Kate Johnson

Montreal — Personality and attitude play a major role in shaping a patient's experience of chronic pain, and understanding this dynamic may help physicians overcome obstacles in treating some of their unresponsive patients, according to Michael Sullivan, Ph.D.

In fact, in recent studies, catastrophizing has emerged as “the most powerful psychological predictor of problematic pain outcomes,” said Dr. Sullivan, professor of psychology, medicine, and neurology at McGill University in Montreal.

In the context of pain, catastrophizing is defined as the tendency to worry and focus on the pain. Individuals who score high on the Pain Catastrophizing Scale (PCS), which was developed by Dr. Sullivan in 1995, tend to magnify and ruminate over their symptoms while feeling helpless about addressing them. “These individuals have an excessively alarmist attitude towards their pain and seem to have a lot more difficulty dealing with it,” he said at the meeting.

In the office setting, chronic pain patients who catastrophize “display more pain behavior such as holding, rubbing, guarding, as well as vocalizations such as moans and sighs,” he said at the meeting, which was sponsored by the International Association for the Study of Pain.

“Research shows that not only are catastrophizers going to have more difficulty in pain situations, they are also going to respond less well to the interventions that we offer them,” he said. In studies, Dr. Sullivan and his colleagues have shown that, compared with non-catastrophizers, catastrophizers are at greater risk of chronic pain following knee arthroplasty (Pain Res. Manag. 2008;13:335–41) and have more difficulty returning to work after whiplash injuries (J. Occup. Rehabil. 2007;17:305–15).

For patients whose chronic pain stems from an accident, perceptions of injustice also are common and can be expressed as anger or noncompliance. “Some of our recent research [Pain 2009;145:325–31] shows that perceptions of injustice are often associated with prolonged disability following a pain-related injury,” he said. For the treating physician, “validation techniques can be useful in reducing the negative impact of the catastrophizing patient's perceptions of injustice.”

By identifying catastrophizers early, physicians can avoid pitfalls that contribute to treatment failure in chronic pain. “There are some very concrete ways in which physicians could be reacting differently with these patients” to make patient management easier, he pointed out.

First and foremost, catastrophizers need to express their suffering and anxiety. “This person does have a story to tell and they need someone to listen. By not listening properly to that story initially, you are going to hear it again every time the patient comes, because the patient is going to feel that the doctor doesn't understand. So, increasing the time you initially spend with the patient can save a lot of headaches further down the line,” Dr. Sullivan explained.

Active listening has even been shown to reduce a patient's perception of pain, at least in the context of acute symptoms, said Dr. Sullivan, who has published several studies showing that allowing catastrophizers to disclose their fear and worry prior to routine dental hygiene procedures can reduce their perception of pain by as much as 50% (J. Indiana Dent. Assoc. 2000–2001;79:16–9; and Pain 1999;79:155–63).

Although a patient's basic personality is a challenge for physicians to work around, attitude – which is also an extremely powerful modifier of pain – is somewhat easier to mold, suggested Stefaan Van Damme, Ph.D., of the department of experimental clinical health and psychology at Ghent (Belgium) University.

In approaching pain control as a goal, chronic pain patients fall into two distinct categories: those who try to overcome it (assimilators) and those who accept it (accommodators). Both attitudes can be helpful or harmful, depending on how realistic pain control is for a particular patient, he said at the meeting.

“When pain is controllable, assimilative coping works. But when it is not controllable it can be maladaptive because it can exacerbate catastrophizing, hypervigilance, and distress,” he said. In a study, he demonstrated that, when attempts to avoid pain are unsuccessful, “individuals persist in their avoidance attempts, try harder, and narrow their focus of attention upon the problem to be solved” (Pain 2008;137:631–9).

Helping patients shift their focus from fighting to accepting their pain is particularly tricky for physicians, commented Dr. Sullivan, who is a psychologist. “I only get sent the patients when their pain has been long-standing. The concept of acceptance works when the pain has been there for 5 years,” he explained, “but for new-onset pain, acceptance is not the message that should be given by the doctor. This should only come up after we've offered everything else we can offer.”

Physicians should also be aware of their own personal psychology when dealing with catastrophizing patients, because catastrophizing personalities are not confined to the patient world. Physicians who are catastrophizers may inadvertently increase a patient's perception of suffering. “Some of our research suggests that if you're a catastrophizer you see 30% more pain in these individuals,” he said.

The speakers did not declare any conflicts of interest.

Montreal — Personality and attitude play a major role in shaping a patient's experience of chronic pain, and understanding this dynamic may help physicians overcome obstacles in treating some of their unresponsive patients, according to Michael Sullivan, Ph.D.

In fact, in recent studies, catastrophizing has emerged as “the most powerful psychological predictor of problematic pain outcomes,” said Dr. Sullivan, professor of psychology, medicine, and neurology at McGill University in Montreal.

In the context of pain, catastrophizing is defined as the tendency to worry and focus on the pain. Individuals who score high on the Pain Catastrophizing Scale (PCS), which was developed by Dr. Sullivan in 1995, tend to magnify and ruminate over their symptoms while feeling helpless about addressing them. “These individuals have an excessively alarmist attitude towards their pain and seem to have a lot more difficulty dealing with it,” he said at the meeting.

In the office setting, chronic pain patients who catastrophize “display more pain behavior such as holding, rubbing, guarding, as well as vocalizations such as moans and sighs,” he said at the meeting, which was sponsored by the International Association for the Study of Pain.

“Research shows that not only are catastrophizers going to have more difficulty in pain situations, they are also going to respond less well to the interventions that we offer them,” he said. In studies, Dr. Sullivan and his colleagues have shown that, compared with non-catastrophizers, catastrophizers are at greater risk of chronic pain following knee arthroplasty (Pain Res. Manag. 2008;13:335–41) and have more difficulty returning to work after whiplash injuries (J. Occup. Rehabil. 2007;17:305–15).

For patients whose chronic pain stems from an accident, perceptions of injustice also are common and can be expressed as anger or noncompliance. “Some of our recent research [Pain 2009;145:325–31] shows that perceptions of injustice are often associated with prolonged disability following a pain-related injury,” he said. For the treating physician, “validation techniques can be useful in reducing the negative impact of the catastrophizing patient's perceptions of injustice.”

By identifying catastrophizers early, physicians can avoid pitfalls that contribute to treatment failure in chronic pain. “There are some very concrete ways in which physicians could be reacting differently with these patients” to make patient management easier, he pointed out.

First and foremost, catastrophizers need to express their suffering and anxiety. “This person does have a story to tell and they need someone to listen. By not listening properly to that story initially, you are going to hear it again every time the patient comes, because the patient is going to feel that the doctor doesn't understand. So, increasing the time you initially spend with the patient can save a lot of headaches further down the line,” Dr. Sullivan explained.

Active listening has even been shown to reduce a patient's perception of pain, at least in the context of acute symptoms, said Dr. Sullivan, who has published several studies showing that allowing catastrophizers to disclose their fear and worry prior to routine dental hygiene procedures can reduce their perception of pain by as much as 50% (J. Indiana Dent. Assoc. 2000–2001;79:16–9; and Pain 1999;79:155–63).

Although a patient's basic personality is a challenge for physicians to work around, attitude – which is also an extremely powerful modifier of pain – is somewhat easier to mold, suggested Stefaan Van Damme, Ph.D., of the department of experimental clinical health and psychology at Ghent (Belgium) University.

In approaching pain control as a goal, chronic pain patients fall into two distinct categories: those who try to overcome it (assimilators) and those who accept it (accommodators). Both attitudes can be helpful or harmful, depending on how realistic pain control is for a particular patient, he said at the meeting.

“When pain is controllable, assimilative coping works. But when it is not controllable it can be maladaptive because it can exacerbate catastrophizing, hypervigilance, and distress,” he said. In a study, he demonstrated that, when attempts to avoid pain are unsuccessful, “individuals persist in their avoidance attempts, try harder, and narrow their focus of attention upon the problem to be solved” (Pain 2008;137:631–9).

Helping patients shift their focus from fighting to accepting their pain is particularly tricky for physicians, commented Dr. Sullivan, who is a psychologist. “I only get sent the patients when their pain has been long-standing. The concept of acceptance works when the pain has been there for 5 years,” he explained, “but for new-onset pain, acceptance is not the message that should be given by the doctor. This should only come up after we've offered everything else we can offer.”

Physicians should also be aware of their own personal psychology when dealing with catastrophizing patients, because catastrophizing personalities are not confined to the patient world. Physicians who are catastrophizers may inadvertently increase a patient's perception of suffering. “Some of our research suggests that if you're a catastrophizer you see 30% more pain in these individuals,” he said.

The speakers did not declare any conflicts of interest.

Montreal — Personality and attitude play a major role in shaping a patient's experience of chronic pain, and understanding this dynamic may help physicians overcome obstacles in treating some of their unresponsive patients, according to Michael Sullivan, Ph.D.

In fact, in recent studies, catastrophizing has emerged as “the most powerful psychological predictor of problematic pain outcomes,” said Dr. Sullivan, professor of psychology, medicine, and neurology at McGill University in Montreal.

In the context of pain, catastrophizing is defined as the tendency to worry and focus on the pain. Individuals who score high on the Pain Catastrophizing Scale (PCS), which was developed by Dr. Sullivan in 1995, tend to magnify and ruminate over their symptoms while feeling helpless about addressing them. “These individuals have an excessively alarmist attitude towards their pain and seem to have a lot more difficulty dealing with it,” he said at the meeting.

In the office setting, chronic pain patients who catastrophize “display more pain behavior such as holding, rubbing, guarding, as well as vocalizations such as moans and sighs,” he said at the meeting, which was sponsored by the International Association for the Study of Pain.

“Research shows that not only are catastrophizers going to have more difficulty in pain situations, they are also going to respond less well to the interventions that we offer them,” he said. In studies, Dr. Sullivan and his colleagues have shown that, compared with non-catastrophizers, catastrophizers are at greater risk of chronic pain following knee arthroplasty (Pain Res. Manag. 2008;13:335–41) and have more difficulty returning to work after whiplash injuries (J. Occup. Rehabil. 2007;17:305–15).

For patients whose chronic pain stems from an accident, perceptions of injustice also are common and can be expressed as anger or noncompliance. “Some of our recent research [Pain 2009;145:325–31] shows that perceptions of injustice are often associated with prolonged disability following a pain-related injury,” he said. For the treating physician, “validation techniques can be useful in reducing the negative impact of the catastrophizing patient's perceptions of injustice.”

By identifying catastrophizers early, physicians can avoid pitfalls that contribute to treatment failure in chronic pain. “There are some very concrete ways in which physicians could be reacting differently with these patients” to make patient management easier, he pointed out.

First and foremost, catastrophizers need to express their suffering and anxiety. “This person does have a story to tell and they need someone to listen. By not listening properly to that story initially, you are going to hear it again every time the patient comes, because the patient is going to feel that the doctor doesn't understand. So, increasing the time you initially spend with the patient can save a lot of headaches further down the line,” Dr. Sullivan explained.

Active listening has even been shown to reduce a patient's perception of pain, at least in the context of acute symptoms, said Dr. Sullivan, who has published several studies showing that allowing catastrophizers to disclose their fear and worry prior to routine dental hygiene procedures can reduce their perception of pain by as much as 50% (J. Indiana Dent. Assoc. 2000–2001;79:16–9; and Pain 1999;79:155–63).

Although a patient's basic personality is a challenge for physicians to work around, attitude – which is also an extremely powerful modifier of pain – is somewhat easier to mold, suggested Stefaan Van Damme, Ph.D., of the department of experimental clinical health and psychology at Ghent (Belgium) University.

In approaching pain control as a goal, chronic pain patients fall into two distinct categories: those who try to overcome it (assimilators) and those who accept it (accommodators). Both attitudes can be helpful or harmful, depending on how realistic pain control is for a particular patient, he said at the meeting.

“When pain is controllable, assimilative coping works. But when it is not controllable it can be maladaptive because it can exacerbate catastrophizing, hypervigilance, and distress,” he said. In a study, he demonstrated that, when attempts to avoid pain are unsuccessful, “individuals persist in their avoidance attempts, try harder, and narrow their focus of attention upon the problem to be solved” (Pain 2008;137:631–9).

Helping patients shift their focus from fighting to accepting their pain is particularly tricky for physicians, commented Dr. Sullivan, who is a psychologist. “I only get sent the patients when their pain has been long-standing. The concept of acceptance works when the pain has been there for 5 years,” he explained, “but for new-onset pain, acceptance is not the message that should be given by the doctor. This should only come up after we've offered everything else we can offer.”

Physicians should also be aware of their own personal psychology when dealing with catastrophizing patients, because catastrophizing personalities are not confined to the patient world. Physicians who are catastrophizers may inadvertently increase a patient's perception of suffering. “Some of our research suggests that if you're a catastrophizer you see 30% more pain in these individuals,” he said.

The speakers did not declare any conflicts of interest.

Major Finding: Women randomized to early or late external cephalic version had nonsignificant differences in cesarean section rate (52% vs. 56%), with a trend toward more preterm deliveries in the early-version group.

Data Source: A study that randomized 1,532 women with breech presentations to either an early external cephalic version or a later version performed at 37 weeks.

Disclosures: Dr. Carson said he had no relevant disclosures. The trial was funded by the Canadian Institutes of Health Research.

MONTREAL — Early external cephalic version increases the likelihood of cephalic presentation at birth, but does not result in fewer cesarean sections compared with later cephalic version, based on the results of an international, multicenter, randomized controlled trial.

In addition, there was a trend toward greater risk of preterm birth when the procedure was done early, defined as between the 34th and 35th weeks, reported Dr. George Carson, one of the investigators on the Early External Cephalic Version 2 (ECV2) Trial.

“This is actually very disappointing,” he said in an interview at the meeting.

“It is worth trying to investigate why turning the baby didn't result in a reduction in cesarean sections. Obviously the purpose of this was not to turn the baby – it was to reduce cesarean sections – and that didn't happen, and that's disappointing.”

The study randomized 1,532 women with breech presentations to either an early version or a later version performed at 37 weeks. The primary end point was the rate of cesarean section, with a secondary end point of preterm birth.

“The concern was that in performing version one might precipitate preterm birth, and so this could be the adverse effect of the attempt to turn the baby,” noted Dr. Carson, director of maternal-fetal medicine at Regina (Sask.) General Hospital.

Baseline characteristics including parity, types of breech presentation, and anterior placenta were similar in both groups.

Cephalic presentation at the time of delivery, due to either successful external version or spontaneous version, was higher in the early-version group (59% vs. 51%), and the difference reached statistical significance, said Dr. Carson. However, there was not a statistically significant difference in the cesarean section rate: 52% in the early group and 56% in the late group.

“More women delivered vaginally than was anticipated in the delayed group – due to spontaneous conversion and a small number of women who decided to deliver vaginally even though their baby was still breech,” he said, adding that overall, the cesarean section rate was high.

“Very few of these were done for nonreassuring monitoring. They were done in places that do a lot of sections anyway, so being cephalic was not in any way a guarantee that one wouldn't have a section done,” he said.

The increased rate of preterm delivery in the early-version group (6.5% vs. 4.4% in the late group) was not statistically significant, but it strengthens the argument against attempting an early cephalic version, said Dr. Carson.

“What I tell the women that I am trying to do a version on is, if we don't do it … they've got about a 70% chance of a cesarean section. If we do it, that could be reduced to about 50%. But my chance of getting the fetus around is only about 50%.

“And if we push hard on the uterus, maybe we could make them deliver prematurely. It won't be very premature, but it's still better to be term than 35 weeks,” he said.

Major Finding: Women randomized to early or late external cephalic version had nonsignificant differences in cesarean section rate (52% vs. 56%), with a trend toward more preterm deliveries in the early-version group.

Data Source: A study that randomized 1,532 women with breech presentations to either an early external cephalic version or a later version performed at 37 weeks.

Disclosures: Dr. Carson said he had no relevant disclosures. The trial was funded by the Canadian Institutes of Health Research.

MONTREAL — Early external cephalic version increases the likelihood of cephalic presentation at birth, but does not result in fewer cesarean sections compared with later cephalic version, based on the results of an international, multicenter, randomized controlled trial.

In addition, there was a trend toward greater risk of preterm birth when the procedure was done early, defined as between the 34th and 35th weeks, reported Dr. George Carson, one of the investigators on the Early External Cephalic Version 2 (ECV2) Trial.

