Kate Johnson

ORLANDO – Despite a high prevalence of chronic pain in older adults, adherence to pain medications is low–fueled largely by patients' stoicism, beliefs about pain and aging, and concerns about safety and addiction, according to Dr. Stephen Thielke, a psychiatrist at the University of Washington, Seattle.

Chronic pain not only results in suffering but also is strongly associated with depression and declines in health status, he reported at the annual meeting of the American Association for Geriatric Psychiatry. Recent work by his group has demonstrated that people who report more pain are less likely to respond to integrated depression treatment, compared with those with less pain (Am. J. Geriatr. Psychiatry 2007;15:699–707).

Although 75% of seniors in Medicare surveys report having arthritis (the most common cause of pain in this population), only about 40% of them report actively treating it. In other samples, only about half of patients who report functional impairments from pain take any medication for it, Dr Thielke noted, which differs from seniors' use of treatments for other chronic medical conditions. “There is clearly something different about treating arthritis pain, compared [with] treating other medical problems,” he said.

Research about the experience of seniors who have arthritis pain has helped to identify some of the factors involved in seniors' use of medications.

In a recent qualitative study of 19 older adults with arthritis pain, only 4 subjects (21%) were taking pain medications as directed; the remaining 79% “purposefully did not take their OA [osteoarthritis] medications as prescribed.” (Arthritis Rheum. 2006;55:272–8) Many of them “described treatment behaviors that we might consider irrational,” noted Dr Thielke, such as filling prescriptions and then throwing the medication away, putting lower dose pills into a bottle with a higher dose on the label, and hiding their nonadherence from family members.

Stoicism was a common theme, he said, with patients minimizing their pain and reporting high pain tolerance. Fear of addiction was reported by many patients as a key barrier to using stronger painkillers. At the same time, 18 of 19 of the participants (95%) were taking at least one herbal remedy and/or vitamin for their arthritis.

Further insights have come from focus groups of older patients with osteoarthritis, which revealed that many of them considered pain “a normal part of getting older,” felt that medications are potentially harmful, and saw medication as masking rather than curing their pain (Arthritis Rheum. 2006;55:905–12).

“Patients placed more emphasis on acceptance, rather than treatment, of pain, and safety, rather than effectiveness, of treatments, and they tended to see pain medications as high risk,” noted Dr Thielke. He also reported other research findings that suggested the elderly have limited knowledge about arthritis medications, with few individuals being able to list potential side effects or to describe preventive use of medications (Rheumatology 2006;46:796–800). He speculated that recent publicized safety concerns about NSAIDs and opioid analgesics further complicate patients' efforts to choose treatments that are safe and that patients might conclude that all pain-relieving medications are too risky to try.

Physicians may be complicit in fostering the expectation that pain should be accepted rather than treated by avoiding direct conversations with patients about the consequences of pain and their concerns about treatments for it, Dr. Thielke said. This can add to the patients' perception that they should tough it out. Patients may consider their need for pain medication as wasteful, rash, hedonistic, or selfish, and their ability to forgo analgesia as stoical, patient, thrifty, and selfless, he said. Prescription directions that advise taking “as needed” also are interpreted differently by patients and physicians. “Many patients will interpret 'as needed' as 'when desperate' or 'when all else fails',” he said, while the provider intends it to mean 'to improve symptoms' or 'to enhance quality of life'. The goal is to make patients understand that their use of pain medication is not a statement about their character strength or toughness; rather, they are trying to improve their health, functioning, overall well-being, and safety. Focus on functioning, not just pain.”

ORLANDO – Despite a high prevalence of chronic pain in older adults, adherence to pain medications is low–fueled largely by patients' stoicism, beliefs about pain and aging, and concerns about safety and addiction, according to Dr. Stephen Thielke, a psychiatrist at the University of Washington, Seattle.

Chronic pain not only results in suffering but also is strongly associated with depression and declines in health status, he reported at the annual meeting of the American Association for Geriatric Psychiatry. Recent work by his group has demonstrated that people who report more pain are less likely to respond to integrated depression treatment, compared with those with less pain (Am. J. Geriatr. Psychiatry 2007;15:699–707).

Although 75% of seniors in Medicare surveys report having arthritis (the most common cause of pain in this population), only about 40% of them report actively treating it. In other samples, only about half of patients who report functional impairments from pain take any medication for it, Dr Thielke noted, which differs from seniors' use of treatments for other chronic medical conditions. “There is clearly something different about treating arthritis pain, compared [with] treating other medical problems,” he said.

Research about the experience of seniors who have arthritis pain has helped to identify some of the factors involved in seniors' use of medications.

In a recent qualitative study of 19 older adults with arthritis pain, only 4 subjects (21%) were taking pain medications as directed; the remaining 79% “purposefully did not take their OA [osteoarthritis] medications as prescribed.” (Arthritis Rheum. 2006;55:272–8) Many of them “described treatment behaviors that we might consider irrational,” noted Dr Thielke, such as filling prescriptions and then throwing the medication away, putting lower dose pills into a bottle with a higher dose on the label, and hiding their nonadherence from family members.

Stoicism was a common theme, he said, with patients minimizing their pain and reporting high pain tolerance. Fear of addiction was reported by many patients as a key barrier to using stronger painkillers. At the same time, 18 of 19 of the participants (95%) were taking at least one herbal remedy and/or vitamin for their arthritis.

Further insights have come from focus groups of older patients with osteoarthritis, which revealed that many of them considered pain “a normal part of getting older,” felt that medications are potentially harmful, and saw medication as masking rather than curing their pain (Arthritis Rheum. 2006;55:905–12).

“Patients placed more emphasis on acceptance, rather than treatment, of pain, and safety, rather than effectiveness, of treatments, and they tended to see pain medications as high risk,” noted Dr Thielke. He also reported other research findings that suggested the elderly have limited knowledge about arthritis medications, with few individuals being able to list potential side effects or to describe preventive use of medications (Rheumatology 2006;46:796–800). He speculated that recent publicized safety concerns about NSAIDs and opioid analgesics further complicate patients' efforts to choose treatments that are safe and that patients might conclude that all pain-relieving medications are too risky to try.

Physicians may be complicit in fostering the expectation that pain should be accepted rather than treated by avoiding direct conversations with patients about the consequences of pain and their concerns about treatments for it, Dr. Thielke said. This can add to the patients' perception that they should tough it out. Patients may consider their need for pain medication as wasteful, rash, hedonistic, or selfish, and their ability to forgo analgesia as stoical, patient, thrifty, and selfless, he said. Prescription directions that advise taking “as needed” also are interpreted differently by patients and physicians. “Many patients will interpret 'as needed' as 'when desperate' or 'when all else fails',” he said, while the provider intends it to mean 'to improve symptoms' or 'to enhance quality of life'. The goal is to make patients understand that their use of pain medication is not a statement about their character strength or toughness; rather, they are trying to improve their health, functioning, overall well-being, and safety. Focus on functioning, not just pain.”

ORLANDO – Despite a high prevalence of chronic pain in older adults, adherence to pain medications is low–fueled largely by patients' stoicism, beliefs about pain and aging, and concerns about safety and addiction, according to Dr. Stephen Thielke, a psychiatrist at the University of Washington, Seattle.

Chronic pain not only results in suffering but also is strongly associated with depression and declines in health status, he reported at the annual meeting of the American Association for Geriatric Psychiatry. Recent work by his group has demonstrated that people who report more pain are less likely to respond to integrated depression treatment, compared with those with less pain (Am. J. Geriatr. Psychiatry 2007;15:699–707).

Although 75% of seniors in Medicare surveys report having arthritis (the most common cause of pain in this population), only about 40% of them report actively treating it. In other samples, only about half of patients who report functional impairments from pain take any medication for it, Dr Thielke noted, which differs from seniors' use of treatments for other chronic medical conditions. “There is clearly something different about treating arthritis pain, compared [with] treating other medical problems,” he said.

Research about the experience of seniors who have arthritis pain has helped to identify some of the factors involved in seniors' use of medications.

In a recent qualitative study of 19 older adults with arthritis pain, only 4 subjects (21%) were taking pain medications as directed; the remaining 79% “purposefully did not take their OA [osteoarthritis] medications as prescribed.” (Arthritis Rheum. 2006;55:272–8) Many of them “described treatment behaviors that we might consider irrational,” noted Dr Thielke, such as filling prescriptions and then throwing the medication away, putting lower dose pills into a bottle with a higher dose on the label, and hiding their nonadherence from family members.

Stoicism was a common theme, he said, with patients minimizing their pain and reporting high pain tolerance. Fear of addiction was reported by many patients as a key barrier to using stronger painkillers. At the same time, 18 of 19 of the participants (95%) were taking at least one herbal remedy and/or vitamin for their arthritis.

Further insights have come from focus groups of older patients with osteoarthritis, which revealed that many of them considered pain “a normal part of getting older,” felt that medications are potentially harmful, and saw medication as masking rather than curing their pain (Arthritis Rheum. 2006;55:905–12).

“Patients placed more emphasis on acceptance, rather than treatment, of pain, and safety, rather than effectiveness, of treatments, and they tended to see pain medications as high risk,” noted Dr Thielke. He also reported other research findings that suggested the elderly have limited knowledge about arthritis medications, with few individuals being able to list potential side effects or to describe preventive use of medications (Rheumatology 2006;46:796–800). He speculated that recent publicized safety concerns about NSAIDs and opioid analgesics further complicate patients' efforts to choose treatments that are safe and that patients might conclude that all pain-relieving medications are too risky to try.

Physicians may be complicit in fostering the expectation that pain should be accepted rather than treated by avoiding direct conversations with patients about the consequences of pain and their concerns about treatments for it, Dr. Thielke said. This can add to the patients' perception that they should tough it out. Patients may consider their need for pain medication as wasteful, rash, hedonistic, or selfish, and their ability to forgo analgesia as stoical, patient, thrifty, and selfless, he said. Prescription directions that advise taking “as needed” also are interpreted differently by patients and physicians. “Many patients will interpret 'as needed' as 'when desperate' or 'when all else fails',” he said, while the provider intends it to mean 'to improve symptoms' or 'to enhance quality of life'. The goal is to make patients understand that their use of pain medication is not a statement about their character strength or toughness; rather, they are trying to improve their health, functioning, overall well-being, and safety. Focus on functioning, not just pain.”

ORLANDO – Pain is a comorbid condition too often overlooked in the setting of geriatric psychiatry, despite the potential for better mental health outcomes when it is treated, Dr. Jordan F. Karp said at the annual meeting of the American Association for Geriatric Psychiatry.

“I don't think enough attention is paid to assessing, diagnosing, and managing pain by many psychiatrists and other physicians who treat older adults,” he said in an interview. “I highly doubt that clinicians are aware of the effects of pain on cognition.”

Because pain has reached “epidemic” proportions among the elderly and can significantly worsen cognition and depression, it should be assessed and treated routinely as part of the psychiatric management of this population, said Dr. Karp, medical director of geriatric psychiatry at one of the referral pain clinics at the University of Pittsburgh Medical Center.

Studies suggest that up to 50% of community-dwelling seniors experience pain that interferes with normal functioning, and up to 80% of nursing home patients live with undertreated pain–the source of which can be musculoskeletal, neuropathic, visceral, metabolic, or other.

It is well known that persistent pain limits mobility, increases the risk of falls, and can lead to social isolation, but it is not always appreciated that pain can also increase anxiety, depression, and cognitive impairment, said Dr. Karp, who has a clinical and research focus on both pain and affective disorders in older adults. He disclosed his advisory role with Eli Lilly & Co. and Myriad Genetics Inc.

In a recent survey of 56 patients in an older adult pain management program, he showed that higher pain severity was associated with poorer performance on a test of number/letter switching (Pain Med. 2006;7:444–52).

In another study of older adults (mean age 73 years), different investigators demonstrated lower neuropsychological function among 163 subjects with chronic low back pain (CLBP), compared with 163 who were pain free (Pain Med. 2006;7:60–70). Recent preliminary evidence also suggests reduced brain volume among eight seniors with CLBP, compared with eight who were pain free (Pain Med. 2008;9:240–8).

The comorbidity of pain and depression is a vicious circle, Dr. Thomas Meeks of the University of California, San Diego, said in a separate presentation at the meeting.

