Sharon Worcester

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. who participated in the survey are doing better as a group, compared with other survey respondents, in regard to following the recommendations, she noted.

Overall, only 59% of the 3,339 survey respondents had ever 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, as an alternative to Pap testing, and upon request of the patient to determine HPV status.

The CDC is using the survey findings to develop clinical training programs, decision support materials, and patient education materials, Dr. Henderson said.

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. who participated in the survey are doing better as a group, compared with other survey respondents, in regard to following the recommendations, she noted.

Overall, only 59% of the 3,339 survey respondents had ever 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, as an alternative to Pap testing, and upon request of the patient to determine HPV status.

The CDC is using the survey findings to develop clinical training programs, decision support materials, and patient education materials, Dr. Henderson said.

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. who participated in the survey are doing better as a group, compared with other survey respondents, in regard to following the recommendations, she noted.

Overall, only 59% of the 3,339 survey respondents had ever 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, as an alternative to Pap testing, and upon request of the patient to determine HPV status.

The CDC is using the survey findings to develop clinical training programs, decision support materials, and patient education materials, Dr. Henderson said.

NEW ORLEANS — The interval between sexual debut and initiation of gynecologic health care was substantial in a recent study of urban adolescent girls, but access to confidential care predicted more timely gynecologic care, M. Diane McKee, M.D., reported at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

More than 800 high school girls participated in the anonymous, self-administered, computer-based survey. Nearly 45% reported that they were at some point sexually active, and of these, 45% had received gynecologic care, which for the purposes of this study was defined as a pelvic examination.

The mean interval between sexual debut and gynecologic care was 11 months, but the range was 6 months before sexual debut up to 6 years after sexual debut. Only about 4% had a pelvic examination before sexual debut, and for the remaining sexually active girls, a negative consequence (such as pregnancy or a sexually transmitted infection) was strongly associated with seeking care. The interval between sexual debut and gynecologic care was more than 2 years when no negative consequence occurred and slightly more than 1 year when such a consequence did occur.

“Gynecologic care in adolescents is largely reactive,” said Dr. McKee of Albert Einstein College of Medicine, New York.

After negative consequences were controlled for, three other factors emerged as predictors of the interval between sexual debut and gynecologic care: access to confidential care (odds ratio 3.1), high self-efficacy for accessing confidential care (odds ratio 2.1), and disclosure of sexual activity to any clinician (odds ratio 1.7).

Confidential care was defined as having at least part of routine visits conducted without parents present. In the absence of these factors, the median interval between sexual debut and gynecologic care was approximately 3 years.

Only 52% said they received safe sex counseling. Of the 45% of respondents who were sexually active, only 27% had informed any clinician of that fact.

More than 25% of the sexually active girls had been pregnant or had a sexually transmitted infection in the past year.

NEW ORLEANS — The interval between sexual debut and initiation of gynecologic health care was substantial in a recent study of urban adolescent girls, but access to confidential care predicted more timely gynecologic care, M. Diane McKee, M.D., reported at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

More than 800 high school girls participated in the anonymous, self-administered, computer-based survey. Nearly 45% reported that they were at some point sexually active, and of these, 45% had received gynecologic care, which for the purposes of this study was defined as a pelvic examination.

The mean interval between sexual debut and gynecologic care was 11 months, but the range was 6 months before sexual debut up to 6 years after sexual debut. Only about 4% had a pelvic examination before sexual debut, and for the remaining sexually active girls, a negative consequence (such as pregnancy or a sexually transmitted infection) was strongly associated with seeking care. The interval between sexual debut and gynecologic care was more than 2 years when no negative consequence occurred and slightly more than 1 year when such a consequence did occur.

“Gynecologic care in adolescents is largely reactive,” said Dr. McKee of Albert Einstein College of Medicine, New York.

After negative consequences were controlled for, three other factors emerged as predictors of the interval between sexual debut and gynecologic care: access to confidential care (odds ratio 3.1), high self-efficacy for accessing confidential care (odds ratio 2.1), and disclosure of sexual activity to any clinician (odds ratio 1.7).

Confidential care was defined as having at least part of routine visits conducted without parents present. In the absence of these factors, the median interval between sexual debut and gynecologic care was approximately 3 years.

Only 52% said they received safe sex counseling. Of the 45% of respondents who were sexually active, only 27% had informed any clinician of that fact.

More than 25% of the sexually active girls had been pregnant or had a sexually transmitted infection in the past year.

NEW ORLEANS — The interval between sexual debut and initiation of gynecologic health care was substantial in a recent study of urban adolescent girls, but access to confidential care predicted more timely gynecologic care, M. Diane McKee, M.D., reported at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

More than 800 high school girls participated in the anonymous, self-administered, computer-based survey. Nearly 45% reported that they were at some point sexually active, and of these, 45% had received gynecologic care, which for the purposes of this study was defined as a pelvic examination.

The mean interval between sexual debut and gynecologic care was 11 months, but the range was 6 months before sexual debut up to 6 years after sexual debut. Only about 4% had a pelvic examination before sexual debut, and for the remaining sexually active girls, a negative consequence (such as pregnancy or a sexually transmitted infection) was strongly associated with seeking care. The interval between sexual debut and gynecologic care was more than 2 years when no negative consequence occurred and slightly more than 1 year when such a consequence did occur.

“Gynecologic care in adolescents is largely reactive,” said Dr. McKee of Albert Einstein College of Medicine, New York.

After negative consequences were controlled for, three other factors emerged as predictors of the interval between sexual debut and gynecologic care: access to confidential care (odds ratio 3.1), high self-efficacy for accessing confidential care (odds ratio 2.1), and disclosure of sexual activity to any clinician (odds ratio 1.7).

Confidential care was defined as having at least part of routine visits conducted without parents present. In the absence of these factors, the median interval between sexual debut and gynecologic care was approximately 3 years.

Only 52% said they received safe sex counseling. Of the 45% of respondents who were sexually active, only 27% had informed any clinician of that fact.

More than 25% of the sexually active girls had been pregnant or had a sexually transmitted infection in the past year.

BAL HARBOUR, FLA. — Diaper-area psoriasis, also known as napkin psoriasis, is a fairly common finding in children, Amy Paller, M.D., said at the annual Masters of Pediatrics conference sponsored by the University of Miami.

Although inclusion of this “rash” in the realm of psoriasis has been controversial, Dr. Paller said she “truly believes” it should be considered a psoriatic condition.

