Christine Kilgore

WASHINGTON – A large proportion of female triathletes who responded to a national Web-based survey have symptoms of pelvic floor disorders, and one in four screened positive for the female athlete triad.

These findings from women in the general population, with a median age range of 35-44 years, echo findings from studies of Olympic and professional athletes, and "show that even young, thin, and otherwise healthy endurance athletes [who are not professional athletes] have pelvic floor disorders," said Dr. Johnny Yi after presenting his findings in a press conference at the scientific meetings of the American Urogynecologic Society and the International Urogynecological Association.

© Fuse/Thinkstock

Currently, "these women may not get screened because they are not believed to be in a high-risk group," said Dr. Yi, a urogynecologist in group practice in Denver.

Of 311 women who responded to the survey, 37% reported symptoms of stress urinary incontinence, and 16% reported symptoms of urgency urinary incontinence. Anal incontinence was also a problem, with 37% reporting symptoms of this condition. Pelvic organ prolapse symptoms were reported by 5%.

Most of the participants were white (90%), nonsmokers (99%), and premenopausal (80%), and had a mean body mass index of 22 kg/m². About half had borne children, almost all of them had vaginal deliveries.

The women were invited to participate through a database of nationwide triathlon interest groups and a triathlete Internet forum. The survey included the Epidemiology of Prolapse and Incontinence Questionnaire (EPIQ) and the Pelvic Girdle Pain Questionnaire (PGPQ), both of which are validated tools; the Female Athlete Triad Screening Questionnaire, which is endorsed by the National Collegiate Athletic Association; and various medical and demographic questions.

Approximately 18% of the women had pelvic girdle pain, although the mean score on the PGPQ (35.6) was relatively low. Respondents with various types of incontinence reported higher levels of pelvic girdle pain, Dr. Yi said.

Of the 75% of respondents who completed the triad questionnaire, 22% screened positive for low energy availability, 24% for menstrual irregularities, and 29% for abnormal bone strength. Eight percent screened positive for all three components of the female athlete triad, which is characterized by a hypoestrogenic state similar to menopause.

Dr. Yi said he is particularly interested in possible associations between the female athlete triad and pelvic floor disorders, and in the pelvic floor consequences of coupling high-impact, high-endurance activity with the potential for a hypoestrogenic state.

This study showed no significant association between the triad and pelvic floor disorders, but the findings emphasize that "both disorders are prevalent" and should be screened for and treated to avoid long-term sequelae and improve quality of life, he said.

Weekly training of the study participants consisted of running for a mean of 3.7 days, biking for a mean of 2.9 days, and swimming for a mean of 2.4 days. Training mileage and intensity were not associated with pelvic floor disorders. Not unexpectedly, parity was associated with a higher prevalence of stress urinary incontinence and pelvic organ prolapse.

Dr. Yi and his coinvestigators reported no disclosures.

WASHINGTON – A large proportion of female triathletes who responded to a national Web-based survey have symptoms of pelvic floor disorders, and one in four screened positive for the female athlete triad.

These findings from women in the general population, with a median age range of 35-44 years, echo findings from studies of Olympic and professional athletes, and "show that even young, thin, and otherwise healthy endurance athletes [who are not professional athletes] have pelvic floor disorders," said Dr. Johnny Yi after presenting his findings in a press conference at the scientific meetings of the American Urogynecologic Society and the International Urogynecological Association.

© Fuse/Thinkstock

Currently, "these women may not get screened because they are not believed to be in a high-risk group," said Dr. Yi, a urogynecologist in group practice in Denver.

Of 311 women who responded to the survey, 37% reported symptoms of stress urinary incontinence, and 16% reported symptoms of urgency urinary incontinence. Anal incontinence was also a problem, with 37% reporting symptoms of this condition. Pelvic organ prolapse symptoms were reported by 5%.

Most of the participants were white (90%), nonsmokers (99%), and premenopausal (80%), and had a mean body mass index of 22 kg/m². About half had borne children, almost all of them had vaginal deliveries.

The women were invited to participate through a database of nationwide triathlon interest groups and a triathlete Internet forum. The survey included the Epidemiology of Prolapse and Incontinence Questionnaire (EPIQ) and the Pelvic Girdle Pain Questionnaire (PGPQ), both of which are validated tools; the Female Athlete Triad Screening Questionnaire, which is endorsed by the National Collegiate Athletic Association; and various medical and demographic questions.

Approximately 18% of the women had pelvic girdle pain, although the mean score on the PGPQ (35.6) was relatively low. Respondents with various types of incontinence reported higher levels of pelvic girdle pain, Dr. Yi said.

Of the 75% of respondents who completed the triad questionnaire, 22% screened positive for low energy availability, 24% for menstrual irregularities, and 29% for abnormal bone strength. Eight percent screened positive for all three components of the female athlete triad, which is characterized by a hypoestrogenic state similar to menopause.

Dr. Yi said he is particularly interested in possible associations between the female athlete triad and pelvic floor disorders, and in the pelvic floor consequences of coupling high-impact, high-endurance activity with the potential for a hypoestrogenic state.

This study showed no significant association between the triad and pelvic floor disorders, but the findings emphasize that "both disorders are prevalent" and should be screened for and treated to avoid long-term sequelae and improve quality of life, he said.

Weekly training of the study participants consisted of running for a mean of 3.7 days, biking for a mean of 2.9 days, and swimming for a mean of 2.4 days. Training mileage and intensity were not associated with pelvic floor disorders. Not unexpectedly, parity was associated with a higher prevalence of stress urinary incontinence and pelvic organ prolapse.

Dr. Yi and his coinvestigators reported no disclosures.

WASHINGTON – A large proportion of female triathletes who responded to a national Web-based survey have symptoms of pelvic floor disorders, and one in four screened positive for the female athlete triad.

These findings from women in the general population, with a median age range of 35-44 years, echo findings from studies of Olympic and professional athletes, and "show that even young, thin, and otherwise healthy endurance athletes [who are not professional athletes] have pelvic floor disorders," said Dr. Johnny Yi after presenting his findings in a press conference at the scientific meetings of the American Urogynecologic Society and the International Urogynecological Association.

© Fuse/Thinkstock

Currently, "these women may not get screened because they are not believed to be in a high-risk group," said Dr. Yi, a urogynecologist in group practice in Denver.

Of 311 women who responded to the survey, 37% reported symptoms of stress urinary incontinence, and 16% reported symptoms of urgency urinary incontinence. Anal incontinence was also a problem, with 37% reporting symptoms of this condition. Pelvic organ prolapse symptoms were reported by 5%.

Most of the participants were white (90%), nonsmokers (99%), and premenopausal (80%), and had a mean body mass index of 22 kg/m². About half had borne children, almost all of them had vaginal deliveries.

The women were invited to participate through a database of nationwide triathlon interest groups and a triathlete Internet forum. The survey included the Epidemiology of Prolapse and Incontinence Questionnaire (EPIQ) and the Pelvic Girdle Pain Questionnaire (PGPQ), both of which are validated tools; the Female Athlete Triad Screening Questionnaire, which is endorsed by the National Collegiate Athletic Association; and various medical and demographic questions.

Approximately 18% of the women had pelvic girdle pain, although the mean score on the PGPQ (35.6) was relatively low. Respondents with various types of incontinence reported higher levels of pelvic girdle pain, Dr. Yi said.

Of the 75% of respondents who completed the triad questionnaire, 22% screened positive for low energy availability, 24% for menstrual irregularities, and 29% for abnormal bone strength. Eight percent screened positive for all three components of the female athlete triad, which is characterized by a hypoestrogenic state similar to menopause.

Dr. Yi said he is particularly interested in possible associations between the female athlete triad and pelvic floor disorders, and in the pelvic floor consequences of coupling high-impact, high-endurance activity with the potential for a hypoestrogenic state.

This study showed no significant association between the triad and pelvic floor disorders, but the findings emphasize that "both disorders are prevalent" and should be screened for and treated to avoid long-term sequelae and improve quality of life, he said.

Weekly training of the study participants consisted of running for a mean of 3.7 days, biking for a mean of 2.9 days, and swimming for a mean of 2.4 days. Training mileage and intensity were not associated with pelvic floor disorders. Not unexpectedly, parity was associated with a higher prevalence of stress urinary incontinence and pelvic organ prolapse.

Dr. Yi and his coinvestigators reported no disclosures.

WASHINGTON – Bowel preparation for vaginal reconstructive surgery does not affect postoperative bowel function and bowel symptoms one way or the other, according to a secondary analysis of a single-blind randomized trial examining various effects of mechanical bowel preparation.

In a primary analysis published earlier this year, investigators found no benefit to mechanical bowel preparation with regard to the operative field quality. They also found that patients who were randomized not to receive bowel preparation were more satisfied and had fewer abdominal symptoms than those who received the intervention – a clear-liquid diet and enemas (Obstet. Gynecol. 2014;123:232-8).

The new analysis, reported at the scientific meetings of the American Urogynecologic Society and the International Urogynecological Association, looked more closely at postoperative bowel habits after vaginal reconstructive surgery.

"As surgical intervention for pelvic organ prolapse increases, so does our need for knowledge of [best] perioperative management practices," said Dr. Alicia C. Ballard of the division of urogynecology and pelvic reconstructive surgery at the University of Alabama at Birmingham, where the study was conducted.

"Concerns about painful defecation and GI symptoms such as nausea and vomiting are significant concerns for women undergoing surgery," she said.

Women may be predisposed to postsurgical constipation as a result of preoperative bowel preparation (including diet), the lasting effects of anesthesia, the use of narcotics, and the surgery itself. Prior research has shown, moreover, that constipation and incomplete bowel evacuation are not uncommon preoperatively in women with pelvic organ prolapse, she noted.

The study randomized 150 women scheduled to undergo vaginal prolapse surgery with, at a minimum, a planned apical suspension and posterior compartment repair. Surgeries included other prolapse and incontinence procedures.

Women randomized to the bowel preparation group were instructed to have a clear-liquid diet and to self-administer two saline enemas in the late afternoon of the day before surgery.

Those who were randomized to receive no intervention were allowed to have a regular diet. Women in both groups were instructed to eat nothing after midnight on the day of surgery.

All study participants were instructed to complete a bowel diary for 7 days preoperatively and 14 days postoperatively. Those who completed the preoperative diary and 10 of 14 days of the postoperative diary were included in the analysis.

Of the 150 women randomized at the preoperative visit in a 1:1 fashion, 5 withdrew from the study or had surgery canceled, and 121 completed the bowel diary.

The mean time to first bowel movement after surgery was similar in the two groups: 3.3 days in the bowel prep group and 3.2 days in the control group. The groups were also similar with regard to pain, fecal urgency, and stool transit times on the day of the first postoperative bowel movement. The use of antiemetics postoperatively was similar as well (48% and 55% in the bowel prep and no-prep groups, respectively.)

Most of the 121 women – across both groups – used at least one laxative postoperatively, mainly osmotic laxatives. Women who had not received bowel preparation were more likely, however, to report daily fiber use.

"Bowel preparation ... doesn’t appear to affect the return of bowel function and other bowel symptoms postoperatively," Dr. Ballard said. Moreover, "the lack of bowel preparation doesn’t seem to impact painful defecation symptoms, and most women use some type of laxative."

The study’s exclusion criteria included colorectal cancer, inflammatory bowel disease, a history of bowel resection, neurological disorders, and symptoms of colonic inertia (fewer than three bowel movements per week). The decision to exclude patients with significant preoperative constipation was made in order to "decrease the risk of bowel dysfunction and was important for our primary outcomes," Dr. Ballard explained. "But there actually were not that many women excluded."

Dr. Ballard reported that she had no disclosures. Two of her five coinvestigators reported various relationships with St. Jude Medical and Pelvalon.

WASHINGTON – Bowel preparation for vaginal reconstructive surgery does not affect postoperative bowel function and bowel symptoms one way or the other, according to a secondary analysis of a single-blind randomized trial examining various effects of mechanical bowel preparation.

In a primary analysis published earlier this year, investigators found no benefit to mechanical bowel preparation with regard to the operative field quality. They also found that patients who were randomized not to receive bowel preparation were more satisfied and had fewer abdominal symptoms than those who received the intervention – a clear-liquid diet and enemas (Obstet. Gynecol. 2014;123:232-8).

The new analysis, reported at the scientific meetings of the American Urogynecologic Society and the International Urogynecological Association, looked more closely at postoperative bowel habits after vaginal reconstructive surgery.

"As surgical intervention for pelvic organ prolapse increases, so does our need for knowledge of [best] perioperative management practices," said Dr. Alicia C. Ballard of the division of urogynecology and pelvic reconstructive surgery at the University of Alabama at Birmingham, where the study was conducted.

"Concerns about painful defecation and GI symptoms such as nausea and vomiting are significant concerns for women undergoing surgery," she said.

Women may be predisposed to postsurgical constipation as a result of preoperative bowel preparation (including diet), the lasting effects of anesthesia, the use of narcotics, and the surgery itself. Prior research has shown, moreover, that constipation and incomplete bowel evacuation are not uncommon preoperatively in women with pelvic organ prolapse, she noted.

The study randomized 150 women scheduled to undergo vaginal prolapse surgery with, at a minimum, a planned apical suspension and posterior compartment repair. Surgeries included other prolapse and incontinence procedures.

Women randomized to the bowel preparation group were instructed to have a clear-liquid diet and to self-administer two saline enemas in the late afternoon of the day before surgery.

Those who were randomized to receive no intervention were allowed to have a regular diet. Women in both groups were instructed to eat nothing after midnight on the day of surgery.

All study participants were instructed to complete a bowel diary for 7 days preoperatively and 14 days postoperatively. Those who completed the preoperative diary and 10 of 14 days of the postoperative diary were included in the analysis.

Of the 150 women randomized at the preoperative visit in a 1:1 fashion, 5 withdrew from the study or had surgery canceled, and 121 completed the bowel diary.

The mean time to first bowel movement after surgery was similar in the two groups: 3.3 days in the bowel prep group and 3.2 days in the control group. The groups were also similar with regard to pain, fecal urgency, and stool transit times on the day of the first postoperative bowel movement. The use of antiemetics postoperatively was similar as well (48% and 55% in the bowel prep and no-prep groups, respectively.)

Most of the 121 women – across both groups – used at least one laxative postoperatively, mainly osmotic laxatives. Women who had not received bowel preparation were more likely, however, to report daily fiber use.

"Bowel preparation ... doesn’t appear to affect the return of bowel function and other bowel symptoms postoperatively," Dr. Ballard said. Moreover, "the lack of bowel preparation doesn’t seem to impact painful defecation symptoms, and most women use some type of laxative."

