Kate Johnson

BOSTON — Obstructive sleep apnea is a risk factor for cardiac arrhythmias, and cardiologists should consider the diagnosis and treatment of this sleep disorder in terms of cardioprotective benefit, according to Dr. Maria Teresa La Rovere.

In a study she presented in a poster at the annual meeting of the Heart Rhythm Society, Dr. La Rovere found a significant correlation between oxygen desaturation in obstructive sleep apnea syndrome (OSAS) and bradyarrhythmias, but not tachyarrhythmias.

“We found strong evidence that bradyarrhythmias are related to sleep apnea syndrome—whereas for tachyarrhythmias, the role of oxygen desaturation is more controversial,” said Dr. La Rovere in an interview. Other factors may contribute to tachyarrhythmias, such as β₂-agonist treatment, which was found to be more common among patients who had tachyarrhythmias, she said.

The study included 300 subjects who were referred for sleep studies because of snoring. OSAS was diagnosed in 248 (83%) of them.

Although there was a trend toward more arrhythmias in the patients with OSAS than in those without OSAS (18% vs. 11%), the difference was not significant, reported Dr. Rovere, a cardiologist at the Fondazione Salvatore Maugeri clinic in Pavia, Italy.

Patients with arrhythmias were older than were nonarrhythmic patients (58 vs. 52 years) and they had more profound oxygen desaturation (23% vs. 15% total sleep time spent with less than 90% oxygen saturation).

Although no significant relationship was found between tachyarrhythmias and hypoxemia, bradyarrhythmias were significantly correlated. Patients with bradyarrhythmias had significantly more hypoxemia, compared with nonarrhythmic patients, with an apnea-hypopnea index of 54 vs. 31 and an oxygen saturation nadir of 69% vs. 77%.

Dr. La Rovere said a recently published study performed in the general population and using a stricter definition of OSAS found similar evidence that people with sleep-disordered breathing have between two and four times the odds of having complex cardiac arrhythmias, compared with those without sleep apnea (Am. J. Respir. Crit. Care. Med. 2006;173:910–6). Specifically, the study found that sleep-disordered breathing was associated with four times the odds of atrial fibrillation, three times the odds of nonsustained ventricular tachycardia, and almost twice the odds of complex ventricular ectopy, after adjustment for age, sex, body mass index, and prevalent coronary heart disease.

Another recently published study found that OSAS was associated with almost double the risk of stroke or death, even after adjustment for age, sex, race, smoking status, alcohol consumption, body mass index, diabetes mellitus, hyperlipidemia, atrial fibrillation, and hypertension (N. Engl. J. Med. 2005;353:2034–41).

Although treatment of OSAS with continuous positive airway pressure (CPAP) is well established for the relief of sleep disturbances and improvement in quality of life, Dr. La Rovere says cardiologists should also recognize its value in preventing the development of cardiac arrhythmias.

“The mechanism of breathing disorders also affects cardiac functioning. So in the long term, these subjects may also develop heart failure,” she said. “I think there is an increasing awareness,” but cardiologists have not yet focused on the cardiac benefits of treating sleep apnea.

She added that although CPAP not only prevents sleep-related heart rhythm disturbances, but can also correct them, it is advisable to consider a pacemaker for patients whose CPAP compliance is questionable. “I know the CPAP will correct my patient's arrhythmia, but I do not know if my patient will use the CPAP,” she said.

BOSTON — Obstructive sleep apnea is a risk factor for cardiac arrhythmias, and cardiologists should consider the diagnosis and treatment of this sleep disorder in terms of cardioprotective benefit, according to Dr. Maria Teresa La Rovere.

In a study she presented in a poster at the annual meeting of the Heart Rhythm Society, Dr. La Rovere found a significant correlation between oxygen desaturation in obstructive sleep apnea syndrome (OSAS) and bradyarrhythmias, but not tachyarrhythmias.

“We found strong evidence that bradyarrhythmias are related to sleep apnea syndrome—whereas for tachyarrhythmias, the role of oxygen desaturation is more controversial,” said Dr. La Rovere in an interview. Other factors may contribute to tachyarrhythmias, such as β₂-agonist treatment, which was found to be more common among patients who had tachyarrhythmias, she said.

The study included 300 subjects who were referred for sleep studies because of snoring. OSAS was diagnosed in 248 (83%) of them.

Although there was a trend toward more arrhythmias in the patients with OSAS than in those without OSAS (18% vs. 11%), the difference was not significant, reported Dr. Rovere, a cardiologist at the Fondazione Salvatore Maugeri clinic in Pavia, Italy.

Patients with arrhythmias were older than were nonarrhythmic patients (58 vs. 52 years) and they had more profound oxygen desaturation (23% vs. 15% total sleep time spent with less than 90% oxygen saturation).

Although no significant relationship was found between tachyarrhythmias and hypoxemia, bradyarrhythmias were significantly correlated. Patients with bradyarrhythmias had significantly more hypoxemia, compared with nonarrhythmic patients, with an apnea-hypopnea index of 54 vs. 31 and an oxygen saturation nadir of 69% vs. 77%.

Dr. La Rovere said a recently published study performed in the general population and using a stricter definition of OSAS found similar evidence that people with sleep-disordered breathing have between two and four times the odds of having complex cardiac arrhythmias, compared with those without sleep apnea (Am. J. Respir. Crit. Care. Med. 2006;173:910–6). Specifically, the study found that sleep-disordered breathing was associated with four times the odds of atrial fibrillation, three times the odds of nonsustained ventricular tachycardia, and almost twice the odds of complex ventricular ectopy, after adjustment for age, sex, body mass index, and prevalent coronary heart disease.

Another recently published study found that OSAS was associated with almost double the risk of stroke or death, even after adjustment for age, sex, race, smoking status, alcohol consumption, body mass index, diabetes mellitus, hyperlipidemia, atrial fibrillation, and hypertension (N. Engl. J. Med. 2005;353:2034–41).

Although treatment of OSAS with continuous positive airway pressure (CPAP) is well established for the relief of sleep disturbances and improvement in quality of life, Dr. La Rovere says cardiologists should also recognize its value in preventing the development of cardiac arrhythmias.

“The mechanism of breathing disorders also affects cardiac functioning. So in the long term, these subjects may also develop heart failure,” she said. “I think there is an increasing awareness,” but cardiologists have not yet focused on the cardiac benefits of treating sleep apnea.

She added that although CPAP not only prevents sleep-related heart rhythm disturbances, but can also correct them, it is advisable to consider a pacemaker for patients whose CPAP compliance is questionable. “I know the CPAP will correct my patient's arrhythmia, but I do not know if my patient will use the CPAP,” she said.

BOSTON — Obstructive sleep apnea is a risk factor for cardiac arrhythmias, and cardiologists should consider the diagnosis and treatment of this sleep disorder in terms of cardioprotective benefit, according to Dr. Maria Teresa La Rovere.

In a study she presented in a poster at the annual meeting of the Heart Rhythm Society, Dr. La Rovere found a significant correlation between oxygen desaturation in obstructive sleep apnea syndrome (OSAS) and bradyarrhythmias, but not tachyarrhythmias.

“We found strong evidence that bradyarrhythmias are related to sleep apnea syndrome—whereas for tachyarrhythmias, the role of oxygen desaturation is more controversial,” said Dr. La Rovere in an interview. Other factors may contribute to tachyarrhythmias, such as β₂-agonist treatment, which was found to be more common among patients who had tachyarrhythmias, she said.

The study included 300 subjects who were referred for sleep studies because of snoring. OSAS was diagnosed in 248 (83%) of them.

Although there was a trend toward more arrhythmias in the patients with OSAS than in those without OSAS (18% vs. 11%), the difference was not significant, reported Dr. Rovere, a cardiologist at the Fondazione Salvatore Maugeri clinic in Pavia, Italy.

Patients with arrhythmias were older than were nonarrhythmic patients (58 vs. 52 years) and they had more profound oxygen desaturation (23% vs. 15% total sleep time spent with less than 90% oxygen saturation).

Although no significant relationship was found between tachyarrhythmias and hypoxemia, bradyarrhythmias were significantly correlated. Patients with bradyarrhythmias had significantly more hypoxemia, compared with nonarrhythmic patients, with an apnea-hypopnea index of 54 vs. 31 and an oxygen saturation nadir of 69% vs. 77%.

Dr. La Rovere said a recently published study performed in the general population and using a stricter definition of OSAS found similar evidence that people with sleep-disordered breathing have between two and four times the odds of having complex cardiac arrhythmias, compared with those without sleep apnea (Am. J. Respir. Crit. Care. Med. 2006;173:910–6). Specifically, the study found that sleep-disordered breathing was associated with four times the odds of atrial fibrillation, three times the odds of nonsustained ventricular tachycardia, and almost twice the odds of complex ventricular ectopy, after adjustment for age, sex, body mass index, and prevalent coronary heart disease.

Another recently published study found that OSAS was associated with almost double the risk of stroke or death, even after adjustment for age, sex, race, smoking status, alcohol consumption, body mass index, diabetes mellitus, hyperlipidemia, atrial fibrillation, and hypertension (N. Engl. J. Med. 2005;353:2034–41).