“This is actually very disappointing,” he said in an interview at the meeting.

“It is worth trying to investigate why turning the baby didn't result in a reduction in cesarean sections. Obviously the purpose of this was not to turn the baby – it was to reduce cesarean sections – and that didn't happen, and that's disappointing.”

The study randomized 1,532 women with breech presentations to either an early version or a later version performed at 37 weeks. The primary end point was the rate of cesarean section, with a secondary end point of preterm birth.

“The concern was that in performing version one might precipitate preterm birth, and so this could be the adverse effect of the attempt to turn the baby,” noted Dr. Carson, director of maternal-fetal medicine at Regina (Sask.) General Hospital.

Baseline characteristics including parity, types of breech presentation, and anterior placenta were similar in both groups.

Cephalic presentation at the time of delivery, due to either successful external version or spontaneous version, was higher in the early-version group (59% vs. 51%), and the difference reached statistical significance, said Dr. Carson. However, there was not a statistically significant difference in the cesarean section rate: 52% in the early group and 56% in the late group.

“More women delivered vaginally than was anticipated in the delayed group – due to spontaneous conversion and a small number of women who decided to deliver vaginally even though their baby was still breech,” he said, adding that overall, the cesarean section rate was high.

“Very few of these were done for nonreassuring monitoring. They were done in places that do a lot of sections anyway, so being cephalic was not in any way a guarantee that one wouldn't have a section done,” he said.

The increased rate of preterm delivery in the early-version group (6.5% vs. 4.4% in the late group) was not statistically significant, but it strengthens the argument against attempting an early cephalic version, said Dr. Carson.

“What I tell the women that I am trying to do a version on is, if we don't do it … they've got about a 70% chance of a cesarean section. If we do it, that could be reduced to about 50%. But my chance of getting the fetus around is only about 50%.

“And if we push hard on the uterus, maybe we could make them deliver prematurely. It won't be very premature, but it's still better to be term than 35 weeks,” he said.

Major Finding: Women randomized to early or late external cephalic version had nonsignificant differences in cesarean section rate (52% vs. 56%), with a trend toward more preterm deliveries in the early-version group.

Data Source: A study that randomized 1,532 women with breech presentations to either an early external cephalic version or a later version performed at 37 weeks.

Disclosures: Dr. Carson said he had no relevant disclosures. The trial was funded by the Canadian Institutes of Health Research.

MONTREAL — Early external cephalic version increases the likelihood of cephalic presentation at birth, but does not result in fewer cesarean sections compared with later cephalic version, based on the results of an international, multicenter, randomized controlled trial.

In addition, there was a trend toward greater risk of preterm birth when the procedure was done early, defined as between the 34th and 35th weeks, reported Dr. George Carson, one of the investigators on the Early External Cephalic Version 2 (ECV2) Trial.

“This is actually very disappointing,” he said in an interview at the meeting.

“It is worth trying to investigate why turning the baby didn't result in a reduction in cesarean sections. Obviously the purpose of this was not to turn the baby – it was to reduce cesarean sections – and that didn't happen, and that's disappointing.”

The study randomized 1,532 women with breech presentations to either an early version or a later version performed at 37 weeks. The primary end point was the rate of cesarean section, with a secondary end point of preterm birth.

“The concern was that in performing version one might precipitate preterm birth, and so this could be the adverse effect of the attempt to turn the baby,” noted Dr. Carson, director of maternal-fetal medicine at Regina (Sask.) General Hospital.

Baseline characteristics including parity, types of breech presentation, and anterior placenta were similar in both groups.

Cephalic presentation at the time of delivery, due to either successful external version or spontaneous version, was higher in the early-version group (59% vs. 51%), and the difference reached statistical significance, said Dr. Carson. However, there was not a statistically significant difference in the cesarean section rate: 52% in the early group and 56% in the late group.

“More women delivered vaginally than was anticipated in the delayed group – due to spontaneous conversion and a small number of women who decided to deliver vaginally even though their baby was still breech,” he said, adding that overall, the cesarean section rate was high.

“Very few of these were done for nonreassuring monitoring. They were done in places that do a lot of sections anyway, so being cephalic was not in any way a guarantee that one wouldn't have a section done,” he said.

The increased rate of preterm delivery in the early-version group (6.5% vs. 4.4% in the late group) was not statistically significant, but it strengthens the argument against attempting an early cephalic version, said Dr. Carson.

“What I tell the women that I am trying to do a version on is, if we don't do it … they've got about a 70% chance of a cesarean section. If we do it, that could be reduced to about 50%. But my chance of getting the fetus around is only about 50%.

“And if we push hard on the uterus, maybe we could make them deliver prematurely. It won't be very premature, but it's still better to be term than 35 weeks,” he said.

MONTREAL – Personality and attitude play a major role in shaping a patient's experience of chronic pain, and understanding this dynamic may help physicians overcome obstacles in treating some of their unresponsive patients, according to Michael Sullivan, Ph.D.

In fact, in recent studies, catastrophizing has emerged as “the most powerful psychological predictor of problematic pain outcomes,” said Dr. Sullivan, professor of psychology, medicine, and neurology at McGill University in Montreal.

In the context of pain, catastrophizing is defined as the tendency to worry and focus on the pain. Individuals who score high on the Pain Catastrophizing Scale (PCS), which was developed by Dr. Sullivan in 1995, tend to magnify and ruminate over their symptoms while feeling helpless about addressing them. “These individuals have an excessively alarmist attitude toward their pain and seem to have a lot more difficulty dealing with it,” he said at the meeting.

In the office setting, chronic pain patients who catastrophize “display more pain behavior such as holding, rubbing, [and] guarding, as well as vocalizations such as moans and sighs,” he said at the meeting, sponsored by the International Association for the Study of Pain.

“Research shows that not only are catastrophizers going to have more difficulty in pain situations, they are also going to respond less well to the interventions that we offer them,” he said. In studies, Dr. Sullivan and his colleagues have shown that, compared with noncatastrophizers, catastrophizers are at greater risk of chronic pain following knee arthroplasty (Pain Res. Manag. 2008;13:335-41) and have more difficulty returning to work after whiplash injuries (J. Occup. Rehabil. 2007;17:305-15).

For patients whose chronic pain stems from an accident, perceptions of injustice also are common and can be expressed as anger or noncompliance. “Some of our recent research [Pain 2009;145:325-31] shows that perceptions of injustice are often associated with prolonged disability following a pain-related injury,” he said. For the treating physician, “validation techniques can be useful in reducing the negative impact of the catastrophizing patient's perceptions of injustice.”

By identifying catastrophizers early, physicians can avoid pitfalls that contribute to treatment failure in chronic pain. “There are some very concrete ways in which physicians could be reacting differently with these patients” to make patient management easier, he pointed out.

First and foremost, catastrophizers need to express their suffering and anxiety. “This person does have a story to tell and they need someone to listen. By not listening properly to that story initially, you are going to hear it again every time the patient comes, because the patient is going to feel that the doctor doesn't understand. So, increasing the time you initially spend with the patient can save a lot of headaches further down the line,” Dr. Sullivan explained.

Active listening has even been shown to reduce a patient's perception of pain, at least in the context of acute symptoms, said Dr. Sullivan, who has published several studies showing that allowing catastrophizers to disclose their fear and worry prior to routine dental hygiene procedures can reduce their perception of pain by as much as 50% (J. Indiana Dent. Assoc. 2000-2001;79:16-9; Pain 1999;79:155-63).

Although a patient's basic personality is a challenge for physicians to work around, attitude – which is also an extremely powerful modifier of pain – is somewhat easier to mold, suggested Stefaan Van Damme, Ph.D., of the department of experimental clinical health and psychology at Ghent (Belgium) University.

In approaching pain control as a goal, chronic pain patients fall into two distinct categories: those who try to overcome it (assimilators) and those who accept it (accommodators). Both attitudes can be helpful or harmful, depending on how realistic pain control is for a particular patient, he said at the meeting.

“When pain is controllable, assimilative coping works. But when it is not controllable, it can be maladaptive because it can exacerbate catastrophizing, hypervigilance, and distress,” he said. In a study, he demonstrated that, when attempts to avoid pain are unsuccessful, “individuals persist in their avoidance attempts, try harder, and narrow their focus of attention upon the problem to be solved” (Pain 2008;137:631-9).

Helping patients shift their focus from fighting to accepting their pain is particularly tricky for physicians, commented Dr. Sullivan, who is a psychologist.

“I only get sent the patients when their pain has been long-standing. The concept of acceptance works when the pain has been there for 5 years,” he explained, “but for new-onset pain, acceptance is not the message that should be given by the doctor. This should only come up after we've offered everything else we can offer.”

Physicians should also be aware of their own personal psychology when dealing with catastrophizing patients, because catastrophizing personalities are not confined to the patient world. Physicians who are catastrophizers may inadvertently increase a patient's perception of suffering.

“Some of our research suggests that if you're a catastrophizer you see 30% more pain in these individuals,” he said, and this could impact a physician's decisions about treatment intervention as well the physician's advice surrounding acceptance.

Disclosures: The speakers did not declare any conflicts of interest.

MONTREAL – Personality and attitude play a major role in shaping a patient's experience of chronic pain, and understanding this dynamic may help physicians overcome obstacles in treating some of their unresponsive patients, according to Michael Sullivan, Ph.D.

In fact, in recent studies, catastrophizing has emerged as “the most powerful psychological predictor of problematic pain outcomes,” said Dr. Sullivan, professor of psychology, medicine, and neurology at McGill University in Montreal.

In the context of pain, catastrophizing is defined as the tendency to worry and focus on the pain. Individuals who score high on the Pain Catastrophizing Scale (PCS), which was developed by Dr. Sullivan in 1995, tend to magnify and ruminate over their symptoms while feeling helpless about addressing them. “These individuals have an excessively alarmist attitude toward their pain and seem to have a lot more difficulty dealing with it,” he said at the meeting.

In the office setting, chronic pain patients who catastrophize “display more pain behavior such as holding, rubbing, [and] guarding, as well as vocalizations such as moans and sighs,” he said at the meeting, sponsored by the International Association for the Study of Pain.

“Research shows that not only are catastrophizers going to have more difficulty in pain situations, they are also going to respond less well to the interventions that we offer them,” he said. In studies, Dr. Sullivan and his colleagues have shown that, compared with noncatastrophizers, catastrophizers are at greater risk of chronic pain following knee arthroplasty (Pain Res. Manag. 2008;13:335-41) and have more difficulty returning to work after whiplash injuries (J. Occup. Rehabil. 2007;17:305-15).

For patients whose chronic pain stems from an accident, perceptions of injustice also are common and can be expressed as anger or noncompliance. “Some of our recent research [Pain 2009;145:325-31] shows that perceptions of injustice are often associated with prolonged disability following a pain-related injury,” he said. For the treating physician, “validation techniques can be useful in reducing the negative impact of the catastrophizing patient's perceptions of injustice.”

By identifying catastrophizers early, physicians can avoid pitfalls that contribute to treatment failure in chronic pain. “There are some very concrete ways in which physicians could be reacting differently with these patients” to make patient management easier, he pointed out.

First and foremost, catastrophizers need to express their suffering and anxiety. “This person does have a story to tell and they need someone to listen. By not listening properly to that story initially, you are going to hear it again every time the patient comes, because the patient is going to feel that the doctor doesn't understand. So, increasing the time you initially spend with the patient can save a lot of headaches further down the line,” Dr. Sullivan explained.

Active listening has even been shown to reduce a patient's perception of pain, at least in the context of acute symptoms, said Dr. Sullivan, who has published several studies showing that allowing catastrophizers to disclose their fear and worry prior to routine dental hygiene procedures can reduce their perception of pain by as much as 50% (J. Indiana Dent. Assoc. 2000-2001;79:16-9; Pain 1999;79:155-63).

Although a patient's basic personality is a challenge for physicians to work around, attitude – which is also an extremely powerful modifier of pain – is somewhat easier to mold, suggested Stefaan Van Damme, Ph.D., of the department of experimental clinical health and psychology at Ghent (Belgium) University.

In approaching pain control as a goal, chronic pain patients fall into two distinct categories: those who try to overcome it (assimilators) and those who accept it (accommodators). Both attitudes can be helpful or harmful, depending on how realistic pain control is for a particular patient, he said at the meeting.

“When pain is controllable, assimilative coping works. But when it is not controllable, it can be maladaptive because it can exacerbate catastrophizing, hypervigilance, and distress,” he said. In a study, he demonstrated that, when attempts to avoid pain are unsuccessful, “individuals persist in their avoidance attempts, try harder, and narrow their focus of attention upon the problem to be solved” (Pain 2008;137:631-9).

Helping patients shift their focus from fighting to accepting their pain is particularly tricky for physicians, commented Dr. Sullivan, who is a psychologist.

“I only get sent the patients when their pain has been long-standing. The concept of acceptance works when the pain has been there for 5 years,” he explained, “but for new-onset pain, acceptance is not the message that should be given by the doctor. This should only come up after we've offered everything else we can offer.”

Physicians should also be aware of their own personal psychology when dealing with catastrophizing patients, because catastrophizing personalities are not confined to the patient world. Physicians who are catastrophizers may inadvertently increase a patient's perception of suffering.

“Some of our research suggests that if you're a catastrophizer you see 30% more pain in these individuals,” he said, and this could impact a physician's decisions about treatment intervention as well the physician's advice surrounding acceptance.

Disclosures: The speakers did not declare any conflicts of interest.

MONTREAL – Personality and attitude play a major role in shaping a patient's experience of chronic pain, and understanding this dynamic may help physicians overcome obstacles in treating some of their unresponsive patients, according to Michael Sullivan, Ph.D.

In fact, in recent studies, catastrophizing has emerged as “the most powerful psychological predictor of problematic pain outcomes,” said Dr. Sullivan, professor of psychology, medicine, and neurology at McGill University in Montreal.

In the context of pain, catastrophizing is defined as the tendency to worry and focus on the pain. Individuals who score high on the Pain Catastrophizing Scale (PCS), which was developed by Dr. Sullivan in 1995, tend to magnify and ruminate over their symptoms while feeling helpless about addressing them. “These individuals have an excessively alarmist attitude toward their pain and seem to have a lot more difficulty dealing with it,” he said at the meeting.

In the office setting, chronic pain patients who catastrophize “display more pain behavior such as holding, rubbing, [and] guarding, as well as vocalizations such as moans and sighs,” he said at the meeting, sponsored by the International Association for the Study of Pain.

“Research shows that not only are catastrophizers going to have more difficulty in pain situations, they are also going to respond less well to the interventions that we offer them,” he said. In studies, Dr. Sullivan and his colleagues have shown that, compared with noncatastrophizers, catastrophizers are at greater risk of chronic pain following knee arthroplasty (Pain Res. Manag. 2008;13:335-41) and have more difficulty returning to work after whiplash injuries (J. Occup. Rehabil. 2007;17:305-15).

For patients whose chronic pain stems from an accident, perceptions of injustice also are common and can be expressed as anger or noncompliance. “Some of our recent research [Pain 2009;145:325-31] shows that perceptions of injustice are often associated with prolonged disability following a pain-related injury,” he said. For the treating physician, “validation techniques can be useful in reducing the negative impact of the catastrophizing patient's perceptions of injustice.”

By identifying catastrophizers early, physicians can avoid pitfalls that contribute to treatment failure in chronic pain. “There are some very concrete ways in which physicians could be reacting differently with these patients” to make patient management easier, he pointed out.

First and foremost, catastrophizers need to express their suffering and anxiety. “This person does have a story to tell and they need someone to listen. By not listening properly to that story initially, you are going to hear it again every time the patient comes, because the patient is going to feel that the doctor doesn't understand. So, increasing the time you initially spend with the patient can save a lot of headaches further down the line,” Dr. Sullivan explained.

Active listening has even been shown to reduce a patient's perception of pain, at least in the context of acute symptoms, said Dr. Sullivan, who has published several studies showing that allowing catastrophizers to disclose their fear and worry prior to routine dental hygiene procedures can reduce their perception of pain by as much as 50% (J. Indiana Dent. Assoc. 2000-2001;79:16-9; Pain 1999;79:155-63).

Although a patient's basic personality is a challenge for physicians to work around, attitude – which is also an extremely powerful modifier of pain – is somewhat easier to mold, suggested Stefaan Van Damme, Ph.D., of the department of experimental clinical health and psychology at Ghent (Belgium) University.