The study’s exclusion criteria included colorectal cancer, inflammatory bowel disease, a history of bowel resection, neurological disorders, and symptoms of colonic inertia (fewer than three bowel movements per week). The decision to exclude patients with significant preoperative constipation was made in order to "decrease the risk of bowel dysfunction and was important for our primary outcomes," Dr. Ballard explained. "But there actually were not that many women excluded."

Dr. Ballard reported that she had no disclosures. Two of her five coinvestigators reported various relationships with St. Jude Medical and Pelvalon.

WASHINGTON – Bowel preparation for vaginal reconstructive surgery does not affect postoperative bowel function and bowel symptoms one way or the other, according to a secondary analysis of a single-blind randomized trial examining various effects of mechanical bowel preparation.

In a primary analysis published earlier this year, investigators found no benefit to mechanical bowel preparation with regard to the operative field quality. They also found that patients who were randomized not to receive bowel preparation were more satisfied and had fewer abdominal symptoms than those who received the intervention – a clear-liquid diet and enemas (Obstet. Gynecol. 2014;123:232-8).

The new analysis, reported at the scientific meetings of the American Urogynecologic Society and the International Urogynecological Association, looked more closely at postoperative bowel habits after vaginal reconstructive surgery.

"As surgical intervention for pelvic organ prolapse increases, so does our need for knowledge of [best] perioperative management practices," said Dr. Alicia C. Ballard of the division of urogynecology and pelvic reconstructive surgery at the University of Alabama at Birmingham, where the study was conducted.

"Concerns about painful defecation and GI symptoms such as nausea and vomiting are significant concerns for women undergoing surgery," she said.

Women may be predisposed to postsurgical constipation as a result of preoperative bowel preparation (including diet), the lasting effects of anesthesia, the use of narcotics, and the surgery itself. Prior research has shown, moreover, that constipation and incomplete bowel evacuation are not uncommon preoperatively in women with pelvic organ prolapse, she noted.

The study randomized 150 women scheduled to undergo vaginal prolapse surgery with, at a minimum, a planned apical suspension and posterior compartment repair. Surgeries included other prolapse and incontinence procedures.

Women randomized to the bowel preparation group were instructed to have a clear-liquid diet and to self-administer two saline enemas in the late afternoon of the day before surgery.

Those who were randomized to receive no intervention were allowed to have a regular diet. Women in both groups were instructed to eat nothing after midnight on the day of surgery.

All study participants were instructed to complete a bowel diary for 7 days preoperatively and 14 days postoperatively. Those who completed the preoperative diary and 10 of 14 days of the postoperative diary were included in the analysis.

Of the 150 women randomized at the preoperative visit in a 1:1 fashion, 5 withdrew from the study or had surgery canceled, and 121 completed the bowel diary.

The mean time to first bowel movement after surgery was similar in the two groups: 3.3 days in the bowel prep group and 3.2 days in the control group. The groups were also similar with regard to pain, fecal urgency, and stool transit times on the day of the first postoperative bowel movement. The use of antiemetics postoperatively was similar as well (48% and 55% in the bowel prep and no-prep groups, respectively.)

Most of the 121 women – across both groups – used at least one laxative postoperatively, mainly osmotic laxatives. Women who had not received bowel preparation were more likely, however, to report daily fiber use.

"Bowel preparation ... doesn’t appear to affect the return of bowel function and other bowel symptoms postoperatively," Dr. Ballard said. Moreover, "the lack of bowel preparation doesn’t seem to impact painful defecation symptoms, and most women use some type of laxative."

The study’s exclusion criteria included colorectal cancer, inflammatory bowel disease, a history of bowel resection, neurological disorders, and symptoms of colonic inertia (fewer than three bowel movements per week). The decision to exclude patients with significant preoperative constipation was made in order to "decrease the risk of bowel dysfunction and was important for our primary outcomes," Dr. Ballard explained. "But there actually were not that many women excluded."

Dr. Ballard reported that she had no disclosures. Two of her five coinvestigators reported various relationships with St. Jude Medical and Pelvalon.

WASHINGTON – Women are not seeking care for even moderate to severe urinary incontinence because they have a fear of treatment and lack knowledge of the etiology of the condition and available treatment options, according to a qualitative focus group study at Kaiser Permanente Orange County (Calif.).

Embarrassment is another barrier. So are physicians themselves, said Dr. Jennifer K. Lee, a urogynecologist at Kaiser in Anaheim, Calif., who reported the findings at the annual meeting of the American Urogynecologic Society.

"Providers were mentioned (in the focus groups) to be barriers," Dr. Lee said. "Patients were either dismissed, or they were given misinformation."

By 2050, an estimated 50 million Americans will have urinary incontinence. Previous research has shown, however, that less than 50% of women with moderate incontinence seek care.

The focus group study involved 19 women – 11 who had not sought care but were found after recruitment to have moderate to severe incontinence by the Sandvik severity index, and 8 who had previous treatment or had been evaluated for urinary incontinence.

A moderator led discussions among small groups of these women, all of whom were fluent in English and most of whom (90%) had a college education or higher. The participants were of varying ethnicities, including Caucasian, Hispanic, and Asian.

A fear of medical or surgical treatment, including medication side effects and recovery time for surgery, was one of the themes to emerge. Women also said they felt embarrassed and were therefore not likely to raise the issue, particularly with time constraints in their medical visits.

There was a prevailing idea that urinary incontinence is a normal part of aging or childbearing, or that it is hereditary, and that other health issues take priority. Physicians, moreover, did not ask about the issue, and in cases in which it was mentioned, physicians were dismissive or gave misinformation, the study showed.

Dr. Lee said the barriers are significant, and that "there’s a lot of work to be done" to facilitate communication and change practices.

Leaders at Kaiser Permanente Orange County, Anaheim, Calif., plan to give physicians question prompts to incorporate into routine and primary care visits, she noted during a press conference at the meeting. "We also want to work on educational tools for the public," she said.

"There are urinary incontinence questions [for] the Medicare wellness visit, but these are for women over 65," she said. "There certainly are plenty of women under 65 who have incontinence."

Food and Drug Administration warnings about complications associated with transvaginal placement of surgical mesh did not come up in the focus group discussions, but Dr. Lee said that in her practice she has seen this controversy feed patients’ fear of incontinence and its treatment.

Study participants were recruited through e-mail research announcements and flyers, as well as more actively through the offices of urogynecology providers.

Dr. Lee said she had no disclosures to report. Her coauthors and research colleagues at the University of California, Irvine, reported numerous disclosures ranging from speakers’ bureau participation and consulting fees at Hospira and Cadence Pharmaceuticals to consultant positions with Medtronic and Boston Scientific.

WASHINGTON – Women are not seeking care for even moderate to severe urinary incontinence because they have a fear of treatment and lack knowledge of the etiology of the condition and available treatment options, according to a qualitative focus group study at Kaiser Permanente Orange County (Calif.).

Embarrassment is another barrier. So are physicians themselves, said Dr. Jennifer K. Lee, a urogynecologist at Kaiser in Anaheim, Calif., who reported the findings at the annual meeting of the American Urogynecologic Society.

"Providers were mentioned (in the focus groups) to be barriers," Dr. Lee said. "Patients were either dismissed, or they were given misinformation."

By 2050, an estimated 50 million Americans will have urinary incontinence. Previous research has shown, however, that less than 50% of women with moderate incontinence seek care.

The focus group study involved 19 women – 11 who had not sought care but were found after recruitment to have moderate to severe incontinence by the Sandvik severity index, and 8 who had previous treatment or had been evaluated for urinary incontinence.

A moderator led discussions among small groups of these women, all of whom were fluent in English and most of whom (90%) had a college education or higher. The participants were of varying ethnicities, including Caucasian, Hispanic, and Asian.

A fear of medical or surgical treatment, including medication side effects and recovery time for surgery, was one of the themes to emerge. Women also said they felt embarrassed and were therefore not likely to raise the issue, particularly with time constraints in their medical visits.

There was a prevailing idea that urinary incontinence is a normal part of aging or childbearing, or that it is hereditary, and that other health issues take priority. Physicians, moreover, did not ask about the issue, and in cases in which it was mentioned, physicians were dismissive or gave misinformation, the study showed.

Dr. Lee said the barriers are significant, and that "there’s a lot of work to be done" to facilitate communication and change practices.

Leaders at Kaiser Permanente Orange County, Anaheim, Calif., plan to give physicians question prompts to incorporate into routine and primary care visits, she noted during a press conference at the meeting. "We also want to work on educational tools for the public," she said.

"There are urinary incontinence questions [for] the Medicare wellness visit, but these are for women over 65," she said. "There certainly are plenty of women under 65 who have incontinence."

Food and Drug Administration warnings about complications associated with transvaginal placement of surgical mesh did not come up in the focus group discussions, but Dr. Lee said that in her practice she has seen this controversy feed patients’ fear of incontinence and its treatment.

Study participants were recruited through e-mail research announcements and flyers, as well as more actively through the offices of urogynecology providers.

Dr. Lee said she had no disclosures to report. Her coauthors and research colleagues at the University of California, Irvine, reported numerous disclosures ranging from speakers’ bureau participation and consulting fees at Hospira and Cadence Pharmaceuticals to consultant positions with Medtronic and Boston Scientific.

WASHINGTON – Women are not seeking care for even moderate to severe urinary incontinence because they have a fear of treatment and lack knowledge of the etiology of the condition and available treatment options, according to a qualitative focus group study at Kaiser Permanente Orange County (Calif.).

Embarrassment is another barrier. So are physicians themselves, said Dr. Jennifer K. Lee, a urogynecologist at Kaiser in Anaheim, Calif., who reported the findings at the annual meeting of the American Urogynecologic Society.

"Providers were mentioned (in the focus groups) to be barriers," Dr. Lee said. "Patients were either dismissed, or they were given misinformation."

By 2050, an estimated 50 million Americans will have urinary incontinence. Previous research has shown, however, that less than 50% of women with moderate incontinence seek care.

The focus group study involved 19 women – 11 who had not sought care but were found after recruitment to have moderate to severe incontinence by the Sandvik severity index, and 8 who had previous treatment or had been evaluated for urinary incontinence.

A moderator led discussions among small groups of these women, all of whom were fluent in English and most of whom (90%) had a college education or higher. The participants were of varying ethnicities, including Caucasian, Hispanic, and Asian.

A fear of medical or surgical treatment, including medication side effects and recovery time for surgery, was one of the themes to emerge. Women also said they felt embarrassed and were therefore not likely to raise the issue, particularly with time constraints in their medical visits.

There was a prevailing idea that urinary incontinence is a normal part of aging or childbearing, or that it is hereditary, and that other health issues take priority. Physicians, moreover, did not ask about the issue, and in cases in which it was mentioned, physicians were dismissive or gave misinformation, the study showed.

Dr. Lee said the barriers are significant, and that "there’s a lot of work to be done" to facilitate communication and change practices.

Leaders at Kaiser Permanente Orange County, Anaheim, Calif., plan to give physicians question prompts to incorporate into routine and primary care visits, she noted during a press conference at the meeting. "We also want to work on educational tools for the public," she said.

"There are urinary incontinence questions [for] the Medicare wellness visit, but these are for women over 65," she said. "There certainly are plenty of women under 65 who have incontinence."

Food and Drug Administration warnings about complications associated with transvaginal placement of surgical mesh did not come up in the focus group discussions, but Dr. Lee said that in her practice she has seen this controversy feed patients’ fear of incontinence and its treatment.

Study participants were recruited through e-mail research announcements and flyers, as well as more actively through the offices of urogynecology providers.

Dr. Lee said she had no disclosures to report. Her coauthors and research colleagues at the University of California, Irvine, reported numerous disclosures ranging from speakers’ bureau participation and consulting fees at Hospira and Cadence Pharmaceuticals to consultant positions with Medtronic and Boston Scientific.

Quality measurement for pediatric health care is accelerating – and maturing, some say – with an increasing focus among policy makers, providers, and other experts on developing common quality measures that can be used more consistently and widely and that better capture outcomes and the patient experience.

The ideas aren’t new, but current efforts may be more successful than past ones in addressing what have been unrelenting challenges. Finding quality measures that work in pediatrics is even tougher than in adult health care: Children are developing, dependent, and less often fit into neat categorical condition groups. The scientific evidence base is much weaker, and the overall goals for children in health care involve maximizing development and growth – an upward trajectory that is challenging to measure.

"The measures we use today for child and adolescent health care are mostly process measures, and it’s not always clear that these correlate with the outcomes we want to see," said Dr. David Keller, professor of pediatrics at the University of Colorado and vice chair of clinical affairs and health care transformation at Children’s Hospital Colorado, Aurora.

Increasingly, however, experts involved in measuring child and adolescent health are pursuing common and consistent quality measures that, when used more widely, will facilitate more comparison and the collection of more data to be used in looking at long-term outcomes and population impact.

"It’s mind-boggling to see all the available [pediatric] measures ... all the indices and projects out there. Yet there’s little pooled data, and no common language – especially for routine, general pediatric primary care," said Judith S. Shaw, Ed.D., M.P.H., R.N., executive director of the Vermont Child Health Improvement Program (VCHIP).

Dr. Shaw’s organization is housed at the University of Vermont, in a small state with an advanced health information infrastructure and a history of multi-insurer payment reforms that support medical homes and community health teams. VCHIP has supported and led a string of quality improvement projects over the years, but "we realized we have no longitudinal database to look at what’s transpiring across the state," she explained.

Dr. Shaw recently led a team of pediatricians and other experts from across the state in culling through almost 200 pediatric quality measures developed by the National Committee for Quality Assurance (NCQA), Bright Futures, and an array of other state and national organizations and efforts. They narrowed the list to a core set of about 40 measures that VCHIP will monitor over the long term in an attempt to bring measures in line with each other, identify gaps and areas for refinement, and more easily inform improvements in child health and health care. Chart auditors will collect data from a random sample of charts from participating practices.

Over time, Dr. Shaw hopes to pool her state’s data with data from other states. VCHIP leads and advises a network of more than 15 states with similar Improvement Partnerships (IPs), or collaborative efforts to measure and improve children’s health care. The network provides an opportunity to create the large data pools that are important for pediatrics and measurement of long-term outcomes. First, though, measures will need to be streamlined.