Although treatment of OSAS with continuous positive airway pressure (CPAP) is well established for the relief of sleep disturbances and improvement in quality of life, Dr. La Rovere says cardiologists should also recognize its value in preventing the development of cardiac arrhythmias.

“The mechanism of breathing disorders also affects cardiac functioning. So in the long term, these subjects may also develop heart failure,” she said. “I think there is an increasing awareness,” but cardiologists have not yet focused on the cardiac benefits of treating sleep apnea.

She added that although CPAP not only prevents sleep-related heart rhythm disturbances, but can also correct them, it is advisable to consider a pacemaker for patients whose CPAP compliance is questionable. “I know the CPAP will correct my patient's arrhythmia, but I do not know if my patient will use the CPAP,” she said.

SAN ANTONIO — A depression prevention course offered during pregnancy significantly reduced the incidence of major depressive episodes before delivery in a group of Hispanic women at high risk for depression, reported Huynh-Nhu Le, Ph.D., at the annual meeting of the Society for Prevention Research. She expects the intervention will ultimately result in reduced rates of postpartum depression as well.

“A lot of research is now moving away from the idea of postpartum depression to a more general idea of pregnancy-related depression. Technically, postpartum depression occurs up to 4 weeks after birth—but in some cases, it may have started before delivery. What we're trying to do is prevent these women from becoming more depressed,” she said in an interview. “We need to integrate mental health screening into primary care settings.”

Her study included 143 Hispanic women, aged 18–35 years, who were less than 24 weeks pregnant. All were considered at high risk for depression based on their history of depression or a score of 16 or higher on the Center for Epidemiologic Studies Depression Scale (CES-D). The women were randomized either to usual care or to an eight-session intervention that taught them mood regulation skills and provided information about parenting and child development.

Preliminary results from the intervention, measured 8 weeks before delivery, showed a significant decrease in the incidence of major depressive episodes in treated vs. nontreated women (1% vs. 7%), said Dr. Le of George Washington University, Washington. And a trend was seen toward lower scores on the Beck Depression Inventory for treated women.

Dr. Le said these outcomes will be measured again at 6 weeks, 4 months, and 12 months post partum.

SAN ANTONIO — A depression prevention course offered during pregnancy significantly reduced the incidence of major depressive episodes before delivery in a group of Hispanic women at high risk for depression, reported Huynh-Nhu Le, Ph.D., at the annual meeting of the Society for Prevention Research. She expects the intervention will ultimately result in reduced rates of postpartum depression as well.

“A lot of research is now moving away from the idea of postpartum depression to a more general idea of pregnancy-related depression. Technically, postpartum depression occurs up to 4 weeks after birth—but in some cases, it may have started before delivery. What we're trying to do is prevent these women from becoming more depressed,” she said in an interview. “We need to integrate mental health screening into primary care settings.”

Her study included 143 Hispanic women, aged 18–35 years, who were less than 24 weeks pregnant. All were considered at high risk for depression based on their history of depression or a score of 16 or higher on the Center for Epidemiologic Studies Depression Scale (CES-D). The women were randomized either to usual care or to an eight-session intervention that taught them mood regulation skills and provided information about parenting and child development.

Preliminary results from the intervention, measured 8 weeks before delivery, showed a significant decrease in the incidence of major depressive episodes in treated vs. nontreated women (1% vs. 7%), said Dr. Le of George Washington University, Washington. And a trend was seen toward lower scores on the Beck Depression Inventory for treated women.

Dr. Le said these outcomes will be measured again at 6 weeks, 4 months, and 12 months post partum.

SAN ANTONIO — A depression prevention course offered during pregnancy significantly reduced the incidence of major depressive episodes before delivery in a group of Hispanic women at high risk for depression, reported Huynh-Nhu Le, Ph.D., at the annual meeting of the Society for Prevention Research. She expects the intervention will ultimately result in reduced rates of postpartum depression as well.

“A lot of research is now moving away from the idea of postpartum depression to a more general idea of pregnancy-related depression. Technically, postpartum depression occurs up to 4 weeks after birth—but in some cases, it may have started before delivery. What we're trying to do is prevent these women from becoming more depressed,” she said in an interview. “We need to integrate mental health screening into primary care settings.”

Her study included 143 Hispanic women, aged 18–35 years, who were less than 24 weeks pregnant. All were considered at high risk for depression based on their history of depression or a score of 16 or higher on the Center for Epidemiologic Studies Depression Scale (CES-D). The women were randomized either to usual care or to an eight-session intervention that taught them mood regulation skills and provided information about parenting and child development.

Preliminary results from the intervention, measured 8 weeks before delivery, showed a significant decrease in the incidence of major depressive episodes in treated vs. nontreated women (1% vs. 7%), said Dr. Le of George Washington University, Washington. And a trend was seen toward lower scores on the Beck Depression Inventory for treated women.

Dr. Le said these outcomes will be measured again at 6 weeks, 4 months, and 12 months post partum.

Community health centers are currently clinically understaffed and will likely face increasing shortages that may limit their expansion, according to a study by the rural health research centers of both the University of Washington, Seattle, and the University of South Carolina, Columbia, and by the National Association of Community Health Centers (JAMA 2006;295:1042–9).

“Workforce shortages may impede the expansion of the U.S. [community health center] safety net, particularly in rural areas,” reported Dr. Roger A. Rosenblatt from the University of Washington, and his colleagues.

The study surveyed 846 federally funded community health centers (CHCs) within the 50 states and the District of Columbia. Mailed questionnaires and telephone surveys asked CHC chief executive officers about staffing and recruiting patterns, use of federal and state recruitment programs, and perceived barriers to recruitment.

Responses were obtained from 79% of the population and revealed that funded clinical staff vacancies are common. The average CHC has 13% of its family physician full-time equivalent positions unfilled. Rural CHCs reported a significantly higher proportion of these vacancies, as well as recruiting difficulties, compared with their urban counterparts, with more than one-third of rural CHCs reporting that they had been trying to recruit a family physician for more than 7 months. “It would require more than 400 FTE family physicians to fill all the vacancies for this discipline,” noted the authors.

Some of the greatest recruitment difficulties were reported for obstetrician/gynecologists and psychiatrists; rural locations reported more than 20% of funded positions vacant, and they had more recruitment difficulties, compared with urban CHCs. Dentists' vacancies also were indicated, with more than half of rural CHCs reporting a vacant position for 7 months or longer. Less difficulty was reported in recruiting nurse-practitioners and physician assistants, with no significant rural-urban differences.

When asked to indicate perceived barriers to recruitment and retention of both rural and urban CHC physicians and nurses, respondents consistently noted the inability to offer competitive compensation packages.

“The lack of spousal employment opportunities, lack of cultural activities and opportunities, lack of adequate housing, and poor-quality schools were perceived as disproportionately greater barriers for rural centers,” noted the authors. Survey respondents suggested three potential interventions to address these perceived barriers: better capacity to provide annual salary increases, more National Health Service Corps loan repayment incentives, and greater visibility of CHCs as desirable practice opportunities during training.

“The clinical role of CHCs is dependent on primary care clinicians, both physicians and nonphysician clinicians,” the authors wrote, noting that the declining production of family physicians from residency programs “may lead to serious workforce shortages, particularly in rural CHCs.” Roughly 66% of the responding CHCs indicated their plans to expand as part of a federal 5-year initiative to increase spending on CHCs by at least $2.2 billion through fiscal year 2006.

However, the decline in “physicians choosing generalist careers may be the rate-limiting step in the nation's ability to staff CHCs and may lead to renewed shortages of safety-net and rural physicians generally,” they wrote.

The authors made several suggestions, including the following, for federal and state governments, as well as for CHCs:

▸ Bolstering elements of the Health Professions Educational Assistance Act of 1976, the only federal program aimed at encouraging primary care clinicians who are likely to practice in underserved areas.

▸ Increasing the use of nurse-practitioners and physician assistants.

▸ Creating new alliances between CHCs and primary care training programs.

▸ Expanding the National Health Service Corps and related programs that provide financial incentives to attract health care clinicians to underserved areas.

▸ Developing new approaches to loan repayment plans.

▸ Creating additional incentives for rural areas.

Community health centers are currently clinically understaffed and will likely face increasing shortages that may limit their expansion, according to a study by the rural health research centers of both the University of Washington, Seattle, and the University of South Carolina, Columbia, and by the National Association of Community Health Centers (JAMA 2006;295:1042–9).

“Workforce shortages may impede the expansion of the U.S. [community health center] safety net, particularly in rural areas,” reported Dr. Roger A. Rosenblatt from the University of Washington, and his colleagues.

The study surveyed 846 federally funded community health centers (CHCs) within the 50 states and the District of Columbia. Mailed questionnaires and telephone surveys asked CHC chief executive officers about staffing and recruiting patterns, use of federal and state recruitment programs, and perceived barriers to recruitment.

Responses were obtained from 79% of the population and revealed that funded clinical staff vacancies are common. The average CHC has 13% of its family physician full-time equivalent positions unfilled. Rural CHCs reported a significantly higher proportion of these vacancies, as well as recruiting difficulties, compared with their urban counterparts, with more than one-third of rural CHCs reporting that they had been trying to recruit a family physician for more than 7 months. “It would require more than 400 FTE family physicians to fill all the vacancies for this discipline,” noted the authors.

