Sharon Worcester

MIAMI BEACH — Pelvic ultrasound is accurate for ruling out placenta accreta, and should be used as the primary screening tool in patients at high risk for this condition, Dr. Carri Warshak said at the annual meeting of the Society for Maternal-Fetal Medicine.

Magnetic resonance imaging also should be considered in the evaluation of all suspected cases, she added.

A historical cohort study of 433 patients with placenta previa who underwent ultrasound showed that this screening modality accurately predicted placenta accreta (which for the purposes of this study also included placenta increta and percreta) in 25 of the 32 women whose diagnosis was confirmed by pathologic examination, for a sensitivity of 0.78. Ultrasound ruled out the condition in 397 of 401 patients, for a specificity of 0.99; MRI ruled out the condition in the remaining 4 patients, said Dr. Warshak of the University of California, San Diego.

Of an additional 58 women who were referred for MRI based on equivocal ultrasound findings, 39 were shown on pathologic examination to have placenta accreta. MRI accurately predicted the condition in 35 of the 39 patients for a sensitivity of 0.90, and ruled out the condition in the remaining 19 patients for a specificity of 1.

Information for the study was obtained from a perinatal database for patients screened by ultrasound between January 2000 and June 2005 and for patients screened by MRI between January 1992 and June 2005.

The findings are important because they confirm the accuracy of ultrasound and MRI for detecting a condition that requires accurate prenatal diagnosis for optimal management, she said.

Furthermore, the incidence of abnormal placentation has increased 10-fold over the past decade, largely due to the increased cesarean section rate. An estimated 9% of pregnancies are affected, she noted.

The findings confirm those from the three largest studies of ultrasound diagnosis for placenta accreta; pooled data from those studies and the current study show pelvic ultrasound is 81% sensitive and 98% specific for diagnosis, she said.

MRI has been less well studied, and results have been conflicting, but the findings of this study suggest it has an important role in optimizing diagnostic accuracy, particularly in patients with equivocal findings on ultrasound, she concluded.

MIAMI BEACH — Pelvic ultrasound is accurate for ruling out placenta accreta, and should be used as the primary screening tool in patients at high risk for this condition, Dr. Carri Warshak said at the annual meeting of the Society for Maternal-Fetal Medicine.

Magnetic resonance imaging also should be considered in the evaluation of all suspected cases, she added.

A historical cohort study of 433 patients with placenta previa who underwent ultrasound showed that this screening modality accurately predicted placenta accreta (which for the purposes of this study also included placenta increta and percreta) in 25 of the 32 women whose diagnosis was confirmed by pathologic examination, for a sensitivity of 0.78. Ultrasound ruled out the condition in 397 of 401 patients, for a specificity of 0.99; MRI ruled out the condition in the remaining 4 patients, said Dr. Warshak of the University of California, San Diego.

Of an additional 58 women who were referred for MRI based on equivocal ultrasound findings, 39 were shown on pathologic examination to have placenta accreta. MRI accurately predicted the condition in 35 of the 39 patients for a sensitivity of 0.90, and ruled out the condition in the remaining 19 patients for a specificity of 1.

Information for the study was obtained from a perinatal database for patients screened by ultrasound between January 2000 and June 2005 and for patients screened by MRI between January 1992 and June 2005.

The findings are important because they confirm the accuracy of ultrasound and MRI for detecting a condition that requires accurate prenatal diagnosis for optimal management, she said.

Furthermore, the incidence of abnormal placentation has increased 10-fold over the past decade, largely due to the increased cesarean section rate. An estimated 9% of pregnancies are affected, she noted.

The findings confirm those from the three largest studies of ultrasound diagnosis for placenta accreta; pooled data from those studies and the current study show pelvic ultrasound is 81% sensitive and 98% specific for diagnosis, she said.

MRI has been less well studied, and results have been conflicting, but the findings of this study suggest it has an important role in optimizing diagnostic accuracy, particularly in patients with equivocal findings on ultrasound, she concluded.

MIAMI BEACH — Pelvic ultrasound is accurate for ruling out placenta accreta, and should be used as the primary screening tool in patients at high risk for this condition, Dr. Carri Warshak said at the annual meeting of the Society for Maternal-Fetal Medicine.

Magnetic resonance imaging also should be considered in the evaluation of all suspected cases, she added.

A historical cohort study of 433 patients with placenta previa who underwent ultrasound showed that this screening modality accurately predicted placenta accreta (which for the purposes of this study also included placenta increta and percreta) in 25 of the 32 women whose diagnosis was confirmed by pathologic examination, for a sensitivity of 0.78. Ultrasound ruled out the condition in 397 of 401 patients, for a specificity of 0.99; MRI ruled out the condition in the remaining 4 patients, said Dr. Warshak of the University of California, San Diego.

Of an additional 58 women who were referred for MRI based on equivocal ultrasound findings, 39 were shown on pathologic examination to have placenta accreta. MRI accurately predicted the condition in 35 of the 39 patients for a sensitivity of 0.90, and ruled out the condition in the remaining 19 patients for a specificity of 1.

Information for the study was obtained from a perinatal database for patients screened by ultrasound between January 2000 and June 2005 and for patients screened by MRI between January 1992 and June 2005.

The findings are important because they confirm the accuracy of ultrasound and MRI for detecting a condition that requires accurate prenatal diagnosis for optimal management, she said.

Furthermore, the incidence of abnormal placentation has increased 10-fold over the past decade, largely due to the increased cesarean section rate. An estimated 9% of pregnancies are affected, she noted.

The findings confirm those from the three largest studies of ultrasound diagnosis for placenta accreta; pooled data from those studies and the current study show pelvic ultrasound is 81% sensitive and 98% specific for diagnosis, she said.

MRI has been less well studied, and results have been conflicting, but the findings of this study suggest it has an important role in optimizing diagnostic accuracy, particularly in patients with equivocal findings on ultrasound, she concluded.

Inhalant abuse, known as “sniffing” or “huffing,” appears to be increasing among teens, and shifting attitudes about the practice are cause for alarm, according to the Partnership for a Drug-Free America.

In a new survey of 7,200 7th-12th graders, about 23% reported abusing inhalants. That's up about 2% since 2001, according to the Partnership, which conducts such surveys annually. The most recent survey—the 2005 Partnership Attitude Tracking Study—was conducted from March through June 2005 and has a margin of error of w 1.5%.

Of particular concern is that the percentage of teens reporting that they “strongly agree” that inhalant abuse can be deadly declined 19% since 2001, with only 64% of respondents in the 2005 survey agreeing that inhalants can kill.

“What stands out is the teens' decreasing perception of risk, because that often correlates with increases in use. We clearly need to address underlying attitudes and help teens understand the dangers associated with this form of substance abuse,” Steve Pasierb, president and CEO of the Partnership said in a written statement.

Substances commonly used for huffing include spray paint, glue, computer duster, cooking spray, and correction fluid. Sniffing highly concentrated amounts of vapors from some products can cause a syndrome known as “sudden sniffing death,” which can result after even a single session of inhalant use. Chronic exposure to inhalants can also cause damage to the brain, heart, lungs, liver, and kidneys.

Educational campaigns about the dangers of inhalant abuse also must target parents, who according to the Partnership report are either not aware or are in denial about the prevalence of inhalant abuse among teens. Of 1,200 parents of teens who were also surveyed, only 5% believe their child ever abused inhalants; teens are four times more likely to report inhalant abuse than parents expect.

Similar campaigns in the 1990s were effective for reducing inhalant abuse; between 1995 and 2001, data suggested these programs led to an increase from 64% to 79% in the proportion of teens who perceived inhalant abuse as risky, and inhalant abuse declined significantly during that period, from 23% to 18%.

Inhalant abuse, known as “sniffing” or “huffing,” appears to be increasing among teens, and shifting attitudes about the practice are cause for alarm, according to the Partnership for a Drug-Free America.

In a new survey of 7,200 7th-12th graders, about 23% reported abusing inhalants. That's up about 2% since 2001, according to the Partnership, which conducts such surveys annually. The most recent survey—the 2005 Partnership Attitude Tracking Study—was conducted from March through June 2005 and has a margin of error of w 1.5%.

Of particular concern is that the percentage of teens reporting that they “strongly agree” that inhalant abuse can be deadly declined 19% since 2001, with only 64% of respondents in the 2005 survey agreeing that inhalants can kill.

“What stands out is the teens' decreasing perception of risk, because that often correlates with increases in use. We clearly need to address underlying attitudes and help teens understand the dangers associated with this form of substance abuse,” Steve Pasierb, president and CEO of the Partnership said in a written statement.

Substances commonly used for huffing include spray paint, glue, computer duster, cooking spray, and correction fluid. Sniffing highly concentrated amounts of vapors from some products can cause a syndrome known as “sudden sniffing death,” which can result after even a single session of inhalant use. Chronic exposure to inhalants can also cause damage to the brain, heart, lungs, liver, and kidneys.

Educational campaigns about the dangers of inhalant abuse also must target parents, who according to the Partnership report are either not aware or are in denial about the prevalence of inhalant abuse among teens. Of 1,200 parents of teens who were also surveyed, only 5% believe their child ever abused inhalants; teens are four times more likely to report inhalant abuse than parents expect.

Similar campaigns in the 1990s were effective for reducing inhalant abuse; between 1995 and 2001, data suggested these programs led to an increase from 64% to 79% in the proportion of teens who perceived inhalant abuse as risky, and inhalant abuse declined significantly during that period, from 23% to 18%.

Inhalant abuse, known as “sniffing” or “huffing,” appears to be increasing among teens, and shifting attitudes about the practice are cause for alarm, according to the Partnership for a Drug-Free America.

In a new survey of 7,200 7th-12th graders, about 23% reported abusing inhalants. That's up about 2% since 2001, according to the Partnership, which conducts such surveys annually. The most recent survey—the 2005 Partnership Attitude Tracking Study—was conducted from March through June 2005 and has a margin of error of w 1.5%.

