Michele G. Sullivan

A protocol of in-field cooling quickly followed by rapid in-hospital hypothermia positively affected neurologic outcomes in patients with cardiac arrest – even among the elderly and those with non–ventricular fibrillation arrest and cardiogenic shock.

In a prospective study of 140 patients, 56% survived to hospital discharge. Of these, 92% had positive neurologic outcomes, compared with 77% of survivors before the hospital developed its integrated hypothermia program, Dr. Michael Mooney and his colleagues reported in the July 11 issue of Circulation (doi:10.1161/circulationaha.110.986257).

The study also determined that each 1-hour delay in initiating hypothermia among out-of-hospital cardiac arrest decreased the chance of survival by 20%." Therefore, the authors wrote, "... it is recommended that therapeutic hypothermia protocols should include a prehospital cooling component. Education and resources should be directed toward emergency medical services and community hospitals to ensure execution of the simple but seemingly effective practice of initiating cooling with ice packs immediately on return of spontaneous circulation."

Dr. Mooney, director of the therapeutic hypothermia program at the Minneapolis Heart Institute, and his colleagues tracked 140 patients with out-of-hospital cardiac arrest during 2006-2009. All patients remained unresponsive despite the return of spontaneous circulation. The patients were all treated according to the hospital’s 2006 "Cool It" initiative – a multidisciplinary care system that allows EMS personnel to begin the cooling procedure after circulation returns and stresses rapid transfer to a hospital capable of therapeutic cooling.

The procedure begins with cardiac arrest guidelines established by the American Heart Association, followed by noninvasive body cooling. Ice packs are placed at the patient’s groin, head, neck, and chest during the first phase of management and transport to a Minneapolis Heart Institute–affiliated hospital.

As soon as EMS identifies a candidate patient, the complementary hospital program kicks into gear. When a patient arrives, a cardiologist and intensivist are ready to implement the standardized therapeutic cooling protocol; if the patient arrives at a nonaffiliate hospital, the emergency department staff initiates the procedure and then transfers the patient to a facility capable of complete therapeutic cooling.

The target body temperature is 33°C. After 24 hours, rewarming proceeds at a rate of 0.5° C/hour until the core temperature reaches 37°C – usually 8 hours.

The mean age of the 140 patients followed was 62 years, with 30 being older than 75 years. Most (102) had ventricular fibrillation or tachycardia; other presenting factors included asystole or pulseless electrical activity (32), ST-segment myocardial infarction (68), and cardiogenic shock (61). EMS personnel initiated some kind of cooling in 43% of the patients.

Most (75%) were taken to a hospital not equipped to administer therapeutic cooling and were transferred to one of the target facilities; the mean transfer distance was 56 miles, although some traveled up to 173 miles. The median time from return of spontaneous circulation to in-hospital cooling was 117 minutes.

Invasive cardiac interventions were performed in most of the patients, with angiography in 101 and percutaneous coronary intervention in 56.

Of the entire cohort, 78 patients (56%) survived to discharge. Of these 78 survivors, 72 (92%) had a good neurologic outcome, defined as a Cerebral Performance Category score of 1 (good) or 2 (moderate disability). Mortality and poor neurologic outcome were significantly related to advanced age (more than 75 years), asystole, or pulseless electrical activity, and cardiogenic shock.

Survival rates were not significantly different among those who arrived at a hypothermia treatment facility and those who did not (52% vs. 57%).

Two other significant prognostic factors were time between arrest to the return of spontaneous circulation and time of returned circulation to application of therapeutic cooling. A total of 36% of those with a circulatory down time of more than 30 minutes survived to hospital discharge. When therapeutic cooling began more than 2.5 hours after circulation returned, patients were 65% less likely to survive.

"When modeled continuously, the relative hazard estimate for a 1-hour increase in time from return of spontaneous circulation to first cooling was 1.20, indicating that for every 1 hour in delay to initiation of cooling, the risk of death increased by 20%," the authors wrote.

Over the study period, the authors also tracked their progress in time to cooling time. The median time from circulatory return to target temperature improved from 345 minutes to 258 minutes. The median time from circulatory return to first cooling shortened by 2 hours, "reflecting increased efforts to initiate early surface cooling," the authors said. "Through ongoing education and outreach, the proportion of cases receiving some cooling before arrival at [a therapeutic cooling facility] has risen consistently and dramatically, from [6% in year 1 to 69% in year 4]."

They said the study argues not only for expanding such a program to more regions, but also for considering a wider variety of patients as candidates, including those with poor prognostic indicators such as advanced age, nonventricular fibrillation arrest, and cardiogenic shock.

"Our work suggests that therapeutic hypothermia should be extended to these patients because, on survival, they appear to benefit substantially from the neuroprotective effects," the authors noted.

The study was sponsored by the Minneapolis Heart Institute Foundation. None of the authors declared any financial disclosures.

A protocol of in-field cooling quickly followed by rapid in-hospital hypothermia positively affected neurologic outcomes in patients with cardiac arrest – even among the elderly and those with non–ventricular fibrillation arrest and cardiogenic shock.

In a prospective study of 140 patients, 56% survived to hospital discharge. Of these, 92% had positive neurologic outcomes, compared with 77% of survivors before the hospital developed its integrated hypothermia program, Dr. Michael Mooney and his colleagues reported in the July 11 issue of Circulation (doi:10.1161/circulationaha.110.986257).

The study also determined that each 1-hour delay in initiating hypothermia among out-of-hospital cardiac arrest decreased the chance of survival by 20%." Therefore, the authors wrote, "... it is recommended that therapeutic hypothermia protocols should include a prehospital cooling component. Education and resources should be directed toward emergency medical services and community hospitals to ensure execution of the simple but seemingly effective practice of initiating cooling with ice packs immediately on return of spontaneous circulation."

Dr. Mooney, director of the therapeutic hypothermia program at the Minneapolis Heart Institute, and his colleagues tracked 140 patients with out-of-hospital cardiac arrest during 2006-2009. All patients remained unresponsive despite the return of spontaneous circulation. The patients were all treated according to the hospital’s 2006 "Cool It" initiative – a multidisciplinary care system that allows EMS personnel to begin the cooling procedure after circulation returns and stresses rapid transfer to a hospital capable of therapeutic cooling.

The procedure begins with cardiac arrest guidelines established by the American Heart Association, followed by noninvasive body cooling. Ice packs are placed at the patient’s groin, head, neck, and chest during the first phase of management and transport to a Minneapolis Heart Institute–affiliated hospital.

As soon as EMS identifies a candidate patient, the complementary hospital program kicks into gear. When a patient arrives, a cardiologist and intensivist are ready to implement the standardized therapeutic cooling protocol; if the patient arrives at a nonaffiliate hospital, the emergency department staff initiates the procedure and then transfers the patient to a facility capable of complete therapeutic cooling.

The target body temperature is 33°C. After 24 hours, rewarming proceeds at a rate of 0.5° C/hour until the core temperature reaches 37°C – usually 8 hours.

The mean age of the 140 patients followed was 62 years, with 30 being older than 75 years. Most (102) had ventricular fibrillation or tachycardia; other presenting factors included asystole or pulseless electrical activity (32), ST-segment myocardial infarction (68), and cardiogenic shock (61). EMS personnel initiated some kind of cooling in 43% of the patients.

Most (75%) were taken to a hospital not equipped to administer therapeutic cooling and were transferred to one of the target facilities; the mean transfer distance was 56 miles, although some traveled up to 173 miles. The median time from return of spontaneous circulation to in-hospital cooling was 117 minutes.

Invasive cardiac interventions were performed in most of the patients, with angiography in 101 and percutaneous coronary intervention in 56.

Of the entire cohort, 78 patients (56%) survived to discharge. Of these 78 survivors, 72 (92%) had a good neurologic outcome, defined as a Cerebral Performance Category score of 1 (good) or 2 (moderate disability). Mortality and poor neurologic outcome were significantly related to advanced age (more than 75 years), asystole, or pulseless electrical activity, and cardiogenic shock.

Survival rates were not significantly different among those who arrived at a hypothermia treatment facility and those who did not (52% vs. 57%).

Two other significant prognostic factors were time between arrest to the return of spontaneous circulation and time of returned circulation to application of therapeutic cooling. A total of 36% of those with a circulatory down time of more than 30 minutes survived to hospital discharge. When therapeutic cooling began more than 2.5 hours after circulation returned, patients were 65% less likely to survive.

"When modeled continuously, the relative hazard estimate for a 1-hour increase in time from return of spontaneous circulation to first cooling was 1.20, indicating that for every 1 hour in delay to initiation of cooling, the risk of death increased by 20%," the authors wrote.

Over the study period, the authors also tracked their progress in time to cooling time. The median time from circulatory return to target temperature improved from 345 minutes to 258 minutes. The median time from circulatory return to first cooling shortened by 2 hours, "reflecting increased efforts to initiate early surface cooling," the authors said. "Through ongoing education and outreach, the proportion of cases receiving some cooling before arrival at [a therapeutic cooling facility] has risen consistently and dramatically, from [6% in year 1 to 69% in year 4]."

They said the study argues not only for expanding such a program to more regions, but also for considering a wider variety of patients as candidates, including those with poor prognostic indicators such as advanced age, nonventricular fibrillation arrest, and cardiogenic shock.

"Our work suggests that therapeutic hypothermia should be extended to these patients because, on survival, they appear to benefit substantially from the neuroprotective effects," the authors noted.

The study was sponsored by the Minneapolis Heart Institute Foundation. None of the authors declared any financial disclosures.

A protocol of in-field cooling quickly followed by rapid in-hospital hypothermia positively affected neurologic outcomes in patients with cardiac arrest – even among the elderly and those with non–ventricular fibrillation arrest and cardiogenic shock.

In a prospective study of 140 patients, 56% survived to hospital discharge. Of these, 92% had positive neurologic outcomes, compared with 77% of survivors before the hospital developed its integrated hypothermia program, Dr. Michael Mooney and his colleagues reported in the July 11 issue of Circulation (doi:10.1161/circulationaha.110.986257).

The study also determined that each 1-hour delay in initiating hypothermia among out-of-hospital cardiac arrest decreased the chance of survival by 20%." Therefore, the authors wrote, "... it is recommended that therapeutic hypothermia protocols should include a prehospital cooling component. Education and resources should be directed toward emergency medical services and community hospitals to ensure execution of the simple but seemingly effective practice of initiating cooling with ice packs immediately on return of spontaneous circulation."

Dr. Mooney, director of the therapeutic hypothermia program at the Minneapolis Heart Institute, and his colleagues tracked 140 patients with out-of-hospital cardiac arrest during 2006-2009. All patients remained unresponsive despite the return of spontaneous circulation. The patients were all treated according to the hospital’s 2006 "Cool It" initiative – a multidisciplinary care system that allows EMS personnel to begin the cooling procedure after circulation returns and stresses rapid transfer to a hospital capable of therapeutic cooling.

The procedure begins with cardiac arrest guidelines established by the American Heart Association, followed by noninvasive body cooling. Ice packs are placed at the patient’s groin, head, neck, and chest during the first phase of management and transport to a Minneapolis Heart Institute–affiliated hospital.

As soon as EMS identifies a candidate patient, the complementary hospital program kicks into gear. When a patient arrives, a cardiologist and intensivist are ready to implement the standardized therapeutic cooling protocol; if the patient arrives at a nonaffiliate hospital, the emergency department staff initiates the procedure and then transfers the patient to a facility capable of complete therapeutic cooling.

The target body temperature is 33°C. After 24 hours, rewarming proceeds at a rate of 0.5° C/hour until the core temperature reaches 37°C – usually 8 hours.

The mean age of the 140 patients followed was 62 years, with 30 being older than 75 years. Most (102) had ventricular fibrillation or tachycardia; other presenting factors included asystole or pulseless electrical activity (32), ST-segment myocardial infarction (68), and cardiogenic shock (61). EMS personnel initiated some kind of cooling in 43% of the patients.

Most (75%) were taken to a hospital not equipped to administer therapeutic cooling and were transferred to one of the target facilities; the mean transfer distance was 56 miles, although some traveled up to 173 miles. The median time from return of spontaneous circulation to in-hospital cooling was 117 minutes.

Invasive cardiac interventions were performed in most of the patients, with angiography in 101 and percutaneous coronary intervention in 56.

Of the entire cohort, 78 patients (56%) survived to discharge. Of these 78 survivors, 72 (92%) had a good neurologic outcome, defined as a Cerebral Performance Category score of 1 (good) or 2 (moderate disability). Mortality and poor neurologic outcome were significantly related to advanced age (more than 75 years), asystole, or pulseless electrical activity, and cardiogenic shock.

Survival rates were not significantly different among those who arrived at a hypothermia treatment facility and those who did not (52% vs. 57%).

Two other significant prognostic factors were time between arrest to the return of spontaneous circulation and time of returned circulation to application of therapeutic cooling. A total of 36% of those with a circulatory down time of more than 30 minutes survived to hospital discharge. When therapeutic cooling began more than 2.5 hours after circulation returned, patients were 65% less likely to survive.

"When modeled continuously, the relative hazard estimate for a 1-hour increase in time from return of spontaneous circulation to first cooling was 1.20, indicating that for every 1 hour in delay to initiation of cooling, the risk of death increased by 20%," the authors wrote.

Over the study period, the authors also tracked their progress in time to cooling time. The median time from circulatory return to target temperature improved from 345 minutes to 258 minutes. The median time from circulatory return to first cooling shortened by 2 hours, "reflecting increased efforts to initiate early surface cooling," the authors said. "Through ongoing education and outreach, the proportion of cases receiving some cooling before arrival at [a therapeutic cooling facility] has risen consistently and dramatically, from [6% in year 1 to 69% in year 4]."

They said the study argues not only for expanding such a program to more regions, but also for considering a wider variety of patients as candidates, including those with poor prognostic indicators such as advanced age, nonventricular fibrillation arrest, and cardiogenic shock.

"Our work suggests that therapeutic hypothermia should be extended to these patients because, on survival, they appear to benefit substantially from the neuroprotective effects," the authors noted.

The study was sponsored by the Minneapolis Heart Institute Foundation. None of the authors declared any financial disclosures.

Who, what, when, where, and why are the questions to ask when a patient comes in for travel vaccinations.

Recommendations vary and must be individualized according to the traveler’s plans, said Dr. Loren Miller, director of the infection control program at Harbor-UCLA Medical Center in Torrance, Calif.

Some infections may be common worldwide, but treatment resistant in certain regions. Some vaccinations must be started weeks before travel. Some infections occur only during the dry season or in rural areas. And some are particular to patients who anticipate a vacation of sexual freedom.

"This might be awkward to ask, but you need to take a sexual history," said Dr. Miller, "Some travelers go with the express intent of having sexual activity, or at least the possibility that it might occur during their travel. For them, a hepatitis B vaccine is certainly recommended."

The first priority in any travel health consultation should focus on the easiest and most effective way to avoid the most common illness: travelers’ diarrhea. "Don’t drink tap water and don’t eat fruits and vegetables that have been rinsed under tap water is the best advice you can give," he said.

However, Dr. Miller said, prophylactic antibiotics are quite effective, reportedly cutting the rate of diarrhea from 40% to 4%. "That figure might not accurately represent what is going on in 2011, however," he cautioned. "These days, fluoroquinolones are the only agents effective in most countries, where antibiotic-resistant bacteria are common. And some of these drugs have lots of drug interactions and potential toxicities."

The Centers for Disease Control and Prevention does not recommend prophylactic treatment unless the trip is considered critical and even a short bout of diarrhea would impact its purpose. "In other words, if you’re on a peacekeeping mission for the U.S. president, take it. Others should not."

An alternative for some reliable patients is to dispense a course of treatment to take in case they come down with the illness. In that case, destination, trip duration, and planned activities are key considerations.

"I have two words for you," to prioritize travel vaccinations, Dr. Miller said: "Yellow Book. And not the one with the phone numbers."

The Yellow Book is the CDC’s interactive, online guide to travelers’ vaccines, including malaria prophylaxis. To use the book, simply click the destination on a drop-down menu. "This will take you to a map of the country and list the vaccinations you should get as well as when you should get them and whether they are required for entry into the country."

The book also includes other important information, such as details on radiation releases in Japan, or the measles outbreak seen in many countries this year.

"Prioritizing is key when planning," Dr. Miller said. "These vaccines are not cheap; to get the entire series can be really expensive and some travelers can’t, or won’t pay. Other things to consider are the patient’s own risk tolerance and the likelihood of infection. Get an idea of some of the activities; will they be mostly urban or rural? Is there adventure travel?"

Since most travel clinics are run by general practice physicians, and not infectious disease specialists, it’s important for providers to do some reading and research before dispensing advice. "For example," he said, "you should know that you can’t give any live oral vaccine along with an antibiotic, or the vaccine will be killed in the stomach."

Some of the more commonly recommended vaccines are for coverage against:

• Yellow fever. "This is single live attenuated vaccine that’s really safe. Some countries even require proof of vaccination to enter," he said. It should not be administered to people older than 70 years, and it can’t simply be ordered up from the pharmacy. "You have to apply to the state health department in order to give this vaccine," Dr. Miller noted. Endemic areas include South America and African countries.