Dr. Shaw and her colleagues recently surveyed the IPs in 12 states and found that, of 100 primary care measures described in the survey, only 8 measures were utilized by more than one state IP. Similarly, among three states measuring asthma care, only 2 of the 14 available measures were used by all three states. "There’s not a lot of overlap in the measures that state QI projects are using," and in the big picture, this is limiting, said Dr. Shaw, also associate professor of pediatrics at the University of Vermont, Burlington.

On a national level, development of the 2013 first "core set" of children’s health care quality measures for voluntary use by Medicaid and State Children’s Health Insurance Programs was driven by the desire to "get everyone [across states] aligned and to be able to make fair comparisons of children’s health across the country," said Sarah H. Scholle, Dr.P.H., vice president of research and analysis at NCQA.

A core set of children’s health care quality measures was mandated by the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) and developed under the auspices of the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS). It is meant to be annually updated and enhanced – a 2014 version is now in use – and to be usable across different settings and by multiple stakeholders including payers, providers, and consumers. This isn’t an easy task: Many experts maintain that data can rarely be used for both accountability and quality improvement.

A CHIPRA-mandated $55-million Pediatric Quality Measures Program (PQMP) has been supporting seven Centers of Excellence in an effort to refine existing measures in both primary and specialty care and develop new ones that are more evidence based. "[Finally], there has been substantial federal investment for the design of pediatric measures to be used nationally," said Dr. Mark Schuster, who is William Berenberg professor of pediatrics at Harvard Medical School and the principal investigator for CHIPRA’s Center of Excellence for Pediatric Quality Measurement at Boston Children’s Hospital.

Thus far, it "has been hard to learn from each other ... To get a sense of what and how well your peer groups are doing," he said. "We want to be able to go to a hospital that’s consistently doing better on a certain measure and ask, ‘How are you doing this? Can you help us?’ "

Experts in quality measurement say that interest and efforts are increasingly focused on measures that address more than the structure and process of care, as well as on measures that address behavioral and mental health. The national Children’s Core Set includes three measures relating to mental and behavioral health.

NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS) measures – which comprise a large portion of the Children’s Core Set – have "provided a basic floor of measures" for various stakeholders in the health care system by looking at factors such as immunization status and whether or not children receive well-child visits, for instance, "but they don’t say anything about what happens when the child is there or" how the child fares afterwards, said Dr. Charles Homer, chief executive officer of the National Initiative for Children’s Healthcare Quality in Boston, which assists practices, hospitals, and others in using data and measurements to improve.

"You can do very well on the HEDIS measures and still not deliver the kind of care you or I would want our children to get," he said. "As part of our efforts to improve quality, we need data-driven, higher-bar measures. ... I don\'t think we’re very far from adding some of these kinds of metrics."

NCQA’s Dr. Scholle doesn’t disagree. Like Dr. Schuster, she also is serving as a principal investigator for the PQMP. One of her main areas of focus has been the development of measures on adolescent depression care. "We need to see whether adolescents [who receive depression care] are actually improving, with a reduction in symptoms over time," she said.

Also of growing importance in pediatric quality measurement is what experts call the patient or family "experiences of care." Dr. Scholle, for one, can attest to the value of such input when it comes to measuring the quality of depression care. NCQA has been incorporating measurement of the patient/ family experience in some of its HEDIS measures, and Dr. Schuster and his colleagues in Boston have been testing a family experience of care measure in pediatric hospitals across the country.

"We’re not talking about patient satisfaction – we’re talking about the experience of care and the outcomes," said Christina Bethell, Ph.D., M.B.A., M.P.H., professor of pediatrics at the Oregon Health & Science University, Portland, and founding director of the Child and Adolescent Health Measurement Initiative, which focuses on developing patient- and family-centered measures of quality.

"We can’t ask patients about what kinds of lab tests they had, but we can ask them about their behaviors and their functioning and their outcome," she said. "Is the child going to school, for instance? Sleeping well?"

Growing use of electronic medical records and other technologies – as well as financial incentives – may help support the collection of such information. And, Dr. Bethell maintains, there is a wealth of information to tap into from national surveys like the National Survey of Children’s Health that can be used to support state and regional-level measurement and quality improvement.

Overall, "we have a lot of what we need right now to" better measure the quality of children’s health and health care. "We just have to use it better," she said, adding that the main supportive pillars of good quality measurement – policy, culture, technology, and financial incentives – "are coming together." That, she said, "is what’s really changing."

Quality measurement for pediatric health care is accelerating – and maturing, some say – with an increasing focus among policy makers, providers, and other experts on developing common quality measures that can be used more consistently and widely and that better capture outcomes and the patient experience.

The ideas aren’t new, but current efforts may be more successful than past ones in addressing what have been unrelenting challenges. Finding quality measures that work in pediatrics is even tougher than in adult health care: Children are developing, dependent, and less often fit into neat categorical condition groups. The scientific evidence base is much weaker, and the overall goals for children in health care involve maximizing development and growth – an upward trajectory that is challenging to measure.

"The measures we use today for child and adolescent health care are mostly process measures, and it’s not always clear that these correlate with the outcomes we want to see," said Dr. David Keller, professor of pediatrics at the University of Colorado and vice chair of clinical affairs and health care transformation at Children’s Hospital Colorado, Aurora.

Increasingly, however, experts involved in measuring child and adolescent health are pursuing common and consistent quality measures that, when used more widely, will facilitate more comparison and the collection of more data to be used in looking at long-term outcomes and population impact.

"It’s mind-boggling to see all the available [pediatric] measures ... all the indices and projects out there. Yet there’s little pooled data, and no common language – especially for routine, general pediatric primary care," said Judith S. Shaw, Ed.D., M.P.H., R.N., executive director of the Vermont Child Health Improvement Program (VCHIP).

Dr. Shaw’s organization is housed at the University of Vermont, in a small state with an advanced health information infrastructure and a history of multi-insurer payment reforms that support medical homes and community health teams. VCHIP has supported and led a string of quality improvement projects over the years, but "we realized we have no longitudinal database to look at what’s transpiring across the state," she explained.

Dr. Shaw recently led a team of pediatricians and other experts from across the state in culling through almost 200 pediatric quality measures developed by the National Committee for Quality Assurance (NCQA), Bright Futures, and an array of other state and national organizations and efforts. They narrowed the list to a core set of about 40 measures that VCHIP will monitor over the long term in an attempt to bring measures in line with each other, identify gaps and areas for refinement, and more easily inform improvements in child health and health care. Chart auditors will collect data from a random sample of charts from participating practices.

Over time, Dr. Shaw hopes to pool her state’s data with data from other states. VCHIP leads and advises a network of more than 15 states with similar Improvement Partnerships (IPs), or collaborative efforts to measure and improve children’s health care. The network provides an opportunity to create the large data pools that are important for pediatrics and measurement of long-term outcomes. First, though, measures will need to be streamlined.

Dr. Shaw and her colleagues recently surveyed the IPs in 12 states and found that, of 100 primary care measures described in the survey, only 8 measures were utilized by more than one state IP. Similarly, among three states measuring asthma care, only 2 of the 14 available measures were used by all three states. "There’s not a lot of overlap in the measures that state QI projects are using," and in the big picture, this is limiting, said Dr. Shaw, also associate professor of pediatrics at the University of Vermont, Burlington.

On a national level, development of the 2013 first "core set" of children’s health care quality measures for voluntary use by Medicaid and State Children’s Health Insurance Programs was driven by the desire to "get everyone [across states] aligned and to be able to make fair comparisons of children’s health across the country," said Sarah H. Scholle, Dr.P.H., vice president of research and analysis at NCQA.

A core set of children’s health care quality measures was mandated by the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) and developed under the auspices of the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS). It is meant to be annually updated and enhanced – a 2014 version is now in use – and to be usable across different settings and by multiple stakeholders including payers, providers, and consumers. This isn’t an easy task: Many experts maintain that data can rarely be used for both accountability and quality improvement.

A CHIPRA-mandated $55-million Pediatric Quality Measures Program (PQMP) has been supporting seven Centers of Excellence in an effort to refine existing measures in both primary and specialty care and develop new ones that are more evidence based. "[Finally], there has been substantial federal investment for the design of pediatric measures to be used nationally," said Dr. Mark Schuster, who is William Berenberg professor of pediatrics at Harvard Medical School and the principal investigator for CHIPRA’s Center of Excellence for Pediatric Quality Measurement at Boston Children’s Hospital.

Thus far, it "has been hard to learn from each other ... To get a sense of what and how well your peer groups are doing," he said. "We want to be able to go to a hospital that’s consistently doing better on a certain measure and ask, ‘How are you doing this? Can you help us?’ "

Experts in quality measurement say that interest and efforts are increasingly focused on measures that address more than the structure and process of care, as well as on measures that address behavioral and mental health. The national Children’s Core Set includes three measures relating to mental and behavioral health.

NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS) measures – which comprise a large portion of the Children’s Core Set – have "provided a basic floor of measures" for various stakeholders in the health care system by looking at factors such as immunization status and whether or not children receive well-child visits, for instance, "but they don’t say anything about what happens when the child is there or" how the child fares afterwards, said Dr. Charles Homer, chief executive officer of the National Initiative for Children’s Healthcare Quality in Boston, which assists practices, hospitals, and others in using data and measurements to improve.

"You can do very well on the HEDIS measures and still not deliver the kind of care you or I would want our children to get," he said. "As part of our efforts to improve quality, we need data-driven, higher-bar measures. ... I don\'t think we’re very far from adding some of these kinds of metrics."

NCQA’s Dr. Scholle doesn’t disagree. Like Dr. Schuster, she also is serving as a principal investigator for the PQMP. One of her main areas of focus has been the development of measures on adolescent depression care. "We need to see whether adolescents [who receive depression care] are actually improving, with a reduction in symptoms over time," she said.

Also of growing importance in pediatric quality measurement is what experts call the patient or family "experiences of care." Dr. Scholle, for one, can attest to the value of such input when it comes to measuring the quality of depression care. NCQA has been incorporating measurement of the patient/ family experience in some of its HEDIS measures, and Dr. Schuster and his colleagues in Boston have been testing a family experience of care measure in pediatric hospitals across the country.

"We’re not talking about patient satisfaction – we’re talking about the experience of care and the outcomes," said Christina Bethell, Ph.D., M.B.A., M.P.H., professor of pediatrics at the Oregon Health & Science University, Portland, and founding director of the Child and Adolescent Health Measurement Initiative, which focuses on developing patient- and family-centered measures of quality.

"We can’t ask patients about what kinds of lab tests they had, but we can ask them about their behaviors and their functioning and their outcome," she said. "Is the child going to school, for instance? Sleeping well?"

Growing use of electronic medical records and other technologies – as well as financial incentives – may help support the collection of such information. And, Dr. Bethell maintains, there is a wealth of information to tap into from national surveys like the National Survey of Children’s Health that can be used to support state and regional-level measurement and quality improvement.

Overall, "we have a lot of what we need right now to" better measure the quality of children’s health and health care. "We just have to use it better," she said, adding that the main supportive pillars of good quality measurement – policy, culture, technology, and financial incentives – "are coming together." That, she said, "is what’s really changing."

Quality measurement for pediatric health care is accelerating – and maturing, some say – with an increasing focus among policy makers, providers, and other experts on developing common quality measures that can be used more consistently and widely and that better capture outcomes and the patient experience.

The ideas aren’t new, but current efforts may be more successful than past ones in addressing what have been unrelenting challenges. Finding quality measures that work in pediatrics is even tougher than in adult health care: Children are developing, dependent, and less often fit into neat categorical condition groups. The scientific evidence base is much weaker, and the overall goals for children in health care involve maximizing development and growth – an upward trajectory that is challenging to measure.

"The measures we use today for child and adolescent health care are mostly process measures, and it’s not always clear that these correlate with the outcomes we want to see," said Dr. David Keller, professor of pediatrics at the University of Colorado and vice chair of clinical affairs and health care transformation at Children’s Hospital Colorado, Aurora.

Increasingly, however, experts involved in measuring child and adolescent health are pursuing common and consistent quality measures that, when used more widely, will facilitate more comparison and the collection of more data to be used in looking at long-term outcomes and population impact.

"It’s mind-boggling to see all the available [pediatric] measures ... all the indices and projects out there. Yet there’s little pooled data, and no common language – especially for routine, general pediatric primary care," said Judith S. Shaw, Ed.D., M.P.H., R.N., executive director of the Vermont Child Health Improvement Program (VCHIP).

Dr. Shaw’s organization is housed at the University of Vermont, in a small state with an advanced health information infrastructure and a history of multi-insurer payment reforms that support medical homes and community health teams. VCHIP has supported and led a string of quality improvement projects over the years, but "we realized we have no longitudinal database to look at what’s transpiring across the state," she explained.

Dr. Shaw recently led a team of pediatricians and other experts from across the state in culling through almost 200 pediatric quality measures developed by the National Committee for Quality Assurance (NCQA), Bright Futures, and an array of other state and national organizations and efforts. They narrowed the list to a core set of about 40 measures that VCHIP will monitor over the long term in an attempt to bring measures in line with each other, identify gaps and areas for refinement, and more easily inform improvements in child health and health care. Chart auditors will collect data from a random sample of charts from participating practices.

Over time, Dr. Shaw hopes to pool her state’s data with data from other states. VCHIP leads and advises a network of more than 15 states with similar Improvement Partnerships (IPs), or collaborative efforts to measure and improve children’s health care. The network provides an opportunity to create the large data pools that are important for pediatrics and measurement of long-term outcomes. First, though, measures will need to be streamlined.

Dr. Shaw and her colleagues recently surveyed the IPs in 12 states and found that, of 100 primary care measures described in the survey, only 8 measures were utilized by more than one state IP. Similarly, among three states measuring asthma care, only 2 of the 14 available measures were used by all three states. "There’s not a lot of overlap in the measures that state QI projects are using," and in the big picture, this is limiting, said Dr. Shaw, also associate professor of pediatrics at the University of Vermont, Burlington.

On a national level, development of the 2013 first "core set" of children’s health care quality measures for voluntary use by Medicaid and State Children’s Health Insurance Programs was driven by the desire to "get everyone [across states] aligned and to be able to make fair comparisons of children’s health across the country," said Sarah H. Scholle, Dr.P.H., vice president of research and analysis at NCQA.

A core set of children’s health care quality measures was mandated by the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) and developed under the auspices of the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS). It is meant to be annually updated and enhanced – a 2014 version is now in use – and to be usable across different settings and by multiple stakeholders including payers, providers, and consumers. This isn’t an easy task: Many experts maintain that data can rarely be used for both accountability and quality improvement.

