomiting, insomnia, convulsions, headache, myalgias and arthralgias, mucosal edema, hepatic intolerance, and skin manifestations. Yearly physicals should be performed, along with an ECG with a rhythm strip.

Treatment should always be offered for acute infections, congenital disease, and for children and adolescents 18 years and younger with chronic infection, and immunocompromised patients with reactivation, said Dr. Cantey. Treatment generally should be offered to women of reproductive age, adults aged 50 years and younger with indeterminate form disease or with mild to moderate cardiomyopathy, and to patients in whom immunosuppression is anticipated.

Treatment generally should not be offered to patients with advanced cardiomyopathy with congestive heart failure and patients with impairment of swallowing. Treatment should almost never be offered during pregnancy or to patients with severe renal or hepatic insufficiency, Dr. Cantey said.

Toxocariasis

Toxocariasis in humans is caused by infection with larval stages of dog/cat roundworm. Toxocara eggs are shed in dog and cat feces, and humans become infected through ingestion. Larvae migrate and encyst in humans but do not develop into adults or reproduce in humans.

According to data from the National Health and Nutrition Examination Survey (NHANES), approximately 14% of the U.S. population is infected. The highest prevalence is in the southern United States (less than 17%). Toxocariasis affects non-Hispanic blacks more than other groups and is associated with poverty, low education level, and dog ownership.

Many infected individuals are asymptomatic, said Dr. Cantey. In children, symptoms include fever, headache, behavioral and sleep disturbances, cough, anorexia, abdominal pain, hepatomegaly, nausea, and vomiting. Eosinophils may or may not be present. In adults, symptoms include chronic dyspnea, weakness, rash, pruritus, and abdominal pain. Eosinophilia is often present in adults.

Visceral toxocariasis typically occurs in children aged 2-7 years. Symptoms include fever, lower respiratory symptoms, hepatomegaly, abdominal pain, and anorexia. Other symptoms are specific to organ involved and include hepatic granulomas, chronic prurigo, pruritus, urticaria, eczema, vasculitis, eosinophilic meningitis or encephalitis, myelitis, optic neuritis, radiculitis, cranial nerve palsy, and, less commonly, myocarditis, nephrotic syndrome, and arthritis. Laboratory test results show marked eosinophilia, anemia, hypergammaglobulinemia, and increased titers to A and B blood group antigens.

Ocular toxocariasis typically occurs in 5- to 10-year-olds. Usually a single eye is affected. Symptoms include strabismus, unilateral decreased vision, and leukokoria.

Enzyme-linked immunosorbent assay (ELISA) is 78% sensitive and 92% specific for the diagnosis of visceral toxocariasis. However, the sensitivity is lower for ocular toxocariasis. The disease cannot be diagnosed from stool, as the eggs are not excreted by humans, said Dr. Cantey.

Mild toxocariasis often does not need treatment. Visceral disease is treated with 5 days of albendazole; corticosteroids may be used for allergic symptoms. Ocular toxocariasis is treated with 2-4 weeks of albendazole, along with aggressive anti-inflammatory treatment with corticosteroids, and surgery. Albendazole is not approved by the FDA for this indication.

Trichomoniasis

Trichomonas vaginalis is a parasite that is spread through sexual contact. It’s estimated that there are 5-7 million cases yearly in the United States. However, the prevalence may be as great as 20 million. The rate is 10-fold greater among black women, compared with non-Hispanic white women (13.3% vs. 1.3% respectively).

Patients with trichomoniasis can be asymptomatic. In women, symptoms include vaginal discharge, pruritus, and dysuria; in men, symptoms include urethral discharge and dysuria.

Physical examination may reveal mucopurulent discharge, "strawberry cervix" (colpitis macularis), cervical erythema, or cervical friability.

T. vaginalis infection can cause premature rupture of membranes in pregnant women, preterm birth, low birth weight, pelvic inflammatory diseases, and increased susceptibility to HIV transmission.

In terms of diagnosis, wet preparation examination is only 60%-70% sensitive in women. Two point-of-care tests (OSOM Trichomonas Rapid Test and Affirm VP III) are available. These tests, performed on vaginal secretions, are more than 83% sensitive and more than 97% specific. Pap smears are not recommended for Trichomonas screening. In men, wet preparation of urethral discharge, prostatic secretions, or urethral scrapings is of uncertain sensitivity. Instead, PCR or culture on special media should be used.

Trichomoniasis is treated with metronidazole or tinidazole. If treatment with 2 g metronidazole given once fails (and reinfection is excluded), then patients should be treated with 500 g metronidazole twice daily for 7 days or with 2 g tinidazole once. If either therapy fails, then treat with 2 g metronidazole or 2 g tinidazole daily for 5 days. If this treatment fails, consult the CDC for testing and management. Sex partners of patients should be treated to prevent reinfection.

Metronidazole is pregnancy category B and tinidazole is pregnancy category C. Asymptomatic pregnant women should be counseled about the risks and benefits of treatment, Dr. Cantey noted.

Certain infectious diseases can concentrate in impoverished areas and disproportionately affect minorities, women, and other disadvantaged groups, according to Dr. Paul T. Cantey.

Clinicians often receive little training on infectious diseases seen in these areas, which include tribal lands and border regions in the southwestern United States, the Mississippi delta, the cotton belt, Appalachia, and some dense urban areas.

Dr. Cantey outlined the diagnosis and treatment of three of these diseases – Chagas disease, toxocariasis, and trichomoniasis – during a teleconference sponsored by the Centers for Disease Control and Prevention. Dr. Cantey is a medical officer in the CDC's division of parasitic diseases and malaria.

Chagas disease

Photo credit: travfotos/flickr (Creative Commons)

Chagas disease is caused by the protozoan parasite Trypanosoma cruzi. The primary mode of transmission is through infected triatomine bugs. Other modes of transmission include blood transfusion, organ and tissue transplantation, congenital infection, laboratory accidents, and food.

Chagas disease is endemic in much of Latin America. However, both the parasite and the triatomine bug are found in the United States. It's estimated that there are at least 300,000 infected Latin American immigrants living in the United States. California, Florida, and Texas are disproportionately affected. Other geographic concentrations include Arizona, Georgia, Illinois, North Carolina, New York, and Virginia.

Blood donor screening for T. cruzi started in early 2007. Since then 1,267 infected donors have been identified. More than 40 of these individuals had no recognized risk factors.

The acute phase of the disease lasts 4-8 weeks. Patients are usually asymptomatic during this period. An estimated 10%-20% of infected individuals may have nonspecific febrile illness. Romana’s sign (chagoma) occurs less frequently.

The chronic phase is lifelong and may be asymptomatic and indeterminate in form. Approximately 20%-30% of infected individuals will manifest symptomatic disease – heart failure, sudden death, stroke, or organomegaly.

Testing for Chagas disease is available through the CDC, Dr. Cantey said. For acute infection, a blood smear, hemoculture, and polymerase chain reaction (PCR) tests are useful. For chronic infection, serologic tests are useful. However, there is no preferred test.

Tests for acute infection are sensitive, but the acute phase often is not recognized. Tests for chronic infection have issues with sensitivity and specificity, and usually positive results from two different tests are needed for diagnosis.

Nifurtimox or benznidazole are used for treatment, although neither drug is approved by the Food and Drug Administration. Both are available through CDC's investigational new drug protocol for compassionate use. Data on the efficacy of these two drugs for the treatment of chronic infection are still evolving. Side effects are frequent, especially in adults, and require monitoring. Side effects include anorexia and weight loss, nausea and vomiting, insomnia, convulsions, headache, myalgias and arthralgias, mucosal edema, hepatic intolerance, and skin manifestations. Yearly physicals should be performed, along with an ECG with a rhythm strip.

Treatment should always be offered for acute infections, congenital disease, and for children and adolescents 18 years and younger with chronic infection, and immunocompromised patients with reactivation, said Dr. Cantey. Treatment generally should be offered to women of reproductive age, adults aged 50 years and younger with indeterminate form disease or with mild to moderate cardiomyopathy, and to patients in whom immunosuppression is anticipated.

Treatment generally should not be offered to patients with advanced cardiomyopathy with congestive heart failure and patients with impairment of swallowing. Treatment should almost never be offered during pregnancy or to patients with severe renal or hepatic insufficiency, Dr. Cantey said.

Toxocariasis

Toxocariasis in humans is caused by infection with larval stages of dog/cat roundworm. Toxocara eggs are shed in dog and cat feces, and humans become infected through ingestion. Larvae migrate and encyst in humans but do not develop into adults or reproduce in humans.

According to data from the National Health and Nutrition Examination Survey (NHANES), approximately 14% of the U.S. population is infected. The highest prevalence is in the southern United States (less than 17%). Toxocariasis affects non-Hispanic blacks more than other groups and is associated with poverty, low education level, and dog ownership.

Many infected individuals are asymptomatic, said Dr. Cantey. In children, symptoms include fever, headache, behavioral and sleep disturbances, cough, anorexia, abdominal pain, hepatomegaly, nausea, and vomiting. Eosinophils may or may not be present. In adults, symptoms include chronic dyspnea, weakness, rash, pruritus, and abdominal pain. Eosinophilia is often present in adults.

Visceral toxocariasis typically occurs in children aged 2-7 years. Symptoms include fever, lower respiratory symptoms, hepatomegaly, abdominal pain, and anorexia. Other symptoms are specific to organ involved and include hepatic granulomas, chronic prurigo, pruritus, urticaria, eczema, vasculitis, eosinophilic meningitis or encephalitis, myelitis, optic neuritis, radiculitis, cranial nerve palsy, and, less commonly, myocarditis, nephrotic syndrome, and arthritis. Laboratory test results show marked eosinophilia, anemia, hypergammaglobulinemia, and increased titers to A and B blood group antigens.

Ocular toxocariasis typically occurs in 5- to 10-year-olds. Usually a single eye is affected. Symptoms include strabismus, unilateral decreased vision, and leukokoria.

Enzyme-linked immunosorbent assay (ELISA) is 78% sensitive and 92% specific for the diagnosis of visceral toxocariasis. However, the sensitivity is lower for ocular toxocariasis. The disease cannot be diagnosed from stool, as the eggs are not excreted by humans, said Dr. Cantey.

Mild toxocariasis often does not need treatment. Visceral disease is treated with 5 days of albendazole; corticosteroids may be used for allergic symptoms. Ocular toxocariasis is treated with 2-4 weeks of albendazole, along with aggressive anti-inflammatory treatment with corticosteroids, and surgery. Albendazole is not approved by the FDA for this indication.

Trichomoniasis

Trichomonas vaginalis is a parasite that is spread through sexual contact. It’s estimated that there are 5-7 million cases yearly in the United States. However, the prevalence may be as great as 20 million. The rate is 10-fold greater among black women, compared with non-Hispanic white women (13.3% vs. 1.3% respectively).

Patients with trichomoniasis can be asymptomatic. In women, symptoms include vaginal discharge, pruritus, and dysuria; in men, symptoms include urethral discharge and dysuria.

Physical examination may reveal mucopurulent discharge, "strawberry cervix" (colpitis macularis), cervical erythema, or cervical friability.

T. vaginalis infection can cause premature rupture of membranes in pregnant women, preterm birth, low birth weight, pelvic inflammatory diseases, and increased susceptibility to HIV transmission.

In terms of diagnosis, wet preparation examination is only 60%-70% sensitive in women. Two point-of-care tests (OSOM Trichomonas Rapid Test and Affirm VP III) are available. These tests, performed on vaginal secretions, are more than 83% sensitive and more than 97% specific. Pap smears are not recommended for Trichomonas screening. In men, wet preparation of urethral discharge, prostatic secretions, or urethral scrapings is of uncertain sensitivity. Instead, PCR or culture on special media should be used.

Trichomoniasis is treated with metronidazole or tinidazole. If treatment with 2 g metronidazole given once fails (and reinfection is excluded), then patients should be treated with 500 g metronidazole twice daily for 7 days or with 2 g tinidazole once. If either therapy fails, then treat with 2 g metronidazole or 2 g tinidazole daily for 5 days. If this treatment fails, consult the CDC for testing and management. Sex partners of patients should be treated to prevent reinfection.

Metronidazole is pregnancy category B and tinidazole is pregnancy category C. Asymptomatic pregnant women should be counseled about the risks and benefits of treatment, Dr. Cantey noted.

Certain infectious diseases can concentrate in impoverished areas and disproportionately affect minorities, women, and other disadvantaged groups, according to Dr. Paul T. Cantey.

Clinicians often receive little training on infectious diseases seen in these areas, which include tribal lands and border regions in the southwestern United States, the Mississippi delta, the cotton belt, Appalachia, and some dense urban areas.