• Japanese encephalitis. "This vaccine was introduced in 2009 and has an excellent safety and efficacy profile," he said. The disease is endemic to rural farming areas in Southeast Asia and the Indian subcontinent, but also in some temperate regions of China and Japan; it peaks in summer and fall.

• Meningococcal vaccines. One vaccine is licensed for adults of all ages, and one only for adults younger than 55 years. "The vaccine protects against most serotypes, but not all," Dr. Miller said. "We really recommend it for travel to the ‘meningitis belt’ in Africa, especially during the dry season, which is when many people make the Hajj pilgrimage."

• Typhoid. This vaccination consists of two oral, live attenuated types in pill form. The pills are taken every other day for 1 week and have to be refrigerated. "But it’s not all that effective – about 50%-80%. An intramuscular injection is available for those with contraindications to the live vaccine, like immunocompromised patients," he said.

• Rabies. "This should be given to high-risk groups, like those going on adventure travel who will spend a lot of time outdoors, or business travelers who take short, frequent trips. This is a three-dose regimen, so you need to plan well in advance of the trip," Dr. Miller advised.

He said he has had relationships with Pfizer, Cubist Pharmaceuticals, GlaxoSmithKline, and Merck. He has been a consultant with Theravance.

Who, what, when, where, and why are the questions to ask when a patient comes in for travel vaccinations.

Recommendations vary and must be individualized according to the traveler’s plans, said Dr. Loren Miller, director of the infection control program at Harbor-UCLA Medical Center in Torrance, Calif.

Some infections may be common worldwide, but treatment resistant in certain regions. Some vaccinations must be started weeks before travel. Some infections occur only during the dry season or in rural areas. And some are particular to patients who anticipate a vacation of sexual freedom.

"This might be awkward to ask, but you need to take a sexual history," said Dr. Miller, "Some travelers go with the express intent of having sexual activity, or at least the possibility that it might occur during their travel. For them, a hepatitis B vaccine is certainly recommended."

The first priority in any travel health consultation should focus on the easiest and most effective way to avoid the most common illness: travelers’ diarrhea. "Don’t drink tap water and don’t eat fruits and vegetables that have been rinsed under tap water is the best advice you can give," he said.

However, Dr. Miller said, prophylactic antibiotics are quite effective, reportedly cutting the rate of diarrhea from 40% to 4%. "That figure might not accurately represent what is going on in 2011, however," he cautioned. "These days, fluoroquinolones are the only agents effective in most countries, where antibiotic-resistant bacteria are common. And some of these drugs have lots of drug interactions and potential toxicities."

The Centers for Disease Control and Prevention does not recommend prophylactic treatment unless the trip is considered critical and even a short bout of diarrhea would impact its purpose. "In other words, if you’re on a peacekeeping mission for the U.S. president, take it. Others should not."

An alternative for some reliable patients is to dispense a course of treatment to take in case they come down with the illness. In that case, destination, trip duration, and planned activities are key considerations.

"I have two words for you," to prioritize travel vaccinations, Dr. Miller said: "Yellow Book. And not the one with the phone numbers."

The Yellow Book is the CDC’s interactive, online guide to travelers’ vaccines, including malaria prophylaxis. To use the book, simply click the destination on a drop-down menu. "This will take you to a map of the country and list the vaccinations you should get as well as when you should get them and whether they are required for entry into the country."

The book also includes other important information, such as details on radiation releases in Japan, or the measles outbreak seen in many countries this year.

"Prioritizing is key when planning," Dr. Miller said. "These vaccines are not cheap; to get the entire series can be really expensive and some travelers can’t, or won’t pay. Other things to consider are the patient’s own risk tolerance and the likelihood of infection. Get an idea of some of the activities; will they be mostly urban or rural? Is there adventure travel?"

Since most travel clinics are run by general practice physicians, and not infectious disease specialists, it’s important for providers to do some reading and research before dispensing advice. "For example," he said, "you should know that you can’t give any live oral vaccine along with an antibiotic, or the vaccine will be killed in the stomach."

Some of the more commonly recommended vaccines are for coverage against:

• Yellow fever. "This is single live attenuated vaccine that’s really safe. Some countries even require proof of vaccination to enter," he said. It should not be administered to people older than 70 years, and it can’t simply be ordered up from the pharmacy. "You have to apply to the state health department in order to give this vaccine," Dr. Miller noted. Endemic areas include South America and African countries.

• Japanese encephalitis. "This vaccine was introduced in 2009 and has an excellent safety and efficacy profile," he said. The disease is endemic to rural farming areas in Southeast Asia and the Indian subcontinent, but also in some temperate regions of China and Japan; it peaks in summer and fall.

• Meningococcal vaccines. One vaccine is licensed for adults of all ages, and one only for adults younger than 55 years. "The vaccine protects against most serotypes, but not all," Dr. Miller said. "We really recommend it for travel to the ‘meningitis belt’ in Africa, especially during the dry season, which is when many people make the Hajj pilgrimage."

• Typhoid. This vaccination consists of two oral, live attenuated types in pill form. The pills are taken every other day for 1 week and have to be refrigerated. "But it’s not all that effective – about 50%-80%. An intramuscular injection is available for those with contraindications to the live vaccine, like immunocompromised patients," he said.

• Rabies. "This should be given to high-risk groups, like those going on adventure travel who will spend a lot of time outdoors, or business travelers who take short, frequent trips. This is a three-dose regimen, so you need to plan well in advance of the trip," Dr. Miller advised.

He said he has had relationships with Pfizer, Cubist Pharmaceuticals, GlaxoSmithKline, and Merck. He has been a consultant with Theravance.

Who, what, when, where, and why are the questions to ask when a patient comes in for travel vaccinations.

Recommendations vary and must be individualized according to the traveler’s plans, said Dr. Loren Miller, director of the infection control program at Harbor-UCLA Medical Center in Torrance, Calif.

Some infections may be common worldwide, but treatment resistant in certain regions. Some vaccinations must be started weeks before travel. Some infections occur only during the dry season or in rural areas. And some are particular to patients who anticipate a vacation of sexual freedom.

"This might be awkward to ask, but you need to take a sexual history," said Dr. Miller, "Some travelers go with the express intent of having sexual activity, or at least the possibility that it might occur during their travel. For them, a hepatitis B vaccine is certainly recommended."

The first priority in any travel health consultation should focus on the easiest and most effective way to avoid the most common illness: travelers’ diarrhea. "Don’t drink tap water and don’t eat fruits and vegetables that have been rinsed under tap water is the best advice you can give," he said.

However, Dr. Miller said, prophylactic antibiotics are quite effective, reportedly cutting the rate of diarrhea from 40% to 4%. "That figure might not accurately represent what is going on in 2011, however," he cautioned. "These days, fluoroquinolones are the only agents effective in most countries, where antibiotic-resistant bacteria are common. And some of these drugs have lots of drug interactions and potential toxicities."

The Centers for Disease Control and Prevention does not recommend prophylactic treatment unless the trip is considered critical and even a short bout of diarrhea would impact its purpose. "In other words, if you’re on a peacekeeping mission for the U.S. president, take it. Others should not."

An alternative for some reliable patients is to dispense a course of treatment to take in case they come down with the illness. In that case, destination, trip duration, and planned activities are key considerations.

"I have two words for you," to prioritize travel vaccinations, Dr. Miller said: "Yellow Book. And not the one with the phone numbers."

The Yellow Book is the CDC’s interactive, online guide to travelers’ vaccines, including malaria prophylaxis. To use the book, simply click the destination on a drop-down menu. "This will take you to a map of the country and list the vaccinations you should get as well as when you should get them and whether they are required for entry into the country."

The book also includes other important information, such as details on radiation releases in Japan, or the measles outbreak seen in many countries this year.

"Prioritizing is key when planning," Dr. Miller said. "These vaccines are not cheap; to get the entire series can be really expensive and some travelers can’t, or won’t pay. Other things to consider are the patient’s own risk tolerance and the likelihood of infection. Get an idea of some of the activities; will they be mostly urban or rural? Is there adventure travel?"

Since most travel clinics are run by general practice physicians, and not infectious disease specialists, it’s important for providers to do some reading and research before dispensing advice. "For example," he said, "you should know that you can’t give any live oral vaccine along with an antibiotic, or the vaccine will be killed in the stomach."

Some of the more commonly recommended vaccines are for coverage against:

• Yellow fever. "This is single live attenuated vaccine that’s really safe. Some countries even require proof of vaccination to enter," he said. It should not be administered to people older than 70 years, and it can’t simply be ordered up from the pharmacy. "You have to apply to the state health department in order to give this vaccine," Dr. Miller noted. Endemic areas include South America and African countries.

• Japanese encephalitis. "This vaccine was introduced in 2009 and has an excellent safety and efficacy profile," he said. The disease is endemic to rural farming areas in Southeast Asia and the Indian subcontinent, but also in some temperate regions of China and Japan; it peaks in summer and fall.

• Meningococcal vaccines. One vaccine is licensed for adults of all ages, and one only for adults younger than 55 years. "The vaccine protects against most serotypes, but not all," Dr. Miller said. "We really recommend it for travel to the ‘meningitis belt’ in Africa, especially during the dry season, which is when many people make the Hajj pilgrimage."

• Typhoid. This vaccination consists of two oral, live attenuated types in pill form. The pills are taken every other day for 1 week and have to be refrigerated. "But it’s not all that effective – about 50%-80%. An intramuscular injection is available for those with contraindications to the live vaccine, like immunocompromised patients," he said.

• Rabies. "This should be given to high-risk groups, like those going on adventure travel who will spend a lot of time outdoors, or business travelers who take short, frequent trips. This is a three-dose regimen, so you need to plan well in advance of the trip," Dr. Miller advised.

He said he has had relationships with Pfizer, Cubist Pharmaceuticals, GlaxoSmithKline, and Merck. He has been a consultant with Theravance.

Who, what, when, where, and why are the questions to ask when a patient comes in for travel vaccinations.

Recommendations vary and must be individualized according to the traveler’s plans, said Dr. Loren Miller, director of the infection control program at Harbor-UCLA Medical Center in Torrance, Calif.

Some infections may be common worldwide, but treatment resistant in certain regions. Some vaccinations must be started weeks before travel. Some infections occur only during the dry season or in rural areas. And some are particular to patients who anticipate a vacation of sexual freedom.

"This might be awkward to ask, but you need to take a sexual history," said Dr. Miller, "Some travelers go with the express intent of having sexual activity, or at least the possibility that it might occur during their travel. For them, a hepatitis B vaccine is certainly recommended."

The first priority in any travel health consultation should focus on the easiest and most effective way to avoid the most common illness: travelers’ diarrhea. "Don’t drink tap water and don’t eat fruits and vegetables that have been rinsed under tap water is the best advice you can give," he said.

However, Dr. Miller said, prophylactic antibiotics are quite effective, reportedly cutting the rate of diarrhea from 40% to 4%. "That figure might not accurately represent what is going on in 2011, however," he cautioned. "These days, fluoroquinolones are the only agents effective in most countries, where antibiotic-resistant bacteria are common. And some of these drugs have lots of drug interactions and potential toxicities."

The Centers for Disease Control and Prevention does not recommend prophylactic treatment unless the trip is considered critical and even a short bout of diarrhea would impact its purpose. "In other words, if you’re on a peacekeeping mission for the U.S. president, take it. Others should not."

An alternative for some reliable patients is to dispense a course of treatment to take in case they come down with the illness. In that case, destination, trip duration, and planned activities are key considerations.

"I have two words for you," to prioritize travel vaccinations, Dr. Miller said: "Yellow Book. And not the one with the phone numbers."

The Yellow Book is the CDC’s interactive, online guide to travelers’ vaccines, including malaria prophylaxis. To use the book, simply click the destination on a drop-down menu. "This will take you to a map of the country and list the vaccinations you should get as well as when you should get them and whether they are required for entry into the country."

The book also includes other important information, such as details on radiation releases in Japan, or the measles outbreak seen in many countries this year.

"Prioritizing is key when planning," Dr. Miller said. "These vaccines are not cheap; to get the entire series can be really expensive and some travelers can’t, or won’t pay. Other things to consider are the patient’s own risk tolerance and the likelihood of infection. Get an idea of some of the activities; will they be mostly urban or rural? Is there adventure travel?"

Since most travel clinics are run by general practice physicians, and not infectious disease specialists, it’s important for providers to do some reading and research before dispensing advice. "For example," he said, "you should know that you can’t give any live oral vaccine along with an antibiotic, or the vaccine will be killed in the stomach."

Some of the more commonly recommended vaccines are for coverage against:

• Yellow fever. "This is single live attenuated vaccine that’s really safe. Some countries even require proof of vaccination to enter," he said. It should not be administered to people older than 70 years, and it can’t simply be ordered up from the pharmacy. "You have to apply to the state health department in order to give this vaccine," Dr. Miller noted. Endemic areas include South America and African countries.

• Japanese encephalitis. "This vaccine was introduced in 2009 and has an excellent safety and efficacy profile," he said. The disease is endemic to rural farming areas in Southeast Asia and the Indian subcontinent, but also in some temperate regions of China and Japan; it peaks in summer and fall.

• Meningococcal vaccines. One vaccine is licensed for adults of all ages, and one only for adults younger than 55 years. "The vaccine protects against most serotypes, but not all," Dr. Miller said. "We really recommend it for travel to the ‘meningitis belt’ in Africa, especially during the dry season, which is when many people make the Hajj pilgrimage."

• Typhoid. This vaccination consists of two oral, live attenuated types in pill form. The pills are taken every other day for 1 week and have to be refrigerated. "But it’s not all that effective – about 50%-80%. An intramuscular injection is available for those with contraindications to the live vaccine, like immunocompromised patients," he said.

• Rabies. "This should be given to high-risk groups, like those going on adventure travel who will spend a lot of time outdoors, or business travelers who take short, frequent trips. This is a three-dose regimen, so you need to plan well in advance of the trip," Dr. Miller advised.

He said he has had relationships with Pfizer, Cubist Pharmaceuticals, GlaxoSmithKline, and Merck. He has been a consultant with Theravance.

Who, what, when, where, and why are the questions to ask when a patient comes in for travel vaccinations.

Recommendations vary and must be individualized according to the traveler’s plans, said Dr. Loren Miller, director of the infection control program at Harbor-UCLA Medical Center in Torrance, Calif.

Some infections may be common worldwide, but treatment resistant in certain regions. Some vaccinations must be started weeks before travel. Some infections occur only during the dry season or in rural areas. And some are particular to patients who anticipate a vacation of sexual freedom.

"This might be awkward to ask, but you need to take a sexual history," said Dr. Miller, "Some travelers go with the express intent of having sexual activity, or at least the possibility that it might occur during their travel. For them, a hepatitis B vaccine is certainly recommended."

The first priority in any travel health consultation should focus on the easiest and most effective way to avoid the most common illness: travelers’ diarrhea. "Don’t drink tap water and don’t eat fruits and vegetables that have been rinsed under tap water is the best advice you can give," he said.

However, Dr. Miller said, prophylactic antibiotics are quite effective, reportedly cutting the rate of diarrhea from 40% to 4%. "That figure might not accurately represent what is going on in 2011, however," he cautioned. "These days, fluoroquinolones are the only agents effective in most countries, where antibiotic-resistant bacteria are common. And some of these drugs have lots of drug interactions and potential toxicities."

The Centers for Disease Control and Prevention does not recommend prophylactic treatment unless the trip is considered critical and even a short bout of diarrhea would impact its purpose. "In other words, if you’re on a peacekeeping mission for the U.S. president, take it. Others should not."

An alternative for some reliable patients is to dispense a course of treatment to take in case they come down with the illness. In that case, destination, trip duration, and planned activities are key considerations.

"I have two words for you," to prioritize travel vaccinations, Dr. Miller said: "Yellow Book. And not the one with the phone numbers."

The Yellow Book is the CDC’s interactive, online guide to travelers’ vaccines, including malaria prophylaxis. To use the book, simply click the destination on a drop-down menu. "This will take you to a map of the country and list the vaccinations you should get as well as when you should get them and whether they are required for entry into the country."

The book also includes other important information, such as details on radiation releases in Japan, or the measles outbreak seen in many countries this year.

"Prioritizing is key when planning," Dr. Miller said. "These vaccines are not cheap; to get the entire series can be really expensive and some travelers can’t, or won’t pay. Other things to consider are the patient’s own risk tolerance and the likelihood of infection. Get an idea of some of the activities; will they be mostly urban or rural? Is there adventure travel?"

Since most travel clinics are run by general practice physicians, and not infectious disease specialists, it’s important for providers to do some reading and research before dispensing advice. "For example," he said, "you should know that you can’t give any live oral vaccine along with an antibiotic, or the vaccine will be killed in the stomach."

Some of the more commonly recommended vaccines are for coverage against:

• Yellow fever. "This is single live attenuated vaccine that’s really safe. Some countries even require proof of vaccination to enter," he said. It should not be administered to people older than 70 years, and it can’t simply be ordered up from the pharmacy. "You have to apply to the state health department in order to give this vaccine," Dr. Miller noted. Endemic areas include South America and African countries.