A CHIPRA-mandated $55-million Pediatric Quality Measures Program (PQMP) has been supporting seven Centers of Excellence in an effort to refine existing measures in both primary and specialty care and develop new ones that are more evidence based. "[Finally], there has been substantial federal investment for the design of pediatric measures to be used nationally," said Dr. Mark Schuster, who is William Berenberg professor of pediatrics at Harvard Medical School and the principal investigator for CHIPRA’s Center of Excellence for Pediatric Quality Measurement at Boston Children’s Hospital.

Thus far, it "has been hard to learn from each other ... To get a sense of what and how well your peer groups are doing," he said. "We want to be able to go to a hospital that’s consistently doing better on a certain measure and ask, ‘How are you doing this? Can you help us?’ "

Experts in quality measurement say that interest and efforts are increasingly focused on measures that address more than the structure and process of care, as well as on measures that address behavioral and mental health. The national Children’s Core Set includes three measures relating to mental and behavioral health.

NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS) measures – which comprise a large portion of the Children’s Core Set – have "provided a basic floor of measures" for various stakeholders in the health care system by looking at factors such as immunization status and whether or not children receive well-child visits, for instance, "but they don’t say anything about what happens when the child is there or" how the child fares afterwards, said Dr. Charles Homer, chief executive officer of the National Initiative for Children’s Healthcare Quality in Boston, which assists practices, hospitals, and others in using data and measurements to improve.

"You can do very well on the HEDIS measures and still not deliver the kind of care you or I would want our children to get," he said. "As part of our efforts to improve quality, we need data-driven, higher-bar measures. ... I don\'t think we’re very far from adding some of these kinds of metrics."

NCQA’s Dr. Scholle doesn’t disagree. Like Dr. Schuster, she also is serving as a principal investigator for the PQMP. One of her main areas of focus has been the development of measures on adolescent depression care. "We need to see whether adolescents [who receive depression care] are actually improving, with a reduction in symptoms over time," she said.

Also of growing importance in pediatric quality measurement is what experts call the patient or family "experiences of care." Dr. Scholle, for one, can attest to the value of such input when it comes to measuring the quality of depression care. NCQA has been incorporating measurement of the patient/ family experience in some of its HEDIS measures, and Dr. Schuster and his colleagues in Boston have been testing a family experience of care measure in pediatric hospitals across the country.

"We’re not talking about patient satisfaction – we’re talking about the experience of care and the outcomes," said Christina Bethell, Ph.D., M.B.A., M.P.H., professor of pediatrics at the Oregon Health & Science University, Portland, and founding director of the Child and Adolescent Health Measurement Initiative, which focuses on developing patient- and family-centered measures of quality.

"We can’t ask patients about what kinds of lab tests they had, but we can ask them about their behaviors and their functioning and their outcome," she said. "Is the child going to school, for instance? Sleeping well?"

Growing use of electronic medical records and other technologies – as well as financial incentives – may help support the collection of such information. And, Dr. Bethell maintains, there is a wealth of information to tap into from national surveys like the National Survey of Children’s Health that can be used to support state and regional-level measurement and quality improvement.

Overall, "we have a lot of what we need right now to" better measure the quality of children’s health and health care. "We just have to use it better," she said, adding that the main supportive pillars of good quality measurement – policy, culture, technology, and financial incentives – "are coming together." That, she said, "is what’s really changing."

WASHINGTON – The rise in gestational diabetes cases demands new strategies for active postpartum care that will not only assist with prevention of type 2 diabetes, but will also prepare women for healthy subsequent pregnancies. New approaches to postpartum care aimed at preventing gestational diabetes in subsequent pregnancies were showcased during sessions at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

The problem is a growing one, with the prevalence of gestational diabetes mellitus (GDM) pregnancies ranging from 2% to 10% depending on screening criteria and demographics/population. The prevalence could rise as high as 18% if diagnostic criteria change in the United States to implement the single-step test recommended in 2008 by the International Association of Diabetes and Pregnancy Study Groups (IADPSG) and adopted by the American Diabetes Association and the World Health Organization.

For now, most U.S. obstetricians are continuing to use the two-step approach to diagnosing GDM, following the advice of a National Institutes of Health consensus development panel and the American College of Gynecologists and Obstetricians. Some physicians, however, are lowering their diagnostic thresholds to capture more at-risk women.

And in the meantime, the prevalence of obesity continues to rise, independently increasing the number of pregnancies complicated by GDM. An estimated 50% of GDM is caused by overweight and obesity, according to Dr. Wanda K. Nicholson, director of the diabetes and obesity core at the University of North Carolina’s Center for Women's Health Research in Chapel Hill.

"We’re not even able to manage our current body of patients," she said. "If we expand this number, we’ll definitely need to develop some new strategies." Studies have also shown that approximately 50% of patients with GDM are screened after delivery for persistent glucose intolerance.

"For most of us, preconception care is increasingly about postpartum care," said Dr. Thomas R. Moore, professor and chairman of the department of reproductive medicine at the University of California, San Diego. "We have to find ways of improving our postpartum follow-up [of GDM pregnancies]."

Follow-up should include checking glycemic status, educating and counseling patients on the risks to newborns of both high maternal HbA_1c levels and maternal obesity, assisting patients with nutritional and lifestyle change, advising the use of effective contraception until conditions are right for another pregnancy, and ensuring proper folic acid supplementation before conception is attempted, he said.

For ob.gyn. practices, more GDM can mean more physician appointments, more staff dedicated to coordinating visits with physicians and educators, expanded diabetes education, and expanded nutritional counseling. "In particular, many practices will need to expand their capacity for nutritional counseling," Dr. Nicholson said. "We know from large randomized trials that even for women with mild GDM, nutritional counseling makes a difference."

The literature hints at the possible promise of using telephonic nurse management and Internet-based self-monitoring and educational tools to enhance the postpartum care of new mothers who had GDM, she said.

At the University of North Carolina, a program called the Gestational Diabetes Management System (GooDMomS) offers women video-supported lessons on GDM, a Web and mobile self-monitoring diary in which they can track their weight and record time spent exercising postpartum, as well as forums to "ask the staff" questions and to communicate with other mothers. The system, which is being pilot-tested in an NIH-funded randomized study, is meant to enhance – not replace – basic postpartum care.

In terms of postpartum testing for type 2 diabetes, a recently published literature review suggests that systematic efforts to proactively contact patients can have an impact. Programs in which patients were contacted via phone calls, mailings, and other reminders increased postpartum testing rates from an average of 33% up to 60% (Prim. Care Diabetes 2013;7:177-86).

"We can’t even begin to deliver a preconception program to women until we know what her glycemic status is," emphasized Dr. Moore.

A meta-analysis published more than a decade ago showed an overall 80% reduction in the incidence of congenital malformations in women with diabetes who received preconception care as compared to those who did not receive such care. This study has increasingly relevance today, with more than 76 million women worldwide at risk of their pregnancies being complicated by pregestational (existing) diabetes or gestational diabetes, he said.

The analysis (QJM 2001;94:435-44) also showed that "only modest reductions in HbA_1c, averaging 17%, can have a profound impact," Dr. Moore said. The patient conversation must go beyond merely recommending that HbA_1c levels be as close to normal as possible before conception is attempted, he emphasized.

A recent report from the Maryland Pregnancy Risk Assessment Monitoring System (PRAMS) shows that women with diabetes were the least likely group among women with various preconception medical problems to report contraception use (Contraception 2013;88:263-8). "They had the lowest uptake on contraception," Dr. Moore said.

An estimate of the "downstream savings" of preventing type 2 diabetes in women with GDM was factored into one of two true cost-effectiveness analyses that have been published thus far of the IADPSG criteria, according to Dr. Aaron B. Caughey, chairman of the department of obstetrics and gynecology at the Oregon Health and Science University in Portland.

Both of the two published analyses concluded that the IADPSG criteria are cost effective, but one of them concluded that the criteria would be cost effective only if post-delivery care reduces diabetes incidence (Diabetes Care 2012;35:529-35).

"The short-term costs (of the one-step approach) are easy to figure out," said Dr. Caughey, an ob.gyn and health economist who also is director of the university’s Center for Women’s Health. "The long-term costs are really tough ... we don’t know, what the impact 20 years downstream is going to be."

Providers at Oregon Health and Science University have been encouraged to adopt the one-step approach and, thus far, the change has resulted in a doubling of GDM incidence from approximately 6% to 12%, he noted.

Dr. Caughey, Dr. Moore, and Dr. Nicholson each reported that they had no conflicts of interest to disclose.

WASHINGTON – The rise in gestational diabetes cases demands new strategies for active postpartum care that will not only assist with prevention of type 2 diabetes, but will also prepare women for healthy subsequent pregnancies. New approaches to postpartum care aimed at preventing gestational diabetes in subsequent pregnancies were showcased during sessions at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

The problem is a growing one, with the prevalence of gestational diabetes mellitus (GDM) pregnancies ranging from 2% to 10% depending on screening criteria and demographics/population. The prevalence could rise as high as 18% if diagnostic criteria change in the United States to implement the single-step test recommended in 2008 by the International Association of Diabetes and Pregnancy Study Groups (IADPSG) and adopted by the American Diabetes Association and the World Health Organization.

For now, most U.S. obstetricians are continuing to use the two-step approach to diagnosing GDM, following the advice of a National Institutes of Health consensus development panel and the American College of Gynecologists and Obstetricians. Some physicians, however, are lowering their diagnostic thresholds to capture more at-risk women.

And in the meantime, the prevalence of obesity continues to rise, independently increasing the number of pregnancies complicated by GDM. An estimated 50% of GDM is caused by overweight and obesity, according to Dr. Wanda K. Nicholson, director of the diabetes and obesity core at the University of North Carolina’s Center for Women's Health Research in Chapel Hill.

"We’re not even able to manage our current body of patients," she said. "If we expand this number, we’ll definitely need to develop some new strategies." Studies have also shown that approximately 50% of patients with GDM are screened after delivery for persistent glucose intolerance.

"For most of us, preconception care is increasingly about postpartum care," said Dr. Thomas R. Moore, professor and chairman of the department of reproductive medicine at the University of California, San Diego. "We have to find ways of improving our postpartum follow-up [of GDM pregnancies]."

Follow-up should include checking glycemic status, educating and counseling patients on the risks to newborns of both high maternal HbA_1c levels and maternal obesity, assisting patients with nutritional and lifestyle change, advising the use of effective contraception until conditions are right for another pregnancy, and ensuring proper folic acid supplementation before conception is attempted, he said.

For ob.gyn. practices, more GDM can mean more physician appointments, more staff dedicated to coordinating visits with physicians and educators, expanded diabetes education, and expanded nutritional counseling. "In particular, many practices will need to expand their capacity for nutritional counseling," Dr. Nicholson said. "We know from large randomized trials that even for women with mild GDM, nutritional counseling makes a difference."

The literature hints at the possible promise of using telephonic nurse management and Internet-based self-monitoring and educational tools to enhance the postpartum care of new mothers who had GDM, she said.

At the University of North Carolina, a program called the Gestational Diabetes Management System (GooDMomS) offers women video-supported lessons on GDM, a Web and mobile self-monitoring diary in which they can track their weight and record time spent exercising postpartum, as well as forums to "ask the staff" questions and to communicate with other mothers. The system, which is being pilot-tested in an NIH-funded randomized study, is meant to enhance – not replace – basic postpartum care.

In terms of postpartum testing for type 2 diabetes, a recently published literature review suggests that systematic efforts to proactively contact patients can have an impact. Programs in which patients were contacted via phone calls, mailings, and other reminders increased postpartum testing rates from an average of 33% up to 60% (Prim. Care Diabetes 2013;7:177-86).

"We can’t even begin to deliver a preconception program to women until we know what her glycemic status is," emphasized Dr. Moore.

A meta-analysis published more than a decade ago showed an overall 80% reduction in the incidence of congenital malformations in women with diabetes who received preconception care as compared to those who did not receive such care. This study has increasingly relevance today, with more than 76 million women worldwide at risk of their pregnancies being complicated by pregestational (existing) diabetes or gestational diabetes, he said.

The analysis (QJM 2001;94:435-44) also showed that "only modest reductions in HbA_1c, averaging 17%, can have a profound impact," Dr. Moore said. The patient conversation must go beyond merely recommending that HbA_1c levels be as close to normal as possible before conception is attempted, he emphasized.

A recent report from the Maryland Pregnancy Risk Assessment Monitoring System (PRAMS) shows that women with diabetes were the least likely group among women with various preconception medical problems to report contraception use (Contraception 2013;88:263-8). "They had the lowest uptake on contraception," Dr. Moore said.

An estimate of the "downstream savings" of preventing type 2 diabetes in women with GDM was factored into one of two true cost-effectiveness analyses that have been published thus far of the IADPSG criteria, according to Dr. Aaron B. Caughey, chairman of the department of obstetrics and gynecology at the Oregon Health and Science University in Portland.

Both of the two published analyses concluded that the IADPSG criteria are cost effective, but one of them concluded that the criteria would be cost effective only if post-delivery care reduces diabetes incidence (Diabetes Care 2012;35:529-35).

"The short-term costs (of the one-step approach) are easy to figure out," said Dr. Caughey, an ob.gyn and health economist who also is director of the university’s Center for Women’s Health. "The long-term costs are really tough ... we don’t know, what the impact 20 years downstream is going to be."

Providers at Oregon Health and Science University have been encouraged to adopt the one-step approach and, thus far, the change has resulted in a doubling of GDM incidence from approximately 6% to 12%, he noted.

Dr. Caughey, Dr. Moore, and Dr. Nicholson each reported that they had no conflicts of interest to disclose.

WASHINGTON – The rise in gestational diabetes cases demands new strategies for active postpartum care that will not only assist with prevention of type 2 diabetes, but will also prepare women for healthy subsequent pregnancies. New approaches to postpartum care aimed at preventing gestational diabetes in subsequent pregnancies were showcased during sessions at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

The problem is a growing one, with the prevalence of gestational diabetes mellitus (GDM) pregnancies ranging from 2% to 10% depending on screening criteria and demographics/population. The prevalence could rise as high as 18% if diagnostic criteria change in the United States to implement the single-step test recommended in 2008 by the International Association of Diabetes and Pregnancy Study Groups (IADPSG) and adopted by the American Diabetes Association and the World Health Organization.

For now, most U.S. obstetricians are continuing to use the two-step approach to diagnosing GDM, following the advice of a National Institutes of Health consensus development panel and the American College of Gynecologists and Obstetricians. Some physicians, however, are lowering their diagnostic thresholds to capture more at-risk women.

