Kate Johnson

TORONTO — A designated care coordinator can significantly improve the management of children and youth with special health care needs, Mary Krauthoefer said at the annual meeting of the Pediatric Academic Societies.

“Complex, medically fragile children with special health care needs require thorough communication and coordination among providers, which are best directed through the primary care setting,” said Ms. Krauthoefer, case manager at Children's Hospital of Wisconsin in Milwaukee. “But this [service] is time consuming and poorly reimbursed, making it difficult for primary care physicians alone to provide medical homes for this population.”

Care coordination provided by a pediatric nurse manager at the Children's Hospital of Wisconsin resulted in more efficient and effective use of resources among these complex patients, according to study results Ms. Krauthoefer presented at the meeting.

She described a Special Needs Program, set up by the hospital, which was established to partner with families and primary care physicians to ensure care coordination. A pediatric nurse manager served as the tertiary center care coordinator for 219 patients with special health care needs enrolled in the program. All patients met complexity and fragility criteria—the presence of five or more specialists, uncertain or multiple diagnoses, use of multiple community services, and frequent visits to a hospital and clinic.

In examining resource utilization among the patients during equal time periods both before and after the implementation of care coordination, the investigators found care coordination resulted in a decreased number of hospital days and an increased number of clinic visits, indicating a shift from inpatient to outpatient care. Hospital length of stay for all patients combined declined by a total of 2,790 days; outpatient clinic visits increased by a total of 1,878 days. There were approximately the same number of hospital admissions as before. Hospital charges and payments decreased by $2.8 million and $2.7 million, respectively.

Surveys of families and patients' primary care physicians indicated a high level of satisfaction with the care coordination initiative, Ms. Krauthoefer said.

TORONTO — A designated care coordinator can significantly improve the management of children and youth with special health care needs, Mary Krauthoefer said at the annual meeting of the Pediatric Academic Societies.

“Complex, medically fragile children with special health care needs require thorough communication and coordination among providers, which are best directed through the primary care setting,” said Ms. Krauthoefer, case manager at Children's Hospital of Wisconsin in Milwaukee. “But this [service] is time consuming and poorly reimbursed, making it difficult for primary care physicians alone to provide medical homes for this population.”

Care coordination provided by a pediatric nurse manager at the Children's Hospital of Wisconsin resulted in more efficient and effective use of resources among these complex patients, according to study results Ms. Krauthoefer presented at the meeting.

She described a Special Needs Program, set up by the hospital, which was established to partner with families and primary care physicians to ensure care coordination. A pediatric nurse manager served as the tertiary center care coordinator for 219 patients with special health care needs enrolled in the program. All patients met complexity and fragility criteria—the presence of five or more specialists, uncertain or multiple diagnoses, use of multiple community services, and frequent visits to a hospital and clinic.

In examining resource utilization among the patients during equal time periods both before and after the implementation of care coordination, the investigators found care coordination resulted in a decreased number of hospital days and an increased number of clinic visits, indicating a shift from inpatient to outpatient care. Hospital length of stay for all patients combined declined by a total of 2,790 days; outpatient clinic visits increased by a total of 1,878 days. There were approximately the same number of hospital admissions as before. Hospital charges and payments decreased by $2.8 million and $2.7 million, respectively.

Surveys of families and patients' primary care physicians indicated a high level of satisfaction with the care coordination initiative, Ms. Krauthoefer said.

TORONTO — A designated care coordinator can significantly improve the management of children and youth with special health care needs, Mary Krauthoefer said at the annual meeting of the Pediatric Academic Societies.

“Complex, medically fragile children with special health care needs require thorough communication and coordination among providers, which are best directed through the primary care setting,” said Ms. Krauthoefer, case manager at Children's Hospital of Wisconsin in Milwaukee. “But this [service] is time consuming and poorly reimbursed, making it difficult for primary care physicians alone to provide medical homes for this population.”

Care coordination provided by a pediatric nurse manager at the Children's Hospital of Wisconsin resulted in more efficient and effective use of resources among these complex patients, according to study results Ms. Krauthoefer presented at the meeting.

She described a Special Needs Program, set up by the hospital, which was established to partner with families and primary care physicians to ensure care coordination. A pediatric nurse manager served as the tertiary center care coordinator for 219 patients with special health care needs enrolled in the program. All patients met complexity and fragility criteria—the presence of five or more specialists, uncertain or multiple diagnoses, use of multiple community services, and frequent visits to a hospital and clinic.

In examining resource utilization among the patients during equal time periods both before and after the implementation of care coordination, the investigators found care coordination resulted in a decreased number of hospital days and an increased number of clinic visits, indicating a shift from inpatient to outpatient care. Hospital length of stay for all patients combined declined by a total of 2,790 days; outpatient clinic visits increased by a total of 1,878 days. There were approximately the same number of hospital admissions as before. Hospital charges and payments decreased by $2.8 million and $2.7 million, respectively.

Surveys of families and patients' primary care physicians indicated a high level of satisfaction with the care coordination initiative, Ms. Krauthoefer said.

TORONTO — Cognitive impairment in patients who have childhood-onset systemic lupus erythematosus can be identified with functional magnetic resonance imaging, reported Svetlana Lvovich, D.O., in a poster presentation at the annual meeting of the Pediatric Academic Societies.

The pilot study, which was done by Dr. Lvovich and her associates, included 10 patients who had systemic lupus erythematosus (SLE). Five of the patients had cognitive impairment (CI), and five of them did not have CI.

Functional magnetic resonance imaging (fMRI) showed differences between the patients with CI and those without.

“They [those with CI] need to recruit more neurons to do the task,” she said in an interview. The three tasks that patients were required to perform during fMRI were specially designed to evaluate attention, working memory, and language processing.

Neuropsychiatric testing is the preferred method for diagnosing CI in SLE patients. However, it is time consuming and it requires extensive training to be able to administer it, said Dr. Lvovich of the Cincinnati Children's Hospital Medical Center.

In contrast, fMRI is quick and easy to perform.

There also were subtle fMRI differences seen between SLE patients with normal cognition, compared with healthy controls, which suggested that it is SLE-specific processes that contribute to CI rather than the long-term use of steroids,” she noted.

“However, to determine this, we will need to look at patients who are on steroids but don't have SLE,” she said.

“We think that fMRI may be useful to investigate and identify cortical roots of cognitive impairment in children with SLE,” she concluded.

TORONTO — Cognitive impairment in patients who have childhood-onset systemic lupus erythematosus can be identified with functional magnetic resonance imaging, reported Svetlana Lvovich, D.O., in a poster presentation at the annual meeting of the Pediatric Academic Societies.

The pilot study, which was done by Dr. Lvovich and her associates, included 10 patients who had systemic lupus erythematosus (SLE). Five of the patients had cognitive impairment (CI), and five of them did not have CI.

Functional magnetic resonance imaging (fMRI) showed differences between the patients with CI and those without.

“They [those with CI] need to recruit more neurons to do the task,” she said in an interview. The three tasks that patients were required to perform during fMRI were specially designed to evaluate attention, working memory, and language processing.

Neuropsychiatric testing is the preferred method for diagnosing CI in SLE patients. However, it is time consuming and it requires extensive training to be able to administer it, said Dr. Lvovich of the Cincinnati Children's Hospital Medical Center.

In contrast, fMRI is quick and easy to perform.

There also were subtle fMRI differences seen between SLE patients with normal cognition, compared with healthy controls, which suggested that it is SLE-specific processes that contribute to CI rather than the long-term use of steroids,” she noted.

“However, to determine this, we will need to look at patients who are on steroids but don't have SLE,” she said.

“We think that fMRI may be useful to investigate and identify cortical roots of cognitive impairment in children with SLE,” she concluded.

TORONTO — Cognitive impairment in patients who have childhood-onset systemic lupus erythematosus can be identified with functional magnetic resonance imaging, reported Svetlana Lvovich, D.O., in a poster presentation at the annual meeting of the Pediatric Academic Societies.

The pilot study, which was done by Dr. Lvovich and her associates, included 10 patients who had systemic lupus erythematosus (SLE). Five of the patients had cognitive impairment (CI), and five of them did not have CI.

Functional magnetic resonance imaging (fMRI) showed differences between the patients with CI and those without.

“They [those with CI] need to recruit more neurons to do the task,” she said in an interview. The three tasks that patients were required to perform during fMRI were specially designed to evaluate attention, working memory, and language processing.

Neuropsychiatric testing is the preferred method for diagnosing CI in SLE patients. However, it is time consuming and it requires extensive training to be able to administer it, said Dr. Lvovich of the Cincinnati Children's Hospital Medical Center.

In contrast, fMRI is quick and easy to perform.

There also were subtle fMRI differences seen between SLE patients with normal cognition, compared with healthy controls, which suggested that it is SLE-specific processes that contribute to CI rather than the long-term use of steroids,” she noted.

“However, to determine this, we will need to look at patients who are on steroids but don't have SLE,” she said.