In approaching pain control as a goal, chronic pain patients fall into two distinct categories: those who try to overcome it (assimilators) and those who accept it (accommodators). Both attitudes can be helpful or harmful, depending on how realistic pain control is for a particular patient, he said at the meeting.

“When pain is controllable, assimilative coping works. But when it is not controllable, it can be maladaptive because it can exacerbate catastrophizing, hypervigilance, and distress,” he said. In a study, he demonstrated that, when attempts to avoid pain are unsuccessful, “individuals persist in their avoidance attempts, try harder, and narrow their focus of attention upon the problem to be solved” (Pain 2008;137:631-9).

Helping patients shift their focus from fighting to accepting their pain is particularly tricky for physicians, commented Dr. Sullivan, who is a psychologist.

“I only get sent the patients when their pain has been long-standing. The concept of acceptance works when the pain has been there for 5 years,” he explained, “but for new-onset pain, acceptance is not the message that should be given by the doctor. This should only come up after we've offered everything else we can offer.”

Physicians should also be aware of their own personal psychology when dealing with catastrophizing patients, because catastrophizing personalities are not confined to the patient world. Physicians who are catastrophizers may inadvertently increase a patient's perception of suffering.

“Some of our research suggests that if you're a catastrophizer you see 30% more pain in these individuals,” he said, and this could impact a physician's decisions about treatment intervention as well the physician's advice surrounding acceptance.

Disclosures: The speakers did not declare any conflicts of interest.

MONTREAL – Personality and attitude play a major role in shaping a patient’s experience of chronic pain, and understanding this dynamic may help physicians overcome obstacles in treating some of their unresponsive patients, according to Michael Sullivan, Ph.D.

In fact, in recent studies, catastrophizing has emerged as “the most powerful psychological predictor of problematic pain outcomes,” said Dr. Sullivan, professor of psychology, medicine, and neurology at McGill University in Montreal.

In the context of pain, catastrophizing is defined as the tendency to worry and focus on the pain. Individuals who score high on the Pain Catastrophizing Scale (PCS), which was developed by Dr. Sullivan in 1995, tend to magnify and ruminate over their symptoms while feeling helpless about addressing them. “These individuals have an excessively alarmist attitude towards their pain and seem to have a lot more difficulty dealing with it,” he said at the World Congress on Pain.

In the office setting, chronic pain patients who catastrophize “display more pain behavior such as holding, rubbing, guarding, as well as vocalizations such as moans and sighs,” he said at the meeting, which was sponsored by the International Association for the Study of Pain.

“Research shows that not only are catastrophizers going to have more difficulty in pain situations, they are also going to respond less well to the interventions that we offer them,” he said. In studies, Dr. Sullivan and his colleagues have shown that, compared with noncatastrophizers, catastrophizers are at greater risk of chronic pain following knee arthroplasty (Pain Res. Manag. 2008;13:335-41) and have more difficulty returning to work after whiplash injuries (J. Occup. Rehabil. 2007;17:305-15).

For patients whose chronic pain stems from an accident, perceptions of injustice also are common and can be expressed as anger or noncompliance. “Some of our recent research [Pain 2009;145:325-31] shows that perceptions of injustice are often associated with prolonged disability following a pain-related injury,” he said. For the treating physician, “validation techniques can be useful in reducing the negative impact of the catastrophizing patient’s perceptions of injustice.”

By identifying catastrophizers early, physicians can avoid pitfalls that contribute to treatment failure in chronic pain. “There are some very concrete ways in which physicians could be reacting differently with these patients” to make patient management easier, he pointed out.

First and foremost, catastrophizers need to express their suffering and anxiety. “This person does have a story to tell and they need someone to listen. By not listening properly to that story initially, you are going to hear it again every time the patient comes, because the patient is going to feel that the doctor doesn’t understand. So, increasing the time you initially spend with the patient can save a lot of headaches further down the line,” Dr. Sullivan explained.

Active listening has even been shown to reduce a patient’s perception of pain, at least in the context of acute symptoms, said Dr. Sullivan, who has published several studies showing that allowing catastrophizers to disclose their fear and worry prior to routine dental hygiene procedures can reduce their perception of pain by as much as 50% (J. Indiana Dent. Assoc. 2000-2001;79:16-9; and Pain 1999;79:155-63).

Although a patient’s basic personality is a challenge for physicians to work around, attitude – which is also an extremely powerful modifier of pain – is somewhat easier to mold, suggested Stefaan Van Damme, Ph.D., of the department of experimental clinical health and psychology at Ghent (Belgium) University.

In approaching pain control as a goal, chronic pain patients fall into two distinct categories: those who try to overcome it (assimilators) and those who accept it (accommodators). Both attitudes can be helpful or harmful, depending on how realistic pain control is for a particular patient, he said at the meeting.

“When pain is controllable, assimilative coping works. But when it is not controllable it can be maladaptive because it can exacerbate catastrophizing, hypervigilance, and distress,” he said. In a study, he demonstrated that, when attempts to avoid pain are unsuccessful, “individuals persist in their avoidance attempts, try harder, and narrow their focus of attention upon the problem to be solved” (Pain 2008;137:631-9).

Helping patients shift their focus from fighting to accepting their pain is particularly tricky for physicians, commented Dr. Sullivan, who is a psychologist. “I only get sent the patients when their pain has been long-standing. The concept of acceptance works when the pain has been there for 5 years,” he explained, “but for new-onset pain, acceptance is not the message that should be given by the doctor. This should only come up after we’ve offered everything else we can offer.”

Physicians should also be aware of their own personal psychology when dealing with catastrophizing patients, because catastrophizing personalities are not confined to the patient world. Physicians who are catastrophizers may inadvertently increase a patient’s perception of suffering. “Some of our research suggests that if you’re a catastrophizer you see 30% more pain in these individuals,” he said, and this could impact a physician’s decisions about treatment intervention as well their advice surrounding acceptance.

The speakers did not declare any conflicts of interest.

MONTREAL – Personality and attitude play a major role in shaping a patient’s experience of chronic pain, and understanding this dynamic may help physicians overcome obstacles in treating some of their unresponsive patients, according to Michael Sullivan, Ph.D.

In fact, in recent studies, catastrophizing has emerged as “the most powerful psychological predictor of problematic pain outcomes,” said Dr. Sullivan, professor of psychology, medicine, and neurology at McGill University in Montreal.

In the context of pain, catastrophizing is defined as the tendency to worry and focus on the pain. Individuals who score high on the Pain Catastrophizing Scale (PCS), which was developed by Dr. Sullivan in 1995, tend to magnify and ruminate over their symptoms while feeling helpless about addressing them. “These individuals have an excessively alarmist attitude towards their pain and seem to have a lot more difficulty dealing with it,” he said at the World Congress on Pain.

In the office setting, chronic pain patients who catastrophize “display more pain behavior such as holding, rubbing, guarding, as well as vocalizations such as moans and sighs,” he said at the meeting, which was sponsored by the International Association for the Study of Pain.

“Research shows that not only are catastrophizers going to have more difficulty in pain situations, they are also going to respond less well to the interventions that we offer them,” he said. In studies, Dr. Sullivan and his colleagues have shown that, compared with noncatastrophizers, catastrophizers are at greater risk of chronic pain following knee arthroplasty (Pain Res. Manag. 2008;13:335-41) and have more difficulty returning to work after whiplash injuries (J. Occup. Rehabil. 2007;17:305-15).

For patients whose chronic pain stems from an accident, perceptions of injustice also are common and can be expressed as anger or noncompliance. “Some of our recent research [Pain 2009;145:325-31] shows that perceptions of injustice are often associated with prolonged disability following a pain-related injury,” he said. For the treating physician, “validation techniques can be useful in reducing the negative impact of the catastrophizing patient’s perceptions of injustice.”

By identifying catastrophizers early, physicians can avoid pitfalls that contribute to treatment failure in chronic pain. “There are some very concrete ways in which physicians could be reacting differently with these patients” to make patient management easier, he pointed out.

First and foremost, catastrophizers need to express their suffering and anxiety. “This person does have a story to tell and they need someone to listen. By not listening properly to that story initially, you are going to hear it again every time the patient comes, because the patient is going to feel that the doctor doesn’t understand. So, increasing the time you initially spend with the patient can save a lot of headaches further down the line,” Dr. Sullivan explained.

Active listening has even been shown to reduce a patient’s perception of pain, at least in the context of acute symptoms, said Dr. Sullivan, who has published several studies showing that allowing catastrophizers to disclose their fear and worry prior to routine dental hygiene procedures can reduce their perception of pain by as much as 50% (J. Indiana Dent. Assoc. 2000-2001;79:16-9; and Pain 1999;79:155-63).

Although a patient’s basic personality is a challenge for physicians to work around, attitude – which is also an extremely powerful modifier of pain – is somewhat easier to mold, suggested Stefaan Van Damme, Ph.D., of the department of experimental clinical health and psychology at Ghent (Belgium) University.

In approaching pain control as a goal, chronic pain patients fall into two distinct categories: those who try to overcome it (assimilators) and those who accept it (accommodators). Both attitudes can be helpful or harmful, depending on how realistic pain control is for a particular patient, he said at the meeting.

“When pain is controllable, assimilative coping works. But when it is not controllable it can be maladaptive because it can exacerbate catastrophizing, hypervigilance, and distress,” he said. In a study, he demonstrated that, when attempts to avoid pain are unsuccessful, “individuals persist in their avoidance attempts, try harder, and narrow their focus of attention upon the problem to be solved” (Pain 2008;137:631-9).

Helping patients shift their focus from fighting to accepting their pain is particularly tricky for physicians, commented Dr. Sullivan, who is a psychologist. “I only get sent the patients when their pain has been long-standing. The concept of acceptance works when the pain has been there for 5 years,” he explained, “but for new-onset pain, acceptance is not the message that should be given by the doctor. This should only come up after we’ve offered everything else we can offer.”

Physicians should also be aware of their own personal psychology when dealing with catastrophizing patients, because catastrophizing personalities are not confined to the patient world. Physicians who are catastrophizers may inadvertently increase a patient’s perception of suffering. “Some of our research suggests that if you’re a catastrophizer you see 30% more pain in these individuals,” he said, and this could impact a physician’s decisions about treatment intervention as well their advice surrounding acceptance.

The speakers did not declare any conflicts of interest.

MONTREAL – Personality and attitude play a major role in shaping a patient’s experience of chronic pain, and understanding this dynamic may help physicians overcome obstacles in treating some of their unresponsive patients, according to Michael Sullivan, Ph.D.

In fact, in recent studies, catastrophizing has emerged as “the most powerful psychological predictor of problematic pain outcomes,” said Dr. Sullivan, professor of psychology, medicine, and neurology at McGill University in Montreal.

In the context of pain, catastrophizing is defined as the tendency to worry and focus on the pain. Individuals who score high on the Pain Catastrophizing Scale (PCS), which was developed by Dr. Sullivan in 1995, tend to magnify and ruminate over their symptoms while feeling helpless about addressing them. “These individuals have an excessively alarmist attitude towards their pain and seem to have a lot more difficulty dealing with it,” he said at the World Congress on Pain.

In the office setting, chronic pain patients who catastrophize “display more pain behavior such as holding, rubbing, guarding, as well as vocalizations such as moans and sighs,” he said at the meeting, which was sponsored by the International Association for the Study of Pain.

“Research shows that not only are catastrophizers going to have more difficulty in pain situations, they are also going to respond less well to the interventions that we offer them,” he said. In studies, Dr. Sullivan and his colleagues have shown that, compared with noncatastrophizers, catastrophizers are at greater risk of chronic pain following knee arthroplasty (Pain Res. Manag. 2008;13:335-41) and have more difficulty returning to work after whiplash injuries (J. Occup. Rehabil. 2007;17:305-15).

For patients whose chronic pain stems from an accident, perceptions of injustice also are common and can be expressed as anger or noncompliance. “Some of our recent research [Pain 2009;145:325-31] shows that perceptions of injustice are often associated with prolonged disability following a pain-related injury,” he said. For the treating physician, “validation techniques can be useful in reducing the negative impact of the catastrophizing patient’s perceptions of injustice.”

By identifying catastrophizers early, physicians can avoid pitfalls that contribute to treatment failure in chronic pain. “There are some very concrete ways in which physicians could be reacting differently with these patients” to make patient management easier, he pointed out.

First and foremost, catastrophizers need to express their suffering and anxiety. “This person does have a story to tell and they need someone to listen. By not listening properly to that story initially, you are going to hear it again every time the patient comes, because the patient is going to feel that the doctor doesn’t understand. So, increasing the time you initially spend with the patient can save a lot of headaches further down the line,” Dr. Sullivan explained.

Active listening has even been shown to reduce a patient’s perception of pain, at least in the context of acute symptoms, said Dr. Sullivan, who has published several studies showing that allowing catastrophizers to disclose their fear and worry prior to routine dental hygiene procedures can reduce their perception of pain by as much as 50% (J. Indiana Dent. Assoc. 2000-2001;79:16-9; and Pain 1999;79:155-63).

Although a patient’s basic personality is a challenge for physicians to work around, attitude – which is also an extremely powerful modifier of pain – is somewhat easier to mold, suggested Stefaan Van Damme, Ph.D., of the department of experimental clinical health and psychology at Ghent (Belgium) University.

In approaching pain control as a goal, chronic pain patients fall into two distinct categories: those who try to overcome it (assimilators) and those who accept it (accommodators). Both attitudes can be helpful or harmful, depending on how realistic pain control is for a particular patient, he said at the meeting.

“When pain is controllable, assimilative coping works. But when it is not controllable it can be maladaptive because it can exacerbate catastrophizing, hypervigilance, and distress,” he said. In a study, he demonstrated that, when attempts to avoid pain are unsuccessful, “individuals persist in their avoidance attempts, try harder, and narrow their focus of attention upon the problem to be solved” (Pain 2008;137:631-9).

Helping patients shift their focus from fighting to accepting their pain is particularly tricky for physicians, commented Dr. Sullivan, who is a psychologist. “I only get sent the patients when their pain has been long-standing. The concept of acceptance works when the pain has been there for 5 years,” he explained, “but for new-onset pain, acceptance is not the message that should be given by the doctor. This should only come up after we’ve offered everything else we can offer.”

Physicians should also be aware of their own personal psychology when dealing with catastrophizing patients, because catastrophizing personalities are not confined to the patient world. Physicians who are catastrophizers may inadvertently increase a patient’s perception of suffering. “Some of our research suggests that if you’re a catastrophizer you see 30% more pain in these individuals,” he said, and this could impact a physician’s decisions about treatment intervention as well their advice surrounding acceptance.

The speakers did not declare any conflicts of interest.

MONTREAL – Psychological interventions such as cognitive behavioral therapy and hypnosis can alter how the brain processes pain, thereby reducing patients’ perception of pain, judging from findings from brain-imaging studies reported recently at the World Congress on Pain.

“This shows how mind and body can work in unison, and one can influence the other,” said Dr. Magdalena Naylor, a psychiatrist and lead investigator of one of the studies performed at the MindBody Medicine Research Clinic and Brain Imaging Program of the University of Vermont, Burlington.

The study, presented as a poster, used functional MRI (fMRI) to show that cognitive behavioral therapy can alter dysfunctional neural circuitry associated with chronic pain. Nine women with chronic pain resulting from low back pain or knee or hip osteoarthritis underwent fMRI before and after an 11-week CBT program for reducing pain and catastrophizing. The women’s mean age was 57.5 years; their pain had an average duration of 11 years.

At baseline, amygdala reactivity in the subjects was different from that of healthy controls when they viewed emotionally upsetting photographs from IAPS (International Affective Picture System). However, this difference disappeared after CBT, with the subjects showing reduced activity in somatosensory, frontal, and limbic areas that are associated with emotional and sensory processing, and increased activation in the left insula, she said. At the same time, the subjects reported decreased pain and better coping. Total Pain Experience scores decreased in correlation with decreased activation in the middle temporal gyrus, and scores on the coping strategies questionnaire subscale of attention diversion. Their score on the Beck Depression Inventory also improved in correlation with decreased activation in the superior frontal gyrus and postcentral gyrus. Dr. Naylor reported that her group has also recently published evidence of reduced pain symptoms and opioid use in a similar population ( J. Pain 2010 July 8 [doi:10.1016/j.jpain.2010.03.019]).

“Our work shows that CBT decreases emotional vulnerability to negative emotions and pain, which go together,” said Dr. Naylor in an interview. “With CBT, these patients are not as emotionally dysregulated.”