A link between depression and immune system dysfunction has been described, and both pain and weakened immunity have been associated with an increase in inflammatory cytokines. Inflammatory cytokines are also associated with anorexia, sleep disturbance, and fatigue and have been shown to negatively affect brain chemicals such as serotonin and norepinephrine, suggesting “there may be a role of inflammatory cytokines in late-life depression,” he said.

Since the rise in inflammatory cytokines seen with acute pain can persist long after the source of the pain has been corrected, prompt diagnosis and treatment of pain is important to reduce the risk of persistent pain and chronic depression, Dr. Meeks said.

“As psychiatrists, we need to keep pain in mind and ask our patients about it,” said Dr. Karp. In addition to various visual or verbal rating scales that can be used to inquire about pain, he said, certain direct questions might be helpful:

▸ Are you in pain now, or if not now, do you hurt more often than not?

▸ Where do you hurt?

▸ How has pain interfered with your life?

▸ Does pain interfere with your sleep?

“Insomnia is ubiquitous in this group,” he said. “It has been associated with a decreased pain threshold, and it decreases patients' ability to actively cope with their pain problem.”

Preliminary analysis from some of his pilot work has shown that insomnia and fatigue among older patients are associated with passive rather than active coping skills.

“Passive skills are less effective and involve things like catastrophizing, praying, or hoping the pain will stop, whereas more active coping involves increasing behavioral activities and using coping self-statements like 'I will get through this,' 'the pain will pass,' or 'the pain will not kill me,'” he said. When direct questioning is not useful or patients are nonverbal, behavioral observation can reveal a great deal about the pain an individual may be experiencing. “They may be grimacing or sighing; they may be irritable, disruptive, or verbally abusive; their body position may be rigid or guarded; or they might show their discomfort by fidgeting,” said Dr. Karp.

The recently validated Elderly Pain Caring Assessment 2 provides further insight into nonverbal cues (Pain 2007;133:87–98). “It's unlikely that we are going to be able to introduce another assessment into our nursing homes, but informing staff about some of these probes may be useful,” he said.

Regardless of whether patients live in the community or in a nursing home, treating their pain with opioids can raise concerns about sedation and cognitive impairment. The decision should involve an individualized risk-benefit analysis.

“While opioids do increase the risk of sedation, confusion, falls, and constipation, for some people the analgesia that results outweighs these potential risks–and cognition actually seems to improve,” he said. “Perhaps they are less distracted by pain and are better able to focus and concentrate.”

Health care professionals should regard persistent pain in the elderly as treatable, with the potential for improvement in many patients. “We need to get the word out that the management of pain should be moved up the priority list, because we can get these patients feeling and functioning better,” Dr. Karp said.

ORLANDO – Pain is a comorbid condition too often overlooked in the setting of geriatric psychiatry, despite the potential for better mental health outcomes when it is treated, Dr. Jordan F. Karp said at the annual meeting of the American Association for Geriatric Psychiatry.

“I don't think enough attention is paid to assessing, diagnosing, and managing pain by many psychiatrists and other physicians who treat older adults,” he said in an interview. “I highly doubt that clinicians are aware of the effects of pain on cognition.”

Because pain has reached “epidemic” proportions among the elderly and can significantly worsen cognition and depression, it should be assessed and treated routinely as part of the psychiatric management of this population, said Dr. Karp, medical director of geriatric psychiatry at one of the referral pain clinics at the University of Pittsburgh Medical Center.

Studies suggest that up to 50% of community-dwelling seniors experience pain that interferes with normal functioning, and up to 80% of nursing home patients live with undertreated pain–the source of which can be musculoskeletal, neuropathic, visceral, metabolic, or other.

It is well known that persistent pain limits mobility, increases the risk of falls, and can lead to social isolation, but it is not always appreciated that pain can also increase anxiety, depression, and cognitive impairment, said Dr. Karp, who has a clinical and research focus on both pain and affective disorders in older adults. He disclosed his advisory role with Eli Lilly & Co. and Myriad Genetics Inc.

In a recent survey of 56 patients in an older adult pain management program, he showed that higher pain severity was associated with poorer performance on a test of number/letter switching (Pain Med. 2006;7:444–52).

In another study of older adults (mean age 73 years), different investigators demonstrated lower neuropsychological function among 163 subjects with chronic low back pain (CLBP), compared with 163 who were pain free (Pain Med. 2006;7:60–70). Recent preliminary evidence also suggests reduced brain volume among eight seniors with CLBP, compared with eight who were pain free (Pain Med. 2008;9:240–8).

The comorbidity of pain and depression is a vicious circle, Dr. Thomas Meeks of the University of California, San Diego, said in a separate presentation at the meeting.

A link between depression and immune system dysfunction has been described, and both pain and weakened immunity have been associated with an increase in inflammatory cytokines. Inflammatory cytokines are also associated with anorexia, sleep disturbance, and fatigue and have been shown to negatively affect brain chemicals such as serotonin and norepinephrine, suggesting “there may be a role of inflammatory cytokines in late-life depression,” he said.

Since the rise in inflammatory cytokines seen with acute pain can persist long after the source of the pain has been corrected, prompt diagnosis and treatment of pain is important to reduce the risk of persistent pain and chronic depression, Dr. Meeks said.

“As psychiatrists, we need to keep pain in mind and ask our patients about it,” said Dr. Karp. In addition to various visual or verbal rating scales that can be used to inquire about pain, he said, certain direct questions might be helpful:

▸ Are you in pain now, or if not now, do you hurt more often than not?

▸ Where do you hurt?

▸ How has pain interfered with your life?

▸ Does pain interfere with your sleep?

“Insomnia is ubiquitous in this group,” he said. “It has been associated with a decreased pain threshold, and it decreases patients' ability to actively cope with their pain problem.”

Preliminary analysis from some of his pilot work has shown that insomnia and fatigue among older patients are associated with passive rather than active coping skills.

“Passive skills are less effective and involve things like catastrophizing, praying, or hoping the pain will stop, whereas more active coping involves increasing behavioral activities and using coping self-statements like 'I will get through this,' 'the pain will pass,' or 'the pain will not kill me,'” he said. When direct questioning is not useful or patients are nonverbal, behavioral observation can reveal a great deal about the pain an individual may be experiencing. “They may be grimacing or sighing; they may be irritable, disruptive, or verbally abusive; their body position may be rigid or guarded; or they might show their discomfort by fidgeting,” said Dr. Karp.

The recently validated Elderly Pain Caring Assessment 2 provides further insight into nonverbal cues (Pain 2007;133:87–98). “It's unlikely that we are going to be able to introduce another assessment into our nursing homes, but informing staff about some of these probes may be useful,” he said.

Regardless of whether patients live in the community or in a nursing home, treating their pain with opioids can raise concerns about sedation and cognitive impairment. The decision should involve an individualized risk-benefit analysis.

“While opioids do increase the risk of sedation, confusion, falls, and constipation, for some people the analgesia that results outweighs these potential risks–and cognition actually seems to improve,” he said. “Perhaps they are less distracted by pain and are better able to focus and concentrate.”

Health care professionals should regard persistent pain in the elderly as treatable, with the potential for improvement in many patients. “We need to get the word out that the management of pain should be moved up the priority list, because we can get these patients feeling and functioning better,” Dr. Karp said.

ORLANDO – Pain is a comorbid condition too often overlooked in the setting of geriatric psychiatry, despite the potential for better mental health outcomes when it is treated, Dr. Jordan F. Karp said at the annual meeting of the American Association for Geriatric Psychiatry.

“I don't think enough attention is paid to assessing, diagnosing, and managing pain by many psychiatrists and other physicians who treat older adults,” he said in an interview. “I highly doubt that clinicians are aware of the effects of pain on cognition.”

Because pain has reached “epidemic” proportions among the elderly and can significantly worsen cognition and depression, it should be assessed and treated routinely as part of the psychiatric management of this population, said Dr. Karp, medical director of geriatric psychiatry at one of the referral pain clinics at the University of Pittsburgh Medical Center.

Studies suggest that up to 50% of community-dwelling seniors experience pain that interferes with normal functioning, and up to 80% of nursing home patients live with undertreated pain–the source of which can be musculoskeletal, neuropathic, visceral, metabolic, or other.

It is well known that persistent pain limits mobility, increases the risk of falls, and can lead to social isolation, but it is not always appreciated that pain can also increase anxiety, depression, and cognitive impairment, said Dr. Karp, who has a clinical and research focus on both pain and affective disorders in older adults. He disclosed his advisory role with Eli Lilly & Co. and Myriad Genetics Inc.

In a recent survey of 56 patients in an older adult pain management program, he showed that higher pain severity was associated with poorer performance on a test of number/letter switching (Pain Med. 2006;7:444–52).

In another study of older adults (mean age 73 years), different investigators demonstrated lower neuropsychological function among 163 subjects with chronic low back pain (CLBP), compared with 163 who were pain free (Pain Med. 2006;7:60–70). Recent preliminary evidence also suggests reduced brain volume among eight seniors with CLBP, compared with eight who were pain free (Pain Med. 2008;9:240–8).

The comorbidity of pain and depression is a vicious circle, Dr. Thomas Meeks of the University of California, San Diego, said in a separate presentation at the meeting.

A link between depression and immune system dysfunction has been described, and both pain and weakened immunity have been associated with an increase in inflammatory cytokines. Inflammatory cytokines are also associated with anorexia, sleep disturbance, and fatigue and have been shown to negatively affect brain chemicals such as serotonin and norepinephrine, suggesting “there may be a role of inflammatory cytokines in late-life depression,” he said.

Since the rise in inflammatory cytokines seen with acute pain can persist long after the source of the pain has been corrected, prompt diagnosis and treatment of pain is important to reduce the risk of persistent pain and chronic depression, Dr. Meeks said.

“As psychiatrists, we need to keep pain in mind and ask our patients about it,” said Dr. Karp. In addition to various visual or verbal rating scales that can be used to inquire about pain, he said, certain direct questions might be helpful:

▸ Are you in pain now, or if not now, do you hurt more often than not?

▸ Where do you hurt?

▸ How has pain interfered with your life?

▸ Does pain interfere with your sleep?

“Insomnia is ubiquitous in this group,” he said. “It has been associated with a decreased pain threshold, and it decreases patients' ability to actively cope with their pain problem.”

Preliminary analysis from some of his pilot work has shown that insomnia and fatigue among older patients are associated with passive rather than active coping skills.

“Passive skills are less effective and involve things like catastrophizing, praying, or hoping the pain will stop, whereas more active coping involves increasing behavioral activities and using coping self-statements like 'I will get through this,' 'the pain will pass,' or 'the pain will not kill me,'” he said. When direct questioning is not useful or patients are nonverbal, behavioral observation can reveal a great deal about the pain an individual may be experiencing. “They may be grimacing or sighing; they may be irritable, disruptive, or verbally abusive; their body position may be rigid or guarded; or they might show their discomfort by fidgeting,” said Dr. Karp.

The recently validated Elderly Pain Caring Assessment 2 provides further insight into nonverbal cues (Pain 2007;133:87–98). “It's unlikely that we are going to be able to introduce another assessment into our nursing homes, but informing staff about some of these probes may be useful,” he said.

Regardless of whether patients live in the community or in a nursing home, treating their pain with opioids can raise concerns about sedation and cognitive impairment. The decision should involve an individualized risk-benefit analysis.

“While opioids do increase the risk of sedation, confusion, falls, and constipation, for some people the analgesia that results outweighs these potential risks–and cognition actually seems to improve,” he said. “Perhaps they are less distracted by pain and are better able to focus and concentrate.”

Health care professionals should regard persistent pain in the elderly as treatable, with the potential for improvement in many patients. “We need to get the word out that the management of pain should be moved up the priority list, because we can get these patients feeling and functioning better,” Dr. Karp said.

To revitalize the field of academic dermatology, residency programs should focus on attracting medical doctors who also have PhDs because they are more likely to choose careers in academia, according to Dr. Jashin J. Wu of the University of California, Irvine, and his associates.

"Unfortunately, there are less and less dermatology residents going into academics—they prefer to go into private practice—so there will be less and less dermatologists to provide training in the future. It is important for us to find out why," Dr. Wu said in an interview.