Of particular concern is that the percentage of teens reporting that they “strongly agree” that inhalant abuse can be deadly declined 19% since 2001, with only 64% of respondents in the 2005 survey agreeing that inhalants can kill.

“What stands out is the teens' decreasing perception of risk, because that often correlates with increases in use. We clearly need to address underlying attitudes and help teens understand the dangers associated with this form of substance abuse,” Steve Pasierb, president and CEO of the Partnership said in a written statement.

Substances commonly used for huffing include spray paint, glue, computer duster, cooking spray, and correction fluid. Sniffing highly concentrated amounts of vapors from some products can cause a syndrome known as “sudden sniffing death,” which can result after even a single session of inhalant use. Chronic exposure to inhalants can also cause damage to the brain, heart, lungs, liver, and kidneys.

Educational campaigns about the dangers of inhalant abuse also must target parents, who according to the Partnership report are either not aware or are in denial about the prevalence of inhalant abuse among teens. Of 1,200 parents of teens who were also surveyed, only 5% believe their child ever abused inhalants; teens are four times more likely to report inhalant abuse than parents expect.

Similar campaigns in the 1990s were effective for reducing inhalant abuse; between 1995 and 2001, data suggested these programs led to an increase from 64% to 79% in the proportion of teens who perceived inhalant abuse as risky, and inhalant abuse declined significantly during that period, from 23% to 18%.

CHICAGO – An important key to the success of an organizational psychiatry consultation lies within the consultant, Dr. C. Donald Williams said at the annual meeting of the Academy of Organizational and Occupational Psychiatry.

“The consultant can be profoundly positively impacting,” said Dr. Williams, an occupational psychiatrist and certified group psychotherapist in Yakima, Wash.

He described several lessons he learned during a 2-year consultation with a private, nonprofit community health plan that was in financial and organizational crisis.

For example, to provide that positive impact, it is important to establish and maintain trust through practical competence, consistency, and complete commitment to the consultation, he said, adding that the consultant should exceed expectations and embody the changes that are promoted.

That is, when a consultant asks a company to be accountable, available, on time with execution, reality focused, and results oriented, that consultant must be accountable, available, on time with execution, reality focused, and results oriented, he said at the meeting, which was cosponsored by the American College of Occupational and Environmental Medicine.

Also, Dr. Williiams learned that parallels exist between organizational change and personal change. For example, organizational change requires commitment by the chief executive officer and the consultant, and individual change requires commitment and time of the patient and the therapist.

Among other important lessons to keep in mind during an organizational consultation are the following:

▸ Character, skills, integrity, and work ethic are indispensable.

▸ A positive change climate is crucial to morale.

▸ The relationship between the CEO and board is key for success, and should be promoted.

▸ The CEO, board, and senior management team must embody best practices.

▸ A healthy organization has a system of checks and balances, without depending entirely on “one good person.” (“I try to model that through the use of consultants,” Dr. Williams said).

▸ A healthy organization maintains standards for work and behavior that promote good “new hires.”

▸ It takes years of ongoing effort to make lasting and effective organizational change.

Dr. Williams said he found his experience as a group psychotherapist to be an asset to this particular consultation. An insistence on a minimum of weekly contacts also was beneficial, as was an entrepreneurial spirit on his part.

Liabilities included remoteness to the consultation site, which required reliance on videoconferencing for weekly contacts, and an incomplete data set. It was a challenge to stay in the information loop without being on site, he explained.

CHICAGO – An important key to the success of an organizational psychiatry consultation lies within the consultant, Dr. C. Donald Williams said at the annual meeting of the Academy of Organizational and Occupational Psychiatry.

“The consultant can be profoundly positively impacting,” said Dr. Williams, an occupational psychiatrist and certified group psychotherapist in Yakima, Wash.

He described several lessons he learned during a 2-year consultation with a private, nonprofit community health plan that was in financial and organizational crisis.

For example, to provide that positive impact, it is important to establish and maintain trust through practical competence, consistency, and complete commitment to the consultation, he said, adding that the consultant should exceed expectations and embody the changes that are promoted.

That is, when a consultant asks a company to be accountable, available, on time with execution, reality focused, and results oriented, that consultant must be accountable, available, on time with execution, reality focused, and results oriented, he said at the meeting, which was cosponsored by the American College of Occupational and Environmental Medicine.

Also, Dr. Williiams learned that parallels exist between organizational change and personal change. For example, organizational change requires commitment by the chief executive officer and the consultant, and individual change requires commitment and time of the patient and the therapist.

Among other important lessons to keep in mind during an organizational consultation are the following:

▸ Character, skills, integrity, and work ethic are indispensable.

▸ A positive change climate is crucial to morale.

▸ The relationship between the CEO and board is key for success, and should be promoted.

▸ The CEO, board, and senior management team must embody best practices.

▸ A healthy organization has a system of checks and balances, without depending entirely on “one good person.” (“I try to model that through the use of consultants,” Dr. Williams said).

▸ A healthy organization maintains standards for work and behavior that promote good “new hires.”

▸ It takes years of ongoing effort to make lasting and effective organizational change.

Dr. Williams said he found his experience as a group psychotherapist to be an asset to this particular consultation. An insistence on a minimum of weekly contacts also was beneficial, as was an entrepreneurial spirit on his part.

Liabilities included remoteness to the consultation site, which required reliance on videoconferencing for weekly contacts, and an incomplete data set. It was a challenge to stay in the information loop without being on site, he explained.

CHICAGO – An important key to the success of an organizational psychiatry consultation lies within the consultant, Dr. C. Donald Williams said at the annual meeting of the Academy of Organizational and Occupational Psychiatry.

“The consultant can be profoundly positively impacting,” said Dr. Williams, an occupational psychiatrist and certified group psychotherapist in Yakima, Wash.

He described several lessons he learned during a 2-year consultation with a private, nonprofit community health plan that was in financial and organizational crisis.

For example, to provide that positive impact, it is important to establish and maintain trust through practical competence, consistency, and complete commitment to the consultation, he said, adding that the consultant should exceed expectations and embody the changes that are promoted.

That is, when a consultant asks a company to be accountable, available, on time with execution, reality focused, and results oriented, that consultant must be accountable, available, on time with execution, reality focused, and results oriented, he said at the meeting, which was cosponsored by the American College of Occupational and Environmental Medicine.

Also, Dr. Williiams learned that parallels exist between organizational change and personal change. For example, organizational change requires commitment by the chief executive officer and the consultant, and individual change requires commitment and time of the patient and the therapist.

Among other important lessons to keep in mind during an organizational consultation are the following:

▸ Character, skills, integrity, and work ethic are indispensable.

▸ A positive change climate is crucial to morale.

▸ The relationship between the CEO and board is key for success, and should be promoted.

▸ The CEO, board, and senior management team must embody best practices.

▸ A healthy organization has a system of checks and balances, without depending entirely on “one good person.” (“I try to model that through the use of consultants,” Dr. Williams said).

▸ A healthy organization maintains standards for work and behavior that promote good “new hires.”

▸ It takes years of ongoing effort to make lasting and effective organizational change.

Dr. Williams said he found his experience as a group psychotherapist to be an asset to this particular consultation. An insistence on a minimum of weekly contacts also was beneficial, as was an entrepreneurial spirit on his part.

Liabilities included remoteness to the consultation site, which required reliance on videoconferencing for weekly contacts, and an incomplete data set. It was a challenge to stay in the information loop without being on site, he explained.

MIAMI BEACH – The risks of not treating attention-deficit hyperactivity disorder are far greater than the risks involved in treating the disorder, Dr. David Goodman reported at the annual meeting of the American Society for Adolescent Psychiatry.

ADHD persists into adulthood in about 50% of cases, and adults who present with previously untreated ADHD often present with comorbid psychiatric disorders and substance abuse disorders. Preventing these problems early by treating ADHD is far more effective and cost-effective than attempting to treat them later, said Dr. Goodman of Johns Hopkins University, Baltimore.

Smoking and substance abuse, sexual activity and related risks, and driving accidents have specifically been shown to be reduced by ADHD treatment.

Studies show that compared with treated ADHD, untreated ADHD is associated with greater risk of smoking at age 11 years and greater risk of substance abuse at age 13.

Preventing smoking in children with ADHD is important because it has been linked with increased risk of drug and alcohol abuse.

In a study of 100 ADHD patients and 200 controls, ADHD smokers were shown to have a significantly higher rate of alcohol and drug abuse, Dr. Goodman noted at the annual meeting, which was cosponsored by the University of Texas at Dallas.

Also, some opponents of treating ADHD argue that misuse and diversion of medication is “rampant,” but research does not bear this out, he said.

In a survey of more than 13,000 high school students, 9% said they had used nonprescribed stimulants, 15% of those who had been prescribed stimulants had given them away, and 13% who had been prescribed stimulants had sold them.

This is a problem that deserves careful consideration when prescribing, but it is not “rampant,” Dr. Goodman said, explaining that the risks of substance abuse in ADHD patients who are not treated outweighs the risk of such misuse and diversion of prescribed medications.

In fact, one study with 5-year follow-up showed that the risk for substance abuse in untreated patients was 75%, compared with 25% in treated patients–a rate not significantly different from that in the general population.

Furthermore, a metaanalysis of seven studies with a total of about 1,000 patients demonstrated that at 4-year follow-up, there was a twofold higher risk of developing substance abuse in untreated vs. treated ADHD patients. The risk was reduced twofold in treated patients. A third study showed no increased risk at ages 15–21 in treated patients.

“Treating is not a gateway to drug abuse, and we need to convey that to parents,” Dr. Goodman said.

Untreated ADHD also has been linked with greater likelihood of being sexually active and becoming pregnant by age 15.

Untreated patients generally have intercourse earlier, and have more sexual partners, which leaves them at fourfold increased risk of sexually transmitted diseases, according to at least one study. These patients also are at substantially increased risk of pregnancy.

