Kate Johnson

MONTREAL — In women with documented cardiovascular risk factors, those with comorbid depression have a greater risk of clinical events, compared with their nondepressed counterparts, according to new findings from the Women's Ischemic Syndrome Evaluation (WISE), trial sponsored by the National Heart, Lung, and Blood Institute.

“Many studies have associated depression with an increased risk of cardiovascular disease incidence, but until now, the predictive value of these risk factors has been unknown,” reported Thomas Rutledge, Ph.D., of the department of psychiatry at the University of California, San Diego.

“We wanted to know whether the added presence of depression would statistically worsen the relationship between cardiac risk factors and outcome,” he explained at the annual meeting of the Society of Behavioral Medicine.

Dr. Rutledge examined the association of cardiovascular disease (CVD) risk factors with actual CVD events in 153 depressed and 718 nondepressed women who were enrolled in the WISE trial. The women were a mean age of 60 years and all of them had been referred for coronary angiography because of symptoms suggestive of myocardial ischemia.

CVD risk factors were assessed, including smoking, dyslipidemia, hypertension, obesity, diabetes, and level of physical activity.

Depression was defined as self-reported current use of antidepressants to treat depression.

Over a mean follow-up period of 5.9 years, the CVD mortality rate was higher in depressed women with CVD risk factors than it was in nondepressed women with the same risk factors (11.5% vs. 9.2%, respectively). Similarly, depressed women experienced more cardiovascular events such as stroke, myocardial infarction, and heart failure (23.9% vs. 13.3%).

For four of the six individual CVD risk factors, “the combination of depression and the risk factor was associated with a significantly worse event rate, compared with the risk factor alone,” said Dr. Rutledge. “The exceptions were smoking and diabetes, but these were the two risk factors for which we had the smallest sample size, so power was possibly an issue.”

Excluding these exceptions, the combination of depression and risk factors was associated with an average 12%-13% increase in death and events, compared with risk factors alone, he said.

MONTREAL — In women with documented cardiovascular risk factors, those with comorbid depression have a greater risk of clinical events, compared with their nondepressed counterparts, according to new findings from the Women's Ischemic Syndrome Evaluation (WISE), trial sponsored by the National Heart, Lung, and Blood Institute.

“Many studies have associated depression with an increased risk of cardiovascular disease incidence, but until now, the predictive value of these risk factors has been unknown,” reported Thomas Rutledge, Ph.D., of the department of psychiatry at the University of California, San Diego.

“We wanted to know whether the added presence of depression would statistically worsen the relationship between cardiac risk factors and outcome,” he explained at the annual meeting of the Society of Behavioral Medicine.

Dr. Rutledge examined the association of cardiovascular disease (CVD) risk factors with actual CVD events in 153 depressed and 718 nondepressed women who were enrolled in the WISE trial. The women were a mean age of 60 years and all of them had been referred for coronary angiography because of symptoms suggestive of myocardial ischemia.

CVD risk factors were assessed, including smoking, dyslipidemia, hypertension, obesity, diabetes, and level of physical activity.

Depression was defined as self-reported current use of antidepressants to treat depression.

Over a mean follow-up period of 5.9 years, the CVD mortality rate was higher in depressed women with CVD risk factors than it was in nondepressed women with the same risk factors (11.5% vs. 9.2%, respectively). Similarly, depressed women experienced more cardiovascular events such as stroke, myocardial infarction, and heart failure (23.9% vs. 13.3%).

For four of the six individual CVD risk factors, “the combination of depression and the risk factor was associated with a significantly worse event rate, compared with the risk factor alone,” said Dr. Rutledge. “The exceptions were smoking and diabetes, but these were the two risk factors for which we had the smallest sample size, so power was possibly an issue.”

Excluding these exceptions, the combination of depression and risk factors was associated with an average 12%-13% increase in death and events, compared with risk factors alone, he said.

MONTREAL — In women with documented cardiovascular risk factors, those with comorbid depression have a greater risk of clinical events, compared with their nondepressed counterparts, according to new findings from the Women's Ischemic Syndrome Evaluation (WISE), trial sponsored by the National Heart, Lung, and Blood Institute.

“Many studies have associated depression with an increased risk of cardiovascular disease incidence, but until now, the predictive value of these risk factors has been unknown,” reported Thomas Rutledge, Ph.D., of the department of psychiatry at the University of California, San Diego.

“We wanted to know whether the added presence of depression would statistically worsen the relationship between cardiac risk factors and outcome,” he explained at the annual meeting of the Society of Behavioral Medicine.

Dr. Rutledge examined the association of cardiovascular disease (CVD) risk factors with actual CVD events in 153 depressed and 718 nondepressed women who were enrolled in the WISE trial. The women were a mean age of 60 years and all of them had been referred for coronary angiography because of symptoms suggestive of myocardial ischemia.

CVD risk factors were assessed, including smoking, dyslipidemia, hypertension, obesity, diabetes, and level of physical activity.

Depression was defined as self-reported current use of antidepressants to treat depression.

Over a mean follow-up period of 5.9 years, the CVD mortality rate was higher in depressed women with CVD risk factors than it was in nondepressed women with the same risk factors (11.5% vs. 9.2%, respectively). Similarly, depressed women experienced more cardiovascular events such as stroke, myocardial infarction, and heart failure (23.9% vs. 13.3%).

For four of the six individual CVD risk factors, “the combination of depression and the risk factor was associated with a significantly worse event rate, compared with the risk factor alone,” said Dr. Rutledge. “The exceptions were smoking and diabetes, but these were the two risk factors for which we had the smallest sample size, so power was possibly an issue.”

Excluding these exceptions, the combination of depression and risk factors was associated with an average 12%-13% increase in death and events, compared with risk factors alone, he said.

MONTREAL — Hypertensive patients who have depression are less likely to stick to their therapy regimen than are those who are not depressed or are in remission from depression, according to a study of 161 patients.

“This suggests that any change in depressive symptomatology over time can affect medication adherence and may be clinically important,” Sara Gallagher said at the annual meeting of the Society of Behavioral Medicine.

Her study was embedded in a randomized, controlled trial of the effect of motivational interviewing on medication adherence (Am. J. Hypertens. 2008;21:1137-43). The 161 hypertensive African Americans in the study were followed in primary care practice. The patients had a mean age of 54 years, and 87% of them were women. Depressive symptomatology was assessed at baseline and at 6 and 12 months using the Center for Epidemiologic Studies–Depression Scale (CES-D).

A total of 44% of the patients were classified as nondepressed, with a CES-D score of less than 16 at all time points, while 19% were considered depressed, with a score of 16 or above at all time points. The remaining 37% of the patients were classified as in remission, meaning that they progressed from depressed to nondepressed during of the study, said Ms. Gallagher, of New York (N.Y.) University.

Medication adherence was assessed at baseline and at 12 months using the self-reported Morisky scale. At baseline, 64% of the study population reported nonadherence to their medication, and this dropped to 48% at the end of the study.

A multivariate analysis revealed that depressive symptoms were associated with medication nonadherence, Ms. Gallagher reported.

Among the depressed patients, only 34% reported adherence at 12 months, compared with 66% of those in the nondepressed group and 47% of those who were in remission.

The study confirms previous findings that depressive symptoms are associated with poor medication adherence, Ms. Gallagher said. However, the finding that remission of depressive symptoms is associated with improved adherence suggests a benefit to addressing patient depression in this context, she said.

MONTREAL — Hypertensive patients who have depression are less likely to stick to their therapy regimen than are those who are not depressed or are in remission from depression, according to a study of 161 patients.

“This suggests that any change in depressive symptomatology over time can affect medication adherence and may be clinically important,” Sara Gallagher said at the annual meeting of the Society of Behavioral Medicine.

Her study was embedded in a randomized, controlled trial of the effect of motivational interviewing on medication adherence (Am. J. Hypertens. 2008;21:1137-43). The 161 hypertensive African Americans in the study were followed in primary care practice. The patients had a mean age of 54 years, and 87% of them were women. Depressive symptomatology was assessed at baseline and at 6 and 12 months using the Center for Epidemiologic Studies–Depression Scale (CES-D).

A total of 44% of the patients were classified as nondepressed, with a CES-D score of less than 16 at all time points, while 19% were considered depressed, with a score of 16 or above at all time points. The remaining 37% of the patients were classified as in remission, meaning that they progressed from depressed to nondepressed during of the study, said Ms. Gallagher, of New York (N.Y.) University.

Medication adherence was assessed at baseline and at 12 months using the self-reported Morisky scale. At baseline, 64% of the study population reported nonadherence to their medication, and this dropped to 48% at the end of the study.

A multivariate analysis revealed that depressive symptoms were associated with medication nonadherence, Ms. Gallagher reported.

Among the depressed patients, only 34% reported adherence at 12 months, compared with 66% of those in the nondepressed group and 47% of those who were in remission.

The study confirms previous findings that depressive symptoms are associated with poor medication adherence, Ms. Gallagher said. However, the finding that remission of depressive symptoms is associated with improved adherence suggests a benefit to addressing patient depression in this context, she said.

MONTREAL — Hypertensive patients who have depression are less likely to stick to their therapy regimen than are those who are not depressed or are in remission from depression, according to a study of 161 patients.