“We think that fMRI may be useful to investigate and identify cortical roots of cognitive impairment in children with SLE,” she concluded.

MONTREAL — Although influenza vaccination continues to be underutilized, it is a success story compared with the use of influenza antiviral medications, experts agreed at an international conference on community-acquired pneumonia.

Medications such as zanamivir and oseltamivir can prevent or greatly reduce the major symptoms and sequelae of influenza, including community-acquired pneumonia, yet they do not currently play a central role in influenza management.

“As long as the bean counters are practicing medicine without a license, this is not going to improve,” said Dr. Grant Stiver, professor of medicine and head of infectious diseases at the University of British Columbia, Vancouver. “We put out money for heart transplants in 75-year-old men because we can see they are dying of heart failure, but to put out money for prophylaxis … seems to be a big stumbling block.”

Besides lack of resources to promote the use of influenza antivirals, there is also a lack of awareness, both in the general public and within the medical community.

“Physicians are very reluctant to prescribe antivirals, and the message to patients has been don't go to the doctor if you have a virus,” said Dr. Karl Weiss of the University of Montreal. “We have a long way to go to educate physicians and also the public,” he said at the meeting, which was sponsored by the International Society of Chemotherapy.

“It's a different paradigm. We were all taught in school that there's nothing you can do for a viral infection, but these drugs work, and the faster we use them after symptom onset the better they work,” Dr. Stiver agreed in an interview. And although clinical trials suggest minimal benefits if antivirals are administered more than 36 hours after symptom onset, the window is likely even shorter.

“There are very significant differences between using them at 36 hours and using them at 12 hours or even 24 hours,” he said, noting that a 3-day reduction in symptoms has been shown when the medications are administered within 12 hours. This tight window of opportunity is a major barrier to the medications' widespread use, he said. “Most patients who develop an acute febrile illness, unless they're very, very sick, don't see a doctor for 48 or 36 hours, so it's a matter of education of the public that there is something available.”

He suggested that in the event of an influenza epidemic, a better system needs to be in place to help patients access antivirals quickly. “You can't do this through doctors' offices. There must be some kind of algorithm set up whereby in major epidemics patients can receive the medication through pharmacies with some prearranged prescription from their physician.” This would have to be directed by a public health alert to prevent patients from stockpiling or self-prescribing to treat other noninfluenza viruses, he said.

MONTREAL — Although influenza vaccination continues to be underutilized, it is a success story compared with the use of influenza antiviral medications, experts agreed at an international conference on community-acquired pneumonia.

Medications such as zanamivir and oseltamivir can prevent or greatly reduce the major symptoms and sequelae of influenza, including community-acquired pneumonia, yet they do not currently play a central role in influenza management.

“As long as the bean counters are practicing medicine without a license, this is not going to improve,” said Dr. Grant Stiver, professor of medicine and head of infectious diseases at the University of British Columbia, Vancouver. “We put out money for heart transplants in 75-year-old men because we can see they are dying of heart failure, but to put out money for prophylaxis … seems to be a big stumbling block.”

Besides lack of resources to promote the use of influenza antivirals, there is also a lack of awareness, both in the general public and within the medical community.

“Physicians are very reluctant to prescribe antivirals, and the message to patients has been don't go to the doctor if you have a virus,” said Dr. Karl Weiss of the University of Montreal. “We have a long way to go to educate physicians and also the public,” he said at the meeting, which was sponsored by the International Society of Chemotherapy.

“It's a different paradigm. We were all taught in school that there's nothing you can do for a viral infection, but these drugs work, and the faster we use them after symptom onset the better they work,” Dr. Stiver agreed in an interview. And although clinical trials suggest minimal benefits if antivirals are administered more than 36 hours after symptom onset, the window is likely even shorter.

“There are very significant differences between using them at 36 hours and using them at 12 hours or even 24 hours,” he said, noting that a 3-day reduction in symptoms has been shown when the medications are administered within 12 hours. This tight window of opportunity is a major barrier to the medications' widespread use, he said. “Most patients who develop an acute febrile illness, unless they're very, very sick, don't see a doctor for 48 or 36 hours, so it's a matter of education of the public that there is something available.”

He suggested that in the event of an influenza epidemic, a better system needs to be in place to help patients access antivirals quickly. “You can't do this through doctors' offices. There must be some kind of algorithm set up whereby in major epidemics patients can receive the medication through pharmacies with some prearranged prescription from their physician.” This would have to be directed by a public health alert to prevent patients from stockpiling or self-prescribing to treat other noninfluenza viruses, he said.

MONTREAL — Although influenza vaccination continues to be underutilized, it is a success story compared with the use of influenza antiviral medications, experts agreed at an international conference on community-acquired pneumonia.

Medications such as zanamivir and oseltamivir can prevent or greatly reduce the major symptoms and sequelae of influenza, including community-acquired pneumonia, yet they do not currently play a central role in influenza management.

“As long as the bean counters are practicing medicine without a license, this is not going to improve,” said Dr. Grant Stiver, professor of medicine and head of infectious diseases at the University of British Columbia, Vancouver. “We put out money for heart transplants in 75-year-old men because we can see they are dying of heart failure, but to put out money for prophylaxis … seems to be a big stumbling block.”

Besides lack of resources to promote the use of influenza antivirals, there is also a lack of awareness, both in the general public and within the medical community.

“Physicians are very reluctant to prescribe antivirals, and the message to patients has been don't go to the doctor if you have a virus,” said Dr. Karl Weiss of the University of Montreal. “We have a long way to go to educate physicians and also the public,” he said at the meeting, which was sponsored by the International Society of Chemotherapy.

“It's a different paradigm. We were all taught in school that there's nothing you can do for a viral infection, but these drugs work, and the faster we use them after symptom onset the better they work,” Dr. Stiver agreed in an interview. And although clinical trials suggest minimal benefits if antivirals are administered more than 36 hours after symptom onset, the window is likely even shorter.

“There are very significant differences between using them at 36 hours and using them at 12 hours or even 24 hours,” he said, noting that a 3-day reduction in symptoms has been shown when the medications are administered within 12 hours. This tight window of opportunity is a major barrier to the medications' widespread use, he said. “Most patients who develop an acute febrile illness, unless they're very, very sick, don't see a doctor for 48 or 36 hours, so it's a matter of education of the public that there is something available.”

He suggested that in the event of an influenza epidemic, a better system needs to be in place to help patients access antivirals quickly. “You can't do this through doctors' offices. There must be some kind of algorithm set up whereby in major epidemics patients can receive the medication through pharmacies with some prearranged prescription from their physician.” This would have to be directed by a public health alert to prevent patients from stockpiling or self-prescribing to treat other noninfluenza viruses, he said.

LYON, FRANCE – Compared with spontaneously conceived twins, twins who are conceived through assisted reproductive technology have an increased rate of umbilical cord abnormalities, according to the first large study to assess this. And the incidence of such abnormalities increases with the invasiveness of the fertility treatment, said lead investigator Ilse Delbaere, a Ph.D. student at University Hospital Ghent, Belgium.

“The umbilical cord characteristics that have been associated with adverse outcomes are seen more frequently after ART [assisted reproductive technology],” she said at the annual meeting of the European Society for Human Reproduction and Embryology. “Considering the effect of cord abnormalities in twin pregnancies after ART may further our understanding of the underlying mechanism responsible for adverse outcomes after ART,” she suggested.

The study compared umbilical cord characteristics in 2,119 spontaneously conceived dizygotic twins and 2,243 dizygotic twins who had been conceived with ART. The incidence of velamentous cord insertion–which has been associated with preterm delivery, low birth weight, fetal growth retardation, and malformations–was 3.6% in spontaneously conceived twins but was roughly doubled (7.4%) in twins conceived with in vitro fertilization (IVF) and tripled (10.4%) in twins conceived with intracytoplasmic sperm injection (ICSI), Ms. Delbaere said. Moreover, the incidence of single umbilical artery (SUA), was significantly higher in twins conceived through ovulation induction (1.9% vs. 0.6%). It was also higher in IVF and ICSI twins, but the difference did not reach significance, she said.

The findings support the trophotropism theory that placental migration is more common in twin pregnancies because of competition for nourishment. ART twin pregnancies are particularly vulnerable because 80% of ART embryos implant near the transfer location, “which is not always ideal,” she said. “The placenta may migrate to more favorable areas, turning an initial central insertion of the cord into something more peripheral.” She hopes to follow up her research by adjusting for cord abnormalities in ART twins to assess whether adverse outcomes are still more common in them than in spontaneously conceived twins.

LYON, FRANCE – Compared with spontaneously conceived twins, twins who are conceived through assisted reproductive technology have an increased rate of umbilical cord abnormalities, according to the first large study to assess this. And the incidence of such abnormalities increases with the invasiveness of the fertility treatment, said lead investigator Ilse Delbaere, a Ph.D. student at University Hospital Ghent, Belgium.