In the study, he and his colleagues analyzed 107 U.S. dermatology residency programs as of December 2004 and identified 782 full-time faculty MDs. Of these, 72 (9.2%) were MD/PhDs (Dermatol. Online J. 2008;14:27).

Using the University of Alabama, Birmingham, National MD/PhD Residency Data, the investigators calculated that another 72 MD/PhDs matched into dermatology residencies between 2004 and 2007, filling 5.8% of 1,236 residency positions during this time period.

Using unpublished data to estimate the total number of dermatology residency graduates over the past 35 years, Dr. Wu and his associates extrapolated that 14% of MD/PhDs were full-time academic dermatologists as of December 2004, compared with 8.6% of MDs—revealing that MD/PhDs were 1.63 times more likely than MDs to enter an academic position after completing residency and 1.58 times more likely to stay in that position.

Among the 72 MD/PhDs who filled full-time faculty positions as of December 2004, 9.7% were dermatology chiefs or department chairs. This compared with 13.2% of full-time academic MDs who filled chief or chair positions, reported Dr. Wu and his colleagues.

"It is imperative that academic dermatologists identify markers that can discern those who are truly interested in academics. The title of MD/PhD could be used as an instrument by dermatology residency directors to choose dermatology applicants who are more dedicated to academics," they wrote.

To revitalize the field of academic dermatology, residency programs should focus on attracting medical doctors who also have PhDs because they are more likely to choose careers in academia, according to Dr. Jashin J. Wu of the University of California, Irvine, and his associates.

"Unfortunately, there are less and less dermatology residents going into academics—they prefer to go into private practice—so there will be less and less dermatologists to provide training in the future. It is important for us to find out why," Dr. Wu said in an interview.

In the study, he and his colleagues analyzed 107 U.S. dermatology residency programs as of December 2004 and identified 782 full-time faculty MDs. Of these, 72 (9.2%) were MD/PhDs (Dermatol. Online J. 2008;14:27).

Using the University of Alabama, Birmingham, National MD/PhD Residency Data, the investigators calculated that another 72 MD/PhDs matched into dermatology residencies between 2004 and 2007, filling 5.8% of 1,236 residency positions during this time period.

Using unpublished data to estimate the total number of dermatology residency graduates over the past 35 years, Dr. Wu and his associates extrapolated that 14% of MD/PhDs were full-time academic dermatologists as of December 2004, compared with 8.6% of MDs—revealing that MD/PhDs were 1.63 times more likely than MDs to enter an academic position after completing residency and 1.58 times more likely to stay in that position.

Among the 72 MD/PhDs who filled full-time faculty positions as of December 2004, 9.7% were dermatology chiefs or department chairs. This compared with 13.2% of full-time academic MDs who filled chief or chair positions, reported Dr. Wu and his colleagues.

"It is imperative that academic dermatologists identify markers that can discern those who are truly interested in academics. The title of MD/PhD could be used as an instrument by dermatology residency directors to choose dermatology applicants who are more dedicated to academics," they wrote.

To revitalize the field of academic dermatology, residency programs should focus on attracting medical doctors who also have PhDs because they are more likely to choose careers in academia, according to Dr. Jashin J. Wu of the University of California, Irvine, and his associates.

"Unfortunately, there are less and less dermatology residents going into academics—they prefer to go into private practice—so there will be less and less dermatologists to provide training in the future. It is important for us to find out why," Dr. Wu said in an interview.

In the study, he and his colleagues analyzed 107 U.S. dermatology residency programs as of December 2004 and identified 782 full-time faculty MDs. Of these, 72 (9.2%) were MD/PhDs (Dermatol. Online J. 2008;14:27).

Using the University of Alabama, Birmingham, National MD/PhD Residency Data, the investigators calculated that another 72 MD/PhDs matched into dermatology residencies between 2004 and 2007, filling 5.8% of 1,236 residency positions during this time period.

Using unpublished data to estimate the total number of dermatology residency graduates over the past 35 years, Dr. Wu and his associates extrapolated that 14% of MD/PhDs were full-time academic dermatologists as of December 2004, compared with 8.6% of MDs—revealing that MD/PhDs were 1.63 times more likely than MDs to enter an academic position after completing residency and 1.58 times more likely to stay in that position.

Among the 72 MD/PhDs who filled full-time faculty positions as of December 2004, 9.7% were dermatology chiefs or department chairs. This compared with 13.2% of full-time academic MDs who filled chief or chair positions, reported Dr. Wu and his colleagues.

"It is imperative that academic dermatologists identify markers that can discern those who are truly interested in academics. The title of MD/PhD could be used as an instrument by dermatology residency directors to choose dermatology applicants who are more dedicated to academics," they wrote.

The type and degree of cancer protection afforded by prophylactic salpingo-oophorectomy varies depending on whether women are BRCA1 or BRCA2 mutations carriers, according to a multicenter, prospective study in the Journal of Clinical Oncology.

In women with BRCA1 mutations, risk-reducing salpingo-oophorectomy (RRSO) significantly reduced gynecologic cancer risk, with only a trend toward breast cancer risk. By comparison, in carriers of the BRCA2 mutation, the surgery's protection against breast cancer was significant, with only a trend toward gynecologic cancer protection, concluded Dr. Noah D. Kauff of Memorial Sloan-Kettering Cancer Center and his colleagues.

“The current report represents, to our knowledge, the first prospective study to evaluate the impact of RRSO on BRCA-associated breast and gynecologic cancer risk when carriers of BRCA2 mutations are evaluated separately from carriers of BRCA1 mutations,” they wrote (doi: 10.1200/JCO.2007.13.9626). “These findings should help women with BRCA mutations and their doctors make more informed choices about strategies to reduce their risk of breast and [gynecologic] cancers,” said Dr. Kauff in a written statement.

The findings are a “strong confirmation that RRSO remains the most effective risk-reduction strategy” for the prevention of BRCA1-associated gynecologic cancer, noted the authors. However, the low incidence of BRCA2-associated gynecologic cancer in the study group limits conclusions about the protective effect of RRSO in this group. This observation “however, may have important implications for women comparing the relative risks and benefits of specific gynecologic cancer risk-reduction strategies,” they suggested. Additionally, “in women with BRCA2 mutations, prophylactic removal of the ovaries and fallopian tubes is profoundly protective against breast cancer. Although the surgery greatly reduces gynecologic cancer risk in women with BRCA1 mutations, they may need to pursue other strategies, such as intensive monitoring or prophylactic mastectomy, to reduce their breast cancer risk.”

The study prospectively enrolled women with confirmed mutation of either the BRCA1 or BRCA2 genes, but not both. A total of 792 participants were followed for a mean of 39 months for gynecologic cancer, 509 of whom had undergone RRSO and 283 of whom had not (surveillance-only group). Additionally, 597 participants were followed for a mean of 35 months for breast cancer events, 303 of whom had undergone RRSO, and 294 of whom were under surveillance only.

Among the participants being followed for gynecologic cancer, 498 had the BRCA1 mutation (325 of whom had undergone RRSO), and 294 had the BRCA2 mutation (184 of whom had undergone the surgery). Cases of gynecologic cancer occurred more frequently in the surveillance-only group (12 vs. 3 cases), revealing a hazard ratio (HR) of 0.12 for developing gynecologic cancer after RRSO, reported the authors. A total of 13 of the 15 gynecologic cancers were identified in BRCA1 mutation carriers.

Among the 597 participants who were followed for breast cancer, 368 had the BRCA1 mutation (190 of whom had undergone RRSO), and 229 had the BRCA2 mutation (113 of whom had undergone the surgery). Again, cases of breast cancer occurred more frequently in the surveillance-only group (28 vs. 19), revealing a HR 0.53 of developing breast cancer after RRSO. The majority (34) of all 47 breast cancers were found in BRCA1 carriers.

When invasive and noninvasive breast cancers were examined independently, RRSO appeared to be more protective against noninvasive breast cancer (HR 0.32) than invasive breast cancer (HR 0.73), wrote the authors. They noted also that when the 34 known invasive cancers were examined, RRSO appeared to be protective against estrogen-receptor (ER) positive invasive breast cancer (HR 0.22), but not ER-negative invasive breast cancer (HR 1.10). “Prevention of ER-negative breast cancer remains a challenge,” they wrote. “The optimal strategy for reducing the risk of this important cancer in carriers of both BRCA1 and BRCA2 mutations will emerge from future prospective studies stratified according to genetic linkage to one or the other of these related, but distinct, cancer susceptibility syndromes.”

The authors suggested one explanation for the study's failure to find a significant protective effect of RRSO against BRCA2-associated gynecologic cancer could be the age of the participants.

As lead author of the study, Dr. Kauff disclosed that he was compensated by Wyeth Pharmaceuticals for a consultant/advisory role, as well as for providing expert testimony. A coauthor, Dr. Judy E. Garber, director of the cancer risk and prevention program at Dana-Farber Cancer Institute, Boston, acknowledged consultant/advisory compensation and honoraria from Myriad Genetics, and remuneration from AstraZeneca Pharmaceuticals was declared by coauthor Dr. Rosalind A. Eeles of the Institute of Cancer Research at the Royal Cancer Hospital, London.

'These findings should help women with BRCA mutations … make more informed choices.' DR. KAUFF

The type and degree of cancer protection afforded by prophylactic salpingo-oophorectomy varies depending on whether women are BRCA1 or BRCA2 mutations carriers, according to a multicenter, prospective study in the Journal of Clinical Oncology.

In women with BRCA1 mutations, risk-reducing salpingo-oophorectomy (RRSO) significantly reduced gynecologic cancer risk, with only a trend toward breast cancer risk. By comparison, in carriers of the BRCA2 mutation, the surgery's protection against breast cancer was significant, with only a trend toward gynecologic cancer protection, concluded Dr. Noah D. Kauff of Memorial Sloan-Kettering Cancer Center and his colleagues.

“The current report represents, to our knowledge, the first prospective study to evaluate the impact of RRSO on BRCA-associated breast and gynecologic cancer risk when carriers of BRCA2 mutations are evaluated separately from carriers of BRCA1 mutations,” they wrote (doi: 10.1200/JCO.2007.13.9626). “These findings should help women with BRCA mutations and their doctors make more informed choices about strategies to reduce their risk of breast and [gynecologic] cancers,” said Dr. Kauff in a written statement.

The findings are a “strong confirmation that RRSO remains the most effective risk-reduction strategy” for the prevention of BRCA1-associated gynecologic cancer, noted the authors. However, the low incidence of BRCA2-associated gynecologic cancer in the study group limits conclusions about the protective effect of RRSO in this group. This observation “however, may have important implications for women comparing the relative risks and benefits of specific gynecologic cancer risk-reduction strategies,” they suggested. Additionally, “in women with BRCA2 mutations, prophylactic removal of the ovaries and fallopian tubes is profoundly protective against breast cancer. Although the surgery greatly reduces gynecologic cancer risk in women with BRCA1 mutations, they may need to pursue other strategies, such as intensive monitoring or prophylactic mastectomy, to reduce their breast cancer risk.”

The study prospectively enrolled women with confirmed mutation of either the BRCA1 or BRCA2 genes, but not both. A total of 792 participants were followed for a mean of 39 months for gynecologic cancer, 509 of whom had undergone RRSO and 283 of whom had not (surveillance-only group). Additionally, 597 participants were followed for a mean of 35 months for breast cancer events, 303 of whom had undergone RRSO, and 294 of whom were under surveillance only.

Among the participants being followed for gynecologic cancer, 498 had the BRCA1 mutation (325 of whom had undergone RRSO), and 294 had the BRCA2 mutation (184 of whom had undergone the surgery). Cases of gynecologic cancer occurred more frequently in the surveillance-only group (12 vs. 3 cases), revealing a hazard ratio (HR) of 0.12 for developing gynecologic cancer after RRSO, reported the authors. A total of 13 of the 15 gynecologic cancers were identified in BRCA1 mutation carriers.

Among the 597 participants who were followed for breast cancer, 368 had the BRCA1 mutation (190 of whom had undergone RRSO), and 229 had the BRCA2 mutation (113 of whom had undergone the surgery). Again, cases of breast cancer occurred more frequently in the surveillance-only group (28 vs. 19), revealing a HR 0.53 of developing breast cancer after RRSO. The majority (34) of all 47 breast cancers were found in BRCA1 carriers.