“This suggests that any change in depressive symptomatology over time can affect medication adherence and may be clinically important,” Sara Gallagher said at the annual meeting of the Society of Behavioral Medicine.

Her study was embedded in a randomized, controlled trial of the effect of motivational interviewing on medication adherence (Am. J. Hypertens. 2008;21:1137-43). The 161 hypertensive African Americans in the study were followed in primary care practice. The patients had a mean age of 54 years, and 87% of them were women. Depressive symptomatology was assessed at baseline and at 6 and 12 months using the Center for Epidemiologic Studies–Depression Scale (CES-D).

A total of 44% of the patients were classified as nondepressed, with a CES-D score of less than 16 at all time points, while 19% were considered depressed, with a score of 16 or above at all time points. The remaining 37% of the patients were classified as in remission, meaning that they progressed from depressed to nondepressed during of the study, said Ms. Gallagher, of New York (N.Y.) University.

Medication adherence was assessed at baseline and at 12 months using the self-reported Morisky scale. At baseline, 64% of the study population reported nonadherence to their medication, and this dropped to 48% at the end of the study.

A multivariate analysis revealed that depressive symptoms were associated with medication nonadherence, Ms. Gallagher reported.

Among the depressed patients, only 34% reported adherence at 12 months, compared with 66% of those in the nondepressed group and 47% of those who were in remission.

The study confirms previous findings that depressive symptoms are associated with poor medication adherence, Ms. Gallagher said. However, the finding that remission of depressive symptoms is associated with improved adherence suggests a benefit to addressing patient depression in this context, she said.

MONTREAL — A single application of a vaginal microbicide gel resulted in persistently protective levels 24 hours later, with no significant side effects, reported Dr. Katherine Bunge of Magee-Womens Hospital in Pittsburgh.

These preliminary safety and persistence data justify daily dosing, she said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

The phase I, single-center trial of the nonnucleoside reverse transcription inhibitor UC-781 randomized 60 healthy women at a ratio of 2:1 to either treatment or placebo, explained Dr. Bunge, who had no disclosures to declare.

The women (mean age 26 years) also were randomized to product exposure durations of either 2, 4, or 8 hours. They received a physician-administered dose of vaginal gel and were then required to stay in the research facility for their assigned time period, after which specimens were collected by cervicovaginal lavage (CVL) and vaginal swabs. The subjects then returned 1 day, 1 week, and 1 month later for follow-up.

Urogenital irritation was assessed by pelvic exam and symptoms, microscopic genital changes were assessed by colposcopy, systemic safety was assessed by history and laboratory parameters, vaginal flora was quantified, and cervical cytokines were measured.

“These are fairly typical safety measures in any phase I trial of a microbicide, but what we attempted to do that hadn't really been looked at before was to figure out a way to determine the persistence of this vaginally applied drug that we didn't really expect to be absorbed,” she said.

To that end, plasma drug levels were measured both immediately after the patients' timed exposure and then again a day later; drug levels were measured in CVL and vaginal swab specimens, which also were collected at those two time points, Dr. Bunge explained.

At 24 hours post exposure, two patients had detectable levels of UC-781 in their plasma, but in both cases the levels were considered below the limits of quantification, she said.

In contrast, “the most important and interesting data” showed persistence of the drug in the vagina, she said. Eight hours after treatment, 100% of the women had detectable drug levels in CVL specimens and 90% had detectable levels in vaginal swab specimens. At 24 hours post exposure, 93% had detectable levels after a second CVL, and 42% showed detectable levels after a second vaginal swab.

Dr. Bunge pointed out that even after 24 hours, the median concentration of UC-781 in CVL specimens was 4,965 pmol/mL.

“The inhibitory concentration of UC-781 is 2 pmol/mL, so in fact at 24 hours after washout, the median concentration of detectable drug in CVL samples was a thousand times the inhibitory concentration,” she said.

Among the 197 adverse events (121 in the treatment group and 76 in the placebo group), 85% were classified as mild. There were four severe events but all were deemed not related or probably not related to treatment, said Dr. Bunge.

MONTREAL — A single application of a vaginal microbicide gel resulted in persistently protective levels 24 hours later, with no significant side effects, reported Dr. Katherine Bunge of Magee-Womens Hospital in Pittsburgh.

These preliminary safety and persistence data justify daily dosing, she said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

The phase I, single-center trial of the nonnucleoside reverse transcription inhibitor UC-781 randomized 60 healthy women at a ratio of 2:1 to either treatment or placebo, explained Dr. Bunge, who had no disclosures to declare.

The women (mean age 26 years) also were randomized to product exposure durations of either 2, 4, or 8 hours. They received a physician-administered dose of vaginal gel and were then required to stay in the research facility for their assigned time period, after which specimens were collected by cervicovaginal lavage (CVL) and vaginal swabs. The subjects then returned 1 day, 1 week, and 1 month later for follow-up.

Urogenital irritation was assessed by pelvic exam and symptoms, microscopic genital changes were assessed by colposcopy, systemic safety was assessed by history and laboratory parameters, vaginal flora was quantified, and cervical cytokines were measured.

“These are fairly typical safety measures in any phase I trial of a microbicide, but what we attempted to do that hadn't really been looked at before was to figure out a way to determine the persistence of this vaginally applied drug that we didn't really expect to be absorbed,” she said.

To that end, plasma drug levels were measured both immediately after the patients' timed exposure and then again a day later; drug levels were measured in CVL and vaginal swab specimens, which also were collected at those two time points, Dr. Bunge explained.

At 24 hours post exposure, two patients had detectable levels of UC-781 in their plasma, but in both cases the levels were considered below the limits of quantification, she said.

In contrast, “the most important and interesting data” showed persistence of the drug in the vagina, she said. Eight hours after treatment, 100% of the women had detectable drug levels in CVL specimens and 90% had detectable levels in vaginal swab specimens. At 24 hours post exposure, 93% had detectable levels after a second CVL, and 42% showed detectable levels after a second vaginal swab.

Dr. Bunge pointed out that even after 24 hours, the median concentration of UC-781 in CVL specimens was 4,965 pmol/mL.

“The inhibitory concentration of UC-781 is 2 pmol/mL, so in fact at 24 hours after washout, the median concentration of detectable drug in CVL samples was a thousand times the inhibitory concentration,” she said.

Among the 197 adverse events (121 in the treatment group and 76 in the placebo group), 85% were classified as mild. There were four severe events but all were deemed not related or probably not related to treatment, said Dr. Bunge.

MONTREAL — A single application of a vaginal microbicide gel resulted in persistently protective levels 24 hours later, with no significant side effects, reported Dr. Katherine Bunge of Magee-Womens Hospital in Pittsburgh.

These preliminary safety and persistence data justify daily dosing, she said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

The phase I, single-center trial of the nonnucleoside reverse transcription inhibitor UC-781 randomized 60 healthy women at a ratio of 2:1 to either treatment or placebo, explained Dr. Bunge, who had no disclosures to declare.

The women (mean age 26 years) also were randomized to product exposure durations of either 2, 4, or 8 hours. They received a physician-administered dose of vaginal gel and were then required to stay in the research facility for their assigned time period, after which specimens were collected by cervicovaginal lavage (CVL) and vaginal swabs. The subjects then returned 1 day, 1 week, and 1 month later for follow-up.

Urogenital irritation was assessed by pelvic exam and symptoms, microscopic genital changes were assessed by colposcopy, systemic safety was assessed by history and laboratory parameters, vaginal flora was quantified, and cervical cytokines were measured.

“These are fairly typical safety measures in any phase I trial of a microbicide, but what we attempted to do that hadn't really been looked at before was to figure out a way to determine the persistence of this vaginally applied drug that we didn't really expect to be absorbed,” she said.

To that end, plasma drug levels were measured both immediately after the patients' timed exposure and then again a day later; drug levels were measured in CVL and vaginal swab specimens, which also were collected at those two time points, Dr. Bunge explained.

At 24 hours post exposure, two patients had detectable levels of UC-781 in their plasma, but in both cases the levels were considered below the limits of quantification, she said.

In contrast, “the most important and interesting data” showed persistence of the drug in the vagina, she said. Eight hours after treatment, 100% of the women had detectable drug levels in CVL specimens and 90% had detectable levels in vaginal swab specimens. At 24 hours post exposure, 93% had detectable levels after a second CVL, and 42% showed detectable levels after a second vaginal swab.

Dr. Bunge pointed out that even after 24 hours, the median concentration of UC-781 in CVL specimens was 4,965 pmol/mL.

“The inhibitory concentration of UC-781 is 2 pmol/mL, so in fact at 24 hours after washout, the median concentration of detectable drug in CVL samples was a thousand times the inhibitory concentration,” she said.

Among the 197 adverse events (121 in the treatment group and 76 in the placebo group), 85% were classified as mild. There were four severe events but all were deemed not related or probably not related to treatment, said Dr. Bunge.

MONTREAL — Cognitive complaints in long-term breast cancer survivors might be better managed if issues of depression and fatigue are addressed, according to Heather McGinty, a doctoral student at the University South Florida in Tampa.

In a study that she presented at the annual meeting of the Society of Behavioral Medicine, Ms. McGinty showed that at 3 years after the end of breast cancer treatment, depression and fatigue were the strongest factors related to women's perceived cognitive decline.