Some of the greatest recruitment difficulties were reported for obstetrician/gynecologists and psychiatrists; rural locations reported more than 20% of funded positions vacant, and they had more recruitment difficulties, compared with urban CHCs. Dentists' vacancies also were indicated, with more than half of rural CHCs reporting a vacant position for 7 months or longer. Less difficulty was reported in recruiting nurse-practitioners and physician assistants, with no significant rural-urban differences.

When asked to indicate perceived barriers to recruitment and retention of both rural and urban CHC physicians and nurses, respondents consistently noted the inability to offer competitive compensation packages.

“The lack of spousal employment opportunities, lack of cultural activities and opportunities, lack of adequate housing, and poor-quality schools were perceived as disproportionately greater barriers for rural centers,” noted the authors. Survey respondents suggested three potential interventions to address these perceived barriers: better capacity to provide annual salary increases, more National Health Service Corps loan repayment incentives, and greater visibility of CHCs as desirable practice opportunities during training.

“The clinical role of CHCs is dependent on primary care clinicians, both physicians and nonphysician clinicians,” the authors wrote, noting that the declining production of family physicians from residency programs “may lead to serious workforce shortages, particularly in rural CHCs.” Roughly 66% of the responding CHCs indicated their plans to expand as part of a federal 5-year initiative to increase spending on CHCs by at least $2.2 billion through fiscal year 2006.

However, the decline in “physicians choosing generalist careers may be the rate-limiting step in the nation's ability to staff CHCs and may lead to renewed shortages of safety-net and rural physicians generally,” they wrote.

The authors made several suggestions, including the following, for federal and state governments, as well as for CHCs:

▸ Bolstering elements of the Health Professions Educational Assistance Act of 1976, the only federal program aimed at encouraging primary care clinicians who are likely to practice in underserved areas.

▸ Increasing the use of nurse-practitioners and physician assistants.

▸ Creating new alliances between CHCs and primary care training programs.

▸ Expanding the National Health Service Corps and related programs that provide financial incentives to attract health care clinicians to underserved areas.

▸ Developing new approaches to loan repayment plans.

▸ Creating additional incentives for rural areas.

Community health centers are currently clinically understaffed and will likely face increasing shortages that may limit their expansion, according to a study by the rural health research centers of both the University of Washington, Seattle, and the University of South Carolina, Columbia, and by the National Association of Community Health Centers (JAMA 2006;295:1042–9).

“Workforce shortages may impede the expansion of the U.S. [community health center] safety net, particularly in rural areas,” reported Dr. Roger A. Rosenblatt from the University of Washington, and his colleagues.

The study surveyed 846 federally funded community health centers (CHCs) within the 50 states and the District of Columbia. Mailed questionnaires and telephone surveys asked CHC chief executive officers about staffing and recruiting patterns, use of federal and state recruitment programs, and perceived barriers to recruitment.

Responses were obtained from 79% of the population and revealed that funded clinical staff vacancies are common. The average CHC has 13% of its family physician full-time equivalent positions unfilled. Rural CHCs reported a significantly higher proportion of these vacancies, as well as recruiting difficulties, compared with their urban counterparts, with more than one-third of rural CHCs reporting that they had been trying to recruit a family physician for more than 7 months. “It would require more than 400 FTE family physicians to fill all the vacancies for this discipline,” noted the authors.

Some of the greatest recruitment difficulties were reported for obstetrician/gynecologists and psychiatrists; rural locations reported more than 20% of funded positions vacant, and they had more recruitment difficulties, compared with urban CHCs. Dentists' vacancies also were indicated, with more than half of rural CHCs reporting a vacant position for 7 months or longer. Less difficulty was reported in recruiting nurse-practitioners and physician assistants, with no significant rural-urban differences.

When asked to indicate perceived barriers to recruitment and retention of both rural and urban CHC physicians and nurses, respondents consistently noted the inability to offer competitive compensation packages.

“The lack of spousal employment opportunities, lack of cultural activities and opportunities, lack of adequate housing, and poor-quality schools were perceived as disproportionately greater barriers for rural centers,” noted the authors. Survey respondents suggested three potential interventions to address these perceived barriers: better capacity to provide annual salary increases, more National Health Service Corps loan repayment incentives, and greater visibility of CHCs as desirable practice opportunities during training.

“The clinical role of CHCs is dependent on primary care clinicians, both physicians and nonphysician clinicians,” the authors wrote, noting that the declining production of family physicians from residency programs “may lead to serious workforce shortages, particularly in rural CHCs.” Roughly 66% of the responding CHCs indicated their plans to expand as part of a federal 5-year initiative to increase spending on CHCs by at least $2.2 billion through fiscal year 2006.

However, the decline in “physicians choosing generalist careers may be the rate-limiting step in the nation's ability to staff CHCs and may lead to renewed shortages of safety-net and rural physicians generally,” they wrote.

The authors made several suggestions, including the following, for federal and state governments, as well as for CHCs:

▸ Bolstering elements of the Health Professions Educational Assistance Act of 1976, the only federal program aimed at encouraging primary care clinicians who are likely to practice in underserved areas.

▸ Increasing the use of nurse-practitioners and physician assistants.

▸ Creating new alliances between CHCs and primary care training programs.

▸ Expanding the National Health Service Corps and related programs that provide financial incentives to attract health care clinicians to underserved areas.

▸ Developing new approaches to loan repayment plans.

▸ Creating additional incentives for rural areas.

TORONTO — Pregnancy could be viewed as a type of cardiovascular “stress test” that could uncover previously silent risk factors for future cardiovascular problems, according to Carl H. Hubel, Ph.D.

“Studying women during pregnancy may facilitate the identification of cardiovascular risk and offer an opportunity for early intervention to decrease their likelihood of developing problems later in life,” said Dr. Hubel of Magee Women's Research Institute in Pittsburgh.

Speaking at the annual meeting of the Society for Gynecologic Investigation, Dr. Hubel outlined his own work and that of other researchers that both show that preeclampsia and other complications relating to placental insufficiency such as low birth weight and preterm delivery are associated with an increased risk of cardiovascular events up to 30 years later.

“Metabolic factors predisposing to endothelial dysfunction such as insulin resistance, dyslipidemia, and inflammation may also predispose to preeclampsia and may later manifest as cardiovascular disease,” he said, suggesting that endothelial repair is a potential target on the horizon. “Surveillance of cardiovascular risk factors during pregnancy per se may help to identify additional subsets of women who would benefit from early and aggressive risk factor modification post partum.”

In a study of 30 women with a previous eclamptic pregnancy, Dr. Hubel and his colleagues found that 33% were taking blood pressure medications 30 years after the index pregnancy, compared with only 7% of controls (BJOG 2000;107:776–84). More recently, the same group of women also showed increased levels of C-reactive protein (CRP), an inflammatory marker of cardiovascular disease risk—and a higher prevalence of dyslipidemia, and insulin resistance compared with controls.

“We cannot rule out that preeclampsia is the cause, not the consequence, of these risk factors,” he said in an interview. “Preeclampsia has a prevalence rate of 3%–5% of pregnancies—so one would have to follow large numbers of women from preconception, through their pregnancies, and into later life just to capture enough women who develop preeclampsia to determine the answer.”

But regardless of this, he suggests women who have had preeclampsia, preterm birth, or a low-birth-weight baby should be monitored more closely for risk factors that might contribute to future cardiovascular risk.

“Perhaps this is a group of women that shouldn't wait until after age 45 to have their CRP and lipids measured,” Dr. Hubel said.

TORONTO — Pregnancy could be viewed as a type of cardiovascular “stress test” that could uncover previously silent risk factors for future cardiovascular problems, according to Carl H. Hubel, Ph.D.

“Studying women during pregnancy may facilitate the identification of cardiovascular risk and offer an opportunity for early intervention to decrease their likelihood of developing problems later in life,” said Dr. Hubel of Magee Women's Research Institute in Pittsburgh.

Speaking at the annual meeting of the Society for Gynecologic Investigation, Dr. Hubel outlined his own work and that of other researchers that both show that preeclampsia and other complications relating to placental insufficiency such as low birth weight and preterm delivery are associated with an increased risk of cardiovascular events up to 30 years later.

“Metabolic factors predisposing to endothelial dysfunction such as insulin resistance, dyslipidemia, and inflammation may also predispose to preeclampsia and may later manifest as cardiovascular disease,” he said, suggesting that endothelial repair is a potential target on the horizon. “Surveillance of cardiovascular risk factors during pregnancy per se may help to identify additional subsets of women who would benefit from early and aggressive risk factor modification post partum.”

In a study of 30 women with a previous eclamptic pregnancy, Dr. Hubel and his colleagues found that 33% were taking blood pressure medications 30 years after the index pregnancy, compared with only 7% of controls (BJOG 2000;107:776–84). More recently, the same group of women also showed increased levels of C-reactive protein (CRP), an inflammatory marker of cardiovascular disease risk—and a higher prevalence of dyslipidemia, and insulin resistance compared with controls.

“We cannot rule out that preeclampsia is the cause, not the consequence, of these risk factors,” he said in an interview. “Preeclampsia has a prevalence rate of 3%–5% of pregnancies—so one would have to follow large numbers of women from preconception, through their pregnancies, and into later life just to capture enough women who develop preeclampsia to determine the answer.”