In a birth registry study of 160 ADHD patients and 76 controls, there were 43 pregnancies, of which 42 were to adolescent ADHD mothers. Fewer than half maintained custody of their children, Dr. Goodman noted.

Driving also is a problem in untreated ADHD adolescents. At age 17, children with untreated ADHD begin having car accidents, and multiple accidents are not uncommon, as shown by several studies, including driving simulation tests of treated and untreated patients.

Reports analyzing national highway safety data have also shown that ADHD is a significant contributor to motor vehicle accidents.

In fact, the risk of a fatal car accident is far greater than the risk of a patient dying from taking an ADHD drug, Dr. Goodman said.

Other risks associated with untreated ADHD include dropping out of high school and college.

Increased high school dropout rates are seen in untreated ADHD at around age 17, and at ages 19–20, those who have made it to college are at greater risk of dropping out. “Adolescent untreated ADHD is not a benign exercise,” Dr. Goodman said. “We're not supposed to stick our heads in the sand and cross our fingers and pray to God that our children will come out of it at the other end of that adolescent tunnel. It's a very, very dark cave.”

Risk Factors for Persistent ADHD

At least a dozen longitudinal studies show that ADHD persists past age 18 in about half of all cases.

Clinicians can no longer tell parents that their children will definitely grow out of ADHD, but it also is not necessary to shrug one's shoulders and say that only time will tell if the child will grow out of it. Family history can help identify children whose conditions might persist, Dr. Goodman said.

The data suggest that if a parent has ADHD and a child has ADHD, the child has a high likelihood of having adult ADHD. If the parent had ADHD but no longer has ADHD, the child is likely to grow out of it.

Other factors associated with increased risk of persistent ADHD include living in a chaotic and tumultuous environment, and having comorbid psychiatric conditions, Dr. Goodman noted.

MIAMI BEACH – The risks of not treating attention-deficit hyperactivity disorder are far greater than the risks involved in treating the disorder, Dr. David Goodman reported at the annual meeting of the American Society for Adolescent Psychiatry.

ADHD persists into adulthood in about 50% of cases, and adults who present with previously untreated ADHD often present with comorbid psychiatric disorders and substance abuse disorders. Preventing these problems early by treating ADHD is far more effective and cost-effective than attempting to treat them later, said Dr. Goodman of Johns Hopkins University, Baltimore.

Smoking and substance abuse, sexual activity and related risks, and driving accidents have specifically been shown to be reduced by ADHD treatment.

Studies show that compared with treated ADHD, untreated ADHD is associated with greater risk of smoking at age 11 years and greater risk of substance abuse at age 13.

Preventing smoking in children with ADHD is important because it has been linked with increased risk of drug and alcohol abuse.

In a study of 100 ADHD patients and 200 controls, ADHD smokers were shown to have a significantly higher rate of alcohol and drug abuse, Dr. Goodman noted at the annual meeting, which was cosponsored by the University of Texas at Dallas.

Also, some opponents of treating ADHD argue that misuse and diversion of medication is “rampant,” but research does not bear this out, he said.

In a survey of more than 13,000 high school students, 9% said they had used nonprescribed stimulants, 15% of those who had been prescribed stimulants had given them away, and 13% who had been prescribed stimulants had sold them.

This is a problem that deserves careful consideration when prescribing, but it is not “rampant,” Dr. Goodman said, explaining that the risks of substance abuse in ADHD patients who are not treated outweighs the risk of such misuse and diversion of prescribed medications.

In fact, one study with 5-year follow-up showed that the risk for substance abuse in untreated patients was 75%, compared with 25% in treated patients–a rate not significantly different from that in the general population.

Furthermore, a metaanalysis of seven studies with a total of about 1,000 patients demonstrated that at 4-year follow-up, there was a twofold higher risk of developing substance abuse in untreated vs. treated ADHD patients. The risk was reduced twofold in treated patients. A third study showed no increased risk at ages 15–21 in treated patients.

“Treating is not a gateway to drug abuse, and we need to convey that to parents,” Dr. Goodman said.

Untreated ADHD also has been linked with greater likelihood of being sexually active and becoming pregnant by age 15.

Untreated patients generally have intercourse earlier, and have more sexual partners, which leaves them at fourfold increased risk of sexually transmitted diseases, according to at least one study. These patients also are at substantially increased risk of pregnancy.

In a birth registry study of 160 ADHD patients and 76 controls, there were 43 pregnancies, of which 42 were to adolescent ADHD mothers. Fewer than half maintained custody of their children, Dr. Goodman noted.

Driving also is a problem in untreated ADHD adolescents. At age 17, children with untreated ADHD begin having car accidents, and multiple accidents are not uncommon, as shown by several studies, including driving simulation tests of treated and untreated patients.

Reports analyzing national highway safety data have also shown that ADHD is a significant contributor to motor vehicle accidents.

In fact, the risk of a fatal car accident is far greater than the risk of a patient dying from taking an ADHD drug, Dr. Goodman said.

Other risks associated with untreated ADHD include dropping out of high school and college.

Increased high school dropout rates are seen in untreated ADHD at around age 17, and at ages 19–20, those who have made it to college are at greater risk of dropping out. “Adolescent untreated ADHD is not a benign exercise,” Dr. Goodman said. “We're not supposed to stick our heads in the sand and cross our fingers and pray to God that our children will come out of it at the other end of that adolescent tunnel. It's a very, very dark cave.”

Risk Factors for Persistent ADHD

At least a dozen longitudinal studies show that ADHD persists past age 18 in about half of all cases.

Clinicians can no longer tell parents that their children will definitely grow out of ADHD, but it also is not necessary to shrug one's shoulders and say that only time will tell if the child will grow out of it. Family history can help identify children whose conditions might persist, Dr. Goodman said.

The data suggest that if a parent has ADHD and a child has ADHD, the child has a high likelihood of having adult ADHD. If the parent had ADHD but no longer has ADHD, the child is likely to grow out of it.

Other factors associated with increased risk of persistent ADHD include living in a chaotic and tumultuous environment, and having comorbid psychiatric conditions, Dr. Goodman noted.

MIAMI BEACH – The risks of not treating attention-deficit hyperactivity disorder are far greater than the risks involved in treating the disorder, Dr. David Goodman reported at the annual meeting of the American Society for Adolescent Psychiatry.

ADHD persists into adulthood in about 50% of cases, and adults who present with previously untreated ADHD often present with comorbid psychiatric disorders and substance abuse disorders. Preventing these problems early by treating ADHD is far more effective and cost-effective than attempting to treat them later, said Dr. Goodman of Johns Hopkins University, Baltimore.

Smoking and substance abuse, sexual activity and related risks, and driving accidents have specifically been shown to be reduced by ADHD treatment.

Studies show that compared with treated ADHD, untreated ADHD is associated with greater risk of smoking at age 11 years and greater risk of substance abuse at age 13.

Preventing smoking in children with ADHD is important because it has been linked with increased risk of drug and alcohol abuse.

In a study of 100 ADHD patients and 200 controls, ADHD smokers were shown to have a significantly higher rate of alcohol and drug abuse, Dr. Goodman noted at the annual meeting, which was cosponsored by the University of Texas at Dallas.

Also, some opponents of treating ADHD argue that misuse and diversion of medication is “rampant,” but research does not bear this out, he said.

In a survey of more than 13,000 high school students, 9% said they had used nonprescribed stimulants, 15% of those who had been prescribed stimulants had given them away, and 13% who had been prescribed stimulants had sold them.

This is a problem that deserves careful consideration when prescribing, but it is not “rampant,” Dr. Goodman said, explaining that the risks of substance abuse in ADHD patients who are not treated outweighs the risk of such misuse and diversion of prescribed medications.

In fact, one study with 5-year follow-up showed that the risk for substance abuse in untreated patients was 75%, compared with 25% in treated patients–a rate not significantly different from that in the general population.

Furthermore, a metaanalysis of seven studies with a total of about 1,000 patients demonstrated that at 4-year follow-up, there was a twofold higher risk of developing substance abuse in untreated vs. treated ADHD patients. The risk was reduced twofold in treated patients. A third study showed no increased risk at ages 15–21 in treated patients.

“Treating is not a gateway to drug abuse, and we need to convey that to parents,” Dr. Goodman said.

Untreated ADHD also has been linked with greater likelihood of being sexually active and becoming pregnant by age 15.

Untreated patients generally have intercourse earlier, and have more sexual partners, which leaves them at fourfold increased risk of sexually transmitted diseases, according to at least one study. These patients also are at substantially increased risk of pregnancy.

In a birth registry study of 160 ADHD patients and 76 controls, there were 43 pregnancies, of which 42 were to adolescent ADHD mothers. Fewer than half maintained custody of their children, Dr. Goodman noted.

Driving also is a problem in untreated ADHD adolescents. At age 17, children with untreated ADHD begin having car accidents, and multiple accidents are not uncommon, as shown by several studies, including driving simulation tests of treated and untreated patients.

Reports analyzing national highway safety data have also shown that ADHD is a significant contributor to motor vehicle accidents.

In fact, the risk of a fatal car accident is far greater than the risk of a patient dying from taking an ADHD drug, Dr. Goodman said.

Other risks associated with untreated ADHD include dropping out of high school and college.

Increased high school dropout rates are seen in untreated ADHD at around age 17, and at ages 19–20, those who have made it to college are at greater risk of dropping out. “Adolescent untreated ADHD is not a benign exercise,” Dr. Goodman said. “We're not supposed to stick our heads in the sand and cross our fingers and pray to God that our children will come out of it at the other end of that adolescent tunnel. It's a very, very dark cave.”

Risk Factors for Persistent ADHD

At least a dozen longitudinal studies show that ADHD persists past age 18 in about half of all cases.

Clinicians can no longer tell parents that their children will definitely grow out of ADHD, but it also is not necessary to shrug one's shoulders and say that only time will tell if the child will grow out of it. Family history can help identify children whose conditions might persist, Dr. Goodman said.