When invasive and noninvasive breast cancers were examined independently, RRSO appeared to be more protective against noninvasive breast cancer (HR 0.32) than invasive breast cancer (HR 0.73), wrote the authors. They noted also that when the 34 known invasive cancers were examined, RRSO appeared to be protective against estrogen-receptor (ER) positive invasive breast cancer (HR 0.22), but not ER-negative invasive breast cancer (HR 1.10). “Prevention of ER-negative breast cancer remains a challenge,” they wrote. “The optimal strategy for reducing the risk of this important cancer in carriers of both BRCA1 and BRCA2 mutations will emerge from future prospective studies stratified according to genetic linkage to one or the other of these related, but distinct, cancer susceptibility syndromes.”

The authors suggested one explanation for the study's failure to find a significant protective effect of RRSO against BRCA2-associated gynecologic cancer could be the age of the participants.

As lead author of the study, Dr. Kauff disclosed that he was compensated by Wyeth Pharmaceuticals for a consultant/advisory role, as well as for providing expert testimony. A coauthor, Dr. Judy E. Garber, director of the cancer risk and prevention program at Dana-Farber Cancer Institute, Boston, acknowledged consultant/advisory compensation and honoraria from Myriad Genetics, and remuneration from AstraZeneca Pharmaceuticals was declared by coauthor Dr. Rosalind A. Eeles of the Institute of Cancer Research at the Royal Cancer Hospital, London.

'These findings should help women with BRCA mutations … make more informed choices.' DR. KAUFF

The type and degree of cancer protection afforded by prophylactic salpingo-oophorectomy varies depending on whether women are BRCA1 or BRCA2 mutations carriers, according to a multicenter, prospective study in the Journal of Clinical Oncology.

In women with BRCA1 mutations, risk-reducing salpingo-oophorectomy (RRSO) significantly reduced gynecologic cancer risk, with only a trend toward breast cancer risk. By comparison, in carriers of the BRCA2 mutation, the surgery's protection against breast cancer was significant, with only a trend toward gynecologic cancer protection, concluded Dr. Noah D. Kauff of Memorial Sloan-Kettering Cancer Center and his colleagues.

“The current report represents, to our knowledge, the first prospective study to evaluate the impact of RRSO on BRCA-associated breast and gynecologic cancer risk when carriers of BRCA2 mutations are evaluated separately from carriers of BRCA1 mutations,” they wrote (doi: 10.1200/JCO.2007.13.9626). “These findings should help women with BRCA mutations and their doctors make more informed choices about strategies to reduce their risk of breast and [gynecologic] cancers,” said Dr. Kauff in a written statement.

The findings are a “strong confirmation that RRSO remains the most effective risk-reduction strategy” for the prevention of BRCA1-associated gynecologic cancer, noted the authors. However, the low incidence of BRCA2-associated gynecologic cancer in the study group limits conclusions about the protective effect of RRSO in this group. This observation “however, may have important implications for women comparing the relative risks and benefits of specific gynecologic cancer risk-reduction strategies,” they suggested. Additionally, “in women with BRCA2 mutations, prophylactic removal of the ovaries and fallopian tubes is profoundly protective against breast cancer. Although the surgery greatly reduces gynecologic cancer risk in women with BRCA1 mutations, they may need to pursue other strategies, such as intensive monitoring or prophylactic mastectomy, to reduce their breast cancer risk.”

The study prospectively enrolled women with confirmed mutation of either the BRCA1 or BRCA2 genes, but not both. A total of 792 participants were followed for a mean of 39 months for gynecologic cancer, 509 of whom had undergone RRSO and 283 of whom had not (surveillance-only group). Additionally, 597 participants were followed for a mean of 35 months for breast cancer events, 303 of whom had undergone RRSO, and 294 of whom were under surveillance only.

Among the participants being followed for gynecologic cancer, 498 had the BRCA1 mutation (325 of whom had undergone RRSO), and 294 had the BRCA2 mutation (184 of whom had undergone the surgery). Cases of gynecologic cancer occurred more frequently in the surveillance-only group (12 vs. 3 cases), revealing a hazard ratio (HR) of 0.12 for developing gynecologic cancer after RRSO, reported the authors. A total of 13 of the 15 gynecologic cancers were identified in BRCA1 mutation carriers.

Among the 597 participants who were followed for breast cancer, 368 had the BRCA1 mutation (190 of whom had undergone RRSO), and 229 had the BRCA2 mutation (113 of whom had undergone the surgery). Again, cases of breast cancer occurred more frequently in the surveillance-only group (28 vs. 19), revealing a HR 0.53 of developing breast cancer after RRSO. The majority (34) of all 47 breast cancers were found in BRCA1 carriers.

When invasive and noninvasive breast cancers were examined independently, RRSO appeared to be more protective against noninvasive breast cancer (HR 0.32) than invasive breast cancer (HR 0.73), wrote the authors. They noted also that when the 34 known invasive cancers were examined, RRSO appeared to be protective against estrogen-receptor (ER) positive invasive breast cancer (HR 0.22), but not ER-negative invasive breast cancer (HR 1.10). “Prevention of ER-negative breast cancer remains a challenge,” they wrote. “The optimal strategy for reducing the risk of this important cancer in carriers of both BRCA1 and BRCA2 mutations will emerge from future prospective studies stratified according to genetic linkage to one or the other of these related, but distinct, cancer susceptibility syndromes.”

The authors suggested one explanation for the study's failure to find a significant protective effect of RRSO against BRCA2-associated gynecologic cancer could be the age of the participants.

As lead author of the study, Dr. Kauff disclosed that he was compensated by Wyeth Pharmaceuticals for a consultant/advisory role, as well as for providing expert testimony. A coauthor, Dr. Judy E. Garber, director of the cancer risk and prevention program at Dana-Farber Cancer Institute, Boston, acknowledged consultant/advisory compensation and honoraria from Myriad Genetics, and remuneration from AstraZeneca Pharmaceuticals was declared by coauthor Dr. Rosalind A. Eeles of the Institute of Cancer Research at the Royal Cancer Hospital, London.

'These findings should help women with BRCA mutations … make more informed choices.' DR. KAUFF

Patients with irritable bowel syndrome have altered brain responses to the anticipation of pain and to pain itself, which may make them more sensitive to painful stimuli.

“During expectation of pain, IBS [irritable bowel syndrome] patients generate higher levels of tonic noradrenergic activity, producing a bias toward interpretation of network activity as pain (speed over accuracy), and are inefficient at reducing such activity when discrimination of nonpainful stimulation should be maximized, or pain should be inhibited,” wrote Dr. Steven M. Berman and his colleagues from the Center for the Neurobiology of Stress at the University of California, Los Angeles (J. Neurosci. 2008;28:349–59).

They used functional magnetic resonance imaging (fMRI) to measure the blood oxygen level-dependent response to anticipated and delivered rectal distention in 14 female IBS patients and 12 healthy controls (mean age 36 years). The imaging showed that, when the control subjects were anticipating a painful stimulus, brain activity decreased in the insula, supragenual anterior cingulate cortex, amygdala, and dorsal brainstem, but there was less of this anticipatory deactivation in the IBS patients.

Visceral distention of the rectum was then performed using a computer-driven pump and rectal balloon, which was inflated, in random order, to pressures of 25 mm Hg, 45 mm Hg, or 5 mm Hg (sham distension). The distention was performed after an 8-hour fast and two enemas.

Four to six sessions of 16 inflations were performed. Each inflation was preceded by an anticipatory cue, then 15 seconds of inflation at the designated pressure.

During rectal distention, increases in activity in the insula, dorsal anterior cingulate cortex, and dorsal brainstem were more extensive in IBS patients than in controls. “The DBS [dorsal brainstem] region contains multiple small structures implicated in the modulation of pain,” the authors wrote.

Patients rated their mood, before and after the visceral distention, using the Stress Symptom Rating scale and they rated the intensity of their discomfort on a 3-point scale. In addition, they were all evaluated for depression and anxiety symptoms.

Overall, depression and anxiety scores fell within the normal range for all controls and 12 of the 14 IBS patients, but both scores were higher in IBS patients than controls, even when the two clinically elevated patients were excluded. Self-reported stress, anxiety, and anger were also higher in IBS patients. “The current results demonstrate that during certain expectation of experimental abdominal/pelvic discomfort, female IBS-C [IBS with constipation] patients are more anxious and less able than healthy controls to downregulate activity within the CNS network activated by potentially aversive interoceptive stimuli,” the authors noted.

Patients with irritable bowel syndrome have altered brain responses to the anticipation of pain and to pain itself, which may make them more sensitive to painful stimuli.

“During expectation of pain, IBS [irritable bowel syndrome] patients generate higher levels of tonic noradrenergic activity, producing a bias toward interpretation of network activity as pain (speed over accuracy), and are inefficient at reducing such activity when discrimination of nonpainful stimulation should be maximized, or pain should be inhibited,” wrote Dr. Steven M. Berman and his colleagues from the Center for the Neurobiology of Stress at the University of California, Los Angeles (J. Neurosci. 2008;28:349–59).

They used functional magnetic resonance imaging (fMRI) to measure the blood oxygen level-dependent response to anticipated and delivered rectal distention in 14 female IBS patients and 12 healthy controls (mean age 36 years). The imaging showed that, when the control subjects were anticipating a painful stimulus, brain activity decreased in the insula, supragenual anterior cingulate cortex, amygdala, and dorsal brainstem, but there was less of this anticipatory deactivation in the IBS patients.

Visceral distention of the rectum was then performed using a computer-driven pump and rectal balloon, which was inflated, in random order, to pressures of 25 mm Hg, 45 mm Hg, or 5 mm Hg (sham distension). The distention was performed after an 8-hour fast and two enemas.

Four to six sessions of 16 inflations were performed. Each inflation was preceded by an anticipatory cue, then 15 seconds of inflation at the designated pressure.

During rectal distention, increases in activity in the insula, dorsal anterior cingulate cortex, and dorsal brainstem were more extensive in IBS patients than in controls. “The DBS [dorsal brainstem] region contains multiple small structures implicated in the modulation of pain,” the authors wrote.

Patients rated their mood, before and after the visceral distention, using the Stress Symptom Rating scale and they rated the intensity of their discomfort on a 3-point scale. In addition, they were all evaluated for depression and anxiety symptoms.

Overall, depression and anxiety scores fell within the normal range for all controls and 12 of the 14 IBS patients, but both scores were higher in IBS patients than controls, even when the two clinically elevated patients were excluded. Self-reported stress, anxiety, and anger were also higher in IBS patients. “The current results demonstrate that during certain expectation of experimental abdominal/pelvic discomfort, female IBS-C [IBS with constipation] patients are more anxious and less able than healthy controls to downregulate activity within the CNS network activated by potentially aversive interoceptive stimuli,” the authors noted.

Patients with irritable bowel syndrome have altered brain responses to the anticipation of pain and to pain itself, which may make them more sensitive to painful stimuli.

“During expectation of pain, IBS [irritable bowel syndrome] patients generate higher levels of tonic noradrenergic activity, producing a bias toward interpretation of network activity as pain (speed over accuracy), and are inefficient at reducing such activity when discrimination of nonpainful stimulation should be maximized, or pain should be inhibited,” wrote Dr. Steven M. Berman and his colleagues from the Center for the Neurobiology of Stress at the University of California, Los Angeles (J. Neurosci. 2008;28:349–59).

They used functional magnetic resonance imaging (fMRI) to measure the blood oxygen level-dependent response to anticipated and delivered rectal distention in 14 female IBS patients and 12 healthy controls (mean age 36 years). The imaging showed that, when the control subjects were anticipating a painful stimulus, brain activity decreased in the insula, supragenual anterior cingulate cortex, amygdala, and dorsal brainstem, but there was less of this anticipatory deactivation in the IBS patients.

Visceral distention of the rectum was then performed using a computer-driven pump and rectal balloon, which was inflated, in random order, to pressures of 25 mm Hg, 45 mm Hg, or 5 mm Hg (sham distension). The distention was performed after an 8-hour fast and two enemas.