“The umbilical cord characteristics that have been associated with adverse outcomes are seen more frequently after ART [assisted reproductive technology],” she said at the annual meeting of the European Society for Human Reproduction and Embryology. “Considering the effect of cord abnormalities in twin pregnancies after ART may further our understanding of the underlying mechanism responsible for adverse outcomes after ART,” she suggested.

The study compared umbilical cord characteristics in 2,119 spontaneously conceived dizygotic twins and 2,243 dizygotic twins who had been conceived with ART. The incidence of velamentous cord insertion–which has been associated with preterm delivery, low birth weight, fetal growth retardation, and malformations–was 3.6% in spontaneously conceived twins but was roughly doubled (7.4%) in twins conceived with in vitro fertilization (IVF) and tripled (10.4%) in twins conceived with intracytoplasmic sperm injection (ICSI), Ms. Delbaere said. Moreover, the incidence of single umbilical artery (SUA), was significantly higher in twins conceived through ovulation induction (1.9% vs. 0.6%). It was also higher in IVF and ICSI twins, but the difference did not reach significance, she said.

The findings support the trophotropism theory that placental migration is more common in twin pregnancies because of competition for nourishment. ART twin pregnancies are particularly vulnerable because 80% of ART embryos implant near the transfer location, “which is not always ideal,” she said. “The placenta may migrate to more favorable areas, turning an initial central insertion of the cord into something more peripheral.” She hopes to follow up her research by adjusting for cord abnormalities in ART twins to assess whether adverse outcomes are still more common in them than in spontaneously conceived twins.

LYON, FRANCE – Compared with spontaneously conceived twins, twins who are conceived through assisted reproductive technology have an increased rate of umbilical cord abnormalities, according to the first large study to assess this. And the incidence of such abnormalities increases with the invasiveness of the fertility treatment, said lead investigator Ilse Delbaere, a Ph.D. student at University Hospital Ghent, Belgium.

“The umbilical cord characteristics that have been associated with adverse outcomes are seen more frequently after ART [assisted reproductive technology],” she said at the annual meeting of the European Society for Human Reproduction and Embryology. “Considering the effect of cord abnormalities in twin pregnancies after ART may further our understanding of the underlying mechanism responsible for adverse outcomes after ART,” she suggested.

The study compared umbilical cord characteristics in 2,119 spontaneously conceived dizygotic twins and 2,243 dizygotic twins who had been conceived with ART. The incidence of velamentous cord insertion–which has been associated with preterm delivery, low birth weight, fetal growth retardation, and malformations–was 3.6% in spontaneously conceived twins but was roughly doubled (7.4%) in twins conceived with in vitro fertilization (IVF) and tripled (10.4%) in twins conceived with intracytoplasmic sperm injection (ICSI), Ms. Delbaere said. Moreover, the incidence of single umbilical artery (SUA), was significantly higher in twins conceived through ovulation induction (1.9% vs. 0.6%). It was also higher in IVF and ICSI twins, but the difference did not reach significance, she said.

The findings support the trophotropism theory that placental migration is more common in twin pregnancies because of competition for nourishment. ART twin pregnancies are particularly vulnerable because 80% of ART embryos implant near the transfer location, “which is not always ideal,” she said. “The placenta may migrate to more favorable areas, turning an initial central insertion of the cord into something more peripheral.” She hopes to follow up her research by adjusting for cord abnormalities in ART twins to assess whether adverse outcomes are still more common in them than in spontaneously conceived twins.

LYON, FRANCE – Europe's focus on avoiding twins from in vitro fertilization may be inappropriate for the United States, suggests Dr. David Adamson, director of Fertility Physicians of Northern California.

Single embryo transfer (SET) has been mandated in many European countries as a means of virtually eliminating twins, but many studies show that in the hands of most fertility specialists, SET results in fewer pregnancies and babies than transfer of two or more embryos, he said in an interview at the annual meeting of the European Society of Human Reproduction and Embryology.

“We have to individualize our approach to each patient, and therefore I don't think [SET] should be regulated by government,” Dr. Adamson said. “A twin outcome, while not optimal by any means–and we want to avoid it if at all possible–is not invariably a bad outcome, and very commonly it's been a good outcome.”

Dr. Adamson touched on the root of the Europe-U.S. rivalry over IVF success rates. While experts at the meeting debated the often microscopic details of IVF, the big picture–the “take-home baby rate”–remained conspicuously out of focus. At a sparsely attended early-morning session, Dr. Jacques Mouzon reported the latest figures (2003) from the International Committee for Monitoring Assisted Reproduction: Europe's overall IVF take-home baby rate was 23% (per egg retrieval), compared with 38% for the United States, said Dr. Mouzon of Institut National de la Santé et de la Recherche Médicale in Paris.

Traditionally lagging behind the United States in this ultimate measurement of IVF success, many European experts say America's higher “take-home baby rate” comes at an unacceptable price: high numbers of twins and triplets, who face poor health outcomes at a steep cost to society. In contrast, they emphasize their impressively low rate of multiple pregnancies.

The latest figures from ESHRE show that in 2004, across Europe, SET was performed in 19% of IVF cycles. Out of all IVF cycles performed, the twin and triplet birth rates were 21.7% and 1.0%, respectively, reported ESHRE spokesman Dr. Anders Nyboe Andersen of Rigshospitalet in Copenhagen. Elsewhere at the meeting it was reported that some individual European countries such as Sweden have a 70% SET rate and have reduced their twin rate practically to zero (OB.GYN. NEWS, July 15, 2007, p. 6).

In contrast, U.S. (2004) figures from the Society for Assisted Reproductive Technology show that SET, in women under age 35, was performed in only 1.2% of cycles, with the twin and triplet pregnancy rate clocking in at 32.7% and 4.9%.

Many experts acknowledge that cost plays a big role in the contrast between continents. National health systems cover IVF treatment in many European countries, which means they can mandate strict policies limiting the number of embryos transferred–and patients accept. In contrast Americans, paying out of pocket at $9,000-$15,000 per IVF cycle (including drugs and all costs), are not so keen to accept only one embryo per transfer.

“There's no question that when patients are paying for it, they really are looking for success on the first cycle,” said Dr. Adamson, who practices in Palo Alto, Calif. In this context, an overenthusiastic use of SET to avoid twins may not be appropriate in the United States, not only because it may reduce the chances of pregnancy, but also because a twin outcome is not entirely undesirable, he said.

“One of my major arguments is you have to look at the benefits of having a child, and there's a benefit to having an extra child, especially if that child is healthy and even, possibly, if that child is not healthy,” he said. “You can't just look at the costs of twins, which are clearly higher, and that the portion of twins that are healthy is a little bit lower, but at the end of the day most twin pregnancies end up with two healthy babies. Such twin pregnancies definitely create a benefit for the family, the children, and society.” Nevertheless, Dr. Adamson emphasized that the ideal outcome, and always the goal, is a healthy singleton pregnancy.

Studies have shown that getting two babies for the price of one IVF cycle is an attractive idea to many patients, regardless of cost, since for many the price of infertility treatment goes beyond money. “What we have to strive for is the best information so we can share it with the patients, and they can be well informed when they elect to undergo these procedures and decide how they want to invest their time, money, and emotional effort,” Dr. Adamson said. “We have to try to find a balance. All reproduction is inherently risky … it's a question of balancing known risks and potential risks versus the expected benefit.”

LYON, FRANCE – Europe's focus on avoiding twins from in vitro fertilization may be inappropriate for the United States, suggests Dr. David Adamson, director of Fertility Physicians of Northern California.

Single embryo transfer (SET) has been mandated in many European countries as a means of virtually eliminating twins, but many studies show that in the hands of most fertility specialists, SET results in fewer pregnancies and babies than transfer of two or more embryos, he said in an interview at the annual meeting of the European Society of Human Reproduction and Embryology.

“We have to individualize our approach to each patient, and therefore I don't think [SET] should be regulated by government,” Dr. Adamson said. “A twin outcome, while not optimal by any means–and we want to avoid it if at all possible–is not invariably a bad outcome, and very commonly it's been a good outcome.”

Dr. Adamson touched on the root of the Europe-U.S. rivalry over IVF success rates. While experts at the meeting debated the often microscopic details of IVF, the big picture–the “take-home baby rate”–remained conspicuously out of focus. At a sparsely attended early-morning session, Dr. Jacques Mouzon reported the latest figures (2003) from the International Committee for Monitoring Assisted Reproduction: Europe's overall IVF take-home baby rate was 23% (per egg retrieval), compared with 38% for the United States, said Dr. Mouzon of Institut National de la Santé et de la Recherche Médicale in Paris.

Traditionally lagging behind the United States in this ultimate measurement of IVF success, many European experts say America's higher “take-home baby rate” comes at an unacceptable price: high numbers of twins and triplets, who face poor health outcomes at a steep cost to society. In contrast, they emphasize their impressively low rate of multiple pregnancies.