“Perhaps women with these psychosocial issues are more vulnerable to cognitive problems,” she suggested.

The principal investigator on this study was Paul B. Jacobsen, Ph.D., of the H. Lee Moffitt Cancer Center in Tampa and the department of psychology at the University of South Florida.

The study included 216 women, with a mean age of 54 years, who had completed breast cancer treatment at least 3 years previously.

Roughly 90% of the women were postmenopausal, and all of them had received surgery: 55% for stage I disease; 35% for stage II; and 10% for stage 0.

In addition, half had received chemotherapy, either alone or in combination with radiotherapy.

Depression, fatigue, and perceived health were measured using the CES-D (Center for Epidemiologic Studies-Depression scale), the FSI (Fatigue Symptom Inventory), and the fatigue and general health subscales of the SF-36 (Medical Outcomes Study 36-Item Short Form Health Survey).

The participants also completed the MASQ (Multiple Abilities Self-Report Questionnaire) that measures perceived cognitive functioning across five cognitive domains, compared with that of same-age peers.

Sample statements about perceived cognitive functioning included: “After putting something away for safekeeping, I may not recall its location” (visual memory); “I can follow telephone conversations” (attention); “I can easily fit the pieces of a jigsaw puzzle together” (visual-perceptual ability); “I am able to recall the details of the evening news report several hours later” (verbal memory); and “I find myself calling a familiar object by the wrong name” (language), Ms. McGinty explained.

Overall, mean perceived cognitive function scores indicated that “these women were functioning quite well, reported rarely experiencing problems, and were frequently able to perform most tasks that were listed,” she said.

A particular combination of demographic, clinical, and psychosocial characteristics was associated with poorer cognitive functioning, however.

“Age, stage of diagnosis, surgery type, and tamoxifen use did not significantly correlate, but postmenopausal status, chemotherapy, depression, and fatigue were associated with worse cognition,” Ms. McGinty said.

“Interventions for fatigue and depression may have beneficial effects on perceived cognitive functioning in this patient population,” she noted.

“Neuropsychological testing may not always be sensitive to cancer-related changes, and lab-based measures may not correspond to people's experiences at home or at work,” Ms. McGinty said.

MONTREAL — Cognitive complaints in long-term breast cancer survivors might be better managed if issues of depression and fatigue are addressed, according to Heather McGinty, a doctoral student at the University South Florida in Tampa.

In a study that she presented at the annual meeting of the Society of Behavioral Medicine, Ms. McGinty showed that at 3 years after the end of breast cancer treatment, depression and fatigue were the strongest factors related to women's perceived cognitive decline.

“Perhaps women with these psychosocial issues are more vulnerable to cognitive problems,” she suggested.

The principal investigator on this study was Paul B. Jacobsen, Ph.D., of the H. Lee Moffitt Cancer Center in Tampa and the department of psychology at the University of South Florida.

The study included 216 women, with a mean age of 54 years, who had completed breast cancer treatment at least 3 years previously.

Roughly 90% of the women were postmenopausal, and all of them had received surgery: 55% for stage I disease; 35% for stage II; and 10% for stage 0.

In addition, half had received chemotherapy, either alone or in combination with radiotherapy.

Depression, fatigue, and perceived health were measured using the CES-D (Center for Epidemiologic Studies-Depression scale), the FSI (Fatigue Symptom Inventory), and the fatigue and general health subscales of the SF-36 (Medical Outcomes Study 36-Item Short Form Health Survey).

The participants also completed the MASQ (Multiple Abilities Self-Report Questionnaire) that measures perceived cognitive functioning across five cognitive domains, compared with that of same-age peers.

Sample statements about perceived cognitive functioning included: “After putting something away for safekeeping, I may not recall its location” (visual memory); “I can follow telephone conversations” (attention); “I can easily fit the pieces of a jigsaw puzzle together” (visual-perceptual ability); “I am able to recall the details of the evening news report several hours later” (verbal memory); and “I find myself calling a familiar object by the wrong name” (language), Ms. McGinty explained.

Overall, mean perceived cognitive function scores indicated that “these women were functioning quite well, reported rarely experiencing problems, and were frequently able to perform most tasks that were listed,” she said.

A particular combination of demographic, clinical, and psychosocial characteristics was associated with poorer cognitive functioning, however.

“Age, stage of diagnosis, surgery type, and tamoxifen use did not significantly correlate, but postmenopausal status, chemotherapy, depression, and fatigue were associated with worse cognition,” Ms. McGinty said.

“Interventions for fatigue and depression may have beneficial effects on perceived cognitive functioning in this patient population,” she noted.

“Neuropsychological testing may not always be sensitive to cancer-related changes, and lab-based measures may not correspond to people's experiences at home or at work,” Ms. McGinty said.

MONTREAL — Cognitive complaints in long-term breast cancer survivors might be better managed if issues of depression and fatigue are addressed, according to Heather McGinty, a doctoral student at the University South Florida in Tampa.

In a study that she presented at the annual meeting of the Society of Behavioral Medicine, Ms. McGinty showed that at 3 years after the end of breast cancer treatment, depression and fatigue were the strongest factors related to women's perceived cognitive decline.

“Perhaps women with these psychosocial issues are more vulnerable to cognitive problems,” she suggested.

The principal investigator on this study was Paul B. Jacobsen, Ph.D., of the H. Lee Moffitt Cancer Center in Tampa and the department of psychology at the University of South Florida.

The study included 216 women, with a mean age of 54 years, who had completed breast cancer treatment at least 3 years previously.

Roughly 90% of the women were postmenopausal, and all of them had received surgery: 55% for stage I disease; 35% for stage II; and 10% for stage 0.

In addition, half had received chemotherapy, either alone or in combination with radiotherapy.

Depression, fatigue, and perceived health were measured using the CES-D (Center for Epidemiologic Studies-Depression scale), the FSI (Fatigue Symptom Inventory), and the fatigue and general health subscales of the SF-36 (Medical Outcomes Study 36-Item Short Form Health Survey).

The participants also completed the MASQ (Multiple Abilities Self-Report Questionnaire) that measures perceived cognitive functioning across five cognitive domains, compared with that of same-age peers.

Sample statements about perceived cognitive functioning included: “After putting something away for safekeeping, I may not recall its location” (visual memory); “I can follow telephone conversations” (attention); “I can easily fit the pieces of a jigsaw puzzle together” (visual-perceptual ability); “I am able to recall the details of the evening news report several hours later” (verbal memory); and “I find myself calling a familiar object by the wrong name” (language), Ms. McGinty explained.

Overall, mean perceived cognitive function scores indicated that “these women were functioning quite well, reported rarely experiencing problems, and were frequently able to perform most tasks that were listed,” she said.

A particular combination of demographic, clinical, and psychosocial characteristics was associated with poorer cognitive functioning, however.

“Age, stage of diagnosis, surgery type, and tamoxifen use did not significantly correlate, but postmenopausal status, chemotherapy, depression, and fatigue were associated with worse cognition,” Ms. McGinty said.

“Interventions for fatigue and depression may have beneficial effects on perceived cognitive functioning in this patient population,” she noted.

“Neuropsychological testing may not always be sensitive to cancer-related changes, and lab-based measures may not correspond to people's experiences at home or at work,” Ms. McGinty said.

AMSTERDAM — New embryo transfer guidelines are expected soon from the American Society for Reproductive Medicine, prompted in part by the birth of the California octuplets earlier this year, according to Dr. David Adamson, immediate past president of the society.

The guidelines will “unquestionably lower the number of embryos transferred or modify how choices are made,” with the goal of further reducing the risk of multiple births, he said in an interview.

Despite considerable pressure to tighten the guidelines in the wake of the octuplets' delivery, the ASRM must carefully protect its vision of individualized patient treatment, Dr. Adamson said at the annual meeting of the European Society of Human Reproduction and Embryology.

“There certainly has been some perspective in the media and elsewhere that, because this occurred, there should be more regulation on the number of embryos transferred, but my perspective is that this was an extreme outlier and you don't want to make regulation based on extreme exceptions to the rule,” said Dr. Adamson, who is in private practice in Palo Alto, Calif. “It's impossible for any regulation, no matter how rigorous, to prevent sociopathic, psychopathic, illegal, or just plain crazy behavior.”

Nevertheless, the new guidelines, expected less than a year since the last ones were issued, reflect the ASRM's awareness of the need to tackle the problem of multiple births more aggressively.

While European experts released figures at the meeting showing that in 2006 twin deliveries resulting from assisted reproductive technologies in Europe dipped below 20% for the first time, the latest U.S. figures (2007) show the rate of IVF twin pregnancies at 33% in women under age 35, 28% in the 35- to 37-year-old age group, 22% in women aged 38–40, and 15% in the over 40 age group.

In the United States, elective single embryo transfer (SET) was performed in just 4.5% of cycles in women under age 35, dropping to 2.6% in women aged 35–37, 1% in those aged 38–40, and 0.3% in those over the age of 40.

In contrast, SET comprised 67% of all transfers in Sweden, where the practice is mandatory in women under age 40, said Dr. Adamson.

“But the average Swedish patient is 30 years old, and treatment is covered by the state,” he commented. “In the U.S. patients are 5 or 6 years older, they've had infertility for much longer, and they have to pay.”