Four to six sessions of 16 inflations were performed. Each inflation was preceded by an anticipatory cue, then 15 seconds of inflation at the designated pressure.

During rectal distention, increases in activity in the insula, dorsal anterior cingulate cortex, and dorsal brainstem were more extensive in IBS patients than in controls. “The DBS [dorsal brainstem] region contains multiple small structures implicated in the modulation of pain,” the authors wrote.

Patients rated their mood, before and after the visceral distention, using the Stress Symptom Rating scale and they rated the intensity of their discomfort on a 3-point scale. In addition, they were all evaluated for depression and anxiety symptoms.

Overall, depression and anxiety scores fell within the normal range for all controls and 12 of the 14 IBS patients, but both scores were higher in IBS patients than controls, even when the two clinically elevated patients were excluded. Self-reported stress, anxiety, and anger were also higher in IBS patients. “The current results demonstrate that during certain expectation of experimental abdominal/pelvic discomfort, female IBS-C [IBS with constipation] patients are more anxious and less able than healthy controls to downregulate activity within the CNS network activated by potentially aversive interoceptive stimuli,” the authors noted.

MONTREAL — Mother-to-mother support can significantly reduce the development of postpartum depression in women who are at high risk for the condition, Cindy-Lee Dennis, Ph.D., said at the annual conference of the Canadian Psychiatric Association.

“Meta-analyses and predictive studies have clearly suggested the importance of psychosocial variables in the development of postpartum depression,” said Dr. Dennis of the Lawrence S. Bloomberg Faculty of Nursing at the University of Toronto.

“When we look at support variables in particular, it's the lack of a confidante that places the mother at risk for postpartum depression,” she noted.

Her study involved 701 women who were less than 2 weeks post partum and considered to be at high risk for developing postpartum depression based on an Edinburgh Postnatal Depression Scale (EPDS) score of greater than 9.

The women were randomized to a control group (n=352), which received usual postpartum care, or an intervention group (n=349) that received usual postpartum care plus telephone peer support. A total of 205 peer support volunteers, all of whom had recovered from self-reported postpartum depression, were recruited from the community through fliers and advertising. They were given a 4-hour training session and then matched to the new mothers based on health region, and, if the mother desired, on ethnicity.

For the primary outcome measure, an EPDS score of greater than 12, the study found a significant benefit to peer support. “Mothers who received the intervention were two times less likely to develop postpartum depression,” said Dr. Dennis, who reported an incidence of 13.5% in the intervention group and a 26% incidence in the control group.

A secondary outcome measure of anxiety also favored the intervention, with incidences of 20.6% in the intervention group and 26.9% in the control group. “This is bordering on statistical significance, but we think it is clinically relevant and suggests anxiety might be relieved with peer support,” she said. There were no differences between the groups in their reports of loneliness.

Predictors of a baseline EPDS score of greater than 12 included non-Canadian ethnicity (reported by 19% of participants), not having been born in Canada (reported by 41% of participants), new immigrant status with less than 5 years in Canada (reported by 43% of those not born in Canada), and no family support (reported by 12% of participants). A total of 59% of the participants were primiparous, 31% had a history of depression, 18% had no other mother to talk to, and almost 10% were very unhappy with the baby's father.

“Because this was a prevention trial, we felt it was unethical to leave a depressed mother in the community. So we administered the SCID [Structured Clinical Interview for DSM Disorders), and if they were diagnosed with clinical depression or had an EPDS score greater than 20, then we referred them back to the public health department and public health did follow up with them,” said Dr. Dennis.

MONTREAL — Mother-to-mother support can significantly reduce the development of postpartum depression in women who are at high risk for the condition, Cindy-Lee Dennis, Ph.D., said at the annual conference of the Canadian Psychiatric Association.

“Meta-analyses and predictive studies have clearly suggested the importance of psychosocial variables in the development of postpartum depression,” said Dr. Dennis of the Lawrence S. Bloomberg Faculty of Nursing at the University of Toronto.

“When we look at support variables in particular, it's the lack of a confidante that places the mother at risk for postpartum depression,” she noted.

Her study involved 701 women who were less than 2 weeks post partum and considered to be at high risk for developing postpartum depression based on an Edinburgh Postnatal Depression Scale (EPDS) score of greater than 9.

The women were randomized to a control group (n=352), which received usual postpartum care, or an intervention group (n=349) that received usual postpartum care plus telephone peer support. A total of 205 peer support volunteers, all of whom had recovered from self-reported postpartum depression, were recruited from the community through fliers and advertising. They were given a 4-hour training session and then matched to the new mothers based on health region, and, if the mother desired, on ethnicity.

For the primary outcome measure, an EPDS score of greater than 12, the study found a significant benefit to peer support. “Mothers who received the intervention were two times less likely to develop postpartum depression,” said Dr. Dennis, who reported an incidence of 13.5% in the intervention group and a 26% incidence in the control group.

A secondary outcome measure of anxiety also favored the intervention, with incidences of 20.6% in the intervention group and 26.9% in the control group. “This is bordering on statistical significance, but we think it is clinically relevant and suggests anxiety might be relieved with peer support,” she said. There were no differences between the groups in their reports of loneliness.

Predictors of a baseline EPDS score of greater than 12 included non-Canadian ethnicity (reported by 19% of participants), not having been born in Canada (reported by 41% of participants), new immigrant status with less than 5 years in Canada (reported by 43% of those not born in Canada), and no family support (reported by 12% of participants). A total of 59% of the participants were primiparous, 31% had a history of depression, 18% had no other mother to talk to, and almost 10% were very unhappy with the baby's father.

“Because this was a prevention trial, we felt it was unethical to leave a depressed mother in the community. So we administered the SCID [Structured Clinical Interview for DSM Disorders), and if they were diagnosed with clinical depression or had an EPDS score greater than 20, then we referred them back to the public health department and public health did follow up with them,” said Dr. Dennis.

MONTREAL — Mother-to-mother support can significantly reduce the development of postpartum depression in women who are at high risk for the condition, Cindy-Lee Dennis, Ph.D., said at the annual conference of the Canadian Psychiatric Association.

“Meta-analyses and predictive studies have clearly suggested the importance of psychosocial variables in the development of postpartum depression,” said Dr. Dennis of the Lawrence S. Bloomberg Faculty of Nursing at the University of Toronto.

“When we look at support variables in particular, it's the lack of a confidante that places the mother at risk for postpartum depression,” she noted.

Her study involved 701 women who were less than 2 weeks post partum and considered to be at high risk for developing postpartum depression based on an Edinburgh Postnatal Depression Scale (EPDS) score of greater than 9.

The women were randomized to a control group (n=352), which received usual postpartum care, or an intervention group (n=349) that received usual postpartum care plus telephone peer support. A total of 205 peer support volunteers, all of whom had recovered from self-reported postpartum depression, were recruited from the community through fliers and advertising. They were given a 4-hour training session and then matched to the new mothers based on health region, and, if the mother desired, on ethnicity.

For the primary outcome measure, an EPDS score of greater than 12, the study found a significant benefit to peer support. “Mothers who received the intervention were two times less likely to develop postpartum depression,” said Dr. Dennis, who reported an incidence of 13.5% in the intervention group and a 26% incidence in the control group.

A secondary outcome measure of anxiety also favored the intervention, with incidences of 20.6% in the intervention group and 26.9% in the control group. “This is bordering on statistical significance, but we think it is clinically relevant and suggests anxiety might be relieved with peer support,” she said. There were no differences between the groups in their reports of loneliness.

Predictors of a baseline EPDS score of greater than 12 included non-Canadian ethnicity (reported by 19% of participants), not having been born in Canada (reported by 41% of participants), new immigrant status with less than 5 years in Canada (reported by 43% of those not born in Canada), and no family support (reported by 12% of participants). A total of 59% of the participants were primiparous, 31% had a history of depression, 18% had no other mother to talk to, and almost 10% were very unhappy with the baby's father.

“Because this was a prevention trial, we felt it was unethical to leave a depressed mother in the community. So we administered the SCID [Structured Clinical Interview for DSM Disorders), and if they were diagnosed with clinical depression or had an EPDS score greater than 20, then we referred them back to the public health department and public health did follow up with them,” said Dr. Dennis.

MONTREAL — Mother-to-mother support can significantly reduce the development of postpartum depression in women who are at high risk for the condition, Cindy-Lee Dennis, Ph.D., said at the annual conference of the Canadian Psychiatric Association.

“Meta-analyses and predictive studies have clearly suggested the importance of psychosocial variables in the development of postpartum depression,” said Dr. Dennis of the Lawrence S. Bloomberg Faculty of Nursing at the University of Toronto.

“When we look at support variables in particular, it's the lack of a confidante that places the mother at risk for postpartum depression,” she noted.

Her study involved 701 women who were less than 2 weeks post partum and considered to be at high risk for developing postpartum depression based on an Edinburgh Postnatal Depression Scale (EPDS) score of greater than 9.

The women were randomized to a control group (n = 352), which received usual postpartum care, or an intervention group (n = 349) that received usual postpartum care plus telephone peer support. A total of 205 peer-support volunteers, all of whom had recovered from self-reported postpartum depression, were recruited from the community through fliers and advertising. They were given a 4-hour training session and then matched to the new mothers based on health region, and, if the mother desired, on ethnicity.

For the primary outcome measure, an EPDS score of greater than 12, the study found a significant benefit to peer support. “Mothers who received the intervention were two times less likely to develop postpartum depression,” said Dr. Dennis, who reported an incidence of 13.5% in the intervention group and a 26% incidence in the control group.

A secondary outcome measure of anxiety also favored the intervention, with incidences of 20.6% in the intervention group and 26.9% in the control group. “This is bordering on statistical significance, but we think it is clinically relevant and suggests anxiety might be relieved with peer support,” she said.

There were no differences between the groups in their reports of loneliness.

Predictors of a baseline EPDS score of greater than 12 included non-Canadian ethnicity (reported by 19% of participants), not having been born in Canada (reported by 41% of participants), new immigrant status with less than 5 years in Canada (reported by 43% of those not born in Canada), and no family support (reported by 12% of participants). A total of 59% of the participants were primiparous, 31% had a history of depression, 18% had no mother to talk to, and almost 10% were very unhappy with the baby's father.

“Because this was a prevention trial, we felt it was unethical to leave a depressed mother in the community. So we administered the SCID [Structured Clinical Interview for DSM Disorders), and if they were diagnosed with clinical depression or had an EPDS score greater than 20, then we referred them back to the public health department and public health did follow up with them,” said Dr. Dennis.

MONTREAL — Mother-to-mother support can significantly reduce the development of postpartum depression in women who are at high risk for the condition, Cindy-Lee Dennis, Ph.D., said at the annual conference of the Canadian Psychiatric Association.

“Meta-analyses and predictive studies have clearly suggested the importance of psychosocial variables in the development of postpartum depression,” said Dr. Dennis of the Lawrence S. Bloomberg Faculty of Nursing at the University of Toronto.

“When we look at support variables in particular, it's the lack of a confidante that places the mother at risk for postpartum depression,” she noted.

Her study involved 701 women who were less than 2 weeks post partum and considered to be at high risk for developing postpartum depression based on an Edinburgh Postnatal Depression Scale (EPDS) score of greater than 9.

The women were randomized to a control group (n = 352), which received usual postpartum care, or an intervention group (n = 349) that received usual postpartum care plus telephone peer support. A total of 205 peer-support volunteers, all of whom had recovered from self-reported postpartum depression, were recruited from the community through fliers and advertising. They were given a 4-hour training session and then matched to the new mothers based on health region, and, if the mother desired, on ethnicity.

For the primary outcome measure, an EPDS score of greater than 12, the study found a significant benefit to peer support. “Mothers who received the intervention were two times less likely to develop postpartum depression,” said Dr. Dennis, who reported an incidence of 13.5% in the intervention group and a 26% incidence in the control group.

A secondary outcome measure of anxiety also favored the intervention, with incidences of 20.6% in the intervention group and 26.9% in the control group. “This is bordering on statistical significance, but we think it is clinically relevant and suggests anxiety might be relieved with peer support,” she said.

There were no differences between the groups in their reports of loneliness.