The latest figures from ESHRE show that in 2004, across Europe, SET was performed in 19% of IVF cycles. Out of all IVF cycles performed, the twin and triplet birth rates were 21.7% and 1.0%, respectively, reported ESHRE spokesman Dr. Anders Nyboe Andersen of Rigshospitalet in Copenhagen. Elsewhere at the meeting it was reported that some individual European countries such as Sweden have a 70% SET rate and have reduced their twin rate practically to zero (OB.GYN. NEWS, July 15, 2007, p. 6).

In contrast, U.S. (2004) figures from the Society for Assisted Reproductive Technology show that SET, in women under age 35, was performed in only 1.2% of cycles, with the twin and triplet pregnancy rate clocking in at 32.7% and 4.9%.

Many experts acknowledge that cost plays a big role in the contrast between continents. National health systems cover IVF treatment in many European countries, which means they can mandate strict policies limiting the number of embryos transferred–and patients accept. In contrast Americans, paying out of pocket at $9,000-$15,000 per IVF cycle (including drugs and all costs), are not so keen to accept only one embryo per transfer.

“There's no question that when patients are paying for it, they really are looking for success on the first cycle,” said Dr. Adamson, who practices in Palo Alto, Calif. In this context, an overenthusiastic use of SET to avoid twins may not be appropriate in the United States, not only because it may reduce the chances of pregnancy, but also because a twin outcome is not entirely undesirable, he said.

“One of my major arguments is you have to look at the benefits of having a child, and there's a benefit to having an extra child, especially if that child is healthy and even, possibly, if that child is not healthy,” he said. “You can't just look at the costs of twins, which are clearly higher, and that the portion of twins that are healthy is a little bit lower, but at the end of the day most twin pregnancies end up with two healthy babies. Such twin pregnancies definitely create a benefit for the family, the children, and society.” Nevertheless, Dr. Adamson emphasized that the ideal outcome, and always the goal, is a healthy singleton pregnancy.

Studies have shown that getting two babies for the price of one IVF cycle is an attractive idea to many patients, regardless of cost, since for many the price of infertility treatment goes beyond money. “What we have to strive for is the best information so we can share it with the patients, and they can be well informed when they elect to undergo these procedures and decide how they want to invest their time, money, and emotional effort,” Dr. Adamson said. “We have to try to find a balance. All reproduction is inherently risky … it's a question of balancing known risks and potential risks versus the expected benefit.”

LYON, FRANCE – Europe's focus on avoiding twins from in vitro fertilization may be inappropriate for the United States, suggests Dr. David Adamson, director of Fertility Physicians of Northern California.

Single embryo transfer (SET) has been mandated in many European countries as a means of virtually eliminating twins, but many studies show that in the hands of most fertility specialists, SET results in fewer pregnancies and babies than transfer of two or more embryos, he said in an interview at the annual meeting of the European Society of Human Reproduction and Embryology.

“We have to individualize our approach to each patient, and therefore I don't think [SET] should be regulated by government,” Dr. Adamson said. “A twin outcome, while not optimal by any means–and we want to avoid it if at all possible–is not invariably a bad outcome, and very commonly it's been a good outcome.”

Dr. Adamson touched on the root of the Europe-U.S. rivalry over IVF success rates. While experts at the meeting debated the often microscopic details of IVF, the big picture–the “take-home baby rate”–remained conspicuously out of focus. At a sparsely attended early-morning session, Dr. Jacques Mouzon reported the latest figures (2003) from the International Committee for Monitoring Assisted Reproduction: Europe's overall IVF take-home baby rate was 23% (per egg retrieval), compared with 38% for the United States, said Dr. Mouzon of Institut National de la Santé et de la Recherche Médicale in Paris.

Traditionally lagging behind the United States in this ultimate measurement of IVF success, many European experts say America's higher “take-home baby rate” comes at an unacceptable price: high numbers of twins and triplets, who face poor health outcomes at a steep cost to society. In contrast, they emphasize their impressively low rate of multiple pregnancies.

The latest figures from ESHRE show that in 2004, across Europe, SET was performed in 19% of IVF cycles. Out of all IVF cycles performed, the twin and triplet birth rates were 21.7% and 1.0%, respectively, reported ESHRE spokesman Dr. Anders Nyboe Andersen of Rigshospitalet in Copenhagen. Elsewhere at the meeting it was reported that some individual European countries such as Sweden have a 70% SET rate and have reduced their twin rate practically to zero (OB.GYN. NEWS, July 15, 2007, p. 6).

In contrast, U.S. (2004) figures from the Society for Assisted Reproductive Technology show that SET, in women under age 35, was performed in only 1.2% of cycles, with the twin and triplet pregnancy rate clocking in at 32.7% and 4.9%.

Many experts acknowledge that cost plays a big role in the contrast between continents. National health systems cover IVF treatment in many European countries, which means they can mandate strict policies limiting the number of embryos transferred–and patients accept. In contrast Americans, paying out of pocket at $9,000-$15,000 per IVF cycle (including drugs and all costs), are not so keen to accept only one embryo per transfer.

“There's no question that when patients are paying for it, they really are looking for success on the first cycle,” said Dr. Adamson, who practices in Palo Alto, Calif. In this context, an overenthusiastic use of SET to avoid twins may not be appropriate in the United States, not only because it may reduce the chances of pregnancy, but also because a twin outcome is not entirely undesirable, he said.

“One of my major arguments is you have to look at the benefits of having a child, and there's a benefit to having an extra child, especially if that child is healthy and even, possibly, if that child is not healthy,” he said. “You can't just look at the costs of twins, which are clearly higher, and that the portion of twins that are healthy is a little bit lower, but at the end of the day most twin pregnancies end up with two healthy babies. Such twin pregnancies definitely create a benefit for the family, the children, and society.” Nevertheless, Dr. Adamson emphasized that the ideal outcome, and always the goal, is a healthy singleton pregnancy.

Studies have shown that getting two babies for the price of one IVF cycle is an attractive idea to many patients, regardless of cost, since for many the price of infertility treatment goes beyond money. “What we have to strive for is the best information so we can share it with the patients, and they can be well informed when they elect to undergo these procedures and decide how they want to invest their time, money, and emotional effort,” Dr. Adamson said. “We have to try to find a balance. All reproduction is inherently risky … it's a question of balancing known risks and potential risks versus the expected benefit.”

For patients with peripheral arterial disease, there is substantial risk and no benefit to combining antiplatelet and anticoagulation therapy, according to the results of a large randomized trial.

“We found that combination therapy was not more effective than antiplatelet therapy alone in preventing major cardiovascular complications and was associated with a substantial increase in the risk of life-threatening bleeding,” wrote Dr. Sonia Anand of McMaster University, Hamilton, Ont., and her coinvestigators on the Warfarin Antiplatelet Vascular Evaluation (WAVE) trial (N. Engl. J. Med. 2007;357:217–27).

“The totality of evidence shows clearly that the addition of an anticoagulant to an antiplatelet drug results in increased rates of bleeding complications,” wrote Dr. Emile Mohler III of the University of Pennsylvania, Philadelphia, in an editorial appearing in the same issue of the journal (N. Engl. J. Med. 2007;357:293–6).

The trial compared outcomes in 1,081 patients randomized to antiplatelet therapy alone and 1,080 patients randomized to a combination of antiplatelet and oral anticoagulant therapy. The mean age of the patients was 64 years, 74% were male, and the mean follow-up time was 35 months.

There were two coprimary composite outcomes: The first was myocardial infarction, stroke, or death from cardiovascular causes; the second was MI, stroke, severe ischemia of the peripheral or coronary arteries leading to urgent intervention, or death from cardiovascular causes. The safety outcomes were life-threatening, moderate, or minor bleeding episodes.

No significant differences were observed between groups for either of the primary outcomes. The first end point occurred in 12.2% of the combination group and 13.3% of the antiplatelet group (relative risk [RR] 0.92), whereas the second end point occurred in 15.9% of the combination group and 17.4% of the antiplatelet group (RR 0.91).

The differences emerged in the safety outcomes. Compared with the antiplatelet group, the combination group showed increases in both life-threatening bleeding (4.0% vs. 1.2%, RR 3.41) and moderate bleeding (2.9% vs. 1.0%, RR 2.82).

“According to our data, treating 1,000 patients with combination therapy as compared with antiplatelet therapy alone for 3 years would lead to 24 fewer cardiovascular events but 28 more episodes of life-threatening bleeding, resulting in a net increase in serious adverse outcomes,” wrote Dr. Anand and her coauthors.

WAVE's findings of increased bleeding associated with combination therapy (as opposed to antiplatelet therapy alone) differ from a similar comparison of treatments in patients with coronary artery disease (N. Engl. J. Med. 2002;347:9609–74) but are consistent with the results of another trial involving patients with peripheral arterial disease (Lancet 2000;355:346–51), the investigators noted.

