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 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.

MONTREAL — Half of abnormal preoperative coagulation results normalize on repeat testing in children undergoing tonsillectomy and adenoidectomy—and among the other half that remain abnormal, 93% of the abnormalities are clinically insignificant, according to a retrospective chart review.

Despite this finding, relying on patient and family bleeding history alone is not sufficient for identifying potentially life-threatening bleeding abnormalities, said Dr. Neha Bhasin and her coauthor, who presented the findings in a poster.

The review included charts from 791 patients who were referred for further work-up over a 15-year period because routine presurgical coagulation tests revealed an elevated prothrombin time (PT) and/or activated partial thromboplastin time (aPTT), said Dr. Bhasin of Stony Brook (N.Y.) University Medical Center. On follow-up, only 3.4% of the cohort had an acute bleeding disorder, and of these patients 40% would have been missed based on personal or family bleeding history alone, she said.

“So we can't say family history is the sole criteria on which we should base an abnormal PT/PTT work-up,” Dr. Bhasin said in an interview. “You should repeat the PT/PTT before you go on a vast search. And if it is still abnormal, a full work-up is a good adjunct to family history to find out why.”

The study revealed no diagnosis for 394 (50%) of the 791 patients. For most in this subgroup, repeat testing showed their values had normalized, while for 131 the results remained abnormal for no apparent reason. “A transient lupus anticoagulant can sometimes cause an elevated PT/PTT temporarily,” she suggested.

Specific diagnoses were found to explain the abnormal results in the remaining 397 patients, but only 27 of these patients had clinically significant conditions: mild to moderate von Willebrand's disease (21), low Factor VII (3), hemophilia (2), and liver disease (1).

In the remaining 370 patients with clinically insignificant abnormalities, the most common explanation was a lupus anticoagulant (29.5%) or presumed lupus anticoagulant (36.5%), she said. Even though these findings had no acute clinical relevance to the patients, a persistent lupus anticoagulant “may be a predictor of an autoimmune process, and has been shown to represent a risk for thrombosis,” wrote the authors. “Therefore, identifying this abnormality on work-up may potentially be of future clinical significance.”

A personal or family bleeding history was documented in 256 (32%) of the 791 patients, but only 107 of them had an abnormality identified on further work-up, and only 16 of these abnormalities were clinically significant.

Additionally, 11 patients with no bleeding history were found to have clinically significant abnormalities. Therefore, relying solely on patient or family history of bleeding would have missed 41% of the 27 that were found, Dr. Bhasin said. “The presence of a positive personal and/or family history of bleeding is a strong but not absolute predictor of identifying a clinically significant bleeding disorder on further evaluation,” wrote the authors. “Therefore, routine preoperative coagulation testing serves as useful adjunct to clinical history.”

The clinical utility of performing routine preoperative coagulation testing on all children when just 3.4% will have clinically significant results “must be weighed against the risk to the patient of not identifying a hemostatic defect preoperatively,” they concluded.

Disclosures: The investigators did not report any financial conflicts of interest.

MONTREAL — Half of abnormal preoperative coagulation results normalize on repeat testing in children undergoing tonsillectomy and adenoidectomy—and among the other half that remain abnormal, 93% of the abnormalities are clinically insignificant, according to a retrospective chart review.

Despite this finding, relying on patient and family bleeding history alone is not sufficient for identifying potentially life-threatening bleeding abnormalities, said Dr. Neha Bhasin and her coauthor, who presented the findings in a poster.

The review included charts from 791 patients who were referred for further work-up over a 15-year period because routine presurgical coagulation tests revealed an elevated prothrombin time (PT) and/or activated partial thromboplastin time (aPTT), said Dr. Bhasin of Stony Brook (N.Y.) University Medical Center. On follow-up, only 3.4% of the cohort had an acute bleeding disorder, and of these patients 40% would have been missed based on personal or family bleeding history alone, she said.