About 13% of children present with napkin psoriasis with dissemination; about 4% present with localized disease. The frequency of this condition in infants reflects the Koebner phenomenon—a response to the constant trauma to the skin that is a consequence of exposure to stool and urine.

It can be difficult to distinguish napkin psoriasis from seborrheic dermatitis, but there are certain characteristics that can help, said Dr. Paller, professor and chair of dermatology at Northwestern University, Chicago.

Plaques associated with napkin psoriasis are sharply defined, brightly erythematous, and larger than those in seborrheic dermatitis. They also tend to have drier scale, which in the diaper area often can be seen only when the skin is scratched.

This is caused by the constant moisture in the area, which also can obscure diagnosis in some cases, Dr. Paller noted.

For treatment, she uses a short course (about 3 weeks) of nonhalogenated topical steroid or topical calcineurin inhibitor and a lot of protective paste.

BAL HARBOUR, FLA. — Diaper-area psoriasis, also known as napkin psoriasis, is a fairly common finding in children, Amy Paller, M.D., said at the annual Masters of Pediatrics conference sponsored by the University of Miami.

Although inclusion of this “rash” in the realm of psoriasis has been controversial, Dr. Paller said she “truly believes” it should be considered a psoriatic condition.

About 13% of children present with napkin psoriasis with dissemination; about 4% present with localized disease. The frequency of this condition in infants reflects the Koebner phenomenon—a response to the constant trauma to the skin that is a consequence of exposure to stool and urine.

It can be difficult to distinguish napkin psoriasis from seborrheic dermatitis, but there are certain characteristics that can help, said Dr. Paller, professor and chair of dermatology at Northwestern University, Chicago.

Plaques associated with napkin psoriasis are sharply defined, brightly erythematous, and larger than those in seborrheic dermatitis. They also tend to have drier scale, which in the diaper area often can be seen only when the skin is scratched.

This is caused by the constant moisture in the area, which also can obscure diagnosis in some cases, Dr. Paller noted.

For treatment, she uses a short course (about 3 weeks) of nonhalogenated topical steroid or topical calcineurin inhibitor and a lot of protective paste.

BAL HARBOUR, FLA. — Diaper-area psoriasis, also known as napkin psoriasis, is a fairly common finding in children, Amy Paller, M.D., said at the annual Masters of Pediatrics conference sponsored by the University of Miami.

Although inclusion of this “rash” in the realm of psoriasis has been controversial, Dr. Paller said she “truly believes” it should be considered a psoriatic condition.

About 13% of children present with napkin psoriasis with dissemination; about 4% present with localized disease. The frequency of this condition in infants reflects the Koebner phenomenon—a response to the constant trauma to the skin that is a consequence of exposure to stool and urine.

It can be difficult to distinguish napkin psoriasis from seborrheic dermatitis, but there are certain characteristics that can help, said Dr. Paller, professor and chair of dermatology at Northwestern University, Chicago.

Plaques associated with napkin psoriasis are sharply defined, brightly erythematous, and larger than those in seborrheic dermatitis. They also tend to have drier scale, which in the diaper area often can be seen only when the skin is scratched.

This is caused by the constant moisture in the area, which also can obscure diagnosis in some cases, Dr. Paller noted.

For treatment, she uses a short course (about 3 weeks) of nonhalogenated topical steroid or topical calcineurin inhibitor and a lot of protective paste.

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 the need for 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% had 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 a “poster of distinction” presented at the 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.

Twenty-three 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 no longer took proton pump inhibitors and were asymptomatic and satisfied with the bands.

In the 14 months since 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 to be performed as appropriate, Dr. Fielding concluded.

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 the need for 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% had 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 a “poster of distinction” presented at the 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.

Twenty-three 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 no longer took proton pump inhibitors and were asymptomatic and satisfied with the bands.

In the 14 months since 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 to be performed as appropriate, Dr. Fielding concluded.

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 the need for 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% had 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 a “poster of distinction” presented at the 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.

Twenty-three 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 no longer took proton pump inhibitors and were asymptomatic and satisfied with the bands.

In the 14 months since 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 to be performed as appropriate, Dr. Fielding concluded.

HOLLYWOOD, FLA. — Consider performing a two-stage procedure in superobese patients undergoing weight loss surgery, Philip Schauer, M.D., advised at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons.

“These patients [those with a body mass index over 60] can be enormously difficult to operate on,” he said, explaining that challenges such as a thick abdominal wall, enlarged liver, and extensive comorbidities can extend operating time and greatly increase the risk of perioperative complications.

A two-stage procedure using a less technically difficult and less risky operation for the first stage can lead to sufficient short-term weight loss that reduces risk for the higher-risk, second-stage procedure such as gastric bypass, said Dr. Schauer, director of advanced laparoscopic and bariatric surgery at the Cleveland Clinic. For the first stage, he recommended vertical sleeve gastrectomy, which is an effective short-term weight loss procedure, or laparoscopic gastric banding. For the second stage, he recommended a Roux-en-Y gastric bypass procedure.

Weight loss after the initial procedure can reduce comorbidities and effectively downstage risk category.

Dr. Schauer reported on a series of 102 patients undergoing a two-stage weight loss procedure at the University of Pittsburgh. The patients' average age at the time of the first procedure was 50, and their BMI ranged up to 91. Each patient had an average of 10 comorbidities, and nearly half had a severe life-threatening disability. All had severe fatty liver disease.

Overall, 23 of the patients had completed the second stage as of February. Most underwent a sleeve gastrectomy followed by Roux-en-Y gastric bypass, Dr. Schauer reported.

After the first stage, average BMI dropped from 65 to the high 30s, and about 45% of excess weight was lost over 12 months. The weight loss had beneficial effects on patients and comorbidities, Dr. Schauer noted.

The rate of major complications in the first stage was 13%, which is “fairly minimal” for this very high-risk population, and the minor complication rate was 16%, he said.

All complications resolved without long-term disability. No deaths occurred.

More than half of the patients in the highest-risk category were downgraded by 1 or 2 categories, which represents a major difference in terms of operative risk at the time of the second procedure. The average number of comorbidities dropped from 10 to 6, and the vast majority of patients experienced major improvements in sleep apnea and diabetes.

Following the second-stage procedure, there were two major complications and three minor complications. None of these resulted in long-term morbidity.

The overall excess weight lost after the second stage was 60%.

The two-stage approach can transform a nonoperative candidate, who would otherwise be denied the most effective weight loss surgery, into a good candidate who has the potential to experience significant weight loss, Dr. Schauer said.