And in the meantime, the prevalence of obesity continues to rise, independently increasing the number of pregnancies complicated by GDM. An estimated 50% of GDM is caused by overweight and obesity, according to Dr. Wanda K. Nicholson, director of the diabetes and obesity core at the University of North Carolina’s Center for Women's Health Research in Chapel Hill.

"We’re not even able to manage our current body of patients," she said. "If we expand this number, we’ll definitely need to develop some new strategies." Studies have also shown that approximately 50% of patients with GDM are screened after delivery for persistent glucose intolerance.

"For most of us, preconception care is increasingly about postpartum care," said Dr. Thomas R. Moore, professor and chairman of the department of reproductive medicine at the University of California, San Diego. "We have to find ways of improving our postpartum follow-up [of GDM pregnancies]."

Follow-up should include checking glycemic status, educating and counseling patients on the risks to newborns of both high maternal HbA_1c levels and maternal obesity, assisting patients with nutritional and lifestyle change, advising the use of effective contraception until conditions are right for another pregnancy, and ensuring proper folic acid supplementation before conception is attempted, he said.

For ob.gyn. practices, more GDM can mean more physician appointments, more staff dedicated to coordinating visits with physicians and educators, expanded diabetes education, and expanded nutritional counseling. "In particular, many practices will need to expand their capacity for nutritional counseling," Dr. Nicholson said. "We know from large randomized trials that even for women with mild GDM, nutritional counseling makes a difference."

The literature hints at the possible promise of using telephonic nurse management and Internet-based self-monitoring and educational tools to enhance the postpartum care of new mothers who had GDM, she said.

At the University of North Carolina, a program called the Gestational Diabetes Management System (GooDMomS) offers women video-supported lessons on GDM, a Web and mobile self-monitoring diary in which they can track their weight and record time spent exercising postpartum, as well as forums to "ask the staff" questions and to communicate with other mothers. The system, which is being pilot-tested in an NIH-funded randomized study, is meant to enhance – not replace – basic postpartum care.

In terms of postpartum testing for type 2 diabetes, a recently published literature review suggests that systematic efforts to proactively contact patients can have an impact. Programs in which patients were contacted via phone calls, mailings, and other reminders increased postpartum testing rates from an average of 33% up to 60% (Prim. Care Diabetes 2013;7:177-86).

"We can’t even begin to deliver a preconception program to women until we know what her glycemic status is," emphasized Dr. Moore.

A meta-analysis published more than a decade ago showed an overall 80% reduction in the incidence of congenital malformations in women with diabetes who received preconception care as compared to those who did not receive such care. This study has increasingly relevance today, with more than 76 million women worldwide at risk of their pregnancies being complicated by pregestational (existing) diabetes or gestational diabetes, he said.

The analysis (QJM 2001;94:435-44) also showed that "only modest reductions in HbA_1c, averaging 17%, can have a profound impact," Dr. Moore said. The patient conversation must go beyond merely recommending that HbA_1c levels be as close to normal as possible before conception is attempted, he emphasized.

A recent report from the Maryland Pregnancy Risk Assessment Monitoring System (PRAMS) shows that women with diabetes were the least likely group among women with various preconception medical problems to report contraception use (Contraception 2013;88:263-8). "They had the lowest uptake on contraception," Dr. Moore said.

An estimate of the "downstream savings" of preventing type 2 diabetes in women with GDM was factored into one of two true cost-effectiveness analyses that have been published thus far of the IADPSG criteria, according to Dr. Aaron B. Caughey, chairman of the department of obstetrics and gynecology at the Oregon Health and Science University in Portland.

Both of the two published analyses concluded that the IADPSG criteria are cost effective, but one of them concluded that the criteria would be cost effective only if post-delivery care reduces diabetes incidence (Diabetes Care 2012;35:529-35).

"The short-term costs (of the one-step approach) are easy to figure out," said Dr. Caughey, an ob.gyn and health economist who also is director of the university’s Center for Women’s Health. "The long-term costs are really tough ... we don’t know, what the impact 20 years downstream is going to be."

Providers at Oregon Health and Science University have been encouraged to adopt the one-step approach and, thus far, the change has resulted in a doubling of GDM incidence from approximately 6% to 12%, he noted.

Dr. Caughey, Dr. Moore, and Dr. Nicholson each reported that they had no conflicts of interest to disclose.

WASHINGTON – Women with a history of gestational diabetes have a sustained long-term risk of developing type 2 diabetes, and this risk continues to be modifiable with either metformin or lifestyle intervention, according to a 10-year follow-up of women who participated in the National Institutes of Health–funded Diabetes Prevention Program trial.

"Even years out from their index pregnancy, women with a history of gestational diabetes are at a significantly increased and sustained risk [compared with women without a GDM history] of developing type 2 [diabetes] ... despite similar baseline metabolic status and despite similar clinical evidence of risk," said Dr. Vanita R. Aroda, who has served as a subinvestigator in the Diabetes Prevention Program (DPP).

Post-hoc analyses of follow-up data from the Diabetes Prevention Program Outcomes Study (DPPOS) show that while lifestyle intervention was similarly effective in reducing risk for all parous women (regardless of whether they had GDM), metformin was effective only in women with a history of GDM, Dr. Aroda reported at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

The original DPP enrolled more than 3,000 individuals at high risk of developing diabetes. Participants were at least 25 years old, were overweight or obese, and had impaired glucose tolerance with fasting plasma glucose levels of 92-125 mg/dL and glucose levels of 140-199 mg/dL 2 hours after a 75-g oral glucose tolerance test.

Approximately 2,100 of the participants were women, 350 of whom had GDM "about 12 years prior," explained Dr. Aroda of Georgetown University, Washington.

Participants were randomized in the main study to placebo, lifestyle intervention, or metformin for approximately 3 years. In women with a history of GDM, lifestyle intervention and metformin reduced the progression to diabetes over this time by 53% and 50%, compared with placebo.

The effects of metformin were greater in these women than in the population as a whole, for which the risk reduction from metformin was 31%. For women without a history of GDM, the risk reduction from metformin was insignificant. Lifestyle intervention – which involved at least 7% weight loss, 150 minutes of activity per week, and a low-fat diet – was similarly effective for all groups.

The long-term DPPOS began after the DPP concluded, with the majority of the original cohort continuing in the follow-up. All participants in the DPPOS received basic lifestyle education at this point, because of its proven benefits. Those originally randomized to the lifestyle group received additional education/support, while those originally assigned to receive metformin or placebo continued in these study groups.

At a mean of 10 years’ follow-up, women with a history of GDM in the placebo group had a 65% higher risk of developing type 2 diabetes compared with women without a history of GDM – despite the fact these women were approximately 9 years younger than those without the GDM history, and an average of 20 years past their index pregnancy, Dr. Aroda said.

Metformin and lifestyle reduced progression to diabetes similarly among those with a GDM history (41% and 35%), compared with placebo. These intervention effects were greater than in those without a GDM history, who saw a 28% risk reduction from lifestyle and an insignificant reduction with metformin.

"For women with a history of GDM, the effectiveness of the initial interventions – lifestyle and metformin – was sustained. There were very nice risk reductions with both," Dr. Aroda said.

The GDM and non-GDM cohorts of women had a similar baseline body mass index and similar fasting and post–oral glucose tolerance test glucose levels. It is not clear why women without prior GDM had a lesser response to metformin, but "it could be that these women had healthier beta-cell function," she said.

Dr. Aroda reported that she receives consulting fees and grant support from Novo Nordisk and Sanofi-Aventis, as well as grant support from Bristol-Myers Squibb, GlaxoSmithKline, Integrium, Takeda Pharmaceuticals, and Boehringer Ingelheim Vetmedica GmbH.

WASHINGTON – Women with a history of gestational diabetes have a sustained long-term risk of developing type 2 diabetes, and this risk continues to be modifiable with either metformin or lifestyle intervention, according to a 10-year follow-up of women who participated in the National Institutes of Health–funded Diabetes Prevention Program trial.

"Even years out from their index pregnancy, women with a history of gestational diabetes are at a significantly increased and sustained risk [compared with women without a GDM history] of developing type 2 [diabetes] ... despite similar baseline metabolic status and despite similar clinical evidence of risk," said Dr. Vanita R. Aroda, who has served as a subinvestigator in the Diabetes Prevention Program (DPP).

Post-hoc analyses of follow-up data from the Diabetes Prevention Program Outcomes Study (DPPOS) show that while lifestyle intervention was similarly effective in reducing risk for all parous women (regardless of whether they had GDM), metformin was effective only in women with a history of GDM, Dr. Aroda reported at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

The original DPP enrolled more than 3,000 individuals at high risk of developing diabetes. Participants were at least 25 years old, were overweight or obese, and had impaired glucose tolerance with fasting plasma glucose levels of 92-125 mg/dL and glucose levels of 140-199 mg/dL 2 hours after a 75-g oral glucose tolerance test.

Approximately 2,100 of the participants were women, 350 of whom had GDM "about 12 years prior," explained Dr. Aroda of Georgetown University, Washington.

Participants were randomized in the main study to placebo, lifestyle intervention, or metformin for approximately 3 years. In women with a history of GDM, lifestyle intervention and metformin reduced the progression to diabetes over this time by 53% and 50%, compared with placebo.

The effects of metformin were greater in these women than in the population as a whole, for which the risk reduction from metformin was 31%. For women without a history of GDM, the risk reduction from metformin was insignificant. Lifestyle intervention – which involved at least 7% weight loss, 150 minutes of activity per week, and a low-fat diet – was similarly effective for all groups.

The long-term DPPOS began after the DPP concluded, with the majority of the original cohort continuing in the follow-up. All participants in the DPPOS received basic lifestyle education at this point, because of its proven benefits. Those originally randomized to the lifestyle group received additional education/support, while those originally assigned to receive metformin or placebo continued in these study groups.

At a mean of 10 years’ follow-up, women with a history of GDM in the placebo group had a 65% higher risk of developing type 2 diabetes compared with women without a history of GDM – despite the fact these women were approximately 9 years younger than those without the GDM history, and an average of 20 years past their index pregnancy, Dr. Aroda said.

Metformin and lifestyle reduced progression to diabetes similarly among those with a GDM history (41% and 35%), compared with placebo. These intervention effects were greater than in those without a GDM history, who saw a 28% risk reduction from lifestyle and an insignificant reduction with metformin.

"For women with a history of GDM, the effectiveness of the initial interventions – lifestyle and metformin – was sustained. There were very nice risk reductions with both," Dr. Aroda said.

The GDM and non-GDM cohorts of women had a similar baseline body mass index and similar fasting and post–oral glucose tolerance test glucose levels. It is not clear why women without prior GDM had a lesser response to metformin, but "it could be that these women had healthier beta-cell function," she said.

Dr. Aroda reported that she receives consulting fees and grant support from Novo Nordisk and Sanofi-Aventis, as well as grant support from Bristol-Myers Squibb, GlaxoSmithKline, Integrium, Takeda Pharmaceuticals, and Boehringer Ingelheim Vetmedica GmbH.

WASHINGTON – Women with a history of gestational diabetes have a sustained long-term risk of developing type 2 diabetes, and this risk continues to be modifiable with either metformin or lifestyle intervention, according to a 10-year follow-up of women who participated in the National Institutes of Health–funded Diabetes Prevention Program trial.

"Even years out from their index pregnancy, women with a history of gestational diabetes are at a significantly increased and sustained risk [compared with women without a GDM history] of developing type 2 [diabetes] ... despite similar baseline metabolic status and despite similar clinical evidence of risk," said Dr. Vanita R. Aroda, who has served as a subinvestigator in the Diabetes Prevention Program (DPP).

Post-hoc analyses of follow-up data from the Diabetes Prevention Program Outcomes Study (DPPOS) show that while lifestyle intervention was similarly effective in reducing risk for all parous women (regardless of whether they had GDM), metformin was effective only in women with a history of GDM, Dr. Aroda reported at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

The original DPP enrolled more than 3,000 individuals at high risk of developing diabetes. Participants were at least 25 years old, were overweight or obese, and had impaired glucose tolerance with fasting plasma glucose levels of 92-125 mg/dL and glucose levels of 140-199 mg/dL 2 hours after a 75-g oral glucose tolerance test.

Approximately 2,100 of the participants were women, 350 of whom had GDM "about 12 years prior," explained Dr. Aroda of Georgetown University, Washington.

Participants were randomized in the main study to placebo, lifestyle intervention, or metformin for approximately 3 years. In women with a history of GDM, lifestyle intervention and metformin reduced the progression to diabetes over this time by 53% and 50%, compared with placebo.

The effects of metformin were greater in these women than in the population as a whole, for which the risk reduction from metformin was 31%. For women without a history of GDM, the risk reduction from metformin was insignificant. Lifestyle intervention – which involved at least 7% weight loss, 150 minutes of activity per week, and a low-fat diet – was similarly effective for all groups.

The long-term DPPOS began after the DPP concluded, with the majority of the original cohort continuing in the follow-up. All participants in the DPPOS received basic lifestyle education at this point, because of its proven benefits. Those originally randomized to the lifestyle group received additional education/support, while those originally assigned to receive metformin or placebo continued in these study groups.

At a mean of 10 years’ follow-up, women with a history of GDM in the placebo group had a 65% higher risk of developing type 2 diabetes compared with women without a history of GDM – despite the fact these women were approximately 9 years younger than those without the GDM history, and an average of 20 years past their index pregnancy, Dr. Aroda said.

Metformin and lifestyle reduced progression to diabetes similarly among those with a GDM history (41% and 35%), compared with placebo. These intervention effects were greater than in those without a GDM history, who saw a 28% risk reduction from lifestyle and an insignificant reduction with metformin.

"For women with a history of GDM, the effectiveness of the initial interventions – lifestyle and metformin – was sustained. There were very nice risk reductions with both," Dr. Aroda said.

The GDM and non-GDM cohorts of women had a similar baseline body mass index and similar fasting and post–oral glucose tolerance test glucose levels. It is not clear why women without prior GDM had a lesser response to metformin, but "it could be that these women had healthier beta-cell function," she said.

Dr. Aroda reported that she receives consulting fees and grant support from Novo Nordisk and Sanofi-Aventis, as well as grant support from Bristol-Myers Squibb, GlaxoSmithKline, Integrium, Takeda Pharmaceuticals, and Boehringer Ingelheim Vetmedica GmbH.

WASHINGTON – Women with a history of gestational diabetes have a sustained long-term risk of developing type 2 diabetes, and this risk continues to be modifiable with either metformin or lifestyle intervention, according to a 10-year follow-up of women who participated in the National Institutes of Health–funded Diabetes Prevention Program trial.