• Japanese encephalitis. "This vaccine was introduced in 2009 and has an excellent safety and efficacy profile," he said. The disease is endemic to rural farming areas in Southeast Asia and the Indian subcontinent, but also in some temperate regions of China and Japan; it peaks in summer and fall.

• Meningococcal vaccines. One vaccine is licensed for adults of all ages, and one only for adults younger than 55 years. "The vaccine protects against most serotypes, but not all," Dr. Miller said. "We really recommend it for travel to the ‘meningitis belt’ in Africa, especially during the dry season, which is when many people make the Hajj pilgrimage."

• Typhoid. This vaccination consists of two oral, live attenuated types in pill form. The pills are taken every other day for 1 week and have to be refrigerated. "But it’s not all that effective – about 50%-80%. An intramuscular injection is available for those with contraindications to the live vaccine, like immunocompromised patients," he said.

• Rabies. "This should be given to high-risk groups, like those going on adventure travel who will spend a lot of time outdoors, or business travelers who take short, frequent trips. This is a three-dose regimen, so you need to plan well in advance of the trip," Dr. Miller advised.

He said he has had relationships with Pfizer, Cubist Pharmaceuticals, GlaxoSmithKline, and Merck. He has been a consultant with Theravance.

Who, what, when, where, and why are the questions to ask when a patient comes in for travel vaccinations.

Recommendations vary and must be individualized according to the traveler’s plans, said Dr. Loren Miller, director of the infection control program at Harbor-UCLA Medical Center in Torrance, Calif.

Some infections may be common worldwide, but treatment resistant in certain regions. Some vaccinations must be started weeks before travel. Some infections occur only during the dry season or in rural areas. And some are particular to patients who anticipate a vacation of sexual freedom.

"This might be awkward to ask, but you need to take a sexual history," said Dr. Miller, "Some travelers go with the express intent of having sexual activity, or at least the possibility that it might occur during their travel. For them, a hepatitis B vaccine is certainly recommended."

The first priority in any travel health consultation should focus on the easiest and most effective way to avoid the most common illness: travelers’ diarrhea. "Don’t drink tap water and don’t eat fruits and vegetables that have been rinsed under tap water is the best advice you can give," he said.

However, Dr. Miller said, prophylactic antibiotics are quite effective, reportedly cutting the rate of diarrhea from 40% to 4%. "That figure might not accurately represent what is going on in 2011, however," he cautioned. "These days, fluoroquinolones are the only agents effective in most countries, where antibiotic-resistant bacteria are common. And some of these drugs have lots of drug interactions and potential toxicities."

The Centers for Disease Control and Prevention does not recommend prophylactic treatment unless the trip is considered critical and even a short bout of diarrhea would impact its purpose. "In other words, if you’re on a peacekeeping mission for the U.S. president, take it. Others should not."

An alternative for some reliable patients is to dispense a course of treatment to take in case they come down with the illness. In that case, destination, trip duration, and planned activities are key considerations.

"I have two words for you," to prioritize travel vaccinations, Dr. Miller said: "Yellow Book. And not the one with the phone numbers."

The Yellow Book is the CDC’s interactive, online guide to travelers’ vaccines, including malaria prophylaxis. To use the book, simply click the destination on a drop-down menu. "This will take you to a map of the country and list the vaccinations you should get as well as when you should get them and whether they are required for entry into the country."

The book also includes other important information, such as details on radiation releases in Japan, or the measles outbreak seen in many countries this year.

"Prioritizing is key when planning," Dr. Miller said. "These vaccines are not cheap; to get the entire series can be really expensive and some travelers can’t, or won’t pay. Other things to consider are the patient’s own risk tolerance and the likelihood of infection. Get an idea of some of the activities; will they be mostly urban or rural? Is there adventure travel?"

Since most travel clinics are run by general practice physicians, and not infectious disease specialists, it’s important for providers to do some reading and research before dispensing advice. "For example," he said, "you should know that you can’t give any live oral vaccine along with an antibiotic, or the vaccine will be killed in the stomach."

Some of the more commonly recommended vaccines are for coverage against:

• Yellow fever. "This is single live attenuated vaccine that’s really safe. Some countries even require proof of vaccination to enter," he said. It should not be administered to people older than 70 years, and it can’t simply be ordered up from the pharmacy. "You have to apply to the state health department in order to give this vaccine," Dr. Miller noted. Endemic areas include South America and African countries.

• Japanese encephalitis. "This vaccine was introduced in 2009 and has an excellent safety and efficacy profile," he said. The disease is endemic to rural farming areas in Southeast Asia and the Indian subcontinent, but also in some temperate regions of China and Japan; it peaks in summer and fall.

• Meningococcal vaccines. One vaccine is licensed for adults of all ages, and one only for adults younger than 55 years. "The vaccine protects against most serotypes, but not all," Dr. Miller said. "We really recommend it for travel to the ‘meningitis belt’ in Africa, especially during the dry season, which is when many people make the Hajj pilgrimage."

• Typhoid. This vaccination consists of two oral, live attenuated types in pill form. The pills are taken every other day for 1 week and have to be refrigerated. "But it’s not all that effective – about 50%-80%. An intramuscular injection is available for those with contraindications to the live vaccine, like immunocompromised patients," he said.

• Rabies. "This should be given to high-risk groups, like those going on adventure travel who will spend a lot of time outdoors, or business travelers who take short, frequent trips. This is a three-dose regimen, so you need to plan well in advance of the trip," Dr. Miller advised.

He said he has had relationships with Pfizer, Cubist Pharmaceuticals, GlaxoSmithKline, and Merck. He has been a consultant with Theravance.

Who, what, when, where, and why are the questions to ask when a patient comes in for travel vaccinations.

Recommendations vary and must be individualized according to the traveler’s plans, said Dr. Loren Miller, director of the infection control program at Harbor-UCLA Medical Center in Torrance, Calif.

Some infections may be common worldwide, but treatment resistant in certain regions. Some vaccinations must be started weeks before travel. Some infections occur only during the dry season or in rural areas. And some are particular to patients who anticipate a vacation of sexual freedom.

"This might be awkward to ask, but you need to take a sexual history," said Dr. Miller, "Some travelers go with the express intent of having sexual activity, or at least the possibility that it might occur during their travel. For them, a hepatitis B vaccine is certainly recommended."

The first priority in any travel health consultation should focus on the easiest and most effective way to avoid the most common illness: travelers’ diarrhea. "Don’t drink tap water and don’t eat fruits and vegetables that have been rinsed under tap water is the best advice you can give," he said.

However, Dr. Miller said, prophylactic antibiotics are quite effective, reportedly cutting the rate of diarrhea from 40% to 4%. "That figure might not accurately represent what is going on in 2011, however," he cautioned. "These days, fluoroquinolones are the only agents effective in most countries, where antibiotic-resistant bacteria are common. And some of these drugs have lots of drug interactions and potential toxicities."

The Centers for Disease Control and Prevention does not recommend prophylactic treatment unless the trip is considered critical and even a short bout of diarrhea would impact its purpose. "In other words, if you’re on a peacekeeping mission for the U.S. president, take it. Others should not."

An alternative for some reliable patients is to dispense a course of treatment to take in case they come down with the illness. In that case, destination, trip duration, and planned activities are key considerations.

"I have two words for you," to prioritize travel vaccinations, Dr. Miller said: "Yellow Book. And not the one with the phone numbers."

The Yellow Book is the CDC’s interactive, online guide to travelers’ vaccines, including malaria prophylaxis. To use the book, simply click the destination on a drop-down menu. "This will take you to a map of the country and list the vaccinations you should get as well as when you should get them and whether they are required for entry into the country."

The book also includes other important information, such as details on radiation releases in Japan, or the measles outbreak seen in many countries this year.

"Prioritizing is key when planning," Dr. Miller said. "These vaccines are not cheap; to get the entire series can be really expensive and some travelers can’t, or won’t pay. Other things to consider are the patient’s own risk tolerance and the likelihood of infection. Get an idea of some of the activities; will they be mostly urban or rural? Is there adventure travel?"

Since most travel clinics are run by general practice physicians, and not infectious disease specialists, it’s important for providers to do some reading and research before dispensing advice. "For example," he said, "you should know that you can’t give any live oral vaccine along with an antibiotic, or the vaccine will be killed in the stomach."

Some of the more commonly recommended vaccines are for coverage against:

• Yellow fever. "This is single live attenuated vaccine that’s really safe. Some countries even require proof of vaccination to enter," he said. It should not be administered to people older than 70 years, and it can’t simply be ordered up from the pharmacy. "You have to apply to the state health department in order to give this vaccine," Dr. Miller noted. Endemic areas include South America and African countries.

• Japanese encephalitis. "This vaccine was introduced in 2009 and has an excellent safety and efficacy profile," he said. The disease is endemic to rural farming areas in Southeast Asia and the Indian subcontinent, but also in some temperate regions of China and Japan; it peaks in summer and fall.

• Meningococcal vaccines. One vaccine is licensed for adults of all ages, and one only for adults younger than 55 years. "The vaccine protects against most serotypes, but not all," Dr. Miller said. "We really recommend it for travel to the ‘meningitis belt’ in Africa, especially during the dry season, which is when many people make the Hajj pilgrimage."

• Typhoid. This vaccination consists of two oral, live attenuated types in pill form. The pills are taken every other day for 1 week and have to be refrigerated. "But it’s not all that effective – about 50%-80%. An intramuscular injection is available for those with contraindications to the live vaccine, like immunocompromised patients," he said.

• Rabies. "This should be given to high-risk groups, like those going on adventure travel who will spend a lot of time outdoors, or business travelers who take short, frequent trips. This is a three-dose regimen, so you need to plan well in advance of the trip," Dr. Miller advised.

He said he has had relationships with Pfizer, Cubist Pharmaceuticals, GlaxoSmithKline, and Merck. He has been a consultant with Theravance.

Who, what, when, where, and why are the questions to ask when a patient comes in for travel vaccinations.

Recommendations vary and must be individualized according to the traveler’s plans, said Dr. Loren Miller, director of the infection control program at Harbor-UCLA Medical Center in Torrance, Calif.

Some infections may be common worldwide, but treatment resistant in certain regions. Some vaccinations must be started weeks before travel. Some infections occur only during the dry season or in rural areas. And some are particular to patients who anticipate a vacation of sexual freedom.

"This might be awkward to ask, but you need to take a sexual history," said Dr. Miller, "Some travelers go with the express intent of having sexual activity, or at least the possibility that it might occur during their travel. For them, a hepatitis B vaccine is certainly recommended."

The first priority in any travel health consultation should focus on the easiest and most effective way to avoid the most common illness: travelers’ diarrhea. "Don’t drink tap water and don’t eat fruits and vegetables that have been rinsed under tap water is the best advice you can give," he said.

However, Dr. Miller said, prophylactic antibiotics are quite effective, reportedly cutting the rate of diarrhea from 40% to 4%. "That figure might not accurately represent what is going on in 2011, however," he cautioned. "These days, fluoroquinolones are the only agents effective in most countries, where antibiotic-resistant bacteria are common. And some of these drugs have lots of drug interactions and potential toxicities."

The Centers for Disease Control and Prevention does not recommend prophylactic treatment unless the trip is considered critical and even a short bout of diarrhea would impact its purpose. "In other words, if you’re on a peacekeeping mission for the U.S. president, take it. Others should not."

An alternative for some reliable patients is to dispense a course of treatment to take in case they come down with the illness. In that case, destination, trip duration, and planned activities are key considerations.

"I have two words for you," to prioritize travel vaccinations, Dr. Miller said: "Yellow Book. And not the one with the phone numbers."

The Yellow Book is the CDC’s interactive, online guide to travelers’ vaccines, including malaria prophylaxis. To use the book, simply click the destination on a drop-down menu. "This will take you to a map of the country and list the vaccinations you should get as well as when you should get them and whether they are required for entry into the country."

The book also includes other important information, such as details on radiation releases in Japan, or the measles outbreak seen in many countries this year.

"Prioritizing is key when planning," Dr. Miller said. "These vaccines are not cheap; to get the entire series can be really expensive and some travelers can’t, or won’t pay. Other things to consider are the patient’s own risk tolerance and the likelihood of infection. Get an idea of some of the activities; will they be mostly urban or rural? Is there adventure travel?"

Since most travel clinics are run by general practice physicians, and not infectious disease specialists, it’s important for providers to do some reading and research before dispensing advice. "For example," he said, "you should know that you can’t give any live oral vaccine along with an antibiotic, or the vaccine will be killed in the stomach."

Some of the more commonly recommended vaccines are for coverage against:

• Yellow fever. "This is single live attenuated vaccine that’s really safe. Some countries even require proof of vaccination to enter," he said. It should not be administered to people older than 70 years, and it can’t simply be ordered up from the pharmacy. "You have to apply to the state health department in order to give this vaccine," Dr. Miller noted. Endemic areas include South America and African countries.

• Japanese encephalitis. "This vaccine was introduced in 2009 and has an excellent safety and efficacy profile," he said. The disease is endemic to rural farming areas in Southeast Asia and the Indian subcontinent, but also in some temperate regions of China and Japan; it peaks in summer and fall.

• Meningococcal vaccines. One vaccine is licensed for adults of all ages, and one only for adults younger than 55 years. "The vaccine protects against most serotypes, but not all," Dr. Miller said. "We really recommend it for travel to the ‘meningitis belt’ in Africa, especially during the dry season, which is when many people make the Hajj pilgrimage."

• Typhoid. This vaccination consists of two oral, live attenuated types in pill form. The pills are taken every other day for 1 week and have to be refrigerated. "But it’s not all that effective – about 50%-80%. An intramuscular injection is available for those with contraindications to the live vaccine, like immunocompromised patients," he said.

• Rabies. "This should be given to high-risk groups, like those going on adventure travel who will spend a lot of time outdoors, or business travelers who take short, frequent trips. This is a three-dose regimen, so you need to plan well in advance of the trip," Dr. Miller advised.

He said he has had relationships with Pfizer, Cubist Pharmaceuticals, GlaxoSmithKline, and Merck. He has been a consultant with Theravance.

Who, what, when, where, and why are the questions to ask when a patient comes in for travel vaccinations.

Recommendations vary and must be individualized according to the traveler’s plans, said Dr. Loren Miller, director of the infection control program at Harbor-UCLA Medical Center in Torrance, Calif.

Some infections may be common worldwide, but treatment resistant in certain regions. Some vaccinations must be started weeks before travel. Some infections occur only during the dry season or in rural areas. And some are particular to patients who anticipate a vacation of sexual freedom.

"This might be awkward to ask, but you need to take a sexual history," said Dr. Miller, "Some travelers go with the express intent of having sexual activity, or at least the possibility that it might occur during their travel. For them, a hepatitis B vaccine is certainly recommended."

The first priority in any travel health consultation should focus on the easiest and most effective way to avoid the most common illness: travelers’ diarrhea. "Don’t drink tap water and don’t eat fruits and vegetables that have been rinsed under tap water is the best advice you can give," he said.

However, Dr. Miller said, prophylactic antibiotics are quite effective, reportedly cutting the rate of diarrhea from 40% to 4%. "That figure might not accurately represent what is going on in 2011, however," he cautioned. "These days, fluoroquinolones are the only agents effective in most countries, where antibiotic-resistant bacteria are common. And some of these drugs have lots of drug interactions and potential toxicities."

The Centers for Disease Control and Prevention does not recommend prophylactic treatment unless the trip is considered critical and even a short bout of diarrhea would impact its purpose. "In other words, if you’re on a peacekeeping mission for the U.S. president, take it. Others should not."

An alternative for some reliable patients is to dispense a course of treatment to take in case they come down with the illness. In that case, destination, trip duration, and planned activities are key considerations.

"I have two words for you," to prioritize travel vaccinations, Dr. Miller said: "Yellow Book. And not the one with the phone numbers."

The Yellow Book is the CDC’s interactive, online guide to travelers’ vaccines, including malaria prophylaxis. To use the book, simply click the destination on a drop-down menu. "This will take you to a map of the country and list the vaccinations you should get as well as when you should get them and whether they are required for entry into the country."

The book also includes other important information, such as details on radiation releases in Japan, or the measles outbreak seen in many countries this year.

"Prioritizing is key when planning," Dr. Miller said. "These vaccines are not cheap; to get the entire series can be really expensive and some travelers can’t, or won’t pay. Other things to consider are the patient’s own risk tolerance and the likelihood of infection. Get an idea of some of the activities; will they be mostly urban or rural? Is there adventure travel?"

Since most travel clinics are run by general practice physicians, and not infectious disease specialists, it’s important for providers to do some reading and research before dispensing advice. "For example," he said, "you should know that you can’t give any live oral vaccine along with an antibiotic, or the vaccine will be killed in the stomach."