Dr. Cantey outlined the diagnosis and treatment of three of these diseases – Chagas disease, toxocariasis, and trichomoniasis – during a teleconference sponsored by the Centers for Disease Control and Prevention. Dr. Cantey is a medical officer in the CDC's division of parasitic diseases and malaria.

Chagas disease

Photo credit: travfotos/flickr (Creative Commons)

Chagas disease is caused by the protozoan parasite Trypanosoma cruzi. The primary mode of transmission is through infected triatomine bugs. Other modes of transmission include blood transfusion, organ and tissue transplantation, congenital infection, laboratory accidents, and food.

Chagas disease is endemic in much of Latin America. However, both the parasite and the triatomine bug are found in the United States. It's estimated that there are at least 300,000 infected Latin American immigrants living in the United States. California, Florida, and Texas are disproportionately affected. Other geographic concentrations include Arizona, Georgia, Illinois, North Carolina, New York, and Virginia.

Blood donor screening for T. cruzi started in early 2007. Since then 1,267 infected donors have been identified. More than 40 of these individuals had no recognized risk factors.

The acute phase of the disease lasts 4-8 weeks. Patients are usually asymptomatic during this period. An estimated 10%-20% of infected individuals may have nonspecific febrile illness. Romana’s sign (chagoma) occurs less frequently.

The chronic phase is lifelong and may be asymptomatic and indeterminate in form. Approximately 20%-30% of infected individuals will manifest symptomatic disease – heart failure, sudden death, stroke, or organomegaly.

Testing for Chagas disease is available through the CDC, Dr. Cantey said. For acute infection, a blood smear, hemoculture, and polymerase chain reaction (PCR) tests are useful. For chronic infection, serologic tests are useful. However, there is no preferred test.

Tests for acute infection are sensitive, but the acute phase often is not recognized. Tests for chronic infection have issues with sensitivity and specificity, and usually positive results from two different tests are needed for diagnosis.

Nifurtimox or benznidazole are used for treatment, although neither drug is approved by the Food and Drug Administration. Both are available through CDC's investigational new drug protocol for compassionate use. Data on the efficacy of these two drugs for the treatment of chronic infection are still evolving. Side effects are frequent, especially in adults, and require monitoring. Side effects include anorexia and weight loss, nausea and vomiting, insomnia, convulsions, headache, myalgias and arthralgias, mucosal edema, hepatic intolerance, and skin manifestations. Yearly physicals should be performed, along with an ECG with a rhythm strip.

Treatment should always be offered for acute infections, congenital disease, and for children and adolescents 18 years and younger with chronic infection, and immunocompromised patients with reactivation, said Dr. Cantey. Treatment generally should be offered to women of reproductive age, adults aged 50 years and younger with indeterminate form disease or with mild to moderate cardiomyopathy, and to patients in whom immunosuppression is anticipated.

Treatment generally should not be offered to patients with advanced cardiomyopathy with congestive heart failure and patients with impairment of swallowing. Treatment should almost never be offered during pregnancy or to patients with severe renal or hepatic insufficiency, Dr. Cantey said.

Toxocariasis

Toxocariasis in humans is caused by infection with larval stages of dog/cat roundworm. Toxocara eggs are shed in dog and cat feces, and humans become infected through ingestion. Larvae migrate and encyst in humans but do not develop into adults or reproduce in humans.

According to data from the National Health and Nutrition Examination Survey (NHANES), approximately 14% of the U.S. population is infected. The highest prevalence is in the southern United States (less than 17%). Toxocariasis affects non-Hispanic blacks more than other groups and is associated with poverty, low education level, and dog ownership.

Many infected individuals are asymptomatic, said Dr. Cantey. In children, symptoms include fever, headache, behavioral and sleep disturbances, cough, anorexia, abdominal pain, hepatomegaly, nausea, and vomiting. Eosinophils may or may not be present. In adults, symptoms include chronic dyspnea, weakness, rash, pruritus, and abdominal pain. Eosinophilia is often present in adults.

Visceral toxocariasis typically occurs in children aged 2-7 years. Symptoms include fever, lower respiratory symptoms, hepatomegaly, abdominal pain, and anorexia. Other symptoms are specific to organ involved and include hepatic granulomas, chronic prurigo, pruritus, urticaria, eczema, vasculitis, eosinophilic meningitis or encephalitis, myelitis, optic neuritis, radiculitis, cranial nerve palsy, and, less commonly, myocarditis, nephrotic syndrome, and arthritis. Laboratory test results show marked eosinophilia, anemia, hypergammaglobulinemia, and increased titers to A and B blood group antigens.

Ocular toxocariasis typically occurs in 5- to 10-year-olds. Usually a single eye is affected. Symptoms include strabismus, unilateral decreased vision, and leukokoria.

Enzyme-linked immunosorbent assay (ELISA) is 78% sensitive and 92% specific for the diagnosis of visceral toxocariasis. However, the sensitivity is lower for ocular toxocariasis. The disease cannot be diagnosed from stool, as the eggs are not excreted by humans, said Dr. Cantey.

Mild toxocariasis often does not need treatment. Visceral disease is treated with 5 days of albendazole; corticosteroids may be used for allergic symptoms. Ocular toxocariasis is treated with 2-4 weeks of albendazole, along with aggressive anti-inflammatory treatment with corticosteroids, and surgery. Albendazole is not approved by the FDA for this indication.

Trichomoniasis

Trichomonas vaginalis is a parasite that is spread through sexual contact. It’s estimated that there are 5-7 million cases yearly in the United States. However, the prevalence may be as great as 20 million. The rate is 10-fold greater among black women, compared with non-Hispanic white women (13.3% vs. 1.3% respectively).

Patients with trichomoniasis can be asymptomatic. In women, symptoms include vaginal discharge, pruritus, and dysuria; in men, symptoms include urethral discharge and dysuria.

Physical examination may reveal mucopurulent discharge, "strawberry cervix" (colpitis macularis), cervical erythema, or cervical friability.

T. vaginalis infection can cause premature rupture of membranes in pregnant women, preterm birth, low birth weight, pelvic inflammatory diseases, and increased susceptibility to HIV transmission.

In terms of diagnosis, wet preparation examination is only 60%-70% sensitive in women. Two point-of-care tests (OSOM Trichomonas Rapid Test and Affirm VP III) are available. These tests, performed on vaginal secretions, are more than 83% sensitive and more than 97% specific. Pap smears are not recommended for Trichomonas screening. In men, wet preparation of urethral discharge, prostatic secretions, or urethral scrapings is of uncertain sensitivity. Instead, PCR or culture on special media should be used.

Trichomoniasis is treated with metronidazole or tinidazole. If treatment with 2 g metronidazole given once fails (and reinfection is excluded), then patients should be treated with 500 g metronidazole twice daily for 7 days or with 2 g tinidazole once. If either therapy fails, then treat with 2 g metronidazole or 2 g tinidazole daily for 5 days. If this treatment fails, consult the CDC for testing and management. Sex partners of patients should be treated to prevent reinfection.

Metronidazole is pregnancy category B and tinidazole is pregnancy category C. Asymptomatic pregnant women should be counseled about the risks and benefits of treatment, Dr. Cantey noted.

Certain infectious diseases can concentrate in impoverished areas and disproportionately affect minorities, women, and other disadvantaged groups, according to Dr. Paul T. Cantey.

Clinicians often receive little training on infectious diseases seen in these areas, which include tribal lands and border regions in the southwestern United States, the Mississippi delta, the cotton belt, Appalachia, and some dense urban areas.

Dr. Cantey outlined the diagnosis and treatment of three of these diseases – Chagas disease, toxocariasis, and trichomoniasis – during a teleconference sponsored by the Centers for Disease Control and Prevention. Dr. Cantey is a medical officer in the CDC’s division of parasitic diseases and malaria.

Chagas disease

Chagas disease is caused by the protozoan parasite Trypanosoma cruzi. The primary mode of transmission is through infected triatomine bugs. Other modes of transmission include blood transfusion, organ and tissue transplantation, congenital infection, laboratory accidents, and food.

Photo credit: travfotos/flickr (Creative Commons)

Chagas disease is endemic in much of Latin America. However, both the parasite and the triatomine bug are found in the United States. It’s estimated that there are at least 300,000 infected Latin American immigrants living in the United States. California, Florida, and Texas are disproportionately affected. Other geographic concentrations include Arizona, Georgia, Illinois, North Carolina, New York, and Virginia.

Blood donor screening for T. cruzi started in early 2007. Since then 1,267 infected donors have been identified. More than 40 of these individuals had no recognized risk factors.

The acute phase of the disease lasts 4-8 weeks. Patients are usually asymptomatic during this period. An estimated 10%-20% of infected individuals may have nonspecific febrile illness. Romaña’s sign (chagoma) occurs less frequently.

The chronic phase is lifelong and may be asymptomatic and indeterminate in form. Approximately 20%-30% of infected individuals will manifest symptomatic disease – heart failure, sudden death, stroke, or organomegaly.

Testing for Chagas disease is available through the CDC, Dr. Cantey said. For acute infection, a blood smear, hemoculture, and polymerase chain reaction (PCR) tests are useful. For chronic infection, serologic tests are useful. However, there is no preferred test.

Tests for acute infection are sensitive, but the acute phase often is not recognized. Tests for chronic infection have issues with sensitivity and specificity, and usually positive results from two different tests are needed for diagnosis.

Nifurtimox or benznidazole are used for treatment, although neither drug is approved by the Food and Drug Administration. Both are available through CDC’s investigational new drug protocol for compassionate use. Data on the efficacy of these two drugs for the treatment of chronic infection are still evolving. Side effects are frequent, especially in adults, and require monitoring. Side effects include anorexia and weight loss, nausea and vomiting, insomnia, convulsions, headache, myalgias and arthralgias, mucosal edema, hepatic intolerance, and skin manifestations. Yearly physicals should be performed, along with an ECG with a rhythm strip.

Treatment should always be offered for acute infections, congenital disease, and for children and adolescents 18 years and younger with chronic infection, and immunocompromised patients with reactivation, said Dr. Cantey. Treatment generally should be offered to women of reproductive age, adults aged 50 years and younger with indeterminate form disease or with mild to moderate cardiomyopathy, and to patients in whom immunosuppression is anticipated.

Treatment generally should not be offered to patients with advanced cardiomyopathy with congestive heart failure and patients with impairment of swallowing. Treatment should almost never be offered during pregnancy or to patients with severe renal or hepatic insufficiency, Dr. Cantey said.

Toxocariasis

Toxocariasis in humans is caused by infection with larval stages of dog/cat roundworm. Toxocara eggs are shed in dog and cat feces, and humans become infected through ingestion. Larvae migrate and encyst in humans but do not develop into adults or reproduce in humans.

According to data from the National Health and Nutrition Examination Survey (NHANES), approximately 14% of the U.S. population is infected. The highest prevalence is in the southern United States (less than 17%). Toxocariasis affects non-Hispanic blacks more than other groups and is associated with poverty, low education level, and dog ownership.

Many infected individuals are asymptomatic, said Dr. Cantey. In children, symptoms include fever, headache, behavioral and sleep disturbances, cough, anorexia, abdominal pain, hepatomegaly, nausea, and vomiting. Eosinophils may or may not be present. In adults, symptoms include chronic dyspnea, weakness, rash, pruritus, and abdominal pain. Eosinophilia is often present in adults.

Visceral toxocariasis typically occurs in children aged 2-7 years. Symptoms include fever, lower respiratory symptoms, hepatomegaly, abdominal pain, and anorexia. Other symptoms are specific to organ involved and include hepatic granulomas, chronic prurigo, pruritus, urticaria, eczema, vasculitis, eosinophilic meningitis or encephalitis, myelitis, optic neuritis, radiculitis, cranial nerve palsy, and, less commonly, myocarditis, nephrotic syndrome, and arthritis. Laboratory test results show marked eosinophilia, anemia, hypergammaglobulinemia, and increased titers to A and B blood group antigens.

Ocular toxocariasis typically occurs in 5- to 10-year-olds. Usually a single eye is affected. Symptoms include strabismus, unilateral decreased vision, and leukokoria.

Enzyme-linked immunosorbent assay (ELISA) is 78% sensitive and 92% specific for the diagnosis of visceral toxocariasis. However, the sensitivity is lower for ocular toxocariasis. The disease cannot be diagnosed from stool, as the eggs are not excreted by humans, said Dr. Cantey.