Her group is now examining brain structure – specifically thickness of cortices – with similar results. “It’s well documented that patients with chronic pain have thinner cortices, and this is correlated with the duration of pain. So we are very happy to see that with CBT we can reverse this structural damage.”

Hypnosis is another psychological intervention that has been shown to alter pain processing and perception of pain, reported Dr. Marie-Elisabeth Faymonville during a workshop at the meeting. Dr. Faymonville, an anesthesiologist from the University Hospital Li?ge (Belgium), uses hypnosedation, a combination of hypnosis and local anesthesia, to help surgical patients avoid general anesthesia. Findings from functional neuroimaging studies by her group and others have shown that patients under hypnosis show changes in neuronal activity in the presence of painful stimuli, she reported. In one recent study, her group showed that under hypnosis, painful stimuli failed to elicit cerebral activity in the pain network (Neuroimage 2009;47:1047-54).

“Increased functional connectivity between S1 and the prefrontal cortex may represent a top-down modulation of pain,” she noted.

Although Dr. Faymonville’s work demonstrates the impact of hypnosis on acute pain perception, another study presented as a poster at the conference showed the beneficial effect of hypnosis on chronic pain. The study included 41 patients with persistent idiopathic orofacial pain, “that is, pain in the mouth or face which cannot be explained by any kind of known disease,” explained Lene Baad-Hansen, D.D.S., the coinvestigator of the study, in an interview.

The subjects were randomized to five 1-hour sessions of active hypnotic intervention (22 subjects), which included progressive relaxation, guided imagery, and suggestions of controlling and changing pain perception, or to the same number of sessions but with progressive relaxation alone (19 subjects). Quantitative sensory testing (QST) involving the subjects’ ratings of psychophysical stimuli (such as cold, warm, tactile, and pin-prick) was performed on all subjects both before and after the intervention.

Subjective reporting showed that those who had undergone hypnosis reported a 33% reduction in orofacial pain, compared with a 3% reduction in the control group. However, the QST tests showed no differences between the groups either before or after the intervention. “Despite clear clinical pain relief, hypnosis does not influence somatosensory sensitivity, said Dr. Baad-Hansen of the department of clinical oral physiology in the dental school at Aarhus (Denmark) University.

None of the researchers reported any conflicts of interest.

MONTREAL – Psychological interventions such as cognitive behavioral therapy and hypnosis can alter how the brain processes pain, thereby reducing patients’ perception of pain, judging from findings from brain-imaging studies reported recently at the World Congress on Pain.

“This shows how mind and body can work in unison, and one can influence the other,” said Dr. Magdalena Naylor, a psychiatrist and lead investigator of one of the studies performed at the MindBody Medicine Research Clinic and Brain Imaging Program of the University of Vermont, Burlington.

The study, presented as a poster, used functional MRI (fMRI) to show that cognitive behavioral therapy can alter dysfunctional neural circuitry associated with chronic pain. Nine women with chronic pain resulting from low back pain or knee or hip osteoarthritis underwent fMRI before and after an 11-week CBT program for reducing pain and catastrophizing. The women’s mean age was 57.5 years; their pain had an average duration of 11 years.

At baseline, amygdala reactivity in the subjects was different from that of healthy controls when they viewed emotionally upsetting photographs from IAPS (International Affective Picture System). However, this difference disappeared after CBT, with the subjects showing reduced activity in somatosensory, frontal, and limbic areas that are associated with emotional and sensory processing, and increased activation in the left insula, she said. At the same time, the subjects reported decreased pain and better coping. Total Pain Experience scores decreased in correlation with decreased activation in the middle temporal gyrus, and scores on the coping strategies questionnaire subscale of attention diversion. Their score on the Beck Depression Inventory also improved in correlation with decreased activation in the superior frontal gyrus and postcentral gyrus. Dr. Naylor reported that her group has also recently published evidence of reduced pain symptoms and opioid use in a similar population ( J. Pain 2010 July 8 [doi:10.1016/j.jpain.2010.03.019]).

“Our work shows that CBT decreases emotional vulnerability to negative emotions and pain, which go together,” said Dr. Naylor in an interview. “With CBT, these patients are not as emotionally dysregulated.”

Her group is now examining brain structure – specifically thickness of cortices – with similar results. “It’s well documented that patients with chronic pain have thinner cortices, and this is correlated with the duration of pain. So we are very happy to see that with CBT we can reverse this structural damage.”

Hypnosis is another psychological intervention that has been shown to alter pain processing and perception of pain, reported Dr. Marie-Elisabeth Faymonville during a workshop at the meeting. Dr. Faymonville, an anesthesiologist from the University Hospital Li?ge (Belgium), uses hypnosedation, a combination of hypnosis and local anesthesia, to help surgical patients avoid general anesthesia. Findings from functional neuroimaging studies by her group and others have shown that patients under hypnosis show changes in neuronal activity in the presence of painful stimuli, she reported. In one recent study, her group showed that under hypnosis, painful stimuli failed to elicit cerebral activity in the pain network (Neuroimage 2009;47:1047-54).

“Increased functional connectivity between S1 and the prefrontal cortex may represent a top-down modulation of pain,” she noted.

Although Dr. Faymonville’s work demonstrates the impact of hypnosis on acute pain perception, another study presented as a poster at the conference showed the beneficial effect of hypnosis on chronic pain. The study included 41 patients with persistent idiopathic orofacial pain, “that is, pain in the mouth or face which cannot be explained by any kind of known disease,” explained Lene Baad-Hansen, D.D.S., the coinvestigator of the study, in an interview.

The subjects were randomized to five 1-hour sessions of active hypnotic intervention (22 subjects), which included progressive relaxation, guided imagery, and suggestions of controlling and changing pain perception, or to the same number of sessions but with progressive relaxation alone (19 subjects). Quantitative sensory testing (QST) involving the subjects’ ratings of psychophysical stimuli (such as cold, warm, tactile, and pin-prick) was performed on all subjects both before and after the intervention.

Subjective reporting showed that those who had undergone hypnosis reported a 33% reduction in orofacial pain, compared with a 3% reduction in the control group. However, the QST tests showed no differences between the groups either before or after the intervention. “Despite clear clinical pain relief, hypnosis does not influence somatosensory sensitivity, said Dr. Baad-Hansen of the department of clinical oral physiology in the dental school at Aarhus (Denmark) University.

None of the researchers reported any conflicts of interest.

MONTREAL – Psychological interventions such as cognitive behavioral therapy and hypnosis can alter how the brain processes pain, thereby reducing patients’ perception of pain, judging from findings from brain-imaging studies reported recently at the World Congress on Pain.

“This shows how mind and body can work in unison, and one can influence the other,” said Dr. Magdalena Naylor, a psychiatrist and lead investigator of one of the studies performed at the MindBody Medicine Research Clinic and Brain Imaging Program of the University of Vermont, Burlington.

The study, presented as a poster, used functional MRI (fMRI) to show that cognitive behavioral therapy can alter dysfunctional neural circuitry associated with chronic pain. Nine women with chronic pain resulting from low back pain or knee or hip osteoarthritis underwent fMRI before and after an 11-week CBT program for reducing pain and catastrophizing. The women’s mean age was 57.5 years; their pain had an average duration of 11 years.

At baseline, amygdala reactivity in the subjects was different from that of healthy controls when they viewed emotionally upsetting photographs from IAPS (International Affective Picture System). However, this difference disappeared after CBT, with the subjects showing reduced activity in somatosensory, frontal, and limbic areas that are associated with emotional and sensory processing, and increased activation in the left insula, she said. At the same time, the subjects reported decreased pain and better coping. Total Pain Experience scores decreased in correlation with decreased activation in the middle temporal gyrus, and scores on the coping strategies questionnaire subscale of attention diversion. Their score on the Beck Depression Inventory also improved in correlation with decreased activation in the superior frontal gyrus and postcentral gyrus. Dr. Naylor reported that her group has also recently published evidence of reduced pain symptoms and opioid use in a similar population ( J. Pain 2010 July 8 [doi:10.1016/j.jpain.2010.03.019]).

“Our work shows that CBT decreases emotional vulnerability to negative emotions and pain, which go together,” said Dr. Naylor in an interview. “With CBT, these patients are not as emotionally dysregulated.”

Her group is now examining brain structure – specifically thickness of cortices – with similar results. “It’s well documented that patients with chronic pain have thinner cortices, and this is correlated with the duration of pain. So we are very happy to see that with CBT we can reverse this structural damage.”

Hypnosis is another psychological intervention that has been shown to alter pain processing and perception of pain, reported Dr. Marie-Elisabeth Faymonville during a workshop at the meeting. Dr. Faymonville, an anesthesiologist from the University Hospital Li?ge (Belgium), uses hypnosedation, a combination of hypnosis and local anesthesia, to help surgical patients avoid general anesthesia. Findings from functional neuroimaging studies by her group and others have shown that patients under hypnosis show changes in neuronal activity in the presence of painful stimuli, she reported. In one recent study, her group showed that under hypnosis, painful stimuli failed to elicit cerebral activity in the pain network (Neuroimage 2009;47:1047-54).

“Increased functional connectivity between S1 and the prefrontal cortex may represent a top-down modulation of pain,” she noted.

Although Dr. Faymonville’s work demonstrates the impact of hypnosis on acute pain perception, another study presented as a poster at the conference showed the beneficial effect of hypnosis on chronic pain. The study included 41 patients with persistent idiopathic orofacial pain, “that is, pain in the mouth or face which cannot be explained by any kind of known disease,” explained Lene Baad-Hansen, D.D.S., the coinvestigator of the study, in an interview.

The subjects were randomized to five 1-hour sessions of active hypnotic intervention (22 subjects), which included progressive relaxation, guided imagery, and suggestions of controlling and changing pain perception, or to the same number of sessions but with progressive relaxation alone (19 subjects). Quantitative sensory testing (QST) involving the subjects’ ratings of psychophysical stimuli (such as cold, warm, tactile, and pin-prick) was performed on all subjects both before and after the intervention.

Subjective reporting showed that those who had undergone hypnosis reported a 33% reduction in orofacial pain, compared with a 3% reduction in the control group. However, the QST tests showed no differences between the groups either before or after the intervention. “Despite clear clinical pain relief, hypnosis does not influence somatosensory sensitivity, said Dr. Baad-Hansen of the department of clinical oral physiology in the dental school at Aarhus (Denmark) University.

None of the researchers reported any conflicts of interest.

MONTREAL — Uptake of human papillomavirus vaccination is too slow, say some experts, while others still question whether enough is known about the risk-benefit ratio to deem the vaccine truly necessary.

In an industry-sponsored symposium held during the meeting, Dr. William Fisher, a consultant to Merck & Co., strongly urged physicians to make HPV vaccination a routine part of their practice. There are about 100 strains of HPV virus, with 15 considered oncogenic. HPV strains 16 and 18 are responsible for about 70% of cervical cancer, while strains 6 and 11 are responsible for genital warts. Merck's Gardasil vaccine targets all four strains, while Cervarix (GlaxoSmithKline PLC) targets the oncogenic strains 16 and 18.

“HPV vaccine would seem to be a very reasonable form of protection for both men and women who may be sexually active in an environment characterized by a very high level of HPV and in which infection is very common,” as the infection may have serious health consequences for the individual and his or her partner, said Dr. Fisher, professor of psychology and of obstetrics and gynecology at the University of Western Ontario, London.

To illustrate the prevalence of HPV infection, Dr. Fisher noted a 25% rate of infection with high-risk oncogenic strains of HPV among Canadian teenage girls, aged 15–19 years, in a low-risk family practice setting who were negative for HPV the previous year (CMAJ 2003;168:421–5). Similarly, among a group of 621 university-age women tested every 6 months for 2 years, the rate of newly acquired high- and low-risk HPV strains was 13% at 1 year, and 29% and 24% at 2 years (Cancer Epidemiol. Biomarkers Prev. 2003;12:485–90).

“We couldn't be talking more clearly about a sociosexual epidemic,” he said. “This is a social disease on steroids,” said Dr. Fisher, who is also with the center for health, intervention, and prevention at the University of Connecticut, in Storrs.

In a recent study involving young Canadian couples, HPV was present in 64% of new couples and the oncogenic HPV-16 strain was the most common strain found at baseline.

Concordance of strains was 41% at baseline and grew to 68% at 6 months, he said (Epidemiology 2010;21:31–7). “There's no doubt in new relationships that HPV is rapidly becoming part of the sociocultural landscape,” Dr. Fisher said. While there is a well-established link between high-risk HPV and gynecologic cancers, HPV-related head and neck cancers are “probably the newest sexually transmitted infections on the radar,” he said.

In a Swedish study, the prevalence of oncogenic HPV strains in head and neck cancer biopsies was found to have increased from 23% in the 1970s to 77% by 2005 (Int. J. Cancer 2009;125:362–6).

In addition, a 2010 study shows that the risk of HPV-related head and neck cancer, while increased with six or more coital partners (odds ratio, 1.25), more than triples with more than four oral-genital partners (OR, 3.36). “Oral-genital sex is the new handshake, and it is actually likely that people have more oral-genital partners than coital partners,” Dr. Fisher added.

Yet while Canadian and U.S. authorities recommend HPV vaccination in young girls and women, and school-based vaccination programs are offered across Canada, such recommendations have not resulted in mass vaccination, he said. A recent study suggests that only about one-third of American girls, aged 13–17 years, have been vaccinated (Am. J. Prev. Med. 2010;38:525–33).

Dr. Marie Plante, president of the Society of Gynecologic Oncologists of Canada, said that as a gynecologic oncologist she sees the downside of such low vaccination rates. “We treat women with cervical cancer…. I've got several of them in their 20s and early 30s and it ruins their lives, and they can't have children sometimes. So we see the frustrating part because it could have been prevented,” said Dr. Plante, chief of the gynecologic oncology division at Laval University in Quebec City. She estimated that about 50% of cervical cancer cases she sees are in women whose regular screening had failed to identify the disease.

“As much as I am very critical of the push from the companies [to market their vaccines], I will tell you that honestly I think the vaccine is safe,” Dr. Plante continued. However, “it is not necessary,” she said. “It does not guarantee 100% protection. It's an option you have to reduce the chances that you develop precancerous cells. In most cases this will be treated quickly and won't take your life away.” Importantly, the vaccine also reduces the potentially significant burden of genital warts, the experience of which is “amazingly negative”—it's “terrible and painful,” she added.

Last year a prominent editorial and article in JAMA questioned the medical arguments for vaccination, as well as the ethics of aggressive marketing campaigns from pharmaceutical companies (2009;302:795–6, 781-6). “If the potential benefits are substantial, most individuals would be willing to accept the risks. But the net benefit of the HPV vaccine to women is uncertain. Even if persistently infected with HPV, a woman most likely will not develop cancer if she is regularly screened,” wrote Dr. Charlotte Haug, editor-in-chief of the Journal of the Norwegian Medical Association.

In their article, Sheila Rothman, Ph.D., and David Rothman, Ph.D., of Columbia University, New York, noted that in 2006, Merck's Gardasil “was named the pharmaceutical 'brand of the year' for building a 'market out of thin air.'”

Alan Cassels, a drug policy researcher at the University of Victoria (B.C.), was critical. “It's not a slam dunk that if you get the HPV vaccine you'll be prevented from developing cancer,” he said in an interview. He compared the vaccine to cholesterol-lowering drugs. “Yes, we can prove that a drug lowers cholesterol, but the question is whether it prevents heart attacks and strokes. So, while the HPV vaccine may prevent transmission of the virus, will that really result in [fewer] cancers? We won't know for 10 or 20 years down the road.”

Given the uncertainty of benefit, or the duration of efficacy, Mr. Cassels cautioned that the risks of any intervention should be minimal, which is not the case with the HPV vaccine.

As of Jan. 31, 2010, there were 49 U.S. reports of death among females who had received Gardasil, according to the Centers for Disease Control and Prevention. Twenty-eight of these reports have been confirmed and 21 remain unconfirmed. In the 28 confirmed reports, “there was no unusual pattern or clustering to the deaths that would suggest that they were caused by the vaccine,” according to a CDC statement.

Disclosures: Merck sponsored the symposium. Dr. Fisher disclosed that he has been a consultant for Merck, Boehringer Ingelheim, and Bayer. Dr. Plante reported having no conflicts of interest.