Other surgeons speaking on the topic of weight loss surgery for the superobese argued in favor of other procedures.

Emma Patterson, M.D., for example, said there are very few data on the use of sleeve gastrectomy in the two-stage procedure for the superobese, but several studies support laparoscopic gastric banding in this population.

Patients prefer gastric banding, she said, as it is more cost-effective and, according to some studies, is associated with a lower mortality (0.02% vs. 1%) and complication rate (3% vs. 10%) than gastric bypass.

At least one other study suggested that bypass surgery is less effective than gastric banding in the superobese, said Dr. Patterson, director of bariatric surgery at Oregon Health and Science University, Portland.

And Ninh T. Nguyen, M.D., argued that not all superobese patients are technically difficult to operate on, and a two-stage procedure might subject patients to an unnecessary second surgery. A Roux-en-Y bypass can be performed from the outset in carefully selected lower-risk patients, he said, noting that at least one study shows that this operation is feasible in the superobese.

Furthermore, data suggest that if you can't safely perform a laparoscopic Roux-en-Y bypass operation, then you probably can't safely perform a laparoscopic sleeve gastrectomy either, said Dr. Nguyen, chief of the division of gastrointestinal surgery, University of California Irvine Medical Center. In these patients, he recommends a staged Roux-en-Y procedure.

HOLLYWOOD, FLA. — Consider performing a two-stage procedure in superobese patients undergoing weight loss surgery, Philip Schauer, M.D., advised at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons.

“These patients [those with a body mass index over 60] can be enormously difficult to operate on,” he said, explaining that challenges such as a thick abdominal wall, enlarged liver, and extensive comorbidities can extend operating time and greatly increase the risk of perioperative complications.

A two-stage procedure using a less technically difficult and less risky operation for the first stage can lead to sufficient short-term weight loss that reduces risk for the higher-risk, second-stage procedure such as gastric bypass, said Dr. Schauer, director of advanced laparoscopic and bariatric surgery at the Cleveland Clinic. For the first stage, he recommended vertical sleeve gastrectomy, which is an effective short-term weight loss procedure, or laparoscopic gastric banding. For the second stage, he recommended a Roux-en-Y gastric bypass procedure.

Weight loss after the initial procedure can reduce comorbidities and effectively downstage risk category.

Dr. Schauer reported on a series of 102 patients undergoing a two-stage weight loss procedure at the University of Pittsburgh. The patients' average age at the time of the first procedure was 50, and their BMI ranged up to 91. Each patient had an average of 10 comorbidities, and nearly half had a severe life-threatening disability. All had severe fatty liver disease.

Overall, 23 of the patients had completed the second stage as of February. Most underwent a sleeve gastrectomy followed by Roux-en-Y gastric bypass, Dr. Schauer reported.

After the first stage, average BMI dropped from 65 to the high 30s, and about 45% of excess weight was lost over 12 months. The weight loss had beneficial effects on patients and comorbidities, Dr. Schauer noted.

The rate of major complications in the first stage was 13%, which is “fairly minimal” for this very high-risk population, and the minor complication rate was 16%, he said.

All complications resolved without long-term disability. No deaths occurred.

More than half of the patients in the highest-risk category were downgraded by 1 or 2 categories, which represents a major difference in terms of operative risk at the time of the second procedure. The average number of comorbidities dropped from 10 to 6, and the vast majority of patients experienced major improvements in sleep apnea and diabetes.

Following the second-stage procedure, there were two major complications and three minor complications. None of these resulted in long-term morbidity.

The overall excess weight lost after the second stage was 60%.

The two-stage approach can transform a nonoperative candidate, who would otherwise be denied the most effective weight loss surgery, into a good candidate who has the potential to experience significant weight loss, Dr. Schauer said.

Other surgeons speaking on the topic of weight loss surgery for the superobese argued in favor of other procedures.

Emma Patterson, M.D., for example, said there are very few data on the use of sleeve gastrectomy in the two-stage procedure for the superobese, but several studies support laparoscopic gastric banding in this population.

Patients prefer gastric banding, she said, as it is more cost-effective and, according to some studies, is associated with a lower mortality (0.02% vs. 1%) and complication rate (3% vs. 10%) than gastric bypass.

At least one other study suggested that bypass surgery is less effective than gastric banding in the superobese, said Dr. Patterson, director of bariatric surgery at Oregon Health and Science University, Portland.

And Ninh T. Nguyen, M.D., argued that not all superobese patients are technically difficult to operate on, and a two-stage procedure might subject patients to an unnecessary second surgery. A Roux-en-Y bypass can be performed from the outset in carefully selected lower-risk patients, he said, noting that at least one study shows that this operation is feasible in the superobese.

Furthermore, data suggest that if you can't safely perform a laparoscopic Roux-en-Y bypass operation, then you probably can't safely perform a laparoscopic sleeve gastrectomy either, said Dr. Nguyen, chief of the division of gastrointestinal surgery, University of California Irvine Medical Center. In these patients, he recommends a staged Roux-en-Y procedure.

HOLLYWOOD, FLA. — Consider performing a two-stage procedure in superobese patients undergoing weight loss surgery, Philip Schauer, M.D., advised at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons.

“These patients [those with a body mass index over 60] can be enormously difficult to operate on,” he said, explaining that challenges such as a thick abdominal wall, enlarged liver, and extensive comorbidities can extend operating time and greatly increase the risk of perioperative complications.

A two-stage procedure using a less technically difficult and less risky operation for the first stage can lead to sufficient short-term weight loss that reduces risk for the higher-risk, second-stage procedure such as gastric bypass, said Dr. Schauer, director of advanced laparoscopic and bariatric surgery at the Cleveland Clinic. For the first stage, he recommended vertical sleeve gastrectomy, which is an effective short-term weight loss procedure, or laparoscopic gastric banding. For the second stage, he recommended a Roux-en-Y gastric bypass procedure.

Weight loss after the initial procedure can reduce comorbidities and effectively downstage risk category.

Dr. Schauer reported on a series of 102 patients undergoing a two-stage weight loss procedure at the University of Pittsburgh. The patients' average age at the time of the first procedure was 50, and their BMI ranged up to 91. Each patient had an average of 10 comorbidities, and nearly half had a severe life-threatening disability. All had severe fatty liver disease.

Overall, 23 of the patients had completed the second stage as of February. Most underwent a sleeve gastrectomy followed by Roux-en-Y gastric bypass, Dr. Schauer reported.