Mild toxocariasis often does not need treatment. Visceral disease is treated with 5 days of albendazole; corticosteroids may be used for allergic symptoms. Ocular toxocariasis is treated with 2-4 weeks of albendazole, along with aggressive anti-inflammatory treatment with corticosteroids, and surgery. Albendazole is not approved by the FDA for this indication.

Trichomoniasis

Trichomonas vaginalis is a parasite that is spread through sexual contact. It’s estimated that there are 5-7 million cases yearly in the United States. However, the prevalence may be as great as 20 million. The rate is 10-fold greater among black women, compared with non-Hispanic white women (13.3% vs. 1.3% respectively).

Patients with trichomoniasis can be asymptomatic. In women, symptoms include vaginal discharge, pruritus, and dysuria; in men, symptoms include urethral discharge and dysuria.

Physical examination may reveal mucopurulent discharge, "strawberry cervix" (colpitis macularis), cervical erythema, or cervical friability.

T. vaginalis infection can cause premature rupture of membranes in pregnant women, preterm birth, low birth weight, pelvic inflammatory diseases, and increased susceptibility to HIV transmission.

In terms of diagnosis, wet preparation examination is only 60%-70% sensitive in women. Two point-of-care tests (OSOM Trichomonas Rapid Test and Affirm VP III) are available. These tests, performed on vaginal secretions, are more than 83% sensitive and more than 97% specific. Pap smears are not recommended for Trichomonas screening. In men, wet preparation of urethral discharge, prostatic secretions, or urethral scrapings is of uncertain sensitivity. Instead, PCR or culture on special media should be used.

Trichomoniasis is treated with metronidazole or tinidazole. If treatment with 2 g metronidazole given once fails (and reinfection is excluded), then patients should be treated with 500 g metronidazole twice daily for 7 days or with 2 g tinidazole once. If either therapy fails, then treat with 2 g metronidazole or 2 g tinidazole daily for 5 days. If this treatment fails, consult the CDC for testing and management. Sex partners of patients should be treated to prevent reinfection.

Metronidazole is pregnancy category B and tinidazole is pregnancy category C. Asymptomatic pregnant women should be counseled about the risks and benefits of treatment, Dr. Cantey noted.

Certain infectious diseases can concentrate in impoverished areas and disproportionately affect minorities, women, and other disadvantaged groups, according to Dr. Paul T. Cantey.

Clinicians often receive little training on infectious diseases seen in these areas, which include tribal lands and border regions in the southwestern United States, the Mississippi delta, the cotton belt, Appalachia, and some dense urban areas.

Dr. Cantey outlined the diagnosis and treatment of three of these diseases – Chagas disease, toxocariasis, and trichomoniasis – during a teleconference sponsored by the Centers for Disease Control and Prevention. Dr. Cantey is a medical officer in the CDC’s division of parasitic diseases and malaria.

Chagas disease

Chagas disease is caused by the protozoan parasite Trypanosoma cruzi. The primary mode of transmission is through infected triatomine bugs. Other modes of transmission include blood transfusion, organ and tissue transplantation, congenital infection, laboratory accidents, and food.

Photo credit: travfotos/flickr (Creative Commons)

Chagas disease is endemic in much of Latin America. However, both the parasite and the triatomine bug are found in the United States. It’s estimated that there are at least 300,000 infected Latin American immigrants living in the United States. California, Florida, and Texas are disproportionately affected. Other geographic concentrations include Arizona, Georgia, Illinois, North Carolina, New York, and Virginia.

Blood donor screening for T. cruzi started in early 2007. Since then 1,267 infected donors have been identified. More than 40 of these individuals had no recognized risk factors.

The acute phase of the disease lasts 4-8 weeks. Patients are usually asymptomatic during this period. An estimated 10%-20% of infected individuals may have nonspecific febrile illness. Romaña’s sign (chagoma) occurs less frequently.

The chronic phase is lifelong and may be asymptomatic and indeterminate in form. Approximately 20%-30% of infected individuals will manifest symptomatic disease – heart failure, sudden death, stroke, or organomegaly.

Testing for Chagas disease is available through the CDC, Dr. Cantey said. For acute infection, a blood smear, hemoculture, and polymerase chain reaction (PCR) tests are useful. For chronic infection, serologic tests are useful. However, there is no preferred test.

Tests for acute infection are sensitive, but the acute phase often is not recognized. Tests for chronic infection have issues with sensitivity and specificity, and usually positive results from two different tests are needed for diagnosis.

Nifurtimox or benznidazole are used for treatment, although neither drug is approved by the Food and Drug Administration. Both are available through CDC’s investigational new drug protocol for compassionate use. Data on the efficacy of these two drugs for the treatment of chronic infection are still evolving. Side effects are frequent, especially in adults, and require monitoring. Side effects include anorexia and weight loss, nausea and vomiting, insomnia, convulsions, headache, myalgias and arthralgias, mucosal edema, hepatic intolerance, and skin manifestations. Yearly physicals should be performed, along with an ECG with a rhythm strip.

Treatment should always be offered for acute infections, congenital disease, and for children and adolescents 18 years and younger with chronic infection, and immunocompromised patients with reactivation, said Dr. Cantey. Treatment generally should be offered to women of reproductive age, adults aged 50 years and younger with indeterminate form disease or with mild to moderate cardiomyopathy, and to patients in whom immunosuppression is anticipated.

Treatment generally should not be offered to patients with advanced cardiomyopathy with congestive heart failure and patients with impairment of swallowing. Treatment should almost never be offered during pregnancy or to patients with severe renal or hepatic insufficiency, Dr. Cantey said.

Toxocariasis

Toxocariasis in humans is caused by infection with larval stages of dog/cat roundworm. Toxocara eggs are shed in dog and cat feces, and humans become infected through ingestion. Larvae migrate and encyst in humans but do not develop into adults or reproduce in humans.

According to data from the National Health and Nutrition Examination Survey (NHANES), approximately 14% of the U.S. population is infected. The highest prevalence is in the southern United States (less than 17%). Toxocariasis affects non-Hispanic blacks more than other groups and is associated with poverty, low education level, and dog ownership.

Many infected individuals are asymptomatic, said Dr. Cantey. In children, symptoms include fever, headache, behavioral and sleep disturbances, cough, anorexia, abdominal pain, hepatomegaly, nausea, and vomiting. Eosinophils may or may not be present. In adults, symptoms include chronic dyspnea, weakness, rash, pruritus, and abdominal pain. Eosinophilia is often present in adults.

Visceral toxocariasis typically occurs in children aged 2-7 years. Symptoms include fever, lower respiratory symptoms, hepatomegaly, abdominal pain, and anorexia. Other symptoms are specific to organ involved and include hepatic granulomas, chronic prurigo, pruritus, urticaria, eczema, vasculitis, eosinophilic meningitis or encephalitis, myelitis, optic neuritis, radiculitis, cranial nerve palsy, and, less commonly, myocarditis, nephrotic syndrome, and arthritis. Laboratory test results show marked eosinophilia, anemia, hypergammaglobulinemia, and increased titers to A and B blood group antigens.

Ocular toxocariasis typically occurs in 5- to 10-year-olds. Usually a single eye is affected. Symptoms include strabismus, unilateral decreased vision, and leukokoria.

Enzyme-linked immunosorbent assay (ELISA) is 78% sensitive and 92% specific for the diagnosis of visceral toxocariasis. However, the sensitivity is lower for ocular toxocariasis. The disease cannot be diagnosed from stool, as the eggs are not excreted by humans, said Dr. Cantey.

Mild toxocariasis often does not need treatment. Visceral disease is treated with 5 days of albendazole; corticosteroids may be used for allergic symptoms. Ocular toxocariasis is treated with 2-4 weeks of albendazole, along with aggressive anti-inflammatory treatment with corticosteroids, and surgery. Albendazole is not approved by the FDA for this indication.

Trichomoniasis

Trichomonas vaginalis is a parasite that is spread through sexual contact. It’s estimated that there are 5-7 million cases yearly in the United States. However, the prevalence may be as great as 20 million. The rate is 10-fold greater among black women, compared with non-Hispanic white women (13.3% vs. 1.3% respectively).

Patients with trichomoniasis can be asymptomatic. In women, symptoms include vaginal discharge, pruritus, and dysuria; in men, symptoms include urethral discharge and dysuria.

Physical examination may reveal mucopurulent discharge, "strawberry cervix" (colpitis macularis), cervical erythema, or cervical friability.

T. vaginalis infection can cause premature rupture of membranes in pregnant women, preterm birth, low birth weight, pelvic inflammatory diseases, and increased susceptibility to HIV transmission.

In terms of diagnosis, wet preparation examination is only 60%-70% sensitive in women. Two point-of-care tests (OSOM Trichomonas Rapid Test and Affirm VP III) are available. These tests, performed on vaginal secretions, are more than 83% sensitive and more than 97% specific. Pap smears are not recommended for Trichomonas screening. In men, wet preparation of urethral discharge, prostatic secretions, or urethral scrapings is of uncertain sensitivity. Instead, PCR or culture on special media should be used.

Trichomoniasis is treated with metronidazole or tinidazole. If treatment with 2 g metronidazole given once fails (and reinfection is excluded), then patients should be treated with 500 g metronidazole twice daily for 7 days or with 2 g tinidazole once. If either therapy fails, then treat with 2 g metronidazole or 2 g tinidazole daily for 5 days. If this treatment fails, consult the CDC for testing and management. Sex partners of patients should be treated to prevent reinfection.

Metronidazole is pregnancy category B and tinidazole is pregnancy category C. Asymptomatic pregnant women should be counseled about the risks and benefits of treatment, Dr. Cantey noted.

Certain infectious diseases can concentrate in impoverished areas and disproportionately affect minorities, women, and other disadvantaged groups, according to Dr. Paul T. Cantey.

Clinicians often receive little training on infectious diseases seen in these areas, which include tribal lands and border regions in the southwestern United States, the Mississippi delta, the cotton belt, Appalachia, and some dense urban areas.

Dr. Cantey outlined the diagnosis and treatment of three of these diseases – Chagas disease, toxocariasis, and trichomoniasis – during a teleconference sponsored by the Centers for Disease Control and Prevention. Dr. Cantey is a medical officer in the CDC’s division of parasitic diseases and malaria.

Chagas disease

Chagas disease is caused by the protozoan parasite Trypanosoma cruzi. The primary mode of transmission is through infected triatomine bugs. Other modes of transmission include blood transfusion, organ and tissue transplantation, congenital infection, laboratory accidents, and food.

Photo credit: travfotos/flickr (Creative Commons)

Chagas disease is endemic in much of Latin America. However, both the parasite and the triatomine bug are found in the United States. It’s estimated that there are at least 300,000 infected Latin American immigrants living in the United States. California, Florida, and Texas are disproportionately affected. Other geographic concentrations include Arizona, Georgia, Illinois, North Carolina, New York, and Virginia.

Blood donor screening for T. cruzi started in early 2007. Since then 1,267 infected donors have been identified. More than 40 of these individuals had no recognized risk factors.

The acute phase of the disease lasts 4-8 weeks. Patients are usually asymptomatic during this period. An estimated 10%-20% of infected individuals may have nonspecific febrile illness. Romaña’s sign (chagoma) occurs less frequently.

The chronic phase is lifelong and may be asymptomatic and indeterminate in form. Approximately 20%-30% of infected individuals will manifest symptomatic disease – heart failure, sudden death, stroke, or organomegaly.

Testing for Chagas disease is available through the CDC, Dr. Cantey said. For acute infection, a blood smear, hemoculture, and polymerase chain reaction (PCR) tests are useful. For chronic infection, serologic tests are useful. However, there is no preferred test.

Tests for acute infection are sensitive, but the acute phase often is not recognized. Tests for chronic infection have issues with sensitivity and specificity, and usually positive results from two different tests are needed for diagnosis.

Nifurtimox or benznidazole are used for treatment, although neither drug is approved by the Food and Drug Administration. Both are available through CDC’s investigational new drug protocol for compassionate use. Data on the efficacy of these two drugs for the treatment of chronic infection are still evolving. Side effects are frequent, especially in adults, and require monitoring. Side effects include anorexia and weight loss, nausea and vomiting, insomnia, convulsions, headache, myalgias and arthralgias, mucosal edema, hepatic intolerance, and skin manifestations. Yearly physicals should be performed, along with an ECG with a rhythm strip.

Treatment should always be offered for acute infections, congenital disease, and for children and adolescents 18 years and younger with chronic infection, and immunocompromised patients with reactivation, said Dr. Cantey. Treatment generally should be offered to women of reproductive age, adults aged 50 years and younger with indeterminate form disease or with mild to moderate cardiomyopathy, and to patients in whom immunosuppression is anticipated.