Some of the more commonly recommended vaccines are for coverage against:

• Yellow fever. "This is single live attenuated vaccine that’s really safe. Some countries even require proof of vaccination to enter," he said. It should not be administered to people older than 70 years, and it can’t simply be ordered up from the pharmacy. "You have to apply to the state health department in order to give this vaccine," Dr. Miller noted. Endemic areas include South America and African countries.

• Japanese encephalitis. "This vaccine was introduced in 2009 and has an excellent safety and efficacy profile," he said. The disease is endemic to rural farming areas in Southeast Asia and the Indian subcontinent, but also in some temperate regions of China and Japan; it peaks in summer and fall.

• Meningococcal vaccines. One vaccine is licensed for adults of all ages, and one only for adults younger than 55 years. "The vaccine protects against most serotypes, but not all," Dr. Miller said. "We really recommend it for travel to the ‘meningitis belt’ in Africa, especially during the dry season, which is when many people make the Hajj pilgrimage."

• Typhoid. This vaccination consists of two oral, live attenuated types in pill form. The pills are taken every other day for 1 week and have to be refrigerated. "But it’s not all that effective – about 50%-80%. An intramuscular injection is available for those with contraindications to the live vaccine, like immunocompromised patients," he said.

• Rabies. "This should be given to high-risk groups, like those going on adventure travel who will spend a lot of time outdoors, or business travelers who take short, frequent trips. This is a three-dose regimen, so you need to plan well in advance of the trip," Dr. Miller advised.

He said he has had relationships with Pfizer, Cubist Pharmaceuticals, GlaxoSmithKline, and Merck. He has been a consultant with Theravance.

It’s never too late for a pregnant woman to stop smoking.

After reviewing the records of more than 50,000 pregnancies, Dr. Nick Macklon concluded that every day a pregnant woman doesn’t smoke is a good day for her developing baby.

"The more a woman smokes during pregnancy, the worse the effect on the baby," Dr. Macklon said during a press briefing at the annual meeting of the European Society of Human Reproduction and Embryology. "But stopping – even at the time a woman discovers she’s pregnant – can completely ameliorate the effects of smoking" on the fetal outcomes of gestational age and birth weight. "For the baby, a mom stopping in the periconceptional phase is as good as her never having smoked at all."

Smoking among pregnant women affects more than the health of mother and child, said Dr. Macklon of the University of Southampton, England.

"We all know that smoking is bad for babies, increasing the rates of stillbirth, neonatal death, congenital malformations, preterm birth, and low birth weight – causing hardship to both parents and child. But it is also a significant public health issue in terms of cost."

Dr. Macklon and his associates reviewed the records of 50,000 women who gave birth at Southampton hospitals from 2002 to 2010. Women were divided into seven groups, depending on how much they smoked: never, stopped in the last year, stopped more than 1 year ago, stopped at confirmation of pregnancy, and current smokers of up to 10 cigarettes each day, 10-20 each day, and more than 20. About 12,000 women decided to stop smoking when they discovered their pregnancy.

For nonsmokers, the mean gestational age at birth was 280 days – significantly longer than for those who smoked up to 10 cigarettes/day (279 days), 10-20/day (277 days), and 20 or more/day (276 days).

The gestational age of infants whose mothers ceased smoking a year or longer before birth was the same as those of never-smoking mothers. The surprise, Dr. Macklon said, was that the gestational age of infants whose mothers who gave up cigarettes only when they became pregnant was exactly the same as the infants of never-smokers. This relationship remained significant even after the researchers corrected for other factors that affect gestational age, including education and socioeconomic status.

Birth weight also showed a similar relationship with smoking. The infants of current smokers were significantly smaller were than those of nonsmokers, as well as those who had quit a year or more before giving birth.

Mothers who smoked up to 10 cigarettes/day had infants with a mean birth weight of 3.25 kg; mothers who smoked 10-20 cigarettes/day had infants weighing a mean 3.2 kg; and the infants of women who smoked more than 20 cigarettes/day weighed in at a mean 3.1 kg.

"This effect is quite substantial, with a difference of more than 300 grams," Dr. Macklon noted.

Again, however, mothers who quit smoking as soon as they became pregnant conferred a significant benefit on their infants; these infants weighed a mean 3.4 kg – the same as those of women who had never smoked.

The findings shouldn’t be construed as a free license to smoke until conception, he warned. "Many women don’t plan their pregnancies and if they come in smoking and pregnant and we tell them it’s too late to do anything, this sends a negative, and unnecessary, message. What we can now say is ‘If you stop smoking now, you and your baby will get a major health benefit.’ "

Smoking directly affects transplacental oxygen and nutrient flow, contributing to low birth weight and premature delivery. But couples who want to conceive should stop smoking for other reasons as well, Dr. Macklon advised.

"Smoking is a contraceptive. It’s been shown to reduce the success of in vitro fertilization by at least 50%. Smoking affects the male partner as well, lowering fertility by impairing the DNA of sperm. Couples who want to conceive quickly and healthily should both stop smoking."

Cigarette smoke contains about 4,000 known chemicals, Dr. Macklon said. "It’s reasonable to assume that at least some of these have effects on fertility, miscarriage, and the health of babies."

For women who want to quit before or during pregnancy, nicotine replacement therapy is a good choice. "It’s far less toxic than smoking, and even if we can’t get a patient to stop completely I would support its use."

Dr. Macklon said he had no relevant financial disclosures.

It’s never too late for a pregnant woman to stop smoking.

After reviewing the records of more than 50,000 pregnancies, Dr. Nick Macklon concluded that every day a pregnant woman doesn’t smoke is a good day for her developing baby.

"The more a woman smokes during pregnancy, the worse the effect on the baby," Dr. Macklon said during a press briefing at the annual meeting of the European Society of Human Reproduction and Embryology. "But stopping – even at the time a woman discovers she’s pregnant – can completely ameliorate the effects of smoking" on the fetal outcomes of gestational age and birth weight. "For the baby, a mom stopping in the periconceptional phase is as good as her never having smoked at all."

Smoking among pregnant women affects more than the health of mother and child, said Dr. Macklon of the University of Southampton, England.

"We all know that smoking is bad for babies, increasing the rates of stillbirth, neonatal death, congenital malformations, preterm birth, and low birth weight – causing hardship to both parents and child. But it is also a significant public health issue in terms of cost."

Dr. Macklon and his associates reviewed the records of 50,000 women who gave birth at Southampton hospitals from 2002 to 2010. Women were divided into seven groups, depending on how much they smoked: never, stopped in the last year, stopped more than 1 year ago, stopped at confirmation of pregnancy, and current smokers of up to 10 cigarettes each day, 10-20 each day, and more than 20. About 12,000 women decided to stop smoking when they discovered their pregnancy.

For nonsmokers, the mean gestational age at birth was 280 days – significantly longer than for those who smoked up to 10 cigarettes/day (279 days), 10-20/day (277 days), and 20 or more/day (276 days).

The gestational age of infants whose mothers ceased smoking a year or longer before birth was the same as those of never-smoking mothers. The surprise, Dr. Macklon said, was that the gestational age of infants whose mothers who gave up cigarettes only when they became pregnant was exactly the same as the infants of never-smokers. This relationship remained significant even after the researchers corrected for other factors that affect gestational age, including education and socioeconomic status.

Birth weight also showed a similar relationship with smoking. The infants of current smokers were significantly smaller were than those of nonsmokers, as well as those who had quit a year or more before giving birth.

Mothers who smoked up to 10 cigarettes/day had infants with a mean birth weight of 3.25 kg; mothers who smoked 10-20 cigarettes/day had infants weighing a mean 3.2 kg; and the infants of women who smoked more than 20 cigarettes/day weighed in at a mean 3.1 kg.

"This effect is quite substantial, with a difference of more than 300 grams," Dr. Macklon noted.

Again, however, mothers who quit smoking as soon as they became pregnant conferred a significant benefit on their infants; these infants weighed a mean 3.4 kg – the same as those of women who had never smoked.

The findings shouldn’t be construed as a free license to smoke until conception, he warned. "Many women don’t plan their pregnancies and if they come in smoking and pregnant and we tell them it’s too late to do anything, this sends a negative, and unnecessary, message. What we can now say is ‘If you stop smoking now, you and your baby will get a major health benefit.’ "

Smoking directly affects transplacental oxygen and nutrient flow, contributing to low birth weight and premature delivery. But couples who want to conceive should stop smoking for other reasons as well, Dr. Macklon advised.

"Smoking is a contraceptive. It’s been shown to reduce the success of in vitro fertilization by at least 50%. Smoking affects the male partner as well, lowering fertility by impairing the DNA of sperm. Couples who want to conceive quickly and healthily should both stop smoking."

Cigarette smoke contains about 4,000 known chemicals, Dr. Macklon said. "It’s reasonable to assume that at least some of these have effects on fertility, miscarriage, and the health of babies."

For women who want to quit before or during pregnancy, nicotine replacement therapy is a good choice. "It’s far less toxic than smoking, and even if we can’t get a patient to stop completely I would support its use."

Dr. Macklon said he had no relevant financial disclosures.

It’s never too late for a pregnant woman to stop smoking.

After reviewing the records of more than 50,000 pregnancies, Dr. Nick Macklon concluded that every day a pregnant woman doesn’t smoke is a good day for her developing baby.

"The more a woman smokes during pregnancy, the worse the effect on the baby," Dr. Macklon said during a press briefing at the annual meeting of the European Society of Human Reproduction and Embryology. "But stopping – even at the time a woman discovers she’s pregnant – can completely ameliorate the effects of smoking" on the fetal outcomes of gestational age and birth weight. "For the baby, a mom stopping in the periconceptional phase is as good as her never having smoked at all."

Smoking among pregnant women affects more than the health of mother and child, said Dr. Macklon of the University of Southampton, England.

"We all know that smoking is bad for babies, increasing the rates of stillbirth, neonatal death, congenital malformations, preterm birth, and low birth weight – causing hardship to both parents and child. But it is also a significant public health issue in terms of cost."

Dr. Macklon and his associates reviewed the records of 50,000 women who gave birth at Southampton hospitals from 2002 to 2010. Women were divided into seven groups, depending on how much they smoked: never, stopped in the last year, stopped more than 1 year ago, stopped at confirmation of pregnancy, and current smokers of up to 10 cigarettes each day, 10-20 each day, and more than 20. About 12,000 women decided to stop smoking when they discovered their pregnancy.

For nonsmokers, the mean gestational age at birth was 280 days – significantly longer than for those who smoked up to 10 cigarettes/day (279 days), 10-20/day (277 days), and 20 or more/day (276 days).

The gestational age of infants whose mothers ceased smoking a year or longer before birth was the same as those of never-smoking mothers. The surprise, Dr. Macklon said, was that the gestational age of infants whose mothers who gave up cigarettes only when they became pregnant was exactly the same as the infants of never-smokers. This relationship remained significant even after the researchers corrected for other factors that affect gestational age, including education and socioeconomic status.

Birth weight also showed a similar relationship with smoking. The infants of current smokers were significantly smaller were than those of nonsmokers, as well as those who had quit a year or more before giving birth.

Mothers who smoked up to 10 cigarettes/day had infants with a mean birth weight of 3.25 kg; mothers who smoked 10-20 cigarettes/day had infants weighing a mean 3.2 kg; and the infants of women who smoked more than 20 cigarettes/day weighed in at a mean 3.1 kg.

"This effect is quite substantial, with a difference of more than 300 grams," Dr. Macklon noted.

Again, however, mothers who quit smoking as soon as they became pregnant conferred a significant benefit on their infants; these infants weighed a mean 3.4 kg – the same as those of women who had never smoked.

The findings shouldn’t be construed as a free license to smoke until conception, he warned. "Many women don’t plan their pregnancies and if they come in smoking and pregnant and we tell them it’s too late to do anything, this sends a negative, and unnecessary, message. What we can now say is ‘If you stop smoking now, you and your baby will get a major health benefit.’ "

Smoking directly affects transplacental oxygen and nutrient flow, contributing to low birth weight and premature delivery. But couples who want to conceive should stop smoking for other reasons as well, Dr. Macklon advised.

"Smoking is a contraceptive. It’s been shown to reduce the success of in vitro fertilization by at least 50%. Smoking affects the male partner as well, lowering fertility by impairing the DNA of sperm. Couples who want to conceive quickly and healthily should both stop smoking."

Cigarette smoke contains about 4,000 known chemicals, Dr. Macklon said. "It’s reasonable to assume that at least some of these have effects on fertility, miscarriage, and the health of babies."

For women who want to quit before or during pregnancy, nicotine replacement therapy is a good choice. "It’s far less toxic than smoking, and even if we can’t get a patient to stop completely I would support its use."

Dr. Macklon said he had no relevant financial disclosures.

New clinical guidelines for eosinophilic esophagitis characterize the disorder as a chronic, immune- and antigen-mediated disease.

The updated consensus recommendations, which constitute the first update since 2007, also suggest that eosinophilic esophagitis (EoE) is truly on the rise in both adults and children, although no one really knows why, according to Dr. Chris A. Liacouras, first author of the paper. The guidelines also suggest for the first time that the disease may have a genetic underpinning – an abnormality in chromosome 5.

In addition to a genetic predisposition, an increase in food allergies may be at the root of the growing incidence, Dr. Liacouras said in an interview.

"This disease is exploding, and many of us believe that foods are responsible. But we don’t know exactly how," said Dr. Liacouras, professor of pediatrics at the University of Pennsylvania, Philadelphia, and codirector of the Center for Pediatric Eosinophilic Disorders at the Children’s Hospital of Philadelphia. "In the 1950s and ’60s, we were pretty much eating the same kinds of the foods that we do today, and the genetics were there, although still unknown. There is something different going on now – maybe something in the way foods are processed," although there are no data yet to support that theory.

Of course, he added, physicians are also "getting better at looking for it and identifying it when we see it."

The paper, printed in the July issue of the Journal of Allergy and Clinical Immunology, combines the diagnostic, treatment, and research recommendations of 33 pediatric and adult gastroenterologists, immunologists, and allergists (J. Allergy Clin. Immunol. July 2011;128:3-20.e6). "The big thing that we are excited about is that this is one of the few times where the pediatric and adult specialists are working together as one group," Dr. Liacouras said.

In addition, pediatric patients seem to be presenting with more advanced disease since the 2007 report was released, he said. "Pediatric gastroenterologists have looked at this and biopsied it for years, but we have never seen this degree of rings and strictures [in children]."

Defining aspects of the new diagnostic criteria include histology results from multiple biopsies, as well as clinical findings. "The problem, especially for adults, has been that a lot of gastroenterologists have expected the pathologist to tell them what’s happening," Dr. Liacouras said. "[Pathologists] can only describe what they’re seeing, so the clinician has to see clinical findings as well as eosinophils to make treatment decisions."

According to the guidelines, "With few exceptions, 15 eosinophils per high-powered field is considered a minimum threshold for a diagnosis of EoE." Other histopathologic findings may include basal cell hyperplasia, dilated intracellular spaces, and lamina propria fibrosis isolated to the esophagus. Because of the disease’s exclusive location in the esophagus, proton pump inhibitors are most often used initially as a way to rule out EoE.

"You want to be sure that reflux acid is not causing this problem. If the patient responds to a proton pump inhibitor, they do not have this disease," said Dr. Liacouras.

Dysphagia, reflux, and heartburn can be early signs, and dysphagia is the most common presenting symptom in adolescents and adults. Infants typically experience feeding problems. "In children, [it] is more often present in association with other manifestations of atopic disorders – food allergy, asthma, eczema, chronic rhinitis, and environmental allergies," the paper notes.

Patch testing is an effective supplemental diagnostic tool, but is not perfect, Dr. Liacouras said. "This disease is not an anaphylactic event, a delayed event, or an immunoglobulin-mediated event, which is why it’s hard to use allergy testing as a diagnostic tool."

Treatment recommendations have evolved since 2007, although children often respond to elimination of typical allergy-inducing foods. Unlike adults, children may be able to reverse the damage when they avoid the problem food or foods. In contrast, adults generally experience a lifelong course of EoE that can only be symptomatically controlled, Dr. Liacouras said.

For both adults and children, topical steroids are usually indicated. These include steroids such as fluticasone, used with a spacer and swallowed instead of inhaled. "Since the 2007 guideline, there’s also an oral viscous suspension of budesonide in sucrose," Dr. Liacouras said. Biologics like infliximab will probably play no role in treating this disorder, he added.

Esophageal dilation can provide relief to some patients, but unless there are high-grade esophageal strictures, it’s reasonable to try medical or dietary therapy first, the authors wrote. Because of an increased risk of perforation, the guidelines advise physicians to use "a more conservative and careful approach" for EoE patients, compared with those who have other benign conditions.

The authors also call for future studies to identify EoE subgroups, further investigate the disease’s genetic underpinning, and study the role of allergy testing. Pediatric and adult specialists should continue their joint efforts to improve diagnostic criteria and determine the optimal therapy.

"The joint effort of pediatric and adult clinical and basic scientists in a variety of subspecialties has been paramount in the rapid understanding of this disease process," the paper said. "It is critical that leaders [in basic science, gastroenterology and allergy and immunology] continue to work together and undertake studies on the natural history, pathophysiology, biomarkers, diagnosis, and therapeutic approaches, not only to increase the scientific and clinical knowledge of EoE but also to improve the lives of children and adults affected by the disease."