“So we can't say family history is the sole criteria on which we should base an abnormal PT/PTT work-up,” Dr. Bhasin said in an interview. “You should repeat the PT/PTT before you go on a vast search. And if it is still abnormal, a full work-up is a good adjunct to family history to find out why.”

The study revealed no diagnosis for 394 (50%) of the 791 patients. For most in this subgroup, repeat testing showed their values had normalized, while for 131 the results remained abnormal for no apparent reason. “A transient lupus anticoagulant can sometimes cause an elevated PT/PTT temporarily,” she suggested.

Specific diagnoses were found to explain the abnormal results in the remaining 397 patients, but only 27 of these patients had clinically significant conditions: mild to moderate von Willebrand's disease (21), low Factor VII (3), hemophilia (2), and liver disease (1).

In the remaining 370 patients with clinically insignificant abnormalities, the most common explanation was a lupus anticoagulant (29.5%) or presumed lupus anticoagulant (36.5%), she said. Even though these findings had no acute clinical relevance to the patients, a persistent lupus anticoagulant “may be a predictor of an autoimmune process, and has been shown to represent a risk for thrombosis,” wrote the authors. “Therefore, identifying this abnormality on work-up may potentially be of future clinical significance.”

A personal or family bleeding history was documented in 256 (32%) of the 791 patients, but only 107 of them had an abnormality identified on further work-up, and only 16 of these abnormalities were clinically significant.

Additionally, 11 patients with no bleeding history were found to have clinically significant abnormalities. Therefore, relying solely on patient or family history of bleeding would have missed 41% of the 27 that were found, Dr. Bhasin said. “The presence of a positive personal and/or family history of bleeding is a strong but not absolute predictor of identifying a clinically significant bleeding disorder on further evaluation,” wrote the authors. “Therefore, routine preoperative coagulation testing serves as useful adjunct to clinical history.”

The clinical utility of performing routine preoperative coagulation testing on all children when just 3.4% will have clinically significant results “must be weighed against the risk to the patient of not identifying a hemostatic defect preoperatively,” they concluded.

Disclosures: The investigators did not report any financial conflicts of interest.

MONTREAL — Half of abnormal preoperative coagulation results normalize on repeat testing in children undergoing tonsillectomy and adenoidectomy—and among the other half that remain abnormal, 93% of the abnormalities are clinically insignificant, according to a retrospective chart review.

Despite this finding, relying on patient and family bleeding history alone is not sufficient for identifying potentially life-threatening bleeding abnormalities, said Dr. Neha Bhasin and her coauthor, who presented the findings in a poster.

The review included charts from 791 patients who were referred for further work-up over a 15-year period because routine presurgical coagulation tests revealed an elevated prothrombin time (PT) and/or activated partial thromboplastin time (aPTT), said Dr. Bhasin of Stony Brook (N.Y.) University Medical Center. On follow-up, only 3.4% of the cohort had an acute bleeding disorder, and of these patients 40% would have been missed based on personal or family bleeding history alone, she said.

“So we can't say family history is the sole criteria on which we should base an abnormal PT/PTT work-up,” Dr. Bhasin said in an interview. “You should repeat the PT/PTT before you go on a vast search. And if it is still abnormal, a full work-up is a good adjunct to family history to find out why.”

The study revealed no diagnosis for 394 (50%) of the 791 patients. For most in this subgroup, repeat testing showed their values had normalized, while for 131 the results remained abnormal for no apparent reason. “A transient lupus anticoagulant can sometimes cause an elevated PT/PTT temporarily,” she suggested.

Specific diagnoses were found to explain the abnormal results in the remaining 397 patients, but only 27 of these patients had clinically significant conditions: mild to moderate von Willebrand's disease (21), low Factor VII (3), hemophilia (2), and liver disease (1).

In the remaining 370 patients with clinically insignificant abnormalities, the most common explanation was a lupus anticoagulant (29.5%) or presumed lupus anticoagulant (36.5%), she said. Even though these findings had no acute clinical relevance to the patients, a persistent lupus anticoagulant “may be a predictor of an autoimmune process, and has been shown to represent a risk for thrombosis,” wrote the authors. “Therefore, identifying this abnormality on work-up may potentially be of future clinical significance.”