MONTREAL — Uptake of human papillomavirus vaccination is too slow, say some experts, while others still question whether enough is known about the risk-benefit ratio to deem the vaccine truly necessary.

In an industry-sponsored symposium held during the meeting, Dr. William Fisher, a consultant to Merck & Co., strongly urged physicians to make HPV vaccination a routine part of their practice. There are about 100 strains of HPV virus, with 15 considered oncogenic. HPV strains 16 and 18 are responsible for about 70% of cervical cancer, while strains 6 and 11 are responsible for genital warts. Merck's Gardasil vaccine targets all four strains, while Cervarix (GlaxoSmithKline PLC) targets the oncogenic strains 16 and 18.

“HPV vaccine would seem to be a very reasonable form of protection for both men and women who may be sexually active in an environment characterized by a very high level of HPV and in which infection is very common,” as the infection may have serious health consequences for the individual and his or her partner, said Dr. Fisher, professor of psychology and of obstetrics and gynecology at the University of Western Ontario, London.

To illustrate the prevalence of HPV infection, Dr. Fisher noted a 25% rate of infection with high-risk oncogenic strains of HPV among Canadian teenage girls, aged 15–19 years, in a low-risk family practice setting who were negative for HPV the previous year (CMAJ 2003;168:421–5). Similarly, among a group of 621 university-age women tested every 6 months for 2 years, the rate of newly acquired high- and low-risk HPV strains was 13% at 1 year, and 29% and 24% at 2 years (Cancer Epidemiol. Biomarkers Prev. 2003;12:485–90).

“We couldn't be talking more clearly about a sociosexual epidemic,” he said. “This is a social disease on steroids,” said Dr. Fisher, who is also with the center for health, intervention, and prevention at the University of Connecticut, in Storrs.

In a recent study involving young Canadian couples, HPV was present in 64% of new couples and the oncogenic HPV-16 strain was the most common strain found at baseline.

Concordance of strains was 41% at baseline and grew to 68% at 6 months, he said (Epidemiology 2010;21:31–7). “There's no doubt in new relationships that HPV is rapidly becoming part of the sociocultural landscape,” Dr. Fisher said. While there is a well-established link between high-risk HPV and gynecologic cancers, HPV-related head and neck cancers are “probably the newest sexually transmitted infections on the radar,” he said.

In a Swedish study, the prevalence of oncogenic HPV strains in head and neck cancer biopsies was found to have increased from 23% in the 1970s to 77% by 2005 (Int. J. Cancer 2009;125:362–6).

In addition, a 2010 study shows that the risk of HPV-related head and neck cancer, while increased with six or more coital partners (odds ratio, 1.25), more than triples with more than four oral-genital partners (OR, 3.36). “Oral-genital sex is the new handshake, and it is actually likely that people have more oral-genital partners than coital partners,” Dr. Fisher added.

Yet while Canadian and U.S. authorities recommend HPV vaccination in young girls and women, and school-based vaccination programs are offered across Canada, such recommendations have not resulted in mass vaccination, he said. A recent study suggests that only about one-third of American girls, aged 13–17 years, have been vaccinated (Am. J. Prev. Med. 2010;38:525–33).

Dr. Marie Plante, president of the Society of Gynecologic Oncologists of Canada, said that as a gynecologic oncologist she sees the downside of such low vaccination rates. “We treat women with cervical cancer…. I've got several of them in their 20s and early 30s and it ruins their lives, and they can't have children sometimes. So we see the frustrating part because it could have been prevented,” said Dr. Plante, chief of the gynecologic oncology division at Laval University in Quebec City. She estimated that about 50% of cervical cancer cases she sees are in women whose regular screening had failed to identify the disease.

“As much as I am very critical of the push from the companies [to market their vaccines], I will tell you that honestly I think the vaccine is safe,” Dr. Plante continued. However, “it is not necessary,” she said. “It does not guarantee 100% protection. It's an option you have to reduce the chances that you develop precancerous cells. In most cases this will be treated quickly and won't take your life away.” Importantly, the vaccine also reduces the potentially significant burden of genital warts, the experience of which is “amazingly negative”—it's “terrible and painful,” she added.

Last year a prominent editorial and article in JAMA questioned the medical arguments for vaccination, as well as the ethics of aggressive marketing campaigns from pharmaceutical companies (2009;302:795–6, 781-6). “If the potential benefits are substantial, most individuals would be willing to accept the risks. But the net benefit of the HPV vaccine to women is uncertain. Even if persistently infected with HPV, a woman most likely will not develop cancer if she is regularly screened,” wrote Dr. Charlotte Haug, editor-in-chief of the Journal of the Norwegian Medical Association.

In their article, Sheila Rothman, Ph.D., and David Rothman, Ph.D., of Columbia University, New York, noted that in 2006, Merck's Gardasil “was named the pharmaceutical 'brand of the year' for building a 'market out of thin air.'”

Alan Cassels, a drug policy researcher at the University of Victoria (B.C.), was critical. “It's not a slam dunk that if you get the HPV vaccine you'll be prevented from developing cancer,” he said in an interview. He compared the vaccine to cholesterol-lowering drugs. “Yes, we can prove that a drug lowers cholesterol, but the question is whether it prevents heart attacks and strokes. So, while the HPV vaccine may prevent transmission of the virus, will that really result in [fewer] cancers? We won't know for 10 or 20 years down the road.”

Given the uncertainty of benefit, or the duration of efficacy, Mr. Cassels cautioned that the risks of any intervention should be minimal, which is not the case with the HPV vaccine.

As of Jan. 31, 2010, there were 49 U.S. reports of death among females who had received Gardasil, according to the Centers for Disease Control and Prevention. Twenty-eight of these reports have been confirmed and 21 remain unconfirmed. In the 28 confirmed reports, “there was no unusual pattern or clustering to the deaths that would suggest that they were caused by the vaccine,” according to a CDC statement.

Disclosures: Merck sponsored the symposium. Dr. Fisher disclosed that he has been a consultant for Merck, Boehringer Ingelheim, and Bayer. Dr. Plante reported having no conflicts of interest.

MONTREAL — Uptake of human papillomavirus vaccination is too slow, say some experts, while others still question whether enough is known about the risk-benefit ratio to deem the vaccine truly necessary.

In an industry-sponsored symposium held during the meeting, Dr. William Fisher, a consultant to Merck & Co., strongly urged physicians to make HPV vaccination a routine part of their practice. There are about 100 strains of HPV virus, with 15 considered oncogenic. HPV strains 16 and 18 are responsible for about 70% of cervical cancer, while strains 6 and 11 are responsible for genital warts. Merck's Gardasil vaccine targets all four strains, while Cervarix (GlaxoSmithKline PLC) targets the oncogenic strains 16 and 18.

“HPV vaccine would seem to be a very reasonable form of protection for both men and women who may be sexually active in an environment characterized by a very high level of HPV and in which infection is very common,” as the infection may have serious health consequences for the individual and his or her partner, said Dr. Fisher, professor of psychology and of obstetrics and gynecology at the University of Western Ontario, London.

To illustrate the prevalence of HPV infection, Dr. Fisher noted a 25% rate of infection with high-risk oncogenic strains of HPV among Canadian teenage girls, aged 15–19 years, in a low-risk family practice setting who were negative for HPV the previous year (CMAJ 2003;168:421–5). Similarly, among a group of 621 university-age women tested every 6 months for 2 years, the rate of newly acquired high- and low-risk HPV strains was 13% at 1 year, and 29% and 24% at 2 years (Cancer Epidemiol. Biomarkers Prev. 2003;12:485–90).

“We couldn't be talking more clearly about a sociosexual epidemic,” he said. “This is a social disease on steroids,” said Dr. Fisher, who is also with the center for health, intervention, and prevention at the University of Connecticut, in Storrs.

In a recent study involving young Canadian couples, HPV was present in 64% of new couples and the oncogenic HPV-16 strain was the most common strain found at baseline.

Concordance of strains was 41% at baseline and grew to 68% at 6 months, he said (Epidemiology 2010;21:31–7). “There's no doubt in new relationships that HPV is rapidly becoming part of the sociocultural landscape,” Dr. Fisher said. While there is a well-established link between high-risk HPV and gynecologic cancers, HPV-related head and neck cancers are “probably the newest sexually transmitted infections on the radar,” he said.

In a Swedish study, the prevalence of oncogenic HPV strains in head and neck cancer biopsies was found to have increased from 23% in the 1970s to 77% by 2005 (Int. J. Cancer 2009;125:362–6).

In addition, a 2010 study shows that the risk of HPV-related head and neck cancer, while increased with six or more coital partners (odds ratio, 1.25), more than triples with more than four oral-genital partners (OR, 3.36). “Oral-genital sex is the new handshake, and it is actually likely that people have more oral-genital partners than coital partners,” Dr. Fisher added.

Yet while Canadian and U.S. authorities recommend HPV vaccination in young girls and women, and school-based vaccination programs are offered across Canada, such recommendations have not resulted in mass vaccination, he said. A recent study suggests that only about one-third of American girls, aged 13–17 years, have been vaccinated (Am. J. Prev. Med. 2010;38:525–33).

Dr. Marie Plante, president of the Society of Gynecologic Oncologists of Canada, said that as a gynecologic oncologist she sees the downside of such low vaccination rates. “We treat women with cervical cancer…. I've got several of them in their 20s and early 30s and it ruins their lives, and they can't have children sometimes. So we see the frustrating part because it could have been prevented,” said Dr. Plante, chief of the gynecologic oncology division at Laval University in Quebec City. She estimated that about 50% of cervical cancer cases she sees are in women whose regular screening had failed to identify the disease.

“As much as I am very critical of the push from the companies [to market their vaccines], I will tell you that honestly I think the vaccine is safe,” Dr. Plante continued. However, “it is not necessary,” she said. “It does not guarantee 100% protection. It's an option you have to reduce the chances that you develop precancerous cells. In most cases this will be treated quickly and won't take your life away.” Importantly, the vaccine also reduces the potentially significant burden of genital warts, the experience of which is “amazingly negative”—it's “terrible and painful,” she added.

Last year a prominent editorial and article in JAMA questioned the medical arguments for vaccination, as well as the ethics of aggressive marketing campaigns from pharmaceutical companies (2009;302:795–6, 781-6). “If the potential benefits are substantial, most individuals would be willing to accept the risks. But the net benefit of the HPV vaccine to women is uncertain. Even if persistently infected with HPV, a woman most likely will not develop cancer if she is regularly screened,” wrote Dr. Charlotte Haug, editor-in-chief of the Journal of the Norwegian Medical Association.

In their article, Sheila Rothman, Ph.D., and David Rothman, Ph.D., of Columbia University, New York, noted that in 2006, Merck's Gardasil “was named the pharmaceutical 'brand of the year' for building a 'market out of thin air.'”

Alan Cassels, a drug policy researcher at the University of Victoria (B.C.), was critical. “It's not a slam dunk that if you get the HPV vaccine you'll be prevented from developing cancer,” he said in an interview. He compared the vaccine to cholesterol-lowering drugs. “Yes, we can prove that a drug lowers cholesterol, but the question is whether it prevents heart attacks and strokes. So, while the HPV vaccine may prevent transmission of the virus, will that really result in [fewer] cancers? We won't know for 10 or 20 years down the road.”

Given the uncertainty of benefit, or the duration of efficacy, Mr. Cassels cautioned that the risks of any intervention should be minimal, which is not the case with the HPV vaccine.

As of Jan. 31, 2010, there were 49 U.S. reports of death among females who had received Gardasil, according to the Centers for Disease Control and Prevention. Twenty-eight of these reports have been confirmed and 21 remain unconfirmed. In the 28 confirmed reports, “there was no unusual pattern or clustering to the deaths that would suggest that they were caused by the vaccine,” according to a CDC statement.

Disclosures: Merck sponsored the symposium. Dr. Fisher disclosed that he has been a consultant for Merck, Boehringer Ingelheim, and Bayer. Dr. Plante reported having no conflicts of interest.

MONTREAL — Uptake of the human papillomavirus vaccination is too slow, say some experts, while others still question whether enough is known about the risk-benefit ratio to deem the vaccination truly necessary.

In an industry-sponsored symposium held during the meeting, Dr. William Fisher, a consultant to Merck, strongly urged physicians to make HPV vaccination a routine part of their practice.

There are about 100 strains of HPV virus, with 15 considered oncogenic. HPV strains 16 and 18 are responsible for about 70% of cervical cancer, while strains 6 and 11 are responsible for genital warts. Merck's Gardasil vaccine targets all four strains, while Cervarix (GlaxoSmithKline PLC) targets the oncogenic strains 16 and 18.

“HPV vaccine would seem to be a very reasonable form of protection, for both men and women, who may be sexually active in an environment characterized by a very high level of HPV,” as the infection may have serious health consequences for the individual and his or her partner, said Dr. Fisher, a professor in the departments of psychology and obstetrics and gynecology at the University of Western Ontario, London.

To illustrate the prevalence of HPV infection, Dr. Fisher noted a 25% rate of infection with high-risk oncogenic strains of HPV among Canadian teenage girls, aged 15-19 years, in a low-risk family practice setting who were negative for HPV the previous year (CMAJ 2003;168:421-5).

Similarly, among a group of 621 university-age women tested every 6 months for 2 years, the rate of newly acquired high- and low-risk HPV strains was 13% at 1 year, and 29% and 24%, respectively, at 2 years (Cancer Epidemiol. Biomarkers Prev. 2003;12:485-90).

“We couldn't be talking more clearly about a sociosexual epidemic,” he said. “This is a social disease on steroids,” said Dr. Fisher, who is also a research affiliate at the Center for Health, Intervention, and Prevention at the University of Connecticut, in Storrs.

In a recent study involving young Canadian couples, HPV was present in 64% of new couples and the oncogenic HPV-16 strain was the most common strain found at baseline.

Concordance of strains was 41% at baseline and grew to 68% at 6 months, he said (Epidemiology 2010;21:31-7). “There's no doubt in new relationships that HPV is rapidly becoming part of the sociocultural landscape,” Dr. Fisher said.

While there is a well-established link between high-risk HPV and gynecologic cancers, HPV-related head and neck cancers are “probably the newest sexually transmitted infections on the radar,” he said.

A recent study shows that in Sweden the prevalence of oncogenic HPV strains in head and neck cancer biopsies has increased from 23% in the 1970s to 77% by 2005 (Int. J. Cancer 2009;125:362-6).

In addition, a study from this year shows that the risk of HPV-related head and neck cancer, while increased with six or more coital partners (odds ratio 1.25), more than triples with more than four oral-genital partners (OR 3.36). “Oral-genital sex is the new handshake, and it is actually likely that people have more oral-genital partners than coital partners,” Dr. Fisher added.

Yet while Canadian and U.S. authorities recommend HPV vaccination in young girls and women, and school-based vaccination programs are offered across Canada, such recommendations have not resulted in mass vaccination, he said. A recent study suggests that only about one-third of American girls, aged 13-17 years, have been vaccinated (Am. J. Prev. Med. 2010;38:525-33).

Dr. Marie Plante, president of the Society of Gynecologic Oncologists of Canada, said that as a gynecologic oncologist she sees the downside of such low vaccination rates. “We treat women with cervical cancer…. I've got several of them in their 20s and early 30s and it ruins their lives, and they can't have children sometimes. So we see the frustrating part because it could have been prevented,” said Dr. Plante, associate professor of obstetrics and gynecology, and chief of the gynecologic oncology division at Laval University in Quebec City. She estimates that about 50% of cervical cancer cases she sees are in women whose regular screening had failed to identify it.

“As much as I am very critical of the push from the companies [to market their vaccines], I will tell you that honestly I think the vaccine is safe,” Dr. Plante continued. Is it necessary? “No, it is not necessary,” she said. “It doesn't guarantee 100% protection. It's an option you have to reduce the chances that you develop precancerous cells. In most cases this will be treated quickly and won't take your life away.” Importantly, the vaccine also reduces the potentially significant burden of genital warts, the experience of which is “amazingly negative”—it's “terrible and painful,” she added.

Last year a prominent editorial and article in the JAMA questioned the medical arguments for vaccination, as well as the ethics of aggressive marketing campaigns from pharmaceutical companies (JAMA 2009;302:795-6, and 781-6).

“If the potential benefits are substantial, most individuals would be willing to accept the risks. But the net benefit of the HPV vaccine to women is uncertain. Even if persistently infected with HPV, a woman most likely will not develop cancer if she is regularly screened,” wrote Dr. Charlotte Haug, editor-in-chief of the Journal of the Norwegian Medical Association.