The authors disclosed potential conflicts of interest including multiple financial relationships with pharmaceutical companies.

New clinical guidelines for eosinophilic esophagitis characterize the disorder as a chronic, immune- and antigen-mediated disease.

The updated consensus recommendations, which constitute the first update since 2007, also suggest that eosinophilic esophagitis (EoE) is truly on the rise in both adults and children, although no one really knows why, according to Dr. Chris A. Liacouras, first author of the paper. The guidelines also suggest for the first time that the disease may have a genetic underpinning – an abnormality in chromosome 5.

In addition to a genetic predisposition, an increase in food allergies may be at the root of the growing incidence, Dr. Liacouras said in an interview.

"This disease is exploding, and many of us believe that foods are responsible. But we don’t know exactly how," said Dr. Liacouras, professor of pediatrics at the University of Pennsylvania, Philadelphia, and codirector of the Center for Pediatric Eosinophilic Disorders at the Children’s Hospital of Philadelphia. "In the 1950s and ’60s, we were pretty much eating the same kinds of the foods that we do today, and the genetics were there, although still unknown. There is something different going on now – maybe something in the way foods are processed," although there are no data yet to support that theory.

Of course, he added, physicians are also "getting better at looking for it and identifying it when we see it."

The paper, printed in the July issue of the Journal of Allergy and Clinical Immunology, combines the diagnostic, treatment, and research recommendations of 33 pediatric and adult gastroenterologists, immunologists, and allergists (J. Allergy Clin. Immunol. July 2011;128:3-20.e6). "The big thing that we are excited about is that this is one of the few times where the pediatric and adult specialists are working together as one group," Dr. Liacouras said.

In addition, pediatric patients seem to be presenting with more advanced disease since the 2007 report was released, he said. "Pediatric gastroenterologists have looked at this and biopsied it for years, but we have never seen this degree of rings and strictures [in children]."

Defining aspects of the new diagnostic criteria include histology results from multiple biopsies, as well as clinical findings. "The problem, especially for adults, has been that a lot of gastroenterologists have expected the pathologist to tell them what’s happening," Dr. Liacouras said. "[Pathologists] can only describe what they’re seeing, so the clinician has to see clinical findings as well as eosinophils to make treatment decisions."

According to the guidelines, "With few exceptions, 15 eosinophils per high-powered field is considered a minimum threshold for a diagnosis of EoE." Other histopathologic findings may include basal cell hyperplasia, dilated intracellular spaces, and lamina propria fibrosis isolated to the esophagus. Because of the disease’s exclusive location in the esophagus, proton pump inhibitors are most often used initially as a way to rule out EoE.

"You want to be sure that reflux acid is not causing this problem. If the patient responds to a proton pump inhibitor, they do not have this disease," said Dr. Liacouras.

Dysphagia, reflux, and heartburn can be early signs, and dysphagia is the most common presenting symptom in adolescents and adults. Infants typically experience feeding problems. "In children, [it] is more often present in association with other manifestations of atopic disorders – food allergy, asthma, eczema, chronic rhinitis, and environmental allergies," the paper notes.

Patch testing is an effective supplemental diagnostic tool, but is not perfect, Dr. Liacouras said. "This disease is not an anaphylactic event, a delayed event, or an immunoglobulin-mediated event, which is why it’s hard to use allergy testing as a diagnostic tool."

Treatment recommendations have evolved since 2007, although children often respond to elimination of typical allergy-inducing foods. Unlike adults, children may be able to reverse the damage when they avoid the problem food or foods. In contrast, adults generally experience a lifelong course of EoE that can only be symptomatically controlled, Dr. Liacouras said.

For both adults and children, topical steroids are usually indicated. These include steroids such as fluticasone, used with a spacer and swallowed instead of inhaled. "Since the 2007 guideline, there’s also an oral viscous suspension of budesonide in sucrose," Dr. Liacouras said. Biologics like infliximab will probably play no role in treating this disorder, he added.

Esophageal dilation can provide relief to some patients, but unless there are high-grade esophageal strictures, it’s reasonable to try medical or dietary therapy first, the authors wrote. Because of an increased risk of perforation, the guidelines advise physicians to use "a more conservative and careful approach" for EoE patients, compared with those who have other benign conditions.

The authors also call for future studies to identify EoE subgroups, further investigate the disease’s genetic underpinning, and study the role of allergy testing. Pediatric and adult specialists should continue their joint efforts to improve diagnostic criteria and determine the optimal therapy.

"The joint effort of pediatric and adult clinical and basic scientists in a variety of subspecialties has been paramount in the rapid understanding of this disease process," the paper said. "It is critical that leaders [in basic science, gastroenterology and allergy and immunology] continue to work together and undertake studies on the natural history, pathophysiology, biomarkers, diagnosis, and therapeutic approaches, not only to increase the scientific and clinical knowledge of EoE but also to improve the lives of children and adults affected by the disease."

The authors disclosed potential conflicts of interest including multiple financial relationships with pharmaceutical companies.

New clinical guidelines for eosinophilic esophagitis characterize the disorder as a chronic, immune- and antigen-mediated disease.

The updated consensus recommendations, which constitute the first update since 2007, also suggest that eosinophilic esophagitis (EoE) is truly on the rise in both adults and children, although no one really knows why, according to Dr. Chris A. Liacouras, first author of the paper. The guidelines also suggest for the first time that the disease may have a genetic underpinning – an abnormality in chromosome 5.

In addition to a genetic predisposition, an increase in food allergies may be at the root of the growing incidence, Dr. Liacouras said in an interview.

"This disease is exploding, and many of us believe that foods are responsible. But we don’t know exactly how," said Dr. Liacouras, professor of pediatrics at the University of Pennsylvania, Philadelphia, and codirector of the Center for Pediatric Eosinophilic Disorders at the Children’s Hospital of Philadelphia. "In the 1950s and ’60s, we were pretty much eating the same kinds of the foods that we do today, and the genetics were there, although still unknown. There is something different going on now – maybe something in the way foods are processed," although there are no data yet to support that theory.

Of course, he added, physicians are also "getting better at looking for it and identifying it when we see it."

The paper, printed in the July issue of the Journal of Allergy and Clinical Immunology, combines the diagnostic, treatment, and research recommendations of 33 pediatric and adult gastroenterologists, immunologists, and allergists (J. Allergy Clin. Immunol. July 2011;128:3-20.e6). "The big thing that we are excited about is that this is one of the few times where the pediatric and adult specialists are working together as one group," Dr. Liacouras said.

In addition, pediatric patients seem to be presenting with more advanced disease since the 2007 report was released, he said. "Pediatric gastroenterologists have looked at this and biopsied it for years, but we have never seen this degree of rings and strictures [in children]."

Defining aspects of the new diagnostic criteria include histology results from multiple biopsies, as well as clinical findings. "The problem, especially for adults, has been that a lot of gastroenterologists have expected the pathologist to tell them what’s happening," Dr. Liacouras said. "[Pathologists] can only describe what they’re seeing, so the clinician has to see clinical findings as well as eosinophils to make treatment decisions."

According to the guidelines, "With few exceptions, 15 eosinophils per high-powered field is considered a minimum threshold for a diagnosis of EoE." Other histopathologic findings may include basal cell hyperplasia, dilated intracellular spaces, and lamina propria fibrosis isolated to the esophagus. Because of the disease’s exclusive location in the esophagus, proton pump inhibitors are most often used initially as a way to rule out EoE.

"You want to be sure that reflux acid is not causing this problem. If the patient responds to a proton pump inhibitor, they do not have this disease," said Dr. Liacouras.

Dysphagia, reflux, and heartburn can be early signs, and dysphagia is the most common presenting symptom in adolescents and adults. Infants typically experience feeding problems. "In children, [it] is more often present in association with other manifestations of atopic disorders – food allergy, asthma, eczema, chronic rhinitis, and environmental allergies," the paper notes.

Patch testing is an effective supplemental diagnostic tool, but is not perfect, Dr. Liacouras said. "This disease is not an anaphylactic event, a delayed event, or an immunoglobulin-mediated event, which is why it’s hard to use allergy testing as a diagnostic tool."

Treatment recommendations have evolved since 2007, although children often respond to elimination of typical allergy-inducing foods. Unlike adults, children may be able to reverse the damage when they avoid the problem food or foods. In contrast, adults generally experience a lifelong course of EoE that can only be symptomatically controlled, Dr. Liacouras said.

For both adults and children, topical steroids are usually indicated. These include steroids such as fluticasone, used with a spacer and swallowed instead of inhaled. "Since the 2007 guideline, there’s also an oral viscous suspension of budesonide in sucrose," Dr. Liacouras said. Biologics like infliximab will probably play no role in treating this disorder, he added.

Esophageal dilation can provide relief to some patients, but unless there are high-grade esophageal strictures, it’s reasonable to try medical or dietary therapy first, the authors wrote. Because of an increased risk of perforation, the guidelines advise physicians to use "a more conservative and careful approach" for EoE patients, compared with those who have other benign conditions.

The authors also call for future studies to identify EoE subgroups, further investigate the disease’s genetic underpinning, and study the role of allergy testing. Pediatric and adult specialists should continue their joint efforts to improve diagnostic criteria and determine the optimal therapy.

"The joint effort of pediatric and adult clinical and basic scientists in a variety of subspecialties has been paramount in the rapid understanding of this disease process," the paper said. "It is critical that leaders [in basic science, gastroenterology and allergy and immunology] continue to work together and undertake studies on the natural history, pathophysiology, biomarkers, diagnosis, and therapeutic approaches, not only to increase the scientific and clinical knowledge of EoE but also to improve the lives of children and adults affected by the disease."

The authors disclosed potential conflicts of interest including multiple financial relationships with pharmaceutical companies.

WASHINGTON – Between 20% and 40% of headache patients have endured some kind of maltreatment during their early lives, several epidemiologic studies have concluded.

Yet no study has ever pinpointed exactly which individuals exposed to a particular type of abuse will develop a certain type of headache – or whether they will get headaches at all, Dr. Gretchen Tietjen said at the annual meeting of the American Headache Society.

Photo credit: Nick Piegari/Elsevier Global Medical News

Nor has any study ever conclusively proven the benefit of screening headache patients for childhood abuse, or even helping those patients cope with their history.

Many studies have attempted to show a benefit of screening and treatment, but these generally "come up empty-handed" said Dr. Tietjen, director of the headache treatment and research program at the University of Toledo (Ohio) Medical Center. "It’s very difficult to identify the downstream evidence of morbidity and mortality, and there is even some concern that we could actually cause harm by [recalling events] that are going to be very difficult for a patient to deal with. The risk/benefit ratio for this has never been clearly elucidated."

Multiple animal studies, and now some clinical ones, have found that chronic early life stress induces a host of physical changes that compromise the body’s ability to cope with stress later on. These changes can manifest not only as headache, but as fibromyalgia, irritable bowel syndrome, interstitial cystitis, and chronic fatigue. Anxiety and depression can emerge as well. And some research even suggests that early stress can lead to a lifelong elevation in inflammatory response, setting the stage for a host of other disorders.

The Adverse Childhood Experiences (ACE) study confirmed a strong association between childhood stress and adult headache. ACE included more than 17,000 adults and examined the relationship between frequent headaches and eight early stressors: emotional, physical, or sexual abuse; domestic violence; parental separation or divorce; and living with an adult who was mentally ill, a substance abuser, or engaged in criminal activity (Headache 2010;50:1473-81).

The study found a dose-response relationship between adverse events in childhood and the frequency of adult headaches, said Dr. Tietjen, who was a primary investigator on ACE. With a possible score of 0-8, subjects who reported having five or more early adverse experiences were more than twice as likely to also report adult headache.

Then again, "not everyone who has a stressful childhood or is abused as a child will develop headaches," Dr. Tietjen said in an interview.

The who’s and why’s are still elusive, said Dr. Linda Carpenter, a psychiatrist and researcher at Brown University, Providence, R.I. The end result emerges from a complex and still somewhat mysterious brew of innate temperament, stress type and duration, and environmental mediators. Animal data not only support a neurobiologic link, but an epigenetic link as well. Chronic stress has the ability to change DNA expression, permanently altering the way a body responds to stress. And those changes may even become part of a new generation’s genetic makeup.

Some research also suggests that a new environment can reverse the physical changes of chronic stress. Rats separated from their mothers as babies develop elevated stress responses as they mature. But after living in an enriched environment – a cage with interconnecting burrows and toys to play with – their corticosterone levels during a stress test returned to normal (J. Neurosci. 2002;22:7840-3).

Individual perceptions can moderate or enhance the downstream effects of early maltreatment, said Dr. Elliott Schulman, an ACE coauthor. What one person perceives as a stressful, abusive situation may not trigger the same response in another. The reaction of adults aware of the early situation can also color the final picture, said Dr. Schulman, a neurologist at the Lankenau Headache Center in Wynnewood, Pa.*

He described a patient with refractory headache who recalled girlhood vacations during which a relative "repeatedly groped her." She reported this to her parents, who assured her that "groping" was not sexual abuse. "If the person believes it was abusive, then it was, for that person," said Dr. Schulman, who routinely addresses abuse during his patient intake. Before the initial visit, each patient receives a registration packet that includes a personal history questionnaire. At the very end of the questionnaire, after the social and marital history, it asks: "Have you been abused?"

The patient can check yes or no and, if the answer is yes, he or she can select the type – physical, emotional, or sexual. "This is akin to every other assessment we do," he said. "We ask if patients are smoking, exercising, sleeping well, having unprotected sex, using drugs. We incorporate all this into a routine history. And now that I have incorporated this question as well, I have found out patients want you to ask. If you do, they will tell you."

The next question is what to do when the answer is yes.

"Often, I find that I am the first person who has ever asked, the first person the patient has ever told, and it can be a very emotional time," Dr. Schulman said. He added that he tries to ascertain the current situation. "If the abuse is ongoing, I get an abuse advocate involved and try to help the patient get to a safe place."

If the abuse is in the past, the discussion centers on the possibility that counseling could not only help the patient come to terms with the experience emotionally, but improve headache outcomes as well.

Dr. Tietjen said she also addresses the issue in a questionnaire about life stress. If the response is positive, "I explain that this might have changed their response to stress, and although I can’t change what happened, there are ways to deal with it. We discuss the idea that cognitive-behavioral therapy can be really helpful, rather than adding another pill."

Dr. Carpenter said she takes a different tack. "I don’t engage in conversations about it," she said. "I try to educate the patient about it if there is a history of early life stress by saying, ‘You are biologically programmed to be prone to the effects of stress the rest of your life.’ "

Stress management is key for these patients. "I tell them to become an antistress expert so that any new stress that enters their life doesn’t refuel the entire system," she said. Having this knowledge is very useful for people and helps them leverage multiple modalities of stress management – yoga, exercise, diet – so they can manage their stress and improve their outcomes. "These are very real things people can do to get better, and by doing them, they learn to be less aroused by stressful events."

Dr. Tietjen did not report having any conflicts. Dr. Carpenter reported receiving numerous research grants from pharmaceutical companies, as well as being a member of several speakers bureaus and advisory boards for pharmaceutical companies. Dr. Schulman said he had no disclosures.

* Correction, 7/22/2011: An earlier version of this article included an incorrect affiliation for Dr. Elliott Schulman. He is with the Lankenau Headache Center in Wynnewood, Pa.

WASHINGTON – Between 20% and 40% of headache patients have endured some kind of maltreatment during their early lives, several epidemiologic studies have concluded.

Yet no study has ever pinpointed exactly which individuals exposed to a particular type of abuse will develop a certain type of headache – or whether they will get headaches at all, Dr. Gretchen Tietjen said at the annual meeting of the American Headache Society.

Photo credit: Nick Piegari/Elsevier Global Medical News

Nor has any study ever conclusively proven the benefit of screening headache patients for childhood abuse, or even helping those patients cope with their history.

Many studies have attempted to show a benefit of screening and treatment, but these generally "come up empty-handed" said Dr. Tietjen, director of the headache treatment and research program at the University of Toledo (Ohio) Medical Center. "It’s very difficult to identify the downstream evidence of morbidity and mortality, and there is even some concern that we could actually cause harm by [recalling events] that are going to be very difficult for a patient to deal with. The risk/benefit ratio for this has never been clearly elucidated."

Multiple animal studies, and now some clinical ones, have found that chronic early life stress induces a host of physical changes that compromise the body’s ability to cope with stress later on. These changes can manifest not only as headache, but as fibromyalgia, irritable bowel syndrome, interstitial cystitis, and chronic fatigue. Anxiety and depression can emerge as well. And some research even suggests that early stress can lead to a lifelong elevation in inflammatory response, setting the stage for a host of other disorders.

The Adverse Childhood Experiences (ACE) study confirmed a strong association between childhood stress and adult headache. ACE included more than 17,000 adults and examined the relationship between frequent headaches and eight early stressors: emotional, physical, or sexual abuse; domestic violence; parental separation or divorce; and living with an adult who was mentally ill, a substance abuser, or engaged in criminal activity (Headache 2010;50:1473-81).