But regardless of this, he suggests women who have had preeclampsia, preterm birth, or a low-birth-weight baby should be monitored more closely for risk factors that might contribute to future cardiovascular risk.

“Perhaps this is a group of women that shouldn't wait until after age 45 to have their CRP and lipids measured,” Dr. Hubel said.

TORONTO — Pregnancy could be viewed as a type of cardiovascular “stress test” that could uncover previously silent risk factors for future cardiovascular problems, according to Carl H. Hubel, Ph.D.

“Studying women during pregnancy may facilitate the identification of cardiovascular risk and offer an opportunity for early intervention to decrease their likelihood of developing problems later in life,” said Dr. Hubel of Magee Women's Research Institute in Pittsburgh.

Speaking at the annual meeting of the Society for Gynecologic Investigation, Dr. Hubel outlined his own work and that of other researchers that both show that preeclampsia and other complications relating to placental insufficiency such as low birth weight and preterm delivery are associated with an increased risk of cardiovascular events up to 30 years later.

“Metabolic factors predisposing to endothelial dysfunction such as insulin resistance, dyslipidemia, and inflammation may also predispose to preeclampsia and may later manifest as cardiovascular disease,” he said, suggesting that endothelial repair is a potential target on the horizon. “Surveillance of cardiovascular risk factors during pregnancy per se may help to identify additional subsets of women who would benefit from early and aggressive risk factor modification post partum.”

In a study of 30 women with a previous eclamptic pregnancy, Dr. Hubel and his colleagues found that 33% were taking blood pressure medications 30 years after the index pregnancy, compared with only 7% of controls (BJOG 2000;107:776–84). More recently, the same group of women also showed increased levels of C-reactive protein (CRP), an inflammatory marker of cardiovascular disease risk—and a higher prevalence of dyslipidemia, and insulin resistance compared with controls.

“We cannot rule out that preeclampsia is the cause, not the consequence, of these risk factors,” he said in an interview. “Preeclampsia has a prevalence rate of 3%–5% of pregnancies—so one would have to follow large numbers of women from preconception, through their pregnancies, and into later life just to capture enough women who develop preeclampsia to determine the answer.”

But regardless of this, he suggests women who have had preeclampsia, preterm birth, or a low-birth-weight baby should be monitored more closely for risk factors that might contribute to future cardiovascular risk.

“Perhaps this is a group of women that shouldn't wait until after age 45 to have their CRP and lipids measured,” Dr. Hubel said.

TORONTO — Physicians weighing the risks versus benefits of medicating nonobstetric conditions during pregnancy should consider that their dilemma is not one of fetal exposure versus nonexposure, according to Dr. Zachary N. Stowe, a psychiatrist and director of the Women's Mental Health Program at Emory University, Atlanta.

“You expose the fetus to something, be it illness or the treatment,” he said at the annual meeting of the Society for Gynecologic Investigation. And amid the growing evidence of risks associated with prenatal exposure to antidepressants is the danger of losing sight of alternative risks, he said.

“Of concern to me is that often, the treatment of mental illness is viewed as more 'optional' than, for example, [the treatment of] epilepsy, hypertension, or infection—despite the fact that there are considerably more data demonstrating that maternal depression and anxiety may have more severe sequelae, particularly with respect to child development,” Dr. Stowe said in an interview.

The impact—both short and long term—of prenatal exposure to untreated mental illness should not be underestimated, he warned. Studies show that low birth weight (LBW), small for gestational age (SGA), and preterm delivery are linked with untreated major depression and anxiety disorders. Untreated schizophrenia is also linked with LBW and SGA, as well as stillbirth and increased infant mortality.

Moreover, untreated eating disorders are associated with LBW and preterm delivery. In the long term, prenatal exposure to untreated major depression has been linked to motor delays, reactivity, attention problems, and EEG alternations in offspring. And untreated anxiety disorders are associated with conduct disorder and increased anxiety in offspring, said Dr. Stowe, who acknowledges receiving research grants and serving on the speakers' bureaus of “most pharmaceutical companies” that make antidepressants.

Even with medication, depression relapse rates are higher in pregnancy than among nonpregnant women. In a recent prospective study of 201 women with major depression, Dr. Stowe and his colleagues showed a 26% relapse rate among those who maintained their medication until delivery. Women who discontinued their medication had a relapse rate of 68% (JAMA 2006;295:499–507).

Dr. Stowe emphasized that his group's recent review of the literature shows that in almost 17,000 cases of prenatal antidepressant exposure, the highest malformation rate associated with a particular antidepressant is 3.5%. That was the rate found for paroxetine (Paxil).

He stressed that while caution is always imperative when prescribing medication during pregnancy, the Food and Drug Administration's drug categorization system is of little help to prescribers and is more useful for those seeking liability protection.

“I agree with Dr. M. Schou, who wrote in the Journal of Affective Disorders that 'when manufacturers and official agencies warn against drug treatment during pregnancy, their warnings serve to protect themselves and are of little use to clinically responsible physicians,' ” he said (J. Affect. Disord. 2001; 67:21–32).

While stressing the importance of treating mental illness in pregnancy, Dr. Stowe said it is important that physicians do not underplay fetal exposure to the medication. “The fetus doesn't get exposed to the mother's dose,” he noted. “It gets exposed to the mother's serum concentrations.” However, his extensive work documenting placental passage of antidepressants and measuring amniotic fluid concentrations of these medications shows that the fetus is exposed to “not a trivial amount. I have heard MDs tell patients that 'the baby really does not get much medication' when they are discussing other medications—which is obviously not true with antidepressants, and mostly unknown for other medications,” he said.

His recently published study measured amniotic fluid concentrations of antidepressants at approximately 10% of maternal serum concentrations (Am. J. Psychiatry 2006;163:145–7), and some of his unpublished work suggests that umbilical cord concentrations of antidepressants at delivery are typically more than 50% of maternal concentrations.

Dr. Stowe said physicians who choose to prescribe antidepressants in pregnancy should also keep the pharmacokinetics and pharmacodynamics of pregnancy in mind and be aware that maternal serum concentrations decrease over the course of pregnancy. “It is important to consider increasing the dose, if necessary, to maintain an adequate maternal response.”

In an accompanying presentation, Dr. Ruth E. Tuomala echoed Dr. Stowe's message, but in the context of a very different condition: HIV. Compared with depression, the consequences of fetal and neonatal exposure to HIV are perhaps more widely appreciated within both medical and lay circles. However, the benefits of perinatal prophylactic measures can be lost if antiretroviral therapy (ART) is inadequate, she warned.

Where physicians often try to minimize certain medication exposures during pregnancy, they should be thinking about maximizing ART in pregnant HIV-positive patients with the goal of reducing the risk of perinatal transmission, said Dr. Tuomala of Harvard Medical School, Boston.

The indications for ART in nonpregnant patients are a CD4+ count of 350 or less and a detectable viral load; however, these requirements are relaxed in pregnancy. “Thus antiretrovirals are given to many pregnant women with HIV who would not otherwise receive them [if they were not pregnant],” she said. Aggressive treatment with potent combination therapies has been shown to reduce the perinatal transmission rate to 1%, compared with a 21% transmission rate when no ART is used (J. Acquir. Immune Defic. Syndr. 2002;29:484–94), she said.

But to maximize its effectiveness, this aggressive therapy must be maintained throughout the pregnancy and the delivery. “The goal should be to minimize the maternal viral load at delivery and maximize fetal intracellular antiretroviral levels, as well as to provide postexposure prophylaxis to infants,” she said.

On the safety of ART, pregnancy outcome studies do not suggest an increase in spontaneous abortion, stillbirth, LBW, or low Apgar scores in association with these medications—and so there is no need to stop these drugs, she said. In fact, if any medication needs to be stopped because of hyperemesis, she recommends all medications be eliminated together to avoid the risk of developing resistance.

The only exception to this is efavirenz (Sustiva, Bristol-Myers Squibb), which is the only HIV medication now classified as category D because it has been linked to an increase in neural tube defects, she said. This drug should ideally be stopped before conception. “Acknowledge that HIV-infected women are choosing to get pregnant; give them preconception counseling, and get them off this drug before they conceive,” she advised. In addition, there is some suggestion of an association between nucleoside reverse transcriptase inhibitors (NRTIs) and neonatal mitochondrial toxicity syndrome.

Maternal toxicities associated with ART can include gastrointestinal problems, anemia, and/or hepatic steatosis/lactic acidosis (NRTIs); hyperglycemia (protease inhibitors); and hepatitis (nevirapine and others).

ELSEVIER GLOBAL MEDICAL NEWS

TORONTO — Physicians weighing the risks versus benefits of medicating nonobstetric conditions during pregnancy should consider that their dilemma is not one of fetal exposure versus nonexposure, according to Dr. Zachary N. Stowe, a psychiatrist and director of the Women's Mental Health Program at Emory University, Atlanta.

“You expose the fetus to something, be it illness or the treatment,” he said at the annual meeting of the Society for Gynecologic Investigation. And amid the growing evidence of risks associated with prenatal exposure to antidepressants is the danger of losing sight of alternative risks, he said.