“Therefore, it appears that patients with peripheral arterial disease who are treated with oral anticoagulation may be more likely to have bleeding complications … than are patients with coronary artery disease.” The reasons for this difference may be that patients with peripheral arterial disease are older, have more systemic atherosclerosis (including cerebrovascular disease), and have more coexisting conditions, they suggested.

The authors noted that the WAVE results are consistent with those of the Department of Veterans Affairs Cooperative Studies Program, the only other large randomized trial comparing these two therapies (J. Vasc. Surg. 2002;35:413–21). However, despite this, their results were not what they had expected.

“On the basis of previous clinical trials, we expected that the rates of minor, and possibly of moderate, bleeding would be significantly increased in the combination-therapy group. However, we also expected that the benefits of treatment would outweigh the risks,” the investigators wrote.

There is a rationale for this hypothesis, noted Dr. Mohler. Antiplatelet treatment has proven benefits for peripheral arterial disease, a common feature of which is atherothrombosis, whereas anticoagulation therapy has proven benefits for venous thrombosis.

“Therefore, the addition of oral anticoagulation to antiplatelet treatment might be presumed to be beneficial for the management of atherothrombosis in patients with peripheral arterial disease as well,” he wrote.

A possible reason that this was not found in the WAVE trial could lie in “the differences in thrombus formation between the arterial and venous systems,” he suggested.

For patients with peripheral arterial disease, there is substantial risk and no benefit to combining antiplatelet and anticoagulation therapy, according to the results of a large randomized trial.

“We found that combination therapy was not more effective than antiplatelet therapy alone in preventing major cardiovascular complications and was associated with a substantial increase in the risk of life-threatening bleeding,” wrote Dr. Sonia Anand of McMaster University, Hamilton, Ont., and her coinvestigators on the Warfarin Antiplatelet Vascular Evaluation (WAVE) trial (N. Engl. J. Med. 2007;357:217–27).

“The totality of evidence shows clearly that the addition of an anticoagulant to an antiplatelet drug results in increased rates of bleeding complications,” wrote Dr. Emile Mohler III of the University of Pennsylvania, Philadelphia, in an editorial appearing in the same issue of the journal (N. Engl. J. Med. 2007;357:293–6).

The trial compared outcomes in 1,081 patients randomized to antiplatelet therapy alone and 1,080 patients randomized to a combination of antiplatelet and oral anticoagulant therapy. The mean age of the patients was 64 years, 74% were male, and the mean follow-up time was 35 months.

There were two coprimary composite outcomes: The first was myocardial infarction, stroke, or death from cardiovascular causes; the second was MI, stroke, severe ischemia of the peripheral or coronary arteries leading to urgent intervention, or death from cardiovascular causes. The safety outcomes were life-threatening, moderate, or minor bleeding episodes.

No significant differences were observed between groups for either of the primary outcomes. The first end point occurred in 12.2% of the combination group and 13.3% of the antiplatelet group (relative risk [RR] 0.92), whereas the second end point occurred in 15.9% of the combination group and 17.4% of the antiplatelet group (RR 0.91).

The differences emerged in the safety outcomes. Compared with the antiplatelet group, the combination group showed increases in both life-threatening bleeding (4.0% vs. 1.2%, RR 3.41) and moderate bleeding (2.9% vs. 1.0%, RR 2.82).

“According to our data, treating 1,000 patients with combination therapy as compared with antiplatelet therapy alone for 3 years would lead to 24 fewer cardiovascular events but 28 more episodes of life-threatening bleeding, resulting in a net increase in serious adverse outcomes,” wrote Dr. Anand and her coauthors.

WAVE's findings of increased bleeding associated with combination therapy (as opposed to antiplatelet therapy alone) differ from a similar comparison of treatments in patients with coronary artery disease (N. Engl. J. Med. 2002;347:9609–74) but are consistent with the results of another trial involving patients with peripheral arterial disease (Lancet 2000;355:346–51), the investigators noted.

“Therefore, it appears that patients with peripheral arterial disease who are treated with oral anticoagulation may be more likely to have bleeding complications … than are patients with coronary artery disease.” The reasons for this difference may be that patients with peripheral arterial disease are older, have more systemic atherosclerosis (including cerebrovascular disease), and have more coexisting conditions, they suggested.

The authors noted that the WAVE results are consistent with those of the Department of Veterans Affairs Cooperative Studies Program, the only other large randomized trial comparing these two therapies (J. Vasc. Surg. 2002;35:413–21). However, despite this, their results were not what they had expected.

“On the basis of previous clinical trials, we expected that the rates of minor, and possibly of moderate, bleeding would be significantly increased in the combination-therapy group. However, we also expected that the benefits of treatment would outweigh the risks,” the investigators wrote.

There is a rationale for this hypothesis, noted Dr. Mohler. Antiplatelet treatment has proven benefits for peripheral arterial disease, a common feature of which is atherothrombosis, whereas anticoagulation therapy has proven benefits for venous thrombosis.

“Therefore, the addition of oral anticoagulation to antiplatelet treatment might be presumed to be beneficial for the management of atherothrombosis in patients with peripheral arterial disease as well,” he wrote.

A possible reason that this was not found in the WAVE trial could lie in “the differences in thrombus formation between the arterial and venous systems,” he suggested.

For patients with peripheral arterial disease, there is substantial risk and no benefit to combining antiplatelet and anticoagulation therapy, according to the results of a large randomized trial.

“We found that combination therapy was not more effective than antiplatelet therapy alone in preventing major cardiovascular complications and was associated with a substantial increase in the risk of life-threatening bleeding,” wrote Dr. Sonia Anand of McMaster University, Hamilton, Ont., and her coinvestigators on the Warfarin Antiplatelet Vascular Evaluation (WAVE) trial (N. Engl. J. Med. 2007;357:217–27).

“The totality of evidence shows clearly that the addition of an anticoagulant to an antiplatelet drug results in increased rates of bleeding complications,” wrote Dr. Emile Mohler III of the University of Pennsylvania, Philadelphia, in an editorial appearing in the same issue of the journal (N. Engl. J. Med. 2007;357:293–6).

The trial compared outcomes in 1,081 patients randomized to antiplatelet therapy alone and 1,080 patients randomized to a combination of antiplatelet and oral anticoagulant therapy. The mean age of the patients was 64 years, 74% were male, and the mean follow-up time was 35 months.

There were two coprimary composite outcomes: The first was myocardial infarction, stroke, or death from cardiovascular causes; the second was MI, stroke, severe ischemia of the peripheral or coronary arteries leading to urgent intervention, or death from cardiovascular causes. The safety outcomes were life-threatening, moderate, or minor bleeding episodes.

No significant differences were observed between groups for either of the primary outcomes. The first end point occurred in 12.2% of the combination group and 13.3% of the antiplatelet group (relative risk [RR] 0.92), whereas the second end point occurred in 15.9% of the combination group and 17.4% of the antiplatelet group (RR 0.91).

The differences emerged in the safety outcomes. Compared with the antiplatelet group, the combination group showed increases in both life-threatening bleeding (4.0% vs. 1.2%, RR 3.41) and moderate bleeding (2.9% vs. 1.0%, RR 2.82).

“According to our data, treating 1,000 patients with combination therapy as compared with antiplatelet therapy alone for 3 years would lead to 24 fewer cardiovascular events but 28 more episodes of life-threatening bleeding, resulting in a net increase in serious adverse outcomes,” wrote Dr. Anand and her coauthors.

WAVE's findings of increased bleeding associated with combination therapy (as opposed to antiplatelet therapy alone) differ from a similar comparison of treatments in patients with coronary artery disease (N. Engl. J. Med. 2002;347:9609–74) but are consistent with the results of another trial involving patients with peripheral arterial disease (Lancet 2000;355:346–51), the investigators noted.

“Therefore, it appears that patients with peripheral arterial disease who are treated with oral anticoagulation may be more likely to have bleeding complications … than are patients with coronary artery disease.” The reasons for this difference may be that patients with peripheral arterial disease are older, have more systemic atherosclerosis (including cerebrovascular disease), and have more coexisting conditions, they suggested.

The authors noted that the WAVE results are consistent with those of the Department of Veterans Affairs Cooperative Studies Program, the only other large randomized trial comparing these two therapies (J. Vasc. Surg. 2002;35:413–21). However, despite this, their results were not what they had expected.

“On the basis of previous clinical trials, we expected that the rates of minor, and possibly of moderate, bleeding would be significantly increased in the combination-therapy group. However, we also expected that the benefits of treatment would outweigh the risks,” the investigators wrote.

There is a rationale for this hypothesis, noted Dr. Mohler. Antiplatelet treatment has proven benefits for peripheral arterial disease, a common feature of which is atherothrombosis, whereas anticoagulation therapy has proven benefits for venous thrombosis.

“Therefore, the addition of oral anticoagulation to antiplatelet treatment might be presumed to be beneficial for the management of atherothrombosis in patients with peripheral arterial disease as well,” he wrote.

A possible reason that this was not found in the WAVE trial could lie in “the differences in thrombus formation between the arterial and venous systems,” he suggested.