"Even years out from their index pregnancy, women with a history of gestational diabetes are at a significantly increased and sustained risk [compared with women without a GDM history] of developing type 2 [diabetes] ... despite similar baseline metabolic status and despite similar clinical evidence of risk," said Dr. Vanita R. Aroda, who has served as a subinvestigator in the Diabetes Prevention Program (DPP).

Post-hoc analyses of follow-up data from the Diabetes Prevention Program Outcomes Study (DPPOS) show that while lifestyle intervention was similarly effective in reducing risk for all parous women (regardless of whether they had GDM), metformin was effective only in women with a history of GDM, Dr. Aroda reported at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

The original DPP enrolled more than 3,000 individuals at high risk of developing diabetes. Participants were at least 25 years old, were overweight or obese, and had impaired glucose tolerance with fasting plasma glucose levels of 92-125 mg/dL and glucose levels of 140-199 mg/dL 2 hours after a 75-g oral glucose tolerance test.

Approximately 2,100 of the participants were women, 350 of whom had GDM "about 12 years prior," explained Dr. Aroda of Georgetown University, Washington.

Participants were randomized in the main study to placebo, lifestyle intervention, or metformin for approximately 3 years. In women with a history of GDM, lifestyle intervention and metformin reduced the progression to diabetes over this time by 53% and 50%, compared with placebo.

The effects of metformin were greater in these women than in the population as a whole, for which the risk reduction from metformin was 31%. For women without a history of GDM, the risk reduction from metformin was insignificant. Lifestyle intervention – which involved at least 7% weight loss, 150 minutes of activity per week, and a low-fat diet – was similarly effective for all groups.

The long-term DPPOS began after the DPP concluded, with the majority of the original cohort continuing in the follow-up. All participants in the DPPOS received basic lifestyle education at this point, because of its proven benefits. Those originally randomized to the lifestyle group received additional education/support, while those originally assigned to receive metformin or placebo continued in these study groups.

At a mean of 10 years’ follow-up, women with a history of GDM in the placebo group had a 65% higher risk of developing type 2 diabetes compared with women without a history of GDM – despite the fact these women were approximately 9 years younger than those without the GDM history, and an average of 20 years past their index pregnancy, Dr. Aroda said.

Metformin and lifestyle reduced progression to diabetes similarly among those with a GDM history (41% and 35%), compared with placebo. These intervention effects were greater than in those without a GDM history, who saw a 28% risk reduction from lifestyle and an insignificant reduction with metformin.

"For women with a history of GDM, the effectiveness of the initial interventions – lifestyle and metformin – was sustained. There were very nice risk reductions with both," Dr. Aroda said.

The GDM and non-GDM cohorts of women had a similar baseline body mass index and similar fasting and post–oral glucose tolerance test glucose levels. It is not clear why women without prior GDM had a lesser response to metformin, but "it could be that these women had healthier beta-cell function," she said.

Dr. Aroda reported that she receives consulting fees and grant support from Novo Nordisk and Sanofi-Aventis, as well as grant support from Bristol-Myers Squibb, GlaxoSmithKline, Integrium, Takeda Pharmaceuticals, and Boehringer Ingelheim Vetmedica GmbH.

WASHINGTON – Women with a history of gestational diabetes have a sustained long-term risk of developing type 2 diabetes, and this risk continues to be modifiable with either metformin or lifestyle intervention, according to a 10-year follow-up of women who participated in the National Institutes of Health–funded Diabetes Prevention Program trial.

"Even years out from their index pregnancy, women with a history of gestational diabetes are at a significantly increased and sustained risk [compared with women without a GDM history] of developing type 2 [diabetes] ... despite similar baseline metabolic status and despite similar clinical evidence of risk," said Dr. Vanita R. Aroda, who has served as a subinvestigator in the Diabetes Prevention Program (DPP).

Post-hoc analyses of follow-up data from the Diabetes Prevention Program Outcomes Study (DPPOS) show that while lifestyle intervention was similarly effective in reducing risk for all parous women (regardless of whether they had GDM), metformin was effective only in women with a history of GDM, Dr. Aroda reported at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

The original DPP enrolled more than 3,000 individuals at high risk of developing diabetes. Participants were at least 25 years old, were overweight or obese, and had impaired glucose tolerance with fasting plasma glucose levels of 92-125 mg/dL and glucose levels of 140-199 mg/dL 2 hours after a 75-g oral glucose tolerance test.

Approximately 2,100 of the participants were women, 350 of whom had GDM "about 12 years prior," explained Dr. Aroda of Georgetown University, Washington.

Participants were randomized in the main study to placebo, lifestyle intervention, or metformin for approximately 3 years. In women with a history of GDM, lifestyle intervention and metformin reduced the progression to diabetes over this time by 53% and 50%, compared with placebo.

The effects of metformin were greater in these women than in the population as a whole, for which the risk reduction from metformin was 31%. For women without a history of GDM, the risk reduction from metformin was insignificant. Lifestyle intervention – which involved at least 7% weight loss, 150 minutes of activity per week, and a low-fat diet – was similarly effective for all groups.

The long-term DPPOS began after the DPP concluded, with the majority of the original cohort continuing in the follow-up. All participants in the DPPOS received basic lifestyle education at this point, because of its proven benefits. Those originally randomized to the lifestyle group received additional education/support, while those originally assigned to receive metformin or placebo continued in these study groups.

At a mean of 10 years’ follow-up, women with a history of GDM in the placebo group had a 65% higher risk of developing type 2 diabetes compared with women without a history of GDM – despite the fact these women were approximately 9 years younger than those without the GDM history, and an average of 20 years past their index pregnancy, Dr. Aroda said.

Metformin and lifestyle reduced progression to diabetes similarly among those with a GDM history (41% and 35%), compared with placebo. These intervention effects were greater than in those without a GDM history, who saw a 28% risk reduction from lifestyle and an insignificant reduction with metformin.

"For women with a history of GDM, the effectiveness of the initial interventions – lifestyle and metformin – was sustained. There were very nice risk reductions with both," Dr. Aroda said.

The GDM and non-GDM cohorts of women had a similar baseline body mass index and similar fasting and post–oral glucose tolerance test glucose levels. It is not clear why women without prior GDM had a lesser response to metformin, but "it could be that these women had healthier beta-cell function," she said.

Dr. Aroda reported that she receives consulting fees and grant support from Novo Nordisk and Sanofi-Aventis, as well as grant support from Bristol-Myers Squibb, GlaxoSmithKline, Integrium, Takeda Pharmaceuticals, and Boehringer Ingelheim Vetmedica GmbH.

WASHINGTON – Women with a history of gestational diabetes have a sustained long-term risk of developing type 2 diabetes, and this risk continues to be modifiable with either metformin or lifestyle intervention, according to a 10-year follow-up of women who participated in the National Institutes of Health–funded Diabetes Prevention Program trial.

"Even years out from their index pregnancy, women with a history of gestational diabetes are at a significantly increased and sustained risk [compared with women without a GDM history] of developing type 2 [diabetes] ... despite similar baseline metabolic status and despite similar clinical evidence of risk," said Dr. Vanita R. Aroda, who has served as a subinvestigator in the Diabetes Prevention Program (DPP).

Post-hoc analyses of follow-up data from the Diabetes Prevention Program Outcomes Study (DPPOS) show that while lifestyle intervention was similarly effective in reducing risk for all parous women (regardless of whether they had GDM), metformin was effective only in women with a history of GDM, Dr. Aroda reported at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

The original DPP enrolled more than 3,000 individuals at high risk of developing diabetes. Participants were at least 25 years old, were overweight or obese, and had impaired glucose tolerance with fasting plasma glucose levels of 92-125 mg/dL and glucose levels of 140-199 mg/dL 2 hours after a 75-g oral glucose tolerance test.

Approximately 2,100 of the participants were women, 350 of whom had GDM "about 12 years prior," explained Dr. Aroda of Georgetown University, Washington.

Participants were randomized in the main study to placebo, lifestyle intervention, or metformin for approximately 3 years. In women with a history of GDM, lifestyle intervention and metformin reduced the progression to diabetes over this time by 53% and 50%, compared with placebo.

The effects of metformin were greater in these women than in the population as a whole, for which the risk reduction from metformin was 31%. For women without a history of GDM, the risk reduction from metformin was insignificant. Lifestyle intervention – which involved at least 7% weight loss, 150 minutes of activity per week, and a low-fat diet – was similarly effective for all groups.

The long-term DPPOS began after the DPP concluded, with the majority of the original cohort continuing in the follow-up. All participants in the DPPOS received basic lifestyle education at this point, because of its proven benefits. Those originally randomized to the lifestyle group received additional education/support, while those originally assigned to receive metformin or placebo continued in these study groups.

At a mean of 10 years’ follow-up, women with a history of GDM in the placebo group had a 65% higher risk of developing type 2 diabetes compared with women without a history of GDM – despite the fact these women were approximately 9 years younger than those without the GDM history, and an average of 20 years past their index pregnancy, Dr. Aroda said.

Metformin and lifestyle reduced progression to diabetes similarly among those with a GDM history (41% and 35%), compared with placebo. These intervention effects were greater than in those without a GDM history, who saw a 28% risk reduction from lifestyle and an insignificant reduction with metformin.

"For women with a history of GDM, the effectiveness of the initial interventions – lifestyle and metformin – was sustained. There were very nice risk reductions with both," Dr. Aroda said.

The GDM and non-GDM cohorts of women had a similar baseline body mass index and similar fasting and post–oral glucose tolerance test glucose levels. It is not clear why women without prior GDM had a lesser response to metformin, but "it could be that these women had healthier beta-cell function," she said.

Dr. Aroda reported that she receives consulting fees and grant support from Novo Nordisk and Sanofi-Aventis, as well as grant support from Bristol-Myers Squibb, GlaxoSmithKline, Integrium, Takeda Pharmaceuticals, and Boehringer Ingelheim Vetmedica GmbH.

WASHINGTON – High levels of concern with muscularity, or with both muscularity and thinness, were relatively common – and were associated with a risk of adverse outcomes – among adolescent boys participating in the ongoing Growing Up Today Study.

Male adolescents may not be recognized as having body shape concerns or weight-related disorders because of their gender and what likely are gender-specific presentations. This analysis of the GUTS cohort, however, should put such concerns and disorders on the radar screen for pediatricians and other clinicians, Alison E. Field, Sc.D., reported at the annual meeting of the Pediatric Academic Societies.

©vizion-photography/iStockphoto.com

The Growing Up Today Study – a National Institutes of Health–funded prospective cohort study established in 1996 to assess factors that influence weight change – has involved approximately 16,800 children (approximately 9,000 girls and 7,800 boys) who are offspring of women participating in the separate Nurses Health Study 2.

Questionnaires sent every 12-24 months to the boys participating in GUTS have assessed concerns with thinness, concerns with muscularity, use of products to enhance physique, bulimic behaviors, weight and height, depressive symptoms, drug use, and binge eating and drinking. To assess concerns about muscularity, for instance, boys were asked, "How frequently do you think about wanting to tone or define muscle?"

The analysis presented at the PAS meeting involved 5,527 male adolescents who had returned at least two questionnaires between 1999 and 2010. The boys ranged in age from 12 to 18 years in 1999.

Thinness itself was the least common concern. It was a significant concern of about 2% of boys aged 13-15 years, and the prevalence of the concern decreased in older age groups.

The prevalence of concerns and behaviors that included muscularity, on the other hand, was much higher, reported Dr. Field of the department of pediatrics at Harvard Medical School, Boston.

"Particularly troubling," Dr. Field said, was the prevalence of muscularity concerns coupled with the reported use of "potentially" unhealthy products (creatine supplements) and "definitely" unhealthy products (growth hormone or steroids). The prevalence grew from approximately 2% among 13- to 15-year-old boys, to about 7% among 16- to 18-year-old boys, to almost 9% among young men aged 19-22.

"A lot of these young men who are using unhealthy products to bulk up won’t be huge – not yet," said Dr. Field. "These are hard issues to assess, but it will be important for clinicians to probe."

Adolescent boys commonly want more muscularity, she said, but "we’re talking here about defining yourself around your physique and being willing to take on whatever it takes to achieve that."

Dr. Field and her coinvestigators used lagged analysis techniques to determine whether these concerns and behaviors led to certain adverse outcomes and risky behaviors.

Boys with thinness concerns, they found, were 2.5 times more likely than their peers without weight concerns to develop a high level of depressive symptoms (the top quartile of the Center for Epidemiologic Studies Depression Scale [CES-D] self-report scale) in the next 1-2 years.

Those with high concerns about both muscularity and thinness were more likely than their peers to start binge drinking frequently (odds ratio, 1.6) and using drugs (OR, 2.5) within the next 1-2 years, as were boys with high muscularity concerns who used supplements and other products to enhance physique (OR, 2.4 and 2, respectively).

The analysis also offers a window into the issue of eating disorders in males. Bulimia nervosa was rare across age groups, as was purging disorder until young adulthood, when the prevalence grew to just under 1% among males aged 23 years and older. The prevalence of meeting partial or full criteria for binge eating disorder (which for this analysis meant binge eating at least monthly), however, was much higher and grew with age, from almost 0.5% among boys aged 9-12, to more than 2% in the 19- to 22-year-old age group.

Research on disordered eating among males is tricky because most scales and other research tools have been validated for females only.

In terms of diagnosis, "the DSM-5 criteria [for eating disorders] have been improved for females, but we may not be capturing the problem for males," Dr. Field said. More discussion is needed, she said, on the possibility of gender differences.

Dr. Field reported no relevant financial disclosures.

WASHINGTON – High levels of concern with muscularity, or with both muscularity and thinness, were relatively common – and were associated with a risk of adverse outcomes – among adolescent boys participating in the ongoing Growing Up Today Study.

Male adolescents may not be recognized as having body shape concerns or weight-related disorders because of their gender and what likely are gender-specific presentations. This analysis of the GUTS cohort, however, should put such concerns and disorders on the radar screen for pediatricians and other clinicians, Alison E. Field, Sc.D., reported at the annual meeting of the Pediatric Academic Societies.

©vizion-photography/iStockphoto.com

The Growing Up Today Study – a National Institutes of Health–funded prospective cohort study established in 1996 to assess factors that influence weight change – has involved approximately 16,800 children (approximately 9,000 girls and 7,800 boys) who are offspring of women participating in the separate Nurses Health Study 2.