Treatment generally should not be offered to patients with advanced cardiomyopathy with congestive heart failure and patients with impairment of swallowing. Treatment should almost never be offered during pregnancy or to patients with severe renal or hepatic insufficiency, Dr. Cantey said.

Toxocariasis

Toxocariasis in humans is caused by infection with larval stages of dog/cat roundworm. Toxocara eggs are shed in dog and cat feces, and humans become infected through ingestion. Larvae migrate and encyst in humans but do not develop into adults or reproduce in humans.

According to data from the National Health and Nutrition Examination Survey (NHANES), approximately 14% of the U.S. population is infected. The highest prevalence is in the southern United States (less than 17%). Toxocariasis affects non-Hispanic blacks more than other groups and is associated with poverty, low education level, and dog ownership.

Many infected individuals are asymptomatic, said Dr. Cantey. In children, symptoms include fever, headache, behavioral and sleep disturbances, cough, anorexia, abdominal pain, hepatomegaly, nausea, and vomiting. Eosinophils may or may not be present. In adults, symptoms include chronic dyspnea, weakness, rash, pruritus, and abdominal pain. Eosinophilia is often present in adults.

Visceral toxocariasis typically occurs in children aged 2-7 years. Symptoms include fever, lower respiratory symptoms, hepatomegaly, abdominal pain, and anorexia. Other symptoms are specific to organ involved and include hepatic granulomas, chronic prurigo, pruritus, urticaria, eczema, vasculitis, eosinophilic meningitis or encephalitis, myelitis, optic neuritis, radiculitis, cranial nerve palsy, and, less commonly, myocarditis, nephrotic syndrome, and arthritis. Laboratory test results show marked eosinophilia, anemia, hypergammaglobulinemia, and increased titers to A and B blood group antigens.

Ocular toxocariasis typically occurs in 5- to 10-year-olds. Usually a single eye is affected. Symptoms include strabismus, unilateral decreased vision, and leukokoria.

Enzyme-linked immunosorbent assay (ELISA) is 78% sensitive and 92% specific for the diagnosis of visceral toxocariasis. However, the sensitivity is lower for ocular toxocariasis. The disease cannot be diagnosed from stool, as the eggs are not excreted by humans, said Dr. Cantey.

Mild toxocariasis often does not need treatment. Visceral disease is treated with 5 days of albendazole; corticosteroids may be used for allergic symptoms. Ocular toxocariasis is treated with 2-4 weeks of albendazole, along with aggressive anti-inflammatory treatment with corticosteroids, and surgery. Albendazole is not approved by the FDA for this indication.

Trichomoniasis

Trichomonas vaginalis is a parasite that is spread through sexual contact. It’s estimated that there are 5-7 million cases yearly in the United States. However, the prevalence may be as great as 20 million. The rate is 10-fold greater among black women, compared with non-Hispanic white women (13.3% vs. 1.3% respectively).

Patients with trichomoniasis can be asymptomatic. In women, symptoms include vaginal discharge, pruritus, and dysuria; in men, symptoms include urethral discharge and dysuria.

Physical examination may reveal mucopurulent discharge, "strawberry cervix" (colpitis macularis), cervical erythema, or cervical friability.

T. vaginalis infection can cause premature rupture of membranes in pregnant women, preterm birth, low birth weight, pelvic inflammatory diseases, and increased susceptibility to HIV transmission.

In terms of diagnosis, wet preparation examination is only 60%-70% sensitive in women. Two point-of-care tests (OSOM Trichomonas Rapid Test and Affirm VP III) are available. These tests, performed on vaginal secretions, are more than 83% sensitive and more than 97% specific. Pap smears are not recommended for Trichomonas screening. In men, wet preparation of urethral discharge, prostatic secretions, or urethral scrapings is of uncertain sensitivity. Instead, PCR or culture on special media should be used.

Trichomoniasis is treated with metronidazole or tinidazole. If treatment with 2 g metronidazole given once fails (and reinfection is excluded), then patients should be treated with 500 g metronidazole twice daily for 7 days or with 2 g tinidazole once. If either therapy fails, then treat with 2 g metronidazole or 2 g tinidazole daily for 5 days. If this treatment fails, consult the CDC for testing and management. Sex partners of patients should be treated to prevent reinfection.

Metronidazole is pregnancy category B and tinidazole is pregnancy category C. Asymptomatic pregnant women should be counseled about the risks and benefits of treatment, Dr. Cantey noted.

Certain infectious diseases can concentrate in impoverished areas and disproportionately affect minorities, women, and other disadvantaged groups, according to Dr. Paul T. Cantey.

Clinicians often receive little training on infectious diseases seen in these areas, which include tribal lands and border regions in the southwestern United States, the Mississippi delta, the cotton belt, Appalachia, and some dense urban areas.

Dr. Cantey outlined the diagnosis and treatment of three of these diseases – Chagas disease, toxocariasis, and trichomoniasis – during a teleconference sponsored by the Centers for Disease Control and Prevention. Dr. Cantey is a medical officer in the CDC’s division of parasitic diseases and malaria.

Chagas disease

Chagas disease is caused by the protozoan parasite Trypanosoma cruzi. The primary mode of transmission is through infected triatomine bugs. Other modes of transmission include blood transfusion, organ and tissue transplantation, congenital infection, laboratory accidents, and food.

Photo credit: travfotos/flickr (Creative Commons)

Chagas disease is endemic in much of Latin America. However, both the parasite and the triatomine bug are found in the United States. It’s estimated that there are at least 300,000 infected Latin American immigrants living in the United States. California, Florida, and Texas are disproportionately affected. Other geographic concentrations include Arizona, Georgia, Illinois, North Carolina, New York, and Virginia.

Blood donor screening for T. cruzi started in early 2007. Since then 1,267 infected donors have been identified. More than 40 of these individuals had no recognized risk factors.

The acute phase of the disease lasts 4-8 weeks. Patients are usually asymptomatic during this period. An estimated 10%-20% of infected individuals may have nonspecific febrile illness. Romaña’s sign (chagoma) occurs less frequently.

The chronic phase is lifelong and may be asymptomatic and indeterminate in form. Approximately 20%-30% of infected individuals will manifest symptomatic disease – heart failure, sudden death, stroke, or organomegaly.

Testing for Chagas disease is available through the CDC, Dr. Cantey said. For acute infection, a blood smear, hemoculture, and polymerase chain reaction (PCR) tests are useful. For chronic infection, serologic tests are useful. However, there is no preferred test.

Tests for acute infection are sensitive, but the acute phase often is not recognized. Tests for chronic infection have issues with sensitivity and specificity, and usually positive results from two different tests are needed for diagnosis.

Nifurtimox or benznidazole are used for treatment, although neither drug is approved by the Food and Drug Administration. Both are available through CDC’s investigational new drug protocol for compassionate use. Data on the efficacy of these two drugs for the treatment of chronic infection are still evolving. Side effects are frequent, especially in adults, and require monitoring. Side effects include anorexia and weight loss, nausea and vomiting, insomnia, convulsions, headache, myalgias and arthralgias, mucosal edema, hepatic intolerance, and skin manifestations. Yearly physicals should be performed, along with an ECG with a rhythm strip.

Treatment should always be offered for acute infections, congenital disease, and for children and adolescents 18 years and younger with chronic infection, and immunocompromised patients with reactivation, said Dr. Cantey. Treatment generally should be offered to women of reproductive age, adults aged 50 years and younger with indeterminate form disease or with mild to moderate cardiomyopathy, and to patients in whom immunosuppression is anticipated.

Treatment generally should not be offered to patients with advanced cardiomyopathy with congestive heart failure and patients with impairment of swallowing. Treatment should almost never be offered during pregnancy or to patients with severe renal or hepatic insufficiency, Dr. Cantey said.

Toxocariasis

Toxocariasis in humans is caused by infection with larval stages of dog/cat roundworm. Toxocara eggs are shed in dog and cat feces, and humans become infected through ingestion. Larvae migrate and encyst in humans but do not develop into adults or reproduce in humans.

According to data from the National Health and Nutrition Examination Survey (NHANES), approximately 14% of the U.S. population is infected. The highest prevalence is in the southern United States (less than 17%). Toxocariasis affects non-Hispanic blacks more than other groups and is associated with poverty, low education level, and dog ownership.

Many infected individuals are asymptomatic, said Dr. Cantey. In children, symptoms include fever, headache, behavioral and sleep disturbances, cough, anorexia, abdominal pain, hepatomegaly, nausea, and vomiting. Eosinophils may or may not be present. In adults, symptoms include chronic dyspnea, weakness, rash, pruritus, and abdominal pain. Eosinophilia is often present in adults.

Visceral toxocariasis typically occurs in children aged 2-7 years. Symptoms include fever, lower respiratory symptoms, hepatomegaly, abdominal pain, and anorexia. Other symptoms are specific to organ involved and include hepatic granulomas, chronic prurigo, pruritus, urticaria, eczema, vasculitis, eosinophilic meningitis or encephalitis, myelitis, optic neuritis, radiculitis, cranial nerve palsy, and, less commonly, myocarditis, nephrotic syndrome, and arthritis. Laboratory test results show marked eosinophilia, anemia, hypergammaglobulinemia, and increased titers to A and B blood group antigens.

Ocular toxocariasis typically occurs in 5- to 10-year-olds. Usually a single eye is affected. Symptoms include strabismus, unilateral decreased vision, and leukokoria.

Enzyme-linked immunosorbent assay (ELISA) is 78% sensitive and 92% specific for the diagnosis of visceral toxocariasis. However, the sensitivity is lower for ocular toxocariasis. The disease cannot be diagnosed from stool, as the eggs are not excreted by humans, said Dr. Cantey.

Mild toxocariasis often does not need treatment. Visceral disease is treated with 5 days of albendazole; corticosteroids may be used for allergic symptoms. Ocular toxocariasis is treated with 2-4 weeks of albendazole, along with aggressive anti-inflammatory treatment with corticosteroids, and surgery. Albendazole is not approved by the FDA for this indication.

Trichomoniasis

Trichomonas vaginalis is a parasite that is spread through sexual contact. It’s estimated that there are 5-7 million cases yearly in the United States. However, the prevalence may be as great as 20 million. The rate is 10-fold greater among black women, compared with non-Hispanic white women (13.3% vs. 1.3% respectively).

Patients with trichomoniasis can be asymptomatic. In women, symptoms include vaginal discharge, pruritus, and dysuria; in men, symptoms include urethral discharge and dysuria.

Physical examination may reveal mucopurulent discharge, "strawberry cervix" (colpitis macularis), cervical erythema, or cervical friability.

T. vaginalis infection can cause premature rupture of membranes in pregnant women, preterm birth, low birth weight, pelvic inflammatory diseases, and increased susceptibility to HIV transmission.

In terms of diagnosis, wet preparation examination is only 60%-70% sensitive in women. Two point-of-care tests (OSOM Trichomonas Rapid Test and Affirm VP III) are available. These tests, performed on vaginal secretions, are more than 83% sensitive and more than 97% specific. Pap smears are not recommended for Trichomonas screening. In men, wet preparation of urethral discharge, prostatic secretions, or urethral scrapings is of uncertain sensitivity. Instead, PCR or culture on special media should be used.

Trichomoniasis is treated with metronidazole or tinidazole. If treatment with 2 g metronidazole given once fails (and reinfection is excluded), then patients should be treated with 500 g metronidazole twice daily for 7 days or with 2 g tinidazole once. If either therapy fails, then treat with 2 g metronidazole or 2 g tinidazole daily for 5 days. If this treatment fails, consult the CDC for testing and management. Sex partners of patients should be treated to prevent reinfection.

Metronidazole is pregnancy category B and tinidazole is pregnancy category C. Asymptomatic pregnant women should be counseled about the risks and benefits of treatment, Dr. Cantey noted.

Certain infectious diseases can concentrate in impoverished areas and disproportionately affect minorities, women, and other disadvantaged groups, according to Dr. Paul T. Cantey.

Clinicians often receive little training on infectious diseases seen in these areas, which include tribal lands and border regions in the southwestern United States, the Mississippi delta, the cotton belt, Appalachia, and some dense urban areas.

Dr. Cantey outlined the diagnosis and treatment of three of these diseases – Chagas disease, toxocariasis, and trichomoniasis – during a teleconference sponsored by the Centers for Disease Control and Prevention. Dr. Cantey is a medical officer in the CDC’s division of parasitic diseases and malaria.

Chagas disease

Chagas disease is caused by the protozoan parasite Trypanosoma cruzi. The primary mode of transmission is through infected triatomine bugs. Other modes of transmission include blood transfusion, organ and tissue transplantation, congenital infection, laboratory accidents, and food.