In their article, Sheila Rothman, Ph.D., and David Rothman, Ph.D., of Columbia University, New York, noted that in 2006, Merck's Gardasil “was named the pharmaceutical 'brand of the year' for building a 'market out of thin air.'”

Alan Cassels, a drug policy researcher at the University of Victoria (B.C.), was critical. “It's not a slam dunk that if you get the HPV vaccine you'll be prevented from developing cancer,” he said in an interview. He compared the vaccine to cholesterol-lowering drugs. “Yes, we can prove that a drug lowers cholesterol, but the question is whether it prevents heart attacks and strokes. So, while the HPV vaccine may prevent transmission of the virus, will that really result in [fewer] cancers? We won't know for 10 or 20 years down the road.”

Given the uncertainty of benefit, or the duration of efficacy, Mr. Cassels cautioned that the risks of any intervention should be minimal, which is not the case with the HPV vaccine, he said.

Merck sponsored the symposium Dr. Fisher disclosed that he has been a consultant for Merck, Boehringer Ingelheim, and Bayer. Dr. Plante reported having no conflicts of interest.

MONTREAL — Uptake of the human papillomavirus vaccination is too slow, say some experts, while others still question whether enough is known about the risk-benefit ratio to deem the vaccination truly necessary.

In an industry-sponsored symposium held during the meeting, Dr. William Fisher, a consultant to Merck, strongly urged physicians to make HPV vaccination a routine part of their practice.

There are about 100 strains of HPV virus, with 15 considered oncogenic. HPV strains 16 and 18 are responsible for about 70% of cervical cancer, while strains 6 and 11 are responsible for genital warts. Merck's Gardasil vaccine targets all four strains, while Cervarix (GlaxoSmithKline PLC) targets the oncogenic strains 16 and 18.

“HPV vaccine would seem to be a very reasonable form of protection, for both men and women, who may be sexually active in an environment characterized by a very high level of HPV,” as the infection may have serious health consequences for the individual and his or her partner, said Dr. Fisher, a professor in the departments of psychology and obstetrics and gynecology at the University of Western Ontario, London.

To illustrate the prevalence of HPV infection, Dr. Fisher noted a 25% rate of infection with high-risk oncogenic strains of HPV among Canadian teenage girls, aged 15-19 years, in a low-risk family practice setting who were negative for HPV the previous year (CMAJ 2003;168:421-5).

Similarly, among a group of 621 university-age women tested every 6 months for 2 years, the rate of newly acquired high- and low-risk HPV strains was 13% at 1 year, and 29% and 24%, respectively, at 2 years (Cancer Epidemiol. Biomarkers Prev. 2003;12:485-90).

“We couldn't be talking more clearly about a sociosexual epidemic,” he said. “This is a social disease on steroids,” said Dr. Fisher, who is also a research affiliate at the Center for Health, Intervention, and Prevention at the University of Connecticut, in Storrs.

In a recent study involving young Canadian couples, HPV was present in 64% of new couples and the oncogenic HPV-16 strain was the most common strain found at baseline.

Concordance of strains was 41% at baseline and grew to 68% at 6 months, he said (Epidemiology 2010;21:31-7). “There's no doubt in new relationships that HPV is rapidly becoming part of the sociocultural landscape,” Dr. Fisher said.

While there is a well-established link between high-risk HPV and gynecologic cancers, HPV-related head and neck cancers are “probably the newest sexually transmitted infections on the radar,” he said.

A recent study shows that in Sweden the prevalence of oncogenic HPV strains in head and neck cancer biopsies has increased from 23% in the 1970s to 77% by 2005 (Int. J. Cancer 2009;125:362-6).

In addition, a study from this year shows that the risk of HPV-related head and neck cancer, while increased with six or more coital partners (odds ratio 1.25), more than triples with more than four oral-genital partners (OR 3.36). “Oral-genital sex is the new handshake, and it is actually likely that people have more oral-genital partners than coital partners,” Dr. Fisher added.

Yet while Canadian and U.S. authorities recommend HPV vaccination in young girls and women, and school-based vaccination programs are offered across Canada, such recommendations have not resulted in mass vaccination, he said. A recent study suggests that only about one-third of American girls, aged 13-17 years, have been vaccinated (Am. J. Prev. Med. 2010;38:525-33).

Dr. Marie Plante, president of the Society of Gynecologic Oncologists of Canada, said that as a gynecologic oncologist she sees the downside of such low vaccination rates. “We treat women with cervical cancer…. I've got several of them in their 20s and early 30s and it ruins their lives, and they can't have children sometimes. So we see the frustrating part because it could have been prevented,” said Dr. Plante, associate professor of obstetrics and gynecology, and chief of the gynecologic oncology division at Laval University in Quebec City. She estimates that about 50% of cervical cancer cases she sees are in women whose regular screening had failed to identify it.

“As much as I am very critical of the push from the companies [to market their vaccines], I will tell you that honestly I think the vaccine is safe,” Dr. Plante continued. Is it necessary? “No, it is not necessary,” she said. “It doesn't guarantee 100% protection. It's an option you have to reduce the chances that you develop precancerous cells. In most cases this will be treated quickly and won't take your life away.” Importantly, the vaccine also reduces the potentially significant burden of genital warts, the experience of which is “amazingly negative”—it's “terrible and painful,” she added.

Last year a prominent editorial and article in the JAMA questioned the medical arguments for vaccination, as well as the ethics of aggressive marketing campaigns from pharmaceutical companies (JAMA 2009;302:795-6, and 781-6).

“If the potential benefits are substantial, most individuals would be willing to accept the risks. But the net benefit of the HPV vaccine to women is uncertain. Even if persistently infected with HPV, a woman most likely will not develop cancer if she is regularly screened,” wrote Dr. Charlotte Haug, editor-in-chief of the Journal of the Norwegian Medical Association.

In their article, Sheila Rothman, Ph.D., and David Rothman, Ph.D., of Columbia University, New York, noted that in 2006, Merck's Gardasil “was named the pharmaceutical 'brand of the year' for building a 'market out of thin air.'”

Alan Cassels, a drug policy researcher at the University of Victoria (B.C.), was critical. “It's not a slam dunk that if you get the HPV vaccine you'll be prevented from developing cancer,” he said in an interview. He compared the vaccine to cholesterol-lowering drugs. “Yes, we can prove that a drug lowers cholesterol, but the question is whether it prevents heart attacks and strokes. So, while the HPV vaccine may prevent transmission of the virus, will that really result in [fewer] cancers? We won't know for 10 or 20 years down the road.”

Given the uncertainty of benefit, or the duration of efficacy, Mr. Cassels cautioned that the risks of any intervention should be minimal, which is not the case with the HPV vaccine, he said.

Merck sponsored the symposium Dr. Fisher disclosed that he has been a consultant for Merck, Boehringer Ingelheim, and Bayer. Dr. Plante reported having no conflicts of interest.

MONTREAL — Uptake of the human papillomavirus vaccination is too slow, say some experts, while others still question whether enough is known about the risk-benefit ratio to deem the vaccination truly necessary.

In an industry-sponsored symposium held during the meeting, Dr. William Fisher, a consultant to Merck, strongly urged physicians to make HPV vaccination a routine part of their practice.

There are about 100 strains of HPV virus, with 15 considered oncogenic. HPV strains 16 and 18 are responsible for about 70% of cervical cancer, while strains 6 and 11 are responsible for genital warts. Merck's Gardasil vaccine targets all four strains, while Cervarix (GlaxoSmithKline PLC) targets the oncogenic strains 16 and 18.

“HPV vaccine would seem to be a very reasonable form of protection, for both men and women, who may be sexually active in an environment characterized by a very high level of HPV,” as the infection may have serious health consequences for the individual and his or her partner, said Dr. Fisher, a professor in the departments of psychology and obstetrics and gynecology at the University of Western Ontario, London.

To illustrate the prevalence of HPV infection, Dr. Fisher noted a 25% rate of infection with high-risk oncogenic strains of HPV among Canadian teenage girls, aged 15-19 years, in a low-risk family practice setting who were negative for HPV the previous year (CMAJ 2003;168:421-5).

Similarly, among a group of 621 university-age women tested every 6 months for 2 years, the rate of newly acquired high- and low-risk HPV strains was 13% at 1 year, and 29% and 24%, respectively, at 2 years (Cancer Epidemiol. Biomarkers Prev. 2003;12:485-90).

“We couldn't be talking more clearly about a sociosexual epidemic,” he said. “This is a social disease on steroids,” said Dr. Fisher, who is also a research affiliate at the Center for Health, Intervention, and Prevention at the University of Connecticut, in Storrs.

In a recent study involving young Canadian couples, HPV was present in 64% of new couples and the oncogenic HPV-16 strain was the most common strain found at baseline.

Concordance of strains was 41% at baseline and grew to 68% at 6 months, he said (Epidemiology 2010;21:31-7). “There's no doubt in new relationships that HPV is rapidly becoming part of the sociocultural landscape,” Dr. Fisher said.

While there is a well-established link between high-risk HPV and gynecologic cancers, HPV-related head and neck cancers are “probably the newest sexually transmitted infections on the radar,” he said.

A recent study shows that in Sweden the prevalence of oncogenic HPV strains in head and neck cancer biopsies has increased from 23% in the 1970s to 77% by 2005 (Int. J. Cancer 2009;125:362-6).

In addition, a study from this year shows that the risk of HPV-related head and neck cancer, while increased with six or more coital partners (odds ratio 1.25), more than triples with more than four oral-genital partners (OR 3.36). “Oral-genital sex is the new handshake, and it is actually likely that people have more oral-genital partners than coital partners,” Dr. Fisher added.

Yet while Canadian and U.S. authorities recommend HPV vaccination in young girls and women, and school-based vaccination programs are offered across Canada, such recommendations have not resulted in mass vaccination, he said. A recent study suggests that only about one-third of American girls, aged 13-17 years, have been vaccinated (Am. J. Prev. Med. 2010;38:525-33).

Dr. Marie Plante, president of the Society of Gynecologic Oncologists of Canada, said that as a gynecologic oncologist she sees the downside of such low vaccination rates. “We treat women with cervical cancer…. I've got several of them in their 20s and early 30s and it ruins their lives, and they can't have children sometimes. So we see the frustrating part because it could have been prevented,” said Dr. Plante, associate professor of obstetrics and gynecology, and chief of the gynecologic oncology division at Laval University in Quebec City. She estimates that about 50% of cervical cancer cases she sees are in women whose regular screening had failed to identify it.

“As much as I am very critical of the push from the companies [to market their vaccines], I will tell you that honestly I think the vaccine is safe,” Dr. Plante continued. Is it necessary? “No, it is not necessary,” she said. “It doesn't guarantee 100% protection. It's an option you have to reduce the chances that you develop precancerous cells. In most cases this will be treated quickly and won't take your life away.” Importantly, the vaccine also reduces the potentially significant burden of genital warts, the experience of which is “amazingly negative”—it's “terrible and painful,” she added.

Last year a prominent editorial and article in the JAMA questioned the medical arguments for vaccination, as well as the ethics of aggressive marketing campaigns from pharmaceutical companies (JAMA 2009;302:795-6, and 781-6).

“If the potential benefits are substantial, most individuals would be willing to accept the risks. But the net benefit of the HPV vaccine to women is uncertain. Even if persistently infected with HPV, a woman most likely will not develop cancer if she is regularly screened,” wrote Dr. Charlotte Haug, editor-in-chief of the Journal of the Norwegian Medical Association.

In their article, Sheila Rothman, Ph.D., and David Rothman, Ph.D., of Columbia University, New York, noted that in 2006, Merck's Gardasil “was named the pharmaceutical 'brand of the year' for building a 'market out of thin air.'”

Alan Cassels, a drug policy researcher at the University of Victoria (B.C.), was critical. “It's not a slam dunk that if you get the HPV vaccine you'll be prevented from developing cancer,” he said in an interview. He compared the vaccine to cholesterol-lowering drugs. “Yes, we can prove that a drug lowers cholesterol, but the question is whether it prevents heart attacks and strokes. So, while the HPV vaccine may prevent transmission of the virus, will that really result in [fewer] cancers? We won't know for 10 or 20 years down the road.”

Given the uncertainty of benefit, or the duration of efficacy, Mr. Cassels cautioned that the risks of any intervention should be minimal, which is not the case with the HPV vaccine, he said.

Merck sponsored the symposium Dr. Fisher disclosed that he has been a consultant for Merck, Boehringer Ingelheim, and Bayer. Dr. Plante reported having no conflicts of interest.

MONTREAL — Uptake of the human papillomavirus vaccination is too slow, say some experts, while others still question whether enough is known about the risk-benefit ratio to deem the vaccination truly necessary.

In an industry-sponsored symposium held during the annual meeting of the Society of Obstetricians and Gynaecologists of Canada, Dr. William Fisher, a consultant to Merck, strongly urged physicians to make HPV vaccination a routine part of their practice.

There are about 100 strains of HPV, with 15 considered oncogenic. HPV strains 16 and 18 are responsible for about 70% of cervical cancer, while strains 6 and 11 are responsible for genital warts. Merck’s Gardasil vaccine targets all four strains, while Cervarix (GlaxoSmithKline PLC) targets the oncogenic strains 16 and 18.

“HPV vaccine would seem to be a very reasonable form of protection, for both men and women, who may be sexually active in an environment characterized by a very high level of HPV and in which infection is very common,” as the infection may have serious health consequences for the individual and his or her partner, said Dr. Fisher, a professor in the departments of psychology and obstetrics and gynecology at the University of Western Ontario, London.

To illustrate the prevalence of HPV infection, Dr. Fisher noted a 25% rate of infection with high-risk oncogenic strains of HPV among Canadian teenage girls, aged 15-19 years, in a low-risk setting who were negative for HPV the previous year (CMAJ 2003;168:421-5).

Similarly, among a group of 621 university-age women tested every 6 months for 2 years, the rate of newly acquired high- and low-risk HPV strains was 13% at 1 year, and 29% and 24% respectively at 2 years (Cancer Epidemiol Biomarkers Prev. 2003;12:485-90).

“We couldn’t be talking more clearly about a sociosexual epidemic,” he said. “This is a social disease on steroids,” said Dr. Fisher, who is also a research affiliate at the Center for Health, Intervention, and Prevention at the University of Connecticut, in Storrs.

In a recent study involving young Canadian couples, HPV was present in 64% of new couples and the oncogenic HPV-16 strain was the most common strain found at baseline.

Concordance of strains was 41% at baseline and grew to 68% at 6 months, he said (Epidemiology 2010;21:31-7). “There’s no doubt in new relationships that HPV is rapidly becoming part of the sociocultural landscape,” Dr. Fisher said.

While there is a well-established link between high-risk HPV and gynecologic cancers, HPV-related head and neck cancers are “probably the newest sexually transmitted infections on the radar,” he said.

A recent study shows that in Sweden the prevalence of oncogenic HPV strains in head and neck cancer biopsies has increased from 23% in the 1970s to 77% by 2005 (Int. J. Cancer 2009;125:362-6).

In addition, a study from this year shows that the risk of HPV-related head and neck cancer, while increased with six or more coital partners (odds ratio 1.25), more than triples with more than four oral-genital partners (OR 3.36). “Oral-genital sex is the new handshake, and it is actually likely that people have more oral-genital partners than coital partners,” Dr. Fisher added.

Yet while Canadian and U.S. authorities recommend HPV vaccination in young girls and women, and school-based vaccination programs are offered across Canada, such recommendations have not resulted in mass vaccination, he said. A recent study suggests that only about one-third of American girls, aged 13-17 years, have been vaccinated (Am. J. Prev. Med. 2010;38:525-33).

Dr. Marie Plante, president of the Society of Gynecologic Oncologists of Canada, said that as a gynecologic oncologist she sees the downside of such low vaccination rates. “We treat women with cervical cancer ... I’ve got several of them in their 20s and early 30s and it ruins their lives, and they can’t have children sometimes. So we see the frustrating part because it could have been prevented,” said Dr. Plante, associate professor of obstetrics and gynecology, and chief of the gynecologic oncology division at Laval University in Quebec City. She estimates that about 50% of cervical cancer cases she sees are in women whose regular screening had failed to identify it.