Questionnaires sent every 12-24 months to the boys participating in GUTS have assessed concerns with thinness, concerns with muscularity, use of products to enhance physique, bulimic behaviors, weight and height, depressive symptoms, drug use, and binge eating and drinking. To assess concerns about muscularity, for instance, boys were asked, "How frequently do you think about wanting to tone or define muscle?"

The analysis presented at the PAS meeting involved 5,527 male adolescents who had returned at least two questionnaires between 1999 and 2010. The boys ranged in age from 12 to 18 years in 1999.

Thinness itself was the least common concern. It was a significant concern of about 2% of boys aged 13-15 years, and the prevalence of the concern decreased in older age groups.

The prevalence of concerns and behaviors that included muscularity, on the other hand, was much higher, reported Dr. Field of the department of pediatrics at Harvard Medical School, Boston.

"Particularly troubling," Dr. Field said, was the prevalence of muscularity concerns coupled with the reported use of "potentially" unhealthy products (creatine supplements) and "definitely" unhealthy products (growth hormone or steroids). The prevalence grew from approximately 2% among 13- to 15-year-old boys, to about 7% among 16- to 18-year-old boys, to almost 9% among young men aged 19-22.

"A lot of these young men who are using unhealthy products to bulk up won’t be huge – not yet," said Dr. Field. "These are hard issues to assess, but it will be important for clinicians to probe."

Adolescent boys commonly want more muscularity, she said, but "we’re talking here about defining yourself around your physique and being willing to take on whatever it takes to achieve that."

Dr. Field and her coinvestigators used lagged analysis techniques to determine whether these concerns and behaviors led to certain adverse outcomes and risky behaviors.

Boys with thinness concerns, they found, were 2.5 times more likely than their peers without weight concerns to develop a high level of depressive symptoms (the top quartile of the Center for Epidemiologic Studies Depression Scale [CES-D] self-report scale) in the next 1-2 years.

Those with high concerns about both muscularity and thinness were more likely than their peers to start binge drinking frequently (odds ratio, 1.6) and using drugs (OR, 2.5) within the next 1-2 years, as were boys with high muscularity concerns who used supplements and other products to enhance physique (OR, 2.4 and 2, respectively).

The analysis also offers a window into the issue of eating disorders in males. Bulimia nervosa was rare across age groups, as was purging disorder until young adulthood, when the prevalence grew to just under 1% among males aged 23 years and older. The prevalence of meeting partial or full criteria for binge eating disorder (which for this analysis meant binge eating at least monthly), however, was much higher and grew with age, from almost 0.5% among boys aged 9-12, to more than 2% in the 19- to 22-year-old age group.

Research on disordered eating among males is tricky because most scales and other research tools have been validated for females only.

In terms of diagnosis, "the DSM-5 criteria [for eating disorders] have been improved for females, but we may not be capturing the problem for males," Dr. Field said. More discussion is needed, she said, on the possibility of gender differences.

Dr. Field reported no relevant financial disclosures.

WASHINGTON – High levels of concern with muscularity, or with both muscularity and thinness, were relatively common – and were associated with a risk of adverse outcomes – among adolescent boys participating in the ongoing Growing Up Today Study.

Male adolescents may not be recognized as having body shape concerns or weight-related disorders because of their gender and what likely are gender-specific presentations. This analysis of the GUTS cohort, however, should put such concerns and disorders on the radar screen for pediatricians and other clinicians, Alison E. Field, Sc.D., reported at the annual meeting of the Pediatric Academic Societies.

©vizion-photography/iStockphoto.com

The Growing Up Today Study – a National Institutes of Health–funded prospective cohort study established in 1996 to assess factors that influence weight change – has involved approximately 16,800 children (approximately 9,000 girls and 7,800 boys) who are offspring of women participating in the separate Nurses Health Study 2.

Questionnaires sent every 12-24 months to the boys participating in GUTS have assessed concerns with thinness, concerns with muscularity, use of products to enhance physique, bulimic behaviors, weight and height, depressive symptoms, drug use, and binge eating and drinking. To assess concerns about muscularity, for instance, boys were asked, "How frequently do you think about wanting to tone or define muscle?"

The analysis presented at the PAS meeting involved 5,527 male adolescents who had returned at least two questionnaires between 1999 and 2010. The boys ranged in age from 12 to 18 years in 1999.

Thinness itself was the least common concern. It was a significant concern of about 2% of boys aged 13-15 years, and the prevalence of the concern decreased in older age groups.

The prevalence of concerns and behaviors that included muscularity, on the other hand, was much higher, reported Dr. Field of the department of pediatrics at Harvard Medical School, Boston.

"Particularly troubling," Dr. Field said, was the prevalence of muscularity concerns coupled with the reported use of "potentially" unhealthy products (creatine supplements) and "definitely" unhealthy products (growth hormone or steroids). The prevalence grew from approximately 2% among 13- to 15-year-old boys, to about 7% among 16- to 18-year-old boys, to almost 9% among young men aged 19-22.

"A lot of these young men who are using unhealthy products to bulk up won’t be huge – not yet," said Dr. Field. "These are hard issues to assess, but it will be important for clinicians to probe."

Adolescent boys commonly want more muscularity, she said, but "we’re talking here about defining yourself around your physique and being willing to take on whatever it takes to achieve that."

Dr. Field and her coinvestigators used lagged analysis techniques to determine whether these concerns and behaviors led to certain adverse outcomes and risky behaviors.

Boys with thinness concerns, they found, were 2.5 times more likely than their peers without weight concerns to develop a high level of depressive symptoms (the top quartile of the Center for Epidemiologic Studies Depression Scale [CES-D] self-report scale) in the next 1-2 years.

Those with high concerns about both muscularity and thinness were more likely than their peers to start binge drinking frequently (odds ratio, 1.6) and using drugs (OR, 2.5) within the next 1-2 years, as were boys with high muscularity concerns who used supplements and other products to enhance physique (OR, 2.4 and 2, respectively).

The analysis also offers a window into the issue of eating disorders in males. Bulimia nervosa was rare across age groups, as was purging disorder until young adulthood, when the prevalence grew to just under 1% among males aged 23 years and older. The prevalence of meeting partial or full criteria for binge eating disorder (which for this analysis meant binge eating at least monthly), however, was much higher and grew with age, from almost 0.5% among boys aged 9-12, to more than 2% in the 19- to 22-year-old age group.

Research on disordered eating among males is tricky because most scales and other research tools have been validated for females only.

In terms of diagnosis, "the DSM-5 criteria [for eating disorders] have been improved for females, but we may not be capturing the problem for males," Dr. Field said. More discussion is needed, she said, on the possibility of gender differences.

Dr. Field reported no relevant financial disclosures.

WASHINGTON – Screening for chlamydia and gonorrhea infections using urine testing alone would have missed more than three-fourths of infections in a population of gay youth, a study has found.

"Urine screening alone is not a reliable proxy for all sites for gonorrhea and chlamydia infections in a youth men-who-have-sex-with-men population," reported Dr. Katie Plax at the annual meeting of the Pediatric Academic Societies (PAS).

Instead, it appears that triple screening – with pharyngeal and rectal testing done along with genital screening through urine tests – can enhance the detection of chlamydia and gonorrhea, especially in this high-risk population.

Dr. Plax and her coinvestigators screened 135 young men who have sex with men (MSM), aged 14-24 years, during 189 visits to a drop-in youth center in St. Louis that provides health and social services. Each of the youth had triple screening with nucleic acid simplification testing of urine, rectum, and pharyngeal specimens.

Of all the positive test results over the 12-month study, only 17% were from urine specimens, whereas 82% were in rectal or throat specimens. (There were 29 positive chlamydia tests in 26 of the 135 men, and 72 positive gonorrhea tests in 51 of the men. Twelve of the young men were positive for both infections.)

Urine screening alone would have missed 85% of chlamydia infections and 72% of gonorrhea infections, their analysis shows, while throat screening alone would have missed 88% of chlamydia infections and 43% of gonorrhea infections. Rectal screening had the highest yield, with the estimated rates of missed infections being 15% and 41%, respectively.

"More attention should be focused on the role that extragenital infections play," said Dr. Plax, director of the Adolescent Center at St. Louis Children’s Hospital and associate professor of pediatrics at Washington University in St. Louis. "For HIV-uninfected patients, this is a public health emergency, because we know that an STD [sexually transmitted disease] diagnosis is both a marker for potentially high-risk activity and also a potential cofactor for HIV acquisition."

Gonorrhea infections in particular "have been identified as one of the strongest and most consistent risk factors associated with HIV seroprevalence and HIV seroconversion," she said.

Almost half of the estimated 19 million new cases of sexually transmitted infections each year occur in youth aged 15-24 years, she noted. Moreover, the vast majority of gonorrhea and chlamydia infections – 85% – are asymptomatic.

The Centers for Disease Control and Prevention recommends routine laboratory screening for common STDs for all sexually active MSM, with screening tests selected based on types of reported intercourse. This is tricky to implement, Dr. Plax said, given that basic sexual history-taking still is challenging for many providers.

"We need to take better sexual histories. We can’t ask people, especially youth, are you gay, straight, or bisexual? They don’t identify that way," she noted. "You have to ask, do you have sex with men, women, or both?"

In another study reported at the PAS meeting, researchers found that physicians are documenting sexual histories and performing tests for sexually transmitted infections (STIs) infrequently in adolescent patients, including those who report sexual activity.

In this retrospective cross-sectional study of 1,000 randomly selected routine visits by patients aged 13-19 years, fewer than one-quarter of the patients had a documented sexual history. Of those who reported being sexually active, 38% underwent STI testing and 22% had ever undergone HIV testing specifically. Overall, only 2.6% of the patients had been tested for STIs in the year preceding their visit, and only 1.1% had been tested for HIV.

The patients were among 40,000 adolescents seeking care at 29 primary care practices affiliated with the Children’s Hospital of Philadelphia and the Children’s National Medical Center in Washington. The findings were reported by Rachel Witt, a medical student at the University of Pennsylvania, Philadelphia.

Dr. Plax reported that she and her coinvestigators had no disclosures. Ms. Witt had no disclosures.

WASHINGTON – Screening for chlamydia and gonorrhea infections using urine testing alone would have missed more than three-fourths of infections in a population of gay youth, a study has found.

"Urine screening alone is not a reliable proxy for all sites for gonorrhea and chlamydia infections in a youth men-who-have-sex-with-men population," reported Dr. Katie Plax at the annual meeting of the Pediatric Academic Societies (PAS).

Instead, it appears that triple screening – with pharyngeal and rectal testing done along with genital screening through urine tests – can enhance the detection of chlamydia and gonorrhea, especially in this high-risk population.

Dr. Plax and her coinvestigators screened 135 young men who have sex with men (MSM), aged 14-24 years, during 189 visits to a drop-in youth center in St. Louis that provides health and social services. Each of the youth had triple screening with nucleic acid simplification testing of urine, rectum, and pharyngeal specimens.

Of all the positive test results over the 12-month study, only 17% were from urine specimens, whereas 82% were in rectal or throat specimens. (There were 29 positive chlamydia tests in 26 of the 135 men, and 72 positive gonorrhea tests in 51 of the men. Twelve of the young men were positive for both infections.)

Urine screening alone would have missed 85% of chlamydia infections and 72% of gonorrhea infections, their analysis shows, while throat screening alone would have missed 88% of chlamydia infections and 43% of gonorrhea infections. Rectal screening had the highest yield, with the estimated rates of missed infections being 15% and 41%, respectively.

"More attention should be focused on the role that extragenital infections play," said Dr. Plax, director of the Adolescent Center at St. Louis Children’s Hospital and associate professor of pediatrics at Washington University in St. Louis. "For HIV-uninfected patients, this is a public health emergency, because we know that an STD [sexually transmitted disease] diagnosis is both a marker for potentially high-risk activity and also a potential cofactor for HIV acquisition."

Gonorrhea infections in particular "have been identified as one of the strongest and most consistent risk factors associated with HIV seroprevalence and HIV seroconversion," she said.

Almost half of the estimated 19 million new cases of sexually transmitted infections each year occur in youth aged 15-24 years, she noted. Moreover, the vast majority of gonorrhea and chlamydia infections – 85% – are asymptomatic.

The Centers for Disease Control and Prevention recommends routine laboratory screening for common STDs for all sexually active MSM, with screening tests selected based on types of reported intercourse. This is tricky to implement, Dr. Plax said, given that basic sexual history-taking still is challenging for many providers.

"We need to take better sexual histories. We can’t ask people, especially youth, are you gay, straight, or bisexual? They don’t identify that way," she noted. "You have to ask, do you have sex with men, women, or both?"

In another study reported at the PAS meeting, researchers found that physicians are documenting sexual histories and performing tests for sexually transmitted infections (STIs) infrequently in adolescent patients, including those who report sexual activity.

In this retrospective cross-sectional study of 1,000 randomly selected routine visits by patients aged 13-19 years, fewer than one-quarter of the patients had a documented sexual history. Of those who reported being sexually active, 38% underwent STI testing and 22% had ever undergone HIV testing specifically. Overall, only 2.6% of the patients had been tested for STIs in the year preceding their visit, and only 1.1% had been tested for HIV.

The patients were among 40,000 adolescents seeking care at 29 primary care practices affiliated with the Children’s Hospital of Philadelphia and the Children’s National Medical Center in Washington. The findings were reported by Rachel Witt, a medical student at the University of Pennsylvania, Philadelphia.

Dr. Plax reported that she and her coinvestigators had no disclosures. Ms. Witt had no disclosures.

WASHINGTON – Screening for chlamydia and gonorrhea infections using urine testing alone would have missed more than three-fourths of infections in a population of gay youth, a study has found.

"Urine screening alone is not a reliable proxy for all sites for gonorrhea and chlamydia infections in a youth men-who-have-sex-with-men population," reported Dr. Katie Plax at the annual meeting of the Pediatric Academic Societies (PAS).

Instead, it appears that triple screening – with pharyngeal and rectal testing done along with genital screening through urine tests – can enhance the detection of chlamydia and gonorrhea, especially in this high-risk population.

Dr. Plax and her coinvestigators screened 135 young men who have sex with men (MSM), aged 14-24 years, during 189 visits to a drop-in youth center in St. Louis that provides health and social services. Each of the youth had triple screening with nucleic acid simplification testing of urine, rectum, and pharyngeal specimens.

Of all the positive test results over the 12-month study, only 17% were from urine specimens, whereas 82% were in rectal or throat specimens. (There were 29 positive chlamydia tests in 26 of the 135 men, and 72 positive gonorrhea tests in 51 of the men. Twelve of the young men were positive for both infections.)

