Sharon Worcester

HOLLYWOOD, FLA. — Undiagnosed hiatal hernias or large hiatal crural defects account for many failed laparoscopic adjustable gastric banding procedures, and correcting these defects can obviate band removal, George A. Fielding, M.B., reported at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons.

In one series of 2,450 patients who underwent laparoscopic adjustable gastric banding (LAGB), 5% experienced symptomatic failure.

Most of these failures were a result of reflux or dysphagia, and many of the patients were found to have a hiatal hernia or large hiatal crural defect, Dr. Fielding wrote in the “poster of distinction” that he presented at the society meeting.

Such patients are now offered repair of the hernia or crural defect. Of those who presented with severe reflux at a mean of 44 months following LAGB, all were on proton pump inhibitor therapy, nine were considering band removal, four had severe dysphagia, nine had hiatal hernia/concentric dilatation, and six had slipped bands.

At an average of 15 visits, the mean band fill was only 1 cc; nine of the patients had empty bands.

A total of 23 patients underwent repairs: 13 had crural defect repair alone, the 4 with severe dysphagia also had a change to an 11-cm band, and the 6 with slipped bands also had repair of the slips, wrote Dr. Fielding of New York University Medical Center, New York.

At a mean follow-up of 13 months, patients had a mean of four postoperative visits and a mean band fill of 2 cc in the standard bands.

All patients were no longer taking proton pump inhibitors and were asymptomatic and reported being satisfied with the bands.

In the 14 months since LAGB, symptomatic patients have been offered defect repair as an alternative to band removal, no bands have been removed, compared with removal of a mean of 10 per year in previous years, Dr. Fielding reported.

The repair of hiatal hernias and large hiatal crural defects will cure reflux symptoms and greatly reduce the need for band removal in LAGB patients with persistent reflux symptoms, allowing band tightening as appropriate, he concluded. Dr. Fielding also noted that surgeons should look for and repair such defects at the time of the original LAGB surgery.

HOLLYWOOD, FLA. — Undiagnosed hiatal hernias or large hiatal crural defects account for many failed laparoscopic adjustable gastric banding procedures, and correcting these defects can obviate band removal, George A. Fielding, M.B., reported at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons.

In one series of 2,450 patients who underwent laparoscopic adjustable gastric banding (LAGB), 5% experienced symptomatic failure.

Most of these failures were a result of reflux or dysphagia, and many of the patients were found to have a hiatal hernia or large hiatal crural defect, Dr. Fielding wrote in the “poster of distinction” that he presented at the society meeting.

Such patients are now offered repair of the hernia or crural defect. Of those who presented with severe reflux at a mean of 44 months following LAGB, all were on proton pump inhibitor therapy, nine were considering band removal, four had severe dysphagia, nine had hiatal hernia/concentric dilatation, and six had slipped bands.

At an average of 15 visits, the mean band fill was only 1 cc; nine of the patients had empty bands.

A total of 23 patients underwent repairs: 13 had crural defect repair alone, the 4 with severe dysphagia also had a change to an 11-cm band, and the 6 with slipped bands also had repair of the slips, wrote Dr. Fielding of New York University Medical Center, New York.

At a mean follow-up of 13 months, patients had a mean of four postoperative visits and a mean band fill of 2 cc in the standard bands.

All patients were no longer taking proton pump inhibitors and were asymptomatic and reported being satisfied with the bands.

In the 14 months since LAGB, symptomatic patients have been offered defect repair as an alternative to band removal, no bands have been removed, compared with removal of a mean of 10 per year in previous years, Dr. Fielding reported.

The repair of hiatal hernias and large hiatal crural defects will cure reflux symptoms and greatly reduce the need for band removal in LAGB patients with persistent reflux symptoms, allowing band tightening as appropriate, he concluded. Dr. Fielding also noted that surgeons should look for and repair such defects at the time of the original LAGB surgery.

HOLLYWOOD, FLA. — Undiagnosed hiatal hernias or large hiatal crural defects account for many failed laparoscopic adjustable gastric banding procedures, and correcting these defects can obviate band removal, George A. Fielding, M.B., reported at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons.

In one series of 2,450 patients who underwent laparoscopic adjustable gastric banding (LAGB), 5% experienced symptomatic failure.

Most of these failures were a result of reflux or dysphagia, and many of the patients were found to have a hiatal hernia or large hiatal crural defect, Dr. Fielding wrote in the “poster of distinction” that he presented at the society meeting.

Such patients are now offered repair of the hernia or crural defect. Of those who presented with severe reflux at a mean of 44 months following LAGB, all were on proton pump inhibitor therapy, nine were considering band removal, four had severe dysphagia, nine had hiatal hernia/concentric dilatation, and six had slipped bands.

At an average of 15 visits, the mean band fill was only 1 cc; nine of the patients had empty bands.

A total of 23 patients underwent repairs: 13 had crural defect repair alone, the 4 with severe dysphagia also had a change to an 11-cm band, and the 6 with slipped bands also had repair of the slips, wrote Dr. Fielding of New York University Medical Center, New York.

At a mean follow-up of 13 months, patients had a mean of four postoperative visits and a mean band fill of 2 cc in the standard bands.

All patients were no longer taking proton pump inhibitors and were asymptomatic and reported being satisfied with the bands.

In the 14 months since LAGB, symptomatic patients have been offered defect repair as an alternative to band removal, no bands have been removed, compared with removal of a mean of 10 per year in previous years, Dr. Fielding reported.

The repair of hiatal hernias and large hiatal crural defects will cure reflux symptoms and greatly reduce the need for band removal in LAGB patients with persistent reflux symptoms, allowing band tightening as appropriate, he concluded. Dr. Fielding also noted that surgeons should look for and repair such defects at the time of the original LAGB surgery.

ST. PETE BEACH, FLA. — Attending a specialized clinic for pregnant women with substance-use disorders helped medical students in a recent study feel more comfortable and less judgmental when working with such patients.

A total of 104 consecutive third-year students rotating on an 8-week obstetrics-gynecology clerkship were enrolled in the study and randomized to attend or not to attend the half-day clinic. Responses to a 36-item survey administered at the start of participants' clerkship and midway through the clerkship showed significant improvements in the comfort level of clinic attendees in regard to talking with patients about smoking, alcohol use, and other substance use, William A. Ramirez-Cacho, M.D., of the University of New Mexico, Albuquerque, and colleagues reported in a poster at the annual meeting of the Teratology Society.

The responses also demonstrated that the clinic attendees were significantly less judgmental of patients with substance-use disorders and significantly more aware of multidisciplinary therapy approaches for treatment. Control students' survey responses indicated a significant decline in comfort level when it came to discussing patients' habits, and a significant decline in awareness regarding how common substance-use disorders are in this population, the investigators noted.

ST. PETE BEACH, FLA. — Attending a specialized clinic for pregnant women with substance-use disorders helped medical students in a recent study feel more comfortable and less judgmental when working with such patients.

A total of 104 consecutive third-year students rotating on an 8-week obstetrics-gynecology clerkship were enrolled in the study and randomized to attend or not to attend the half-day clinic. Responses to a 36-item survey administered at the start of participants' clerkship and midway through the clerkship showed significant improvements in the comfort level of clinic attendees in regard to talking with patients about smoking, alcohol use, and other substance use, William A. Ramirez-Cacho, M.D., of the University of New Mexico, Albuquerque, and colleagues reported in a poster at the annual meeting of the Teratology Society.

The responses also demonstrated that the clinic attendees were significantly less judgmental of patients with substance-use disorders and significantly more aware of multidisciplinary therapy approaches for treatment. Control students' survey responses indicated a significant decline in comfort level when it came to discussing patients' habits, and a significant decline in awareness regarding how common substance-use disorders are in this population, the investigators noted.

ST. PETE BEACH, FLA. — Attending a specialized clinic for pregnant women with substance-use disorders helped medical students in a recent study feel more comfortable and less judgmental when working with such patients.

A total of 104 consecutive third-year students rotating on an 8-week obstetrics-gynecology clerkship were enrolled in the study and randomized to attend or not to attend the half-day clinic. Responses to a 36-item survey administered at the start of participants' clerkship and midway through the clerkship showed significant improvements in the comfort level of clinic attendees in regard to talking with patients about smoking, alcohol use, and other substance use, William A. Ramirez-Cacho, M.D., of the University of New Mexico, Albuquerque, and colleagues reported in a poster at the annual meeting of the Teratology Society.

The responses also demonstrated that the clinic attendees were significantly less judgmental of patients with substance-use disorders and significantly more aware of multidisciplinary therapy approaches for treatment. Control students' survey responses indicated a significant decline in comfort level when it came to discussing patients' habits, and a significant decline in awareness regarding how common substance-use disorders are in this population, the investigators noted.