“Of concern to me is that often, the treatment of mental illness is viewed as more 'optional' than, for example, [the treatment of] epilepsy, hypertension, or infection—despite the fact that there are considerably more data demonstrating that maternal depression and anxiety may have more severe sequelae, particularly with respect to child development,” Dr. Stowe said in an interview.

The impact—both short and long term—of prenatal exposure to untreated mental illness should not be underestimated, he warned. Studies show that low birth weight (LBW), small for gestational age (SGA), and preterm delivery are linked with untreated major depression and anxiety disorders. Untreated schizophrenia is also linked with LBW and SGA, as well as stillbirth and increased infant mortality.

Moreover, untreated eating disorders are associated with LBW and preterm delivery. In the long term, prenatal exposure to untreated major depression has been linked to motor delays, reactivity, attention problems, and EEG alternations in offspring. And untreated anxiety disorders are associated with conduct disorder and increased anxiety in offspring, said Dr. Stowe, who acknowledges receiving research grants and serving on the speakers' bureaus of “most pharmaceutical companies” that make antidepressants.

Even with medication, depression relapse rates are higher in pregnancy than among nonpregnant women. In a recent prospective study of 201 women with major depression, Dr. Stowe and his colleagues showed a 26% relapse rate among those who maintained their medication until delivery. Women who discontinued their medication had a relapse rate of 68% (JAMA 2006;295:499–507).

Dr. Stowe emphasized that his group's recent review of the literature shows that in almost 17,000 cases of prenatal antidepressant exposure, the highest malformation rate associated with a particular antidepressant is 3.5%. That was the rate found for paroxetine (Paxil).

He stressed that while caution is always imperative when prescribing medication during pregnancy, the Food and Drug Administration's drug categorization system is of little help to prescribers and is more useful for those seeking liability protection.

“I agree with Dr. M. Schou, who wrote in the Journal of Affective Disorders that 'when manufacturers and official agencies warn against drug treatment during pregnancy, their warnings serve to protect themselves and are of little use to clinically responsible physicians,' ” he said (J. Affect. Disord. 2001; 67:21–32).

While stressing the importance of treating mental illness in pregnancy, Dr. Stowe said it is important that physicians do not underplay fetal exposure to the medication. “The fetus doesn't get exposed to the mother's dose,” he noted. “It gets exposed to the mother's serum concentrations.” However, his extensive work documenting placental passage of antidepressants and measuring amniotic fluid concentrations of these medications shows that the fetus is exposed to “not a trivial amount. I have heard MDs tell patients that 'the baby really does not get much medication' when they are discussing other medications—which is obviously not true with antidepressants, and mostly unknown for other medications,” he said.

His recently published study measured amniotic fluid concentrations of antidepressants at approximately 10% of maternal serum concentrations (Am. J. Psychiatry 2006;163:145–7), and some of his unpublished work suggests that umbilical cord concentrations of antidepressants at delivery are typically more than 50% of maternal concentrations.

Dr. Stowe said physicians who choose to prescribe antidepressants in pregnancy should also keep the pharmacokinetics and pharmacodynamics of pregnancy in mind and be aware that maternal serum concentrations decrease over the course of pregnancy. “It is important to consider increasing the dose, if necessary, to maintain an adequate maternal response.”

In an accompanying presentation, Dr. Ruth E. Tuomala echoed Dr. Stowe's message, but in the context of a very different condition: HIV. Compared with depression, the consequences of fetal and neonatal exposure to HIV are perhaps more widely appreciated within both medical and lay circles. However, the benefits of perinatal prophylactic measures can be lost if antiretroviral therapy (ART) is inadequate, she warned.

Where physicians often try to minimize certain medication exposures during pregnancy, they should be thinking about maximizing ART in pregnant HIV-positive patients with the goal of reducing the risk of perinatal transmission, said Dr. Tuomala of Harvard Medical School, Boston.

The indications for ART in nonpregnant patients are a CD4+ count of 350 or less and a detectable viral load; however, these requirements are relaxed in pregnancy. “Thus antiretrovirals are given to many pregnant women with HIV who would not otherwise receive them [if they were not pregnant],” she said. Aggressive treatment with potent combination therapies has been shown to reduce the perinatal transmission rate to 1%, compared with a 21% transmission rate when no ART is used (J. Acquir. Immune Defic. Syndr. 2002;29:484–94), she said.

But to maximize its effectiveness, this aggressive therapy must be maintained throughout the pregnancy and the delivery. “The goal should be to minimize the maternal viral load at delivery and maximize fetal intracellular antiretroviral levels, as well as to provide postexposure prophylaxis to infants,” she said.

On the safety of ART, pregnancy outcome studies do not suggest an increase in spontaneous abortion, stillbirth, LBW, or low Apgar scores in association with these medications—and so there is no need to stop these drugs, she said. In fact, if any medication needs to be stopped because of hyperemesis, she recommends all medications be eliminated together to avoid the risk of developing resistance.

The only exception to this is efavirenz (Sustiva, Bristol-Myers Squibb), which is the only HIV medication now classified as category D because it has been linked to an increase in neural tube defects, she said. This drug should ideally be stopped before conception. “Acknowledge that HIV-infected women are choosing to get pregnant; give them preconception counseling, and get them off this drug before they conceive,” she advised. In addition, there is some suggestion of an association between nucleoside reverse transcriptase inhibitors (NRTIs) and neonatal mitochondrial toxicity syndrome.

Maternal toxicities associated with ART can include gastrointestinal problems, anemia, and/or hepatic steatosis/lactic acidosis (NRTIs); hyperglycemia (protease inhibitors); and hepatitis (nevirapine and others).

ELSEVIER GLOBAL MEDICAL NEWS

TORONTO — Physicians weighing the risks versus benefits of medicating nonobstetric conditions during pregnancy should consider that their dilemma is not one of fetal exposure versus nonexposure, according to Dr. Zachary N. Stowe, a psychiatrist and director of the Women's Mental Health Program at Emory University, Atlanta.

“You expose the fetus to something, be it illness or the treatment,” he said at the annual meeting of the Society for Gynecologic Investigation. And amid the growing evidence of risks associated with prenatal exposure to antidepressants is the danger of losing sight of alternative risks, he said.

“Of concern to me is that often, the treatment of mental illness is viewed as more 'optional' than, for example, [the treatment of] epilepsy, hypertension, or infection—despite the fact that there are considerably more data demonstrating that maternal depression and anxiety may have more severe sequelae, particularly with respect to child development,” Dr. Stowe said in an interview.

The impact—both short and long term—of prenatal exposure to untreated mental illness should not be underestimated, he warned. Studies show that low birth weight (LBW), small for gestational age (SGA), and preterm delivery are linked with untreated major depression and anxiety disorders. Untreated schizophrenia is also linked with LBW and SGA, as well as stillbirth and increased infant mortality.

Moreover, untreated eating disorders are associated with LBW and preterm delivery. In the long term, prenatal exposure to untreated major depression has been linked to motor delays, reactivity, attention problems, and EEG alternations in offspring. And untreated anxiety disorders are associated with conduct disorder and increased anxiety in offspring, said Dr. Stowe, who acknowledges receiving research grants and serving on the speakers' bureaus of “most pharmaceutical companies” that make antidepressants.

Even with medication, depression relapse rates are higher in pregnancy than among nonpregnant women. In a recent prospective study of 201 women with major depression, Dr. Stowe and his colleagues showed a 26% relapse rate among those who maintained their medication until delivery. Women who discontinued their medication had a relapse rate of 68% (JAMA 2006;295:499–507).

Dr. Stowe emphasized that his group's recent review of the literature shows that in almost 17,000 cases of prenatal antidepressant exposure, the highest malformation rate associated with a particular antidepressant is 3.5%. That was the rate found for paroxetine (Paxil).

He stressed that while caution is always imperative when prescribing medication during pregnancy, the Food and Drug Administration's drug categorization system is of little help to prescribers and is more useful for those seeking liability protection.

“I agree with Dr. M. Schou, who wrote in the Journal of Affective Disorders that 'when manufacturers and official agencies warn against drug treatment during pregnancy, their warnings serve to protect themselves and are of little use to clinically responsible physicians,' ” he said (J. Affect. Disord. 2001; 67:21–32).

While stressing the importance of treating mental illness in pregnancy, Dr. Stowe said it is important that physicians do not underplay fetal exposure to the medication. “The fetus doesn't get exposed to the mother's dose,” he noted. “It gets exposed to the mother's serum concentrations.” However, his extensive work documenting placental passage of antidepressants and measuring amniotic fluid concentrations of these medications shows that the fetus is exposed to “not a trivial amount. I have heard MDs tell patients that 'the baby really does not get much medication' when they are discussing other medications—which is obviously not true with antidepressants, and mostly unknown for other medications,” he said.

His recently published study measured amniotic fluid concentrations of antidepressants at approximately 10% of maternal serum concentrations (Am. J. Psychiatry 2006;163:145–7), and some of his unpublished work suggests that umbilical cord concentrations of antidepressants at delivery are typically more than 50% of maternal concentrations.

Dr. Stowe said physicians who choose to prescribe antidepressants in pregnancy should also keep the pharmacokinetics and pharmacodynamics of pregnancy in mind and be aware that maternal serum concentrations decrease over the course of pregnancy. “It is important to consider increasing the dose, if necessary, to maintain an adequate maternal response.”