Predictors of a baseline EPDS score of greater than 12 included non-Canadian ethnicity (reported by 19% of participants), not having been born in Canada (reported by 41% of participants), new immigrant status with less than 5 years in Canada (reported by 43% of those not born in Canada), and no family support (reported by 12% of participants). A total of 59% of the participants were primiparous, 31% had a history of depression, 18% had no mother to talk to, and almost 10% were very unhappy with the baby's father.

“Because this was a prevention trial, we felt it was unethical to leave a depressed mother in the community. So we administered the SCID [Structured Clinical Interview for DSM Disorders), and if they were diagnosed with clinical depression or had an EPDS score greater than 20, then we referred them back to the public health department and public health did follow up with them,” said Dr. Dennis.

MONTREAL — Mother-to-mother support can significantly reduce the development of postpartum depression in women who are at high risk for the condition, Cindy-Lee Dennis, Ph.D., said at the annual conference of the Canadian Psychiatric Association.

“Meta-analyses and predictive studies have clearly suggested the importance of psychosocial variables in the development of postpartum depression,” said Dr. Dennis of the Lawrence S. Bloomberg Faculty of Nursing at the University of Toronto.

“When we look at support variables in particular, it's the lack of a confidante that places the mother at risk for postpartum depression,” she noted.

Her study involved 701 women who were less than 2 weeks post partum and considered to be at high risk for developing postpartum depression based on an Edinburgh Postnatal Depression Scale (EPDS) score of greater than 9.

The women were randomized to a control group (n = 352), which received usual postpartum care, or an intervention group (n = 349) that received usual postpartum care plus telephone peer support. A total of 205 peer-support volunteers, all of whom had recovered from self-reported postpartum depression, were recruited from the community through fliers and advertising. They were given a 4-hour training session and then matched to the new mothers based on health region, and, if the mother desired, on ethnicity.

For the primary outcome measure, an EPDS score of greater than 12, the study found a significant benefit to peer support. “Mothers who received the intervention were two times less likely to develop postpartum depression,” said Dr. Dennis, who reported an incidence of 13.5% in the intervention group and a 26% incidence in the control group.

A secondary outcome measure of anxiety also favored the intervention, with incidences of 20.6% in the intervention group and 26.9% in the control group. “This is bordering on statistical significance, but we think it is clinically relevant and suggests anxiety might be relieved with peer support,” she said.

There were no differences between the groups in their reports of loneliness.

Predictors of a baseline EPDS score of greater than 12 included non-Canadian ethnicity (reported by 19% of participants), not having been born in Canada (reported by 41% of participants), new immigrant status with less than 5 years in Canada (reported by 43% of those not born in Canada), and no family support (reported by 12% of participants). A total of 59% of the participants were primiparous, 31% had a history of depression, 18% had no mother to talk to, and almost 10% were very unhappy with the baby's father.

“Because this was a prevention trial, we felt it was unethical to leave a depressed mother in the community. So we administered the SCID [Structured Clinical Interview for DSM Disorders), and if they were diagnosed with clinical depression or had an EPDS score greater than 20, then we referred them back to the public health department and public health did follow up with them,” said Dr. Dennis.

Updated recommendations from the U.S. Preventive Services Task Force advise against screening for bacterial vaginosis in pregnant women who are asymptomatic and at low risk for preterm delivery.

However, the recommendations remain neutral about such screening in high-risk pregnancies because “current evidence is insufficient to assess the balance of benefits and harms,” reported Dr. Ned Calonge, chair of the U.S. Preventive Services Task Force (USPSTF) and his colleagues.

The new recommendations (Ann. Intern. Med. 2008;148:214–9) are an update of those compiled by the task force in 2001 (Am. J. Prev. Med. 2001;20:59–61). They are based on an analysis of new evidence, which was conducted for the task force by Peggy Nygren of the Oregon Health and Science University, Portland, and her associates and funded by the Agency for Healthcare Research and Quality (Ann. Intern. Med. 2008;148:220–33).

The analysis addressed “previously identified gaps, such as the characterization of patients most likely to benefit from screening and the optimal timing of screening and treatment in pregnancy outcomes,” said Dr. Calonge, who is also chief medical officer of the Colorado Department of Public Health and Environment, Denver, and his colleagues.

Ms. Nygren and her associates noted the recent concerns that metronidazole—the antibiotic most commonly used to treat bacterial vaginosis—might increase preterm births in certain populations. “The juxtaposition of these data, along with epidemiologic evidence associating bacterial vaginosis with preterm birth, leads to considerable confusion for clinicians and researchers alike. Whether to screen or treat multiple times, when to start, and at what interval during pregnancy are unanswered questions, as bacterial vaginosis may not necessarily persist throughout pregnancy,” they wrote.

The analysis included studies published after the release of the task force's 2001 recommendations to examine “new evidence on the benefits and harms of screening and treating bacterial vaginosis in asymptomatic pregnant women.”

Asymptomatic patients were defined as those presenting for routine prenatal care and not for evaluation of vaginal discharge, odor, or itching. Low-risk patients were defined as having no history of and no risk factors for preterm delivery, whereas average-risk patients were defined as “the general population,” regardless of risk status. Women with a history of preterm delivery related to spontaneous rupture of membranes or spontaneous preterm labor were categorized as high risk.

The analysis found no benefit in treating women with low- or average-risk pregnancies if they were asymptomatic. For high-risk asymptomatic pregnancies, Ms. Nygren and her colleagues noted that findings from one trial that had been published since the USPSTF 2001 recommendations showed “a significant adverse effect of treatment on delivery before 37 weeks” in 127 women, “indicating that treatment of bacterial vaginosis increased the chance of preterm delivery” significantly (S. Afr. Med. J. 2002;92:231–4).

However, when this study was considered with previous studies that had been included in the 2001 recommendations, the results were “heterogenous and conflicting,” they wrote.

For the outcome of delivery before 37 weeks, three of the trials reported a significant treatment benefit, one showed significant treatment harm, and one showed no benefit.

In keeping with the USPSTF recommendation against screening in low-risk pregnancies, the Centers for Disease Control and Prevention (CDC), the American College of Obstetricians and Gynecologists (ACOG), the Cochrane Pregnancy and Childbirth Group, the British Association for Sexual Health and HIV/Clinical Effectiveness Group (BASHH), and the American Academy of Family Physicians (AAFP) have similar recommendations, according to the authors of the task force's report.

However, although the task force maintains its neutral position regarding high-risk pregnancies, the CDC, ACOG, AAFP and BASHH say there might be high-risk women for whom screening and treatment may be beneficial, the USPSTF authors wrote, noting that optimal treatment for bacterial vaginosis in pregnancy remains unclear.

Updated recommendations from the U.S. Preventive Services Task Force advise against screening for bacterial vaginosis in pregnant women who are asymptomatic and at low risk for preterm delivery.

However, the recommendations remain neutral about such screening in high-risk pregnancies because “current evidence is insufficient to assess the balance of benefits and harms,” reported Dr. Ned Calonge, chair of the U.S. Preventive Services Task Force (USPSTF) and his colleagues.

The new recommendations (Ann. Intern. Med. 2008;148:214–9) are an update of those compiled by the task force in 2001 (Am. J. Prev. Med. 2001;20:59–61). They are based on an analysis of new evidence, which was conducted for the task force by Peggy Nygren of the Oregon Health and Science University, Portland, and her associates and funded by the Agency for Healthcare Research and Quality (Ann. Intern. Med. 2008;148:220–33).

The analysis addressed “previously identified gaps, such as the characterization of patients most likely to benefit from screening and the optimal timing of screening and treatment in pregnancy outcomes,” said Dr. Calonge, who is also chief medical officer of the Colorado Department of Public Health and Environment, Denver, and his colleagues.

Ms. Nygren and her associates noted the recent concerns that metronidazole—the antibiotic most commonly used to treat bacterial vaginosis—might increase preterm births in certain populations. “The juxtaposition of these data, along with epidemiologic evidence associating bacterial vaginosis with preterm birth, leads to considerable confusion for clinicians and researchers alike. Whether to screen or treat multiple times, when to start, and at what interval during pregnancy are unanswered questions, as bacterial vaginosis may not necessarily persist throughout pregnancy,” they wrote.

The analysis included studies published after the release of the task force's 2001 recommendations to examine “new evidence on the benefits and harms of screening and treating bacterial vaginosis in asymptomatic pregnant women.”

Asymptomatic patients were defined as those presenting for routine prenatal care and not for evaluation of vaginal discharge, odor, or itching. Low-risk patients were defined as having no history of and no risk factors for preterm delivery, whereas average-risk patients were defined as “the general population,” regardless of risk status. Women with a history of preterm delivery related to spontaneous rupture of membranes or spontaneous preterm labor were categorized as high risk.

The analysis found no benefit in treating women with low- or average-risk pregnancies if they were asymptomatic. For high-risk asymptomatic pregnancies, Ms. Nygren and her colleagues noted that findings from one trial that had been published since the USPSTF 2001 recommendations showed “a significant adverse effect of treatment on delivery before 37 weeks” in 127 women, “indicating that treatment of bacterial vaginosis increased the chance of preterm delivery” significantly (S. Afr. Med. J. 2002;92:231–4).

However, when this study was considered with previous studies that had been included in the 2001 recommendations, the results were “heterogenous and conflicting,” they wrote.

For the outcome of delivery before 37 weeks, three of the trials reported a significant treatment benefit, one showed significant treatment harm, and one showed no benefit.

In keeping with the USPSTF recommendation against screening in low-risk pregnancies, the Centers for Disease Control and Prevention (CDC), the American College of Obstetricians and Gynecologists (ACOG), the Cochrane Pregnancy and Childbirth Group, the British Association for Sexual Health and HIV/Clinical Effectiveness Group (BASHH), and the American Academy of Family Physicians (AAFP) have similar recommendations, according to the authors of the task force's report.

However, although the task force maintains its neutral position regarding high-risk pregnancies, the CDC, ACOG, AAFP and BASHH say there might be high-risk women for whom screening and treatment may be beneficial, the USPSTF authors wrote, noting that optimal treatment for bacterial vaginosis in pregnancy remains unclear.

Updated recommendations from the U.S. Preventive Services Task Force advise against screening for bacterial vaginosis in pregnant women who are asymptomatic and at low risk for preterm delivery.

However, the recommendations remain neutral about such screening in high-risk pregnancies because “current evidence is insufficient to assess the balance of benefits and harms,” reported Dr. Ned Calonge, chair of the U.S. Preventive Services Task Force (USPSTF) and his colleagues.

The new recommendations (Ann. Intern. Med. 2008;148:214–9) are an update of those compiled by the task force in 2001 (Am. J. Prev. Med. 2001;20:59–61). They are based on an analysis of new evidence, which was conducted for the task force by Peggy Nygren of the Oregon Health and Science University, Portland, and her associates and funded by the Agency for Healthcare Research and Quality (Ann. Intern. Med. 2008;148:220–33).

The analysis addressed “previously identified gaps, such as the characterization of patients most likely to benefit from screening and the optimal timing of screening and treatment in pregnancy outcomes,” said Dr. Calonge, who is also chief medical officer of the Colorado Department of Public Health and Environment, Denver, and his colleagues.

Ms. Nygren and her associates noted the recent concerns that metronidazole—the antibiotic most commonly used to treat bacterial vaginosis—might increase preterm births in certain populations. “The juxtaposition of these data, along with epidemiologic evidence associating bacterial vaginosis with preterm birth, leads to considerable confusion for clinicians and researchers alike. Whether to screen or treat multiple times, when to start, and at what interval during pregnancy are unanswered questions, as bacterial vaginosis may not necessarily persist throughout pregnancy,” they wrote.

The analysis included studies published after the release of the task force's 2001 recommendations to examine “new evidence on the benefits and harms of screening and treating bacterial vaginosis in asymptomatic pregnant women.”

Asymptomatic patients were defined as those presenting for routine prenatal care and not for evaluation of vaginal discharge, odor, or itching. Low-risk patients were defined as having no history of and no risk factors for preterm delivery, whereas average-risk patients were defined as “the general population,” regardless of risk status. Women with a history of preterm delivery related to spontaneous rupture of membranes or spontaneous preterm labor were categorized as high risk.