“As much as I am very critical of the push from the companies [to market their vaccines] I will tell you that honestly I think the vaccine is safe,” Dr. Plante continued. Is it necessary? “No, it is not necessary,” she said. “It doesn’t guarantee 100% protection. It’s an option you have to reduce the chances that you develop precancerous cells. In most cases this will be treated quickly and won’t take your life away.” Importantly, the vaccine also reduces the potentially significant burden of genital warts, the experience of which is “amazingly negative” – it’s “terrible and painful,” she added.

Last year a prominent article and editorial in the JAMA questioned the medical arguments for vaccination, as well as the ethics of aggressive marketing campaigns from pharmaceutical companies (JAMA 2009;302:795-6, and 781-6).

“If the potential benefits are substantial, most individuals would be willing to accept the risks. But the net benefit of the HPV vaccine to women is uncertain. Even if persistently infected with HPV, a woman most likely will not develop cancer if she is regularly screened,” wrote Dr. Charlotte Haug, editor-in-chief of the Journal of the Norwegian Medical Association.

In their article, Sheila Rothman, Ph.D., and David Rothman, Ph.D., of Columbia University, New York, noted that in 2006, Merck’s Gardasil “was named the pharmaceutical ‘brand of the year’ for building a ‘market out of thin air.’ ”

Alan Cassels, a drug policy researcher at the University of Victoria (B.C.), was critical. “It’s not a slam dunk that if you get the HPV vaccine you’ll be prevented from developing cancer,” he said in an interview. He compared the vaccine to cholesterol-lowering drugs. “Yes, we can prove that a drug lowers cholesterol, but the question is whether it prevents heart attacks and strokes. So, while the HPV vaccine may prevent transmission of the virus, will that really result in [fewer] cancers? We won’t know for 10 or 20 years down the road.”

Given the uncertainty of benefit, or the duration of efficacy, Mr. Cassels cautioned that the risks of any intervention should be minimal, which is not the case with the HPV vaccine, he said.

As of Jan. 31, 2010, there were 49 U.S. reports of death among females who had received Gardasil, according to the Centers for Disease Control and Prevention. Twenty eight of these reports have been confirmed and 21 remain unconfirmed. In the 28 confirmed reports, “there was no unusual pattern or clustering to the deaths that would suggest that they were caused by the vaccine,” according to a CDC statement.

Merck sponsored the symposium Dr. Fisher disclosed that he has been a consultant for Merck, Boehringer Ingelheim and Bayer. Dr. Plante reported having no conflicts of interest.

MONTREAL — Uptake of the human papillomavirus vaccination is too slow, say some experts, while others still question whether enough is known about the risk-benefit ratio to deem the vaccination truly necessary.

In an industry-sponsored symposium held during the annual meeting of the Society of Obstetricians and Gynaecologists of Canada, Dr. William Fisher, a consultant to Merck, strongly urged physicians to make HPV vaccination a routine part of their practice.

There are about 100 strains of HPV, with 15 considered oncogenic. HPV strains 16 and 18 are responsible for about 70% of cervical cancer, while strains 6 and 11 are responsible for genital warts. Merck’s Gardasil vaccine targets all four strains, while Cervarix (GlaxoSmithKline PLC) targets the oncogenic strains 16 and 18.

“HPV vaccine would seem to be a very reasonable form of protection, for both men and women, who may be sexually active in an environment characterized by a very high level of HPV and in which infection is very common,” as the infection may have serious health consequences for the individual and his or her partner, said Dr. Fisher, a professor in the departments of psychology and obstetrics and gynecology at the University of Western Ontario, London.

To illustrate the prevalence of HPV infection, Dr. Fisher noted a 25% rate of infection with high-risk oncogenic strains of HPV among Canadian teenage girls, aged 15-19 years, in a low-risk setting who were negative for HPV the previous year (CMAJ 2003;168:421-5).

Similarly, among a group of 621 university-age women tested every 6 months for 2 years, the rate of newly acquired high- and low-risk HPV strains was 13% at 1 year, and 29% and 24% respectively at 2 years (Cancer Epidemiol Biomarkers Prev. 2003;12:485-90).

“We couldn’t be talking more clearly about a sociosexual epidemic,” he said. “This is a social disease on steroids,” said Dr. Fisher, who is also a research affiliate at the Center for Health, Intervention, and Prevention at the University of Connecticut, in Storrs.

In a recent study involving young Canadian couples, HPV was present in 64% of new couples and the oncogenic HPV-16 strain was the most common strain found at baseline.

Concordance of strains was 41% at baseline and grew to 68% at 6 months, he said (Epidemiology 2010;21:31-7). “There’s no doubt in new relationships that HPV is rapidly becoming part of the sociocultural landscape,” Dr. Fisher said.

While there is a well-established link between high-risk HPV and gynecologic cancers, HPV-related head and neck cancers are “probably the newest sexually transmitted infections on the radar,” he said.

A recent study shows that in Sweden the prevalence of oncogenic HPV strains in head and neck cancer biopsies has increased from 23% in the 1970s to 77% by 2005 (Int. J. Cancer 2009;125:362-6).

In addition, a study from this year shows that the risk of HPV-related head and neck cancer, while increased with six or more coital partners (odds ratio 1.25), more than triples with more than four oral-genital partners (OR 3.36). “Oral-genital sex is the new handshake, and it is actually likely that people have more oral-genital partners than coital partners,” Dr. Fisher added.

Yet while Canadian and U.S. authorities recommend HPV vaccination in young girls and women, and school-based vaccination programs are offered across Canada, such recommendations have not resulted in mass vaccination, he said. A recent study suggests that only about one-third of American girls, aged 13-17 years, have been vaccinated (Am. J. Prev. Med. 2010;38:525-33).

Dr. Marie Plante, president of the Society of Gynecologic Oncologists of Canada, said that as a gynecologic oncologist she sees the downside of such low vaccination rates. “We treat women with cervical cancer ... I’ve got several of them in their 20s and early 30s and it ruins their lives, and they can’t have children sometimes. So we see the frustrating part because it could have been prevented,” said Dr. Plante, associate professor of obstetrics and gynecology, and chief of the gynecologic oncology division at Laval University in Quebec City. She estimates that about 50% of cervical cancer cases she sees are in women whose regular screening had failed to identify it.

“As much as I am very critical of the push from the companies [to market their vaccines] I will tell you that honestly I think the vaccine is safe,” Dr. Plante continued. Is it necessary? “No, it is not necessary,” she said. “It doesn’t guarantee 100% protection. It’s an option you have to reduce the chances that you develop precancerous cells. In most cases this will be treated quickly and won’t take your life away.” Importantly, the vaccine also reduces the potentially significant burden of genital warts, the experience of which is “amazingly negative” – it’s “terrible and painful,” she added.

Last year a prominent article and editorial in the JAMA questioned the medical arguments for vaccination, as well as the ethics of aggressive marketing campaigns from pharmaceutical companies (JAMA 2009;302:795-6, and 781-6).

“If the potential benefits are substantial, most individuals would be willing to accept the risks. But the net benefit of the HPV vaccine to women is uncertain. Even if persistently infected with HPV, a woman most likely will not develop cancer if she is regularly screened,” wrote Dr. Charlotte Haug, editor-in-chief of the Journal of the Norwegian Medical Association.

In their article, Sheila Rothman, Ph.D., and David Rothman, Ph.D., of Columbia University, New York, noted that in 2006, Merck’s Gardasil “was named the pharmaceutical ‘brand of the year’ for building a ‘market out of thin air.’ ”

Alan Cassels, a drug policy researcher at the University of Victoria (B.C.), was critical. “It’s not a slam dunk that if you get the HPV vaccine you’ll be prevented from developing cancer,” he said in an interview. He compared the vaccine to cholesterol-lowering drugs. “Yes, we can prove that a drug lowers cholesterol, but the question is whether it prevents heart attacks and strokes. So, while the HPV vaccine may prevent transmission of the virus, will that really result in [fewer] cancers? We won’t know for 10 or 20 years down the road.”

Given the uncertainty of benefit, or the duration of efficacy, Mr. Cassels cautioned that the risks of any intervention should be minimal, which is not the case with the HPV vaccine, he said.

As of Jan. 31, 2010, there were 49 U.S. reports of death among females who had received Gardasil, according to the Centers for Disease Control and Prevention. Twenty eight of these reports have been confirmed and 21 remain unconfirmed. In the 28 confirmed reports, “there was no unusual pattern or clustering to the deaths that would suggest that they were caused by the vaccine,” according to a CDC statement.

Merck sponsored the symposium Dr. Fisher disclosed that he has been a consultant for Merck, Boehringer Ingelheim and Bayer. Dr. Plante reported having no conflicts of interest.

MONTREAL — Uptake of the human papillomavirus vaccination is too slow, say some experts, while others still question whether enough is known about the risk-benefit ratio to deem the vaccination truly necessary.

In an industry-sponsored symposium held during the annual meeting of the Society of Obstetricians and Gynaecologists of Canada, Dr. William Fisher, a consultant to Merck, strongly urged physicians to make HPV vaccination a routine part of their practice.

There are about 100 strains of HPV, with 15 considered oncogenic. HPV strains 16 and 18 are responsible for about 70% of cervical cancer, while strains 6 and 11 are responsible for genital warts. Merck’s Gardasil vaccine targets all four strains, while Cervarix (GlaxoSmithKline PLC) targets the oncogenic strains 16 and 18.

“HPV vaccine would seem to be a very reasonable form of protection, for both men and women, who may be sexually active in an environment characterized by a very high level of HPV and in which infection is very common,” as the infection may have serious health consequences for the individual and his or her partner, said Dr. Fisher, a professor in the departments of psychology and obstetrics and gynecology at the University of Western Ontario, London.

To illustrate the prevalence of HPV infection, Dr. Fisher noted a 25% rate of infection with high-risk oncogenic strains of HPV among Canadian teenage girls, aged 15-19 years, in a low-risk setting who were negative for HPV the previous year (CMAJ 2003;168:421-5).

Similarly, among a group of 621 university-age women tested every 6 months for 2 years, the rate of newly acquired high- and low-risk HPV strains was 13% at 1 year, and 29% and 24% respectively at 2 years (Cancer Epidemiol Biomarkers Prev. 2003;12:485-90).

“We couldn’t be talking more clearly about a sociosexual epidemic,” he said. “This is a social disease on steroids,” said Dr. Fisher, who is also a research affiliate at the Center for Health, Intervention, and Prevention at the University of Connecticut, in Storrs.

In a recent study involving young Canadian couples, HPV was present in 64% of new couples and the oncogenic HPV-16 strain was the most common strain found at baseline.

Concordance of strains was 41% at baseline and grew to 68% at 6 months, he said (Epidemiology 2010;21:31-7). “There’s no doubt in new relationships that HPV is rapidly becoming part of the sociocultural landscape,” Dr. Fisher said.

While there is a well-established link between high-risk HPV and gynecologic cancers, HPV-related head and neck cancers are “probably the newest sexually transmitted infections on the radar,” he said.

A recent study shows that in Sweden the prevalence of oncogenic HPV strains in head and neck cancer biopsies has increased from 23% in the 1970s to 77% by 2005 (Int. J. Cancer 2009;125:362-6).

In addition, a study from this year shows that the risk of HPV-related head and neck cancer, while increased with six or more coital partners (odds ratio 1.25), more than triples with more than four oral-genital partners (OR 3.36). “Oral-genital sex is the new handshake, and it is actually likely that people have more oral-genital partners than coital partners,” Dr. Fisher added.

Yet while Canadian and U.S. authorities recommend HPV vaccination in young girls and women, and school-based vaccination programs are offered across Canada, such recommendations have not resulted in mass vaccination, he said. A recent study suggests that only about one-third of American girls, aged 13-17 years, have been vaccinated (Am. J. Prev. Med. 2010;38:525-33).

Dr. Marie Plante, president of the Society of Gynecologic Oncologists of Canada, said that as a gynecologic oncologist she sees the downside of such low vaccination rates. “We treat women with cervical cancer ... I’ve got several of them in their 20s and early 30s and it ruins their lives, and they can’t have children sometimes. So we see the frustrating part because it could have been prevented,” said Dr. Plante, associate professor of obstetrics and gynecology, and chief of the gynecologic oncology division at Laval University in Quebec City. She estimates that about 50% of cervical cancer cases she sees are in women whose regular screening had failed to identify it.

“As much as I am very critical of the push from the companies [to market their vaccines] I will tell you that honestly I think the vaccine is safe,” Dr. Plante continued. Is it necessary? “No, it is not necessary,” she said. “It doesn’t guarantee 100% protection. It’s an option you have to reduce the chances that you develop precancerous cells. In most cases this will be treated quickly and won’t take your life away.” Importantly, the vaccine also reduces the potentially significant burden of genital warts, the experience of which is “amazingly negative” – it’s “terrible and painful,” she added.

Last year a prominent article and editorial in the JAMA questioned the medical arguments for vaccination, as well as the ethics of aggressive marketing campaigns from pharmaceutical companies (JAMA 2009;302:795-6, and 781-6).

“If the potential benefits are substantial, most individuals would be willing to accept the risks. But the net benefit of the HPV vaccine to women is uncertain. Even if persistently infected with HPV, a woman most likely will not develop cancer if she is regularly screened,” wrote Dr. Charlotte Haug, editor-in-chief of the Journal of the Norwegian Medical Association.

In their article, Sheila Rothman, Ph.D., and David Rothman, Ph.D., of Columbia University, New York, noted that in 2006, Merck’s Gardasil “was named the pharmaceutical ‘brand of the year’ for building a ‘market out of thin air.’ ”

Alan Cassels, a drug policy researcher at the University of Victoria (B.C.), was critical. “It’s not a slam dunk that if you get the HPV vaccine you’ll be prevented from developing cancer,” he said in an interview. He compared the vaccine to cholesterol-lowering drugs. “Yes, we can prove that a drug lowers cholesterol, but the question is whether it prevents heart attacks and strokes. So, while the HPV vaccine may prevent transmission of the virus, will that really result in [fewer] cancers? We won’t know for 10 or 20 years down the road.”

Given the uncertainty of benefit, or the duration of efficacy, Mr. Cassels cautioned that the risks of any intervention should be minimal, which is not the case with the HPV vaccine, he said.

As of Jan. 31, 2010, there were 49 U.S. reports of death among females who had received Gardasil, according to the Centers for Disease Control and Prevention. Twenty eight of these reports have been confirmed and 21 remain unconfirmed. In the 28 confirmed reports, “there was no unusual pattern or clustering to the deaths that would suggest that they were caused by the vaccine,” according to a CDC statement.

Merck sponsored the symposium Dr. Fisher disclosed that he has been a consultant for Merck, Boehringer Ingelheim and Bayer. Dr. Plante reported having no conflicts of interest.

Major Finding: The rates of preeclampsia were not significantly different between groups, occurring in 7.2% of the women receiving vitamin C and vitamin E and 6.7% of the placebo group.

Data Source: A large multicenter trial of 10,154 low-risk, nulliparous women from 16 clinical centers.

Disclosures: The study was supported by grants from the National Institute of Child Health and Human Development; the National Heart, Lung, and Blood Institute; and the National Center for Research Resources. Some of the investigators disclosed financial conflicts.

Daily supplementation with vitamins C and E starting between 9 and 16 weeks' gestation did not reduce the rate of pregnancy-associated hypertension, according to a large multicenter trial in low-risk, nulliparous women.

The findings “provide no support for the use of vitamin C and E supplementation in pregnancy to reduce the risk of preeclampsia or its complications,” wrote Dr. James M. Roberts of the University of Pittsburgh and his colleagues (N. Engl. J. Med. 2010;362:1282-91).

The study randomized 10,154 nulliparous women from 16 clinical centers. All women had singleton pregnancies, with gestational age at randomization ranging between 9 weeks, 0 days and 16 weeks, 6 days. The women were randomly assigned to take 1,000 mg of vitamin C and 400 IU of vitamin E daily, or matching placebo, until the end of their pregnancies. They returned any unused study drug each month and received a new batch, at which time they reported any side effects, and had their blood pressure and urine protein levels measured.

The primary outcome of the study was a composite of pregnancy-associated hypertension and serious adverse outcomes in the mother, fetus, or neonate, while the secondary outcomes included preeclampsia and other maternal and neonatal outcomes.

After some subjects were lost to follow-up or removed, a total of 4,993 women from the vitamin arm and 4,976 from the placebo arm were included in the final analysis.