A personal or family bleeding history was documented in 256 (32%) of the 791 patients, but only 107 of them had an abnormality identified on further work-up, and only 16 of these abnormalities were clinically significant.

Additionally, 11 patients with no bleeding history were found to have clinically significant abnormalities. Therefore, relying solely on patient or family history of bleeding would have missed 41% of the 27 that were found, Dr. Bhasin said. “The presence of a positive personal and/or family history of bleeding is a strong but not absolute predictor of identifying a clinically significant bleeding disorder on further evaluation,” wrote the authors. “Therefore, routine preoperative coagulation testing serves as useful adjunct to clinical history.”

The clinical utility of performing routine preoperative coagulation testing on all children when just 3.4% will have clinically significant results “must be weighed against the risk to the patient of not identifying a hemostatic defect preoperatively,” they concluded.

Disclosures: The investigators did not report any financial conflicts of interest.

The pandemic influenza A(H1N1) virus has been virtually the only influenza virus circulating in the United States since it was first identified in April 2009, according to a report from Quest Diagnostics.

In an analysis of 195,000 lab tests performed at five of the company's laboratories, 99% of samples testing positive for influenza A were identified as H1N1, according to the report, titled “H1N1 Testing in America: H1N1 the Dominant Flu of 2009–2010.” “Our laboratory testing data also show an absence of influenza B viruses,” it noted. “These findings suggest the H1N1 virus has 'crowded out' other flu viruses.”

The data confirm that two waves of H1N1 infection have occurred, with no evidence of a third wave, the report's authors explained. The first wave, beginning in April or May 2009, ended in mid-August 2009. The second wave started in late August/early September 2009, and peaked in late October 2009. “Our data suggest that the return of children to school in the fall was likely the trigger for a second wave of H1N1 infection,” the report's authors wrote. “This trend—where children are the first to suffer from a new influenza virus that then spreads to other age groups—is consistent with the behavior of prior flu viruses.”

The report showed that H1N1 positivity was highest among children aged 10–14 years during both waves. Among that age group, the rate of H1N1-positive tests was 83% and 82% in the first and second waves, respectively. That compares with rates of 76% and 78%, respectively, in the 5- to 9-year age group. Among adults aged 25–49 years, the rates were 46% and 50%, respectively.

Since the end of the second wave, older children continue to have the highest positivity rates, compared with the other age groups, according to the report. In the 4 weeks ending April 15, 2010, 26% of tests were positive in the 10- to 14-year age group, compared with 18% among younger children and 13% among adults.

When analyzed by geographic region, positivity rates during the same 4-week period were highest (26%) in the southeastern United States (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee). In the central southern states (Arkansas, Louisiana, New Mexico, Oklahoma, and Texas), the rate was 22%. Those rates are in contrast to a combined 6% rate in the rest of the country.

The full report is available at www.QuestDiagnostics.com/HealthTrends

The H1N1 virus has “crowded out” other influenza A and B viruses.

Source Courtesy CDC

The pandemic influenza A(H1N1) virus has been virtually the only influenza virus circulating in the United States since it was first identified in April 2009, according to a report from Quest Diagnostics.

In an analysis of 195,000 lab tests performed at five of the company's laboratories, 99% of samples testing positive for influenza A were identified as H1N1, according to the report, titled “H1N1 Testing in America: H1N1 the Dominant Flu of 2009–2010.” “Our laboratory testing data also show an absence of influenza B viruses,” it noted. “These findings suggest the H1N1 virus has 'crowded out' other flu viruses.”

The data confirm that two waves of H1N1 infection have occurred, with no evidence of a third wave, the report's authors explained. The first wave, beginning in April or May 2009, ended in mid-August 2009. The second wave started in late August/early September 2009, and peaked in late October 2009. “Our data suggest that the return of children to school in the fall was likely the trigger for a second wave of H1N1 infection,” the report's authors wrote. “This trend—where children are the first to suffer from a new influenza virus that then spreads to other age groups—is consistent with the behavior of prior flu viruses.”