The data suggest that if a parent has ADHD and a child has ADHD, the child has a high likelihood of having adult ADHD. If the parent had ADHD but no longer has ADHD, the child is likely to grow out of it.

Other factors associated with increased risk of persistent ADHD include living in a chaotic and tumultuous environment, and having comorbid psychiatric conditions, Dr. Goodman noted.

Senior writer Heidi Splete contributed to this report.

Inhalant abuse, known as “sniffing” or “huffing,” appears to be increasing among teens, and shifting attitudes about the practice are cause for alarm, according to the Partnership for a Drug-Free America.

In a new survey of 7,200 7th-12th graders, about 23% reported abusing inhalants. That's up about 2% since 2001, according to the Partnership, which conducts such surveys annually. The most recent survey–the 2005 Partnership Attitude Tracking Study–was conducted from March through June 2005 and has a margin of error of +/− 1.5%.

Of particular concern is that the percentage of teens reporting that they “strongly agree” that inhalant abuse can be deadly declined 19% since 2001, with only 64% of respondents in the 2005 survey agreeing that inhalants can kill.

“What stands out is the teens' decreasing perception of risk because that often correlates with increases in use. We clearly need to address underlying attitudes and help teens understand the dangers associated with this form of substance abuse,” Steve Pasierb, president and chief executive officer of the Partnership, said in a written statement.

Earlier this year, a report by the National Survey on Drug Use and Health called “Characteristics of Recent Adolescent Inhalant Intitiates” found that recent inhalant initiates were significantly more likely to be white, compared with the general population (70% vs. 62%), and significantly more likely to be 14–15 years old, compared with the general population (39% vs. 34%).

Among adolescents, substances commonly used for huffing include spray paint, glue, computer duster, cooking spray, and correction fluid. Sniffing highly concentrated amounts of vapors from some products can cause a syndrome known as “sudden sniffing death,” which can result after even a single session of inhalant use.

The most common causes of death as a result of inhalant use are sudden cardiac death and suffocation or asphyxiation. Chronic exposure to inhalants can also cause damage to the brain, heart, lungs, liver, and kidneys.

Educational campaigns about the dangers of inhalant abuse also must target parents, who according to the Partnership report are either not aware or are in denial about the prevalence of inhalant abuse among teens.

Of 1,200 parents of teens who were also surveyed, only 5% believe their child ever abused inhalants; teens are four times more likely to report inhalant abuse than parents expect.

Although about 75% of parents reported discussing cigarettes “a lot” with their children, only 50% reported spending the same amount of time discussing the risks of inhalant abuse.

A new educational campaign from the Partnership and the Alliance for Consumer Education will seek to educate parents and teens through a mass media campaign and via outreach to school counselors and nurses.

Similar campaigns in the 1990s were effective for reducing inhalant abuse; between 1995 and 2001, data suggested these programs led to an increase from 64% to 79% in the proportion of teens who perceived inhalant abuse as risky, and inhalant abuse declined significantly during that period, from 23% to 18%.

However, today's middle school kids weren't exposed to those educational campaigns, and the result is “generational forgetting” and a new generation of kids that clearly need to be educated, Mr. Pasierb said.

Another dangerous aspect of inhalant abuse is that inhalants may serve as a starter. The National Survey on Drug Use and Health data showed that 23% of recent inhalant initiates had not used cigarettes, alcohol, or marijuana prior to their first use of inhalants.

KATHRYN DALES

Signs and Symptoms of Inhalant Abuse

Someone who is abusing inhalants may exhibit one or all of the following symptoms:

▸ Burning sensation on the tongue.

▸ Dazed, dizzy, or drunken-seeming appearance.

▸ Nausea and/or loss of appetite.

▸ Neurologic problems including peripheral neuropathy, loss of vision, severe cognitive impairment, and seizures.

▸ Red or runny eyes and/or nose.

▸ Signs of paint, correction fluid, or other chemical products in unusual places, such as the face or fingers.

▸ Slurred or disoriented speech.

▸ Unusual behaviors such as anxiety, irritability, anger, excitability, or restlessness with no discernable cause.

▸ Unusual odor on the breath or chemical odor on clothing.

Sources: U.S. Consumer Product Safety Commission and the National Inhalant Prevention Coalition

Senior writer Heidi Splete contributed to this report.

Inhalant abuse, known as “sniffing” or “huffing,” appears to be increasing among teens, and shifting attitudes about the practice are cause for alarm, according to the Partnership for a Drug-Free America.

In a new survey of 7,200 7th-12th graders, about 23% reported abusing inhalants. That's up about 2% since 2001, according to the Partnership, which conducts such surveys annually. The most recent survey–the 2005 Partnership Attitude Tracking Study–was conducted from March through June 2005 and has a margin of error of +/− 1.5%.

Of particular concern is that the percentage of teens reporting that they “strongly agree” that inhalant abuse can be deadly declined 19% since 2001, with only 64% of respondents in the 2005 survey agreeing that inhalants can kill.

“What stands out is the teens' decreasing perception of risk because that often correlates with increases in use. We clearly need to address underlying attitudes and help teens understand the dangers associated with this form of substance abuse,” Steve Pasierb, president and chief executive officer of the Partnership, said in a written statement.

Earlier this year, a report by the National Survey on Drug Use and Health called “Characteristics of Recent Adolescent Inhalant Intitiates” found that recent inhalant initiates were significantly more likely to be white, compared with the general population (70% vs. 62%), and significantly more likely to be 14–15 years old, compared with the general population (39% vs. 34%).

Among adolescents, substances commonly used for huffing include spray paint, glue, computer duster, cooking spray, and correction fluid. Sniffing highly concentrated amounts of vapors from some products can cause a syndrome known as “sudden sniffing death,” which can result after even a single session of inhalant use.

The most common causes of death as a result of inhalant use are sudden cardiac death and suffocation or asphyxiation. Chronic exposure to inhalants can also cause damage to the brain, heart, lungs, liver, and kidneys.

Educational campaigns about the dangers of inhalant abuse also must target parents, who according to the Partnership report are either not aware or are in denial about the prevalence of inhalant abuse among teens.

Of 1,200 parents of teens who were also surveyed, only 5% believe their child ever abused inhalants; teens are four times more likely to report inhalant abuse than parents expect.

Although about 75% of parents reported discussing cigarettes “a lot” with their children, only 50% reported spending the same amount of time discussing the risks of inhalant abuse.

A new educational campaign from the Partnership and the Alliance for Consumer Education will seek to educate parents and teens through a mass media campaign and via outreach to school counselors and nurses.

Similar campaigns in the 1990s were effective for reducing inhalant abuse; between 1995 and 2001, data suggested these programs led to an increase from 64% to 79% in the proportion of teens who perceived inhalant abuse as risky, and inhalant abuse declined significantly during that period, from 23% to 18%.

However, today's middle school kids weren't exposed to those educational campaigns, and the result is “generational forgetting” and a new generation of kids that clearly need to be educated, Mr. Pasierb said.

Another dangerous aspect of inhalant abuse is that inhalants may serve as a starter. The National Survey on Drug Use and Health data showed that 23% of recent inhalant initiates had not used cigarettes, alcohol, or marijuana prior to their first use of inhalants.

KATHRYN DALES

Signs and Symptoms of Inhalant Abuse

Someone who is abusing inhalants may exhibit one or all of the following symptoms:

▸ Burning sensation on the tongue.

▸ Dazed, dizzy, or drunken-seeming appearance.

▸ Nausea and/or loss of appetite.

▸ Neurologic problems including peripheral neuropathy, loss of vision, severe cognitive impairment, and seizures.

▸ Red or runny eyes and/or nose.

▸ Signs of paint, correction fluid, or other chemical products in unusual places, such as the face or fingers.

▸ Slurred or disoriented speech.

▸ Unusual behaviors such as anxiety, irritability, anger, excitability, or restlessness with no discernable cause.

▸ Unusual odor on the breath or chemical odor on clothing.

Sources: U.S. Consumer Product Safety Commission and the National Inhalant Prevention Coalition

Senior writer Heidi Splete contributed to this report.

Inhalant abuse, known as “sniffing” or “huffing,” appears to be increasing among teens, and shifting attitudes about the practice are cause for alarm, according to the Partnership for a Drug-Free America.

In a new survey of 7,200 7th-12th graders, about 23% reported abusing inhalants. That's up about 2% since 2001, according to the Partnership, which conducts such surveys annually. The most recent survey–the 2005 Partnership Attitude Tracking Study–was conducted from March through June 2005 and has a margin of error of +/− 1.5%.

Of particular concern is that the percentage of teens reporting that they “strongly agree” that inhalant abuse can be deadly declined 19% since 2001, with only 64% of respondents in the 2005 survey agreeing that inhalants can kill.

“What stands out is the teens' decreasing perception of risk because that often correlates with increases in use. We clearly need to address underlying attitudes and help teens understand the dangers associated with this form of substance abuse,” Steve Pasierb, president and chief executive officer of the Partnership, said in a written statement.

Earlier this year, a report by the National Survey on Drug Use and Health called “Characteristics of Recent Adolescent Inhalant Intitiates” found that recent inhalant initiates were significantly more likely to be white, compared with the general population (70% vs. 62%), and significantly more likely to be 14–15 years old, compared with the general population (39% vs. 34%).

Among adolescents, substances commonly used for huffing include spray paint, glue, computer duster, cooking spray, and correction fluid. Sniffing highly concentrated amounts of vapors from some products can cause a syndrome known as “sudden sniffing death,” which can result after even a single session of inhalant use.

The most common causes of death as a result of inhalant use are sudden cardiac death and suffocation or asphyxiation. Chronic exposure to inhalants can also cause damage to the brain, heart, lungs, liver, and kidneys.