ST. PETE BEACH, FLA. — Typical primary effects of parvovirus B19 infection during pregnancy include hydrops fetalis, fetal death, and spontaneous abortion, but a recent case and a review of the literature suggest that central nervous system abnormalities are a rare but possible effect of such infection, Dr. Kenneth Lyon Jones reported at the annual meeting of the Teratology Society.

Dr. Jones' case involved an 11-year-old boy whose mother had documented parvovirus B19 infection early in her first trimester. The child had severe brain development defects secondary to the prenatal exposure. Mental retardation was severe; he had not learned to speak and had been diagnosed with hypertonic cerebral palsy.

Diagnosis of maternal infection was made during the first trimester. An ultrasound at 20.5 weeks' gestation indicated fetal ventricular enlargement, and at birth the boy weighed 2,898 g. At day 5 he received a blood transfusion because he had severe anemia, said Dr. Jones of the University of California, San Diego.

During the newborn period, ultrasound showed severe cerebral atrophy.

At age 11, his height was 122 cm (below the 3rd percentile) and his weight was 27.3 kg (10th percentile).

The child was markedly hirsute and had a frontal hair upsweep, a large hemangioma over the helix of his right ear, a large space between his upper central incisors, and clinodactyly of the index and fifth fingers of his left hand, Dr. Jones noted.

In addition, his inner canthal distance was 2.7 cm (25th percentile), and his palpebral fissure was 2.3 cm (below the 2nd percentile).

Valproic acid and carbamazepine treatment failed to control seizures, which he began having at birth.

A search of the literature revealed three publications documenting CNS abnormalities after maternal parvovirus B19 infection, Dr. Jones said.

The first, which was published as an abstract, involved three cases. In one case the fetus died, and in the other two cases the fetuses survived but had severe mental retardation.

Neuropathology at the time of death in the nonsurviving fetus, which was exposed to infection at 24 weeks' gestation, showed brain atrophy with widespread dysplasia and focal destruction of spinal cord and piriform cells, among other abnormal findings noted Dr. Jones.

One of the survivors was exposed to infection at 18 weeks' gestation. The child had cerebral palsy, developmental delay, and infantile spasms. Neuroimaging revealed enlarged ventricles with small periventricular calcifications, cortical dysplasia with polymicrogyria, and periventricular hypodensity.

The final case in that report involved a fetus exposed at 23 weeks' gestation. A CT scan of the brain revealed periventricular calcifications.

The second publication was a case report involving a fetus that was exposed at 15 weeks' gestation and died 7 hours after birth. Neuropathology showed multinucleated giant cells, macrophages, microglia, and many small calcifications around the vessels, predominantly in the cerebral white matter. Polymerase chain reaction amplification showed that parvovirus DNA was present in the nuclei of the multinucleated giant cells and endothelial cells, Dr. Jones said.

The final publication involved a series of 92 consecutive singleton pregnancies with serologic evidence of parvovirus B19 infection. There were 3 therapeutic abortions, 64 fetal deaths, 10 premature births (8 of the babies subsequently died), and 15 term births (1 baby subsequently died).

Of the 73 fetal or neonatal deaths, 21 had adequate histologic evaluation of the brain, and 9 of these showed CNS abnormalities. Of the 16 surviving babies, 5 had CNS abnormalities.

One of the 14 with CNS abnormalities had trisomy 13 syndrome; no etiology was determined in the remaining cases, but the findings suggested anemia might be an important mechanism for CNS abnormalities, Dr. Jones noted.

Based on the findings of the published reports, it appears three patterns of abnormalities are associated with maternal parvovirus B19 infection: positional limb deformities, radiographic evidence of intercranial calcifications, and dysplastic changes, including agyria, macrogyria, polymicrogyria, and dysgenesis of the corpus callosum, he said.

“CNS involvement is a rare occurrence following maternal parvovirus infection, but it clearly occurs, and when it does, it's clearly significant,” Dr. Jones said, noting that the mechanism of action most likely includes both infection of cells in the central nervous system and hypoxia secondary to severe anemia.

It is possible that subtle neurobehavioral effects in otherwise normal children result from a mild case of maternal parvovirus B19 infection, he added.

ST. PETE BEACH, FLA. — Typical primary effects of parvovirus B19 infection during pregnancy include hydrops fetalis, fetal death, and spontaneous abortion, but a recent case and a review of the literature suggest that central nervous system abnormalities are a rare but possible effect of such infection, Dr. Kenneth Lyon Jones reported at the annual meeting of the Teratology Society.

Dr. Jones' case involved an 11-year-old boy whose mother had documented parvovirus B19 infection early in her first trimester. The child had severe brain development defects secondary to the prenatal exposure. Mental retardation was severe; he had not learned to speak and had been diagnosed with hypertonic cerebral palsy.

Diagnosis of maternal infection was made during the first trimester. An ultrasound at 20.5 weeks' gestation indicated fetal ventricular enlargement, and at birth the boy weighed 2,898 g. At day 5 he received a blood transfusion because he had severe anemia, said Dr. Jones of the University of California, San Diego.

During the newborn period, ultrasound showed severe cerebral atrophy.

At age 11, his height was 122 cm (below the 3rd percentile) and his weight was 27.3 kg (10th percentile).

The child was markedly hirsute and had a frontal hair upsweep, a large hemangioma over the helix of his right ear, a large space between his upper central incisors, and clinodactyly of the index and fifth fingers of his left hand, Dr. Jones noted.

In addition, his inner canthal distance was 2.7 cm (25th percentile), and his palpebral fissure was 2.3 cm (below the 2nd percentile).

Valproic acid and carbamazepine treatment failed to control seizures, which he began having at birth.

A search of the literature revealed three publications documenting CNS abnormalities after maternal parvovirus B19 infection, Dr. Jones said.

The first, which was published as an abstract, involved three cases. In one case the fetus died, and in the other two cases the fetuses survived but had severe mental retardation.

Neuropathology at the time of death in the nonsurviving fetus, which was exposed to infection at 24 weeks' gestation, showed brain atrophy with widespread dysplasia and focal destruction of spinal cord and piriform cells, among other abnormal findings noted Dr. Jones.

One of the survivors was exposed to infection at 18 weeks' gestation. The child had cerebral palsy, developmental delay, and infantile spasms. Neuroimaging revealed enlarged ventricles with small periventricular calcifications, cortical dysplasia with polymicrogyria, and periventricular hypodensity.

The final case in that report involved a fetus exposed at 23 weeks' gestation. A CT scan of the brain revealed periventricular calcifications.

The second publication was a case report involving a fetus that was exposed at 15 weeks' gestation and died 7 hours after birth. Neuropathology showed multinucleated giant cells, macrophages, microglia, and many small calcifications around the vessels, predominantly in the cerebral white matter. Polymerase chain reaction amplification showed that parvovirus DNA was present in the nuclei of the multinucleated giant cells and endothelial cells, Dr. Jones said.

The final publication involved a series of 92 consecutive singleton pregnancies with serologic evidence of parvovirus B19 infection. There were 3 therapeutic abortions, 64 fetal deaths, 10 premature births (8 of the babies subsequently died), and 15 term births (1 baby subsequently died).

Of the 73 fetal or neonatal deaths, 21 had adequate histologic evaluation of the brain, and 9 of these showed CNS abnormalities. Of the 16 surviving babies, 5 had CNS abnormalities.

One of the 14 with CNS abnormalities had trisomy 13 syndrome; no etiology was determined in the remaining cases, but the findings suggested anemia might be an important mechanism for CNS abnormalities, Dr. Jones noted.

Based on the findings of the published reports, it appears three patterns of abnormalities are associated with maternal parvovirus B19 infection: positional limb deformities, radiographic evidence of intercranial calcifications, and dysplastic changes, including agyria, macrogyria, polymicrogyria, and dysgenesis of the corpus callosum, he said.

“CNS involvement is a rare occurrence following maternal parvovirus infection, but it clearly occurs, and when it does, it's clearly significant,” Dr. Jones said, noting that the mechanism of action most likely includes both infection of cells in the central nervous system and hypoxia secondary to severe anemia.

It is possible that subtle neurobehavioral effects in otherwise normal children result from a mild case of maternal parvovirus B19 infection, he added.

ST. PETE BEACH, FLA. — Typical primary effects of parvovirus B19 infection during pregnancy include hydrops fetalis, fetal death, and spontaneous abortion, but a recent case and a review of the literature suggest that central nervous system abnormalities are a rare but possible effect of such infection, Dr. Kenneth Lyon Jones reported at the annual meeting of the Teratology Society.

Dr. Jones' case involved an 11-year-old boy whose mother had documented parvovirus B19 infection early in her first trimester. The child had severe brain development defects secondary to the prenatal exposure. Mental retardation was severe; he had not learned to speak and had been diagnosed with hypertonic cerebral palsy.