The report showed that H1N1 positivity was highest among children aged 10–14 years during both waves. Among that age group, the rate of H1N1-positive tests was 83% and 82% in the first and second waves, respectively. That compares with rates of 76% and 78%, respectively, in the 5- to 9-year age group. Among adults aged 25–49 years, the rates were 46% and 50%, respectively.

Since the end of the second wave, older children continue to have the highest positivity rates, compared with the other age groups, according to the report. In the 4 weeks ending April 15, 2010, 26% of tests were positive in the 10- to 14-year age group, compared with 18% among younger children and 13% among adults.

When analyzed by geographic region, positivity rates during the same 4-week period were highest (26%) in the southeastern United States (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee). In the central southern states (Arkansas, Louisiana, New Mexico, Oklahoma, and Texas), the rate was 22%. Those rates are in contrast to a combined 6% rate in the rest of the country.

The full report is available at www.QuestDiagnostics.com/HealthTrends

The H1N1 virus has “crowded out” other influenza A and B viruses.

Source Courtesy CDC

The pandemic influenza A(H1N1) virus has been virtually the only influenza virus circulating in the United States since it was first identified in April 2009, according to a report from Quest Diagnostics.

In an analysis of 195,000 lab tests performed at five of the company's laboratories, 99% of samples testing positive for influenza A were identified as H1N1, according to the report, titled “H1N1 Testing in America: H1N1 the Dominant Flu of 2009–2010.” “Our laboratory testing data also show an absence of influenza B viruses,” it noted. “These findings suggest the H1N1 virus has 'crowded out' other flu viruses.”

The data confirm that two waves of H1N1 infection have occurred, with no evidence of a third wave, the report's authors explained. The first wave, beginning in April or May 2009, ended in mid-August 2009. The second wave started in late August/early September 2009, and peaked in late October 2009. “Our data suggest that the return of children to school in the fall was likely the trigger for a second wave of H1N1 infection,” the report's authors wrote. “This trend—where children are the first to suffer from a new influenza virus that then spreads to other age groups—is consistent with the behavior of prior flu viruses.”

The report showed that H1N1 positivity was highest among children aged 10–14 years during both waves. Among that age group, the rate of H1N1-positive tests was 83% and 82% in the first and second waves, respectively. That compares with rates of 76% and 78%, respectively, in the 5- to 9-year age group. Among adults aged 25–49 years, the rates were 46% and 50%, respectively.

Since the end of the second wave, older children continue to have the highest positivity rates, compared with the other age groups, according to the report. In the 4 weeks ending April 15, 2010, 26% of tests were positive in the 10- to 14-year age group, compared with 18% among younger children and 13% among adults.

When analyzed by geographic region, positivity rates during the same 4-week period were highest (26%) in the southeastern United States (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee). In the central southern states (Arkansas, Louisiana, New Mexico, Oklahoma, and Texas), the rate was 22%. Those rates are in contrast to a combined 6% rate in the rest of the country.

The full report is available at www.QuestDiagnostics.com/HealthTrends

The H1N1 virus has “crowded out” other influenza A and B viruses.

Source Courtesy CDC

Adolescent obesity is associated with midlife nulliparity and nulligravidity even after adjustment for adult weight, amenorrhea, and other reproductive problems according to an analysis of the Study of Women's Health Across the Nation (SWAN).

“While the data are overwhelming that obesity influences fertility, it should be noted that the precise mechanism remains to be elucidated,” emphasized Dr. Alex J. Polotsky of Albert Einstein College of Medicine, New York, and colleagues (Fertil. Steril. 2010;93:2004–11).

Previous studies have shown that adult obesity is associated with anovulation, amenorrhea, and hyperandrogenism—all of which are directly linked to reproductive problems.