Educational campaigns about the dangers of inhalant abuse also must target parents, who according to the Partnership report are either not aware or are in denial about the prevalence of inhalant abuse among teens.

Of 1,200 parents of teens who were also surveyed, only 5% believe their child ever abused inhalants; teens are four times more likely to report inhalant abuse than parents expect.

Although about 75% of parents reported discussing cigarettes “a lot” with their children, only 50% reported spending the same amount of time discussing the risks of inhalant abuse.

A new educational campaign from the Partnership and the Alliance for Consumer Education will seek to educate parents and teens through a mass media campaign and via outreach to school counselors and nurses.

Similar campaigns in the 1990s were effective for reducing inhalant abuse; between 1995 and 2001, data suggested these programs led to an increase from 64% to 79% in the proportion of teens who perceived inhalant abuse as risky, and inhalant abuse declined significantly during that period, from 23% to 18%.

However, today's middle school kids weren't exposed to those educational campaigns, and the result is “generational forgetting” and a new generation of kids that clearly need to be educated, Mr. Pasierb said.

Another dangerous aspect of inhalant abuse is that inhalants may serve as a starter. The National Survey on Drug Use and Health data showed that 23% of recent inhalant initiates had not used cigarettes, alcohol, or marijuana prior to their first use of inhalants.

KATHRYN DALES

Signs and Symptoms of Inhalant Abuse

Someone who is abusing inhalants may exhibit one or all of the following symptoms:

▸ Burning sensation on the tongue.

▸ Dazed, dizzy, or drunken-seeming appearance.

▸ Nausea and/or loss of appetite.

▸ Neurologic problems including peripheral neuropathy, loss of vision, severe cognitive impairment, and seizures.

▸ Red or runny eyes and/or nose.

▸ Signs of paint, correction fluid, or other chemical products in unusual places, such as the face or fingers.

▸ Slurred or disoriented speech.

▸ Unusual behaviors such as anxiety, irritability, anger, excitability, or restlessness with no discernable cause.

▸ Unusual odor on the breath or chemical odor on clothing.

Sources: U.S. Consumer Product Safety Commission and the National Inhalant Prevention Coalition

MIAMI BEACH — The risks of not treating attention-deficit hyperactivity disorder are far greater than the risks of treating the disorder, Dr. David Goodman reported at the annual meeting of the American Society for Adolescent Psychiatry.

ADHD persists into adulthood in about 50% of cases, and adults who present with previously untreated ADHD often present with comorbid psychiatric disorders and substance abuse disorders. Preventing these problems early by treating ADHD is far more effective and cost effective than attempting to treat them later, said Dr. Goodman of Johns Hopkins University, Baltimore.

Smoking and substance abuse, sexual activity and related risks, and driving accidents have specifically been shown to be reduced by ADHD treatment.

Studies show that compared with treated ADHD, untreated ADHD is associated with greater risk of smoking at age 11 years and greater risk of substance abuse at age 13. Preventing smoking in children with ADHD is important, because it has been linked with increased risk of drug and alcohol abuse. In a study of 100 ADHD patients and 200 controls, ADHD smokers were shown to have a significantly higher rate of alcohol and drug abuse, Dr. Goodman noted at the meeting, which was cosponsored by the University of Texas at Dallas.

Also, some opponents of treating ADHD argue that misuse and diversion of medication is “rampant,” but research does not bear this out, he said.

In a survey of more than 13,000 high school students, 9% said they had used nonprescribed stimulants, 15% of those who had been prescribed stimulants had given them away, and 13% who had been prescribed stimulants had sold them.

This is a problem that deserves careful consideration when prescribing, but it is not “rampant,” Dr. Goodman said, explaining that the risks of substance abuse in ADHD patients who are not treated outweighs the risk of such misuse and diversion of prescribed medications.

In fact, one study with 5-year follow-up showed that the risk for substance abuse in untreated patients was 75%, compared with 25% in treated patients—a rate not significantly different from that in the general population. And a metaanalysis of seven studies with a total of about 1,000 patients demonstrated that at 4-year follow-up, there was a twofold higher risk of developing substance abuse in untreated vs. treated ADHD patients. The risk was reduced twofold in treated patients. A third study showed no increased risk at ages 15–21 in treated patients.

“Treating is not a gateway to drug abuse, and we need to convey that to parents,” Dr. Goodman said.

Untreated ADHD also has been linked with greater likelihood of being sexually active and becoming pregnant by age 15.

Untreated patients generally have intercourse earlier, and have more sexual partners, which leaves them at fourfold increased risk of sexually transmitted diseases, according to at least one study.

In a birth registry study of 160 ADHD patients and 76 controls, there were 43 pregnancies, of which 42 were to adolescent ADHD mothers. Fewer than half maintained custody of their children, Dr. Goodman noted.

Driving also is a problem in untreated ADHD adolescents. At age 17, children with untreated ADHD begin having car accidents, and multiple accidents are not uncommon, as shown by several studies, including driving simulation tests of treated and untreated patients. National Highway Safety Data also show that ADHD is a significant contributor to motor vehicle accidents.

In fact, the risk of a fatal car accident is far greater than the risk of a patient dying from taking an ADHD drug, Dr. Goodman said.

Other risks associated with untreated ADHD include dropping out of high school and college. Increased high school dropout rates are seen in untreated ADHD at around age 17, and at ages 19–20, those who have made it to college are at greater risk of dropping out.

“Adolescent untreated ADHD is not a benign exercise,” Dr. Goodman said. “We're not supposed to stick our heads in the sand and cross our fingers and pray to God that our children will come out of it at the other end of that adolescent tunnel. It's a very, very dark cave.”

Who Will Grow Out of It?

At least a dozen longitudinal studies show that ADHD persists past age 18 in about half of all cases.

Clinicians can no longer tell parents that their children will definitely grow out of ADHD, but it also is not necessary to shrug one's shoulders and say that only time will tell if the child will grow out of it. Family history can help identify children whose conditions might persist, Dr. Goodman said.

The data suggest that if a parent has ADHD and a child has ADHD, the child has a high likelihood of having adult ADHD. If the parent had ADHD but no longer has ADHD, the child is likely to grow out of it.

Other factors associated with increased risk of persistent ADHD include living in a chaotic and tumultuous environment, and having comorbid psychiatric conditions, Dr. Goodman noted.

MIAMI BEACH — The risks of not treating attention-deficit hyperactivity disorder are far greater than the risks of treating the disorder, Dr. David Goodman reported at the annual meeting of the American Society for Adolescent Psychiatry.

ADHD persists into adulthood in about 50% of cases, and adults who present with previously untreated ADHD often present with comorbid psychiatric disorders and substance abuse disorders. Preventing these problems early by treating ADHD is far more effective and cost effective than attempting to treat them later, said Dr. Goodman of Johns Hopkins University, Baltimore.

Smoking and substance abuse, sexual activity and related risks, and driving accidents have specifically been shown to be reduced by ADHD treatment.

Studies show that compared with treated ADHD, untreated ADHD is associated with greater risk of smoking at age 11 years and greater risk of substance abuse at age 13. Preventing smoking in children with ADHD is important, because it has been linked with increased risk of drug and alcohol abuse. In a study of 100 ADHD patients and 200 controls, ADHD smokers were shown to have a significantly higher rate of alcohol and drug abuse, Dr. Goodman noted at the meeting, which was cosponsored by the University of Texas at Dallas.

Also, some opponents of treating ADHD argue that misuse and diversion of medication is “rampant,” but research does not bear this out, he said.

In a survey of more than 13,000 high school students, 9% said they had used nonprescribed stimulants, 15% of those who had been prescribed stimulants had given them away, and 13% who had been prescribed stimulants had sold them.

This is a problem that deserves careful consideration when prescribing, but it is not “rampant,” Dr. Goodman said, explaining that the risks of substance abuse in ADHD patients who are not treated outweighs the risk of such misuse and diversion of prescribed medications.

In fact, one study with 5-year follow-up showed that the risk for substance abuse in untreated patients was 75%, compared with 25% in treated patients—a rate not significantly different from that in the general population. And a metaanalysis of seven studies with a total of about 1,000 patients demonstrated that at 4-year follow-up, there was a twofold higher risk of developing substance abuse in untreated vs. treated ADHD patients. The risk was reduced twofold in treated patients. A third study showed no increased risk at ages 15–21 in treated patients.

“Treating is not a gateway to drug abuse, and we need to convey that to parents,” Dr. Goodman said.

Untreated ADHD also has been linked with greater likelihood of being sexually active and becoming pregnant by age 15.

Untreated patients generally have intercourse earlier, and have more sexual partners, which leaves them at fourfold increased risk of sexually transmitted diseases, according to at least one study.

In a birth registry study of 160 ADHD patients and 76 controls, there were 43 pregnancies, of which 42 were to adolescent ADHD mothers. Fewer than half maintained custody of their children, Dr. Goodman noted.

Driving also is a problem in untreated ADHD adolescents. At age 17, children with untreated ADHD begin having car accidents, and multiple accidents are not uncommon, as shown by several studies, including driving simulation tests of treated and untreated patients. National Highway Safety Data also show that ADHD is a significant contributor to motor vehicle accidents.

In fact, the risk of a fatal car accident is far greater than the risk of a patient dying from taking an ADHD drug, Dr. Goodman said.

Other risks associated with untreated ADHD include dropping out of high school and college. Increased high school dropout rates are seen in untreated ADHD at around age 17, and at ages 19–20, those who have made it to college are at greater risk of dropping out.

“Adolescent untreated ADHD is not a benign exercise,” Dr. Goodman said. “We're not supposed to stick our heads in the sand and cross our fingers and pray to God that our children will come out of it at the other end of that adolescent tunnel. It's a very, very dark cave.”

Who Will Grow Out of It?

At least a dozen longitudinal studies show that ADHD persists past age 18 in about half of all cases.

Clinicians can no longer tell parents that their children will definitely grow out of ADHD, but it also is not necessary to shrug one's shoulders and say that only time will tell if the child will grow out of it. Family history can help identify children whose conditions might persist, Dr. Goodman said.