Diagnosis of maternal infection was made during the first trimester. An ultrasound at 20.5 weeks' gestation indicated fetal ventricular enlargement, and at birth the boy weighed 2,898 g. At day 5 he received a blood transfusion because he had severe anemia, said Dr. Jones of the University of California, San Diego.

During the newborn period, ultrasound showed severe cerebral atrophy.

At age 11, his height was 122 cm (below the 3rd percentile) and his weight was 27.3 kg (10th percentile).

The child was markedly hirsute and had a frontal hair upsweep, a large hemangioma over the helix of his right ear, a large space between his upper central incisors, and clinodactyly of the index and fifth fingers of his left hand, Dr. Jones noted.

In addition, his inner canthal distance was 2.7 cm (25th percentile), and his palpebral fissure was 2.3 cm (below the 2nd percentile).

Valproic acid and carbamazepine treatment failed to control seizures, which he began having at birth.

A search of the literature revealed three publications documenting CNS abnormalities after maternal parvovirus B19 infection, Dr. Jones said.

The first, which was published as an abstract, involved three cases. In one case the fetus died, and in the other two cases the fetuses survived but had severe mental retardation.

Neuropathology at the time of death in the nonsurviving fetus, which was exposed to infection at 24 weeks' gestation, showed brain atrophy with widespread dysplasia and focal destruction of spinal cord and piriform cells, among other abnormal findings noted Dr. Jones.

One of the survivors was exposed to infection at 18 weeks' gestation. The child had cerebral palsy, developmental delay, and infantile spasms. Neuroimaging revealed enlarged ventricles with small periventricular calcifications, cortical dysplasia with polymicrogyria, and periventricular hypodensity.

The final case in that report involved a fetus exposed at 23 weeks' gestation. A CT scan of the brain revealed periventricular calcifications.

The second publication was a case report involving a fetus that was exposed at 15 weeks' gestation and died 7 hours after birth. Neuropathology showed multinucleated giant cells, macrophages, microglia, and many small calcifications around the vessels, predominantly in the cerebral white matter. Polymerase chain reaction amplification showed that parvovirus DNA was present in the nuclei of the multinucleated giant cells and endothelial cells, Dr. Jones said.

The final publication involved a series of 92 consecutive singleton pregnancies with serologic evidence of parvovirus B19 infection. There were 3 therapeutic abortions, 64 fetal deaths, 10 premature births (8 of the babies subsequently died), and 15 term births (1 baby subsequently died).

Of the 73 fetal or neonatal deaths, 21 had adequate histologic evaluation of the brain, and 9 of these showed CNS abnormalities. Of the 16 surviving babies, 5 had CNS abnormalities.

One of the 14 with CNS abnormalities had trisomy 13 syndrome; no etiology was determined in the remaining cases, but the findings suggested anemia might be an important mechanism for CNS abnormalities, Dr. Jones noted.

Based on the findings of the published reports, it appears three patterns of abnormalities are associated with maternal parvovirus B19 infection: positional limb deformities, radiographic evidence of intercranial calcifications, and dysplastic changes, including agyria, macrogyria, polymicrogyria, and dysgenesis of the corpus callosum, he said.

“CNS involvement is a rare occurrence following maternal parvovirus infection, but it clearly occurs, and when it does, it's clearly significant,” Dr. Jones said, noting that the mechanism of action most likely includes both infection of cells in the central nervous system and hypoxia secondary to severe anemia.

It is possible that subtle neurobehavioral effects in otherwise normal children result from a mild case of maternal parvovirus B19 infection, he added.

A Chicago-area hospital system has launched an ambitious effort to sharply reduce the rate of in-hospital methicillin-resistant Staphylococcus aureus infections by screening all patients.

The new admissions screening process at each of three Evanston Northwestern Healthcare (ENH) hospitals is intended to reduce the rate of MRSA infections by 50% within 2 years.

A recent prevalence study conducted by ENH showed that about 8% of patients being admitted were colonized with MRSA, Lance Peterson, M.D., told this newspaper. That figure is in line with other studies from around the United States that also suggest that the incidence of this dangerous disease is on the rise.

“Our feeling was that we were seeing more and more patients with MRSA in the hospital … and we decided that it was necessary to go ahead and start dealing with MRSA from a patient safety standpoint,” said Dr. Peterson, director of clinical microbiology and infectious diseases research at ENH.

Patients with active infection can infect others in the hospital, and those who are colonized with MRSA pose a risk to others as well as to themselves; about 75% of infections originate from a person's own strains, he explained.

Furthermore, the cost of infection is high, as is the mortality. Some estimates put the total cost at about $30,000 for an inpatient with a bloodstream infection, and at $40,000 for a wound infection. A recent study suggests the 30-day mortality is 50%, with 23% directly related to the MRSA.

“It's a very aggressive organism to get in the blood … but MRSA infection is totally preventable,” said Dr. Peterson, who also is professor of pathology and medicine at Northwestern University, Chicago.

“If we get it out of health care, we can eliminate this problem,” he added, noting that Dutch and Swedish hospitals have been successful in their efforts at eliminating MRSA.

The ENH effort involves an attempt to screen every patient on admission. A nasal swab is collected from each patient as part of the admission process, and the swab is tested for MRSA using new real-time DNA analysis that can detect the microorganism at the molecular level within 2 hours, compared with the 2–3 days that previous culture methods required.

Patients diagnosed with MRSA are treated with a nasal antibiotic ointment for 5 days, and must bathe using a special antiseptic soap on the first, third, and last day of the treatment. A recent study showed that this approach decolonized 95% of patients who had unexpected MRSA colonization, Dr. Peterson noted.

Screening for S. aureus has been used successfully throughout the ENH system for the past 2 years in high-risk patient areas, such as the infant special care unit. A pilot program was also implemented using a rapid molecular testing method for MRSA in patients undergoing knee replacement.

That program reduced the rate of postsurgical S. aureus infection by nearly fourfold, according to an ENH statement.

The new screening process, which is being watched closely nationwide by other hospital systems that are also battling MRSA, is off to a good start, Dr. Peterson said.

After a year of planning, including a cost-benefit analysis showing that a 50% reduction in the bacteremia rate is necessary for the screening program to break even, 90% of patients were being captured within the second week of implementation, he said.

Patients—who are often well aware of the risk of nosocomial infection—have been amenable to the process, he added.

Hospital systems and infectious disease experts alike are keeping a close eye on the program. Several facilities have inquired about the process. Interest in the idea also is growing because the molecular technology for testing was recently approved for use. It is an approach that every hospital could do right now, Dr. Peterson said.

Michael Climo, M.D., of Hunter Holmes McGuire VA Medical Center in Richmond, Va., is among those watching closely.

The ENH approach is a novel one on a large scale, and it will be interesting to see if these aggressive—and costly—measures are worthwhile, Dr. Climo said in an interview.

Among the questions that remain to be answered include what the actual cost and feasibility of such a process might be, whether hospital laboratories can shoulder the burden of tens of thousands of additional tests each year, and whether the hospitals can adequately manage MRSA patients once they are identified.

“These are complicated patients in complicated hospital settings, and it's difficult to determine the best strategies,” he said, noting that a tremendous amount of hospital resources will be required to manage the large number of MRSA patients now being admitted.

The ENH program makes sense, but it will be some time before it's clear how effective it will be and whether it can be done logistically and financially. “But it's commendable that they're trying,” Dr. Climo said.

A Chicago-area hospital system has launched an ambitious effort to sharply reduce the rate of in-hospital methicillin-resistant Staphylococcus aureus infections by screening all patients.

The new admissions screening process at each of three Evanston Northwestern Healthcare (ENH) hospitals is intended to reduce the rate of MRSA infections by 50% within 2 years.

A recent prevalence study conducted by ENH showed that about 8% of patients being admitted were colonized with MRSA, Lance Peterson, M.D., told this newspaper. That figure is in line with other studies from around the United States that also suggest that the incidence of this dangerous disease is on the rise.

“Our feeling was that we were seeing more and more patients with MRSA in the hospital … and we decided that it was necessary to go ahead and start dealing with MRSA from a patient safety standpoint,” said Dr. Peterson, director of clinical microbiology and infectious diseases research at ENH.

Patients with active infection can infect others in the hospital, and those who are colonized with MRSA pose a risk to others as well as to themselves; about 75% of infections originate from a person's own strains, he explained.

Furthermore, the cost of infection is high, as is the mortality. Some estimates put the total cost at about $30,000 for an inpatient with a bloodstream infection, and at $40,000 for a wound infection. A recent study suggests the 30-day mortality is 50%, with 23% directly related to the MRSA.