Compared to laws and guidelines in many European countries, the current ASRM guidelines are more vague and less ambitious. For example, the ASRM guidelines simply state that “consideration should be given” to SET in women who are under the age of 35 and have a good chance of getting pregnant. But there is more emphasis placed on double embryo transfer, and the door is left open for the transfer of even more embryos, depending on the age of the patient and the prognosis.

While he said that the U.S. twin pregnancy rate following IVF needs to come down, Dr. Adamson added that this should not be at the cost of removing the ASRM's individualized approach to care.

“The risks are higher for twins and for their mothers, but they are not so high that twins are necessarily always a bad outcome. Clearly, the objective is a healthy singleton baby, but we have to make sure we don't reduce the overall quality of care by trying to make the twin rate 0% because that won't happen unless no one becomes pregnant,” he said.

Dr. Adamson receives research funding from Institut Biochimique SA and EMD Serono Inc.

AMSTERDAM — New embryo transfer guidelines are expected soon from the American Society for Reproductive Medicine, prompted in part by the birth of the California octuplets earlier this year, according to Dr. David Adamson, immediate past president of the society.

The guidelines will “unquestionably lower the number of embryos transferred or modify how choices are made,” with the goal of further reducing the risk of multiple births, he said in an interview.

Despite considerable pressure to tighten the guidelines in the wake of the octuplets' delivery, the ASRM must carefully protect its vision of individualized patient treatment, Dr. Adamson said at the annual meeting of the European Society of Human Reproduction and Embryology.

“There certainly has been some perspective in the media and elsewhere that, because this occurred, there should be more regulation on the number of embryos transferred, but my perspective is that this was an extreme outlier and you don't want to make regulation based on extreme exceptions to the rule,” said Dr. Adamson, who is in private practice in Palo Alto, Calif. “It's impossible for any regulation, no matter how rigorous, to prevent sociopathic, psychopathic, illegal, or just plain crazy behavior.”

Nevertheless, the new guidelines, expected less than a year since the last ones were issued, reflect the ASRM's awareness of the need to tackle the problem of multiple births more aggressively.

While European experts released figures at the meeting showing that in 2006 twin deliveries resulting from assisted reproductive technologies in Europe dipped below 20% for the first time, the latest U.S. figures (2007) show the rate of IVF twin pregnancies at 33% in women under age 35, 28% in the 35- to 37-year-old age group, 22% in women aged 38–40, and 15% in the over 40 age group.

In the United States, elective single embryo transfer (SET) was performed in just 4.5% of cycles in women under age 35, dropping to 2.6% in women aged 35–37, 1% in those aged 38–40, and 0.3% in those over the age of 40.

In contrast, SET comprised 67% of all transfers in Sweden, where the practice is mandatory in women under age 40, said Dr. Adamson.

“But the average Swedish patient is 30 years old, and treatment is covered by the state,” he commented. “In the U.S. patients are 5 or 6 years older, they've had infertility for much longer, and they have to pay.”

Compared to laws and guidelines in many European countries, the current ASRM guidelines are more vague and less ambitious. For example, the ASRM guidelines simply state that “consideration should be given” to SET in women who are under the age of 35 and have a good chance of getting pregnant. But there is more emphasis placed on double embryo transfer, and the door is left open for the transfer of even more embryos, depending on the age of the patient and the prognosis.

While he said that the U.S. twin pregnancy rate following IVF needs to come down, Dr. Adamson added that this should not be at the cost of removing the ASRM's individualized approach to care.

“The risks are higher for twins and for their mothers, but they are not so high that twins are necessarily always a bad outcome. Clearly, the objective is a healthy singleton baby, but we have to make sure we don't reduce the overall quality of care by trying to make the twin rate 0% because that won't happen unless no one becomes pregnant,” he said.

Dr. Adamson receives research funding from Institut Biochimique SA and EMD Serono Inc.

AMSTERDAM — New embryo transfer guidelines are expected soon from the American Society for Reproductive Medicine, prompted in part by the birth of the California octuplets earlier this year, according to Dr. David Adamson, immediate past president of the society.

The guidelines will “unquestionably lower the number of embryos transferred or modify how choices are made,” with the goal of further reducing the risk of multiple births, he said in an interview.

Despite considerable pressure to tighten the guidelines in the wake of the octuplets' delivery, the ASRM must carefully protect its vision of individualized patient treatment, Dr. Adamson said at the annual meeting of the European Society of Human Reproduction and Embryology.

“There certainly has been some perspective in the media and elsewhere that, because this occurred, there should be more regulation on the number of embryos transferred, but my perspective is that this was an extreme outlier and you don't want to make regulation based on extreme exceptions to the rule,” said Dr. Adamson, who is in private practice in Palo Alto, Calif. “It's impossible for any regulation, no matter how rigorous, to prevent sociopathic, psychopathic, illegal, or just plain crazy behavior.”

Nevertheless, the new guidelines, expected less than a year since the last ones were issued, reflect the ASRM's awareness of the need to tackle the problem of multiple births more aggressively.

While European experts released figures at the meeting showing that in 2006 twin deliveries resulting from assisted reproductive technologies in Europe dipped below 20% for the first time, the latest U.S. figures (2007) show the rate of IVF twin pregnancies at 33% in women under age 35, 28% in the 35- to 37-year-old age group, 22% in women aged 38–40, and 15% in the over 40 age group.

In the United States, elective single embryo transfer (SET) was performed in just 4.5% of cycles in women under age 35, dropping to 2.6% in women aged 35–37, 1% in those aged 38–40, and 0.3% in those over the age of 40.

In contrast, SET comprised 67% of all transfers in Sweden, where the practice is mandatory in women under age 40, said Dr. Adamson.

“But the average Swedish patient is 30 years old, and treatment is covered by the state,” he commented. “In the U.S. patients are 5 or 6 years older, they've had infertility for much longer, and they have to pay.”

Compared to laws and guidelines in many European countries, the current ASRM guidelines are more vague and less ambitious. For example, the ASRM guidelines simply state that “consideration should be given” to SET in women who are under the age of 35 and have a good chance of getting pregnant. But there is more emphasis placed on double embryo transfer, and the door is left open for the transfer of even more embryos, depending on the age of the patient and the prognosis.

While he said that the U.S. twin pregnancy rate following IVF needs to come down, Dr. Adamson added that this should not be at the cost of removing the ASRM's individualized approach to care.

“The risks are higher for twins and for their mothers, but they are not so high that twins are necessarily always a bad outcome. Clearly, the objective is a healthy singleton baby, but we have to make sure we don't reduce the overall quality of care by trying to make the twin rate 0% because that won't happen unless no one becomes pregnant,” he said.

Dr. Adamson receives research funding from Institut Biochimique SA and EMD Serono Inc.

AMSTERDAM — A bright light in the floundering U.S. economy may be an influx of foreign fertility patients, several experts suggested.

Last year, up to 5,000 patients seeking fertility treatment—8% of the national U.S. annual volume—came to the U.S. from abroad, with European and Latin American populations comprising the bulk of those patients, according to study findings from a survey of American and Canadian fertility clinics conducted in October 2008 that were presented at the annual meeting of the European Society of Human Reproduction and Embryology.

“There is significant transatlantic traffic of patients to the U.S,” said the study's lead author, Dr. Edward Hughes from McMaster University in Hamilton, Ontario, Canada. These patients are seeking conventional in vitro fertilization (IVF), as well as anonymous egg donation and gestational carriers.

The influx is thanks to a glut of European patients, attracted by the faltering U.S. dollar as well as by less restrictive access to certain treatments, particularly third-party reproduction, according Dr. Brian Kaplan, a reproductive endocrinologist with Fertility Centers of Illinois in the Chicago area.

“There are favorable laws in the U.S. compared with many European countries, which have banned certain treatments. Combine this with the excellent pregnancy rates at our center, and most of the centers in the U.S., and the fact that U.S. fees are more attractive because of the recession, and that's why they're coming,” Dr. Kaplan said in an interview.

Although U.S. fees have traditionally been, and remain considerably higher than those in many European countries, they are offset by better success rates and access, he emphasized.

Indeed, the U.S. has always been an attractive choice for many foreign infertile couples hampered by restrictions they face at home, says Dr. David Adamson, immediate past president of the American Society for Reproductive Medicine.

“Patients with infertility will do almost anything they can to have a family. If a country has a situation where a large number of citizens are deciding to go elsewhere for care, then it's very important for that country to look at the reasons and to decide if their regulations are appropriate or not,” he said in an interview.

A good example is the recent influx of Canadian patients across the U.S. border. According to the survey, the U.S. received 7% of Canada's national volume of in vitro fertilization patients last year. A full 80% of those patients were seeking egg donation, which has become virtually unavailable in their own country since a ban on payment to donors, said Dr. Hughes.

“If a patient in Canada has an altruistic donor she can certainly have care, but in the absence of that, donor egg patients have been traveling to the States in increasing numbers,” he said.

The economy may also be providing additional incentives in this context, as more U.S. women are considering egg donation as a means to supplement their income.

“Clinics are reporting a surge in egg donors as a result of the economic climate,” reported Wendy Kramer from the Donor Sibling Registry. She cited a Wall Street Journal headline from last December, which read “Women Line Up to Donate Eggs—for Money.”