In an accompanying presentation, Dr. Ruth E. Tuomala echoed Dr. Stowe's message, but in the context of a very different condition: HIV. Compared with depression, the consequences of fetal and neonatal exposure to HIV are perhaps more widely appreciated within both medical and lay circles. However, the benefits of perinatal prophylactic measures can be lost if antiretroviral therapy (ART) is inadequate, she warned.

Where physicians often try to minimize certain medication exposures during pregnancy, they should be thinking about maximizing ART in pregnant HIV-positive patients with the goal of reducing the risk of perinatal transmission, said Dr. Tuomala of Harvard Medical School, Boston.

The indications for ART in nonpregnant patients are a CD4+ count of 350 or less and a detectable viral load; however, these requirements are relaxed in pregnancy. “Thus antiretrovirals are given to many pregnant women with HIV who would not otherwise receive them [if they were not pregnant],” she said. Aggressive treatment with potent combination therapies has been shown to reduce the perinatal transmission rate to 1%, compared with a 21% transmission rate when no ART is used (J. Acquir. Immune Defic. Syndr. 2002;29:484–94), she said.

But to maximize its effectiveness, this aggressive therapy must be maintained throughout the pregnancy and the delivery. “The goal should be to minimize the maternal viral load at delivery and maximize fetal intracellular antiretroviral levels, as well as to provide postexposure prophylaxis to infants,” she said.

On the safety of ART, pregnancy outcome studies do not suggest an increase in spontaneous abortion, stillbirth, LBW, or low Apgar scores in association with these medications—and so there is no need to stop these drugs, she said. In fact, if any medication needs to be stopped because of hyperemesis, she recommends all medications be eliminated together to avoid the risk of developing resistance.

The only exception to this is efavirenz (Sustiva, Bristol-Myers Squibb), which is the only HIV medication now classified as category D because it has been linked to an increase in neural tube defects, she said. This drug should ideally be stopped before conception. “Acknowledge that HIV-infected women are choosing to get pregnant; give them preconception counseling, and get them off this drug before they conceive,” she advised. In addition, there is some suggestion of an association between nucleoside reverse transcriptase inhibitors (NRTIs) and neonatal mitochondrial toxicity syndrome.

Maternal toxicities associated with ART can include gastrointestinal problems, anemia, and/or hepatic steatosis/lactic acidosis (NRTIs); hyperglycemia (protease inhibitors); and hepatitis (nevirapine and others).

ELSEVIER GLOBAL MEDICAL NEWS

TORONTO — Physicians weighing the risks versus benefits of medicating nonobstetric conditions during pregnancy should consider that their dilemma is not one of fetal exposure versus nonexposure, according to Dr. Zachary N. Stowe, a psychiatrist and director of the Women's Mental Health Program at Emory University, Atlanta.

“You expose the fetus to something, be it illness or the treatment,” he said at the annual meeting of the Society for Gynecologic Investigation. And amid the growing evidence of risks associated with prenatal exposure to antidepressants is the danger of losing sight of alternative risks, he said.

“Of concern to me is that often, the treatment of mental illness is viewed as more 'optional' than, for example, [the treatment of] epilepsy, hypertension, or infection—despite the fact that there are considerably more data demonstrating that maternal depression and anxiety may have more severe sequelae, particularly with respect to child development,” Dr. Stowe said in an interview.

The impact—both short- and long-term—of prenatal exposure to untreated mental illness should not be underestimated, he warned. Studies show that low birth weight (LBW), small for gestational age (SGA), and preterm delivery are linked with untreated major depression and anxiety disorders. Untreated schizophrenia is also linked with LBW and SGA, as well as stillbirth and increased infant mortality.

And untreated eating disorders are associated with LBW and preterm delivery. In the long term, prenatal exposure to untreated major depression has been linked to motor delays, reactivity, attention problems, and EEG alternations in offspring. And untreated anxiety disorders are associated with conduct disorder and increased anxiety in offspring, said Dr. Stowe, who acknowledges receiving research grants and serving on the speakers' bureaus of “most pharmaceutical companies” that make antidepressants.

Even with medication, depression relapse rates are higher in pregnancy than among nonpregnant women. In a recent prospective study of 201 women with major depression, Dr. Stowe and his colleagues showed a 26% relapse rate among those who maintained their medication until delivery. Women who discontinued their medication had a relapse rate of 68% (JAMA 2006;295:499–507).

In his group's recent review of the literature, in almost 17,000 cases of prenatal antidepressant exposure, the highest malformation rate associated with a particular antidepressant is 3.5%. That was the rate found for paroxetine (Paxil).

He stressed that while caution is always imperative when prescribing medication during pregnancy, the Food and Drug Administration's drug categorization system is of little help to prescribers and is more useful for those seeking liability protection.

While stressing the importance of treating mental illness in pregnancy, Dr. Stowe said it is important that physicians do not underplay fetal exposure to the medication. “The fetus doesn't get exposed to the mother's dose,” he noted. “It gets exposed to the mother's serum concentrations.” However, his extensive work documenting placental passage of antidepressants and measuring amniotic fluid concentrations of these medications shows that the fetus is exposed to “not a trivial amount,” he said.

His recently published study measured amniotic fluid concentrations of antidepressants at approximately 10% of maternal serum concentrations (Am. J. Psychiatry 2006;163:145–7), and some of his unpublished work suggests that umbilical cord concentrations of antidepressants at delivery are typically more than 50% of maternal concentrations.

Dr. Stowe said physicians who choose to prescribe antidepressants in pregnancy should also keep the pharmacokinetics and pharmacodynamics of pregnancy in mind and be aware that maternal serum concentrations decrease over the course of pregnancy.

In an accompanying presentation, Dr. Ruth E. Tuomala echoed Dr. Stowe's message, but in the context of a very different condition: HIV. Compared with depression, the consequences of fetal and neonatal exposure to HIV are perhaps more widely appreciated within both medical and lay circles. However, the benefits of perinatal prophylactic measures can be lost if antiretroviral therapy (ART) is inadequate, she warned.

The indications for ART in nonpregnant patients are a CD4+ count of 350 or less and a detectable viral load; however, these requirements are relaxed in pregnancy. “Thus antiretrovirals are given to many pregnant women with HIV who would not otherwise receive them [if they were not pregnant],” she said. Aggressive treatment with potent combination therapies has been shown to reduce the perinatal transmission rate to 1%, compared with a 21% transmission rate when no ART is used (J. Acquir. Immune Defic. Syndr. 2002;29:484–94), she said.

But to maximize its effectiveness, this aggressive therapy must be maintained throughout the pregnancy and the delivery. “The goal should be to minimize the maternal viral load at delivery and maximize fetal intracellular antiretroviral levels, as well as to provide postexposure prophylaxis to infants,” said Dr. Tuomala of Harvard Medical School, Boston..

On the safety of ART, pregnancy outcome studies do not suggest an increase in spontaneous abortion, stillbirth, LBW, or low Apgar scores in association with these medications—and so there is no need to stop these drugs, she said. In fact, if any medication needs to be stopped because of hyperemesis, she recommends all medications be eliminated together to avoid the risk of developing resistance.

The only exception to this is efavirenz (Sustiva, Bristol-Myers Squibb), which is the only HIV medication now classified as category D because it has been linked to an increase in neural tube defects, she said. This drug should ideally be stopped before conception.

TORONTO — Physicians weighing the risks versus benefits of medicating nonobstetric conditions during pregnancy should consider that their dilemma is not one of fetal exposure versus nonexposure, according to Dr. Zachary N. Stowe, a psychiatrist and director of the Women's Mental Health Program at Emory University, Atlanta.

“You expose the fetus to something, be it illness or the treatment,” he said at the annual meeting of the Society for Gynecologic Investigation. And amid the growing evidence of risks associated with prenatal exposure to antidepressants is the danger of losing sight of alternative risks, he said.

“Of concern to me is that often, the treatment of mental illness is viewed as more 'optional' than, for example, [the treatment of] epilepsy, hypertension, or infection—despite the fact that there are considerably more data demonstrating that maternal depression and anxiety may have more severe sequelae, particularly with respect to child development,” Dr. Stowe said in an interview.

The impact—both short- and long-term—of prenatal exposure to untreated mental illness should not be underestimated, he warned. Studies show that low birth weight (LBW), small for gestational age (SGA), and preterm delivery are linked with untreated major depression and anxiety disorders. Untreated schizophrenia is also linked with LBW and SGA, as well as stillbirth and increased infant mortality.

And untreated eating disorders are associated with LBW and preterm delivery. In the long term, prenatal exposure to untreated major depression has been linked to motor delays, reactivity, attention problems, and EEG alternations in offspring. And untreated anxiety disorders are associated with conduct disorder and increased anxiety in offspring, said Dr. Stowe, who acknowledges receiving research grants and serving on the speakers' bureaus of “most pharmaceutical companies” that make antidepressants.

Even with medication, depression relapse rates are higher in pregnancy than among nonpregnant women. In a recent prospective study of 201 women with major depression, Dr. Stowe and his colleagues showed a 26% relapse rate among those who maintained their medication until delivery. Women who discontinued their medication had a relapse rate of 68% (JAMA 2006;295:499–507).