Photo credit: travfotos/flickr (Creative Commons)

Chagas disease is endemic in much of Latin America. However, both the parasite and the triatomine bug are found in the United States. It’s estimated that there are at least 300,000 infected Latin American immigrants living in the United States. California, Florida, and Texas are disproportionately affected. Other geographic concentrations include Arizona, Georgia, Illinois, North Carolina, New York, and Virginia.

Blood donor screening for T. cruzi started in early 2007. Since then 1,267 infected donors have been identified. More than 40 of these individuals had no recognized risk factors.

The acute phase of the disease lasts 4-8 weeks. Patients are usually asymptomatic during this period. An estimated 10%-20% of infected individuals may have nonspecific febrile illness. Romaña’s sign (chagoma) occurs less frequently.

The chronic phase is lifelong and may be asymptomatic and indeterminate in form. Approximately 20%-30% of infected individuals will manifest symptomatic disease – heart failure, sudden death, stroke, or organomegaly.

Testing for Chagas disease is available through the CDC, Dr. Cantey said. For acute infection, a blood smear, hemoculture, and polymerase chain reaction (PCR) tests are useful. For chronic infection, serologic tests are useful. However, there is no preferred test.

Tests for acute infection are sensitive, but the acute phase often is not recognized. Tests for chronic infection have issues with sensitivity and specificity, and usually positive results from two different tests are needed for diagnosis.

Nifurtimox or benznidazole are used for treatment, although neither drug is approved by the Food and Drug Administration. Both are available through CDC’s investigational new drug protocol for compassionate use. Data on the efficacy of these two drugs for the treatment of chronic infection are still evolving. Side effects are frequent, especially in adults, and require monitoring. Side effects include anorexia and weight loss, nausea and vomiting, insomnia, convulsions, headache, myalgias and arthralgias, mucosal edema, hepatic intolerance, and skin manifestations. Yearly physicals should be performed, along with an ECG with a rhythm strip.

Treatment should always be offered for acute infections, congenital disease, and for children and adolescents 18 years and younger with chronic infection, and immunocompromised patients with reactivation, said Dr. Cantey. Treatment generally should be offered to women of reproductive age, adults aged 50 years and younger with indeterminate form disease or with mild to moderate cardiomyopathy, and to patients in whom immunosuppression is anticipated.

Treatment generally should not be offered to patients with advanced cardiomyopathy with congestive heart failure and patients with impairment of swallowing. Treatment should almost never be offered during pregnancy or to patients with severe renal or hepatic insufficiency, Dr. Cantey said.

Toxocariasis

Toxocariasis in humans is caused by infection with larval stages of dog/cat roundworm. Toxocara eggs are shed in dog and cat feces, and humans become infected through ingestion. Larvae migrate and encyst in humans but do not develop into adults or reproduce in humans.

According to data from the National Health and Nutrition Examination Survey (NHANES), approximately 14% of the U.S. population is infected. The highest prevalence is in the southern United States (less than 17%). Toxocariasis affects non-Hispanic blacks more than other groups and is associated with poverty, low education level, and dog ownership.

Many infected individuals are asymptomatic, said Dr. Cantey. In children, symptoms include fever, headache, behavioral and sleep disturbances, cough, anorexia, abdominal pain, hepatomegaly, nausea, and vomiting. Eosinophils may or may not be present. In adults, symptoms include chronic dyspnea, weakness, rash, pruritus, and abdominal pain. Eosinophilia is often present in adults.

Visceral toxocariasis typically occurs in children aged 2-7 years. Symptoms include fever, lower respiratory symptoms, hepatomegaly, abdominal pain, and anorexia. Other symptoms are specific to organ involved and include hepatic granulomas, chronic prurigo, pruritus, urticaria, eczema, vasculitis, eosinophilic meningitis or encephalitis, myelitis, optic neuritis, radiculitis, cranial nerve palsy, and, less commonly, myocarditis, nephrotic syndrome, and arthritis. Laboratory test results show marked eosinophilia, anemia, hypergammaglobulinemia, and increased titers to A and B blood group antigens.

Ocular toxocariasis typically occurs in 5- to 10-year-olds. Usually a single eye is affected. Symptoms include strabismus, unilateral decreased vision, and leukokoria.

Enzyme-linked immunosorbent assay (ELISA) is 78% sensitive and 92% specific for the diagnosis of visceral toxocariasis. However, the sensitivity is lower for ocular toxocariasis. The disease cannot be diagnosed from stool, as the eggs are not excreted by humans, said Dr. Cantey.

Mild toxocariasis often does not need treatment. Visceral disease is treated with 5 days of albendazole; corticosteroids may be used for allergic symptoms. Ocular toxocariasis is treated with 2-4 weeks of albendazole, along with aggressive anti-inflammatory treatment with corticosteroids, and surgery. Albendazole is not approved by the FDA for this indication.

Trichomoniasis

Trichomonas vaginalis is a parasite that is spread through sexual contact. It’s estimated that there are 5-7 million cases yearly in the United States. However, the prevalence may be as great as 20 million. The rate is 10-fold greater among black women, compared with non-Hispanic white women (13.3% vs. 1.3% respectively).

Patients with trichomoniasis can be asymptomatic. In women, symptoms include vaginal discharge, pruritus, and dysuria; in men, symptoms include urethral discharge and dysuria.

Physical examination may reveal mucopurulent discharge, "strawberry cervix" (colpitis macularis), cervical erythema, or cervical friability.

T. vaginalis infection can cause premature rupture of membranes in pregnant women, preterm birth, low birth weight, pelvic inflammatory diseases, and increased susceptibility to HIV transmission.

In terms of diagnosis, wet preparation examination is only 60%-70% sensitive in women. Two point-of-care tests (OSOM Trichomonas Rapid Test and Affirm VP III) are available. These tests, performed on vaginal secretions, are more than 83% sensitive and more than 97% specific. Pap smears are not recommended for Trichomonas screening. In men, wet preparation of urethral discharge, prostatic secretions, or urethral scrapings is of uncertain sensitivity. Instead, PCR or culture on special media should be used.

Trichomoniasis is treated with metronidazole or tinidazole. If treatment with 2 g metronidazole given once fails (and reinfection is excluded), then patients should be treated with 500 g metronidazole twice daily for 7 days or with 2 g tinidazole once. If either therapy fails, then treat with 2 g metronidazole or 2 g tinidazole daily for 5 days. If this treatment fails, consult the CDC for testing and management. Sex partners of patients should be treated to prevent reinfection.

Metronidazole is pregnancy category B and tinidazole is pregnancy category C. Asymptomatic pregnant women should be counseled about the risks and benefits of treatment, Dr. Cantey noted.

Certain infectious diseases can concentrate in impoverished areas and disproportionately affect minorities, women, and other disadvantaged groups, according to Dr. Paul T. Cantey.

Clinicians often receive little training on infectious diseases seen in these areas, which include tribal lands and border regions in the southwestern United States, the Mississippi delta, the cotton belt, Appalachia, and some dense urban areas.

Dr. Cantey outlined the diagnosis and treatment of three of these diseases – Chagas disease, toxocariasis, and trichomoniasis – during a teleconference sponsored by the Centers for Disease Control and Prevention. Dr. Cantey is a medical officer in the CDC’s division of parasitic diseases and malaria.

Chagas disease

Chagas disease is caused by the protozoan parasite Trypanosoma cruzi. The primary mode of transmission is through infected triatomine bugs. Other modes of transmission include blood transfusion, organ and tissue transplantation, congenital infection, laboratory accidents, and food.

Photo credit: travfotos/flickr (Creative Commons)

Chagas disease is endemic in much of Latin America. However, both the parasite and the triatomine bug are found in the United States. It’s estimated that there are at least 300,000 infected Latin American immigrants living in the United States. California, Florida, and Texas are disproportionately affected. Other geographic concentrations include Arizona, Georgia, Illinois, North Carolina, New York, and Virginia.

Blood donor screening for T. cruzi started in early 2007. Since then 1,267 infected donors have been identified. More than 40 of these individuals had no recognized risk factors.

The acute phase of the disease lasts 4-8 weeks. Patients are usually asymptomatic during this period. An estimated 10%-20% of infected individuals may have nonspecific febrile illness. Romaña’s sign (chagoma) occurs less frequently.

The chronic phase is lifelong and may be asymptomatic and indeterminate in form. Approximately 20%-30% of infected individuals will manifest symptomatic disease – heart failure, sudden death, stroke, or organomegaly.

Testing for Chagas disease is available through the CDC, Dr. Cantey said. For acute infection, a blood smear, hemoculture, and polymerase chain reaction (PCR) tests are useful. For chronic infection, serologic tests are useful. However, there is no preferred test.

Tests for acute infection are sensitive, but the acute phase often is not recognized. Tests for chronic infection have issues with sensitivity and specificity, and usually positive results from two different tests are needed for diagnosis.

Nifurtimox or benznidazole are used for treatment, although neither drug is approved by the Food and Drug Administration. Both are available through CDC’s investigational new drug protocol for compassionate use. Data on the efficacy of these two drugs for the treatment of chronic infection are still evolving. Side effects are frequent, especially in adults, and require monitoring. Side effects include anorexia and weight loss, nausea and vomiting, insomnia, convulsions, headache, myalgias and arthralgias, mucosal edema, hepatic intolerance, and skin manifestations. Yearly physicals should be performed, along with an ECG with a rhythm strip.

Treatment should always be offered for acute infections, congenital disease, and for children and adolescents 18 years and younger with chronic infection, and immunocompromised patients with reactivation, said Dr. Cantey. Treatment generally should be offered to women of reproductive age, adults aged 50 years and younger with indeterminate form disease or with mild to moderate cardiomyopathy, and to patients in whom immunosuppression is anticipated.

Treatment generally should not be offered to patients with advanced cardiomyopathy with congestive heart failure and patients with impairment of swallowing. Treatment should almost never be offered during pregnancy or to patients with severe renal or hepatic insufficiency, Dr. Cantey said.

Toxocariasis

Toxocariasis in humans is caused by infection with larval stages of dog/cat roundworm. Toxocara eggs are shed in dog and cat feces, and humans become infected through ingestion. Larvae migrate and encyst in humans but do not develop into adults or reproduce in humans.

According to data from the National Health and Nutrition Examination Survey (NHANES), approximately 14% of the U.S. population is infected. The highest prevalence is in the southern United States (less than 17%). Toxocariasis affects non-Hispanic blacks more than other groups and is associated with poverty, low education level, and dog ownership.

Many infected individuals are asymptomatic, said Dr. Cantey. In children, symptoms include fever, headache, behavioral and sleep disturbances, cough, anorexia, abdominal pain, hepatomegaly, nausea, and vomiting. Eosinophils may or may not be present. In adults, symptoms include chronic dyspnea, weakness, rash, pruritus, and abdominal pain. Eosinophilia is often present in adults.

Visceral toxocariasis typically occurs in children aged 2-7 years. Symptoms include fever, lower respiratory symptoms, hepatomegaly, abdominal pain, and anorexia. Other symptoms are specific to organ involved and include hepatic granulomas, chronic prurigo, pruritus, urticaria, eczema, vasculitis, eosinophilic meningitis or encephalitis, myelitis, optic neuritis, radiculitis, cranial nerve palsy, and, less commonly, myocarditis, nephrotic syndrome, and arthritis. Laboratory test results show marked eosinophilia, anemia, hypergammaglobulinemia, and increased titers to A and B blood group antigens.

Ocular toxocariasis typically occurs in 5- to 10-year-olds. Usually a single eye is affected. Symptoms include strabismus, unilateral decreased vision, and leukokoria.

Enzyme-linked immunosorbent assay (ELISA) is 78% sensitive and 92% specific for the diagnosis of visceral toxocariasis. However, the sensitivity is lower for ocular toxocariasis. The disease cannot be diagnosed from stool, as the eggs are not excreted by humans, said Dr. Cantey.

Mild toxocariasis often does not need treatment. Visceral disease is treated with 5 days of albendazole; corticosteroids may be used for allergic symptoms. Ocular toxocariasis is treated with 2-4 weeks of albendazole, along with aggressive anti-inflammatory treatment with corticosteroids, and surgery. Albendazole is not approved by the FDA for this indication.

Trichomoniasis

Trichomonas vaginalis is a parasite that is spread through sexual contact. It’s estimated that there are 5-7 million cases yearly in the United States. However, the prevalence may be as great as 20 million. The rate is 10-fold greater among black women, compared with non-Hispanic white women (13.3% vs. 1.3% respectively).

Patients with trichomoniasis can be asymptomatic. In women, symptoms include vaginal discharge, pruritus, and dysuria; in men, symptoms include urethral discharge and dysuria.