Regardless of the economy, cross-border fertility “tourism” is a growing reality that will continue to flourish as long as countries differ regarding regulation and access, Dr. Adamson said.

“One can expect in the future there will probably be slow harmonization of legislation, guidelines, and oversight, but I don't see that there will be complete unanimity for decades and decades to come—if ever,” he said.

The survey was a joint effort of Assisted Human Reproduction Canada, and the U.S. Society for Assisted Reproductive Technology.

It involved the polling of 392 U.S. and 34 Canadian fertility providers. A total of 125 (32%) U.S. providers responded, and it was estimated that they were responsible for providing about 42% of national fertility services, said Dr. Hughes. The Canadian response rate was 82%, representing 77% of that country's fertility services.

U.S. clinics reported a total of 1,809 patients entering the country for treatment, 1,400 for IVF. “That's about 4% of the national volume, but in absolute terms these numbers need to at least be doubled,” he said, explaining that the responders provided less than half of the fertility services in the country. “There are probably 5,000 incoming patients, about 3,000 of them for IVF,” he concluded.

Regardless of the economy, cross-border fertility 'tourism' is a growing reality that will continue to flourish.

Source DR. ADAMSON

AMSTERDAM — A bright light in the floundering U.S. economy may be an influx of foreign fertility patients, several experts suggested.

Last year, up to 5,000 patients seeking fertility treatment—8% of the national U.S. annual volume—came to the U.S. from abroad, with European and Latin American populations comprising the bulk of those patients, according to study findings from a survey of American and Canadian fertility clinics conducted in October 2008 that were presented at the annual meeting of the European Society of Human Reproduction and Embryology.

“There is significant transatlantic traffic of patients to the U.S,” said the study's lead author, Dr. Edward Hughes from McMaster University in Hamilton, Ontario, Canada. These patients are seeking conventional in vitro fertilization (IVF), as well as anonymous egg donation and gestational carriers.

The influx is thanks to a glut of European patients, attracted by the faltering U.S. dollar as well as by less restrictive access to certain treatments, particularly third-party reproduction, according Dr. Brian Kaplan, a reproductive endocrinologist with Fertility Centers of Illinois in the Chicago area.

“There are favorable laws in the U.S. compared with many European countries, which have banned certain treatments. Combine this with the excellent pregnancy rates at our center, and most of the centers in the U.S., and the fact that U.S. fees are more attractive because of the recession, and that's why they're coming,” Dr. Kaplan said in an interview.

Although U.S. fees have traditionally been, and remain considerably higher than those in many European countries, they are offset by better success rates and access, he emphasized.

Indeed, the U.S. has always been an attractive choice for many foreign infertile couples hampered by restrictions they face at home, says Dr. David Adamson, immediate past president of the American Society for Reproductive Medicine.

“Patients with infertility will do almost anything they can to have a family. If a country has a situation where a large number of citizens are deciding to go elsewhere for care, then it's very important for that country to look at the reasons and to decide if their regulations are appropriate or not,” he said in an interview.

A good example is the recent influx of Canadian patients across the U.S. border. According to the survey, the U.S. received 7% of Canada's national volume of in vitro fertilization patients last year. A full 80% of those patients were seeking egg donation, which has become virtually unavailable in their own country since a ban on payment to donors, said Dr. Hughes.

“If a patient in Canada has an altruistic donor she can certainly have care, but in the absence of that, donor egg patients have been traveling to the States in increasing numbers,” he said.

The economy may also be providing additional incentives in this context, as more U.S. women are considering egg donation as a means to supplement their income.

“Clinics are reporting a surge in egg donors as a result of the economic climate,” reported Wendy Kramer from the Donor Sibling Registry. She cited a Wall Street Journal headline from last December, which read “Women Line Up to Donate Eggs—for Money.”

Regardless of the economy, cross-border fertility “tourism” is a growing reality that will continue to flourish as long as countries differ regarding regulation and access, Dr. Adamson said.

“One can expect in the future there will probably be slow harmonization of legislation, guidelines, and oversight, but I don't see that there will be complete unanimity for decades and decades to come—if ever,” he said.

The survey was a joint effort of Assisted Human Reproduction Canada, and the U.S. Society for Assisted Reproductive Technology.

It involved the polling of 392 U.S. and 34 Canadian fertility providers. A total of 125 (32%) U.S. providers responded, and it was estimated that they were responsible for providing about 42% of national fertility services, said Dr. Hughes. The Canadian response rate was 82%, representing 77% of that country's fertility services.

U.S. clinics reported a total of 1,809 patients entering the country for treatment, 1,400 for IVF. “That's about 4% of the national volume, but in absolute terms these numbers need to at least be doubled,” he said, explaining that the responders provided less than half of the fertility services in the country. “There are probably 5,000 incoming patients, about 3,000 of them for IVF,” he concluded.

Regardless of the economy, cross-border fertility 'tourism' is a growing reality that will continue to flourish.

Source DR. ADAMSON

AMSTERDAM — A bright light in the floundering U.S. economy may be an influx of foreign fertility patients, several experts suggested.

Last year, up to 5,000 patients seeking fertility treatment—8% of the national U.S. annual volume—came to the U.S. from abroad, with European and Latin American populations comprising the bulk of those patients, according to study findings from a survey of American and Canadian fertility clinics conducted in October 2008 that were presented at the annual meeting of the European Society of Human Reproduction and Embryology.

“There is significant transatlantic traffic of patients to the U.S,” said the study's lead author, Dr. Edward Hughes from McMaster University in Hamilton, Ontario, Canada. These patients are seeking conventional in vitro fertilization (IVF), as well as anonymous egg donation and gestational carriers.

The influx is thanks to a glut of European patients, attracted by the faltering U.S. dollar as well as by less restrictive access to certain treatments, particularly third-party reproduction, according Dr. Brian Kaplan, a reproductive endocrinologist with Fertility Centers of Illinois in the Chicago area.

“There are favorable laws in the U.S. compared with many European countries, which have banned certain treatments. Combine this with the excellent pregnancy rates at our center, and most of the centers in the U.S., and the fact that U.S. fees are more attractive because of the recession, and that's why they're coming,” Dr. Kaplan said in an interview.

Although U.S. fees have traditionally been, and remain considerably higher than those in many European countries, they are offset by better success rates and access, he emphasized.

Indeed, the U.S. has always been an attractive choice for many foreign infertile couples hampered by restrictions they face at home, says Dr. David Adamson, immediate past president of the American Society for Reproductive Medicine.

“Patients with infertility will do almost anything they can to have a family. If a country has a situation where a large number of citizens are deciding to go elsewhere for care, then it's very important for that country to look at the reasons and to decide if their regulations are appropriate or not,” he said in an interview.

A good example is the recent influx of Canadian patients across the U.S. border. According to the survey, the U.S. received 7% of Canada's national volume of in vitro fertilization patients last year. A full 80% of those patients were seeking egg donation, which has become virtually unavailable in their own country since a ban on payment to donors, said Dr. Hughes.

“If a patient in Canada has an altruistic donor she can certainly have care, but in the absence of that, donor egg patients have been traveling to the States in increasing numbers,” he said.

The economy may also be providing additional incentives in this context, as more U.S. women are considering egg donation as a means to supplement their income.

“Clinics are reporting a surge in egg donors as a result of the economic climate,” reported Wendy Kramer from the Donor Sibling Registry. She cited a Wall Street Journal headline from last December, which read “Women Line Up to Donate Eggs—for Money.”

Regardless of the economy, cross-border fertility “tourism” is a growing reality that will continue to flourish as long as countries differ regarding regulation and access, Dr. Adamson said.

“One can expect in the future there will probably be slow harmonization of legislation, guidelines, and oversight, but I don't see that there will be complete unanimity for decades and decades to come—if ever,” he said.

The survey was a joint effort of Assisted Human Reproduction Canada, and the U.S. Society for Assisted Reproductive Technology.

It involved the polling of 392 U.S. and 34 Canadian fertility providers. A total of 125 (32%) U.S. providers responded, and it was estimated that they were responsible for providing about 42% of national fertility services, said Dr. Hughes. The Canadian response rate was 82%, representing 77% of that country's fertility services.

U.S. clinics reported a total of 1,809 patients entering the country for treatment, 1,400 for IVF. “That's about 4% of the national volume, but in absolute terms these numbers need to at least be doubled,” he said, explaining that the responders provided less than half of the fertility services in the country. “There are probably 5,000 incoming patients, about 3,000 of them for IVF,” he concluded.

Regardless of the economy, cross-border fertility 'tourism' is a growing reality that will continue to flourish.

Source DR. ADAMSON

MONTREAL — Prenatal care providers need to take a frontline attitude about novel influenza A (H1N1) because pregnant women are among those at highest risk for infection and serious complications.

“We need to get the message out to the practitioners in the field that they've really got to be thinking about this. They need to recognize that influenza in pregnancy is not trivial, and they should consider early treatment,” said Dr. Deborah Money, president-elect of the Infectious Diseases Society for Obstetrics and Gynecology.

Speaking after chairing an urgent update session on novel H1N1 influenza at the society's annual meeting, Dr. Money said the latest figures on the infection in pregnancy, published in Lancet (doi:10.1016/S0140-6736[09]61304-0) paint a worrisome picture of practitioner's reaction time.