In his group's recent review of the literature, in almost 17,000 cases of prenatal antidepressant exposure, the highest malformation rate associated with a particular antidepressant is 3.5%. That was the rate found for paroxetine (Paxil).

He stressed that while caution is always imperative when prescribing medication during pregnancy, the Food and Drug Administration's drug categorization system is of little help to prescribers and is more useful for those seeking liability protection.

While stressing the importance of treating mental illness in pregnancy, Dr. Stowe said it is important that physicians do not underplay fetal exposure to the medication. “The fetus doesn't get exposed to the mother's dose,” he noted. “It gets exposed to the mother's serum concentrations.” However, his extensive work documenting placental passage of antidepressants and measuring amniotic fluid concentrations of these medications shows that the fetus is exposed to “not a trivial amount,” he said.

His recently published study measured amniotic fluid concentrations of antidepressants at approximately 10% of maternal serum concentrations (Am. J. Psychiatry 2006;163:145–7), and some of his unpublished work suggests that umbilical cord concentrations of antidepressants at delivery are typically more than 50% of maternal concentrations.

Dr. Stowe said physicians who choose to prescribe antidepressants in pregnancy should also keep the pharmacokinetics and pharmacodynamics of pregnancy in mind and be aware that maternal serum concentrations decrease over the course of pregnancy.

In an accompanying presentation, Dr. Ruth E. Tuomala echoed Dr. Stowe's message, but in the context of a very different condition: HIV. Compared with depression, the consequences of fetal and neonatal exposure to HIV are perhaps more widely appreciated within both medical and lay circles. However, the benefits of perinatal prophylactic measures can be lost if antiretroviral therapy (ART) is inadequate, she warned.

The indications for ART in nonpregnant patients are a CD4+ count of 350 or less and a detectable viral load; however, these requirements are relaxed in pregnancy. “Thus antiretrovirals are given to many pregnant women with HIV who would not otherwise receive them [if they were not pregnant],” she said. Aggressive treatment with potent combination therapies has been shown to reduce the perinatal transmission rate to 1%, compared with a 21% transmission rate when no ART is used (J. Acquir. Immune Defic. Syndr. 2002;29:484–94), she said.

But to maximize its effectiveness, this aggressive therapy must be maintained throughout the pregnancy and the delivery. “The goal should be to minimize the maternal viral load at delivery and maximize fetal intracellular antiretroviral levels, as well as to provide postexposure prophylaxis to infants,” said Dr. Tuomala of Harvard Medical School, Boston..

On the safety of ART, pregnancy outcome studies do not suggest an increase in spontaneous abortion, stillbirth, LBW, or low Apgar scores in association with these medications—and so there is no need to stop these drugs, she said. In fact, if any medication needs to be stopped because of hyperemesis, she recommends all medications be eliminated together to avoid the risk of developing resistance.

The only exception to this is efavirenz (Sustiva, Bristol-Myers Squibb), which is the only HIV medication now classified as category D because it has been linked to an increase in neural tube defects, she said. This drug should ideally be stopped before conception.

TORONTO — Physicians weighing the risks versus benefits of medicating nonobstetric conditions during pregnancy should consider that their dilemma is not one of fetal exposure versus nonexposure, according to Dr. Zachary N. Stowe, a psychiatrist and director of the Women's Mental Health Program at Emory University, Atlanta.

“You expose the fetus to something, be it illness or the treatment,” he said at the annual meeting of the Society for Gynecologic Investigation. And amid the growing evidence of risks associated with prenatal exposure to antidepressants is the danger of losing sight of alternative risks, he said.

“Of concern to me is that often, the treatment of mental illness is viewed as more 'optional' than, for example, [the treatment of] epilepsy, hypertension, or infection—despite the fact that there are considerably more data demonstrating that maternal depression and anxiety may have more severe sequelae, particularly with respect to child development,” Dr. Stowe said in an interview.

The impact—both short- and long-term—of prenatal exposure to untreated mental illness should not be underestimated, he warned. Studies show that low birth weight (LBW), small for gestational age (SGA), and preterm delivery are linked with untreated major depression and anxiety disorders. Untreated schizophrenia is also linked with LBW and SGA, as well as stillbirth and increased infant mortality.

And untreated eating disorders are associated with LBW and preterm delivery. In the long term, prenatal exposure to untreated major depression has been linked to motor delays, reactivity, attention problems, and EEG alternations in offspring. And untreated anxiety disorders are associated with conduct disorder and increased anxiety in offspring, said Dr. Stowe, who acknowledges receiving research grants and serving on the speakers' bureaus of “most pharmaceutical companies” that make antidepressants.

Even with medication, depression relapse rates are higher in pregnancy than among nonpregnant women. In a recent prospective study of 201 women with major depression, Dr. Stowe and his colleagues showed a 26% relapse rate among those who maintained their medication until delivery. Women who discontinued their medication had a relapse rate of 68% (JAMA 2006;295:499–507).

In his group's recent review of the literature, in almost 17,000 cases of prenatal antidepressant exposure, the highest malformation rate associated with a particular antidepressant is 3.5%. That was the rate found for paroxetine (Paxil).

He stressed that while caution is always imperative when prescribing medication during pregnancy, the Food and Drug Administration's drug categorization system is of little help to prescribers and is more useful for those seeking liability protection.

While stressing the importance of treating mental illness in pregnancy, Dr. Stowe said it is important that physicians do not underplay fetal exposure to the medication. “The fetus doesn't get exposed to the mother's dose,” he noted. “It gets exposed to the mother's serum concentrations.” However, his extensive work documenting placental passage of antidepressants and measuring amniotic fluid concentrations of these medications shows that the fetus is exposed to “not a trivial amount,” he said.

His recently published study measured amniotic fluid concentrations of antidepressants at approximately 10% of maternal serum concentrations (Am. J. Psychiatry 2006;163:145–7), and some of his unpublished work suggests that umbilical cord concentrations of antidepressants at delivery are typically more than 50% of maternal concentrations.

Dr. Stowe said physicians who choose to prescribe antidepressants in pregnancy should also keep the pharmacokinetics and pharmacodynamics of pregnancy in mind and be aware that maternal serum concentrations decrease over the course of pregnancy.

In an accompanying presentation, Dr. Ruth E. Tuomala echoed Dr. Stowe's message, but in the context of a very different condition: HIV. Compared with depression, the consequences of fetal and neonatal exposure to HIV are perhaps more widely appreciated within both medical and lay circles. However, the benefits of perinatal prophylactic measures can be lost if antiretroviral therapy (ART) is inadequate, she warned.

The indications for ART in nonpregnant patients are a CD4+ count of 350 or less and a detectable viral load; however, these requirements are relaxed in pregnancy. “Thus antiretrovirals are given to many pregnant women with HIV who would not otherwise receive them [if they were not pregnant],” she said. Aggressive treatment with potent combination therapies has been shown to reduce the perinatal transmission rate to 1%, compared with a 21% transmission rate when no ART is used (J. Acquir. Immune Defic. Syndr. 2002;29:484–94), she said.

But to maximize its effectiveness, this aggressive therapy must be maintained throughout the pregnancy and the delivery. “The goal should be to minimize the maternal viral load at delivery and maximize fetal intracellular antiretroviral levels, as well as to provide postexposure prophylaxis to infants,” said Dr. Tuomala of Harvard Medical School, Boston..

On the safety of ART, pregnancy outcome studies do not suggest an increase in spontaneous abortion, stillbirth, LBW, or low Apgar scores in association with these medications—and so there is no need to stop these drugs, she said. In fact, if any medication needs to be stopped because of hyperemesis, she recommends all medications be eliminated together to avoid the risk of developing resistance.

The only exception to this is efavirenz (Sustiva, Bristol-Myers Squibb), which is the only HIV medication now classified as category D because it has been linked to an increase in neural tube defects, she said. This drug should ideally be stopped before conception.

CHICAGO — The “D test” is a critical second-step test when methicillin-resistant Staphylococcus aureus cultures come back showing erythromycin resistance and clindamycin susceptibility, according to Dr. Jeffrey Starke.

“It should be automatic—every hospital in the country should know about this test. If you are not running it, you have to start,” cautioned Dr. Starke, professor and vice chairman of pediatrics at Baylor College of Medicine, Houston.

As the number of methicillin-resistant Staphylococcus aureus (MRSA) infections has escalated to epidemic proportions at Texas Children's Hospital, discordance in the bacteria's response to erythromycin and clindamycin has become a red flag for the organism's potential to develop “inducible resistance” to clindamycin, Dr. Starke said at a meeting sponsored by the American College of Emergency Physicians.

“If it's erythromycin and clindamycin susceptible initially, or resistant to both initially, there is no issue,” he explained. “But it's when there is discordance—when it shows erythromycin resistance but clindamycin susceptibility—that this test needs to be done.”

The clindamycin disk induction test, or D test, will determine if the organism is truly susceptible to clindamycin or if there is a risk of inducible clindamycin resistance, he said.

“When an isolate has inducible clindamycin resistance, treatment failures often occur when clindamycin is used—especially if the infection is serious or deep-seated,” Dr. Starke said.

The current epidemic of community-acquired MRSA infection differs from the traditional disease in terms of both the risk factors and the aggressiveness of the infection, he said.

“Patients are almost exclusively normal hosts,” he said, listing current risk factors as race (African Americans have significantly increased risk, compared with whites), prior infections, infected household contacts, day care, and competitive athletics.