Neither the primary or secondary outcomes of the study were significantly affected by vitamin treatment. A total of 6.1% of the vitamin group and 5.7% of the placebo group met criteria for the primary outcome. Similarly, the rates of the secondary outcome, preeclampsia, were not significantly different between groups—occurring in 7.2% of the vitamin group and 6.7% of the placebo group.

Several other studies have found a similar lack of benefit to antioxidant vitamins in terms of altering the risk of hypertension in pregnancy, and the authors suggested several possible explanations.

First, although there is evidence of oxidative stress in preeclampsia, it might not necessarily be important in the pathophysiology of the disease. Or, perhaps it is relevant, but only to a subset of preeclamptic women.

Yet another suggestion was that supplemental vitamin C and E may not be beneficial if women already have adequate concentrations at baseline. It has been suggested that the therapeutic antioxidant window might be between 8 and 10 weeks' gestation at the initiation of intervillous blood flow. However a post hoc subgroup analysis limited to women who were treated before 13 weeks' gestation showed no difference in outcome.

This and other studies have found no benefit of the antioxidant vitamins C and E in altering the risk of hypertension in pregnancy.

Source James E. Reinaker/Elsevier Global Medical News

Major Finding: The rates of preeclampsia were not significantly different between groups, occurring in 7.2% of the women receiving vitamin C and vitamin E and 6.7% of the placebo group.

Data Source: A large multicenter trial of 10,154 low-risk, nulliparous women from 16 clinical centers.

Disclosures: The study was supported by grants from the National Institute of Child Health and Human Development; the National Heart, Lung, and Blood Institute; and the National Center for Research Resources. Some of the investigators disclosed financial conflicts.

Daily supplementation with vitamins C and E starting between 9 and 16 weeks' gestation did not reduce the rate of pregnancy-associated hypertension, according to a large multicenter trial in low-risk, nulliparous women.

The findings “provide no support for the use of vitamin C and E supplementation in pregnancy to reduce the risk of preeclampsia or its complications,” wrote Dr. James M. Roberts of the University of Pittsburgh and his colleagues (N. Engl. J. Med. 2010;362:1282-91).

The study randomized 10,154 nulliparous women from 16 clinical centers. All women had singleton pregnancies, with gestational age at randomization ranging between 9 weeks, 0 days and 16 weeks, 6 days. The women were randomly assigned to take 1,000 mg of vitamin C and 400 IU of vitamin E daily, or matching placebo, until the end of their pregnancies. They returned any unused study drug each month and received a new batch, at which time they reported any side effects, and had their blood pressure and urine protein levels measured.

The primary outcome of the study was a composite of pregnancy-associated hypertension and serious adverse outcomes in the mother, fetus, or neonate, while the secondary outcomes included preeclampsia and other maternal and neonatal outcomes.

After some subjects were lost to follow-up or removed, a total of 4,993 women from the vitamin arm and 4,976 from the placebo arm were included in the final analysis.

Neither the primary or secondary outcomes of the study were significantly affected by vitamin treatment. A total of 6.1% of the vitamin group and 5.7% of the placebo group met criteria for the primary outcome. Similarly, the rates of the secondary outcome, preeclampsia, were not significantly different between groups—occurring in 7.2% of the vitamin group and 6.7% of the placebo group.

Several other studies have found a similar lack of benefit to antioxidant vitamins in terms of altering the risk of hypertension in pregnancy, and the authors suggested several possible explanations.

First, although there is evidence of oxidative stress in preeclampsia, it might not necessarily be important in the pathophysiology of the disease. Or, perhaps it is relevant, but only to a subset of preeclamptic women.

Yet another suggestion was that supplemental vitamin C and E may not be beneficial if women already have adequate concentrations at baseline. It has been suggested that the therapeutic antioxidant window might be between 8 and 10 weeks' gestation at the initiation of intervillous blood flow. However a post hoc subgroup analysis limited to women who were treated before 13 weeks' gestation showed no difference in outcome.

This and other studies have found no benefit of the antioxidant vitamins C and E in altering the risk of hypertension in pregnancy.

Source James E. Reinaker/Elsevier Global Medical News

Major Finding: The rates of preeclampsia were not significantly different between groups, occurring in 7.2% of the women receiving vitamin C and vitamin E and 6.7% of the placebo group.

Data Source: A large multicenter trial of 10,154 low-risk, nulliparous women from 16 clinical centers.

Disclosures: The study was supported by grants from the National Institute of Child Health and Human Development; the National Heart, Lung, and Blood Institute; and the National Center for Research Resources. Some of the investigators disclosed financial conflicts.

Daily supplementation with vitamins C and E starting between 9 and 16 weeks' gestation did not reduce the rate of pregnancy-associated hypertension, according to a large multicenter trial in low-risk, nulliparous women.

The findings “provide no support for the use of vitamin C and E supplementation in pregnancy to reduce the risk of preeclampsia or its complications,” wrote Dr. James M. Roberts of the University of Pittsburgh and his colleagues (N. Engl. J. Med. 2010;362:1282-91).

The study randomized 10,154 nulliparous women from 16 clinical centers. All women had singleton pregnancies, with gestational age at randomization ranging between 9 weeks, 0 days and 16 weeks, 6 days. The women were randomly assigned to take 1,000 mg of vitamin C and 400 IU of vitamin E daily, or matching placebo, until the end of their pregnancies. They returned any unused study drug each month and received a new batch, at which time they reported any side effects, and had their blood pressure and urine protein levels measured.

The primary outcome of the study was a composite of pregnancy-associated hypertension and serious adverse outcomes in the mother, fetus, or neonate, while the secondary outcomes included preeclampsia and other maternal and neonatal outcomes.

After some subjects were lost to follow-up or removed, a total of 4,993 women from the vitamin arm and 4,976 from the placebo arm were included in the final analysis.

Neither the primary or secondary outcomes of the study were significantly affected by vitamin treatment. A total of 6.1% of the vitamin group and 5.7% of the placebo group met criteria for the primary outcome. Similarly, the rates of the secondary outcome, preeclampsia, were not significantly different between groups—occurring in 7.2% of the vitamin group and 6.7% of the placebo group.

Several other studies have found a similar lack of benefit to antioxidant vitamins in terms of altering the risk of hypertension in pregnancy, and the authors suggested several possible explanations.

First, although there is evidence of oxidative stress in preeclampsia, it might not necessarily be important in the pathophysiology of the disease. Or, perhaps it is relevant, but only to a subset of preeclamptic women.

Yet another suggestion was that supplemental vitamin C and E may not be beneficial if women already have adequate concentrations at baseline. It has been suggested that the therapeutic antioxidant window might be between 8 and 10 weeks' gestation at the initiation of intervillous blood flow. However a post hoc subgroup analysis limited to women who were treated before 13 weeks' gestation showed no difference in outcome.

This and other studies have found no benefit of the antioxidant vitamins C and E in altering the risk of hypertension in pregnancy.

Source James E. Reinaker/Elsevier Global Medical News

Hyperglycemia after myocardial infarction is a red flag for nondiabetic patients about to undergo coronary angiography because it is a risk factor for contrast-induced acute kidney injury, according to a large, retrospective analysis study.

“Hyperglycemic patients without known diabetes should be recognized as a high-risk group for CI-AKI [contrast-induced acute kidney injury] and should be considered for prophylactic measures similar to those used in other high-risk patients,” wrote Dr. Joshua M. Stolker of the Mid American Heart Institute of Saint Luke's Hospital, Kansas City, Mo., and colleagues (J. Am. Coll. Cardiol. 2010;55:1433–40).

The study is the first to document an increasing risk of CI-AKI with progressive blood glucose elevations in patients who do not have diabetes, Dr. Martin A. Alpert and Dr. Carl Carlino of the division of cardiovascular medicine, University of Missouri, Columbia, noted in an editorial (J. Am. Coll. Cardiol. 2010;55:1441–3). “Hyperglycemia … occurs in more than 40% of patients without diabetes with acute myocardial infarction. In the critical care population, hyperglycemia in patients without diabetes is seen by some as a 'stress test' denoting the failure of endogenous insulin reserves to adequately control blood glucose.”

The study analyzed 6,358 consecutive patients from the Health Facts database who underwent coronary angiography after acute MI. Of them, 1,929 (30%) had known diabetes. Preprocedural hyperglycemia (blood glucose at least 140 mg/dL) was present in 42% of the entire cohort, of whom 48% were nondiabetic. All patients were stratified according to their preprocedural blood glucose level: less than 110 mg/dL; 110 to less than 140 mg/dL; 140 to less than 170 mg/dL; 170 to less than 200 mg/dL; and 200 mg/dL or more.

After coronary angiography, 823 patients (13%) developed CI-AKI (an absolute serum creatinine increase of 0.3 mg/dL or more, or a relative increase in serum creatinine of 50% or more within 48 hours of the procedure), the primary study end point. After adjustment for confounders, there was a strong association between preprocedural glucose levels and CI-AKI risk in patients without diabetes, but not in patients with established diabetes—regardless of their glucose levels, reported the authors.

Among the nondiabetic patients, the risk for CI-AKI increased with increasing glucose levels. Compared with patients with blood glucose levels below 100 mg/dL (reference), those in the higher glucose categories had increasingly higher risks for CI-AKI, with odds ratios of 1.31, 1.51, 1.58, and 2.14, all significant differences. This pattern was not seen in diabetic patients (OR 0.71, 0.82, 0.73, 0.94).

Nondiabetic, hyperglycemic acute MI patients may receive less aggressive glucose control than their diabetic counterparts, and may also receive less aggressive CI-AKI prophylaxis, the authors said. Additionally, some hyperglycemic patients may have undiagnosed and untreated diabetes, putting them at higher risk. Also, nondiabetic patients who become hyperglycemic may be experiencing more severe illness compared with diabetes patients who become hyperglycemic.

The results identify a new risk marker and “raise the question of whether interventions such as intensive insulin therapy might reduce risk in this population,” noted the editorialists.

The American Heart Association funded the research. Dr. Stolker has financial ties with AstraZeneca Pharmaceuticals, Pfizer Pharmaceuticals, and Novo Nordisk, and Educational Testing Consultants LLC.

Hyperglycemia after myocardial infarction is a red flag for nondiabetic patients about to undergo coronary angiography because it is a risk factor for contrast-induced acute kidney injury, according to a large, retrospective analysis study.

“Hyperglycemic patients without known diabetes should be recognized as a high-risk group for CI-AKI [contrast-induced acute kidney injury] and should be considered for prophylactic measures similar to those used in other high-risk patients,” wrote Dr. Joshua M. Stolker of the Mid American Heart Institute of Saint Luke's Hospital, Kansas City, Mo., and colleagues (J. Am. Coll. Cardiol. 2010;55:1433–40).

The study is the first to document an increasing risk of CI-AKI with progressive blood glucose elevations in patients who do not have diabetes, Dr. Martin A. Alpert and Dr. Carl Carlino of the division of cardiovascular medicine, University of Missouri, Columbia, noted in an editorial (J. Am. Coll. Cardiol. 2010;55:1441–3). “Hyperglycemia … occurs in more than 40% of patients without diabetes with acute myocardial infarction. In the critical care population, hyperglycemia in patients without diabetes is seen by some as a 'stress test' denoting the failure of endogenous insulin reserves to adequately control blood glucose.”

The study analyzed 6,358 consecutive patients from the Health Facts database who underwent coronary angiography after acute MI. Of them, 1,929 (30%) had known diabetes. Preprocedural hyperglycemia (blood glucose at least 140 mg/dL) was present in 42% of the entire cohort, of whom 48% were nondiabetic. All patients were stratified according to their preprocedural blood glucose level: less than 110 mg/dL; 110 to less than 140 mg/dL; 140 to less than 170 mg/dL; 170 to less than 200 mg/dL; and 200 mg/dL or more.

After coronary angiography, 823 patients (13%) developed CI-AKI (an absolute serum creatinine increase of 0.3 mg/dL or more, or a relative increase in serum creatinine of 50% or more within 48 hours of the procedure), the primary study end point. After adjustment for confounders, there was a strong association between preprocedural glucose levels and CI-AKI risk in patients without diabetes, but not in patients with established diabetes—regardless of their glucose levels, reported the authors.

Among the nondiabetic patients, the risk for CI-AKI increased with increasing glucose levels. Compared with patients with blood glucose levels below 100 mg/dL (reference), those in the higher glucose categories had increasingly higher risks for CI-AKI, with odds ratios of 1.31, 1.51, 1.58, and 2.14, all significant differences. This pattern was not seen in diabetic patients (OR 0.71, 0.82, 0.73, 0.94).

Nondiabetic, hyperglycemic acute MI patients may receive less aggressive glucose control than their diabetic counterparts, and may also receive less aggressive CI-AKI prophylaxis, the authors said. Additionally, some hyperglycemic patients may have undiagnosed and untreated diabetes, putting them at higher risk. Also, nondiabetic patients who become hyperglycemic may be experiencing more severe illness compared with diabetes patients who become hyperglycemic.

The results identify a new risk marker and “raise the question of whether interventions such as intensive insulin therapy might reduce risk in this population,” noted the editorialists.

The American Heart Association funded the research. Dr. Stolker has financial ties with AstraZeneca Pharmaceuticals, Pfizer Pharmaceuticals, and Novo Nordisk, and Educational Testing Consultants LLC.

Hyperglycemia after myocardial infarction is a red flag for nondiabetic patients about to undergo coronary angiography because it is a risk factor for contrast-induced acute kidney injury, according to a large, retrospective analysis study.

“Hyperglycemic patients without known diabetes should be recognized as a high-risk group for CI-AKI [contrast-induced acute kidney injury] and should be considered for prophylactic measures similar to those used in other high-risk patients,” wrote Dr. Joshua M. Stolker of the Mid American Heart Institute of Saint Luke's Hospital, Kansas City, Mo., and colleagues (J. Am. Coll. Cardiol. 2010;55:1433–40).

The study is the first to document an increasing risk of CI-AKI with progressive blood glucose elevations in patients who do not have diabetes, Dr. Martin A. Alpert and Dr. Carl Carlino of the division of cardiovascular medicine, University of Missouri, Columbia, noted in an editorial (J. Am. Coll. Cardiol. 2010;55:1441–3). “Hyperglycemia … occurs in more than 40% of patients without diabetes with acute myocardial infarction. In the critical care population, hyperglycemia in patients without diabetes is seen by some as a 'stress test' denoting the failure of endogenous insulin reserves to adequately control blood glucose.”

The study analyzed 6,358 consecutive patients from the Health Facts database who underwent coronary angiography after acute MI. Of them, 1,929 (30%) had known diabetes. Preprocedural hyperglycemia (blood glucose at least 140 mg/dL) was present in 42% of the entire cohort, of whom 48% were nondiabetic. All patients were stratified according to their preprocedural blood glucose level: less than 110 mg/dL; 110 to less than 140 mg/dL; 140 to less than 170 mg/dL; 170 to less than 200 mg/dL; and 200 mg/dL or more.

After coronary angiography, 823 patients (13%) developed CI-AKI (an absolute serum creatinine increase of 0.3 mg/dL or more, or a relative increase in serum creatinine of 50% or more within 48 hours of the procedure), the primary study end point. After adjustment for confounders, there was a strong association between preprocedural glucose levels and CI-AKI risk in patients without diabetes, but not in patients with established diabetes—regardless of their glucose levels, reported the authors.

Among the nondiabetic patients, the risk for CI-AKI increased with increasing glucose levels. Compared with patients with blood glucose levels below 100 mg/dL (reference), those in the higher glucose categories had increasingly higher risks for CI-AKI, with odds ratios of 1.31, 1.51, 1.58, and 2.14, all significant differences. This pattern was not seen in diabetic patients (OR 0.71, 0.82, 0.73, 0.94).

Nondiabetic, hyperglycemic acute MI patients may receive less aggressive glucose control than their diabetic counterparts, and may also receive less aggressive CI-AKI prophylaxis, the authors said. Additionally, some hyperglycemic patients may have undiagnosed and untreated diabetes, putting them at higher risk. Also, nondiabetic patients who become hyperglycemic may be experiencing more severe illness compared with diabetes patients who become hyperglycemic.

The results identify a new risk marker and “raise the question of whether interventions such as intensive insulin therapy might reduce risk in this population,” noted the editorialists.

The American Heart Association funded the research. Dr. Stolker has financial ties with AstraZeneca Pharmaceuticals, Pfizer Pharmaceuticals, and Novo Nordisk, and Educational Testing Consultants LLC.