After the first stage, average BMI dropped from 65 to the high 30s, and about 45% of excess weight was lost over 12 months. The weight loss had beneficial effects on patients and comorbidities, Dr. Schauer noted.

The rate of major complications in the first stage was 13%, which is “fairly minimal” for this very high-risk population, and the minor complication rate was 16%, he said.

All complications resolved without long-term disability. No deaths occurred.

More than half of the patients in the highest-risk category were downgraded by 1 or 2 categories, which represents a major difference in terms of operative risk at the time of the second procedure. The average number of comorbidities dropped from 10 to 6, and the vast majority of patients experienced major improvements in sleep apnea and diabetes.

Following the second-stage procedure, there were two major complications and three minor complications. None of these resulted in long-term morbidity.

The overall excess weight lost after the second stage was 60%.

The two-stage approach can transform a nonoperative candidate, who would otherwise be denied the most effective weight loss surgery, into a good candidate who has the potential to experience significant weight loss, Dr. Schauer said.

Other surgeons speaking on the topic of weight loss surgery for the superobese argued in favor of other procedures.

Emma Patterson, M.D., for example, said there are very few data on the use of sleeve gastrectomy in the two-stage procedure for the superobese, but several studies support laparoscopic gastric banding in this population.

Patients prefer gastric banding, she said, as it is more cost-effective and, according to some studies, is associated with a lower mortality (0.02% vs. 1%) and complication rate (3% vs. 10%) than gastric bypass.

At least one other study suggested that bypass surgery is less effective than gastric banding in the superobese, said Dr. Patterson, director of bariatric surgery at Oregon Health and Science University, Portland.

And Ninh T. Nguyen, M.D., argued that not all superobese patients are technically difficult to operate on, and a two-stage procedure might subject patients to an unnecessary second surgery. A Roux-en-Y bypass can be performed from the outset in carefully selected lower-risk patients, he said, noting that at least one study shows that this operation is feasible in the superobese.

Furthermore, data suggest that if you can't safely perform a laparoscopic Roux-en-Y bypass operation, then you probably can't safely perform a laparoscopic sleeve gastrectomy either, said Dr. Nguyen, chief of the division of gastrointestinal surgery, University of California Irvine Medical Center. In these patients, he recommends a staged Roux-en-Y procedure.

TB in Thai Immigrants

Tuberculosis is the most frequently diagnosed illness in immigrants who apply for permanent U.S. residence, but enhanced screening may reduce the number of cases, according to the Centers for Disease Control and Prevention.

From June 2004 to January 2005, 37 TB cases—including 4 multidrug-resistant cases—were identified among 9,459 Thai refugees. Standard screening had included history, physical exam, and a chest radiograph for those aged 15 years or older; in May 2004, mycobacterial culture and drug-susceptibility testing were added. In January 2005, the cases prompted a 1-month travel suspension and further enhancement of the screening and control process. As of February 2005, those aged at least 6 months underwent chest radiographs and those aged 6 months to 10 years underwent skin testing (MMWR 2005;54:741–4).

None of the approximately 3,500 refugees who arrived after implementation of the new algorithm, was diagnosed with TB after arrival.

The Iraq Infection

An outbreak of Acinetobacter infection that appears to have originated in Iraq has affected nearly 300 people, mostly returning soldiers, according to the International Society for Infectious Diseases.

Many of the soldiers contracted the potentially deadly drug-resistant illness while in the hospital with others who were infected or who had Acinetobacter on their skin, the society reported on its disease-outbreak-report Web site (

ProMED-mail.org/pls/pm/pm?an=20050803.2248

In an effort to contain the outbreak, hospitals are assuming that patients from the battlefield are infected until proven otherwise. A Navy hospital reported that 10% of 396 patients treated there were infected, and another 20% were carriers—that is, they had the bacteria on their skin but were not infected. Army hospitals have reported another 240 infections and 500 carriers.

HAART Outcomes

Highly active antiretroviral therapy works.

That is the finding of the first randomized, placebo-controlled trial evaluating the long-term effectiveness of HAART. Most trials have used surrogate end points over short periods to estimate treatment effects. Jonathan A.C. Sterne, Ph.D., of the University of Bristol, England, and his colleagues used a novel methodology that eliminated some of the biases in earlier trials. They found that the use of HAART reduced the rate of progression to AIDS or death by 86% over a median of 54 months (Lancet 2005;366:378–84).

Compared with no treatment, the overall hazard ratio (HR) for HAART in the study of 3,245 patients from the Swiss HIV Cohort Study was 0.14; compared with dual therapy, it was 0.49. Over time, treatment became more beneficial, but this was less true in those thought to have contracted HIV through IV drug use (HR 0.27) than for those with other modes of transmission (HR 0.08).

West Nile Virus in Blood

Nucleic acid-amplification minipool testing of donated blood has been successful for preventing transfusion-transmitted West Nile virus, but targeted testing of individual donations in regions with a high disease prevalence is warranted, based on two recent studies involving testing of about 7 million blood units.

In one study, 183 viremic donations were detected in 677,603 donations screened by minipool testing of 16 units per pool. Retrospective individual testing of 23,088 of the initially negative donations, which came from high-prevalence regions, yielded 30 more positive units. Another 17 viremic units were detected using prospective screening of individual donations later in that 2003 season, Michael P. Busch, M.D., of the Blood Systems Research Institute in San Francisco and his colleagues reported. In 2004, prospective testing of individual donations in high-prevalence regions resulted in a 32% incremental yield of units that would have been missed by minipool testing (N. Engl. J. Med. 2005;353:460–7).

In another study during the same time periods, routine screening identified 540 WNV-positive donations, of which 362 were most likely infectious. Of the 362, 148 were detectable only by individual donation testing, and 10% of the 148 were most likely infectious, Susan L. Stramer, Ph.D., of the American Red Cross, Gaithersburg, Md., and her colleagues reported (N. Engl. J. Med. 2005;353:451–9).

No known cases of transfusion-transmitted infection occurred among recipients of tested blood during the study period. That success is attributable to rapid implementation of the nucleic acid-amplification testing method in 2003, the investigators said, noting that the testing identified 519 donors positive for WNV RNA, and led to removal of more than 1,000 potentially infectious blood components from the blood supply.

TB in Thai Immigrants

Tuberculosis is the most frequently diagnosed illness in immigrants who apply for permanent U.S. residence, but enhanced screening may reduce the number of cases, according to the Centers for Disease Control and Prevention.