The study found a dose-response relationship between adverse events in childhood and the frequency of adult headaches, said Dr. Tietjen, who was a primary investigator on ACE. With a possible score of 0-8, subjects who reported having five or more early adverse experiences were more than twice as likely to also report adult headache.

Then again, "not everyone who has a stressful childhood or is abused as a child will develop headaches," Dr. Tietjen said in an interview.

The who’s and why’s are still elusive, said Dr. Linda Carpenter, a psychiatrist and researcher at Brown University, Providence, R.I. The end result emerges from a complex and still somewhat mysterious brew of innate temperament, stress type and duration, and environmental mediators. Animal data not only support a neurobiologic link, but an epigenetic link as well. Chronic stress has the ability to change DNA expression, permanently altering the way a body responds to stress. And those changes may even become part of a new generation’s genetic makeup.

Some research also suggests that a new environment can reverse the physical changes of chronic stress. Rats separated from their mothers as babies develop elevated stress responses as they mature. But after living in an enriched environment – a cage with interconnecting burrows and toys to play with – their corticosterone levels during a stress test returned to normal (J. Neurosci. 2002;22:7840-3).

Individual perceptions can moderate or enhance the downstream effects of early maltreatment, said Dr. Elliott Schulman, an ACE coauthor. What one person perceives as a stressful, abusive situation may not trigger the same response in another. The reaction of adults aware of the early situation can also color the final picture, said Dr. Schulman, a neurologist at the Lankenau Headache Center in Wynnewood, Pa.*

He described a patient with refractory headache who recalled girlhood vacations during which a relative "repeatedly groped her." She reported this to her parents, who assured her that "groping" was not sexual abuse. "If the person believes it was abusive, then it was, for that person," said Dr. Schulman, who routinely addresses abuse during his patient intake. Before the initial visit, each patient receives a registration packet that includes a personal history questionnaire. At the very end of the questionnaire, after the social and marital history, it asks: "Have you been abused?"

The patient can check yes or no and, if the answer is yes, he or she can select the type – physical, emotional, or sexual. "This is akin to every other assessment we do," he said. "We ask if patients are smoking, exercising, sleeping well, having unprotected sex, using drugs. We incorporate all this into a routine history. And now that I have incorporated this question as well, I have found out patients want you to ask. If you do, they will tell you."

The next question is what to do when the answer is yes.

"Often, I find that I am the first person who has ever asked, the first person the patient has ever told, and it can be a very emotional time," Dr. Schulman said. He added that he tries to ascertain the current situation. "If the abuse is ongoing, I get an abuse advocate involved and try to help the patient get to a safe place."

If the abuse is in the past, the discussion centers on the possibility that counseling could not only help the patient come to terms with the experience emotionally, but improve headache outcomes as well.

Dr. Tietjen said she also addresses the issue in a questionnaire about life stress. If the response is positive, "I explain that this might have changed their response to stress, and although I can’t change what happened, there are ways to deal with it. We discuss the idea that cognitive-behavioral therapy can be really helpful, rather than adding another pill."

Dr. Carpenter said she takes a different tack. "I don’t engage in conversations about it," she said. "I try to educate the patient about it if there is a history of early life stress by saying, ‘You are biologically programmed to be prone to the effects of stress the rest of your life.’ "

Stress management is key for these patients. "I tell them to become an antistress expert so that any new stress that enters their life doesn’t refuel the entire system," she said. Having this knowledge is very useful for people and helps them leverage multiple modalities of stress management – yoga, exercise, diet – so they can manage their stress and improve their outcomes. "These are very real things people can do to get better, and by doing them, they learn to be less aroused by stressful events."

Dr. Tietjen did not report having any conflicts. Dr. Carpenter reported receiving numerous research grants from pharmaceutical companies, as well as being a member of several speakers bureaus and advisory boards for pharmaceutical companies. Dr. Schulman said he had no disclosures.

* Correction, 7/22/2011: An earlier version of this article included an incorrect affiliation for Dr. Elliott Schulman. He is with the Lankenau Headache Center in Wynnewood, Pa.

WASHINGTON – Between 20% and 40% of headache patients have endured some kind of maltreatment during their early lives, several epidemiologic studies have concluded.

Yet no study has ever pinpointed exactly which individuals exposed to a particular type of abuse will develop a certain type of headache – or whether they will get headaches at all, Dr. Gretchen Tietjen said at the annual meeting of the American Headache Society.

Photo credit: Nick Piegari/Elsevier Global Medical News

Nor has any study ever conclusively proven the benefit of screening headache patients for childhood abuse, or even helping those patients cope with their history.

Many studies have attempted to show a benefit of screening and treatment, but these generally "come up empty-handed" said Dr. Tietjen, director of the headache treatment and research program at the University of Toledo (Ohio) Medical Center. "It’s very difficult to identify the downstream evidence of morbidity and mortality, and there is even some concern that we could actually cause harm by [recalling events] that are going to be very difficult for a patient to deal with. The risk/benefit ratio for this has never been clearly elucidated."

Multiple animal studies, and now some clinical ones, have found that chronic early life stress induces a host of physical changes that compromise the body’s ability to cope with stress later on. These changes can manifest not only as headache, but as fibromyalgia, irritable bowel syndrome, interstitial cystitis, and chronic fatigue. Anxiety and depression can emerge as well. And some research even suggests that early stress can lead to a lifelong elevation in inflammatory response, setting the stage for a host of other disorders.

The Adverse Childhood Experiences (ACE) study confirmed a strong association between childhood stress and adult headache. ACE included more than 17,000 adults and examined the relationship between frequent headaches and eight early stressors: emotional, physical, or sexual abuse; domestic violence; parental separation or divorce; and living with an adult who was mentally ill, a substance abuser, or engaged in criminal activity (Headache 2010;50:1473-81).

The study found a dose-response relationship between adverse events in childhood and the frequency of adult headaches, said Dr. Tietjen, who was a primary investigator on ACE. With a possible score of 0-8, subjects who reported having five or more early adverse experiences were more than twice as likely to also report adult headache.

Then again, "not everyone who has a stressful childhood or is abused as a child will develop headaches," Dr. Tietjen said in an interview.

The who’s and why’s are still elusive, said Dr. Linda Carpenter, a psychiatrist and researcher at Brown University, Providence, R.I. The end result emerges from a complex and still somewhat mysterious brew of innate temperament, stress type and duration, and environmental mediators. Animal data not only support a neurobiologic link, but an epigenetic link as well. Chronic stress has the ability to change DNA expression, permanently altering the way a body responds to stress. And those changes may even become part of a new generation’s genetic makeup.

Some research also suggests that a new environment can reverse the physical changes of chronic stress. Rats separated from their mothers as babies develop elevated stress responses as they mature. But after living in an enriched environment – a cage with interconnecting burrows and toys to play with – their corticosterone levels during a stress test returned to normal (J. Neurosci. 2002;22:7840-3).

Individual perceptions can moderate or enhance the downstream effects of early maltreatment, said Dr. Elliott Schulman, an ACE coauthor. What one person perceives as a stressful, abusive situation may not trigger the same response in another. The reaction of adults aware of the early situation can also color the final picture, said Dr. Schulman, a neurologist at the Lankenau Headache Center in Wynnewood, Pa.*

He described a patient with refractory headache who recalled girlhood vacations during which a relative "repeatedly groped her." She reported this to her parents, who assured her that "groping" was not sexual abuse. "If the person believes it was abusive, then it was, for that person," said Dr. Schulman, who routinely addresses abuse during his patient intake. Before the initial visit, each patient receives a registration packet that includes a personal history questionnaire. At the very end of the questionnaire, after the social and marital history, it asks: "Have you been abused?"

The patient can check yes or no and, if the answer is yes, he or she can select the type – physical, emotional, or sexual. "This is akin to every other assessment we do," he said. "We ask if patients are smoking, exercising, sleeping well, having unprotected sex, using drugs. We incorporate all this into a routine history. And now that I have incorporated this question as well, I have found out patients want you to ask. If you do, they will tell you."

The next question is what to do when the answer is yes.

"Often, I find that I am the first person who has ever asked, the first person the patient has ever told, and it can be a very emotional time," Dr. Schulman said. He added that he tries to ascertain the current situation. "If the abuse is ongoing, I get an abuse advocate involved and try to help the patient get to a safe place."

If the abuse is in the past, the discussion centers on the possibility that counseling could not only help the patient come to terms with the experience emotionally, but improve headache outcomes as well.

Dr. Tietjen said she also addresses the issue in a questionnaire about life stress. If the response is positive, "I explain that this might have changed their response to stress, and although I can’t change what happened, there are ways to deal with it. We discuss the idea that cognitive-behavioral therapy can be really helpful, rather than adding another pill."

Dr. Carpenter said she takes a different tack. "I don’t engage in conversations about it," she said. "I try to educate the patient about it if there is a history of early life stress by saying, ‘You are biologically programmed to be prone to the effects of stress the rest of your life.’ "

Stress management is key for these patients. "I tell them to become an antistress expert so that any new stress that enters their life doesn’t refuel the entire system," she said. Having this knowledge is very useful for people and helps them leverage multiple modalities of stress management – yoga, exercise, diet – so they can manage their stress and improve their outcomes. "These are very real things people can do to get better, and by doing them, they learn to be less aroused by stressful events."

Dr. Tietjen did not report having any conflicts. Dr. Carpenter reported receiving numerous research grants from pharmaceutical companies, as well as being a member of several speakers bureaus and advisory boards for pharmaceutical companies. Dr. Schulman said he had no disclosures.

* Correction, 7/22/2011: An earlier version of this article included an incorrect affiliation for Dr. Elliott Schulman. He is with the Lankenau Headache Center in Wynnewood, Pa.

WASHINGTON – Between 20% and 40% of headache patients have endured some kind of maltreatment during their early lives, several epidemiologic studies have concluded.

Yet no study has ever pinpointed exactly which individuals exposed to a particular type of abuse will develop a certain type of headache – or whether they will get headaches at all, Dr. Gretchen Tietjen said at the annual meeting of the American Headache Society.

Photo credit: Nick Piegari/Elsevier Global Medical News

Nor has any study ever conclusively proven the benefit of screening headache patients for childhood abuse, or even helping those patients cope with their history.

Many studies have attempted to show a benefit of screening and treatment, but these generally "come up empty-handed" said Dr. Tietjen, director of the headache treatment and research program at the University of Toledo (Ohio) Medical Center. "It’s very difficult to identify the downstream evidence of morbidity and mortality, and there is even some concern that we could actually cause harm by [recalling events] that are going to be very difficult for a patient to deal with. The risk/benefit ratio for this has never been clearly elucidated."

Multiple animal studies, and now some clinical ones, have found that chronic early life stress induces a host of physical changes that compromise the body’s ability to cope with stress later on. These changes can manifest not only as headache, but as fibromyalgia, irritable bowel syndrome, interstitial cystitis, and chronic fatigue. Anxiety and depression can emerge as well. And some research even suggests that early stress can lead to a lifelong elevation in inflammatory response, setting the stage for a host of other disorders.

The Adverse Childhood Experiences (ACE) study confirmed a strong association between childhood stress and adult headache. ACE included more than 17,000 adults and examined the relationship between frequent headaches and eight early stressors: emotional, physical, or sexual abuse; domestic violence; parental separation or divorce; and living with an adult who was mentally ill, a substance abuser, or engaged in criminal activity (Headache 2010;50:1473-81).

The study found a dose-response relationship between adverse events in childhood and the frequency of adult headaches, said Dr. Tietjen, who was a primary investigator on ACE. With a possible score of 0-8, subjects who reported having five or more early adverse experiences were more than twice as likely to also report adult headache.

Then again, "not everyone who has a stressful childhood or is abused as a child will develop headaches," Dr. Tietjen said in an interview.

The who’s and why’s are still elusive, said Dr. Linda Carpenter, a psychiatrist and researcher at Brown University, Providence, R.I. The end result emerges from a complex and still somewhat mysterious brew of innate temperament, stress type and duration, and environmental mediators. Animal data not only support a neurobiologic link, but an epigenetic link as well. Chronic stress has the ability to change DNA expression, permanently altering the way a body responds to stress. And those changes may even become part of a new generation’s genetic makeup.

Some research also suggests that a new environment can reverse the physical changes of chronic stress. Rats separated from their mothers as babies develop elevated stress responses as they mature. But after living in an enriched environment – a cage with interconnecting burrows and toys to play with – their corticosterone levels during a stress test returned to normal (J. Neurosci. 2002;22:7840-3).

Individual perceptions can moderate or enhance the downstream effects of early maltreatment, said Dr. Elliott Schulman, an ACE coauthor. What one person perceives as a stressful, abusive situation may not trigger the same response in another. The reaction of adults aware of the early situation can also color the final picture, said Dr. Schulman, a neurologist at the Lankenau Headache Center in Wynnewood, Pa.*

He described a patient with refractory headache who recalled girlhood vacations during which a relative "repeatedly groped her." She reported this to her parents, who assured her that "groping" was not sexual abuse. "If the person believes it was abusive, then it was, for that person," said Dr. Schulman, who routinely addresses abuse during his patient intake. Before the initial visit, each patient receives a registration packet that includes a personal history questionnaire. At the very end of the questionnaire, after the social and marital history, it asks: "Have you been abused?"

The patient can check yes or no and, if the answer is yes, he or she can select the type – physical, emotional, or sexual. "This is akin to every other assessment we do," he said. "We ask if patients are smoking, exercising, sleeping well, having unprotected sex, using drugs. We incorporate all this into a routine history. And now that I have incorporated this question as well, I have found out patients want you to ask. If you do, they will tell you."

The next question is what to do when the answer is yes.

"Often, I find that I am the first person who has ever asked, the first person the patient has ever told, and it can be a very emotional time," Dr. Schulman said. He added that he tries to ascertain the current situation. "If the abuse is ongoing, I get an abuse advocate involved and try to help the patient get to a safe place."

If the abuse is in the past, the discussion centers on the possibility that counseling could not only help the patient come to terms with the experience emotionally, but improve headache outcomes as well.

Dr. Tietjen said she also addresses the issue in a questionnaire about life stress. If the response is positive, "I explain that this might have changed their response to stress, and although I can’t change what happened, there are ways to deal with it. We discuss the idea that cognitive-behavioral therapy can be really helpful, rather than adding another pill."

Dr. Carpenter said she takes a different tack. "I don’t engage in conversations about it," she said. "I try to educate the patient about it if there is a history of early life stress by saying, ‘You are biologically programmed to be prone to the effects of stress the rest of your life.’ "

Stress management is key for these patients. "I tell them to become an antistress expert so that any new stress that enters their life doesn’t refuel the entire system," she said. Having this knowledge is very useful for people and helps them leverage multiple modalities of stress management – yoga, exercise, diet – so they can manage their stress and improve their outcomes. "These are very real things people can do to get better, and by doing them, they learn to be less aroused by stressful events."

Dr. Tietjen did not report having any conflicts. Dr. Carpenter reported receiving numerous research grants from pharmaceutical companies, as well as being a member of several speakers bureaus and advisory boards for pharmaceutical companies. Dr. Schulman said he had no disclosures.

* Correction, 7/22/2011: An earlier version of this article included an incorrect affiliation for Dr. Elliott Schulman. He is with the Lankenau Headache Center in Wynnewood, Pa.

WASHINGTON – Between 20% and 40% of headache patients have endured some kind of maltreatment during their early lives, several epidemiologic studies have concluded.

Yet no study has ever pinpointed exactly which individuals exposed to a particular type of abuse will develop a certain type of headache – or whether they will get headaches at all, Dr. Gretchen Tietjen said at the annual meeting of the American Headache Society.

Photo credit: Nick Piegari/Elsevier Global Medical News

Nor has any study ever conclusively proven the benefit of screening headache patients for childhood abuse, or even helping those patients cope with their history.

Many studies have attempted to show a benefit of screening and treatment, but these generally "come up empty-handed" said Dr. Tietjen, director of the headache treatment and research program at the University of Toledo (Ohio) Medical Center. "It’s very difficult to identify the downstream evidence of morbidity and mortality, and there is even some concern that we could actually cause harm by [recalling events] that are going to be very difficult for a patient to deal with. The risk/benefit ratio for this has never been clearly elucidated."

Multiple animal studies, and now some clinical ones, have found that chronic early life stress induces a host of physical changes that compromise the body’s ability to cope with stress later on. These changes can manifest not only as headache, but as fibromyalgia, irritable bowel syndrome, interstitial cystitis, and chronic fatigue. Anxiety and depression can emerge as well. And some research even suggests that early stress can lead to a lifelong elevation in inflammatory response, setting the stage for a host of other disorders.

The Adverse Childhood Experiences (ACE) study confirmed a strong association between childhood stress and adult headache. ACE included more than 17,000 adults and examined the relationship between frequent headaches and eight early stressors: emotional, physical, or sexual abuse; domestic violence; parental separation or divorce; and living with an adult who was mentally ill, a substance abuser, or engaged in criminal activity (Headache 2010;50:1473-81).