“It's a very aggressive organism to get in the blood … but MRSA infection is totally preventable,” said Dr. Peterson, who also is professor of pathology and medicine at Northwestern University, Chicago.

“If we get it out of health care, we can eliminate this problem,” he added, noting that Dutch and Swedish hospitals have been successful in their efforts at eliminating MRSA.

The ENH effort involves an attempt to screen every patient on admission. A nasal swab is collected from each patient as part of the admission process, and the swab is tested for MRSA using new real-time DNA analysis that can detect the microorganism at the molecular level within 2 hours, compared with the 2–3 days that previous culture methods required.

Patients diagnosed with MRSA are treated with a nasal antibiotic ointment for 5 days, and must bathe using a special antiseptic soap on the first, third, and last day of the treatment. A recent study showed that this approach decolonized 95% of patients who had unexpected MRSA colonization, Dr. Peterson noted.

Screening for S. aureus has been used successfully throughout the ENH system for the past 2 years in high-risk patient areas, such as the infant special care unit. A pilot program was also implemented using a rapid molecular testing method for MRSA in patients undergoing knee replacement.

That program reduced the rate of postsurgical S. aureus infection by nearly fourfold, according to an ENH statement.

The new screening process, which is being watched closely nationwide by other hospital systems that are also battling MRSA, is off to a good start, Dr. Peterson said.

After a year of planning, including a cost-benefit analysis showing that a 50% reduction in the bacteremia rate is necessary for the screening program to break even, 90% of patients were being captured within the second week of implementation, he said.

Patients—who are often well aware of the risk of nosocomial infection—have been amenable to the process, he added.

Hospital systems and infectious disease experts alike are keeping a close eye on the program. Several facilities have inquired about the process. Interest in the idea also is growing because the molecular technology for testing was recently approved for use. It is an approach that every hospital could do right now, Dr. Peterson said.

Michael Climo, M.D., of Hunter Holmes McGuire VA Medical Center in Richmond, Va., is among those watching closely.

The ENH approach is a novel one on a large scale, and it will be interesting to see if these aggressive—and costly—measures are worthwhile, Dr. Climo said in an interview.

Among the questions that remain to be answered include what the actual cost and feasibility of such a process might be, whether hospital laboratories can shoulder the burden of tens of thousands of additional tests each year, and whether the hospitals can adequately manage MRSA patients once they are identified.

“These are complicated patients in complicated hospital settings, and it's difficult to determine the best strategies,” he said, noting that a tremendous amount of hospital resources will be required to manage the large number of MRSA patients now being admitted.

The ENH program makes sense, but it will be some time before it's clear how effective it will be and whether it can be done logistically and financially. “But it's commendable that they're trying,” Dr. Climo said.

A Chicago-area hospital system has launched an ambitious effort to sharply reduce the rate of in-hospital methicillin-resistant Staphylococcus aureus infections by screening all patients.

The new admissions screening process at each of three Evanston Northwestern Healthcare (ENH) hospitals is intended to reduce the rate of MRSA infections by 50% within 2 years.

A recent prevalence study conducted by ENH showed that about 8% of patients being admitted were colonized with MRSA, Lance Peterson, M.D., told this newspaper. That figure is in line with other studies from around the United States that also suggest that the incidence of this dangerous disease is on the rise.

“Our feeling was that we were seeing more and more patients with MRSA in the hospital … and we decided that it was necessary to go ahead and start dealing with MRSA from a patient safety standpoint,” said Dr. Peterson, director of clinical microbiology and infectious diseases research at ENH.

Patients with active infection can infect others in the hospital, and those who are colonized with MRSA pose a risk to others as well as to themselves; about 75% of infections originate from a person's own strains, he explained.

Furthermore, the cost of infection is high, as is the mortality. Some estimates put the total cost at about $30,000 for an inpatient with a bloodstream infection, and at $40,000 for a wound infection. A recent study suggests the 30-day mortality is 50%, with 23% directly related to the MRSA.

“It's a very aggressive organism to get in the blood … but MRSA infection is totally preventable,” said Dr. Peterson, who also is professor of pathology and medicine at Northwestern University, Chicago.

“If we get it out of health care, we can eliminate this problem,” he added, noting that Dutch and Swedish hospitals have been successful in their efforts at eliminating MRSA.

The ENH effort involves an attempt to screen every patient on admission. A nasal swab is collected from each patient as part of the admission process, and the swab is tested for MRSA using new real-time DNA analysis that can detect the microorganism at the molecular level within 2 hours, compared with the 2–3 days that previous culture methods required.

Patients diagnosed with MRSA are treated with a nasal antibiotic ointment for 5 days, and must bathe using a special antiseptic soap on the first, third, and last day of the treatment. A recent study showed that this approach decolonized 95% of patients who had unexpected MRSA colonization, Dr. Peterson noted.

Screening for S. aureus has been used successfully throughout the ENH system for the past 2 years in high-risk patient areas, such as the infant special care unit. A pilot program was also implemented using a rapid molecular testing method for MRSA in patients undergoing knee replacement.

That program reduced the rate of postsurgical S. aureus infection by nearly fourfold, according to an ENH statement.

The new screening process, which is being watched closely nationwide by other hospital systems that are also battling MRSA, is off to a good start, Dr. Peterson said.

After a year of planning, including a cost-benefit analysis showing that a 50% reduction in the bacteremia rate is necessary for the screening program to break even, 90% of patients were being captured within the second week of implementation, he said.

Patients—who are often well aware of the risk of nosocomial infection—have been amenable to the process, he added.

Hospital systems and infectious disease experts alike are keeping a close eye on the program. Several facilities have inquired about the process. Interest in the idea also is growing because the molecular technology for testing was recently approved for use. It is an approach that every hospital could do right now, Dr. Peterson said.

Michael Climo, M.D., of Hunter Holmes McGuire VA Medical Center in Richmond, Va., is among those watching closely.

The ENH approach is a novel one on a large scale, and it will be interesting to see if these aggressive—and costly—measures are worthwhile, Dr. Climo said in an interview.

Among the questions that remain to be answered include what the actual cost and feasibility of such a process might be, whether hospital laboratories can shoulder the burden of tens of thousands of additional tests each year, and whether the hospitals can adequately manage MRSA patients once they are identified.

“These are complicated patients in complicated hospital settings, and it's difficult to determine the best strategies,” he said, noting that a tremendous amount of hospital resources will be required to manage the large number of MRSA patients now being admitted.

The ENH program makes sense, but it will be some time before it's clear how effective it will be and whether it can be done logistically and financially. “But it's commendable that they're trying,” Dr. Climo said.

Food-Borne Hepatitis A

A large hepatitis A outbreak in November 2003 among patrons of a Pennsylvania restaurant was linked to green onions that were apparently contaminated at farms in northern Mexico.

A case-control study involving 240 of the 601 patients showed that 91% had eaten mild salsa containing green onions, compared with 35% of 134 controls (odds ratio 19.6), and that 98% of patients vs. 58% of controls had eaten a menu item containing green onions (odds ratio 33.3), reported Charlotte Wheeler, M.D., of the Centers for Disease Control and Prevention, and her colleagues.

Restaurant workers were ruled out as the source of the outbreak. An analysis of serum samples from 170 patients showed that the sequences of hepatitis A virus were identical in all the patients (N. Engl. J. Med. 2005;353:890–7).

The findings highlight the increasing proportion of outbreaks associated with fresh produce. Hepatitis A caused by green onions has been a particular concern: outbreaks have been reported in Ohio, Kentucky, Florida, Tennessee, Georgia, and North Carolina. The findings may mean rethinking targeted hepatitis A vaccination strategies, Loriana Di Giammarino, M.D., and Jules L. Dienstag, M.D., wrote in an editorial (N. Engl. J. Med. 2005;353:944–6).

They argued that the current policy of targeting people at high risk does not address the problem of increasing food-borne infections, but universal childhood vaccination has the potential to eliminate “the specter of outbreaks of food-borne hepatitis” in a cost-effective manner.

Artesunate for Malaria

The drug artesunate should be the treatment of choice for severe malaria, according to the Southeast Asian Quinine Artesunate Malaria Trial group.

Artesunate is easier to administer, faster acting, and safer than quinine, which is the mainstay of severe malaria treatment. In a randomized controlled trial, artesunate also proved significantly better for reducing mortality: 15% of 730 patients in the artesunate group vs. 22% of 731 in the quinine group died from malaria during the study (Lancet 2005;366:717–25).

Artesunate was administered as a 2–4 mg/kg bolus at 0, 12, and 24 hours and then daily, followed by oral therapy; it was well tolerated. Quinine was administered as a 20 mg/kg loading dose in dextrose water and saline infused over 4 hours, followed by 10 mg/kg infused over 2–8 hours three times daily, followed by oral therapy; this regimen was associated with a significantly increased risk of hypoglycemia (relative risk 3.2).