Of 34 pregnant women who contracted the virus, only 50% were treated with oseltamivir, and just 8 (24%) received treatment within 48 hours of symptom onset.

“Antivirals have the best impact within the first 48 hours of treatment and the latest deaths in this population had late starts with oseltamivir treatment,” she said in an interview. Among the six women who died, the earliest initiation of oseltamivir was 6 days after symptom onset, and the latest was 15 days.

The most common presentation was a febrile, influenzalike illness (94% of the patients), which included fever plus cough or sore throat. Vomiting and diarrhea occurred in only 18% and 12% of pregnant patients. Pregnant women were more likely to report shortness of breath (41%) than patients in the general population (15%). Rhinorrhea occurred in 59% of pregnant patients.

Patient awareness also may be an issue, since many pregnant women might not think to call their obstetricians when they come down with the sniffles, she acknowledged.

Dr. Money, an associate professor of obstetrics and gynecology at the University of British Columbia, Vancouver, said prenatal care providers must now make new plans, not only to include influenza patients in their daily schedules, but to ensure that these patients do not put their other patients at risk.

“If the woman really needs to be seen, [providers] need to orchestrate this in a way that is safe for their other patients—either at the end of the day, or in a place with a negative pressure room, or by getting them to wear a mask on entry.”

The drug of choice is oseltamivir, at a dosage of 75 mg twice per day for 5 days (www.cdc.gov/h1n1flu/

“We already have a poor track record with the seasonal influenza. U.S. guidelines have recommended the seasonal influenza vaccine for pregnant women for some time, but despite those recommendations the uptake in studies has been in the 14% range. So given that poor track record, how are we going to manage immunizing women against both seasonal and H1N1 influenza?”

In the Lancet study, 56% of the pregnant women with novel H1N1 influenza had not received the seasonal influenza vaccine, 9% had been vaccinated, and vaccination status was unknown for the remaining 35%.

“The H1N1 vaccine might turn out to be two doses, although that is still to be determined. So, with the addition of the seasonal vaccine we're looking potentially at three doses through the fall and winter of all pregnant women going to care providers, and the logistics start to boggle the mind.”

Discussion at the meeting explored the possibility of setting up influenza vaccination clinics at teaching hospitals to relieve small clinics and private practitioners. However, this plan would still rely on vaccination recommendations from private practitioners.

“Our experience anecdotally is that care providers have been advising against vaccination in pregnancy because they misunderstand which ones you can give in pregnancy and which ones you can't. Our anxiety is that they won't give oseltamivir, and they won't give the vaccine because they are in that mind set. But generally speaking, those of us in academic centers that see complications, end up seeing more complications related to under-treatment rather than overtreatment,” Dr. Money said.

Among the six women who died, the earliest initiation of oseltamivir was 6 days after symptom onset.

Source DR. MONEY

MONTREAL — Prenatal care providers need to take a frontline attitude about novel influenza A (H1N1) because pregnant women are among those at highest risk for infection and serious complications.

“We need to get the message out to the practitioners in the field that they've really got to be thinking about this. They need to recognize that influenza in pregnancy is not trivial, and they should consider early treatment,” said Dr. Deborah Money, president-elect of the Infectious Diseases Society for Obstetrics and Gynecology.

Speaking after chairing an urgent update session on novel H1N1 influenza at the society's annual meeting, Dr. Money said the latest figures on the infection in pregnancy, published in Lancet (doi:10.1016/S0140-6736[09]61304-0) paint a worrisome picture of practitioner's reaction time.

Of 34 pregnant women who contracted the virus, only 50% were treated with oseltamivir, and just 8 (24%) received treatment within 48 hours of symptom onset.

“Antivirals have the best impact within the first 48 hours of treatment and the latest deaths in this population had late starts with oseltamivir treatment,” she said in an interview. Among the six women who died, the earliest initiation of oseltamivir was 6 days after symptom onset, and the latest was 15 days.

The most common presentation was a febrile, influenzalike illness (94% of the patients), which included fever plus cough or sore throat. Vomiting and diarrhea occurred in only 18% and 12% of pregnant patients. Pregnant women were more likely to report shortness of breath (41%) than patients in the general population (15%). Rhinorrhea occurred in 59% of pregnant patients.

Patient awareness also may be an issue, since many pregnant women might not think to call their obstetricians when they come down with the sniffles, she acknowledged.

Dr. Money, an associate professor of obstetrics and gynecology at the University of British Columbia, Vancouver, said prenatal care providers must now make new plans, not only to include influenza patients in their daily schedules, but to ensure that these patients do not put their other patients at risk.

“If the woman really needs to be seen, [providers] need to orchestrate this in a way that is safe for their other patients—either at the end of the day, or in a place with a negative pressure room, or by getting them to wear a mask on entry.”

The drug of choice is oseltamivir, at a dosage of 75 mg twice per day for 5 days (www.cdc.gov/h1n1flu/

“We already have a poor track record with the seasonal influenza. U.S. guidelines have recommended the seasonal influenza vaccine for pregnant women for some time, but despite those recommendations the uptake in studies has been in the 14% range. So given that poor track record, how are we going to manage immunizing women against both seasonal and H1N1 influenza?”

In the Lancet study, 56% of the pregnant women with novel H1N1 influenza had not received the seasonal influenza vaccine, 9% had been vaccinated, and vaccination status was unknown for the remaining 35%.

“The H1N1 vaccine might turn out to be two doses, although that is still to be determined. So, with the addition of the seasonal vaccine we're looking potentially at three doses through the fall and winter of all pregnant women going to care providers, and the logistics start to boggle the mind.”

Discussion at the meeting explored the possibility of setting up influenza vaccination clinics at teaching hospitals to relieve small clinics and private practitioners. However, this plan would still rely on vaccination recommendations from private practitioners.

“Our experience anecdotally is that care providers have been advising against vaccination in pregnancy because they misunderstand which ones you can give in pregnancy and which ones you can't. Our anxiety is that they won't give oseltamivir, and they won't give the vaccine because they are in that mind set. But generally speaking, those of us in academic centers that see complications, end up seeing more complications related to under-treatment rather than overtreatment,” Dr. Money said.

Among the six women who died, the earliest initiation of oseltamivir was 6 days after symptom onset.

Source DR. MONEY

MONTREAL — Prenatal care providers need to take a frontline attitude about novel influenza A (H1N1) because pregnant women are among those at highest risk for infection and serious complications.

“We need to get the message out to the practitioners in the field that they've really got to be thinking about this. They need to recognize that influenza in pregnancy is not trivial, and they should consider early treatment,” said Dr. Deborah Money, president-elect of the Infectious Diseases Society for Obstetrics and Gynecology.

Speaking after chairing an urgent update session on novel H1N1 influenza at the society's annual meeting, Dr. Money said the latest figures on the infection in pregnancy, published in Lancet (doi:10.1016/S0140-6736[09]61304-0) paint a worrisome picture of practitioner's reaction time.

Of 34 pregnant women who contracted the virus, only 50% were treated with oseltamivir, and just 8 (24%) received treatment within 48 hours of symptom onset.

“Antivirals have the best impact within the first 48 hours of treatment and the latest deaths in this population had late starts with oseltamivir treatment,” she said in an interview. Among the six women who died, the earliest initiation of oseltamivir was 6 days after symptom onset, and the latest was 15 days.

The most common presentation was a febrile, influenzalike illness (94% of the patients), which included fever plus cough or sore throat. Vomiting and diarrhea occurred in only 18% and 12% of pregnant patients. Pregnant women were more likely to report shortness of breath (41%) than patients in the general population (15%). Rhinorrhea occurred in 59% of pregnant patients.

Patient awareness also may be an issue, since many pregnant women might not think to call their obstetricians when they come down with the sniffles, she acknowledged.

Dr. Money, an associate professor of obstetrics and gynecology at the University of British Columbia, Vancouver, said prenatal care providers must now make new plans, not only to include influenza patients in their daily schedules, but to ensure that these patients do not put their other patients at risk.

“If the woman really needs to be seen, [providers] need to orchestrate this in a way that is safe for their other patients—either at the end of the day, or in a place with a negative pressure room, or by getting them to wear a mask on entry.”

The drug of choice is oseltamivir, at a dosage of 75 mg twice per day for 5 days (www.cdc.gov/h1n1flu/

“We already have a poor track record with the seasonal influenza. U.S. guidelines have recommended the seasonal influenza vaccine for pregnant women for some time, but despite those recommendations the uptake in studies has been in the 14% range. So given that poor track record, how are we going to manage immunizing women against both seasonal and H1N1 influenza?”

In the Lancet study, 56% of the pregnant women with novel H1N1 influenza had not received the seasonal influenza vaccine, 9% had been vaccinated, and vaccination status was unknown for the remaining 35%.

“The H1N1 vaccine might turn out to be two doses, although that is still to be determined. So, with the addition of the seasonal vaccine we're looking potentially at three doses through the fall and winter of all pregnant women going to care providers, and the logistics start to boggle the mind.”

Discussion at the meeting explored the possibility of setting up influenza vaccination clinics at teaching hospitals to relieve small clinics and private practitioners. However, this plan would still rely on vaccination recommendations from private practitioners.