However, this study adjusted for adult body mass index (BMI) as well as many explanations for infertility. “Therefore our data point to influences on fertility that are weight-related yet are not necessarily linked with anovulation,” the researchers said.

The study included 3,154 participants in the SWAN study who were aged 42–52 years, had at least one period and no hormone therapy in the prior 3 months, and had an intact uterus and at least one ovary.

Baseline weight and height were measured, and self-reported high school BMI was recorded. Race/ethnicity, education, and marital, smoking, and socioeconomic status were recorded.

The subjects were asked to report the number of times they had been pregnant and the outcome of each pregnancy. The number of induced and spontaneous abortions was recorded as well as any history of infertility, including self-reported use of fertility medications, history of eating disorders, and history of salpingitis. Questions about menstrual regularity and oral contraception were also asked, including details about any history of nongestational amenorrhea. Male factor infertility, decisions to remain childless, and preference for same-sex relationships were also recorded.

A total of 527 (16.7%) of the cohort reported childlessness, and increased high school BMI was associated with higher rates of nulliparity, despite no difference in the rate of induced or spontaneous abortions.

Among women who were underweight in high school (BMI less than 18.5 kg/m

A total of 23% of participants reported a history of a period of infertility, and there were no significant differences in this rate across the weight categories. However, a history of amenorrhea was significantly more common among those with higher high school weights (13.2% and 15.4% in those reporting underweight and normal weight in adolescence, respectively, compared with 21.5% and 30.9% in those reporting overweight and obesity in adolescence).

There was also a higher number of women who never tried to get pregnant in the higher weight categories, and although this was statistically significant (P = .2), the difference was small.

“The findings were not affected by tubal or male factor infertility, use of fertility treatments, decisions to remain voluntarily childless, or preference for same-sex sexual relationship,” wrote the authors. After adjustment for adult BMI, history of amenorrhea, marital status, ethnicity, study site, education, and socioeconomic status, adolescent obesity remained independently associated with lifetime nulliparity and nulligravidity (odds ratios 2.84 an 3.93, respectively), they concluded.

“The cross-sectional nature of our study implies that it should be hypothesis-generating: Does adolescent obesity result in diminished fertility?”

The authors reported having no disclosures. The study was supported by the National Institutes of Health.

Adolescent obesity is associated with midlife nulliparity and nulligravidity even after adjustment for adult weight, amenorrhea, and other reproductive problems according to an analysis of the Study of Women's Health Across the Nation (SWAN).

“While the data are overwhelming that obesity influences fertility, it should be noted that the precise mechanism remains to be elucidated,” emphasized Dr. Alex J. Polotsky of Albert Einstein College of Medicine, New York, and colleagues (Fertil. Steril. 2010;93:2004–11).

Previous studies have shown that adult obesity is associated with anovulation, amenorrhea, and hyperandrogenism—all of which are directly linked to reproductive problems.

However, this study adjusted for adult body mass index (BMI) as well as many explanations for infertility. “Therefore our data point to influences on fertility that are weight-related yet are not necessarily linked with anovulation,” the researchers said.

The study included 3,154 participants in the SWAN study who were aged 42–52 years, had at least one period and no hormone therapy in the prior 3 months, and had an intact uterus and at least one ovary.

Baseline weight and height were measured, and self-reported high school BMI was recorded. Race/ethnicity, education, and marital, smoking, and socioeconomic status were recorded.

The subjects were asked to report the number of times they had been pregnant and the outcome of each pregnancy. The number of induced and spontaneous abortions was recorded as well as any history of infertility, including self-reported use of fertility medications, history of eating disorders, and history of salpingitis. Questions about menstrual regularity and oral contraception were also asked, including details about any history of nongestational amenorrhea. Male factor infertility, decisions to remain childless, and preference for same-sex relationships were also recorded.

A total of 527 (16.7%) of the cohort reported childlessness, and increased high school BMI was associated with higher rates of nulliparity, despite no difference in the rate of induced or spontaneous abortions.