TORONTO — Asthma symptoms improve in children whose homes are remodeled to reduce triggers such as dust mites, mold, mice, and cockroaches, Dr. Megan Sandel reported in a poster presentation at the annual meeting of the Pediatric Academic Societies.

Families were randomly assigned to receive education plus an intervention (remodeling) or education only with the intervention delayed for 4 months. The data were collected before the second group received the intervention, explained Dr. Sandel of Boston University.

Among the 56 families with complete data representing 81 children with asthma, home remodeling resulted in better asthma outcomes, compared with education only. In total, 78% of homes required integrated pest control for mice and cockroaches, 40% required carpet removal to control dust mites, 36% required a bathroom fan to control mold, 12% required a high-efficiency particulate air filter, 10% required a kitchen fan, and 15% required a window fan.

Compared with homes in the education-only group, intervention homes showed lower mouse infestation scores (0.7 vs. 1.4). Similarly, bathroom mold improved from 17% to 8% after the intervention, compared with worsening in homes with education only (15% to 49%).

Over a 2-week period, the intervention group also had fewer asthma symptoms (23% vs. 38%) and fewer periods of stopped play because of asthma (8% vs. 21%), compared with the education-only group. The need for quick-relief medication over 2 weeks also was less in the intervention group, compared with the education-alone group (48% vs. 67%); this represented a reduction of 10% in the intervention group, compared with an 11% increase in the education group.

ELSEVIER GLOBAL MEDICAL NEWS

TORONTO — Asthma symptoms improve in children whose homes are remodeled to reduce triggers such as dust mites, mold, mice, and cockroaches, Dr. Megan Sandel reported in a poster presentation at the annual meeting of the Pediatric Academic Societies.

Families were randomly assigned to receive education plus an intervention (remodeling) or education only with the intervention delayed for 4 months. The data were collected before the second group received the intervention, explained Dr. Sandel of Boston University.

Among the 56 families with complete data representing 81 children with asthma, home remodeling resulted in better asthma outcomes, compared with education only. In total, 78% of homes required integrated pest control for mice and cockroaches, 40% required carpet removal to control dust mites, 36% required a bathroom fan to control mold, 12% required a high-efficiency particulate air filter, 10% required a kitchen fan, and 15% required a window fan.

Compared with homes in the education-only group, intervention homes showed lower mouse infestation scores (0.7 vs. 1.4). Similarly, bathroom mold improved from 17% to 8% after the intervention, compared with worsening in homes with education only (15% to 49%).

Over a 2-week period, the intervention group also had fewer asthma symptoms (23% vs. 38%) and fewer periods of stopped play because of asthma (8% vs. 21%), compared with the education-only group. The need for quick-relief medication over 2 weeks also was less in the intervention group, compared with the education-alone group (48% vs. 67%); this represented a reduction of 10% in the intervention group, compared with an 11% increase in the education group.

ELSEVIER GLOBAL MEDICAL NEWS

TORONTO — Asthma symptoms improve in children whose homes are remodeled to reduce triggers such as dust mites, mold, mice, and cockroaches, Dr. Megan Sandel reported in a poster presentation at the annual meeting of the Pediatric Academic Societies.

Families were randomly assigned to receive education plus an intervention (remodeling) or education only with the intervention delayed for 4 months. The data were collected before the second group received the intervention, explained Dr. Sandel of Boston University.

Among the 56 families with complete data representing 81 children with asthma, home remodeling resulted in better asthma outcomes, compared with education only. In total, 78% of homes required integrated pest control for mice and cockroaches, 40% required carpet removal to control dust mites, 36% required a bathroom fan to control mold, 12% required a high-efficiency particulate air filter, 10% required a kitchen fan, and 15% required a window fan.

Compared with homes in the education-only group, intervention homes showed lower mouse infestation scores (0.7 vs. 1.4). Similarly, bathroom mold improved from 17% to 8% after the intervention, compared with worsening in homes with education only (15% to 49%).

Over a 2-week period, the intervention group also had fewer asthma symptoms (23% vs. 38%) and fewer periods of stopped play because of asthma (8% vs. 21%), compared with the education-only group. The need for quick-relief medication over 2 weeks also was less in the intervention group, compared with the education-alone group (48% vs. 67%); this represented a reduction of 10% in the intervention group, compared with an 11% increase in the education group.

ELSEVIER GLOBAL MEDICAL NEWS

MONTREAL — Hospitalization can be reduced by more than half among nursing home residents with pneumonia and other lower respiratory tract infections, with no compromise in morbidity or mortality, Dr. Mark Loeb said at an international conference on community-acquired pneumonia.

“Pneumonia is the most important reason why residents are transferred to hospital, but hospitalization can lead to functional decline, infection with multiresistant organisms, urinary tract infections, and delirium,” said Dr. Loeb of the department of pathology and molecular medicine at McMaster University, Hamilton, Ont.

Reducing the rate of hospitalization in this population would not only avoid these potential hazards, but also reduce the overall burden on the health care system, an issue “which has particular relevance for pandemic planning,” he noted at the conference, which was sponsored by the International Society for Chemotherapy. “Most pandemic plans tend to ignore the long-term care facilities—they basically focus on the acute care setting—but a very relevant issue is when there's a pandemic, what happens to nursing home residents? Do they get sent to the acute care hospital for management, or do we just manage them on-site?”

A study by Dr. Loeb and his colleagues randomized 680 nursing home residents with pneumonia or other lower respiratory tract infections to either usual care or treatment according to a clinical algorithm designed to encourage on-site care (JAMA 2006;295:2503–10).

Patients were eligible to be treated on-site only if they could eat and drink and had stable vital signs; otherwise, they were transferred to a hospital.

The clinical algorithm involved the use of oral antimicrobials, portable chest radiographs, oxygen saturation monitoring, rehydration, and close monitoring by a research nurse.

Only 10% of patients randomized to the algorithm were hospitalized, compared with 22% of the usual care patients, Dr. Loeb said at the meeting. Over the 30-day follow-up, there were no significant differences in quality of life scores, functional status, or mortality (8% in the algorithm group vs. 9% in the usual care group), but there was a marked reduction in cost associated with the treatment algorithm.

Although the initial cost was $87 more per resident in the algorithm vs. usual care groups (because of the up-front cost of oxygen and hydration therapy, mobile radiographs, and administration), this was offset by reduced professional billing, transportation, and hospitalization costs, he said. Overall, the algorithm resulted in a saving of $1,016 (in U.S. dollars) per patient, based on the Canadian health care costs. Using U.S. prices, the saving was $1,517 (in U.S. dollars). The researchers estimated that the clinical algorithm could save $831 million annually among the approximately 1.5 million elderly residents in U.S. nursing homes.

Dr. Loeb and his coauthors acknowledged that health care funding in the United States could pose a barrier to the implementation of such an algorithm because, unlike in Canada, the costs of implementation would be shouldered by the nursing home, while the resulting savings would be realized by the hospital.

“Prospective payment and flat-rate systems of Medicare reimbursement to nursing homes represent financial disincentives to have residents treated on-site in the nursing home,” they wrote. “Therefore, nursing homes would need to receive supplemental funding to implement the pathway [algorithm].”

MONTREAL — Hospitalization can be reduced by more than half among nursing home residents with pneumonia and other lower respiratory tract infections, with no compromise in morbidity or mortality, Dr. Mark Loeb said at an international conference on community-acquired pneumonia.

“Pneumonia is the most important reason why residents are transferred to hospital, but hospitalization can lead to functional decline, infection with multiresistant organisms, urinary tract infections, and delirium,” said Dr. Loeb of the department of pathology and molecular medicine at McMaster University, Hamilton, Ont.

Reducing the rate of hospitalization in this population would not only avoid these potential hazards, but also reduce the overall burden on the health care system, an issue “which has particular relevance for pandemic planning,” he noted at the conference, which was sponsored by the International Society for Chemotherapy. “Most pandemic plans tend to ignore the long-term care facilities—they basically focus on the acute care setting—but a very relevant issue is when there's a pandemic, what happens to nursing home residents? Do they get sent to the acute care hospital for management, or do we just manage them on-site?”

A study by Dr. Loeb and his colleagues randomized 680 nursing home residents with pneumonia or other lower respiratory tract infections to either usual care or treatment according to a clinical algorithm designed to encourage on-site care (JAMA 2006;295:2503–10).

Patients were eligible to be treated on-site only if they could eat and drink and had stable vital signs; otherwise, they were transferred to a hospital.

The clinical algorithm involved the use of oral antimicrobials, portable chest radiographs, oxygen saturation monitoring, rehydration, and close monitoring by a research nurse.

Only 10% of patients randomized to the algorithm were hospitalized, compared with 22% of the usual care patients, Dr. Loeb said at the meeting. Over the 30-day follow-up, there were no significant differences in quality of life scores, functional status, or mortality (8% in the algorithm group vs. 9% in the usual care group), but there was a marked reduction in cost associated with the treatment algorithm.