The data suggest that if a parent has ADHD and a child has ADHD, the child has a high likelihood of having adult ADHD. If the parent had ADHD but no longer has ADHD, the child is likely to grow out of it.

Other factors associated with increased risk of persistent ADHD include living in a chaotic and tumultuous environment, and having comorbid psychiatric conditions, Dr. Goodman noted.

MIAMI BEACH — The risks of not treating attention-deficit hyperactivity disorder are far greater than the risks of treating the disorder, Dr. David Goodman reported at the annual meeting of the American Society for Adolescent Psychiatry.

ADHD persists into adulthood in about 50% of cases, and adults who present with previously untreated ADHD often present with comorbid psychiatric disorders and substance abuse disorders. Preventing these problems early by treating ADHD is far more effective and cost effective than attempting to treat them later, said Dr. Goodman of Johns Hopkins University, Baltimore.

Smoking and substance abuse, sexual activity and related risks, and driving accidents have specifically been shown to be reduced by ADHD treatment.

Studies show that compared with treated ADHD, untreated ADHD is associated with greater risk of smoking at age 11 years and greater risk of substance abuse at age 13. Preventing smoking in children with ADHD is important, because it has been linked with increased risk of drug and alcohol abuse. In a study of 100 ADHD patients and 200 controls, ADHD smokers were shown to have a significantly higher rate of alcohol and drug abuse, Dr. Goodman noted at the meeting, which was cosponsored by the University of Texas at Dallas.

Also, some opponents of treating ADHD argue that misuse and diversion of medication is “rampant,” but research does not bear this out, he said.

In a survey of more than 13,000 high school students, 9% said they had used nonprescribed stimulants, 15% of those who had been prescribed stimulants had given them away, and 13% who had been prescribed stimulants had sold them.

This is a problem that deserves careful consideration when prescribing, but it is not “rampant,” Dr. Goodman said, explaining that the risks of substance abuse in ADHD patients who are not treated outweighs the risk of such misuse and diversion of prescribed medications.

In fact, one study with 5-year follow-up showed that the risk for substance abuse in untreated patients was 75%, compared with 25% in treated patients—a rate not significantly different from that in the general population. And a metaanalysis of seven studies with a total of about 1,000 patients demonstrated that at 4-year follow-up, there was a twofold higher risk of developing substance abuse in untreated vs. treated ADHD patients. The risk was reduced twofold in treated patients. A third study showed no increased risk at ages 15–21 in treated patients.

“Treating is not a gateway to drug abuse, and we need to convey that to parents,” Dr. Goodman said.

Untreated ADHD also has been linked with greater likelihood of being sexually active and becoming pregnant by age 15.

Untreated patients generally have intercourse earlier, and have more sexual partners, which leaves them at fourfold increased risk of sexually transmitted diseases, according to at least one study.

In a birth registry study of 160 ADHD patients and 76 controls, there were 43 pregnancies, of which 42 were to adolescent ADHD mothers. Fewer than half maintained custody of their children, Dr. Goodman noted.

Driving also is a problem in untreated ADHD adolescents. At age 17, children with untreated ADHD begin having car accidents, and multiple accidents are not uncommon, as shown by several studies, including driving simulation tests of treated and untreated patients. National Highway Safety Data also show that ADHD is a significant contributor to motor vehicle accidents.

In fact, the risk of a fatal car accident is far greater than the risk of a patient dying from taking an ADHD drug, Dr. Goodman said.

Other risks associated with untreated ADHD include dropping out of high school and college. Increased high school dropout rates are seen in untreated ADHD at around age 17, and at ages 19–20, those who have made it to college are at greater risk of dropping out.

“Adolescent untreated ADHD is not a benign exercise,” Dr. Goodman said. “We're not supposed to stick our heads in the sand and cross our fingers and pray to God that our children will come out of it at the other end of that adolescent tunnel. It's a very, very dark cave.”

Who Will Grow Out of It?

At least a dozen longitudinal studies show that ADHD persists past age 18 in about half of all cases.

Clinicians can no longer tell parents that their children will definitely grow out of ADHD, but it also is not necessary to shrug one's shoulders and say that only time will tell if the child will grow out of it. Family history can help identify children whose conditions might persist, Dr. Goodman said.

The data suggest that if a parent has ADHD and a child has ADHD, the child has a high likelihood of having adult ADHD. If the parent had ADHD but no longer has ADHD, the child is likely to grow out of it.

Other factors associated with increased risk of persistent ADHD include living in a chaotic and tumultuous environment, and having comorbid psychiatric conditions, Dr. Goodman noted.

MIAMI BEACH — Oral nifedipine is a faster acting and safer tocolytic than magnesium sulfate is, findings of a recent randomized study suggest.

A total of 192 women who presented between 24 and 34 weeks' gestation with contractions and cervical change or ruptured membranes were enrolled in the study. Of those randomized to receive nifedipine, significantly fewer achieved uterine quiescence (12 hours of six or fewer contractions per hour and no further cervical change within 48 hours), compared with the magnesium sulfate group (72% vs. 87%), Dr. Deirdre J. Lyell reported at the annual meeting of the Society for Maternal-Fetal Medicine.

However, in those who achieved quiescence, nifedipine acted within 6 hours vs. 8 hours for magnesium sulfate, and 34% of patients in the nifedipine group experienced side effects, compared with 65% in the magnesium sulfate group, said Dr. Lyell of Stanford (Calif.) University.

No side effects were significantly increased with nifedipine, compared with magnesium sulfate, although there was a trend toward greater risk for headache with nifedipine. Serious side effects such as shortness of breath were significantly more common with magnesium sulfate, and the three cases of pulmonary edema seen in this study all occurred in the magnesium sulfate group. Neonatal outcomes did not differ significantly between the two groups; birth weight, composite neonatal morbidity, and individual morbidity were similar, but neonates exposed to magnesium sulfate spent a slightly higher number of days overall in neonatal intensive care, Dr. Lyell noted.

An analysis of failed tocolysis in this study showed that 12 patients failed magnesium sulfate and 28 failed nifedipine. However, of 11 patients with continued contractions who were switched to an alternative tocolytic, all were in the nifedipine group. This finding raises the question of whether there was a physician bias against nifedipine in this unblinded study, she said.

“Interestingly, the majority of magnesium sulfate failures delivered within 40 hours vs. only 30% in the nifedipine group,” she said, adding that time to delivery was significantly shorter in those with magnesium sulfate failure. Nifedipine is increasingly used as a tocolytic and was associated in two small previous studies with fewer side effects than magnesium sulfate.

MIAMI BEACH — Oral nifedipine is a faster acting and safer tocolytic than magnesium sulfate is, findings of a recent randomized study suggest.

A total of 192 women who presented between 24 and 34 weeks' gestation with contractions and cervical change or ruptured membranes were enrolled in the study. Of those randomized to receive nifedipine, significantly fewer achieved uterine quiescence (12 hours of six or fewer contractions per hour and no further cervical change within 48 hours), compared with the magnesium sulfate group (72% vs. 87%), Dr. Deirdre J. Lyell reported at the annual meeting of the Society for Maternal-Fetal Medicine.

However, in those who achieved quiescence, nifedipine acted within 6 hours vs. 8 hours for magnesium sulfate, and 34% of patients in the nifedipine group experienced side effects, compared with 65% in the magnesium sulfate group, said Dr. Lyell of Stanford (Calif.) University.

No side effects were significantly increased with nifedipine, compared with magnesium sulfate, although there was a trend toward greater risk for headache with nifedipine. Serious side effects such as shortness of breath were significantly more common with magnesium sulfate, and the three cases of pulmonary edema seen in this study all occurred in the magnesium sulfate group. Neonatal outcomes did not differ significantly between the two groups; birth weight, composite neonatal morbidity, and individual morbidity were similar, but neonates exposed to magnesium sulfate spent a slightly higher number of days overall in neonatal intensive care, Dr. Lyell noted.

An analysis of failed tocolysis in this study showed that 12 patients failed magnesium sulfate and 28 failed nifedipine. However, of 11 patients with continued contractions who were switched to an alternative tocolytic, all were in the nifedipine group. This finding raises the question of whether there was a physician bias against nifedipine in this unblinded study, she said.

“Interestingly, the majority of magnesium sulfate failures delivered within 40 hours vs. only 30% in the nifedipine group,” she said, adding that time to delivery was significantly shorter in those with magnesium sulfate failure. Nifedipine is increasingly used as a tocolytic and was associated in two small previous studies with fewer side effects than magnesium sulfate.

MIAMI BEACH — Oral nifedipine is a faster acting and safer tocolytic than magnesium sulfate is, findings of a recent randomized study suggest.

A total of 192 women who presented between 24 and 34 weeks' gestation with contractions and cervical change or ruptured membranes were enrolled in the study. Of those randomized to receive nifedipine, significantly fewer achieved uterine quiescence (12 hours of six or fewer contractions per hour and no further cervical change within 48 hours), compared with the magnesium sulfate group (72% vs. 87%), Dr. Deirdre J. Lyell reported at the annual meeting of the Society for Maternal-Fetal Medicine.

However, in those who achieved quiescence, nifedipine acted within 6 hours vs. 8 hours for magnesium sulfate, and 34% of patients in the nifedipine group experienced side effects, compared with 65% in the magnesium sulfate group, said Dr. Lyell of Stanford (Calif.) University.

No side effects were significantly increased with nifedipine, compared with magnesium sulfate, although there was a trend toward greater risk for headache with nifedipine. Serious side effects such as shortness of breath were significantly more common with magnesium sulfate, and the three cases of pulmonary edema seen in this study all occurred in the magnesium sulfate group. Neonatal outcomes did not differ significantly between the two groups; birth weight, composite neonatal morbidity, and individual morbidity were similar, but neonates exposed to magnesium sulfate spent a slightly higher number of days overall in neonatal intensive care, Dr. Lyell noted.