Shigella Risk

An increase in Shigella infection in men is probably attributable to outbreaks in men who have sex with men, the CDC said.

Shigellosis outbreaks have been reported in that population (MSM) in major cities across North America, Europe, and Australia. Although risk factors for sexual transmission are not well defined, exposure to fecal material is likely to blame. In studies, up to 90% of those affected by outbreaks among MSM have reported oral-genital or oral-anal contact in the week prior to diagnosis (MMWR 2005;54:820–2).

To reduce the risk of shigellosis and other enteric illnesses that can be transmitted sexually, those with diarrhea should refrain from oral-anal, oral-genital, and anal-genital contact while symptomatic. Those engaging in sexual contact should wash their hands and anal-genital region thoroughly before and after sexual activity, and condoms, dental dams, and gloves should be utilized for protection. Clinicians should request appropriate laboratory examinations in patients with diarrhea who are MSM and counsel patients about the risks involved in exposure to fecal matter.

Flu Treatment Donation

A donation by Roche of three million treatment courses of oseltamivir for a World Health Organization antiviral stockpile will bolster the organization's ability to respond quickly in the event of an emerging influenza pandemic, WHO announced.

The donation of 30 million capsules could help reduce illness and death, and assist in containing or slowing the spread of disease in the event of such a pandemic, according to a WHO statement.

Roche will reserve the treatment courses for up to 5 years. Ten million capsules will be available in 2006, with the remaining capsules available by mid-2006, the company reported.

Experts predict that an influenza pandemic will indeed occur. The timing and severity of a pandemic are uncertain, but WHO noted that it is keeping a close eye on avian influenza outbreaks in Asia, Russia, and Kazakhstan, which have the potential to trigger a human pandemic should the virus mutate into a form that could transmit easily between people.

Food-Borne Hepatitis A

A large hepatitis A outbreak in November 2003 among patrons of a Pennsylvania restaurant was linked to green onions that were apparently contaminated at farms in northern Mexico.

A case-control study involving 240 of the 601 patients showed that 91% had eaten mild salsa containing green onions, compared with 35% of 134 controls (odds ratio 19.6), and that 98% of patients vs. 58% of controls had eaten a menu item containing green onions (odds ratio 33.3), reported Charlotte Wheeler, M.D., of the Centers for Disease Control and Prevention, and her colleagues.

Restaurant workers were ruled out as the source of the outbreak. An analysis of serum samples from 170 patients showed that the sequences of hepatitis A virus were identical in all the patients (N. Engl. J. Med. 2005;353:890–7).

The findings highlight the increasing proportion of outbreaks associated with fresh produce. Hepatitis A caused by green onions has been a particular concern: outbreaks have been reported in Ohio, Kentucky, Florida, Tennessee, Georgia, and North Carolina. The findings may mean rethinking targeted hepatitis A vaccination strategies, Loriana Di Giammarino, M.D., and Jules L. Dienstag, M.D., wrote in an editorial (N. Engl. J. Med. 2005;353:944–6).

They argued that the current policy of targeting people at high risk does not address the problem of increasing food-borne infections, but universal childhood vaccination has the potential to eliminate “the specter of outbreaks of food-borne hepatitis” in a cost-effective manner.

Artesunate for Malaria

The drug artesunate should be the treatment of choice for severe malaria, according to the Southeast Asian Quinine Artesunate Malaria Trial group.

Artesunate is easier to administer, faster acting, and safer than quinine, which is the mainstay of severe malaria treatment. In a randomized controlled trial, artesunate also proved significantly better for reducing mortality: 15% of 730 patients in the artesunate group vs. 22% of 731 in the quinine group died from malaria during the study (Lancet 2005;366:717–25).

Artesunate was administered as a 2–4 mg/kg bolus at 0, 12, and 24 hours and then daily, followed by oral therapy; it was well tolerated. Quinine was administered as a 20 mg/kg loading dose in dextrose water and saline infused over 4 hours, followed by 10 mg/kg infused over 2–8 hours three times daily, followed by oral therapy; this regimen was associated with a significantly increased risk of hypoglycemia (relative risk 3.2).

Shigella Risk

An increase in Shigella infection in men is probably attributable to outbreaks in men who have sex with men, the CDC said.

Shigellosis outbreaks have been reported in that population (MSM) in major cities across North America, Europe, and Australia. Although risk factors for sexual transmission are not well defined, exposure to fecal material is likely to blame. In studies, up to 90% of those affected by outbreaks among MSM have reported oral-genital or oral-anal contact in the week prior to diagnosis (MMWR 2005;54:820–2).

To reduce the risk of shigellosis and other enteric illnesses that can be transmitted sexually, those with diarrhea should refrain from oral-anal, oral-genital, and anal-genital contact while symptomatic. Those engaging in sexual contact should wash their hands and anal-genital region thoroughly before and after sexual activity, and condoms, dental dams, and gloves should be utilized for protection. Clinicians should request appropriate laboratory examinations in patients with diarrhea who are MSM and counsel patients about the risks involved in exposure to fecal matter.

Flu Treatment Donation

A donation by Roche of three million treatment courses of oseltamivir for a World Health Organization antiviral stockpile will bolster the organization's ability to respond quickly in the event of an emerging influenza pandemic, WHO announced.

The donation of 30 million capsules could help reduce illness and death, and assist in containing or slowing the spread of disease in the event of such a pandemic, according to a WHO statement.

Roche will reserve the treatment courses for up to 5 years. Ten million capsules will be available in 2006, with the remaining capsules available by mid-2006, the company reported.

Experts predict that an influenza pandemic will indeed occur. The timing and severity of a pandemic are uncertain, but WHO noted that it is keeping a close eye on avian influenza outbreaks in Asia, Russia, and Kazakhstan, which have the potential to trigger a human pandemic should the virus mutate into a form that could transmit easily between people.

Food-Borne Hepatitis A

A large hepatitis A outbreak in November 2003 among patrons of a Pennsylvania restaurant was linked to green onions that were apparently contaminated at farms in northern Mexico.

A case-control study involving 240 of the 601 patients showed that 91% had eaten mild salsa containing green onions, compared with 35% of 134 controls (odds ratio 19.6), and that 98% of patients vs. 58% of controls had eaten a menu item containing green onions (odds ratio 33.3), reported Charlotte Wheeler, M.D., of the Centers for Disease Control and Prevention, and her colleagues.

Restaurant workers were ruled out as the source of the outbreak. An analysis of serum samples from 170 patients showed that the sequences of hepatitis A virus were identical in all the patients (N. Engl. J. Med. 2005;353:890–7).

The findings highlight the increasing proportion of outbreaks associated with fresh produce. Hepatitis A caused by green onions has been a particular concern: outbreaks have been reported in Ohio, Kentucky, Florida, Tennessee, Georgia, and North Carolina. The findings may mean rethinking targeted hepatitis A vaccination strategies, Loriana Di Giammarino, M.D., and Jules L. Dienstag, M.D., wrote in an editorial (N. Engl. J. Med. 2005;353:944–6).

They argued that the current policy of targeting people at high risk does not address the problem of increasing food-borne infections, but universal childhood vaccination has the potential to eliminate “the specter of outbreaks of food-borne hepatitis” in a cost-effective manner.

Artesunate for Malaria

The drug artesunate should be the treatment of choice for severe malaria, according to the Southeast Asian Quinine Artesunate Malaria Trial group.

Artesunate is easier to administer, faster acting, and safer than quinine, which is the mainstay of severe malaria treatment. In a randomized controlled trial, artesunate also proved significantly better for reducing mortality: 15% of 730 patients in the artesunate group vs. 22% of 731 in the quinine group died from malaria during the study (Lancet 2005;366:717–25).

Artesunate was administered as a 2–4 mg/kg bolus at 0, 12, and 24 hours and then daily, followed by oral therapy; it was well tolerated. Quinine was administered as a 20 mg/kg loading dose in dextrose water and saline infused over 4 hours, followed by 10 mg/kg infused over 2–8 hours three times daily, followed by oral therapy; this regimen was associated with a significantly increased risk of hypoglycemia (relative risk 3.2).

Shigella Risk

An increase in Shigella infection in men is probably attributable to outbreaks in men who have sex with men, the CDC said.

Shigellosis outbreaks have been reported in that population (MSM) in major cities across North America, Europe, and Australia. Although risk factors for sexual transmission are not well defined, exposure to fecal material is likely to blame. In studies, up to 90% of those affected by outbreaks among MSM have reported oral-genital or oral-anal contact in the week prior to diagnosis (MMWR 2005;54:820–2).