The analysis found no benefit in treating women with low- or average-risk pregnancies if they were asymptomatic. For high-risk asymptomatic pregnancies, Ms. Nygren and her colleagues noted that findings from one trial that had been published since the USPSTF 2001 recommendations showed “a significant adverse effect of treatment on delivery before 37 weeks” in 127 women, “indicating that treatment of bacterial vaginosis increased the chance of preterm delivery” significantly (S. Afr. Med. J. 2002;92:231–4).

However, when this study was considered with previous studies that had been included in the 2001 recommendations, the results were “heterogenous and conflicting,” they wrote.

For the outcome of delivery before 37 weeks, three of the trials reported a significant treatment benefit, one showed significant treatment harm, and one showed no benefit.

In keeping with the USPSTF recommendation against screening in low-risk pregnancies, the Centers for Disease Control and Prevention (CDC), the American College of Obstetricians and Gynecologists (ACOG), the Cochrane Pregnancy and Childbirth Group, the British Association for Sexual Health and HIV/Clinical Effectiveness Group (BASHH), and the American Academy of Family Physicians (AAFP) have similar recommendations, according to the authors of the task force's report.

However, although the task force maintains its neutral position regarding high-risk pregnancies, the CDC, ACOG, AAFP and BASHH say there might be high-risk women for whom screening and treatment may be beneficial, the USPSTF authors wrote, noting that optimal treatment for bacterial vaginosis in pregnancy remains unclear.

Updated recommendations from the U.S. Preventive Services Task Force advise against screening for bacterial vaginosis in pregnant women who are asymptomatic and at low risk for preterm delivery.

But the recommendations remain neutral about screening in high-risk pregnancies because “current evidence is insufficient to assess the balance of benefits and harms,” said Dr. Ned Calonge, chair of the U.S. Preventive Services Task Force (USPSTF) and colleagues.

The new recommendations (Ann. Intern. Med. 2008;148:214-9) are an update of those compiled by the task force in 2001 (Am. J. Prev. Med. 2001;20:59-61). They are based on an analysis of new evidence, conducted for the task force by Peggy Nygren of the Oregon Health and Science University, Portland, and her associates and funded by the Agency for Healthcare Research and Quality (Ann. Intern. Med. 2008;148:220-33).

The analysis addressed “previously identified gaps, such as the characterization of patients most likely to benefit from screening and the optimal timing of screening and treatment in pregnancy outcomes,” said Dr. Calonge, who is also chief medical officer of the Colorado Department of Public Health and Environment, Denver, and his colleagues.

Ms. Nygren and her associates noted the recent concerns that metronidazole, the antibiotic most commonly used to treat bacterial vaginosis, might increase preterm births in some populations. “The juxtaposition of these data, along with epidemiologic evidence associating bacterial vaginosis with preterm birth, leads to considerable confusion for clinicians and researchers alike. Whether to screen or treat multiple times, when to start, and at what interval during pregnancy are unanswered questions, as bacterial vaginosis may not necessarily persist throughout pregnancy,” they wrote.

The analysis included studies published after the release of the task force's 2001 recommendations to examine “new evidence on … screening and treating bacterial vaginosis in asymptomatic pregnant women.”

Asymptomatic patients were defined as those presenting for routine prenatal care and not for evaluation of vaginal discharge, odor, or itching. Low-risk patients were defined as having no history of and no risk factors for preterm delivery, whereas average-risk patients were defined as “the general population,” regardless of risk status. Women with a history of preterm delivery related to spontaneous rupture of membranes or spontaneous preterm labor were categorized as high risk.

The analysis found no benefit in treating women with low- or average-risk pregnancies if they were asymptomatic. For high-risk asymptomatic pregnancies, Ms. Nygren and her colleagues noted that findings from one trial that had been published since the USPSTF 2001 recommendations showed “a significant adverse effect of treatment on delivery before 37 weeks” in 127 women, “indicating that treatment of bacterial vaginosis increased the chance of preterm delivery” significantly (S. Afr. Med. J. 2002;92:231-4).

However, when this study was considered with previous studies that had been included in the 2001 recommendations, the results were “heterogenous and conflicting,” they wrote. For the outcome of delivery before 37 weeks, three of the trials reported a significant treatment benefit, one showed significant treatment harm, and one showed no benefit. “Inherent differences in populations, such as previous pregnancy complications, gestational age, ethnicity, or co-infection, may also influence which women are helped or harmed by screening and treatment for bacterial vaginosis,” they wrote, noting “a potential but unclear benefit of treatment for some [high-risk] patients.”

In keeping with the USPSTF recommendation against screening in low-risk pregnancies, the Centers for Disease Control and Prevention (CDC), the American Academy of Family Physicians (AAFP), the American College of Obstetricians and Gynecologists (ACOG), the Cochrane Pregnancy and Childbirth Group, the British Association for Sexual Health and HIV/Clinical Effectiveness Group (BASHH) have similar recommendations.

Although the task force maintains its neutral position regarding high-risk pregnancies, the CDC, ACOG, AAFP and BASHH say there might be high-risk women for whom screening and treatment may be beneficial, the USPSTF authors wrote, noting that optimal treatment for bacterial vaginosis in pregnancy remains unclear.

Updated recommendations from the U.S. Preventive Services Task Force advise against screening for bacterial vaginosis in pregnant women who are asymptomatic and at low risk for preterm delivery.

But the recommendations remain neutral about screening in high-risk pregnancies because “current evidence is insufficient to assess the balance of benefits and harms,” said Dr. Ned Calonge, chair of the U.S. Preventive Services Task Force (USPSTF) and colleagues.

The new recommendations (Ann. Intern. Med. 2008;148:214-9) are an update of those compiled by the task force in 2001 (Am. J. Prev. Med. 2001;20:59-61). They are based on an analysis of new evidence, conducted for the task force by Peggy Nygren of the Oregon Health and Science University, Portland, and her associates and funded by the Agency for Healthcare Research and Quality (Ann. Intern. Med. 2008;148:220-33).

The analysis addressed “previously identified gaps, such as the characterization of patients most likely to benefit from screening and the optimal timing of screening and treatment in pregnancy outcomes,” said Dr. Calonge, who is also chief medical officer of the Colorado Department of Public Health and Environment, Denver, and his colleagues.

Ms. Nygren and her associates noted the recent concerns that metronidazole, the antibiotic most commonly used to treat bacterial vaginosis, might increase preterm births in some populations. “The juxtaposition of these data, along with epidemiologic evidence associating bacterial vaginosis with preterm birth, leads to considerable confusion for clinicians and researchers alike. Whether to screen or treat multiple times, when to start, and at what interval during pregnancy are unanswered questions, as bacterial vaginosis may not necessarily persist throughout pregnancy,” they wrote.

The analysis included studies published after the release of the task force's 2001 recommendations to examine “new evidence on … screening and treating bacterial vaginosis in asymptomatic pregnant women.”

Asymptomatic patients were defined as those presenting for routine prenatal care and not for evaluation of vaginal discharge, odor, or itching. Low-risk patients were defined as having no history of and no risk factors for preterm delivery, whereas average-risk patients were defined as “the general population,” regardless of risk status. Women with a history of preterm delivery related to spontaneous rupture of membranes or spontaneous preterm labor were categorized as high risk.

The analysis found no benefit in treating women with low- or average-risk pregnancies if they were asymptomatic. For high-risk asymptomatic pregnancies, Ms. Nygren and her colleagues noted that findings from one trial that had been published since the USPSTF 2001 recommendations showed “a significant adverse effect of treatment on delivery before 37 weeks” in 127 women, “indicating that treatment of bacterial vaginosis increased the chance of preterm delivery” significantly (S. Afr. Med. J. 2002;92:231-4).

However, when this study was considered with previous studies that had been included in the 2001 recommendations, the results were “heterogenous and conflicting,” they wrote. For the outcome of delivery before 37 weeks, three of the trials reported a significant treatment benefit, one showed significant treatment harm, and one showed no benefit. “Inherent differences in populations, such as previous pregnancy complications, gestational age, ethnicity, or co-infection, may also influence which women are helped or harmed by screening and treatment for bacterial vaginosis,” they wrote, noting “a potential but unclear benefit of treatment for some [high-risk] patients.”

In keeping with the USPSTF recommendation against screening in low-risk pregnancies, the Centers for Disease Control and Prevention (CDC), the American Academy of Family Physicians (AAFP), the American College of Obstetricians and Gynecologists (ACOG), the Cochrane Pregnancy and Childbirth Group, the British Association for Sexual Health and HIV/Clinical Effectiveness Group (BASHH) have similar recommendations.

Although the task force maintains its neutral position regarding high-risk pregnancies, the CDC, ACOG, AAFP and BASHH say there might be high-risk women for whom screening and treatment may be beneficial, the USPSTF authors wrote, noting that optimal treatment for bacterial vaginosis in pregnancy remains unclear.

Updated recommendations from the U.S. Preventive Services Task Force advise against screening for bacterial vaginosis in pregnant women who are asymptomatic and at low risk for preterm delivery.

But the recommendations remain neutral about screening in high-risk pregnancies because “current evidence is insufficient to assess the balance of benefits and harms,” said Dr. Ned Calonge, chair of the U.S. Preventive Services Task Force (USPSTF) and colleagues.

The new recommendations (Ann. Intern. Med. 2008;148:214-9) are an update of those compiled by the task force in 2001 (Am. J. Prev. Med. 2001;20:59-61). They are based on an analysis of new evidence, conducted for the task force by Peggy Nygren of the Oregon Health and Science University, Portland, and her associates and funded by the Agency for Healthcare Research and Quality (Ann. Intern. Med. 2008;148:220-33).

The analysis addressed “previously identified gaps, such as the characterization of patients most likely to benefit from screening and the optimal timing of screening and treatment in pregnancy outcomes,” said Dr. Calonge, who is also chief medical officer of the Colorado Department of Public Health and Environment, Denver, and his colleagues.

Ms. Nygren and her associates noted the recent concerns that metronidazole, the antibiotic most commonly used to treat bacterial vaginosis, might increase preterm births in some populations. “The juxtaposition of these data, along with epidemiologic evidence associating bacterial vaginosis with preterm birth, leads to considerable confusion for clinicians and researchers alike. Whether to screen or treat multiple times, when to start, and at what interval during pregnancy are unanswered questions, as bacterial vaginosis may not necessarily persist throughout pregnancy,” they wrote.

The analysis included studies published after the release of the task force's 2001 recommendations to examine “new evidence on … screening and treating bacterial vaginosis in asymptomatic pregnant women.”

Asymptomatic patients were defined as those presenting for routine prenatal care and not for evaluation of vaginal discharge, odor, or itching. Low-risk patients were defined as having no history of and no risk factors for preterm delivery, whereas average-risk patients were defined as “the general population,” regardless of risk status. Women with a history of preterm delivery related to spontaneous rupture of membranes or spontaneous preterm labor were categorized as high risk.

The analysis found no benefit in treating women with low- or average-risk pregnancies if they were asymptomatic. For high-risk asymptomatic pregnancies, Ms. Nygren and her colleagues noted that findings from one trial that had been published since the USPSTF 2001 recommendations showed “a significant adverse effect of treatment on delivery before 37 weeks” in 127 women, “indicating that treatment of bacterial vaginosis increased the chance of preterm delivery” significantly (S. Afr. Med. J. 2002;92:231-4).

However, when this study was considered with previous studies that had been included in the 2001 recommendations, the results were “heterogenous and conflicting,” they wrote. For the outcome of delivery before 37 weeks, three of the trials reported a significant treatment benefit, one showed significant treatment harm, and one showed no benefit. “Inherent differences in populations, such as previous pregnancy complications, gestational age, ethnicity, or co-infection, may also influence which women are helped or harmed by screening and treatment for bacterial vaginosis,” they wrote, noting “a potential but unclear benefit of treatment for some [high-risk] patients.”

In keeping with the USPSTF recommendation against screening in low-risk pregnancies, the Centers for Disease Control and Prevention (CDC), the American Academy of Family Physicians (AAFP), the American College of Obstetricians and Gynecologists (ACOG), the Cochrane Pregnancy and Childbirth Group, the British Association for Sexual Health and HIV/Clinical Effectiveness Group (BASHH) have similar recommendations.