An analysis of failed tocolysis in this study showed that 12 patients failed magnesium sulfate and 28 failed nifedipine. However, of 11 patients with continued contractions who were switched to an alternative tocolytic, all were in the nifedipine group. This finding raises the question of whether there was a physician bias against nifedipine in this unblinded study, she said.

“Interestingly, the majority of magnesium sulfate failures delivered within 40 hours vs. only 30% in the nifedipine group,” she said, adding that time to delivery was significantly shorter in those with magnesium sulfate failure. Nifedipine is increasingly used as a tocolytic and was associated in two small previous studies with fewer side effects than magnesium sulfate.

MIAMI BEACH — A prenatal sonographic finding of single umbilical artery is an indication for fetal echocardiography, Dr. Lami Yeo said at the annual meeting of the Society for Maternal-Fetal Medicine.

In a case series of 430 fetuses with this finding who were identified retrospectively from a database of more than 42,600 patients, 13% had sonographic structural cardiac abnormalities, said Dr. Yeo of Robert Wood Johnson Medical School, Piscataway, N.J.

About 67% of the 430 patients had isolated single umbilical artery, and the remaining 20% had only noncardiac defects, she noted.

Of the structural cardiac abnormalities, 26% were complex cardiac defects, 26% were septal defects only, 19% were left or right hypoplastic heart, 15% were conotruncal abnormalities, 6% were defects of the atrioventricular canal, and 9% were classified as “other” defects. (Percentages add to more than 100% due to rounding.) Nearly 75% of the defects were significant defects, Dr. Yeo said.

Furthermore, 80% of those with structural cardiac defects also had other anomalies.

The patients were all diagnosed with single umbilical artery from 1994 to 2005 using color Doppler imaging around the fetal bladder. Previous studies have suggested a connection between single umbilical artery and cardiac defects, but the studies were small, and the rates varied from 2% to 23%, Dr. Yeo noted.

This series—the largest reported from a single institution—confirms the significant incidence of structural cardiac abnormalities and therefore the need for fetal echocardiography in those with a prenatal diagnosis of single umbilical artery.

MIAMI BEACH — A prenatal sonographic finding of single umbilical artery is an indication for fetal echocardiography, Dr. Lami Yeo said at the annual meeting of the Society for Maternal-Fetal Medicine.

In a case series of 430 fetuses with this finding who were identified retrospectively from a database of more than 42,600 patients, 13% had sonographic structural cardiac abnormalities, said Dr. Yeo of Robert Wood Johnson Medical School, Piscataway, N.J.

About 67% of the 430 patients had isolated single umbilical artery, and the remaining 20% had only noncardiac defects, she noted.

Of the structural cardiac abnormalities, 26% were complex cardiac defects, 26% were septal defects only, 19% were left or right hypoplastic heart, 15% were conotruncal abnormalities, 6% were defects of the atrioventricular canal, and 9% were classified as “other” defects. (Percentages add to more than 100% due to rounding.) Nearly 75% of the defects were significant defects, Dr. Yeo said.

Furthermore, 80% of those with structural cardiac defects also had other anomalies.

The patients were all diagnosed with single umbilical artery from 1994 to 2005 using color Doppler imaging around the fetal bladder. Previous studies have suggested a connection between single umbilical artery and cardiac defects, but the studies were small, and the rates varied from 2% to 23%, Dr. Yeo noted.

This series—the largest reported from a single institution—confirms the significant incidence of structural cardiac abnormalities and therefore the need for fetal echocardiography in those with a prenatal diagnosis of single umbilical artery.

MIAMI BEACH — A prenatal sonographic finding of single umbilical artery is an indication for fetal echocardiography, Dr. Lami Yeo said at the annual meeting of the Society for Maternal-Fetal Medicine.

In a case series of 430 fetuses with this finding who were identified retrospectively from a database of more than 42,600 patients, 13% had sonographic structural cardiac abnormalities, said Dr. Yeo of Robert Wood Johnson Medical School, Piscataway, N.J.

About 67% of the 430 patients had isolated single umbilical artery, and the remaining 20% had only noncardiac defects, she noted.

Of the structural cardiac abnormalities, 26% were complex cardiac defects, 26% were septal defects only, 19% were left or right hypoplastic heart, 15% were conotruncal abnormalities, 6% were defects of the atrioventricular canal, and 9% were classified as “other” defects. (Percentages add to more than 100% due to rounding.) Nearly 75% of the defects were significant defects, Dr. Yeo said.

Furthermore, 80% of those with structural cardiac defects also had other anomalies.

The patients were all diagnosed with single umbilical artery from 1994 to 2005 using color Doppler imaging around the fetal bladder. Previous studies have suggested a connection between single umbilical artery and cardiac defects, but the studies were small, and the rates varied from 2% to 23%, Dr. Yeo noted.

This series—the largest reported from a single institution—confirms the significant incidence of structural cardiac abnormalities and therefore the need for fetal echocardiography in those with a prenatal diagnosis of single umbilical artery.

MIAMI BEACH — Pelvic ultrasound is accurate for ruling out placenta accreta, and should be used as the primary screening tool in patients at high risk for this condition, Dr. Carri Warshak said at the annual meeting of the Society for Maternal-Fetal Medicine.

Magnetic resonance imaging also should be considered in the evaluation of all suspected cases, she added.

A historical cohort study of 433 patients with placenta previa who underwent ultrasound showed that this screening modality accurately predicted placenta accreta (which for the purposes of this study also included placenta increta and percreta) in 25 of the 32 women whose diagnosis was confirmed by pathologic examination, for a sensitivity of 0.78.

Ultrasound ruled out the condition in 397 of 401 patients, for a specificity of 0.99; MRI ruled out the condition in the remaining 4 patients, reported Dr. Warshak of the University of California, San Diego.

Of an additional 58 women who were referred for MRI based on equivocal ultrasound findings, 39 were shown on pathologic examination to have placenta accreta. MRI accurately predicted the condition in 35 of the 39 patients for a sensitivity of 0.90, and ruled out the condition in the remaining 19 patients for a specificity of 1.

Information for the study was obtained from a perinatal database for patients screened by ultrasound between January 2000 and June 2005 and for patients screened by MRI between January 1992 and June 2005. The findings are important because they confirm the accuracy of ultrasound and MRI for detecting a condition that requires accurate prenatal diagnosis for optimal management, she said.

Furthermore, the incidence of abnormal placentation has increased 10-fold over the past decade, largely due to the increased cesarean section rate. An estimated 9% of pregnancies are affected, she noted.

The findings confirm those from the three largest studies of ultrasound diagnosis for placenta accreta; pooled data from those studies and the current study show pelvic ultrasound is 81% sensitive and 98% specific for diagnosis, she said.

MRI has been less well studied, and results have been conflicting, but the findings of this study suggest it has an important role in optimizing diagnostic accuracy, particularly in patients with equivocal findings on ultrasound, she concluded.

MIAMI BEACH — Pelvic ultrasound is accurate for ruling out placenta accreta, and should be used as the primary screening tool in patients at high risk for this condition, Dr. Carri Warshak said at the annual meeting of the Society for Maternal-Fetal Medicine.

Magnetic resonance imaging also should be considered in the evaluation of all suspected cases, she added.

A historical cohort study of 433 patients with placenta previa who underwent ultrasound showed that this screening modality accurately predicted placenta accreta (which for the purposes of this study also included placenta increta and percreta) in 25 of the 32 women whose diagnosis was confirmed by pathologic examination, for a sensitivity of 0.78.

Ultrasound ruled out the condition in 397 of 401 patients, for a specificity of 0.99; MRI ruled out the condition in the remaining 4 patients, reported Dr. Warshak of the University of California, San Diego.

Of an additional 58 women who were referred for MRI based on equivocal ultrasound findings, 39 were shown on pathologic examination to have placenta accreta. MRI accurately predicted the condition in 35 of the 39 patients for a sensitivity of 0.90, and ruled out the condition in the remaining 19 patients for a specificity of 1.

Information for the study was obtained from a perinatal database for patients screened by ultrasound between January 2000 and June 2005 and for patients screened by MRI between January 1992 and June 2005. The findings are important because they confirm the accuracy of ultrasound and MRI for detecting a condition that requires accurate prenatal diagnosis for optimal management, she said.

Furthermore, the incidence of abnormal placentation has increased 10-fold over the past decade, largely due to the increased cesarean section rate. An estimated 9% of pregnancies are affected, she noted.

The findings confirm those from the three largest studies of ultrasound diagnosis for placenta accreta; pooled data from those studies and the current study show pelvic ultrasound is 81% sensitive and 98% specific for diagnosis, she said.

MRI has been less well studied, and results have been conflicting, but the findings of this study suggest it has an important role in optimizing diagnostic accuracy, particularly in patients with equivocal findings on ultrasound, she concluded.

MIAMI BEACH — Pelvic ultrasound is accurate for ruling out placenta accreta, and should be used as the primary screening tool in patients at high risk for this condition, Dr. Carri Warshak said at the annual meeting of the Society for Maternal-Fetal Medicine.

Magnetic resonance imaging also should be considered in the evaluation of all suspected cases, she added.

A historical cohort study of 433 patients with placenta previa who underwent ultrasound showed that this screening modality accurately predicted placenta accreta (which for the purposes of this study also included placenta increta and percreta) in 25 of the 32 women whose diagnosis was confirmed by pathologic examination, for a sensitivity of 0.78.

Ultrasound ruled out the condition in 397 of 401 patients, for a specificity of 0.99; MRI ruled out the condition in the remaining 4 patients, reported Dr. Warshak of the University of California, San Diego.

Of an additional 58 women who were referred for MRI based on equivocal ultrasound findings, 39 were shown on pathologic examination to have placenta accreta. MRI accurately predicted the condition in 35 of the 39 patients for a sensitivity of 0.90, and ruled out the condition in the remaining 19 patients for a specificity of 1.