Among women who were underweight in high school (BMI less than 18.5 kg/m

A total of 23% of participants reported a history of a period of infertility, and there were no significant differences in this rate across the weight categories. However, a history of amenorrhea was significantly more common among those with higher high school weights (13.2% and 15.4% in those reporting underweight and normal weight in adolescence, respectively, compared with 21.5% and 30.9% in those reporting overweight and obesity in adolescence).

There was also a higher number of women who never tried to get pregnant in the higher weight categories, and although this was statistically significant (P = .2), the difference was small.

“The findings were not affected by tubal or male factor infertility, use of fertility treatments, decisions to remain voluntarily childless, or preference for same-sex sexual relationship,” wrote the authors. After adjustment for adult BMI, history of amenorrhea, marital status, ethnicity, study site, education, and socioeconomic status, adolescent obesity remained independently associated with lifetime nulliparity and nulligravidity (odds ratios 2.84 an 3.93, respectively), they concluded.

“The cross-sectional nature of our study implies that it should be hypothesis-generating: Does adolescent obesity result in diminished fertility?”

The authors reported having no disclosures. The study was supported by the National Institutes of Health.

Adolescent obesity is associated with midlife nulliparity and nulligravidity even after adjustment for adult weight, amenorrhea, and other reproductive problems according to an analysis of the Study of Women's Health Across the Nation (SWAN).

“While the data are overwhelming that obesity influences fertility, it should be noted that the precise mechanism remains to be elucidated,” emphasized Dr. Alex J. Polotsky of Albert Einstein College of Medicine, New York, and colleagues (Fertil. Steril. 2010;93:2004–11).

Previous studies have shown that adult obesity is associated with anovulation, amenorrhea, and hyperandrogenism—all of which are directly linked to reproductive problems.

However, this study adjusted for adult body mass index (BMI) as well as many explanations for infertility. “Therefore our data point to influences on fertility that are weight-related yet are not necessarily linked with anovulation,” the researchers said.

The study included 3,154 participants in the SWAN study who were aged 42–52 years, had at least one period and no hormone therapy in the prior 3 months, and had an intact uterus and at least one ovary.

Baseline weight and height were measured, and self-reported high school BMI was recorded. Race/ethnicity, education, and marital, smoking, and socioeconomic status were recorded.

The subjects were asked to report the number of times they had been pregnant and the outcome of each pregnancy. The number of induced and spontaneous abortions was recorded as well as any history of infertility, including self-reported use of fertility medications, history of eating disorders, and history of salpingitis. Questions about menstrual regularity and oral contraception were also asked, including details about any history of nongestational amenorrhea. Male factor infertility, decisions to remain childless, and preference for same-sex relationships were also recorded.

A total of 527 (16.7%) of the cohort reported childlessness, and increased high school BMI was associated with higher rates of nulliparity, despite no difference in the rate of induced or spontaneous abortions.

Among women who were underweight in high school (BMI less than 18.5 kg/m

A total of 23% of participants reported a history of a period of infertility, and there were no significant differences in this rate across the weight categories. However, a history of amenorrhea was significantly more common among those with higher high school weights (13.2% and 15.4% in those reporting underweight and normal weight in adolescence, respectively, compared with 21.5% and 30.9% in those reporting overweight and obesity in adolescence).

There was also a higher number of women who never tried to get pregnant in the higher weight categories, and although this was statistically significant (P = .2), the difference was small.

“The findings were not affected by tubal or male factor infertility, use of fertility treatments, decisions to remain voluntarily childless, or preference for same-sex sexual relationship,” wrote the authors. After adjustment for adult BMI, history of amenorrhea, marital status, ethnicity, study site, education, and socioeconomic status, adolescent obesity remained independently associated with lifetime nulliparity and nulligravidity (odds ratios 2.84 an 3.93, respectively), they concluded.

“The cross-sectional nature of our study implies that it should be hypothesis-generating: Does adolescent obesity result in diminished fertility?”

The authors reported having no disclosures. The study was supported by the National Institutes of Health.