Physical examination may reveal mucopurulent discharge, "strawberry cervix" (colpitis macularis), cervical erythema, or cervical friability.

T. vaginalis infection can cause premature rupture of membranes in pregnant women, preterm birth, low birth weight, pelvic inflammatory diseases, and increased susceptibility to HIV transmission.

In terms of diagnosis, wet preparation examination is only 60%-70% sensitive in women. Two point-of-care tests (OSOM Trichomonas Rapid Test and Affirm VP III) are available. These tests, performed on vaginal secretions, are more than 83% sensitive and more than 97% specific. Pap smears are not recommended for Trichomonas screening. In men, wet preparation of urethral discharge, prostatic secretions, or urethral scrapings is of uncertain sensitivity. Instead, PCR or culture on special media should be used.

Trichomoniasis is treated with metronidazole or tinidazole. If treatment with 2 g metronidazole given once fails (and reinfection is excluded), then patients should be treated with 500 g metronidazole twice daily for 7 days or with 2 g tinidazole once. If either therapy fails, then treat with 2 g metronidazole or 2 g tinidazole daily for 5 days. If this treatment fails, consult the CDC for testing and management. Sex partners of patients should be treated to prevent reinfection.

Metronidazole is pregnancy category B and tinidazole is pregnancy category C. Asymptomatic pregnant women should be counseled about the risks and benefits of treatment, Dr. Cantey noted.

Women at high risk of ovarian cancer based on family history and BRCA1 or BRCA2 mutation should undergo risk-reducing prophylactic bilateral salpingo-oophorectomy once childbearing is complete, according to guidelines released by the Society of Gynecologic Oncologists.

“For women at average risk of ovarian cancer who are undergoing a hysterectomy for benign conditions, the decision should be individualized after appropriate informed consent, including a careful analysis of personal risk factors, concomitant disease, presence of gynecologic disease (endometriosis, chronic pain, infection), and age,” wrote members of the SGO's clinical practice committee. Some evidence suggests that bilateral salpingo-oophorectomy (BSO) has a negative impact on health when performed prior to menopause – including increased risk of cardiovascular disease, lung cancer, and possibly neurologic conditions.

Dr. Ritu Salani agreed with the recommendations, saying that the high risk for ovarian cancer in these women outweighs any potential benefits from retaining the ovaries. Dr. Salani is assistant professor of ob.gyn. at the Arthur G. James Cancer Hospital and the Richard J. Solove Research Institute in Columbus, Ohio.

The SGO also pointed out that there are insufficient data to provide sound counseling on the long-term health impact of BSO for postmenopausal women.

“This should be an individualized decision, and patients [in this age group] should be aware of pros and cons for each until we have better data,” Dr. Salani said in an interview. “Typical practice is to advocate BSO for this patient population.”

“This paper offers some insight with regard to counseling discussion recommendations, and emphasizes the need for additional research concerning BSO's long-term impact on a woman's health, especially as it relates to cardiovascular and neurologic diseases,” lead author Dr. Jonathan S. Berek said in a press release. Dr. Berek is the chair of obstetrics and gynecology at Stanford (Calif.) University.

In the guidelines – released in the September issue of the journal Obstetrics & Gynecology (2010;116:733–43) – the authors also highlighted the lack of an effective screening tool for ovarian cancer: “There is no proven method of screening for ovarian cancer that effectively reduces mortality. CA 125 monitoring and transvaginal ultrasonography have high false-positive rates, especially in premenopausal women.”

Women who are carriers of a germline mutation in BRCA1 or BRCA2 have the greatest risk of ovarian cancer – an estimated 15%-60% risk over a lifetime. For these women, the value of prophylactic salpingo-oophorectomy has been well documented, the committee noted.

Women with a strong family history of either ovarian or breast cancer may carry a deleterious mutation and should be presumed to have higher-than-average risk. This is especially true if there are a number of family members who developed these cancers when they were premenopausal. “These women are potentially at high risk even if they have not been tested because there could be other mutations that are either untested or yet undiscovered that confirm higher-than-average risk of these diseases,” the committee members wrote.

The decision to perform a hysterectomy in conjunction with BSO in the high-risk group should be individualized. The committee members offered several examples. For women receiving tamoxifen, which is associated with an increased risk of polyps and endometrial cancer, hysterectomy may be appropriate. Women who carry mutations in BRCA1 or BRCA2 do not appear to have an increased risk of uterine or cervical cancer, so “routine performance of a prophylactic hysterectomy is discretionary,” according to the guidelines.

Women who do not have a strong family history suggesting the possibility that they carry a germline mutation or who do not have a documented germline mutation were considered by the committee to be at average risk of ovarian and breast cancer. To assess the benefits and risks of BSO, the committee reviewed 11 studies of oophorectomy performed in women who were presumed to be at average risk of ovarian cancer.

It is important that women at average risk of ovarian cancer and their gynecologists consider carefully the indications for hysterectomy and whether BSO also should be performed, despite the potential negative long-term effects, according to the guidelines.

A number of studies have suggested a cardioprotective effect for estrogen because the reduction of endogenous estrogen (as with BSO) correlates with an increase in lipids, a reduction in carotid artery blood flow, and an increase in subclinical atherosclerosis, the authors noted.

In addition to adverse effects on cardiac and bone health, increased risks of Parkinson's disease and cognitive impairment or dementia have recently been reported among women who underwent bilateral oophorectomy. Importantly, the increased risk of cognitive impairment and Parkinson's disease did not appear to be altered by estrogen. However, these increased risks appear to be dependent on the age at oophorectomy and the use of estrogen replacement.

“There are clinical situations in which patients should be counseled strongly to undergo elective BSO. As pointed out, patients found to have severe endometriosis, pelvic infection, benign ovarian neoplasms, and chronic pelvic pain have a higher probability of undergoing BSO. This seems warranted given that women with these conditions have a significantly higher risk of repeat surgery,” the committee members wrote.

The authors did not report any potential conflicts of interest.

Women at high risk of ovarian cancer based on family history and BRCA1 or BRCA2 mutation should undergo risk-reducing prophylactic bilateral salpingo-oophorectomy once childbearing is complete, according to guidelines released by the Society of Gynecologic Oncologists.

“For women at average risk of ovarian cancer who are undergoing a hysterectomy for benign conditions, the decision should be individualized after appropriate informed consent, including a careful analysis of personal risk factors, concomitant disease, presence of gynecologic disease (endometriosis, chronic pain, infection), and age,” wrote members of the SGO's clinical practice committee. Some evidence suggests that bilateral salpingo-oophorectomy (BSO) has a negative impact on health when performed prior to menopause – including increased risk of cardiovascular disease, lung cancer, and possibly neurologic conditions.

Dr. Ritu Salani agreed with the recommendations, saying that the high risk for ovarian cancer in these women outweighs any potential benefits from retaining the ovaries. Dr. Salani is assistant professor of ob.gyn. at the Arthur G. James Cancer Hospital and the Richard J. Solove Research Institute in Columbus, Ohio.

The SGO also pointed out that there are insufficient data to provide sound counseling on the long-term health impact of BSO for postmenopausal women.

“This should be an individualized decision, and patients [in this age group] should be aware of pros and cons for each until we have better data,” Dr. Salani said in an interview. “Typical practice is to advocate BSO for this patient population.”

“This paper offers some insight with regard to counseling discussion recommendations, and emphasizes the need for additional research concerning BSO's long-term impact on a woman's health, especially as it relates to cardiovascular and neurologic diseases,” lead author Dr. Jonathan S. Berek said in a press release. Dr. Berek is the chair of obstetrics and gynecology at Stanford (Calif.) University.

In the guidelines – released in the September issue of the journal Obstetrics & Gynecology (2010;116:733–43) – the authors also highlighted the lack of an effective screening tool for ovarian cancer: “There is no proven method of screening for ovarian cancer that effectively reduces mortality. CA 125 monitoring and transvaginal ultrasonography have high false-positive rates, especially in premenopausal women.”

Women who are carriers of a germline mutation in BRCA1 or BRCA2 have the greatest risk of ovarian cancer – an estimated 15%-60% risk over a lifetime. For these women, the value of prophylactic salpingo-oophorectomy has been well documented, the committee noted.

Women with a strong family history of either ovarian or breast cancer may carry a deleterious mutation and should be presumed to have higher-than-average risk. This is especially true if there are a number of family members who developed these cancers when they were premenopausal. “These women are potentially at high risk even if they have not been tested because there could be other mutations that are either untested or yet undiscovered that confirm higher-than-average risk of these diseases,” the committee members wrote.

The decision to perform a hysterectomy in conjunction with BSO in the high-risk group should be individualized. The committee members offered several examples. For women receiving tamoxifen, which is associated with an increased risk of polyps and endometrial cancer, hysterectomy may be appropriate. Women who carry mutations in BRCA1 or BRCA2 do not appear to have an increased risk of uterine or cervical cancer, so “routine performance of a prophylactic hysterectomy is discretionary,” according to the guidelines.

Women who do not have a strong family history suggesting the possibility that they carry a germline mutation or who do not have a documented germline mutation were considered by the committee to be at average risk of ovarian and breast cancer. To assess the benefits and risks of BSO, the committee reviewed 11 studies of oophorectomy performed in women who were presumed to be at average risk of ovarian cancer.

It is important that women at average risk of ovarian cancer and their gynecologists consider carefully the indications for hysterectomy and whether BSO also should be performed, despite the potential negative long-term effects, according to the guidelines.

A number of studies have suggested a cardioprotective effect for estrogen because the reduction of endogenous estrogen (as with BSO) correlates with an increase in lipids, a reduction in carotid artery blood flow, and an increase in subclinical atherosclerosis, the authors noted.

In addition to adverse effects on cardiac and bone health, increased risks of Parkinson's disease and cognitive impairment or dementia have recently been reported among women who underwent bilateral oophorectomy. Importantly, the increased risk of cognitive impairment and Parkinson's disease did not appear to be altered by estrogen. However, these increased risks appear to be dependent on the age at oophorectomy and the use of estrogen replacement.

“There are clinical situations in which patients should be counseled strongly to undergo elective BSO. As pointed out, patients found to have severe endometriosis, pelvic infection, benign ovarian neoplasms, and chronic pelvic pain have a higher probability of undergoing BSO. This seems warranted given that women with these conditions have a significantly higher risk of repeat surgery,” the committee members wrote.

The authors did not report any potential conflicts of interest.

Women at high risk of ovarian cancer based on family history and BRCA1 or BRCA2 mutation should undergo risk-reducing prophylactic bilateral salpingo-oophorectomy once childbearing is complete, according to guidelines released by the Society of Gynecologic Oncologists.

“For women at average risk of ovarian cancer who are undergoing a hysterectomy for benign conditions, the decision should be individualized after appropriate informed consent, including a careful analysis of personal risk factors, concomitant disease, presence of gynecologic disease (endometriosis, chronic pain, infection), and age,” wrote members of the SGO's clinical practice committee. Some evidence suggests that bilateral salpingo-oophorectomy (BSO) has a negative impact on health when performed prior to menopause – including increased risk of cardiovascular disease, lung cancer, and possibly neurologic conditions.

Dr. Ritu Salani agreed with the recommendations, saying that the high risk for ovarian cancer in these women outweighs any potential benefits from retaining the ovaries. Dr. Salani is assistant professor of ob.gyn. at the Arthur G. James Cancer Hospital and the Richard J. Solove Research Institute in Columbus, Ohio.

The SGO also pointed out that there are insufficient data to provide sound counseling on the long-term health impact of BSO for postmenopausal women.

“This should be an individualized decision, and patients [in this age group] should be aware of pros and cons for each until we have better data,” Dr. Salani said in an interview. “Typical practice is to advocate BSO for this patient population.”

“This paper offers some insight with regard to counseling discussion recommendations, and emphasizes the need for additional research concerning BSO's long-term impact on a woman's health, especially as it relates to cardiovascular and neurologic diseases,” lead author Dr. Jonathan S. Berek said in a press release. Dr. Berek is the chair of obstetrics and gynecology at Stanford (Calif.) University.

In the guidelines – released in the September issue of the journal Obstetrics & Gynecology (2010;116:733–43) – the authors also highlighted the lack of an effective screening tool for ovarian cancer: “There is no proven method of screening for ovarian cancer that effectively reduces mortality. CA 125 monitoring and transvaginal ultrasonography have high false-positive rates, especially in premenopausal women.”

Women who are carriers of a germline mutation in BRCA1 or BRCA2 have the greatest risk of ovarian cancer – an estimated 15%-60% risk over a lifetime. For these women, the value of prophylactic salpingo-oophorectomy has been well documented, the committee noted.