To reduce the risk of shigellosis and other enteric illnesses that can be transmitted sexually, those with diarrhea should refrain from oral-anal, oral-genital, and anal-genital contact while symptomatic. Those engaging in sexual contact should wash their hands and anal-genital region thoroughly before and after sexual activity, and condoms, dental dams, and gloves should be utilized for protection. Clinicians should request appropriate laboratory examinations in patients with diarrhea who are MSM and counsel patients about the risks involved in exposure to fecal matter.

Flu Treatment Donation

A donation by Roche of three million treatment courses of oseltamivir for a World Health Organization antiviral stockpile will bolster the organization's ability to respond quickly in the event of an emerging influenza pandemic, WHO announced.

The donation of 30 million capsules could help reduce illness and death, and assist in containing or slowing the spread of disease in the event of such a pandemic, according to a WHO statement.

Roche will reserve the treatment courses for up to 5 years. Ten million capsules will be available in 2006, with the remaining capsules available by mid-2006, the company reported.

Experts predict that an influenza pandemic will indeed occur. The timing and severity of a pandemic are uncertain, but WHO noted that it is keeping a close eye on avian influenza outbreaks in Asia, Russia, and Kazakhstan, which have the potential to trigger a human pandemic should the virus mutate into a form that could transmit easily between people.

The HIV/AIDS epidemic can be controlled but only with intensified global attention in the form of funding and leadership, United Nations officials and AIDS experts said in response to a status report by U.N. Secretary-General Kofi Annan.

The threat of HIV/AIDS requires the kind of attention being paid to other major concerns such as global security, Peter Piot, M.D., executive director of the Joint United Nations Programme on HIV/AIDS, said at a press briefing on the new report, which was prepared for a high-level U.N. ministerial gathering to assess progress on meeting goals set out in a Declaration of Commitment on HIV/AIDS. The declaration was adopted in 2001 by the U.N. General Assembly special session on HIV/AIDS.

The report states that “despite encouraging signs that the epidemic is beginning to be contained in a small but growing number of countries, the overall epidemic continues to expand, with much of the world at risk of falling short of the targets set forth in the declaration.”

In 2004 there were more new infections (4.9 million) and more AIDS deaths (3.1 million) than in previous years, and as of December, an estimated 39.4 million people were living with HIV, Secretary-General Annan wrote. Furthermore, the toll of HIV/AIDS on women and girls has intensified, and many of the countries most affected are falling short of the 2005 target of reducing the level of infection in young people.

The expansion of the epidemic is outpacing the global response. About $6 billion were available in 2004 to implement comprehensive programs in 135 low- and middle-income countries, up 23% from 2003. But by 2007, if current trends in spending continue, funding will be insufficient to finance a response that is “comprehensive in both scope and coverage,” according to the report.

Achieving the targets specified in the declaration, including rapid expansion of HIV prevention, care, treatment, and impact alleviation programs, will require immediate government action and substantial increases in funding.

“We are seeing real signs of progress in tackling AIDS at the community level, but it is still not enough,” Secretary-General Annan said at the press briefing. “It is time for governments to translate commitment into concrete action.”

Dr. Piot agreed, adding that access to prevention and treatment must be expanded. As of December, only 12% of those requiring antiretroviral therapy were receiving it.

The HIV/AIDS epidemic can be controlled but only with intensified global attention in the form of funding and leadership, United Nations officials and AIDS experts said in response to a status report by U.N. Secretary-General Kofi Annan.

The threat of HIV/AIDS requires the kind of attention being paid to other major concerns such as global security, Peter Piot, M.D., executive director of the Joint United Nations Programme on HIV/AIDS, said at a press briefing on the new report, which was prepared for a high-level U.N. ministerial gathering to assess progress on meeting goals set out in a Declaration of Commitment on HIV/AIDS. The declaration was adopted in 2001 by the U.N. General Assembly special session on HIV/AIDS.

The report states that “despite encouraging signs that the epidemic is beginning to be contained in a small but growing number of countries, the overall epidemic continues to expand, with much of the world at risk of falling short of the targets set forth in the declaration.”

In 2004 there were more new infections (4.9 million) and more AIDS deaths (3.1 million) than in previous years, and as of December, an estimated 39.4 million people were living with HIV, Secretary-General Annan wrote. Furthermore, the toll of HIV/AIDS on women and girls has intensified, and many of the countries most affected are falling short of the 2005 target of reducing the level of infection in young people.

The expansion of the epidemic is outpacing the global response. About $6 billion were available in 2004 to implement comprehensive programs in 135 low- and middle-income countries, up 23% from 2003. But by 2007, if current trends in spending continue, funding will be insufficient to finance a response that is “comprehensive in both scope and coverage,” according to the report.

Achieving the targets specified in the declaration, including rapid expansion of HIV prevention, care, treatment, and impact alleviation programs, will require immediate government action and substantial increases in funding.

“We are seeing real signs of progress in tackling AIDS at the community level, but it is still not enough,” Secretary-General Annan said at the press briefing. “It is time for governments to translate commitment into concrete action.”

Dr. Piot agreed, adding that access to prevention and treatment must be expanded. As of December, only 12% of those requiring antiretroviral therapy were receiving it.

The HIV/AIDS epidemic can be controlled but only with intensified global attention in the form of funding and leadership, United Nations officials and AIDS experts said in response to a status report by U.N. Secretary-General Kofi Annan.

The threat of HIV/AIDS requires the kind of attention being paid to other major concerns such as global security, Peter Piot, M.D., executive director of the Joint United Nations Programme on HIV/AIDS, said at a press briefing on the new report, which was prepared for a high-level U.N. ministerial gathering to assess progress on meeting goals set out in a Declaration of Commitment on HIV/AIDS. The declaration was adopted in 2001 by the U.N. General Assembly special session on HIV/AIDS.

The report states that “despite encouraging signs that the epidemic is beginning to be contained in a small but growing number of countries, the overall epidemic continues to expand, with much of the world at risk of falling short of the targets set forth in the declaration.”

In 2004 there were more new infections (4.9 million) and more AIDS deaths (3.1 million) than in previous years, and as of December, an estimated 39.4 million people were living with HIV, Secretary-General Annan wrote. Furthermore, the toll of HIV/AIDS on women and girls has intensified, and many of the countries most affected are falling short of the 2005 target of reducing the level of infection in young people.

The expansion of the epidemic is outpacing the global response. About $6 billion were available in 2004 to implement comprehensive programs in 135 low- and middle-income countries, up 23% from 2003. But by 2007, if current trends in spending continue, funding will be insufficient to finance a response that is “comprehensive in both scope and coverage,” according to the report.

Achieving the targets specified in the declaration, including rapid expansion of HIV prevention, care, treatment, and impact alleviation programs, will require immediate government action and substantial increases in funding.

“We are seeing real signs of progress in tackling AIDS at the community level, but it is still not enough,” Secretary-General Annan said at the press briefing. “It is time for governments to translate commitment into concrete action.”

Dr. Piot agreed, adding that access to prevention and treatment must be expanded. As of December, only 12% of those requiring antiretroviral therapy were receiving it.

CHARLESTON, S.C. — Most ob.gyns. are ordering human papillomavirus testing for borderline Pap test results as recommended, but a substantial number are using the HPV test for nonrecommended purposes, or are ignoring other recommendations for the testing, a Centers for Disease Control and Prevention survey shows.

Current recommendations of several U.S. organizations, including the CDC, the American College of Obstetricians and Gynecologists, and the American Cancer Society, support HPV testing to help guide management in patients with Pap test results showing atypical squamous cells of undetermined significance (ASCUS). Both ACOG and the ACS also endorse HPV testing in those over 29 years old to identify infected women who might benefit from frequent follow-up Pap testing, Zsakeba Henderson, M.D., of the CDC, Atlanta, said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology. These uses for the HPV test, which tests for oncogenic HPV types, have been approved by the Food and Drug Administration, she noted.

To determine the effects of the HPV testing guidelines on clinical practice, the CDC surveyed 3,339 physicians and midlevel clinicians who provide cervical cancer screening. Respondents included 464 ob.gyns., of whom 93% reported ever using the HPV test. Of those, nearly all (99.6%) said they used it for ASCUS Pap test results as recommended. However, many were also using HPV testing for patients with Pap test results showing higher-grade lesions; 84% said they used it for atypical squamous cells results (cannot exclude high-grade squamous intraepithelial lesions); 61% said they used it for low-grade squamous intraepithelial lesions results; and 46% said they used it for high-grade squamous intraepithelial lesions results, Dr. Henderson noted.

Additionally, many of the ob.gyn. respondents used the test for nonrecommended purposes, including in patients with anogenital warts (26%), as a primary screen for HPV infection (28%), and to test for HPV in patients with other STDs (32%). Only 37% reported ordering HPV testing as an adjunct to Pap testing in women older than 29 years as recommended; as many who were using it for this purpose in the over-29 population were using it for screening in those aged 29 and younger, Dr. Henderson said. But ob.gyns. in the survey are doing better as a group, compared with other respondents, at following the recommendations, she noted.