Although the initial cost was $87 more per resident in the algorithm vs. usual care groups (because of the up-front cost of oxygen and hydration therapy, mobile radiographs, and administration), this was offset by reduced professional billing, transportation, and hospitalization costs, he said. Overall, the algorithm resulted in a saving of $1,016 (in U.S. dollars) per patient, based on the Canadian health care costs. Using U.S. prices, the saving was $1,517 (in U.S. dollars). The researchers estimated that the clinical algorithm could save $831 million annually among the approximately 1.5 million elderly residents in U.S. nursing homes.

Dr. Loeb and his coauthors acknowledged that health care funding in the United States could pose a barrier to the implementation of such an algorithm because, unlike in Canada, the costs of implementation would be shouldered by the nursing home, while the resulting savings would be realized by the hospital.

“Prospective payment and flat-rate systems of Medicare reimbursement to nursing homes represent financial disincentives to have residents treated on-site in the nursing home,” they wrote. “Therefore, nursing homes would need to receive supplemental funding to implement the pathway [algorithm].”

MONTREAL — Hospitalization can be reduced by more than half among nursing home residents with pneumonia and other lower respiratory tract infections, with no compromise in morbidity or mortality, Dr. Mark Loeb said at an international conference on community-acquired pneumonia.

“Pneumonia is the most important reason why residents are transferred to hospital, but hospitalization can lead to functional decline, infection with multiresistant organisms, urinary tract infections, and delirium,” said Dr. Loeb of the department of pathology and molecular medicine at McMaster University, Hamilton, Ont.

Reducing the rate of hospitalization in this population would not only avoid these potential hazards, but also reduce the overall burden on the health care system, an issue “which has particular relevance for pandemic planning,” he noted at the conference, which was sponsored by the International Society for Chemotherapy. “Most pandemic plans tend to ignore the long-term care facilities—they basically focus on the acute care setting—but a very relevant issue is when there's a pandemic, what happens to nursing home residents? Do they get sent to the acute care hospital for management, or do we just manage them on-site?”

A study by Dr. Loeb and his colleagues randomized 680 nursing home residents with pneumonia or other lower respiratory tract infections to either usual care or treatment according to a clinical algorithm designed to encourage on-site care (JAMA 2006;295:2503–10).

Patients were eligible to be treated on-site only if they could eat and drink and had stable vital signs; otherwise, they were transferred to a hospital.

The clinical algorithm involved the use of oral antimicrobials, portable chest radiographs, oxygen saturation monitoring, rehydration, and close monitoring by a research nurse.

Only 10% of patients randomized to the algorithm were hospitalized, compared with 22% of the usual care patients, Dr. Loeb said at the meeting. Over the 30-day follow-up, there were no significant differences in quality of life scores, functional status, or mortality (8% in the algorithm group vs. 9% in the usual care group), but there was a marked reduction in cost associated with the treatment algorithm.

Although the initial cost was $87 more per resident in the algorithm vs. usual care groups (because of the up-front cost of oxygen and hydration therapy, mobile radiographs, and administration), this was offset by reduced professional billing, transportation, and hospitalization costs, he said. Overall, the algorithm resulted in a saving of $1,016 (in U.S. dollars) per patient, based on the Canadian health care costs. Using U.S. prices, the saving was $1,517 (in U.S. dollars). The researchers estimated that the clinical algorithm could save $831 million annually among the approximately 1.5 million elderly residents in U.S. nursing homes.

Dr. Loeb and his coauthors acknowledged that health care funding in the United States could pose a barrier to the implementation of such an algorithm because, unlike in Canada, the costs of implementation would be shouldered by the nursing home, while the resulting savings would be realized by the hospital.

“Prospective payment and flat-rate systems of Medicare reimbursement to nursing homes represent financial disincentives to have residents treated on-site in the nursing home,” they wrote. “Therefore, nursing homes would need to receive supplemental funding to implement the pathway [algorithm].”

LYON, FRANCE — Canadian researchers have announced the birth of the world's first baby that was conceived from an egg matured in vitro and then frozen, thawed, and fertilized.

Three other pregnancies conceived in the same way are ongoing, Dr. Hananel Holzer of the McGill Reproductive Center in Montreal reported at the annual meeting of the European Society for Human Reproduction and Embryology.

The conceptions occurred in a group of 20 women, all with polycystic ovarian syndrome (PCOS), or polycystic ovaries detected on ultrasound. However, the findings may have important clinical implications for women with systemic lupus erythematosus (SLE) and other autoimmune diseases as well as cancer patients who must undergo potentially gonadotoxic chemotherapy, said Dr. Holzer in an interview.

Women with SLE who receive high dose cyclophosphamide, and those with other autoimmune indications for cytotoxic therapy such as Behcet's disease, steroid-resistant glomerulonephritis, inflammatory bowel diseases and pemphigus vulgaris are all potential candidates for fertility preservation techniques.

“These are preliminary results, and they have not yet been proven in cancer patients,” he cautioned. “But this treatment has the potential to become one of the main options for fertility preservation, especially for patients who cannot have ovarian stimulation and all patients who do not have enough time to undergo ovarian stimulation.”

Patients choosing in vitro maturation (IVM) of oocytes can avoid ovulation induction by having immature oocytes removed and then matured in the lab, Dr. Holzer explained.

The researchers collected from among the 20 patients a total of 312 oocytes, of which 305 were immature. Of these immature eggs, 209 (68%) were successfully matured in the lab and frozen, along with 6 of the naturally matured oocytes.

A total of 148 of these 215 oocytes (69%) survived freezing and thawing, and 96 were successfully fertilized. There were 64 embryos transferred, resulting in four clinical pregnancies—including one live birth and three ongoing pregnancies.

While IVM is routinely used by the center to avoid the increased hyperstimulation risks in patients with PCOS, oocyte cryopreservation and subsequent fertilization has not been attempted previously.

Although cryopreservation is not essential for patients with PCOS, it is necessary for patients undergoing chemotherapy. In such patients, the procedure presents no risk of aggravating existing disease, and there is theoretically no risk of reintroducing a metastatic malignancy when an embryo is implanted, Dr. Holzer added.

“We have demonstrated for the first time that this is possible to do. … However, we have to remember that these are only preliminary results from a small number of patients who were not cancer patients themselves.” In the context of all other methods of fertility preservation, these results “should be looked at as preliminary and experimental,” he said.

“We need to inform patients about the early stage of these treatments without giving any false hope,” Dr. Holzer added.

Autoimmune disease patients facing gonadotoxic therapy can avoid ovulation induction by having immature oocytes (pictured) removed and then matured in a lab. Courtesy Dr. Hananel Holzer/McGill Universty/Montreal

LYON, FRANCE — Canadian researchers have announced the birth of the world's first baby that was conceived from an egg matured in vitro and then frozen, thawed, and fertilized.

Three other pregnancies conceived in the same way are ongoing, Dr. Hananel Holzer of the McGill Reproductive Center in Montreal reported at the annual meeting of the European Society for Human Reproduction and Embryology.

The conceptions occurred in a group of 20 women, all with polycystic ovarian syndrome (PCOS), or polycystic ovaries detected on ultrasound. However, the findings may have important clinical implications for women with systemic lupus erythematosus (SLE) and other autoimmune diseases as well as cancer patients who must undergo potentially gonadotoxic chemotherapy, said Dr. Holzer in an interview.

Women with SLE who receive high dose cyclophosphamide, and those with other autoimmune indications for cytotoxic therapy such as Behcet's disease, steroid-resistant glomerulonephritis, inflammatory bowel diseases and pemphigus vulgaris are all potential candidates for fertility preservation techniques.

“These are preliminary results, and they have not yet been proven in cancer patients,” he cautioned. “But this treatment has the potential to become one of the main options for fertility preservation, especially for patients who cannot have ovarian stimulation and all patients who do not have enough time to undergo ovarian stimulation.”

Patients choosing in vitro maturation (IVM) of oocytes can avoid ovulation induction by having immature oocytes removed and then matured in the lab, Dr. Holzer explained.

The researchers collected from among the 20 patients a total of 312 oocytes, of which 305 were immature. Of these immature eggs, 209 (68%) were successfully matured in the lab and frozen, along with 6 of the naturally matured oocytes.

A total of 148 of these 215 oocytes (69%) survived freezing and thawing, and 96 were successfully fertilized. There were 64 embryos transferred, resulting in four clinical pregnancies—including one live birth and three ongoing pregnancies.

While IVM is routinely used by the center to avoid the increased hyperstimulation risks in patients with PCOS, oocyte cryopreservation and subsequent fertilization has not been attempted previously.

Although cryopreservation is not essential for patients with PCOS, it is necessary for patients undergoing chemotherapy. In such patients, the procedure presents no risk of aggravating existing disease, and there is theoretically no risk of reintroducing a metastatic malignancy when an embryo is implanted, Dr. Holzer added.