Women with a strong family history of either ovarian or breast cancer may carry a deleterious mutation and should be presumed to have higher-than-average risk. This is especially true if there are a number of family members who developed these cancers when they were premenopausal. “These women are potentially at high risk even if they have not been tested because there could be other mutations that are either untested or yet undiscovered that confirm higher-than-average risk of these diseases,” the committee members wrote.

The decision to perform a hysterectomy in conjunction with BSO in the high-risk group should be individualized. The committee members offered several examples. For women receiving tamoxifen, which is associated with an increased risk of polyps and endometrial cancer, hysterectomy may be appropriate. Women who carry mutations in BRCA1 or BRCA2 do not appear to have an increased risk of uterine or cervical cancer, so “routine performance of a prophylactic hysterectomy is discretionary,” according to the guidelines.

Women who do not have a strong family history suggesting the possibility that they carry a germline mutation or who do not have a documented germline mutation were considered by the committee to be at average risk of ovarian and breast cancer. To assess the benefits and risks of BSO, the committee reviewed 11 studies of oophorectomy performed in women who were presumed to be at average risk of ovarian cancer.

It is important that women at average risk of ovarian cancer and their gynecologists consider carefully the indications for hysterectomy and whether BSO also should be performed, despite the potential negative long-term effects, according to the guidelines.

A number of studies have suggested a cardioprotective effect for estrogen because the reduction of endogenous estrogen (as with BSO) correlates with an increase in lipids, a reduction in carotid artery blood flow, and an increase in subclinical atherosclerosis, the authors noted.

In addition to adverse effects on cardiac and bone health, increased risks of Parkinson's disease and cognitive impairment or dementia have recently been reported among women who underwent bilateral oophorectomy. Importantly, the increased risk of cognitive impairment and Parkinson's disease did not appear to be altered by estrogen. However, these increased risks appear to be dependent on the age at oophorectomy and the use of estrogen replacement.

“There are clinical situations in which patients should be counseled strongly to undergo elective BSO. As pointed out, patients found to have severe endometriosis, pelvic infection, benign ovarian neoplasms, and chronic pelvic pain have a higher probability of undergoing BSO. This seems warranted given that women with these conditions have a significantly higher risk of repeat surgery,” the committee members wrote.

The authors did not report any potential conflicts of interest.

Daily fondaparinux significantly reduced the relative risk of symptomatic thromboembolic complications or death by 85% – without increasing the incidence of bleeding – in a study of some 3,000 patients with acute symptomatic lower-limb superficial-vein thrombosis.

“Fondaparinux also reduced the risk of symptomatic recurrence of superficial-vein thrombosis and, more important, its extension to the saphenofemoral junction – a finding that is clinically relevant because such extension is considered to increase the risk of deep-vein thrombosis and pulmonary embolism, thereby prompting escalation of therapy (for example, to full-dose anticoagulation or surgery),” Dr. Hervé Decousus and his coinvestigators reported.

The results may help fill in knowledge gaps about the appropriate treatment for superficial-vein thrombosis. Currently, therapeutic strategies range from no treatment to the use of anti-inflammatory drugs, anticoagulant agents, or even surgery.

Investigators in the study, known as the Comparison of Arixtra in Lower Limb Superficial Vein Thrombosis with Placebo (CALISTO) trial, compared the efficacy and safety of the specific factor Xa inhibitor fondaparinux with placebo in reducing symptomatic venous thromboembolic complications or death from any cause. The study comprised 3,002 patients with acute, isolated superficial-vein thrombosis of the legs (N. Engl. J. Med. 2010;363:1222-32).

Patients 18 years or older with acute, symptomatic lower-limb superficial-vein thrombosis at least 5-cm long were eligible for the study. They were excluded from the study if they met various specific criteria, such as a documented history of SVT within the past 3 months or DVT or PE within the past 6 months.

Between March 2007 and May 2009, a total of 3,002 patients were enrolled and randomized to receive 2.5 mg subcutaneous fondaparinux per day or daily subcutaneous placebo for 45 days. Overall, 1,481 patients in the fondaparinux group and 1,467 in the placebo group completed the follow-up visit at day 75, wrote Dr. Decousus of the Centre Hôpitalier Universitaire Saint-Étienne in France, and his coinvestigators.

Patients could choose whether to self-administer the injections, were encouraged to use graduated compression stockings, and were allowed to take acetaminophen or topical NSAIDs as needed. Concomitant treatment with other thrombolytic, anticoagulant, or antiplatelet agents was prohibited.

The primary efficacy outcome – the composite of death from any cause, symptomatic confirmed PE or DVT, or confirmed symptomatic extension to the saphenofemoral junction or symptomatic recurrence of superficial-vein thrombosis up to day 47 – occurred in a significantly greater percentage of those in the placebo group (5.9% vs. 0.9%; relative risk with fondaparinux, 0.15). Twenty patients would need to be treated to prevent one death, PE, DVT, extension to the saphenofemoral junction or symptomatic recurrence of superficial-vein thrombosis.

In addition, the incidence of each component of the primary efficacy outcome was significantly reduced in the fondaparinux group, except for the incidence of death, which did not differ significantly. The risk of the composite of DVT or PE was significantly reduced by 85% with fondaparinux, compared with placebo (0.2% vs. 1.3% affected in each group, respectively). To prevent one DVT or PE, 88 patients would need to be treated.

“This benefit was evident within the first days after treatment was initiated, supporting the adequacy of the prophylactic dose of 2.5 mg of fondaparinux and in accord with the substantial efficacy data already available with respect to a dose of 2.5 mg of fondaparinux in various clinical settings,” the investigators wrote.

In addition, more patients in the placebo group underwent surgery for superficial-vein thrombosis than in the fondaparinux group (3.5% vs. 0.5% by day 77), including ligation of the saphenofemoral junction. Major bleeding had occurred in one patient in each group by day 47. The rates of clinically relevant nonmajor, minor, and total bleeding and arterial thromboembolic complications did not differ significantly between groups.

The study was supported by GlaxoSmithKline, which markets Arixtra (fondaparinux). In addition, 8 of the 11 study authors reported significant financial relationships with several pharmaceutical companies, including GlaxoSmithKline.

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Consider Cost in Drug Approvals

While overall efficacy and safety information are crucial for the approval and widespread use of a new drug, so is cost effectiveness, Dr. Lee Goldman and Dr. Jeffrey Ginsberg wrote in a commentary.

The study authors determined that 88 patients would need to be treated with fondaparinux to prevent one nonfatal episode of deep-vein thrombosis or pulmonary embolism (N. Engl. J. Med. 2010;363:1278-80). “In New York City, the price of a 45-day regimen of 2.5 mg of fondaparinux once daily ranged from $2,124 to $7,380 at four major pharmacies. Even at the lowest quoted price and considering the 98.3% estimated adherence rate, the cost of the treatment for 1,500 patients would be about $3.13 million,” they wrote.

“On the basis of the incremental 1-year costs for the medical care of a patient with a pulmonary embolus or deep-vein thrombosis, an estimated $250,000 or so in medical care costs would be averted, resulting in a net cost of fondaparinux treatment of about $2.88 million, or about $1,900 per treated patient, without any lives saved.”

No clinical trial phases assess this information. Likewise, decisions regarding Medicare reimbursement do not “consider the cost or cost-effectiveness of the agent itself or of the strategy into which it is incorporated,” wrote Dr. Goldman and Dr. Ginsberg.

“We recommend that the Food and Drug Administration give serious thought to mandating phase 3.5 trials to document the costs, the effects on quality of life, and the cost-effectiveness of new interventions so as to reach a consensus regarding their worthiness.”

DR. GOLDMAN is executive vice president of Health and Biomedical Sciences and dean of the Faculties of Health Sciences and Medicine at Columbia University, New York. DR. GINSBERG is professor of hematology and thromboembolism at McMaster University, Hamilton, Ont. They reported that they have no financial conflicts.

Daily fondaparinux significantly reduced the relative risk of symptomatic thromboembolic complications or death by 85% – without increasing the incidence of bleeding – in a study of some 3,000 patients with acute symptomatic lower-limb superficial-vein thrombosis.

“Fondaparinux also reduced the risk of symptomatic recurrence of superficial-vein thrombosis and, more important, its extension to the saphenofemoral junction – a finding that is clinically relevant because such extension is considered to increase the risk of deep-vein thrombosis and pulmonary embolism, thereby prompting escalation of therapy (for example, to full-dose anticoagulation or surgery),” Dr. Hervé Decousus and his coinvestigators reported.

The results may help fill in knowledge gaps about the appropriate treatment for superficial-vein thrombosis. Currently, therapeutic strategies range from no treatment to the use of anti-inflammatory drugs, anticoagulant agents, or even surgery.

Investigators in the study, known as the Comparison of Arixtra in Lower Limb Superficial Vein Thrombosis with Placebo (CALISTO) trial, compared the efficacy and safety of the specific factor Xa inhibitor fondaparinux with placebo in reducing symptomatic venous thromboembolic complications or death from any cause. The study comprised 3,002 patients with acute, isolated superficial-vein thrombosis of the legs (N. Engl. J. Med. 2010;363:1222-32).

Patients 18 years or older with acute, symptomatic lower-limb superficial-vein thrombosis at least 5-cm long were eligible for the study. They were excluded from the study if they met various specific criteria, such as a documented history of SVT within the past 3 months or DVT or PE within the past 6 months.

Between March 2007 and May 2009, a total of 3,002 patients were enrolled and randomized to receive 2.5 mg subcutaneous fondaparinux per day or daily subcutaneous placebo for 45 days. Overall, 1,481 patients in the fondaparinux group and 1,467 in the placebo group completed the follow-up visit at day 75, wrote Dr. Decousus of the Centre Hôpitalier Universitaire Saint-Étienne in France, and his coinvestigators.

Patients could choose whether to self-administer the injections, were encouraged to use graduated compression stockings, and were allowed to take acetaminophen or topical NSAIDs as needed. Concomitant treatment with other thrombolytic, anticoagulant, or antiplatelet agents was prohibited.

The primary efficacy outcome – the composite of death from any cause, symptomatic confirmed PE or DVT, or confirmed symptomatic extension to the saphenofemoral junction or symptomatic recurrence of superficial-vein thrombosis up to day 47 – occurred in a significantly greater percentage of those in the placebo group (5.9% vs. 0.9%; relative risk with fondaparinux, 0.15). Twenty patients would need to be treated to prevent one death, PE, DVT, extension to the saphenofemoral junction or symptomatic recurrence of superficial-vein thrombosis.

In addition, the incidence of each component of the primary efficacy outcome was significantly reduced in the fondaparinux group, except for the incidence of death, which did not differ significantly. The risk of the composite of DVT or PE was significantly reduced by 85% with fondaparinux, compared with placebo (0.2% vs. 1.3% affected in each group, respectively). To prevent one DVT or PE, 88 patients would need to be treated.

“This benefit was evident within the first days after treatment was initiated, supporting the adequacy of the prophylactic dose of 2.5 mg of fondaparinux and in accord with the substantial efficacy data already available with respect to a dose of 2.5 mg of fondaparinux in various clinical settings,” the investigators wrote.

In addition, more patients in the placebo group underwent surgery for superficial-vein thrombosis than in the fondaparinux group (3.5% vs. 0.5% by day 77), including ligation of the saphenofemoral junction. Major bleeding had occurred in one patient in each group by day 47. The rates of clinically relevant nonmajor, minor, and total bleeding and arterial thromboembolic complications did not differ significantly between groups.

The study was supported by GlaxoSmithKline, which markets Arixtra (fondaparinux). In addition, 8 of the 11 study authors reported significant financial relationships with several pharmaceutical companies, including GlaxoSmithKline.

View on the News

Consider Cost in Drug Approvals

While overall efficacy and safety information are crucial for the approval and widespread use of a new drug, so is cost effectiveness, Dr. Lee Goldman and Dr. Jeffrey Ginsberg wrote in a commentary.

The study authors determined that 88 patients would need to be treated with fondaparinux to prevent one nonfatal episode of deep-vein thrombosis or pulmonary embolism (N. Engl. J. Med. 2010;363:1278-80). “In New York City, the price of a 45-day regimen of 2.5 mg of fondaparinux once daily ranged from $2,124 to $7,380 at four major pharmacies. Even at the lowest quoted price and considering the 98.3% estimated adherence rate, the cost of the treatment for 1,500 patients would be about $3.13 million,” they wrote.