Overall, only 59% of the 3,339 survey respondents had used the HPV test (compared with 93% of ob.gyns.), about half of those used it for guiding management of ASCUS Pap test results (compared with nearly all of the ob.gyns. using the HPV test), and only 21% used it as an adjunct to Pap testing in women over 29, compared with 37% of ob.gyns.

Nonrecommended uses in the overall survey population included testing of sexual partners of women with an STD.

CHARLESTON, S.C. — Most ob.gyns. are ordering human papillomavirus testing for borderline Pap test results as recommended, but a substantial number are using the HPV test for nonrecommended purposes, or are ignoring other recommendations for the testing, a Centers for Disease Control and Prevention survey shows.

Current recommendations of several U.S. organizations, including the CDC, the American College of Obstetricians and Gynecologists, and the American Cancer Society, support HPV testing to help guide management in patients with Pap test results showing atypical squamous cells of undetermined significance (ASCUS). Both ACOG and the ACS also endorse HPV testing in those over 29 years old to identify infected women who might benefit from frequent follow-up Pap testing, Zsakeba Henderson, M.D., of the CDC, Atlanta, said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology. These uses for the HPV test, which tests for oncogenic HPV types, have been approved by the Food and Drug Administration, she noted.

To determine the effects of the HPV testing guidelines on clinical practice, the CDC surveyed 3,339 physicians and midlevel clinicians who provide cervical cancer screening. Respondents included 464 ob.gyns., of whom 93% reported ever using the HPV test. Of those, nearly all (99.6%) said they used it for ASCUS Pap test results as recommended. However, many were also using HPV testing for patients with Pap test results showing higher-grade lesions; 84% said they used it for atypical squamous cells results (cannot exclude high-grade squamous intraepithelial lesions); 61% said they used it for low-grade squamous intraepithelial lesions results; and 46% said they used it for high-grade squamous intraepithelial lesions results, Dr. Henderson noted.

Additionally, many of the ob.gyn. respondents used the test for nonrecommended purposes, including in patients with anogenital warts (26%), as a primary screen for HPV infection (28%), and to test for HPV in patients with other STDs (32%). Only 37% reported ordering HPV testing as an adjunct to Pap testing in women older than 29 years as recommended; as many who were using it for this purpose in the over-29 population were using it for screening in those aged 29 and younger, Dr. Henderson said. But ob.gyns. in the survey are doing better as a group, compared with other respondents, at following the recommendations, she noted.

Overall, only 59% of the 3,339 survey respondents had used the HPV test (compared with 93% of ob.gyns.), about half of those used it for guiding management of ASCUS Pap test results (compared with nearly all of the ob.gyns. using the HPV test), and only 21% used it as an adjunct to Pap testing in women over 29, compared with 37% of ob.gyns.

Nonrecommended uses in the overall survey population included testing of sexual partners of women with an STD.

CHARLESTON, S.C. — Most ob.gyns. are ordering human papillomavirus testing for borderline Pap test results as recommended, but a substantial number are using the HPV test for nonrecommended purposes, or are ignoring other recommendations for the testing, a Centers for Disease Control and Prevention survey shows.

Current recommendations of several U.S. organizations, including the CDC, the American College of Obstetricians and Gynecologists, and the American Cancer Society, support HPV testing to help guide management in patients with Pap test results showing atypical squamous cells of undetermined significance (ASCUS). Both ACOG and the ACS also endorse HPV testing in those over 29 years old to identify infected women who might benefit from frequent follow-up Pap testing, Zsakeba Henderson, M.D., of the CDC, Atlanta, said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology. These uses for the HPV test, which tests for oncogenic HPV types, have been approved by the Food and Drug Administration, she noted.

To determine the effects of the HPV testing guidelines on clinical practice, the CDC surveyed 3,339 physicians and midlevel clinicians who provide cervical cancer screening. Respondents included 464 ob.gyns., of whom 93% reported ever using the HPV test. Of those, nearly all (99.6%) said they used it for ASCUS Pap test results as recommended. However, many were also using HPV testing for patients with Pap test results showing higher-grade lesions; 84% said they used it for atypical squamous cells results (cannot exclude high-grade squamous intraepithelial lesions); 61% said they used it for low-grade squamous intraepithelial lesions results; and 46% said they used it for high-grade squamous intraepithelial lesions results, Dr. Henderson noted.

Additionally, many of the ob.gyn. respondents used the test for nonrecommended purposes, including in patients with anogenital warts (26%), as a primary screen for HPV infection (28%), and to test for HPV in patients with other STDs (32%). Only 37% reported ordering HPV testing as an adjunct to Pap testing in women older than 29 years as recommended; as many who were using it for this purpose in the over-29 population were using it for screening in those aged 29 and younger, Dr. Henderson said. But ob.gyns. in the survey are doing better as a group, compared with other respondents, at following the recommendations, she noted.

Overall, only 59% of the 3,339 survey respondents had used the HPV test (compared with 93% of ob.gyns.), about half of those used it for guiding management of ASCUS Pap test results (compared with nearly all of the ob.gyns. using the HPV test), and only 21% used it as an adjunct to Pap testing in women over 29, compared with 37% of ob.gyns.

Nonrecommended uses in the overall survey population included testing of sexual partners of women with an STD.

ST. PETE BEACH, FLA. — Diclectin used for nausea and vomiting of pregnancy does not appear to affect the later neurocognitive development of children who are exposed to the drug in utero, Irena Nulman, M.D., and her colleagues at the Hospital for Sick Children, Toronto, reported at the annual meeting of the Teratology Society.

The drug, available in Canada but not in the United States at this time, has proved safe in terms of fetal dysmorphology, but its effects on the developing central nervous system have been unclear, the investigators reported in a poster presentation at the meeting.

In a prospective, randomized, double-blind study, they compared the children's neurocognitive development and measures of child behavior and language development. The study included 42 mother-child pairs exposed to nausea and vomiting of pregnancy (NVP) and diclectin, 37 pairs exposed to NVP but not to pharmacotherapy, and 25 pairs not exposed to NVP.

No significant differences were found among groups in any of these measures. Children in all groups had scores in the normal range on total indexes of IQ and on measures of temperament, behavior, and language. For example, performance IQ scores were a mean of 119.76 in the NVP/diclectin-exposed group, 111.75 in the NVP-only group, and 110.08 in the unexposed group.

NVP affects 70%–80% of pregnant women and can lead to hyperemesis gravidarum, the investigators noted.

“Exposure to diclectin does not adversely affect child long-term full-scale IQ. … When indicated, diclectin therapy should be instituted to prevent hyperemesis gravid[ar]um and improve pregnant women's life style,” they concluded.

Diclectin, manufactured by Duchesnay Inc., is a generic form of the drug Bendectin, which was marketed in the United States until 1983 when it was voluntarily withdrawn by its manufacturer, Merrell Dow Pharmaceuticals Inc., following a series of lawsuits claiming the drug caused birth defects. Although the company won every case and numerous studies have confirmed the drug's safety, the drug was never put back on the U.S. market. Duchesnay Inc. is currently attempting to gain Food and Drug Administration clearance to market diclectin in the United States.

ST. PETE BEACH, FLA. — Diclectin used for nausea and vomiting of pregnancy does not appear to affect the later neurocognitive development of children who are exposed to the drug in utero, Irena Nulman, M.D., and her colleagues at the Hospital for Sick Children, Toronto, reported at the annual meeting of the Teratology Society.

The drug, available in Canada but not in the United States at this time, has proved safe in terms of fetal dysmorphology, but its effects on the developing central nervous system have been unclear, the investigators reported in a poster presentation at the meeting.

In a prospective, randomized, double-blind study, they compared the children's neurocognitive development and measures of child behavior and language development. The study included 42 mother-child pairs exposed to nausea and vomiting of pregnancy (NVP) and diclectin, 37 pairs exposed to NVP but not to pharmacotherapy, and 25 pairs not exposed to NVP.

No significant differences were found among groups in any of these measures. Children in all groups had scores in the normal range on total indexes of IQ and on measures of temperament, behavior, and language. For example, performance IQ scores were a mean of 119.76 in the NVP/diclectin-exposed group, 111.75 in the NVP-only group, and 110.08 in the unexposed group.

NVP affects 70%–80% of pregnant women and can lead to hyperemesis gravidarum, the investigators noted.

“Exposure to diclectin does not adversely affect child long-term full-scale IQ. … When indicated, diclectin therapy should be instituted to prevent hyperemesis gravid[ar]um and improve pregnant women's life style,” they concluded.