Urine screening alone would have missed 85% of chlamydia infections and 72% of gonorrhea infections, their analysis shows, while throat screening alone would have missed 88% of chlamydia infections and 43% of gonorrhea infections. Rectal screening had the highest yield, with the estimated rates of missed infections being 15% and 41%, respectively.

"More attention should be focused on the role that extragenital infections play," said Dr. Plax, director of the Adolescent Center at St. Louis Children’s Hospital and associate professor of pediatrics at Washington University in St. Louis. "For HIV-uninfected patients, this is a public health emergency, because we know that an STD [sexually transmitted disease] diagnosis is both a marker for potentially high-risk activity and also a potential cofactor for HIV acquisition."

Gonorrhea infections in particular "have been identified as one of the strongest and most consistent risk factors associated with HIV seroprevalence and HIV seroconversion," she said.

Almost half of the estimated 19 million new cases of sexually transmitted infections each year occur in youth aged 15-24 years, she noted. Moreover, the vast majority of gonorrhea and chlamydia infections – 85% – are asymptomatic.

The Centers for Disease Control and Prevention recommends routine laboratory screening for common STDs for all sexually active MSM, with screening tests selected based on types of reported intercourse. This is tricky to implement, Dr. Plax said, given that basic sexual history-taking still is challenging for many providers.

"We need to take better sexual histories. We can’t ask people, especially youth, are you gay, straight, or bisexual? They don’t identify that way," she noted. "You have to ask, do you have sex with men, women, or both?"

In another study reported at the PAS meeting, researchers found that physicians are documenting sexual histories and performing tests for sexually transmitted infections (STIs) infrequently in adolescent patients, including those who report sexual activity.

In this retrospective cross-sectional study of 1,000 randomly selected routine visits by patients aged 13-19 years, fewer than one-quarter of the patients had a documented sexual history. Of those who reported being sexually active, 38% underwent STI testing and 22% had ever undergone HIV testing specifically. Overall, only 2.6% of the patients had been tested for STIs in the year preceding their visit, and only 1.1% had been tested for HIV.

The patients were among 40,000 adolescents seeking care at 29 primary care practices affiliated with the Children’s Hospital of Philadelphia and the Children’s National Medical Center in Washington. The findings were reported by Rachel Witt, a medical student at the University of Pennsylvania, Philadelphia.

Dr. Plax reported that she and her coinvestigators had no disclosures. Ms. Witt had no disclosures.

WASHINGTON – Poverty-related disparities in school readiness are a "major public health crisis," in the opinion of Dr. Alan L. Mendelsohn and his colleagues at Bellevue Hospital Center in New York, and they have long been thinking about how to best take advantage of pediatric well-child care visits to promote parent-child interactions that can reduce these disparities.

One of the parenting interventions they are studying – a program called the Video Interaction Project (VIP) – already has been shown to enhance parent-child interactions at the 6-month mark.

Now, it seems that the parenting program can have a long-term impact as well – and that continuing the interventions into the 3- to 5-year age group can have further, independent effects on parent-child interactions.

"Our new findings provide support for interventions based in pediatric primary care to enhance parenting in both the infant and toddler years and the preschool periods," Dr. Mendelsohn, a pediatric developmental behavioral health specialist, reported at the annual meeting of the Pediatric Academic Societies.

Enhancing parent-child interactions, he believes, should improve language and cognitive social-emotional development and ultimately promote school readiness and school performance. Poor children are exposed to 75% fewer words, he noted.

In the VIP program, a child development specialist videotapes the parent and child interacting together with a book or a toy either before or after routine primary care visits. The parent and specialist then watch the video together, with the specialist reinforcing positive interactions, offering suggestions for further interaction, and promoting parent self-reflection. VIP families also receive parenting pamphlets and learning materials at each visit.

The project has been developed in two phases, with VIP 0-3 covering children from birth through 3 years of age, and VIP 3-5 covering the preschool years and entailing increasingly rich play and literacy activities. All told, from birth through 5 years, about 15 VIP sessions take place for each participating family.

The research is part of the Bellevue Project for Early Language, Literacy, and Educational Success (BELLE Project). New mothers were enrolled during the postpartum period at Bellevue Hospital Center and randomized to VIP 0-3 or control; then at age 3 years, the VIP and control families were re-randomized to receive either additional VIP during ages 3-5 years or to control during that period. At 54 months, investigators performed single-blind assessments of parenting and child development.

Bellevue Hospital Center is a public hospital serving families of low socioeconomic status throughout New York City. The 450 mothers enrolled in BELLE are primarily first-generation Hispanic/Latino immigrants. All had singleton, full-term uncomplicated births and spoke English or Spanish as their primary language.

A prior published analysis of the cohort showed enhanced infant-parent interactions as reflected by significantly higher StimQ scores in the VIP 0-3 group at 6 months of age (Arch. Pediatr. Adolesc. Med. 2011;165:33-41). Another analysis at 33 months showed lower levels of parenting stress and a greater likelihood of normal cognitive development in VIP children (J. Dev. Behav. Pediatr. 2007;28:206-12).

The StimQ is an office-based survey developed by Dr. Mendelsohn and others at New York University (NYU) for measuring cognitive stimulation in the homes of young children. It is validated for use in low-socioeconomic populations whose primary language is English or Spanish.

The new 54-month analysis used adaptations of three StimQ-Preschool subscales: Parent Verbal Responsivity, Reading Activities, and Parent Involvement in Developmental Advance, the last of which measures the number of different interactional activities occurring between the caregiver and child that promote cognitive development.

At 54 months, VIP 0-3 was associated with significant increases in scores for parent verbal responsivity (8.98 vs. 7.95) and reading (24.91 vs. 23.75), but only a minimal increase in the score for teaching activities. VIP 3-5 was independently associated with significant increases in verbal responsivity (9.14 vs. 7.99) and teaching (13.18 vs. 12.04), with a trend toward enhancements in reading, Dr. Mendelsohn reported.

"Importantly, the effects were independent, suggesting additive impacts for those receiving interventions during both periods," he said.

Among the next steps in their research are comprehensive assessments in the first grade.

"We also need to work on replication and on understanding whether this is equally effective in other low-income groups," Dr. Mendelsohn said. "We need to build on this burgeoning science ... but we don’t want to just dilute and spread."

Dr. Alan L. Mendelsohn reported no disclosures. VIP has been funded by the National Institute of Child Health and Human Development, the Marks Family Foundation, the Tiger Foundation, Children of Bellevue, and KiDS of NYU.

WASHINGTON – Poverty-related disparities in school readiness are a "major public health crisis," in the opinion of Dr. Alan L. Mendelsohn and his colleagues at Bellevue Hospital Center in New York, and they have long been thinking about how to best take advantage of pediatric well-child care visits to promote parent-child interactions that can reduce these disparities.

One of the parenting interventions they are studying – a program called the Video Interaction Project (VIP) – already has been shown to enhance parent-child interactions at the 6-month mark.

Now, it seems that the parenting program can have a long-term impact as well – and that continuing the interventions into the 3- to 5-year age group can have further, independent effects on parent-child interactions.

"Our new findings provide support for interventions based in pediatric primary care to enhance parenting in both the infant and toddler years and the preschool periods," Dr. Mendelsohn, a pediatric developmental behavioral health specialist, reported at the annual meeting of the Pediatric Academic Societies.

Enhancing parent-child interactions, he believes, should improve language and cognitive social-emotional development and ultimately promote school readiness and school performance. Poor children are exposed to 75% fewer words, he noted.

In the VIP program, a child development specialist videotapes the parent and child interacting together with a book or a toy either before or after routine primary care visits. The parent and specialist then watch the video together, with the specialist reinforcing positive interactions, offering suggestions for further interaction, and promoting parent self-reflection. VIP families also receive parenting pamphlets and learning materials at each visit.

The project has been developed in two phases, with VIP 0-3 covering children from birth through 3 years of age, and VIP 3-5 covering the preschool years and entailing increasingly rich play and literacy activities. All told, from birth through 5 years, about 15 VIP sessions take place for each participating family.

The research is part of the Bellevue Project for Early Language, Literacy, and Educational Success (BELLE Project). New mothers were enrolled during the postpartum period at Bellevue Hospital Center and randomized to VIP 0-3 or control; then at age 3 years, the VIP and control families were re-randomized to receive either additional VIP during ages 3-5 years or to control during that period. At 54 months, investigators performed single-blind assessments of parenting and child development.

Bellevue Hospital Center is a public hospital serving families of low socioeconomic status throughout New York City. The 450 mothers enrolled in BELLE are primarily first-generation Hispanic/Latino immigrants. All had singleton, full-term uncomplicated births and spoke English or Spanish as their primary language.

A prior published analysis of the cohort showed enhanced infant-parent interactions as reflected by significantly higher StimQ scores in the VIP 0-3 group at 6 months of age (Arch. Pediatr. Adolesc. Med. 2011;165:33-41). Another analysis at 33 months showed lower levels of parenting stress and a greater likelihood of normal cognitive development in VIP children (J. Dev. Behav. Pediatr. 2007;28:206-12).

The StimQ is an office-based survey developed by Dr. Mendelsohn and others at New York University (NYU) for measuring cognitive stimulation in the homes of young children. It is validated for use in low-socioeconomic populations whose primary language is English or Spanish.

The new 54-month analysis used adaptations of three StimQ-Preschool subscales: Parent Verbal Responsivity, Reading Activities, and Parent Involvement in Developmental Advance, the last of which measures the number of different interactional activities occurring between the caregiver and child that promote cognitive development.

At 54 months, VIP 0-3 was associated with significant increases in scores for parent verbal responsivity (8.98 vs. 7.95) and reading (24.91 vs. 23.75), but only a minimal increase in the score for teaching activities. VIP 3-5 was independently associated with significant increases in verbal responsivity (9.14 vs. 7.99) and teaching (13.18 vs. 12.04), with a trend toward enhancements in reading, Dr. Mendelsohn reported.

"Importantly, the effects were independent, suggesting additive impacts for those receiving interventions during both periods," he said.

Among the next steps in their research are comprehensive assessments in the first grade.

"We also need to work on replication and on understanding whether this is equally effective in other low-income groups," Dr. Mendelsohn said. "We need to build on this burgeoning science ... but we don’t want to just dilute and spread."

Dr. Alan L. Mendelsohn reported no disclosures. VIP has been funded by the National Institute of Child Health and Human Development, the Marks Family Foundation, the Tiger Foundation, Children of Bellevue, and KiDS of NYU.

WASHINGTON – Poverty-related disparities in school readiness are a "major public health crisis," in the opinion of Dr. Alan L. Mendelsohn and his colleagues at Bellevue Hospital Center in New York, and they have long been thinking about how to best take advantage of pediatric well-child care visits to promote parent-child interactions that can reduce these disparities.

One of the parenting interventions they are studying – a program called the Video Interaction Project (VIP) – already has been shown to enhance parent-child interactions at the 6-month mark.

Now, it seems that the parenting program can have a long-term impact as well – and that continuing the interventions into the 3- to 5-year age group can have further, independent effects on parent-child interactions.

"Our new findings provide support for interventions based in pediatric primary care to enhance parenting in both the infant and toddler years and the preschool periods," Dr. Mendelsohn, a pediatric developmental behavioral health specialist, reported at the annual meeting of the Pediatric Academic Societies.

Enhancing parent-child interactions, he believes, should improve language and cognitive social-emotional development and ultimately promote school readiness and school performance. Poor children are exposed to 75% fewer words, he noted.

In the VIP program, a child development specialist videotapes the parent and child interacting together with a book or a toy either before or after routine primary care visits. The parent and specialist then watch the video together, with the specialist reinforcing positive interactions, offering suggestions for further interaction, and promoting parent self-reflection. VIP families also receive parenting pamphlets and learning materials at each visit.

The project has been developed in two phases, with VIP 0-3 covering children from birth through 3 years of age, and VIP 3-5 covering the preschool years and entailing increasingly rich play and literacy activities. All told, from birth through 5 years, about 15 VIP sessions take place for each participating family.

The research is part of the Bellevue Project for Early Language, Literacy, and Educational Success (BELLE Project). New mothers were enrolled during the postpartum period at Bellevue Hospital Center and randomized to VIP 0-3 or control; then at age 3 years, the VIP and control families were re-randomized to receive either additional VIP during ages 3-5 years or to control during that period. At 54 months, investigators performed single-blind assessments of parenting and child development.

Bellevue Hospital Center is a public hospital serving families of low socioeconomic status throughout New York City. The 450 mothers enrolled in BELLE are primarily first-generation Hispanic/Latino immigrants. All had singleton, full-term uncomplicated births and spoke English or Spanish as their primary language.

A prior published analysis of the cohort showed enhanced infant-parent interactions as reflected by significantly higher StimQ scores in the VIP 0-3 group at 6 months of age (Arch. Pediatr. Adolesc. Med. 2011;165:33-41). Another analysis at 33 months showed lower levels of parenting stress and a greater likelihood of normal cognitive development in VIP children (J. Dev. Behav. Pediatr. 2007;28:206-12).

The StimQ is an office-based survey developed by Dr. Mendelsohn and others at New York University (NYU) for measuring cognitive stimulation in the homes of young children. It is validated for use in low-socioeconomic populations whose primary language is English or Spanish.

The new 54-month analysis used adaptations of three StimQ-Preschool subscales: Parent Verbal Responsivity, Reading Activities, and Parent Involvement in Developmental Advance, the last of which measures the number of different interactional activities occurring between the caregiver and child that promote cognitive development.

At 54 months, VIP 0-3 was associated with significant increases in scores for parent verbal responsivity (8.98 vs. 7.95) and reading (24.91 vs. 23.75), but only a minimal increase in the score for teaching activities. VIP 3-5 was independently associated with significant increases in verbal responsivity (9.14 vs. 7.99) and teaching (13.18 vs. 12.04), with a trend toward enhancements in reading, Dr. Mendelsohn reported.

"Importantly, the effects were independent, suggesting additive impacts for those receiving interventions during both periods," he said.

Among the next steps in their research are comprehensive assessments in the first grade.

"We also need to work on replication and on understanding whether this is equally effective in other low-income groups," Dr. Mendelsohn said. "We need to build on this burgeoning science ... but we don’t want to just dilute and spread."

Dr. Alan L. Mendelsohn reported no disclosures. VIP has been funded by the National Institute of Child Health and Human Development, the Marks Family Foundation, the Tiger Foundation, Children of Bellevue, and KiDS of NYU.