“On the basis of the incremental 1-year costs for the medical care of a patient with a pulmonary embolus or deep-vein thrombosis, an estimated $250,000 or so in medical care costs would be averted, resulting in a net cost of fondaparinux treatment of about $2.88 million, or about $1,900 per treated patient, without any lives saved.”

No clinical trial phases assess this information. Likewise, decisions regarding Medicare reimbursement do not “consider the cost or cost-effectiveness of the agent itself or of the strategy into which it is incorporated,” wrote Dr. Goldman and Dr. Ginsberg.

“We recommend that the Food and Drug Administration give serious thought to mandating phase 3.5 trials to document the costs, the effects on quality of life, and the cost-effectiveness of new interventions so as to reach a consensus regarding their worthiness.”

DR. GOLDMAN is executive vice president of Health and Biomedical Sciences and dean of the Faculties of Health Sciences and Medicine at Columbia University, New York. DR. GINSBERG is professor of hematology and thromboembolism at McMaster University, Hamilton, Ont. They reported that they have no financial conflicts.

Daily fondaparinux significantly reduced the relative risk of symptomatic thromboembolic complications or death by 85% – without increasing the incidence of bleeding – in a study of some 3,000 patients with acute symptomatic lower-limb superficial-vein thrombosis.

“Fondaparinux also reduced the risk of symptomatic recurrence of superficial-vein thrombosis and, more important, its extension to the saphenofemoral junction – a finding that is clinically relevant because such extension is considered to increase the risk of deep-vein thrombosis and pulmonary embolism, thereby prompting escalation of therapy (for example, to full-dose anticoagulation or surgery),” Dr. Hervé Decousus and his coinvestigators reported.

The results may help fill in knowledge gaps about the appropriate treatment for superficial-vein thrombosis. Currently, therapeutic strategies range from no treatment to the use of anti-inflammatory drugs, anticoagulant agents, or even surgery.

Investigators in the study, known as the Comparison of Arixtra in Lower Limb Superficial Vein Thrombosis with Placebo (CALISTO) trial, compared the efficacy and safety of the specific factor Xa inhibitor fondaparinux with placebo in reducing symptomatic venous thromboembolic complications or death from any cause. The study comprised 3,002 patients with acute, isolated superficial-vein thrombosis of the legs (N. Engl. J. Med. 2010;363:1222-32).

Patients 18 years or older with acute, symptomatic lower-limb superficial-vein thrombosis at least 5-cm long were eligible for the study. They were excluded from the study if they met various specific criteria, such as a documented history of SVT within the past 3 months or DVT or PE within the past 6 months.

Between March 2007 and May 2009, a total of 3,002 patients were enrolled and randomized to receive 2.5 mg subcutaneous fondaparinux per day or daily subcutaneous placebo for 45 days. Overall, 1,481 patients in the fondaparinux group and 1,467 in the placebo group completed the follow-up visit at day 75, wrote Dr. Decousus of the Centre Hôpitalier Universitaire Saint-Étienne in France, and his coinvestigators.

Patients could choose whether to self-administer the injections, were encouraged to use graduated compression stockings, and were allowed to take acetaminophen or topical NSAIDs as needed. Concomitant treatment with other thrombolytic, anticoagulant, or antiplatelet agents was prohibited.

The primary efficacy outcome – the composite of death from any cause, symptomatic confirmed PE or DVT, or confirmed symptomatic extension to the saphenofemoral junction or symptomatic recurrence of superficial-vein thrombosis up to day 47 – occurred in a significantly greater percentage of those in the placebo group (5.9% vs. 0.9%; relative risk with fondaparinux, 0.15). Twenty patients would need to be treated to prevent one death, PE, DVT, extension to the saphenofemoral junction or symptomatic recurrence of superficial-vein thrombosis.

In addition, the incidence of each component of the primary efficacy outcome was significantly reduced in the fondaparinux group, except for the incidence of death, which did not differ significantly. The risk of the composite of DVT or PE was significantly reduced by 85% with fondaparinux, compared with placebo (0.2% vs. 1.3% affected in each group, respectively). To prevent one DVT or PE, 88 patients would need to be treated.

“This benefit was evident within the first days after treatment was initiated, supporting the adequacy of the prophylactic dose of 2.5 mg of fondaparinux and in accord with the substantial efficacy data already available with respect to a dose of 2.5 mg of fondaparinux in various clinical settings,” the investigators wrote.

In addition, more patients in the placebo group underwent surgery for superficial-vein thrombosis than in the fondaparinux group (3.5% vs. 0.5% by day 77), including ligation of the saphenofemoral junction. Major bleeding had occurred in one patient in each group by day 47. The rates of clinically relevant nonmajor, minor, and total bleeding and arterial thromboembolic complications did not differ significantly between groups.

The study was supported by GlaxoSmithKline, which markets Arixtra (fondaparinux). In addition, 8 of the 11 study authors reported significant financial relationships with several pharmaceutical companies, including GlaxoSmithKline.

View on the News

Consider Cost in Drug Approvals

While overall efficacy and safety information are crucial for the approval and widespread use of a new drug, so is cost effectiveness, Dr. Lee Goldman and Dr. Jeffrey Ginsberg wrote in a commentary.

The study authors determined that 88 patients would need to be treated with fondaparinux to prevent one nonfatal episode of deep-vein thrombosis or pulmonary embolism (N. Engl. J. Med. 2010;363:1278-80). “In New York City, the price of a 45-day regimen of 2.5 mg of fondaparinux once daily ranged from $2,124 to $7,380 at four major pharmacies. Even at the lowest quoted price and considering the 98.3% estimated adherence rate, the cost of the treatment for 1,500 patients would be about $3.13 million,” they wrote.

“On the basis of the incremental 1-year costs for the medical care of a patient with a pulmonary embolus or deep-vein thrombosis, an estimated $250,000 or so in medical care costs would be averted, resulting in a net cost of fondaparinux treatment of about $2.88 million, or about $1,900 per treated patient, without any lives saved.”

No clinical trial phases assess this information. Likewise, decisions regarding Medicare reimbursement do not “consider the cost or cost-effectiveness of the agent itself or of the strategy into which it is incorporated,” wrote Dr. Goldman and Dr. Ginsberg.

“We recommend that the Food and Drug Administration give serious thought to mandating phase 3.5 trials to document the costs, the effects on quality of life, and the cost-effectiveness of new interventions so as to reach a consensus regarding their worthiness.”

DR. GOLDMAN is executive vice president of Health and Biomedical Sciences and dean of the Faculties of Health Sciences and Medicine at Columbia University, New York. DR. GINSBERG is professor of hematology and thromboembolism at McMaster University, Hamilton, Ont. They reported that they have no financial conflicts.

Bone metabolism appears to change before patients show clinical signs of rheumatoid arthritis and could ultimately serve as an early marker of disease, based on a study of 79 patients with the disease.

"There appears to be an alteration in bone metabolism parallel to inflammation and autoimmunity in the asymptomatic preclinical phase of RA, which may reflect the beginning of joint destruction," Dr. Dirkjan van Schaardenburg and his coinvestigators wrote in an article in the Annals of the Rheumatic Diseases, published online on Oct. 18, 2010.

They found significantly increased average levels of only P1NP (procollagen type I intact N-terminal propeptide) and osteoprotegerin in the group of preclinical RA patients, compared with a control group of healthy individuals. Specifically, P1NP increased by 5 ng/mL and osteoprotegerin increased by 4 pmol/L (Ann. Rheum. Dis. 2010 Oct. 18 [doi:10.1136/ard.2010.135723]). P1NP promotes bone growth, and osteoprotegerin inhibits bone resorption.

Three blood samples taken 1, 2, and 5 years prior to the onset of symptoms were identified for 47 patients with RA; two samples were collected from 18 patients and one sample was collected from 14 patients. The individuals had been blood donors prior to developing the disease.

Control samples from healthy individuals who were matched for sex, age, and time of blood donation were also obtained. Osteocalcin, P1NP, beta-CTX, osteoprotegerin, and RANKL (receptor-activated nuclear factor–kappaB ligand) were measured and compared between preclinical RA patients and control individuals.

Models were corrected for age, sex, time of donation, autoantibodies (IgM rheumatoid factor and antibodies against cyclic citrullinated peptides) and markers of inflammation (C-reactive protein and secretory phospholipase A2).

Interestingly, after adjustment for age, sex, and autoantibodies, the researchers found negative associations between preclinical levels of both P1NP and osteoprotegerin and Sharp/van der Heijde scores on x-ray, although these differences were not significant.

Dr. van Schaardenburg is a rheumatologist at Jan van Breemen Institute in Amsterdam.

The study was funded by the Dutch Arthritis Association. The authors reported that they had no competing interests.

Bone metabolism appears to change before patients show clinical signs of rheumatoid arthritis and could ultimately serve as an early marker of disease, based on a study of 79 patients with the disease.

"There appears to be an alteration in bone metabolism parallel to inflammation and autoimmunity in the asymptomatic preclinical phase of RA, which may reflect the beginning of joint destruction," Dr. Dirkjan van Schaardenburg and his coinvestigators wrote in an article in the Annals of the Rheumatic Diseases, published online on Oct. 18, 2010.

They found significantly increased average levels of only P1NP (procollagen type I intact N-terminal propeptide) and osteoprotegerin in the group of preclinical RA patients, compared with a control group of healthy individuals. Specifically, P1NP increased by 5 ng/mL and osteoprotegerin increased by 4 pmol/L (Ann. Rheum. Dis. 2010 Oct. 18 [doi:10.1136/ard.2010.135723]). P1NP promotes bone growth, and osteoprotegerin inhibits bone resorption.

Three blood samples taken 1, 2, and 5 years prior to the onset of symptoms were identified for 47 patients with RA; two samples were collected from 18 patients and one sample was collected from 14 patients. The individuals had been blood donors prior to developing the disease.

Control samples from healthy individuals who were matched for sex, age, and time of blood donation were also obtained. Osteocalcin, P1NP, beta-CTX, osteoprotegerin, and RANKL (receptor-activated nuclear factor–kappaB ligand) were measured and compared between preclinical RA patients and control individuals.

Models were corrected for age, sex, time of donation, autoantibodies (IgM rheumatoid factor and antibodies against cyclic citrullinated peptides) and markers of inflammation (C-reactive protein and secretory phospholipase A2).

Interestingly, after adjustment for age, sex, and autoantibodies, the researchers found negative associations between preclinical levels of both P1NP and osteoprotegerin and Sharp/van der Heijde scores on x-ray, although these differences were not significant.

Dr. van Schaardenburg is a rheumatologist at Jan van Breemen Institute in Amsterdam.

The study was funded by the Dutch Arthritis Association. The authors reported that they had no competing interests.

Bone metabolism appears to change before patients show clinical signs of rheumatoid arthritis and could ultimately serve as an early marker of disease, based on a study of 79 patients with the disease.

"There appears to be an alteration in bone metabolism parallel to inflammation and autoimmunity in the asymptomatic preclinical phase of RA, which may reflect the beginning of joint destruction," Dr. Dirkjan van Schaardenburg and his coinvestigators wrote in an article in the Annals of the Rheumatic Diseases, published online on Oct. 18, 2010.

They found significantly increased average levels of only P1NP (procollagen type I intact N-terminal propeptide) and osteoprotegerin in the group of preclinical RA patients, compared with a control group of healthy individuals. Specifically, P1NP increased by 5 ng/mL and osteoprotegerin increased by 4 pmol/L (Ann. Rheum. Dis. 2010 Oct. 18 [doi:10.1136/ard.2010.135723]). P1NP promotes bone growth, and osteoprotegerin inhibits bone resorption.

Three blood samples taken 1, 2, and 5 years prior to the onset of symptoms were identified for 47 patients with RA; two samples were collected from 18 patients and one sample was collected from 14 patients. The individuals had been blood donors prior to developing the disease.

Control samples from healthy individuals who were matched for sex, age, and time of blood donation were also obtained. Osteocalcin, P1NP, beta-CTX, osteoprotegerin, and RANKL (receptor-activated nuclear factor–kappaB ligand) were measured and compared between preclinical RA patients and control individuals.

Models were corrected for age, sex, time of donation, autoantibodies (IgM rheumatoid factor and antibodies against cyclic citrullinated peptides) and markers of inflammation (C-reactive protein and secretory phospholipase A2).

Interestingly, after adjustment for age, sex, and autoantibodies, the researchers found negative associations between preclinical levels of both P1NP and osteoprotegerin and Sharp/van der Heijde scores on x-ray, although these differences were not significant.

Dr. van Schaardenburg is a rheumatologist at Jan van Breemen Institute in Amsterdam.

The study was funded by the Dutch Arthritis Association. The authors reported that they had no competing interests.