“Our experience anecdotally is that care providers have been advising against vaccination in pregnancy because they misunderstand which ones you can give in pregnancy and which ones you can't. Our anxiety is that they won't give oseltamivir, and they won't give the vaccine because they are in that mind set. But generally speaking, those of us in academic centers that see complications, end up seeing more complications related to under-treatment rather than overtreatment,” Dr. Money said.

Among the six women who died, the earliest initiation of oseltamivir was 6 days after symptom onset.

Source DR. MONEY

MONTREAL — Women who have not yet established prenatal care have a significantly higher rate of acute pyelonephritis before 12 weeks of gestation compared with women who already have an obstetric provider by 12 weeks, according to a new study.

“Many providers do not see patients early in the first trimester, because they often like to ensure there is an established pregnancy. But we would encourage them to have patients present as early as possible, at least for labs and urine screening,” said Dr. Mollie Ann McDonnold, who presented her findings at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

Her retrospective study examined 254 consecutive hospital admissions for acute pyelonephritis in pregnancy between January 2004 and June 2007. Overall, there were 29 cases (11%) occurring before 12 weeks' gestation, and 60 cases (24%) before 16 weeks' gestation.

Among women who had already established prenatal care (219), most infections occurred later in pregnancy, with only 5% of cases occurring before 12 weeks, and 16% occurring prior to 16 weeks of gestation.

Among women without prenatal care (35), however, 51% of cases presented prior to 12 weeks and 74% occurred prior to 16 weeks of gestation.

“These results were expected as it is not common to establish prenatal care prior to 12 weeks,” said Dr. McDonnold of the Warren Alpert Medical School of Brown University, Providence, R.I.

There were no differences in age, ethnicity, parity, length of hospital stay, presence or degree of fever, or heart rate at admission between women with or without established prenatal care.

However, there was a statistically significant difference in insurance status between the groups. While 57% of women with no prenatal care had no insurance, only 1.6% of women with prenatal care were in this situation. And 24% of women with prenatal care had private insurance, compared to just 2.4% of women without prenatal care.

“I think this is an extremely important observation,” commented Dr. Michael Gravett, president of IDSOG and professor of obstetrics and gynecology at the University of Washington in Seattle.

“The trend in prenatal care is that since we now do a lot of prenatal diagnosis we frequently defer initiation of care and labs until about 12 or 13 weeks. This is a reminder that common things occur more commonly and we tend to overlook them. This is a caution to see women earlier at least for urinalysis,” Dr. Gravett said.

MONTREAL — Women who have not yet established prenatal care have a significantly higher rate of acute pyelonephritis before 12 weeks of gestation compared with women who already have an obstetric provider by 12 weeks, according to a new study.

“Many providers do not see patients early in the first trimester, because they often like to ensure there is an established pregnancy. But we would encourage them to have patients present as early as possible, at least for labs and urine screening,” said Dr. Mollie Ann McDonnold, who presented her findings at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

Her retrospective study examined 254 consecutive hospital admissions for acute pyelonephritis in pregnancy between January 2004 and June 2007. Overall, there were 29 cases (11%) occurring before 12 weeks' gestation, and 60 cases (24%) before 16 weeks' gestation.

Among women who had already established prenatal care (219), most infections occurred later in pregnancy, with only 5% of cases occurring before 12 weeks, and 16% occurring prior to 16 weeks of gestation.

Among women without prenatal care (35), however, 51% of cases presented prior to 12 weeks and 74% occurred prior to 16 weeks of gestation.

“These results were expected as it is not common to establish prenatal care prior to 12 weeks,” said Dr. McDonnold of the Warren Alpert Medical School of Brown University, Providence, R.I.

There were no differences in age, ethnicity, parity, length of hospital stay, presence or degree of fever, or heart rate at admission between women with or without established prenatal care.

However, there was a statistically significant difference in insurance status between the groups. While 57% of women with no prenatal care had no insurance, only 1.6% of women with prenatal care were in this situation. And 24% of women with prenatal care had private insurance, compared to just 2.4% of women without prenatal care.

“I think this is an extremely important observation,” commented Dr. Michael Gravett, president of IDSOG and professor of obstetrics and gynecology at the University of Washington in Seattle.

“The trend in prenatal care is that since we now do a lot of prenatal diagnosis we frequently defer initiation of care and labs until about 12 or 13 weeks. This is a reminder that common things occur more commonly and we tend to overlook them. This is a caution to see women earlier at least for urinalysis,” Dr. Gravett said.

MONTREAL — Women who have not yet established prenatal care have a significantly higher rate of acute pyelonephritis before 12 weeks of gestation compared with women who already have an obstetric provider by 12 weeks, according to a new study.

“Many providers do not see patients early in the first trimester, because they often like to ensure there is an established pregnancy. But we would encourage them to have patients present as early as possible, at least for labs and urine screening,” said Dr. Mollie Ann McDonnold, who presented her findings at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

Her retrospective study examined 254 consecutive hospital admissions for acute pyelonephritis in pregnancy between January 2004 and June 2007. Overall, there were 29 cases (11%) occurring before 12 weeks' gestation, and 60 cases (24%) before 16 weeks' gestation.

Among women who had already established prenatal care (219), most infections occurred later in pregnancy, with only 5% of cases occurring before 12 weeks, and 16% occurring prior to 16 weeks of gestation.

Among women without prenatal care (35), however, 51% of cases presented prior to 12 weeks and 74% occurred prior to 16 weeks of gestation.

“These results were expected as it is not common to establish prenatal care prior to 12 weeks,” said Dr. McDonnold of the Warren Alpert Medical School of Brown University, Providence, R.I.

There were no differences in age, ethnicity, parity, length of hospital stay, presence or degree of fever, or heart rate at admission between women with or without established prenatal care.

However, there was a statistically significant difference in insurance status between the groups. While 57% of women with no prenatal care had no insurance, only 1.6% of women with prenatal care were in this situation. And 24% of women with prenatal care had private insurance, compared to just 2.4% of women without prenatal care.

“I think this is an extremely important observation,” commented Dr. Michael Gravett, president of IDSOG and professor of obstetrics and gynecology at the University of Washington in Seattle.

“The trend in prenatal care is that since we now do a lot of prenatal diagnosis we frequently defer initiation of care and labs until about 12 or 13 weeks. This is a reminder that common things occur more commonly and we tend to overlook them. This is a caution to see women earlier at least for urinalysis,” Dr. Gravett said.

MONTREAL — HIV screening of pregnant women falls well short of national guidelines, particularly among patients seen in private practice, according to a study presented at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

“We have to really reinforce with all providers the importance of universal screening,” said Dr. Harold Wiesenfeld, senior investigator of the study, which found that patients were 17.5 times less likely to undergo screening in private practice than were those seen in a clinic setting.

The study of 300 women revealed that 61% had no HIV screening results in their medical record at the time of parturition.

Guidelines that were adopted in 1999 by the Institute of Medicine, the Centers for Disease Control, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics recommend routine, universal HIV screening in pregnancy to avoid vertical transmission, noted study presenter Margaret Kennedy, who is a medical student at the University of Pittsburgh.

But among the study's subjects, all of whom were questioned up to 72 hours before delivery, only 65% reported undergoing HIV screening during pregnancy, while 25% reported no screening, and 10% were not sure if they had been tested.

A multivariate analysis revealed that being white and married were each independently associated with a threefold greater risk of not being screened.

The provider's influence was the most important factor in screening, said Ms. Kennedy.

Women whose provider did not consider screening important were 14 times more likely to be unscreened; those whose providers considered screening optional were 2.9 times more likely to be unscreened. On the other hand, women whose providers encouraged screening were 3.7 times more likely to have undergone screening.

“My personal opinion is the importance of HIV screening is not stressed in many patient/provider encounters,” said Dr. Wiesenfeld, who is also with the university. “Some providers don't think HIV is relevant to their population because they have an affluent, white population. It mirrors chlamydia screening. They don't think their patients are at risk.”

A comparison of medical records with subjects' responses revealed some recall bias: Two percent of those who reported having been tested had actually declined testing. Of those who reporting no screening, 11% had actually been screened (35% said they had not been offered screening, and 65% said they had declined). In addition, 17% of those who were unsure had been screened.

“Universal offering of HIV screening as an opt-out, in conjunction with encouragement from providers, may greatly increase prenatal HIV screening rates,” she said.

“Universal HIV screening is not at the rates we would like across the country,” concluded Dr. Wiesenfeld.

“The take-home message is that it's low—but what's more important is who is not being screened. Women who are white, and affluent, and in a private practice center … are less likely to be screened, as are those who don't feel their provider is encouraging it,” he added.

The investigators said they had no conflicts of interest.

MONTREAL — HIV screening of pregnant women falls well short of national guidelines, particularly among patients seen in private practice, according to a study presented at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

“We have to really reinforce with all providers the importance of universal screening,” said Dr. Harold Wiesenfeld, senior investigator of the study, which found that patients were 17.5 times less likely to undergo screening in private practice than were those seen in a clinic setting.

The study of 300 women revealed that 61% had no HIV screening results in their medical record at the time of parturition.