From June 2004 to January 2005, 37 TB cases—including 4 multidrug-resistant cases—were identified among 9,459 Thai refugees. Standard screening had included history, physical exam, and a chest radiograph for those aged 15 years or older; in May 2004, mycobacterial culture and drug-susceptibility testing were added. In January 2005, the cases prompted a 1-month travel suspension and further enhancement of the screening and control process. As of February 2005, those aged at least 6 months underwent chest radiographs and those aged 6 months to 10 years underwent skin testing (MMWR 2005;54:741–4).

None of the approximately 3,500 refugees who arrived after implementation of the new algorithm, was diagnosed with TB after arrival.

The Iraq Infection

An outbreak of Acinetobacter infection that appears to have originated in Iraq has affected nearly 300 people, mostly returning soldiers, according to the International Society for Infectious Diseases.

Many of the soldiers contracted the potentially deadly drug-resistant illness while in the hospital with others who were infected or who had Acinetobacter on their skin, the society reported on its disease-outbreak-report Web site (

ProMED-mail.org/pls/pm/pm?an=20050803.2248

In an effort to contain the outbreak, hospitals are assuming that patients from the battlefield are infected until proven otherwise. A Navy hospital reported that 10% of 396 patients treated there were infected, and another 20% were carriers—that is, they had the bacteria on their skin but were not infected. Army hospitals have reported another 240 infections and 500 carriers.

HAART Outcomes

Highly active antiretroviral therapy works.

That is the finding of the first randomized, placebo-controlled trial evaluating the long-term effectiveness of HAART. Most trials have used surrogate end points over short periods to estimate treatment effects. Jonathan A.C. Sterne, Ph.D., of the University of Bristol, England, and his colleagues used a novel methodology that eliminated some of the biases in earlier trials. They found that the use of HAART reduced the rate of progression to AIDS or death by 86% over a median of 54 months (Lancet 2005;366:378–84).

Compared with no treatment, the overall hazard ratio (HR) for HAART in the study of 3,245 patients from the Swiss HIV Cohort Study was 0.14; compared with dual therapy, it was 0.49. Over time, treatment became more beneficial, but this was less true in those thought to have contracted HIV through IV drug use (HR 0.27) than for those with other modes of transmission (HR 0.08).

West Nile Virus in Blood

Nucleic acid-amplification minipool testing of donated blood has been successful for preventing transfusion-transmitted West Nile virus, but targeted testing of individual donations in regions with a high disease prevalence is warranted, based on two recent studies involving testing of about 7 million blood units.

In one study, 183 viremic donations were detected in 677,603 donations screened by minipool testing of 16 units per pool. Retrospective individual testing of 23,088 of the initially negative donations, which came from high-prevalence regions, yielded 30 more positive units. Another 17 viremic units were detected using prospective screening of individual donations later in that 2003 season, Michael P. Busch, M.D., of the Blood Systems Research Institute in San Francisco and his colleagues reported. In 2004, prospective testing of individual donations in high-prevalence regions resulted in a 32% incremental yield of units that would have been missed by minipool testing (N. Engl. J. Med. 2005;353:460–7).

In another study during the same time periods, routine screening identified 540 WNV-positive donations, of which 362 were most likely infectious. Of the 362, 148 were detectable only by individual donation testing, and 10% of the 148 were most likely infectious, Susan L. Stramer, Ph.D., of the American Red Cross, Gaithersburg, Md., and her colleagues reported (N. Engl. J. Med. 2005;353:451–9).

No known cases of transfusion-transmitted infection occurred among recipients of tested blood during the study period. That success is attributable to rapid implementation of the nucleic acid-amplification testing method in 2003, the investigators said, noting that the testing identified 519 donors positive for WNV RNA, and led to removal of more than 1,000 potentially infectious blood components from the blood supply.

TB in Thai Immigrants

Tuberculosis is the most frequently diagnosed illness in immigrants who apply for permanent U.S. residence, but enhanced screening may reduce the number of cases, according to the Centers for Disease Control and Prevention.

From June 2004 to January 2005, 37 TB cases—including 4 multidrug-resistant cases—were identified among 9,459 Thai refugees. Standard screening had included history, physical exam, and a chest radiograph for those aged 15 years or older; in May 2004, mycobacterial culture and drug-susceptibility testing were added. In January 2005, the cases prompted a 1-month travel suspension and further enhancement of the screening and control process. As of February 2005, those aged at least 6 months underwent chest radiographs and those aged 6 months to 10 years underwent skin testing (MMWR 2005;54:741–4).

None of the approximately 3,500 refugees who arrived after implementation of the new algorithm, was diagnosed with TB after arrival.

The Iraq Infection

An outbreak of Acinetobacter infection that appears to have originated in Iraq has affected nearly 300 people, mostly returning soldiers, according to the International Society for Infectious Diseases.

Many of the soldiers contracted the potentially deadly drug-resistant illness while in the hospital with others who were infected or who had Acinetobacter on their skin, the society reported on its disease-outbreak-report Web site (

ProMED-mail.org/pls/pm/pm?an=20050803.2248

In an effort to contain the outbreak, hospitals are assuming that patients from the battlefield are infected until proven otherwise. A Navy hospital reported that 10% of 396 patients treated there were infected, and another 20% were carriers—that is, they had the bacteria on their skin but were not infected. Army hospitals have reported another 240 infections and 500 carriers.

HAART Outcomes

Highly active antiretroviral therapy works.

That is the finding of the first randomized, placebo-controlled trial evaluating the long-term effectiveness of HAART. Most trials have used surrogate end points over short periods to estimate treatment effects. Jonathan A.C. Sterne, Ph.D., of the University of Bristol, England, and his colleagues used a novel methodology that eliminated some of the biases in earlier trials. They found that the use of HAART reduced the rate of progression to AIDS or death by 86% over a median of 54 months (Lancet 2005;366:378–84).

Compared with no treatment, the overall hazard ratio (HR) for HAART in the study of 3,245 patients from the Swiss HIV Cohort Study was 0.14; compared with dual therapy, it was 0.49. Over time, treatment became more beneficial, but this was less true in those thought to have contracted HIV through IV drug use (HR 0.27) than for those with other modes of transmission (HR 0.08).

West Nile Virus in Blood

Nucleic acid-amplification minipool testing of donated blood has been successful for preventing transfusion-transmitted West Nile virus, but targeted testing of individual donations in regions with a high disease prevalence is warranted, based on two recent studies involving testing of about 7 million blood units.