Although the task force maintains its neutral position regarding high-risk pregnancies, the CDC, ACOG, AAFP and BASHH say there might be high-risk women for whom screening and treatment may be beneficial, the USPSTF authors wrote, noting that optimal treatment for bacterial vaginosis in pregnancy remains unclear.

Electrocardiograms showing marked repolarization abnormalities in young athletes may predict their subsequent development of heart disease, according to Italian researchers.

“Contrary to previous reports describing such ECG patterns as innocent manifestations of 'athlete's heart' without adverse clinical consequences, the present study shows that these abnormal ECGs may represent the initial expression of genetic cardiac disease, preceding by many years phenotypic expression and adverse clinical outcomes,” wrote Dr. Antonio Pelliccia from the Institute of Sports Medicine and Science, Italian National Olympic Committee, Rome, and colleagues (N. Engl. J. Med. 2008;358:152-61).

The study included high-level athletes from the Italian Institute of Sports Medicine and Science database, all of whom are required by law to undergo preparticipation screening to rule out the presence of cardiovascular disease.

Of 12,880 athletes screened at the institute between 1979 and 2001, 81 were identified as having sufficient data showing marked repolarization abnormalities without evidence of structural heart disease, over a mean 10 years of serial clinical, ECG, and echocardiographic studies. A control group of 229 athletes of similar age, sex, and duration of follow-up was also selected from the same database. Marked repolarization abnormalities were defined as inverted T waves of 2 mm or more in depth in at least three leads (exclusive of standard lead III), and predominantly in the anterior and lateral precordial leads V2 through V6.

The 81 subjects in the study group included 63 men and 18 women, with a mean age of 23 years at their initial evaluation and 32 years at their most recent assessment. They were most commonly involved in soccer, rowing or canoeing, track and field, swimming, and cycling. They had participated in regular training and competition for a mean duration of 12 years, and 70% had achieved recognition at national or international events, including 14 who had participated in the Olympic Games. Among the 229 control subjects there were 157 men and 72 women who were a mean age of 22 years at initial evaluation. They participated in rowing or canoeing, soccer, water polo, track and field, shooting, and judo, and 80% had reached national or international levels of competition.

In the study group of 81 subjects with abnormal ECGs, evidence of cardiomyopathy developed in 5 (6%), and evidence of other cardiovascular disorders developed in 6 (7%) during the follow-up period, for a total of 11 subjects (14%), reported the authors. Among the five with evidence of cardiomyopathy, one died at age 24 years (1 year after the initial evaluation) from clinically undetected arrhythmogenic right ventricular cardiomyopathy.

Clinical and phenotypic features of hypertrophic cardiomyopathy developed in three other subjects (at ages 27, 32, and 50 years), including one who survived a cardiac arrest after 16 years of follow-up. The fifth athlete developed dilated cardiomyopathy over a 9-year follow-up.

Among the other six athletes in the study group who developed other cardiovascular conditions, there was systemic hypertension in three, atherosclerotic coronary artery disease (requiring bypass grafting) in one, myocarditis in one, and supraventricular tachycardia (requiring radiofrequency ablation) in one. The remaining 70 (86%) subjects in the study group had unremarkable clinical courses.

In contrast, there was no evidence of cardiomyopathy in any of the athletes in the control group over an average of 9 years of follow-up, and only four (2%) had evidence of other cardiovascular disorders. These included myocarditis in one athlete at age 19 years, 1 year after the initial evaluation; pericarditis in one athlete at age 28 years, 2 years after the initial evaluation; and supraventricular tachycardia in two athletes, identified after 2 and 3 years of follow-up.

“The negative predictive value of a normal ECG was 100% to exclude the development of cardiomyopathy and 98% to exclude the development of any cardiac abnormalities,” said the authors. “The positive predictive value of an abnormal ECG was 6% for cardiomyopathy and 14% for any cardiac condition.”

Although they noted that ECGs showing marked repolarization abnormalities “may be useful for identifying athletes at risk for the subsequent development of structural heart disease,” they suggested that such findings “underscore the importance of greater diagnostic scrutiny and continued clinical surveillance.” Serial ECG alone may not be sufficient for such surveillance, they added, suggesting “echocardiography and selective additional testing are necessary to clarify the cardiac diagnosis.” On the other hand, a normal ECG “can be regarded as reasonably reliable evidence to exclude the presence of potentially lethal cardiac disease,” they concluded.

Electrocardiograms showing marked repolarization abnormalities in young athletes may predict their subsequent development of heart disease, according to Italian researchers.

“Contrary to previous reports describing such ECG patterns as innocent manifestations of 'athlete's heart' without adverse clinical consequences, the present study shows that these abnormal ECGs may represent the initial expression of genetic cardiac disease, preceding by many years phenotypic expression and adverse clinical outcomes,” wrote Dr. Antonio Pelliccia from the Institute of Sports Medicine and Science, Italian National Olympic Committee, Rome, and colleagues (N. Engl. J. Med. 2008;358:152-61).

The study included high-level athletes from the Italian Institute of Sports Medicine and Science database, all of whom are required by law to undergo preparticipation screening to rule out the presence of cardiovascular disease.

Of 12,880 athletes screened at the institute between 1979 and 2001, 81 were identified as having sufficient data showing marked repolarization abnormalities without evidence of structural heart disease, over a mean 10 years of serial clinical, ECG, and echocardiographic studies. A control group of 229 athletes of similar age, sex, and duration of follow-up was also selected from the same database. Marked repolarization abnormalities were defined as inverted T waves of 2 mm or more in depth in at least three leads (exclusive of standard lead III), and predominantly in the anterior and lateral precordial leads V2 through V6.

The 81 subjects in the study group included 63 men and 18 women, with a mean age of 23 years at their initial evaluation and 32 years at their most recent assessment. They were most commonly involved in soccer, rowing or canoeing, track and field, swimming, and cycling. They had participated in regular training and competition for a mean duration of 12 years, and 70% had achieved recognition at national or international events, including 14 who had participated in the Olympic Games. Among the 229 control subjects there were 157 men and 72 women who were a mean age of 22 years at initial evaluation. They participated in rowing or canoeing, soccer, water polo, track and field, shooting, and judo, and 80% had reached national or international levels of competition.

In the study group of 81 subjects with abnormal ECGs, evidence of cardiomyopathy developed in 5 (6%), and evidence of other cardiovascular disorders developed in 6 (7%) during the follow-up period, for a total of 11 subjects (14%), reported the authors. Among the five with evidence of cardiomyopathy, one died at age 24 years (1 year after the initial evaluation) from clinically undetected arrhythmogenic right ventricular cardiomyopathy.

Clinical and phenotypic features of hypertrophic cardiomyopathy developed in three other subjects (at ages 27, 32, and 50 years), including one who survived a cardiac arrest after 16 years of follow-up. The fifth athlete developed dilated cardiomyopathy over a 9-year follow-up.

Among the other six athletes in the study group who developed other cardiovascular conditions, there was systemic hypertension in three, atherosclerotic coronary artery disease (requiring bypass grafting) in one, myocarditis in one, and supraventricular tachycardia (requiring radiofrequency ablation) in one. The remaining 70 (86%) subjects in the study group had unremarkable clinical courses.

In contrast, there was no evidence of cardiomyopathy in any of the athletes in the control group over an average of 9 years of follow-up, and only four (2%) had evidence of other cardiovascular disorders. These included myocarditis in one athlete at age 19 years, 1 year after the initial evaluation; pericarditis in one athlete at age 28 years, 2 years after the initial evaluation; and supraventricular tachycardia in two athletes, identified after 2 and 3 years of follow-up.

“The negative predictive value of a normal ECG was 100% to exclude the development of cardiomyopathy and 98% to exclude the development of any cardiac abnormalities,” said the authors. “The positive predictive value of an abnormal ECG was 6% for cardiomyopathy and 14% for any cardiac condition.”

Although they noted that ECGs showing marked repolarization abnormalities “may be useful for identifying athletes at risk for the subsequent development of structural heart disease,” they suggested that such findings “underscore the importance of greater diagnostic scrutiny and continued clinical surveillance.” Serial ECG alone may not be sufficient for such surveillance, they added, suggesting “echocardiography and selective additional testing are necessary to clarify the cardiac diagnosis.” On the other hand, a normal ECG “can be regarded as reasonably reliable evidence to exclude the presence of potentially lethal cardiac disease,” they concluded.

Electrocardiograms showing marked repolarization abnormalities in young athletes may predict their subsequent development of heart disease, according to Italian researchers.

“Contrary to previous reports describing such ECG patterns as innocent manifestations of 'athlete's heart' without adverse clinical consequences, the present study shows that these abnormal ECGs may represent the initial expression of genetic cardiac disease, preceding by many years phenotypic expression and adverse clinical outcomes,” wrote Dr. Antonio Pelliccia from the Institute of Sports Medicine and Science, Italian National Olympic Committee, Rome, and colleagues (N. Engl. J. Med. 2008;358:152-61).

The study included high-level athletes from the Italian Institute of Sports Medicine and Science database, all of whom are required by law to undergo preparticipation screening to rule out the presence of cardiovascular disease.

Of 12,880 athletes screened at the institute between 1979 and 2001, 81 were identified as having sufficient data showing marked repolarization abnormalities without evidence of structural heart disease, over a mean 10 years of serial clinical, ECG, and echocardiographic studies. A control group of 229 athletes of similar age, sex, and duration of follow-up was also selected from the same database. Marked repolarization abnormalities were defined as inverted T waves of 2 mm or more in depth in at least three leads (exclusive of standard lead III), and predominantly in the anterior and lateral precordial leads V2 through V6.

The 81 subjects in the study group included 63 men and 18 women, with a mean age of 23 years at their initial evaluation and 32 years at their most recent assessment. They were most commonly involved in soccer, rowing or canoeing, track and field, swimming, and cycling. They had participated in regular training and competition for a mean duration of 12 years, and 70% had achieved recognition at national or international events, including 14 who had participated in the Olympic Games. Among the 229 control subjects there were 157 men and 72 women who were a mean age of 22 years at initial evaluation. They participated in rowing or canoeing, soccer, water polo, track and field, shooting, and judo, and 80% had reached national or international levels of competition.

In the study group of 81 subjects with abnormal ECGs, evidence of cardiomyopathy developed in 5 (6%), and evidence of other cardiovascular disorders developed in 6 (7%) during the follow-up period, for a total of 11 subjects (14%), reported the authors. Among the five with evidence of cardiomyopathy, one died at age 24 years (1 year after the initial evaluation) from clinically undetected arrhythmogenic right ventricular cardiomyopathy.

Clinical and phenotypic features of hypertrophic cardiomyopathy developed in three other subjects (at ages 27, 32, and 50 years), including one who survived a cardiac arrest after 16 years of follow-up. The fifth athlete developed dilated cardiomyopathy over a 9-year follow-up.

Among the other six athletes in the study group who developed other cardiovascular conditions, there was systemic hypertension in three, atherosclerotic coronary artery disease (requiring bypass grafting) in one, myocarditis in one, and supraventricular tachycardia (requiring radiofrequency ablation) in one. The remaining 70 (86%) subjects in the study group had unremarkable clinical courses.

In contrast, there was no evidence of cardiomyopathy in any of the athletes in the control group over an average of 9 years of follow-up, and only four (2%) had evidence of other cardiovascular disorders. These included myocarditis in one athlete at age 19 years, 1 year after the initial evaluation; pericarditis in one athlete at age 28 years, 2 years after the initial evaluation; and supraventricular tachycardia in two athletes, identified after 2 and 3 years of follow-up.

“The negative predictive value of a normal ECG was 100% to exclude the development of cardiomyopathy and 98% to exclude the development of any cardiac abnormalities,” said the authors. “The positive predictive value of an abnormal ECG was 6% for cardiomyopathy and 14% for any cardiac condition.”

Although they noted that ECGs showing marked repolarization abnormalities “may be useful for identifying athletes at risk for the subsequent development of structural heart disease,” they suggested that such findings “underscore the importance of greater diagnostic scrutiny and continued clinical surveillance.” Serial ECG alone may not be sufficient for such surveillance, they added, suggesting “echocardiography and selective additional testing are necessary to clarify the cardiac diagnosis.” On the other hand, a normal ECG “can be regarded as reasonably reliable evidence to exclude the presence of potentially lethal cardiac disease,” they concluded.