Information for the study was obtained from a perinatal database for patients screened by ultrasound between January 2000 and June 2005 and for patients screened by MRI between January 1992 and June 2005. The findings are important because they confirm the accuracy of ultrasound and MRI for detecting a condition that requires accurate prenatal diagnosis for optimal management, she said.

Furthermore, the incidence of abnormal placentation has increased 10-fold over the past decade, largely due to the increased cesarean section rate. An estimated 9% of pregnancies are affected, she noted.

The findings confirm those from the three largest studies of ultrasound diagnosis for placenta accreta; pooled data from those studies and the current study show pelvic ultrasound is 81% sensitive and 98% specific for diagnosis, she said.

MRI has been less well studied, and results have been conflicting, but the findings of this study suggest it has an important role in optimizing diagnostic accuracy, particularly in patients with equivocal findings on ultrasound, she concluded.

MIAMI BEACH — Unexplained vaginal bleeding and fetal exposure to oral pathogens have been linked individually with spontaneous preterm birth, and new data suggest the presence of both is associated with greater risk than either alone.

Of 660 pregnancies analyzed, 229 (35%) demonstrated fetal exposure to oral pathogens. Pregnancies that demonstrated such exposure were more likely to be in white women, women who had symptomatic bacterial vaginosis, and women who experienced vaginal bleeding, which was the most significant variable associated with oral pathogen exposure (adjusted risk ratio 1.6).

A total of 51 women (8%) in this planned secondary analysis of the Oral Conditions and Pregnancy Study—a prospective observational study of oral health and pregnancy outcomes—delivered before 35 weeks' gestation, Dr. Kim Boggess reported at the annual meeting of the Society for Maternal-Fetal Medicine.

When women with vaginal bleeding were stratified according to whether fetal exposure to oral pathogens occurred, preterm birth rates were significantly higher in those with both factors. Preterm birth occurred in 30% of those with both factors, compared with 8% in those with only vaginal bleeding, 9% of those with only oral pathogen exposure, and 6% of those with neither.

After adjusting for age, race, prior preterm birth, prior elective or spontaneous abortion, bacterial vaginosis, and enrollment weight, the differences remained. The adjusted hazard ratio for spontaneous preterm birth, compared with those with neither risk factor, was 6.4 for those with both factors, 1.9 for those with only vaginal bleeding, and 2.0 for those with only exposure to oral pathogens, said Dr. Boggess of the University of North Carolina at Chapel Hill.

Fetal exposure to oral pathogens was considered to have occurred if umbilical cord serum at delivery demonstrated an immunoglobulin M-positive (IgM-positive) response to at least one of five oral pathogens, she explained.

“Our findings show that antepartum vaginal bleeding is associated with fetal exposure to oral pathogens, and that the combination of fetal exposure to oral pathogens and vaginal bleeding provides the highest risk for premature birth at less than 35 weeks,” Dr. Boggess said.

“We think that vaginal bleeding may in fact be an effect measure modifier of fetal exposure to oral pathogens.”

Unexplained vaginal bleeding may be one of the mechanisms of fetal exposure to oral pathogens during pregnancy, but further study is needed to determine whether vaginal bleeding is the cause or the effect of fetal exposure to oral pathogens, she said.

The findings also suggest that clinical determination of periodontal disease is a poor marker for fetal exposure to oral pathogens, she noted.

Dr. Boggess indicated two weaknesses of the study: Detected pathogens could reside in the vagina of affected patients, causing fetuses to be exposed via pathogen ascent through the vagina; and the vaginal bleeding detected in this study may have actually been from some undetected underlying cause.

More data are needed before a position on interventions in women with periodontal disease can be officially taken, but two ongoing intervention trials may shed some light on the impact of treatment of periodontal disease during pregnancy, Dr. Boggess noted.

'We think that vaginal bleeding may in fact be an effect measure modifier of fetal exposure to oral pathogens.' DR. BOGGESS

MIAMI BEACH — Unexplained vaginal bleeding and fetal exposure to oral pathogens have been linked individually with spontaneous preterm birth, and new data suggest the presence of both is associated with greater risk than either alone.

Of 660 pregnancies analyzed, 229 (35%) demonstrated fetal exposure to oral pathogens. Pregnancies that demonstrated such exposure were more likely to be in white women, women who had symptomatic bacterial vaginosis, and women who experienced vaginal bleeding, which was the most significant variable associated with oral pathogen exposure (adjusted risk ratio 1.6).

A total of 51 women (8%) in this planned secondary analysis of the Oral Conditions and Pregnancy Study—a prospective observational study of oral health and pregnancy outcomes—delivered before 35 weeks' gestation, Dr. Kim Boggess reported at the annual meeting of the Society for Maternal-Fetal Medicine.

When women with vaginal bleeding were stratified according to whether fetal exposure to oral pathogens occurred, preterm birth rates were significantly higher in those with both factors. Preterm birth occurred in 30% of those with both factors, compared with 8% in those with only vaginal bleeding, 9% of those with only oral pathogen exposure, and 6% of those with neither.

After adjusting for age, race, prior preterm birth, prior elective or spontaneous abortion, bacterial vaginosis, and enrollment weight, the differences remained. The adjusted hazard ratio for spontaneous preterm birth, compared with those with neither risk factor, was 6.4 for those with both factors, 1.9 for those with only vaginal bleeding, and 2.0 for those with only exposure to oral pathogens, said Dr. Boggess of the University of North Carolina at Chapel Hill.

Fetal exposure to oral pathogens was considered to have occurred if umbilical cord serum at delivery demonstrated an immunoglobulin M-positive (IgM-positive) response to at least one of five oral pathogens, she explained.

“Our findings show that antepartum vaginal bleeding is associated with fetal exposure to oral pathogens, and that the combination of fetal exposure to oral pathogens and vaginal bleeding provides the highest risk for premature birth at less than 35 weeks,” Dr. Boggess said.

“We think that vaginal bleeding may in fact be an effect measure modifier of fetal exposure to oral pathogens.”

Unexplained vaginal bleeding may be one of the mechanisms of fetal exposure to oral pathogens during pregnancy, but further study is needed to determine whether vaginal bleeding is the cause or the effect of fetal exposure to oral pathogens, she said.

The findings also suggest that clinical determination of periodontal disease is a poor marker for fetal exposure to oral pathogens, she noted.

Dr. Boggess indicated two weaknesses of the study: Detected pathogens could reside in the vagina of affected patients, causing fetuses to be exposed via pathogen ascent through the vagina; and the vaginal bleeding detected in this study may have actually been from some undetected underlying cause.

More data are needed before a position on interventions in women with periodontal disease can be officially taken, but two ongoing intervention trials may shed some light on the impact of treatment of periodontal disease during pregnancy, Dr. Boggess noted.

'We think that vaginal bleeding may in fact be an effect measure modifier of fetal exposure to oral pathogens.' DR. BOGGESS

MIAMI BEACH — Unexplained vaginal bleeding and fetal exposure to oral pathogens have been linked individually with spontaneous preterm birth, and new data suggest the presence of both is associated with greater risk than either alone.

Of 660 pregnancies analyzed, 229 (35%) demonstrated fetal exposure to oral pathogens. Pregnancies that demonstrated such exposure were more likely to be in white women, women who had symptomatic bacterial vaginosis, and women who experienced vaginal bleeding, which was the most significant variable associated with oral pathogen exposure (adjusted risk ratio 1.6).

A total of 51 women (8%) in this planned secondary analysis of the Oral Conditions and Pregnancy Study—a prospective observational study of oral health and pregnancy outcomes—delivered before 35 weeks' gestation, Dr. Kim Boggess reported at the annual meeting of the Society for Maternal-Fetal Medicine.

When women with vaginal bleeding were stratified according to whether fetal exposure to oral pathogens occurred, preterm birth rates were significantly higher in those with both factors. Preterm birth occurred in 30% of those with both factors, compared with 8% in those with only vaginal bleeding, 9% of those with only oral pathogen exposure, and 6% of those with neither.

After adjusting for age, race, prior preterm birth, prior elective or spontaneous abortion, bacterial vaginosis, and enrollment weight, the differences remained. The adjusted hazard ratio for spontaneous preterm birth, compared with those with neither risk factor, was 6.4 for those with both factors, 1.9 for those with only vaginal bleeding, and 2.0 for those with only exposure to oral pathogens, said Dr. Boggess of the University of North Carolina at Chapel Hill.

Fetal exposure to oral pathogens was considered to have occurred if umbilical cord serum at delivery demonstrated an immunoglobulin M-positive (IgM-positive) response to at least one of five oral pathogens, she explained.

“Our findings show that antepartum vaginal bleeding is associated with fetal exposure to oral pathogens, and that the combination of fetal exposure to oral pathogens and vaginal bleeding provides the highest risk for premature birth at less than 35 weeks,” Dr. Boggess said.

“We think that vaginal bleeding may in fact be an effect measure modifier of fetal exposure to oral pathogens.”

Unexplained vaginal bleeding may be one of the mechanisms of fetal exposure to oral pathogens during pregnancy, but further study is needed to determine whether vaginal bleeding is the cause or the effect of fetal exposure to oral pathogens, she said.

The findings also suggest that clinical determination of periodontal disease is a poor marker for fetal exposure to oral pathogens, she noted.

Dr. Boggess indicated two weaknesses of the study: Detected pathogens could reside in the vagina of affected patients, causing fetuses to be exposed via pathogen ascent through the vagina; and the vaginal bleeding detected in this study may have actually been from some undetected underlying cause.

More data are needed before a position on interventions in women with periodontal disease can be officially taken, but two ongoing intervention trials may shed some light on the impact of treatment of periodontal disease during pregnancy, Dr. Boggess noted.

'We think that vaginal bleeding may in fact be an effect measure modifier of fetal exposure to oral pathogens.' DR. BOGGESS