Diclectin, manufactured by Duchesnay Inc., is a generic form of the drug Bendectin, which was marketed in the United States until 1983 when it was voluntarily withdrawn by its manufacturer, Merrell Dow Pharmaceuticals Inc., following a series of lawsuits claiming the drug caused birth defects. Although the company won every case and numerous studies have confirmed the drug's safety, the drug was never put back on the U.S. market. Duchesnay Inc. is currently attempting to gain Food and Drug Administration clearance to market diclectin in the United States.

ST. PETE BEACH, FLA. — Diclectin used for nausea and vomiting of pregnancy does not appear to affect the later neurocognitive development of children who are exposed to the drug in utero, Irena Nulman, M.D., and her colleagues at the Hospital for Sick Children, Toronto, reported at the annual meeting of the Teratology Society.

The drug, available in Canada but not in the United States at this time, has proved safe in terms of fetal dysmorphology, but its effects on the developing central nervous system have been unclear, the investigators reported in a poster presentation at the meeting.

In a prospective, randomized, double-blind study, they compared the children's neurocognitive development and measures of child behavior and language development. The study included 42 mother-child pairs exposed to nausea and vomiting of pregnancy (NVP) and diclectin, 37 pairs exposed to NVP but not to pharmacotherapy, and 25 pairs not exposed to NVP.

No significant differences were found among groups in any of these measures. Children in all groups had scores in the normal range on total indexes of IQ and on measures of temperament, behavior, and language. For example, performance IQ scores were a mean of 119.76 in the NVP/diclectin-exposed group, 111.75 in the NVP-only group, and 110.08 in the unexposed group.

NVP affects 70%–80% of pregnant women and can lead to hyperemesis gravidarum, the investigators noted.

“Exposure to diclectin does not adversely affect child long-term full-scale IQ. … When indicated, diclectin therapy should be instituted to prevent hyperemesis gravid[ar]um and improve pregnant women's life style,” they concluded.

Diclectin, manufactured by Duchesnay Inc., is a generic form of the drug Bendectin, which was marketed in the United States until 1983 when it was voluntarily withdrawn by its manufacturer, Merrell Dow Pharmaceuticals Inc., following a series of lawsuits claiming the drug caused birth defects. Although the company won every case and numerous studies have confirmed the drug's safety, the drug was never put back on the U.S. market. Duchesnay Inc. is currently attempting to gain Food and Drug Administration clearance to market diclectin in the United States.

ST. PETE BEACH, FLA. — Periconceptional exposure to oral contraceptives was not associated with increased risk of adverse fetal outcomes in a recent prospective study.

None of the 45 woman who were exposed to oral contraceptives during the periconceptional period and were followed until after delivery gave birth to an infant with congenital malformations, compared with 6 of 225 controls.

The difference in the congenital malformation rate between the exposed group and control group was not significant, according to H.K. Ahn, M.D., and colleagues of the Motherisk Program at Sungkyunkwan University, Seoul, South Korea, during a poster presentation at the annual meeting of the Teratology Society.

The groups were also similar in regard to mean gestational age at delivery (39 weeks in both groups) and birth weight (3,257g in the exposed group, and 3,268g in the controls), the investigators said.

Women who were in the exposed group took oral contraceptives that contained either combined ethinyl estradiol and progesterone, or high-dose progesterone.

Although some earlier studies suggested a link between oral contraceptive use during pregnancy and increased risk of birth defects, later studies—including the current study—have failed to reproduce these findings.

“Exposure to oral contraceptives, including high doses of progesterone … did not increase adverse fetal outcomes,” the investigators said.

ST. PETE BEACH, FLA. — Periconceptional exposure to oral contraceptives was not associated with increased risk of adverse fetal outcomes in a recent prospective study.

None of the 45 woman who were exposed to oral contraceptives during the periconceptional period and were followed until after delivery gave birth to an infant with congenital malformations, compared with 6 of 225 controls.

The difference in the congenital malformation rate between the exposed group and control group was not significant, according to H.K. Ahn, M.D., and colleagues of the Motherisk Program at Sungkyunkwan University, Seoul, South Korea, during a poster presentation at the annual meeting of the Teratology Society.

The groups were also similar in regard to mean gestational age at delivery (39 weeks in both groups) and birth weight (3,257g in the exposed group, and 3,268g in the controls), the investigators said.

Women who were in the exposed group took oral contraceptives that contained either combined ethinyl estradiol and progesterone, or high-dose progesterone.

Although some earlier studies suggested a link between oral contraceptive use during pregnancy and increased risk of birth defects, later studies—including the current study—have failed to reproduce these findings.

“Exposure to oral contraceptives, including high doses of progesterone … did not increase adverse fetal outcomes,” the investigators said.

ST. PETE BEACH, FLA. — Periconceptional exposure to oral contraceptives was not associated with increased risk of adverse fetal outcomes in a recent prospective study.

None of the 45 woman who were exposed to oral contraceptives during the periconceptional period and were followed until after delivery gave birth to an infant with congenital malformations, compared with 6 of 225 controls.

The difference in the congenital malformation rate between the exposed group and control group was not significant, according to H.K. Ahn, M.D., and colleagues of the Motherisk Program at Sungkyunkwan University, Seoul, South Korea, during a poster presentation at the annual meeting of the Teratology Society.

The groups were also similar in regard to mean gestational age at delivery (39 weeks in both groups) and birth weight (3,257g in the exposed group, and 3,268g in the controls), the investigators said.

Women who were in the exposed group took oral contraceptives that contained either combined ethinyl estradiol and progesterone, or high-dose progesterone.

Although some earlier studies suggested a link between oral contraceptive use during pregnancy and increased risk of birth defects, later studies—including the current study—have failed to reproduce these findings.

“Exposure to oral contraceptives, including high doses of progesterone … did not increase adverse fetal outcomes,” the investigators said.

ST. PETE BEACH, FLA. — Attending a specialized clinic for pregnant women with substance use disorders helped medical students in a recent study feel more comfortable and less judgmental when working with such patients.

A total of 104 consecutive third-year students rotating on an 8-week obstetrics-gynecology clerkship were enrolled in the study and randomized to attend or not to attend the half-day clinic. Responses to a 36-item survey administered at the start of participants' clerkship and midway through the clerkship showed significant improvements in the comfort level of clinic attendees in regard to talking with patients about smoking, alcohol use, and other substance use, William A. Ramirez-Cacho, M.D., of the University of New Mexico, Albuquerque, and colleagues reported in a poster that was presented during the annual meeting of the Teratology Society.

The responses also demonstrated that the clinic attendees were significantly less judgmental of patients with substance use disorders and significantly more aware of multidisciplinary therapy approaches for treatment.

Control students' survey responses indicated a significant decline in comfort level when it came to discussing patients' habits, and a significant decline in awareness regarding how common substance use disorders are in this population, the investigators noted.

ST. PETE BEACH, FLA. — Attending a specialized clinic for pregnant women with substance use disorders helped medical students in a recent study feel more comfortable and less judgmental when working with such patients.

A total of 104 consecutive third-year students rotating on an 8-week obstetrics-gynecology clerkship were enrolled in the study and randomized to attend or not to attend the half-day clinic. Responses to a 36-item survey administered at the start of participants' clerkship and midway through the clerkship showed significant improvements in the comfort level of clinic attendees in regard to talking with patients about smoking, alcohol use, and other substance use, William A. Ramirez-Cacho, M.D., of the University of New Mexico, Albuquerque, and colleagues reported in a poster that was presented during the annual meeting of the Teratology Society.

The responses also demonstrated that the clinic attendees were significantly less judgmental of patients with substance use disorders and significantly more aware of multidisciplinary therapy approaches for treatment.

Control students' survey responses indicated a significant decline in comfort level when it came to discussing patients' habits, and a significant decline in awareness regarding how common substance use disorders are in this population, the investigators noted.

ST. PETE BEACH, FLA. — Attending a specialized clinic for pregnant women with substance use disorders helped medical students in a recent study feel more comfortable and less judgmental when working with such patients.

A total of 104 consecutive third-year students rotating on an 8-week obstetrics-gynecology clerkship were enrolled in the study and randomized to attend or not to attend the half-day clinic. Responses to a 36-item survey administered at the start of participants' clerkship and midway through the clerkship showed significant improvements in the comfort level of clinic attendees in regard to talking with patients about smoking, alcohol use, and other substance use, William A. Ramirez-Cacho, M.D., of the University of New Mexico, Albuquerque, and colleagues reported in a poster that was presented during the annual meeting of the Teratology Society.

The responses also demonstrated that the clinic attendees were significantly less judgmental of patients with substance use disorders and significantly more aware of multidisciplinary therapy approaches for treatment.

Control students' survey responses indicated a significant decline in comfort level when it came to discussing patients' habits, and a significant decline in awareness regarding how common substance use disorders are in this population, the investigators noted.