Guidelines that were adopted in 1999 by the Institute of Medicine, the Centers for Disease Control, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics recommend routine, universal HIV screening in pregnancy to avoid vertical transmission, noted study presenter Margaret Kennedy, who is a medical student at the University of Pittsburgh.

But among the study's subjects, all of whom were questioned up to 72 hours before delivery, only 65% reported undergoing HIV screening during pregnancy, while 25% reported no screening, and 10% were not sure if they had been tested.

A multivariate analysis revealed that being white and married were each independently associated with a threefold greater risk of not being screened.

The provider's influence was the most important factor in screening, said Ms. Kennedy.

Women whose provider did not consider screening important were 14 times more likely to be unscreened; those whose providers considered screening optional were 2.9 times more likely to be unscreened. On the other hand, women whose providers encouraged screening were 3.7 times more likely to have undergone screening.

“My personal opinion is the importance of HIV screening is not stressed in many patient/provider encounters,” said Dr. Wiesenfeld, who is also with the university. “Some providers don't think HIV is relevant to their population because they have an affluent, white population. It mirrors chlamydia screening. They don't think their patients are at risk.”

A comparison of medical records with subjects' responses revealed some recall bias: Two percent of those who reported having been tested had actually declined testing. Of those who reporting no screening, 11% had actually been screened (35% said they had not been offered screening, and 65% said they had declined). In addition, 17% of those who were unsure had been screened.

“Universal offering of HIV screening as an opt-out, in conjunction with encouragement from providers, may greatly increase prenatal HIV screening rates,” she said.

“Universal HIV screening is not at the rates we would like across the country,” concluded Dr. Wiesenfeld.

“The take-home message is that it's low—but what's more important is who is not being screened. Women who are white, and affluent, and in a private practice center … are less likely to be screened, as are those who don't feel their provider is encouraging it,” he added.

The investigators said they had no conflicts of interest.

MONTREAL — HIV screening of pregnant women falls well short of national guidelines, particularly among patients seen in private practice, according to a study presented at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

“We have to really reinforce with all providers the importance of universal screening,” said Dr. Harold Wiesenfeld, senior investigator of the study, which found that patients were 17.5 times less likely to undergo screening in private practice than were those seen in a clinic setting.

The study of 300 women revealed that 61% had no HIV screening results in their medical record at the time of parturition.

Guidelines that were adopted in 1999 by the Institute of Medicine, the Centers for Disease Control, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics recommend routine, universal HIV screening in pregnancy to avoid vertical transmission, noted study presenter Margaret Kennedy, who is a medical student at the University of Pittsburgh.

But among the study's subjects, all of whom were questioned up to 72 hours before delivery, only 65% reported undergoing HIV screening during pregnancy, while 25% reported no screening, and 10% were not sure if they had been tested.

A multivariate analysis revealed that being white and married were each independently associated with a threefold greater risk of not being screened.

The provider's influence was the most important factor in screening, said Ms. Kennedy.

Women whose provider did not consider screening important were 14 times more likely to be unscreened; those whose providers considered screening optional were 2.9 times more likely to be unscreened. On the other hand, women whose providers encouraged screening were 3.7 times more likely to have undergone screening.

“My personal opinion is the importance of HIV screening is not stressed in many patient/provider encounters,” said Dr. Wiesenfeld, who is also with the university. “Some providers don't think HIV is relevant to their population because they have an affluent, white population. It mirrors chlamydia screening. They don't think their patients are at risk.”

A comparison of medical records with subjects' responses revealed some recall bias: Two percent of those who reported having been tested had actually declined testing. Of those who reporting no screening, 11% had actually been screened (35% said they had not been offered screening, and 65% said they had declined). In addition, 17% of those who were unsure had been screened.

“Universal offering of HIV screening as an opt-out, in conjunction with encouragement from providers, may greatly increase prenatal HIV screening rates,” she said.

“Universal HIV screening is not at the rates we would like across the country,” concluded Dr. Wiesenfeld.

“The take-home message is that it's low—but what's more important is who is not being screened. Women who are white, and affluent, and in a private practice center … are less likely to be screened, as are those who don't feel their provider is encouraging it,” he added.

The investigators said they had no conflicts of interest.

MONTREAL – A simple saliva test to assess a smoker's degree of nicotine dependence could become the first step of a smoking cessation treatment, a study has shown.

Light or heavy nicotine dependence can predict a person's success in quitting or risk of relapse, Caryn Lerman, Ph.D., said at the annual meeting of the Society of Behavioral Medicine. Clinicians could use this information to guide treatment choices for their patients.

“We could decide whether someone needs smoking cessation counseling only, or whether they would do better with a patch, or if they need a medication such as bupropion or varenicline,” said Dr. Lerman of the Transdisciplinary Tobacco Use Research Center at the University of Pennsylvania, Philadelphia.

The saliva test measures the ratio of two nicotine metabolites, 3′-hydroxycotinine and cotinine, to determine a person's rate of nicotine clearance or metabolism, Dr. Lerman said.

A new study by her group has validated that smokers with the slowest nicotine metabolism are about twice as likely to quit as are smokers with faster nicotine metabolism (Pharmacol. Biochem. Behav. 2009;92:6-11). The study enrolled 568 smokers who were given counseling and 8 weeks of a 21-mg nicotine patch. The saliva test measured the metabolite ratio pretreatment to distinguish fast from slow nicotine metabolizers. Eight weeks after the quit date, fast metabolizers were approximately 50% less likely to be abstinent, compared with slow metabolizers (28% vs. 42%).

The findings support the value of the saliva test as a biomarker to predict success with transdermal nicotine for smoking cessation, the authors concluded. “We are developing a treatment algorithm which suggests that slow metabolizers may need nothing more than counseling or nicotine patch, but fast metabolizers are candidates for more nonnicotine medications which may be more costly and have more side effects than the patch,” they wrote (Clin. Pharmacol. Ther. 2008;84:320-5).

MONTREAL – A simple saliva test to assess a smoker's degree of nicotine dependence could become the first step of a smoking cessation treatment, a study has shown.

Light or heavy nicotine dependence can predict a person's success in quitting or risk of relapse, Caryn Lerman, Ph.D., said at the annual meeting of the Society of Behavioral Medicine. Clinicians could use this information to guide treatment choices for their patients.

“We could decide whether someone needs smoking cessation counseling only, or whether they would do better with a patch, or if they need a medication such as bupropion or varenicline,” said Dr. Lerman of the Transdisciplinary Tobacco Use Research Center at the University of Pennsylvania, Philadelphia.

The saliva test measures the ratio of two nicotine metabolites, 3′-hydroxycotinine and cotinine, to determine a person's rate of nicotine clearance or metabolism, Dr. Lerman said.

A new study by her group has validated that smokers with the slowest nicotine metabolism are about twice as likely to quit as are smokers with faster nicotine metabolism (Pharmacol. Biochem. Behav. 2009;92:6-11). The study enrolled 568 smokers who were given counseling and 8 weeks of a 21-mg nicotine patch. The saliva test measured the metabolite ratio pretreatment to distinguish fast from slow nicotine metabolizers. Eight weeks after the quit date, fast metabolizers were approximately 50% less likely to be abstinent, compared with slow metabolizers (28% vs. 42%).

The findings support the value of the saliva test as a biomarker to predict success with transdermal nicotine for smoking cessation, the authors concluded. “We are developing a treatment algorithm which suggests that slow metabolizers may need nothing more than counseling or nicotine patch, but fast metabolizers are candidates for more nonnicotine medications which may be more costly and have more side effects than the patch,” they wrote (Clin. Pharmacol. Ther. 2008;84:320-5).

MONTREAL – A simple saliva test to assess a smoker's degree of nicotine dependence could become the first step of a smoking cessation treatment, a study has shown.

Light or heavy nicotine dependence can predict a person's success in quitting or risk of relapse, Caryn Lerman, Ph.D., said at the annual meeting of the Society of Behavioral Medicine. Clinicians could use this information to guide treatment choices for their patients.

“We could decide whether someone needs smoking cessation counseling only, or whether they would do better with a patch, or if they need a medication such as bupropion or varenicline,” said Dr. Lerman of the Transdisciplinary Tobacco Use Research Center at the University of Pennsylvania, Philadelphia.

The saliva test measures the ratio of two nicotine metabolites, 3′-hydroxycotinine and cotinine, to determine a person's rate of nicotine clearance or metabolism, Dr. Lerman said.

A new study by her group has validated that smokers with the slowest nicotine metabolism are about twice as likely to quit as are smokers with faster nicotine metabolism (Pharmacol. Biochem. Behav. 2009;92:6-11). The study enrolled 568 smokers who were given counseling and 8 weeks of a 21-mg nicotine patch. The saliva test measured the metabolite ratio pretreatment to distinguish fast from slow nicotine metabolizers. Eight weeks after the quit date, fast metabolizers were approximately 50% less likely to be abstinent, compared with slow metabolizers (28% vs. 42%).

The findings support the value of the saliva test as a biomarker to predict success with transdermal nicotine for smoking cessation, the authors concluded. “We are developing a treatment algorithm which suggests that slow metabolizers may need nothing more than counseling or nicotine patch, but fast metabolizers are candidates for more nonnicotine medications which may be more costly and have more side effects than the patch,” they wrote (Clin. Pharmacol. Ther. 2008;84:320-5).