The study found a dose-response relationship between adverse events in childhood and the frequency of adult headaches, said Dr. Tietjen, who was a primary investigator on ACE. With a possible score of 0-8, subjects who reported having five or more early adverse experiences were more than twice as likely to also report adult headache.

Then again, "not everyone who has a stressful childhood or is abused as a child will develop headaches," Dr. Tietjen said in an interview.

The who’s and why’s are still elusive, said Dr. Linda Carpenter, a psychiatrist and researcher at Brown University, Providence, R.I. The end result emerges from a complex and still somewhat mysterious brew of innate temperament, stress type and duration, and environmental mediators. Animal data not only support a neurobiologic link, but an epigenetic link as well. Chronic stress has the ability to change DNA expression, permanently altering the way a body responds to stress. And those changes may even become part of a new generation’s genetic makeup.

Some research also suggests that a new environment can reverse the physical changes of chronic stress. Rats separated from their mothers as babies develop elevated stress responses as they mature. But after living in an enriched environment – a cage with interconnecting burrows and toys to play with – their corticosterone levels during a stress test returned to normal (J. Neurosci. 2002;22:7840-3).

Individual perceptions can moderate or enhance the downstream effects of early maltreatment, said Dr. Elliott Schulman, an ACE coauthor. What one person perceives as a stressful, abusive situation may not trigger the same response in another. The reaction of adults aware of the early situation can also color the final picture, said Dr. Schulman, a neurologist at the Lankenau Headache Center in Wynnewood, Pa.*

He described a patient with refractory headache who recalled girlhood vacations during which a relative "repeatedly groped her." She reported this to her parents, who assured her that "groping" was not sexual abuse. "If the person believes it was abusive, then it was, for that person," said Dr. Schulman, who routinely addresses abuse during his patient intake. Before the initial visit, each patient receives a registration packet that includes a personal history questionnaire. At the very end of the questionnaire, after the social and marital history, it asks: "Have you been abused?"

The patient can check yes or no and, if the answer is yes, he or she can select the type – physical, emotional, or sexual. "This is akin to every other assessment we do," he said. "We ask if patients are smoking, exercising, sleeping well, having unprotected sex, using drugs. We incorporate all this into a routine history. And now that I have incorporated this question as well, I have found out patients want you to ask. If you do, they will tell you."

The next question is what to do when the answer is yes.

"Often, I find that I am the first person who has ever asked, the first person the patient has ever told, and it can be a very emotional time," Dr. Schulman said. He added that he tries to ascertain the current situation. "If the abuse is ongoing, I get an abuse advocate involved and try to help the patient get to a safe place."

If the abuse is in the past, the discussion centers on the possibility that counseling could not only help the patient come to terms with the experience emotionally, but improve headache outcomes as well.

Dr. Tietjen said she also addresses the issue in a questionnaire about life stress. If the response is positive, "I explain that this might have changed their response to stress, and although I can’t change what happened, there are ways to deal with it. We discuss the idea that cognitive-behavioral therapy can be really helpful, rather than adding another pill."

Dr. Carpenter said she takes a different tack. "I don’t engage in conversations about it," she said. "I try to educate the patient about it if there is a history of early life stress by saying, ‘You are biologically programmed to be prone to the effects of stress the rest of your life.’ "

Stress management is key for these patients. "I tell them to become an antistress expert so that any new stress that enters their life doesn’t refuel the entire system," she said. Having this knowledge is very useful for people and helps them leverage multiple modalities of stress management – yoga, exercise, diet – so they can manage their stress and improve their outcomes. "These are very real things people can do to get better, and by doing them, they learn to be less aroused by stressful events."

Dr. Tietjen did not report having any conflicts. Dr. Carpenter reported receiving numerous research grants from pharmaceutical companies, as well as being a member of several speakers bureaus and advisory boards for pharmaceutical companies. Dr. Schulman said he had no disclosures.

* Correction, 7/22/2011: An earlier version of this article included an incorrect affiliation for Dr. Elliott Schulman. He is with the Lankenau Headache Center in Wynnewood, Pa.

WASHINGTON – Between 20% and 40% of headache patients have endured some kind of maltreatment during their early lives, several epidemiologic studies have concluded.

Yet no study has ever pinpointed exactly which individuals exposed to a particular type of abuse will develop a certain type of headache – or whether they will get headaches at all, Dr. Gretchen Tietjen said at the annual meeting of the American Headache Society.

Photo credit: Nick Piegari/Elsevier Global Medical News

Nor has any study ever conclusively proven the benefit of screening headache patients for childhood abuse, or even helping those patients cope with their history.

Many studies have attempted to show a benefit of screening and treatment, but these generally "come up empty-handed" said Dr. Tietjen, director of the headache treatment and research program at the University of Toledo (Ohio) Medical Center. "It’s very difficult to identify the downstream evidence of morbidity and mortality, and there is even some concern that we could actually cause harm by [recalling events] that are going to be very difficult for a patient to deal with. The risk/benefit ratio for this has never been clearly elucidated."

Multiple animal studies, and now some clinical ones, have found that chronic early life stress induces a host of physical changes that compromise the body’s ability to cope with stress later on. These changes can manifest not only as headache, but as fibromyalgia, irritable bowel syndrome, interstitial cystitis, and chronic fatigue. Anxiety and depression can emerge as well. And some research even suggests that early stress can lead to a lifelong elevation in inflammatory response, setting the stage for a host of other disorders.

The Adverse Childhood Experiences (ACE) study confirmed a strong association between childhood stress and adult headache. ACE included more than 17,000 adults and examined the relationship between frequent headaches and eight early stressors: emotional, physical, or sexual abuse; domestic violence; parental separation or divorce; and living with an adult who was mentally ill, a substance abuser, or engaged in criminal activity (Headache 2010;50:1473-81).

The study found a dose-response relationship between adverse events in childhood and the frequency of adult headaches, said Dr. Tietjen, who was a primary investigator on ACE. With a possible score of 0-8, subjects who reported having five or more early adverse experiences were more than twice as likely to also report adult headache.

Then again, "not everyone who has a stressful childhood or is abused as a child will develop headaches," Dr. Tietjen said in an interview.

The who’s and why’s are still elusive, said Dr. Linda Carpenter, a psychiatrist and researcher at Brown University, Providence, R.I. The end result emerges from a complex and still somewhat mysterious brew of innate temperament, stress type and duration, and environmental mediators. Animal data not only support a neurobiologic link, but an epigenetic link as well. Chronic stress has the ability to change DNA expression, permanently altering the way a body responds to stress. And those changes may even become part of a new generation’s genetic makeup.

Some research also suggests that a new environment can reverse the physical changes of chronic stress. Rats separated from their mothers as babies develop elevated stress responses as they mature. But after living in an enriched environment – a cage with interconnecting burrows and toys to play with – their corticosterone levels during a stress test returned to normal (J. Neurosci. 2002;22:7840-3).

Individual perceptions can moderate or enhance the downstream effects of early maltreatment, said Dr. Elliott Schulman, an ACE coauthor. What one person perceives as a stressful, abusive situation may not trigger the same response in another. The reaction of adults aware of the early situation can also color the final picture, said Dr. Schulman, a neurologist at the Lankenau Headache Center in Wynnewood, Pa.*

He described a patient with refractory headache who recalled girlhood vacations during which a relative "repeatedly groped her." She reported this to her parents, who assured her that "groping" was not sexual abuse. "If the person believes it was abusive, then it was, for that person," said Dr. Schulman, who routinely addresses abuse during his patient intake. Before the initial visit, each patient receives a registration packet that includes a personal history questionnaire. At the very end of the questionnaire, after the social and marital history, it asks: "Have you been abused?"

The patient can check yes or no and, if the answer is yes, he or she can select the type – physical, emotional, or sexual. "This is akin to every other assessment we do," he said. "We ask if patients are smoking, exercising, sleeping well, having unprotected sex, using drugs. We incorporate all this into a routine history. And now that I have incorporated this question as well, I have found out patients want you to ask. If you do, they will tell you."

The next question is what to do when the answer is yes.

"Often, I find that I am the first person who has ever asked, the first person the patient has ever told, and it can be a very emotional time," Dr. Schulman said. He added that he tries to ascertain the current situation. "If the abuse is ongoing, I get an abuse advocate involved and try to help the patient get to a safe place."

If the abuse is in the past, the discussion centers on the possibility that counseling could not only help the patient come to terms with the experience emotionally, but improve headache outcomes as well.

Dr. Tietjen said she also addresses the issue in a questionnaire about life stress. If the response is positive, "I explain that this might have changed their response to stress, and although I can’t change what happened, there are ways to deal with it. We discuss the idea that cognitive-behavioral therapy can be really helpful, rather than adding another pill."

Dr. Carpenter said she takes a different tack. "I don’t engage in conversations about it," she said. "I try to educate the patient about it if there is a history of early life stress by saying, ‘You are biologically programmed to be prone to the effects of stress the rest of your life.’ "

Stress management is key for these patients. "I tell them to become an antistress expert so that any new stress that enters their life doesn’t refuel the entire system," she said. Having this knowledge is very useful for people and helps them leverage multiple modalities of stress management – yoga, exercise, diet – so they can manage their stress and improve their outcomes. "These are very real things people can do to get better, and by doing them, they learn to be less aroused by stressful events."

Dr. Tietjen did not report having any conflicts. Dr. Carpenter reported receiving numerous research grants from pharmaceutical companies, as well as being a member of several speakers bureaus and advisory boards for pharmaceutical companies. Dr. Schulman said he had no disclosures.

* Correction, 7/22/2011: An earlier version of this article included an incorrect affiliation for Dr. Elliott Schulman. He is with the Lankenau Headache Center in Wynnewood, Pa.

WASHINGTON – Between 20% and 40% of headache patients have endured some kind of maltreatment during their early lives, several epidemiologic studies have concluded.

Yet no study has ever pinpointed exactly which individuals exposed to a particular type of abuse will develop a certain type of headache – or whether they will get headaches at all, Dr. Gretchen Tietjen said at the annual meeting of the American Headache Society.

Photo credit: Nick Piegari/Elsevier Global Medical News

Nor has any study ever conclusively proven the benefit of screening headache patients for childhood abuse, or even helping those patients cope with their history.

Many studies have attempted to show a benefit of screening and treatment, but these generally "come up empty-handed" said Dr. Tietjen, director of the headache treatment and research program at the University of Toledo (Ohio) Medical Center. "It’s very difficult to identify the downstream evidence of morbidity and mortality, and there is even some concern that we could actually cause harm by [recalling events] that are going to be very difficult for a patient to deal with. The risk/benefit ratio for this has never been clearly elucidated."

Multiple animal studies, and now some clinical ones, have found that chronic early life stress induces a host of physical changes that compromise the body’s ability to cope with stress later on. These changes can manifest not only as headache, but as fibromyalgia, irritable bowel syndrome, interstitial cystitis, and chronic fatigue. Anxiety and depression can emerge as well. And some research even suggests that early stress can lead to a lifelong elevation in inflammatory response, setting the stage for a host of other disorders.

The Adverse Childhood Experiences (ACE) study confirmed a strong association between childhood stress and adult headache. ACE included more than 17,000 adults and examined the relationship between frequent headaches and eight early stressors: emotional, physical, or sexual abuse; domestic violence; parental separation or divorce; and living with an adult who was mentally ill, a substance abuser, or engaged in criminal activity (Headache 2010;50:1473-81).

The study found a dose-response relationship between adverse events in childhood and the frequency of adult headaches, said Dr. Tietjen, who was a primary investigator on ACE. With a possible score of 0-8, subjects who reported having five or more early adverse experiences were more than twice as likely to also report adult headache.

Then again, "not everyone who has a stressful childhood or is abused as a child will develop headaches," Dr. Tietjen said in an interview.

The who’s and why’s are still elusive, said Dr. Linda Carpenter, a psychiatrist and researcher at Brown University, Providence, R.I. The end result emerges from a complex and still somewhat mysterious brew of innate temperament, stress type and duration, and environmental mediators. Animal data not only support a neurobiologic link, but an epigenetic link as well. Chronic stress has the ability to change DNA expression, permanently altering the way a body responds to stress. And those changes may even become part of a new generation’s genetic makeup.

Some research also suggests that a new environment can reverse the physical changes of chronic stress. Rats separated from their mothers as babies develop elevated stress responses as they mature. But after living in an enriched environment – a cage with interconnecting burrows and toys to play with – their corticosterone levels during a stress test returned to normal (J. Neurosci. 2002;22:7840-3).

Individual perceptions can moderate or enhance the downstream effects of early maltreatment, said Dr. Elliott Schulman, an ACE coauthor. What one person perceives as a stressful, abusive situation may not trigger the same response in another. The reaction of adults aware of the early situation can also color the final picture, said Dr. Schulman, a neurologist at the Jefferson Headache Center, Philadelphia.

He described a patient with refractory headache who recalled girlhood vacations during which a relative "repeatedly groped her." She reported this to her parents, who assured her that "groping" was not sexual abuse. "If the person believes it was abusive, then it was, for that person," said Dr. Schulman, who routinely addresses abuse during his patient intake. Before the initial visit, each patient receives a registration packet that includes a personal history questionnaire. At the very end of the questionnaire, after the social and marital history, it asks: "Have you been abused?"

The patient can check yes or no and, if the answer is yes, he or she can select the type – physical, emotional, or sexual. "This is akin to every other assessment we do," he said. "We ask if patients are smoking, exercising, sleeping well, having unprotected sex, using drugs. We incorporate all this into a routine history. And now that I have incorporated this question as well, I have found out patients want you to ask. If you do, they will tell you."

The next question is what to do when the answer is yes.

"Often, I find that I am the first person who has ever asked, the first person the patient has ever told, and it can be a very emotional time," Dr. Schulman said. He added that he tries to ascertain the current situation. "If the abuse is ongoing, I get an abuse advocate involved and try to help the patient get to a safe place."

If the abuse is in the past, the discussion centers on the possibility that counseling could not only help the patient come to terms with the experience emotionally, but improve headache outcomes as well.

Dr. Tietjen said she also addresses the issue in a questionnaire about life stress. If the response is positive, "I explain that this might have changed their response to stress, and although I can’t change what happened, there are ways to deal with it. We discuss the idea that cognitive-behavioral therapy can be really helpful, rather than adding another pill."

Dr. Carpenter said she takes a different tack. "I don’t engage in conversations about it," she said. "I try to educate the patient about it if there is a history of early life stress by saying, ‘You are biologically programmed to be prone to the effects of stress the rest of your life.’ "

Stress management is key for these patients. "I tell them to become an antistress expert so that any new stress that enters their life doesn’t refuel the entire system," she said. Having this knowledge is very useful for people and helps them leverage multiple modalities of stress management – yoga, exercise, diet – so they can manage their stress and improve their outcomes. "These are very real things people can do to get better, and by doing them, they learn to be less aroused by stressful events."

Dr. Tietjen did not report having any conflicts. Dr. Carpenter reported receiving numerous research grants from pharmaceutical companies, as well as being a member of several speakers bureaus and advisory boards for pharmaceutical companies. Dr. Schulman said he had no disclosures.

WASHINGTON – Between 20% and 40% of headache patients have endured some kind of maltreatment during their early lives, several epidemiologic studies have concluded.

Yet no study has ever pinpointed exactly which individuals exposed to a particular type of abuse will develop a certain type of headache – or whether they will get headaches at all, Dr. Gretchen Tietjen said at the annual meeting of the American Headache Society.

Photo credit: Nick Piegari/Elsevier Global Medical News

Nor has any study ever conclusively proven the benefit of screening headache patients for childhood abuse, or even helping those patients cope with their history.

Many studies have attempted to show a benefit of screening and treatment, but these generally "come up empty-handed" said Dr. Tietjen, director of the headache treatment and research program at the University of Toledo (Ohio) Medical Center. "It’s very difficult to identify the downstream evidence of morbidity and mortality, and there is even some concern that we could actually cause harm by [recalling events] that are going to be very difficult for a patient to deal with. The risk/benefit ratio for this has never been clearly elucidated."

Multiple animal studies, and now some clinical ones, have found that chronic early life stress induces a host of physical changes that compromise the body’s ability to cope with stress later on. These changes can manifest not only as headache, but as fibromyalgia, irritable bowel syndrome, interstitial cystitis, and chronic fatigue. Anxiety and depression can emerge as well. And some research even suggests that early stress can lead to a lifelong elevation in inflammatory response, setting the stage for a host of other disorders.

The Adverse Childhood Experiences (ACE) study confirmed a strong association between childhood stress and adult headache. ACE included more than 17,000 adults and examined the relationship between frequent headaches and eight early stressors: emotional, physical, or sexual abuse; domestic violence; parental separation or divorce; and living with an adult who was mentally ill, a substance abuser, or engaged in criminal activity (Headache 2010;50:1473-81).

The study found a dose-response relationship between adverse events in childhood and the frequency of adult headaches, said Dr. Tietjen, who was a primary investigator on ACE. With a possible score of 0-8, subjects who reported having five or more early adverse experiences were more than twice as likely to also report adult headache.