In one study, 183 viremic donations were detected in 677,603 donations screened by minipool testing of 16 units per pool. Retrospective individual testing of 23,088 of the initially negative donations, which came from high-prevalence regions, yielded 30 more positive units. Another 17 viremic units were detected using prospective screening of individual donations later in that 2003 season, Michael P. Busch, M.D., of the Blood Systems Research Institute in San Francisco and his colleagues reported. In 2004, prospective testing of individual donations in high-prevalence regions resulted in a 32% incremental yield of units that would have been missed by minipool testing (N. Engl. J. Med. 2005;353:460–7).

In another study during the same time periods, routine screening identified 540 WNV-positive donations, of which 362 were most likely infectious. Of the 362, 148 were detectable only by individual donation testing, and 10% of the 148 were most likely infectious, Susan L. Stramer, Ph.D., of the American Red Cross, Gaithersburg, Md., and her colleagues reported (N. Engl. J. Med. 2005;353:451–9).

No known cases of transfusion-transmitted infection occurred among recipients of tested blood during the study period. That success is attributable to rapid implementation of the nucleic acid-amplification testing method in 2003, the investigators said, noting that the testing identified 519 donors positive for WNV RNA, and led to removal of more than 1,000 potentially infectious blood components from the blood supply.

ST. PETE BEACH, FLA. — Maternal infection with the Epstein-Barr virus does not appear to represent a major teratogenic risk, Meytal Avgil, M.D., reported at the annual meeting of the Teratology Society.

The herpesvirus—and the cause of infectious mononucleosis—has not been well studied in pregnancy, but in a recent prospective study, the rate of major anomalies was 5% in a group of more than 200 EBV-exposed pregnancies, and 3% in a group of nearly 1,200 controls.

The difference between groups was not statistically significant, and the rates were within the expected baseline risk for the general population, said Dr. Avgil of Hebrew University, Jerusalem.

Furthermore, the anomalies did not follow any specific pattern in the EBV group, and were similar in the two groups, she noted.

There also were no differences in the rate of live births, miscarriages, or elective terminations of pregnancy between the two groups; the median birth weight of infants was similar in both groups, ranging from about 3,200 to 3,300 g.

The median gestational age at delivery was 40 weeks in both groups.

ST. PETE BEACH, FLA. — Maternal infection with the Epstein-Barr virus does not appear to represent a major teratogenic risk, Meytal Avgil, M.D., reported at the annual meeting of the Teratology Society.

The herpesvirus—and the cause of infectious mononucleosis—has not been well studied in pregnancy, but in a recent prospective study, the rate of major anomalies was 5% in a group of more than 200 EBV-exposed pregnancies, and 3% in a group of nearly 1,200 controls.

The difference between groups was not statistically significant, and the rates were within the expected baseline risk for the general population, said Dr. Avgil of Hebrew University, Jerusalem.

Furthermore, the anomalies did not follow any specific pattern in the EBV group, and were similar in the two groups, she noted.

There also were no differences in the rate of live births, miscarriages, or elective terminations of pregnancy between the two groups; the median birth weight of infants was similar in both groups, ranging from about 3,200 to 3,300 g.

The median gestational age at delivery was 40 weeks in both groups.

ST. PETE BEACH, FLA. — Maternal infection with the Epstein-Barr virus does not appear to represent a major teratogenic risk, Meytal Avgil, M.D., reported at the annual meeting of the Teratology Society.

The herpesvirus—and the cause of infectious mononucleosis—has not been well studied in pregnancy, but in a recent prospective study, the rate of major anomalies was 5% in a group of more than 200 EBV-exposed pregnancies, and 3% in a group of nearly 1,200 controls.

The difference between groups was not statistically significant, and the rates were within the expected baseline risk for the general population, said Dr. Avgil of Hebrew University, Jerusalem.

Furthermore, the anomalies did not follow any specific pattern in the EBV group, and were similar in the two groups, she noted.

There also were no differences in the rate of live births, miscarriages, or elective terminations of pregnancy between the two groups; the median birth weight of infants was similar in both groups, ranging from about 3,200 to 3,300 g.

The median gestational age at delivery was 40 weeks in both groups.

ST. PETE BEACH, FLA. — Take time to focus specifically on wine consumption when routinely questioning pregnant patients about their use of alcohol.

That was the message in a poster on a study of alcohol consumption during pregnancy presented at the annual meeting of the Teratology Society.

The prospective, clinic-based cohort study involved 4,494 women interviewed at their first prenatal visit. Of these, 16% reported signs consistent with alcohol abuse and dependence, and half of those reported steady or binge drinking during pregnancy, reported William Rayburn, M.D., of the University of New Mexico, Albuquerque, and his colleagues.

A total of 208 women with signs of alcohol abuse or dependence completed the study, including a 1-month postpartum interview.

Wine was the beverage of choice for about 25% of participants. Those who drank wine tended to consume lower quantities of alcohol, but a high percentage (43%) of wine drinkers continued their wine drinking after becoming aware of their pregnancy. This was particularly true among older white women, who were significantly more likely than younger women and minorities to continue drinking after pregnancy awareness.

Wine is one of the most widely consumed alcoholic beverages among women of reproductive age, including those who are problem drinkers both before and after becoming aware of their pregnancy. Specifically discussing the matter of wine consumption with pregnant patients is worthwhile, the researchers said.

ST. PETE BEACH, FLA. — Take time to focus specifically on wine consumption when routinely questioning pregnant patients about their use of alcohol.

That was the message in a poster on a study of alcohol consumption during pregnancy presented at the annual meeting of the Teratology Society.

The prospective, clinic-based cohort study involved 4,494 women interviewed at their first prenatal visit. Of these, 16% reported signs consistent with alcohol abuse and dependence, and half of those reported steady or binge drinking during pregnancy, reported William Rayburn, M.D., of the University of New Mexico, Albuquerque, and his colleagues.

A total of 208 women with signs of alcohol abuse or dependence completed the study, including a 1-month postpartum interview.

Wine was the beverage of choice for about 25% of participants. Those who drank wine tended to consume lower quantities of alcohol, but a high percentage (43%) of wine drinkers continued their wine drinking after becoming aware of their pregnancy. This was particularly true among older white women, who were significantly more likely than younger women and minorities to continue drinking after pregnancy awareness.

Wine is one of the most widely consumed alcoholic beverages among women of reproductive age, including those who are problem drinkers both before and after becoming aware of their pregnancy. Specifically discussing the matter of wine consumption with pregnant patients is worthwhile, the researchers said.