“We have demonstrated for the first time that this is possible to do. … However, we have to remember that these are only preliminary results from a small number of patients who were not cancer patients themselves.” In the context of all other methods of fertility preservation, these results “should be looked at as preliminary and experimental,” he said.

“We need to inform patients about the early stage of these treatments without giving any false hope,” Dr. Holzer added.

Autoimmune disease patients facing gonadotoxic therapy can avoid ovulation induction by having immature oocytes (pictured) removed and then matured in a lab. Courtesy Dr. Hananel Holzer/McGill Universty/Montreal

LYON, FRANCE — Canadian researchers have announced the birth of the world's first baby that was conceived from an egg matured in vitro and then frozen, thawed, and fertilized.

Three other pregnancies conceived in the same way are ongoing, Dr. Hananel Holzer of the McGill Reproductive Center in Montreal reported at the annual meeting of the European Society for Human Reproduction and Embryology.

The conceptions occurred in a group of 20 women, all with polycystic ovarian syndrome (PCOS), or polycystic ovaries detected on ultrasound. However, the findings may have important clinical implications for women with systemic lupus erythematosus (SLE) and other autoimmune diseases as well as cancer patients who must undergo potentially gonadotoxic chemotherapy, said Dr. Holzer in an interview.

Women with SLE who receive high dose cyclophosphamide, and those with other autoimmune indications for cytotoxic therapy such as Behcet's disease, steroid-resistant glomerulonephritis, inflammatory bowel diseases and pemphigus vulgaris are all potential candidates for fertility preservation techniques.

“These are preliminary results, and they have not yet been proven in cancer patients,” he cautioned. “But this treatment has the potential to become one of the main options for fertility preservation, especially for patients who cannot have ovarian stimulation and all patients who do not have enough time to undergo ovarian stimulation.”

Patients choosing in vitro maturation (IVM) of oocytes can avoid ovulation induction by having immature oocytes removed and then matured in the lab, Dr. Holzer explained.

The researchers collected from among the 20 patients a total of 312 oocytes, of which 305 were immature. Of these immature eggs, 209 (68%) were successfully matured in the lab and frozen, along with 6 of the naturally matured oocytes.

A total of 148 of these 215 oocytes (69%) survived freezing and thawing, and 96 were successfully fertilized. There were 64 embryos transferred, resulting in four clinical pregnancies—including one live birth and three ongoing pregnancies.

While IVM is routinely used by the center to avoid the increased hyperstimulation risks in patients with PCOS, oocyte cryopreservation and subsequent fertilization has not been attempted previously.

Although cryopreservation is not essential for patients with PCOS, it is necessary for patients undergoing chemotherapy. In such patients, the procedure presents no risk of aggravating existing disease, and there is theoretically no risk of reintroducing a metastatic malignancy when an embryo is implanted, Dr. Holzer added.

“We have demonstrated for the first time that this is possible to do. … However, we have to remember that these are only preliminary results from a small number of patients who were not cancer patients themselves.” In the context of all other methods of fertility preservation, these results “should be looked at as preliminary and experimental,” he said.

“We need to inform patients about the early stage of these treatments without giving any false hope,” Dr. Holzer added.

Autoimmune disease patients facing gonadotoxic therapy can avoid ovulation induction by having immature oocytes (pictured) removed and then matured in a lab. Courtesy Dr. Hananel Holzer/McGill Universty/Montreal

TORONTO – The establishment of an interdisciplinary outpatient clinic for patients with bronchopulmonary dysplasia can significantly improve care and decrease hospital readmissions, reported Dr. Stephen Welty of Columbus Children's Hospital.

Before the establishment of his hospital's outpatient clinic, an analysis of 269 children with bronchopulmonary dysplasia (BPD) discharged to their general follow-up clinic in 2003 revealed that 29% were readmitted within 1 month of discharge, Dr. Welty said at the annual meeting of the Pediatric Academic Societies.

“When we first saw that number we were horrified,” he said. “And for two of those patients their stay [after readmission] was about 6 months, which was quite alarming.”

Staff felt that factors contributing to the high readmission rate included family anxiety and lack of education about caring for their child at home, medical conditions such as reactive airway disease, and resource issues such as living remotely. In addition, BPD patients have complex, multidisciplinary needs that require social, nutritional, and developmental specialists, said Dr. Welty.

“Our hypothesis was that by seeing children at regular scheduled intervals in an interdisciplinary BPD clinic, we would reduce readmission rates,” he said.

The BPD clinic staff saw all patients before discharge to assess the adequacy of oxygenation and whether discharge was realistic, and then saw them again 2 weeks after discharge to reevaluate. A study comparing outcomes within 30 days of discharge found that readmissions went from 29% before the establishment of the BPD clinic, to 3% the first year after its establishment, 6% the second year, and 5% the third year. Dr. Welty suggested this reduction in readmissions was mostly due to the prevention of pulmonary exacerbations.

The study estimated that the BPD clinic resulted in a cost saving of $2.5 million to $3 million per year based on the fact that the average length of stay on readmission was 19 days, with an average cost of $53,600 per patient. The average cost of a BPD clinic visit is $533.

“We believe other potential benefits of the clinic are improved family satisfaction, improved feeding, nutrition and growth, and improved developmental outcomes,” he added.

TORONTO – The establishment of an interdisciplinary outpatient clinic for patients with bronchopulmonary dysplasia can significantly improve care and decrease hospital readmissions, reported Dr. Stephen Welty of Columbus Children's Hospital.

Before the establishment of his hospital's outpatient clinic, an analysis of 269 children with bronchopulmonary dysplasia (BPD) discharged to their general follow-up clinic in 2003 revealed that 29% were readmitted within 1 month of discharge, Dr. Welty said at the annual meeting of the Pediatric Academic Societies.

“When we first saw that number we were horrified,” he said. “And for two of those patients their stay [after readmission] was about 6 months, which was quite alarming.”

Staff felt that factors contributing to the high readmission rate included family anxiety and lack of education about caring for their child at home, medical conditions such as reactive airway disease, and resource issues such as living remotely. In addition, BPD patients have complex, multidisciplinary needs that require social, nutritional, and developmental specialists, said Dr. Welty.

“Our hypothesis was that by seeing children at regular scheduled intervals in an interdisciplinary BPD clinic, we would reduce readmission rates,” he said.

The BPD clinic staff saw all patients before discharge to assess the adequacy of oxygenation and whether discharge was realistic, and then saw them again 2 weeks after discharge to reevaluate. A study comparing outcomes within 30 days of discharge found that readmissions went from 29% before the establishment of the BPD clinic, to 3% the first year after its establishment, 6% the second year, and 5% the third year. Dr. Welty suggested this reduction in readmissions was mostly due to the prevention of pulmonary exacerbations.

The study estimated that the BPD clinic resulted in a cost saving of $2.5 million to $3 million per year based on the fact that the average length of stay on readmission was 19 days, with an average cost of $53,600 per patient. The average cost of a BPD clinic visit is $533.

“We believe other potential benefits of the clinic are improved family satisfaction, improved feeding, nutrition and growth, and improved developmental outcomes,” he added.

TORONTO – The establishment of an interdisciplinary outpatient clinic for patients with bronchopulmonary dysplasia can significantly improve care and decrease hospital readmissions, reported Dr. Stephen Welty of Columbus Children's Hospital.

Before the establishment of his hospital's outpatient clinic, an analysis of 269 children with bronchopulmonary dysplasia (BPD) discharged to their general follow-up clinic in 2003 revealed that 29% were readmitted within 1 month of discharge, Dr. Welty said at the annual meeting of the Pediatric Academic Societies.

“When we first saw that number we were horrified,” he said. “And for two of those patients their stay [after readmission] was about 6 months, which was quite alarming.”

Staff felt that factors contributing to the high readmission rate included family anxiety and lack of education about caring for their child at home, medical conditions such as reactive airway disease, and resource issues such as living remotely. In addition, BPD patients have complex, multidisciplinary needs that require social, nutritional, and developmental specialists, said Dr. Welty.

“Our hypothesis was that by seeing children at regular scheduled intervals in an interdisciplinary BPD clinic, we would reduce readmission rates,” he said.

The BPD clinic staff saw all patients before discharge to assess the adequacy of oxygenation and whether discharge was realistic, and then saw them again 2 weeks after discharge to reevaluate. A study comparing outcomes within 30 days of discharge found that readmissions went from 29% before the establishment of the BPD clinic, to 3% the first year after its establishment, 6% the second year, and 5% the third year. Dr. Welty suggested this reduction in readmissions was mostly due to the prevention of pulmonary exacerbations.

The study estimated that the BPD clinic resulted in a cost saving of $2.5 million to $3 million per year based on the fact that the average length of stay on readmission was 19 days, with an average cost of $53,600 per patient. The average cost of a BPD clinic visit is $533.

“We believe other potential benefits of the clinic are improved family satisfaction, improved feeding, nutrition and growth, and improved developmental outcomes,” he added.