Then again, "not everyone who has a stressful childhood or is abused as a child will develop headaches," Dr. Tietjen said in an interview.

The who’s and why’s are still elusive, said Dr. Linda Carpenter, a psychiatrist and researcher at Brown University, Providence, R.I. The end result emerges from a complex and still somewhat mysterious brew of innate temperament, stress type and duration, and environmental mediators. Animal data not only support a neurobiologic link, but an epigenetic link as well. Chronic stress has the ability to change DNA expression, permanently altering the way a body responds to stress. And those changes may even become part of a new generation’s genetic makeup.

Some research also suggests that a new environment can reverse the physical changes of chronic stress. Rats separated from their mothers as babies develop elevated stress responses as they mature. But after living in an enriched environment – a cage with interconnecting burrows and toys to play with – their corticosterone levels during a stress test returned to normal (J. Neurosci. 2002;22:7840-3).

Individual perceptions can moderate or enhance the downstream effects of early maltreatment, said Dr. Elliott Schulman, an ACE coauthor. What one person perceives as a stressful, abusive situation may not trigger the same response in another. The reaction of adults aware of the early situation can also color the final picture, said Dr. Schulman, a neurologist at the Jefferson Headache Center, Philadelphia.

He described a patient with refractory headache who recalled girlhood vacations during which a relative "repeatedly groped her." She reported this to her parents, who assured her that "groping" was not sexual abuse. "If the person believes it was abusive, then it was, for that person," said Dr. Schulman, who routinely addresses abuse during his patient intake. Before the initial visit, each patient receives a registration packet that includes a personal history questionnaire. At the very end of the questionnaire, after the social and marital history, it asks: "Have you been abused?"

The patient can check yes or no and, if the answer is yes, he or she can select the type – physical, emotional, or sexual. "This is akin to every other assessment we do," he said. "We ask if patients are smoking, exercising, sleeping well, having unprotected sex, using drugs. We incorporate all this into a routine history. And now that I have incorporated this question as well, I have found out patients want you to ask. If you do, they will tell you."

The next question is what to do when the answer is yes.

"Often, I find that I am the first person who has ever asked, the first person the patient has ever told, and it can be a very emotional time," Dr. Schulman said. He added that he tries to ascertain the current situation. "If the abuse is ongoing, I get an abuse advocate involved and try to help the patient get to a safe place."

If the abuse is in the past, the discussion centers on the possibility that counseling could not only help the patient come to terms with the experience emotionally, but improve headache outcomes as well.

Dr. Tietjen said she also addresses the issue in a questionnaire about life stress. If the response is positive, "I explain that this might have changed their response to stress, and although I can’t change what happened, there are ways to deal with it. We discuss the idea that cognitive-behavioral therapy can be really helpful, rather than adding another pill."

Dr. Carpenter said she takes a different tack. "I don’t engage in conversations about it," she said. "I try to educate the patient about it if there is a history of early life stress by saying, ‘You are biologically programmed to be prone to the effects of stress the rest of your life.’ "

Stress management is key for these patients. "I tell them to become an antistress expert so that any new stress that enters their life doesn’t refuel the entire system," she said. Having this knowledge is very useful for people and helps them leverage multiple modalities of stress management – yoga, exercise, diet – so they can manage their stress and improve their outcomes. "These are very real things people can do to get better, and by doing them, they learn to be less aroused by stressful events."

Dr. Tietjen did not report having any conflicts. Dr. Carpenter reported receiving numerous research grants from pharmaceutical companies, as well as being a member of several speakers bureaus and advisory boards for pharmaceutical companies. Dr. Schulman said he had no disclosures.

WASHINGTON – Between 20% and 40% of headache patients have endured some kind of maltreatment during their early lives, several epidemiologic studies have concluded.

Yet no study has ever pinpointed exactly which individuals exposed to a particular type of abuse will develop a certain type of headache – or whether they will get headaches at all, Dr. Gretchen Tietjen said at the annual meeting of the American Headache Society.

Photo credit: Nick Piegari/Elsevier Global Medical News

Nor has any study ever conclusively proven the benefit of screening headache patients for childhood abuse, or even helping those patients cope with their history.

Many studies have attempted to show a benefit of screening and treatment, but these generally "come up empty-handed" said Dr. Tietjen, director of the headache treatment and research program at the University of Toledo (Ohio) Medical Center. "It’s very difficult to identify the downstream evidence of morbidity and mortality, and there is even some concern that we could actually cause harm by [recalling events] that are going to be very difficult for a patient to deal with. The risk/benefit ratio for this has never been clearly elucidated."

Multiple animal studies, and now some clinical ones, have found that chronic early life stress induces a host of physical changes that compromise the body’s ability to cope with stress later on. These changes can manifest not only as headache, but as fibromyalgia, irritable bowel syndrome, interstitial cystitis, and chronic fatigue. Anxiety and depression can emerge as well. And some research even suggests that early stress can lead to a lifelong elevation in inflammatory response, setting the stage for a host of other disorders.

The Adverse Childhood Experiences (ACE) study confirmed a strong association between childhood stress and adult headache. ACE included more than 17,000 adults and examined the relationship between frequent headaches and eight early stressors: emotional, physical, or sexual abuse; domestic violence; parental separation or divorce; and living with an adult who was mentally ill, a substance abuser, or engaged in criminal activity (Headache 2010;50:1473-81).

The study found a dose-response relationship between adverse events in childhood and the frequency of adult headaches, said Dr. Tietjen, who was a primary investigator on ACE. With a possible score of 0-8, subjects who reported having five or more early adverse experiences were more than twice as likely to also report adult headache.

Then again, "not everyone who has a stressful childhood or is abused as a child will develop headaches," Dr. Tietjen said in an interview.

The who’s and why’s are still elusive, said Dr. Linda Carpenter, a psychiatrist and researcher at Brown University, Providence, R.I. The end result emerges from a complex and still somewhat mysterious brew of innate temperament, stress type and duration, and environmental mediators. Animal data not only support a neurobiologic link, but an epigenetic link as well. Chronic stress has the ability to change DNA expression, permanently altering the way a body responds to stress. And those changes may even become part of a new generation’s genetic makeup.

Some research also suggests that a new environment can reverse the physical changes of chronic stress. Rats separated from their mothers as babies develop elevated stress responses as they mature. But after living in an enriched environment – a cage with interconnecting burrows and toys to play with – their corticosterone levels during a stress test returned to normal (J. Neurosci. 2002;22:7840-3).

Individual perceptions can moderate or enhance the downstream effects of early maltreatment, said Dr. Elliott Schulman, an ACE coauthor. What one person perceives as a stressful, abusive situation may not trigger the same response in another. The reaction of adults aware of the early situation can also color the final picture, said Dr. Schulman, a neurologist at the Jefferson Headache Center, Philadelphia.

He described a patient with refractory headache who recalled girlhood vacations during which a relative "repeatedly groped her." She reported this to her parents, who assured her that "groping" was not sexual abuse. "If the person believes it was abusive, then it was, for that person," said Dr. Schulman, who routinely addresses abuse during his patient intake. Before the initial visit, each patient receives a registration packet that includes a personal history questionnaire. At the very end of the questionnaire, after the social and marital history, it asks: "Have you been abused?"

The patient can check yes or no and, if the answer is yes, he or she can select the type – physical, emotional, or sexual. "This is akin to every other assessment we do," he said. "We ask if patients are smoking, exercising, sleeping well, having unprotected sex, using drugs. We incorporate all this into a routine history. And now that I have incorporated this question as well, I have found out patients want you to ask. If you do, they will tell you."

The next question is what to do when the answer is yes.

"Often, I find that I am the first person who has ever asked, the first person the patient has ever told, and it can be a very emotional time," Dr. Schulman said. He added that he tries to ascertain the current situation. "If the abuse is ongoing, I get an abuse advocate involved and try to help the patient get to a safe place."

If the abuse is in the past, the discussion centers on the possibility that counseling could not only help the patient come to terms with the experience emotionally, but improve headache outcomes as well.

Dr. Tietjen said she also addresses the issue in a questionnaire about life stress. If the response is positive, "I explain that this might have changed their response to stress, and although I can’t change what happened, there are ways to deal with it. We discuss the idea that cognitive-behavioral therapy can be really helpful, rather than adding another pill."

Dr. Carpenter said she takes a different tack. "I don’t engage in conversations about it," she said. "I try to educate the patient about it if there is a history of early life stress by saying, ‘You are biologically programmed to be prone to the effects of stress the rest of your life.’ "

Stress management is key for these patients. "I tell them to become an antistress expert so that any new stress that enters their life doesn’t refuel the entire system," she said. Having this knowledge is very useful for people and helps them leverage multiple modalities of stress management – yoga, exercise, diet – so they can manage their stress and improve their outcomes. "These are very real things people can do to get better, and by doing them, they learn to be less aroused by stressful events."

Dr. Tietjen did not report having any conflicts. Dr. Carpenter reported receiving numerous research grants from pharmaceutical companies, as well as being a member of several speakers bureaus and advisory boards for pharmaceutical companies. Dr. Schulman said he had no disclosures.

A combination of vaginal bleeding score and human chorionic gonadotropin levels may predict the possibility of miscarriage by up to 77%, and the possibility of ongoing pregnancy by 94%.

The "pregnancy viability index" could help physicians reassure women who present with threatened miscarriage that the pregnancy is likely to continue and prepare those who may face miscarriage. Additionally, the score might help channel medical interventions more appropriately, Dr. Kaltum Adam said at the annual meeting of the European Society of Human Reproduction and Embryology.

"It will enable us to provide targeted management and counseling for the affected women and reassure those who are likely to achieve a live birth," said Dr. Adam, an honorary clinical research fellow at St. Mary’s Hospital in Manchester, England.

Her prospective longitudinal study included 112 women who presented with threatened miscarriage at 6-10 weeks’ gestation and with a confirmed intrauterine pregnancy. They were followed for 5 weeks, during which time they completed daily charts of pain and vaginal bleeding; had a weekly ultrasound and physical exam; and contributed weekly blood samples that were analyzed for progesterone, human chorionic gonadotropin (hCG), hemoglobin, and other standard blood chemistry factors. Baseline screening also included maternal demographics, educational, and socioeconomic status. At the final visit, there was an ultrasound exam to confirm the pregnancy’s outcome.

Of the 112 women, 22 (20%) miscarried. Time of first vaginal bleeding to miscarriage was available for 20 women: 11 miscarried in the first 7 days, 15 within 14 days, and 18 within 21 days. All of the miscarriages occurred within 28 days of the first bleed.

Dr. Adam determined that six baseline biomarkers were significantly associated with miscarriage at the 20th percentile: history of subfertility, bleeding score of two on a five-point scale, gestational age of the fetus, fetal crown-rump length of 4 mm, and serum levels of progesterone and hCG (32 nmol/L and 1,500 iU/L, respectively).

"All of these had good positive predictive values, indicating that a pregnancy had a good chance of surviving," Dr. Adam said, "but the negative predictive values were not useful for clinical practice or research."

A multivariate regression analysis, however, did identify that a combination of baseline bleeding score (two on a five-point scale) and baseline hCG level (1,500 iU/L) exhibited excellent positive and negative predictive values (94% and 77%, respectively). The equation used for computing the pregnancy viability index was hCG level/bleeding score × 1.87 × 10, where the bleeding score odds ratio for miscarriage is 1.87.

"This research has, for the first time, offered us a tool to begin to attempt to rescue pregnancies threatening to miscarry when, currently, all we can do is fold our hands and hope for the best," Dr. Adam said.

Dr. Adam plans to carry out a validation study on at least 1,000 women in the near future.

The study was funded by the Central Manchester Foundation Trust Biomedical Research Center. Dr. Adam said she had no relevant financial disclosures.

A combination of vaginal bleeding score and human chorionic gonadotropin levels may predict the possibility of miscarriage by up to 77%, and the possibility of ongoing pregnancy by 94%.

The "pregnancy viability index" could help physicians reassure women who present with threatened miscarriage that the pregnancy is likely to continue and prepare those who may face miscarriage. Additionally, the score might help channel medical interventions more appropriately, Dr. Kaltum Adam said at the annual meeting of the European Society of Human Reproduction and Embryology.

"It will enable us to provide targeted management and counseling for the affected women and reassure those who are likely to achieve a live birth," said Dr. Adam, an honorary clinical research fellow at St. Mary’s Hospital in Manchester, England.

Her prospective longitudinal study included 112 women who presented with threatened miscarriage at 6-10 weeks’ gestation and with a confirmed intrauterine pregnancy. They were followed for 5 weeks, during which time they completed daily charts of pain and vaginal bleeding; had a weekly ultrasound and physical exam; and contributed weekly blood samples that were analyzed for progesterone, human chorionic gonadotropin (hCG), hemoglobin, and other standard blood chemistry factors. Baseline screening also included maternal demographics, educational, and socioeconomic status. At the final visit, there was an ultrasound exam to confirm the pregnancy’s outcome.

Of the 112 women, 22 (20%) miscarried. Time of first vaginal bleeding to miscarriage was available for 20 women: 11 miscarried in the first 7 days, 15 within 14 days, and 18 within 21 days. All of the miscarriages occurred within 28 days of the first bleed.

Dr. Adam determined that six baseline biomarkers were significantly associated with miscarriage at the 20th percentile: history of subfertility, bleeding score of two on a five-point scale, gestational age of the fetus, fetal crown-rump length of 4 mm, and serum levels of progesterone and hCG (32 nmol/L and 1,500 iU/L, respectively).

"All of these had good positive predictive values, indicating that a pregnancy had a good chance of surviving," Dr. Adam said, "but the negative predictive values were not useful for clinical practice or research."

A multivariate regression analysis, however, did identify that a combination of baseline bleeding score (two on a five-point scale) and baseline hCG level (1,500 iU/L) exhibited excellent positive and negative predictive values (94% and 77%, respectively). The equation used for computing the pregnancy viability index was hCG level/bleeding score × 1.87 × 10, where the bleeding score odds ratio for miscarriage is 1.87.

"This research has, for the first time, offered us a tool to begin to attempt to rescue pregnancies threatening to miscarry when, currently, all we can do is fold our hands and hope for the best," Dr. Adam said.

Dr. Adam plans to carry out a validation study on at least 1,000 women in the near future.

The study was funded by the Central Manchester Foundation Trust Biomedical Research Center. Dr. Adam said she had no relevant financial disclosures.

A combination of vaginal bleeding score and human chorionic gonadotropin levels may predict the possibility of miscarriage by up to 77%, and the possibility of ongoing pregnancy by 94%.

The "pregnancy viability index" could help physicians reassure women who present with threatened miscarriage that the pregnancy is likely to continue and prepare those who may face miscarriage. Additionally, the score might help channel medical interventions more appropriately, Dr. Kaltum Adam said at the annual meeting of the European Society of Human Reproduction and Embryology.

"It will enable us to provide targeted management and counseling for the affected women and reassure those who are likely to achieve a live birth," said Dr. Adam, an honorary clinical research fellow at St. Mary’s Hospital in Manchester, England.

Her prospective longitudinal study included 112 women who presented with threatened miscarriage at 6-10 weeks’ gestation and with a confirmed intrauterine pregnancy. They were followed for 5 weeks, during which time they completed daily charts of pain and vaginal bleeding; had a weekly ultrasound and physical exam; and contributed weekly blood samples that were analyzed for progesterone, human chorionic gonadotropin (hCG), hemoglobin, and other standard blood chemistry factors. Baseline screening also included maternal demographics, educational, and socioeconomic status. At the final visit, there was an ultrasound exam to confirm the pregnancy’s outcome.

Of the 112 women, 22 (20%) miscarried. Time of first vaginal bleeding to miscarriage was available for 20 women: 11 miscarried in the first 7 days, 15 within 14 days, and 18 within 21 days. All of the miscarriages occurred within 28 days of the first bleed.

Dr. Adam determined that six baseline biomarkers were significantly associated with miscarriage at the 20th percentile: history of subfertility, bleeding score of two on a five-point scale, gestational age of the fetus, fetal crown-rump length of 4 mm, and serum levels of progesterone and hCG (32 nmol/L and 1,500 iU/L, respectively).

"All of these had good positive predictive values, indicating that a pregnancy had a good chance of surviving," Dr. Adam said, "but the negative predictive values were not useful for clinical practice or research."

A multivariate regression analysis, however, did identify that a combination of baseline bleeding score (two on a five-point scale) and baseline hCG level (1,500 iU/L) exhibited excellent positive and negative predictive values (94% and 77%, respectively). The equation used for computing the pregnancy viability index was hCG level/bleeding score × 1.87 × 10, where the bleeding score odds ratio for miscarriage is 1.87.

"This research has, for the first time, offered us a tool to begin to attempt to rescue pregnancies threatening to miscarry when, currently, all we can do is fold our hands and hope for the best," Dr. Adam said.

Dr. Adam plans to carry out a validation study on at least 1,000 women in the near future.

The study was funded by the Central Manchester Foundation Trust Biomedical Research Center. Dr. Adam said she had no relevant financial disclosures.