ST. PETE BEACH, FLA. — Take time to focus specifically on wine consumption when routinely questioning pregnant patients about their use of alcohol.

That was the message in a poster on a study of alcohol consumption during pregnancy presented at the annual meeting of the Teratology Society.

The prospective, clinic-based cohort study involved 4,494 women interviewed at their first prenatal visit. Of these, 16% reported signs consistent with alcohol abuse and dependence, and half of those reported steady or binge drinking during pregnancy, reported William Rayburn, M.D., of the University of New Mexico, Albuquerque, and his colleagues.

A total of 208 women with signs of alcohol abuse or dependence completed the study, including a 1-month postpartum interview.

Wine was the beverage of choice for about 25% of participants. Those who drank wine tended to consume lower quantities of alcohol, but a high percentage (43%) of wine drinkers continued their wine drinking after becoming aware of their pregnancy. This was particularly true among older white women, who were significantly more likely than younger women and minorities to continue drinking after pregnancy awareness.

Wine is one of the most widely consumed alcoholic beverages among women of reproductive age, including those who are problem drinkers both before and after becoming aware of their pregnancy. Specifically discussing the matter of wine consumption with pregnant patients is worthwhile, the researchers said.

NEW ORLEANS — The interval between sexual debut and initiation of gynecologic health care was substantial in a recent study of urban adolescent girls, but access to confidential care predicted more timely gynecologic care, M. Diane McKee, M.D., reported at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

More than 800 high school girls participated in the anonymous, self-administered, computer-based survey. Nearly 45% reported that they were at some point sexually active, and of these, 45% had received gynecologic care, which for the purposes of this study was defined as a pelvic examination.

The mean interval between sexual debut and gynecologic care was 11 months, but the range was 6 months before sexual debut up to 6 years after sexual debut. Only about 4% had a pelvic examination before sexual debut, and for the remaining sexually active girls, a negative consequence (such as pregnancy or a sexually transmitted infection) was strongly associated with seeking care.

The interval between sexual debut and gynecologic care was more than 2 years when no negative consequence occurred and slightly more than 1 year when such a consequence did occur.

“Gynecologic care in adolescents is largely reactive,” said Dr. McKee of Albert Einstein College of Medicine, New York.

After negative consequences were controlled for, three other factors emerged as predictors of the interval between sexual debut and gynecologic care: access to confidential care (odds ratio 3.1), high self-efficacy for accessing confidential care (odds ratio 2.1), and disclosure of sexual activity to any clinician (odds ratio 1.7).

Confidential care was defined as having at least part of routine visits conducted without parents present.

In the absence of these factors, the median interval between sexual debut and gynecologic care was approximately 3 years.

Other findings from the survey underscore the need for better patient education. Nearly 80% of respondents said they have a regular source of care, and 60% said they had an opportunity for confidential care for at least part of their last clinical visit. But only 52% said they received safe sex counseling. Of the 45% of respondents who were sexually active, only 27% had informed any clinician of that fact.

More than 25% of the sexually active girls had been pregnant or had a sexually transmitted infection in the past year.

NEW ORLEANS — The interval between sexual debut and initiation of gynecologic health care was substantial in a recent study of urban adolescent girls, but access to confidential care predicted more timely gynecologic care, M. Diane McKee, M.D., reported at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

More than 800 high school girls participated in the anonymous, self-administered, computer-based survey. Nearly 45% reported that they were at some point sexually active, and of these, 45% had received gynecologic care, which for the purposes of this study was defined as a pelvic examination.

The mean interval between sexual debut and gynecologic care was 11 months, but the range was 6 months before sexual debut up to 6 years after sexual debut. Only about 4% had a pelvic examination before sexual debut, and for the remaining sexually active girls, a negative consequence (such as pregnancy or a sexually transmitted infection) was strongly associated with seeking care.

The interval between sexual debut and gynecologic care was more than 2 years when no negative consequence occurred and slightly more than 1 year when such a consequence did occur.

“Gynecologic care in adolescents is largely reactive,” said Dr. McKee of Albert Einstein College of Medicine, New York.

After negative consequences were controlled for, three other factors emerged as predictors of the interval between sexual debut and gynecologic care: access to confidential care (odds ratio 3.1), high self-efficacy for accessing confidential care (odds ratio 2.1), and disclosure of sexual activity to any clinician (odds ratio 1.7).

Confidential care was defined as having at least part of routine visits conducted without parents present.

In the absence of these factors, the median interval between sexual debut and gynecologic care was approximately 3 years.

Other findings from the survey underscore the need for better patient education. Nearly 80% of respondents said they have a regular source of care, and 60% said they had an opportunity for confidential care for at least part of their last clinical visit. But only 52% said they received safe sex counseling. Of the 45% of respondents who were sexually active, only 27% had informed any clinician of that fact.

More than 25% of the sexually active girls had been pregnant or had a sexually transmitted infection in the past year.

NEW ORLEANS — The interval between sexual debut and initiation of gynecologic health care was substantial in a recent study of urban adolescent girls, but access to confidential care predicted more timely gynecologic care, M. Diane McKee, M.D., reported at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

More than 800 high school girls participated in the anonymous, self-administered, computer-based survey. Nearly 45% reported that they were at some point sexually active, and of these, 45% had received gynecologic care, which for the purposes of this study was defined as a pelvic examination.

The mean interval between sexual debut and gynecologic care was 11 months, but the range was 6 months before sexual debut up to 6 years after sexual debut. Only about 4% had a pelvic examination before sexual debut, and for the remaining sexually active girls, a negative consequence (such as pregnancy or a sexually transmitted infection) was strongly associated with seeking care.

The interval between sexual debut and gynecologic care was more than 2 years when no negative consequence occurred and slightly more than 1 year when such a consequence did occur.

“Gynecologic care in adolescents is largely reactive,” said Dr. McKee of Albert Einstein College of Medicine, New York.

After negative consequences were controlled for, three other factors emerged as predictors of the interval between sexual debut and gynecologic care: access to confidential care (odds ratio 3.1), high self-efficacy for accessing confidential care (odds ratio 2.1), and disclosure of sexual activity to any clinician (odds ratio 1.7).

Confidential care was defined as having at least part of routine visits conducted without parents present.

In the absence of these factors, the median interval between sexual debut and gynecologic care was approximately 3 years.

Other findings from the survey underscore the need for better patient education. Nearly 80% of respondents said they have a regular source of care, and 60% said they had an opportunity for confidential care for at least part of their last clinical visit. But only 52% said they received safe sex counseling. Of the 45% of respondents who were sexually active, only 27% had informed any clinician of that fact.

More than 25% of the sexually active girls had been pregnant or had a sexually transmitted infection in the past year.

NEW ORLEANS — Despite the growing consensus that douching can threaten gynecologic health, the practice is not widely discouraged by health care providers, results of a small survey suggest.

Furthermore, 73% of the 57 women surveyed (all douched or had practiced douching at some point) said they had encouraged or would encourage the girl or girls they were parenting to douche, Richard Rupp, M.D., reported in a poster that was presented during the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

The women, who were recruited from a university-based teen clinic, were the mothers, grandmothers, or aunts of girls aged 11–21 years. The women ranged in age from 30 to 68 years (mean age 41 years).

More than half (53%) were African American, 28% were non-Hispanic white, 17% were Hispanic, and 2% were of other ethnicities, reported Dr. Rupp of the University of Texas, Galveston.

The women were questioned about their personal douching history, beliefs about douching, and any discussions they had or planned to have with the girls regarding the practice. Douching frequency was once every 2 months or less in 20% of respondents, once or twice each month in 66% of respondents, and at least once each week in 14% of respondents.

All except one of the 57 women had discussed or planned to discuss douching with the girl or girls they were parenting.

Only 10 of the surveyed women said a health care professional had ever discussed douching with them or the girls, and only 5 said they felt the health care professional discouraged the practice.

More than 40% of the respondents had not discussed—and had no plans for discussing—any negative aspects of douching with the girls.

The most common statements that the women made or planned to make were that douching:

▸ Helps with cleanliness/feminine hygiene (89% of respondents).

▸ Treats vaginal odor (43% of respondents).

▸ Can cause vaginal irritation (36% of respondents).

▸ May cause vaginal infections (30%).

▸ Is not reliable for birth control (27%).

▸ Is unnecessary (24%).

The mean age of girls with whom they already discussed douching was 16 years, and the mean age of the girls with whom they had not discussed douching was 14 years, Dr. Rupp noted in the poster.

The findings of this study show that adult women are an important source of information about douching for the girls they parent, and suggest that health care professionals should address the matter of douching with adult patients as their girls enter the 14- to 16-year age group, he concluded, noting that public campaigns designed to decrease douching should target the matter of intergenerational information exchange.

NEW ORLEANS — Despite the growing consensus that douching can threaten gynecologic health, the practice is not widely discouraged by health care providers, results of a small survey suggest.

Furthermore, 73% of the 57 women surveyed (all douched or had practiced douching at some point) said they had encouraged or would encourage the girl or girls they were parenting to douche, Richard Rupp, M.D., reported in a poster that was presented during the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

The women, who were recruited from a university-based teen clinic, were the mothers, grandmothers, or aunts of girls aged 11–21 years. The women ranged in age from 30 to 68 years (mean age 41 years).

More than half (53%) were African American, 28% were non-Hispanic white, 17% were Hispanic, and 2% were of other ethnicities, reported Dr. Rupp of the University of Texas, Galveston.

The women were questioned about their personal douching history, beliefs about douching, and any discussions they had or planned to have with the girls regarding the practice. Douching frequency was once every 2 months or less in 20% of respondents, once or twice each month in 66% of respondents, and at least once each week in 14% of respondents.

All except one of the 57 women had discussed or planned to discuss douching with the girl or girls they were parenting.

Only 10 of the surveyed women said a health care professional had ever discussed douching with them or the girls, and only 5 said they felt the health care professional discouraged the practice.

More than 40% of the respondents had not discussed—and had no plans for discussing—any negative aspects of douching with the girls.

The most common statements that the women made or planned to make were that douching:

▸ Helps with cleanliness/feminine hygiene (89% of respondents).

▸ Treats vaginal odor (43% of respondents).

▸ Can cause vaginal irritation (36% of respondents).

▸ May cause vaginal infections (30%).

▸ Is not reliable for birth control (27%).

▸ Is unnecessary (24%).

The mean age of girls with whom they already discussed douching was 16 years, and the mean age of the girls with whom they had not discussed douching was 14 years, Dr. Rupp noted in the poster.

The findings of this study show that adult women are an important source of information about douching for the girls they parent, and suggest that health care professionals should address the matter of douching with adult patients as their girls enter the 14- to 16-year age group, he concluded, noting that public campaigns designed to decrease douching should target the matter of intergenerational information exchange.

NEW ORLEANS — Despite the growing consensus that douching can threaten gynecologic health, the practice is not widely discouraged by health care providers, results of a small survey suggest.

Furthermore, 73% of the 57 women surveyed (all douched or had practiced douching at some point) said they had encouraged or would encourage the girl or girls they were parenting to douche, Richard Rupp, M.D., reported in a poster that was presented during the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

The women, who were recruited from a university-based teen clinic, were the mothers, grandmothers, or aunts of girls aged 11–21 years. The women ranged in age from 30 to 68 years (mean age 41 years).

More than half (53%) were African American, 28% were non-Hispanic white, 17% were Hispanic, and 2% were of other ethnicities, reported Dr. Rupp of the University of Texas, Galveston.

The women were questioned about their personal douching history, beliefs about douching, and any discussions they had or planned to have with the girls regarding the practice. Douching frequency was once every 2 months or less in 20% of respondents, once or twice each month in 66% of respondents, and at least once each week in 14% of respondents.

All except one of the 57 women had discussed or planned to discuss douching with the girl or girls they were parenting.

Only 10 of the surveyed women said a health care professional had ever discussed douching with them or the girls, and only 5 said they felt the health care professional discouraged the practice.

More than 40% of the respondents had not discussed—and had no plans for discussing—any negative aspects of douching with the girls.

The most common statements that the women made or planned to make were that douching:

▸ Helps with cleanliness/feminine hygiene (89% of respondents).

▸ Treats vaginal odor (43% of respondents).

▸ Can cause vaginal irritation (36% of respondents).

▸ May cause vaginal infections (30%).

▸ Is not reliable for birth control (27%).

▸ Is unnecessary (24%).

The mean age of girls with whom they already discussed douching was 16 years, and the mean age of the girls with whom they had not discussed douching was 14 years, Dr. Rupp noted in the poster.

The findings of this study show that adult women are an important source of information about douching for the girls they parent, and suggest that health care professionals should address the matter of douching with adult patients as their girls enter the 14- to 16-year age group, he concluded, noting that public campaigns designed to decrease douching should target the matter of intergenerational information exchange.