Unlike the traditional MRSA involvement of skin and soft tissue (and sometimes muscle, bone, or joints), current infections can involve all these areas simultaneously and continue to progress. “We are seeing a large number of complicated necrotizing pneumonias and empyemas, we are seeing S. aureus meningitis, sepsis, and septic venous thrombosis,” he said. “If you are not seeing this yet, it is coming,” he warned.

In the case of such deep, acute involvement, the role of surgical intervention is equal to, if not more important than, that of antibiotics, Dr. Starke emphasized.

CHICAGO — The “D test” is a critical second-step test when methicillin-resistant Staphylococcus aureus cultures come back showing erythromycin resistance and clindamycin susceptibility, according to Dr. Jeffrey Starke.

“It should be automatic—every hospital in the country should know about this test. If you are not running it, you have to start,” cautioned Dr. Starke, professor and vice chairman of pediatrics at Baylor College of Medicine, Houston.

As the number of methicillin-resistant Staphylococcus aureus (MRSA) infections has escalated to epidemic proportions at Texas Children's Hospital, discordance in the bacteria's response to erythromycin and clindamycin has become a red flag for the organism's potential to develop “inducible resistance” to clindamycin, Dr. Starke said at a meeting sponsored by the American College of Emergency Physicians.

“If it's erythromycin and clindamycin susceptible initially, or resistant to both initially, there is no issue,” he explained. “But it's when there is discordance—when it shows erythromycin resistance but clindamycin susceptibility—that this test needs to be done.”

The clindamycin disk induction test, or D test, will determine if the organism is truly susceptible to clindamycin or if there is a risk of inducible clindamycin resistance, he said.

“When an isolate has inducible clindamycin resistance, treatment failures often occur when clindamycin is used—especially if the infection is serious or deep-seated,” Dr. Starke said.

The current epidemic of community-acquired MRSA infection differs from the traditional disease in terms of both the risk factors and the aggressiveness of the infection, he said.

“Patients are almost exclusively normal hosts,” he said, listing current risk factors as race (African Americans have significantly increased risk, compared with whites), prior infections, infected household contacts, day care, and competitive athletics.

Unlike the traditional MRSA involvement of skin and soft tissue (and sometimes muscle, bone, or joints), current infections can involve all these areas simultaneously and continue to progress. “We are seeing a large number of complicated necrotizing pneumonias and empyemas, we are seeing S. aureus meningitis, sepsis, and septic venous thrombosis,” he said. “If you are not seeing this yet, it is coming,” he warned.

In the case of such deep, acute involvement, the role of surgical intervention is equal to, if not more important than, that of antibiotics, Dr. Starke emphasized.

CHICAGO — The “D test” is a critical second-step test when methicillin-resistant Staphylococcus aureus cultures come back showing erythromycin resistance and clindamycin susceptibility, according to Dr. Jeffrey Starke.

“It should be automatic—every hospital in the country should know about this test. If you are not running it, you have to start,” cautioned Dr. Starke, professor and vice chairman of pediatrics at Baylor College of Medicine, Houston.

As the number of methicillin-resistant Staphylococcus aureus (MRSA) infections has escalated to epidemic proportions at Texas Children's Hospital, discordance in the bacteria's response to erythromycin and clindamycin has become a red flag for the organism's potential to develop “inducible resistance” to clindamycin, Dr. Starke said at a meeting sponsored by the American College of Emergency Physicians.

“If it's erythromycin and clindamycin susceptible initially, or resistant to both initially, there is no issue,” he explained. “But it's when there is discordance—when it shows erythromycin resistance but clindamycin susceptibility—that this test needs to be done.”

The clindamycin disk induction test, or D test, will determine if the organism is truly susceptible to clindamycin or if there is a risk of inducible clindamycin resistance, he said.

“When an isolate has inducible clindamycin resistance, treatment failures often occur when clindamycin is used—especially if the infection is serious or deep-seated,” Dr. Starke said.

The current epidemic of community-acquired MRSA infection differs from the traditional disease in terms of both the risk factors and the aggressiveness of the infection, he said.

“Patients are almost exclusively normal hosts,” he said, listing current risk factors as race (African Americans have significantly increased risk, compared with whites), prior infections, infected household contacts, day care, and competitive athletics.

Unlike the traditional MRSA involvement of skin and soft tissue (and sometimes muscle, bone, or joints), current infections can involve all these areas simultaneously and continue to progress. “We are seeing a large number of complicated necrotizing pneumonias and empyemas, we are seeing S. aureus meningitis, sepsis, and septic venous thrombosis,” he said. “If you are not seeing this yet, it is coming,” he warned.

In the case of such deep, acute involvement, the role of surgical intervention is equal to, if not more important than, that of antibiotics, Dr. Starke emphasized.

CHICAGO — Aggressive fluid management and avoidance of medication are key in preventing the development of hemolytic uremic syndrome in children with Escherichia coli diarrhea, said Dr. Marianne Gausche-Hill at a meeting sponsored by the American College of Emergency Physicians.

Although other types of diarrhea may require antibiotic therapy, E. coli O157:H7 infection can be distinguished from them by its hallmarks: acute, bloody diarrhea; abdominal pain out of proportion to diarrhea; and pain on defecation, said Dr. Gausche-Hill, who is director of emergency medical services and pediatric emergency medicine fellowships at Harbor-UCLA Medical Center and professor of medicine at the University of California, Los Angeles.

“Children with E. coli also tend to be afebrile vs. those with other forms of diarrhea, such as Shigella, who are often highly febrile. So, although they could have a fever, the absence of a fever would be another clue.” Despite being afebrile on presentation, about half of children with E. coli have a history of fever before presentation, she added.

In addition to elderly people, children younger than 5 years are the highest-risk group for E. coli infection. And although 2%–7% of adult E. coli infections result in hemolytic uremic syndrome (HUS), 15% of infected children are at risk for this potentially fatal complication, she said.

Avoidance of antibiotics is key in this population, based on a prospective study showing higher rates of HUS among E. coli-infected children receiving antibiotic therapy (56%), compared with those who did not receive antibiotics (8%)—a relative risk of 14 (N. Engl. J. Med. 2000;342:1930–6). The increased risk is likely due to the antibiotic's liberation of shiga toxin, she noted.

Antimotility agents should also be avoided, based on the theory that they keep the toxin in the intestine. Narcotic opioids should be avoided because they have an antimotility effect and can increase the risk of neurologic complications.

Aggressive fluid management offers nephroprotection and should be started as soon as possible, she said. “Oral rehydration is not enough—they need intravenous fluid resuscitation. We highly recommend they receive saline boluses … and then they should be carefully watched for early signs of HUS,” she said.

CHICAGO — Aggressive fluid management and avoidance of medication are key in preventing the development of hemolytic uremic syndrome in children with Escherichia coli diarrhea, said Dr. Marianne Gausche-Hill at a meeting sponsored by the American College of Emergency Physicians.

Although other types of diarrhea may require antibiotic therapy, E. coli O157:H7 infection can be distinguished from them by its hallmarks: acute, bloody diarrhea; abdominal pain out of proportion to diarrhea; and pain on defecation, said Dr. Gausche-Hill, who is director of emergency medical services and pediatric emergency medicine fellowships at Harbor-UCLA Medical Center and professor of medicine at the University of California, Los Angeles.

“Children with E. coli also tend to be afebrile vs. those with other forms of diarrhea, such as Shigella, who are often highly febrile. So, although they could have a fever, the absence of a fever would be another clue.” Despite being afebrile on presentation, about half of children with E. coli have a history of fever before presentation, she added.

In addition to elderly people, children younger than 5 years are the highest-risk group for E. coli infection. And although 2%–7% of adult E. coli infections result in hemolytic uremic syndrome (HUS), 15% of infected children are at risk for this potentially fatal complication, she said.

Avoidance of antibiotics is key in this population, based on a prospective study showing higher rates of HUS among E. coli-infected children receiving antibiotic therapy (56%), compared with those who did not receive antibiotics (8%)—a relative risk of 14 (N. Engl. J. Med. 2000;342:1930–6). The increased risk is likely due to the antibiotic's liberation of shiga toxin, she noted.

Antimotility agents should also be avoided, based on the theory that they keep the toxin in the intestine. Narcotic opioids should be avoided because they have an antimotility effect and can increase the risk of neurologic complications.

Aggressive fluid management offers nephroprotection and should be started as soon as possible, she said. “Oral rehydration is not enough—they need intravenous fluid resuscitation. We highly recommend they receive saline boluses … and then they should be carefully watched for early signs of HUS,” she said.

CHICAGO — Aggressive fluid management and avoidance of medication are key in preventing the development of hemolytic uremic syndrome in children with Escherichia coli diarrhea, said Dr. Marianne Gausche-Hill at a meeting sponsored by the American College of Emergency Physicians.

Although other types of diarrhea may require antibiotic therapy, E. coli O157:H7 infection can be distinguished from them by its hallmarks: acute, bloody diarrhea; abdominal pain out of proportion to diarrhea; and pain on defecation, said Dr. Gausche-Hill, who is director of emergency medical services and pediatric emergency medicine fellowships at Harbor-UCLA Medical Center and professor of medicine at the University of California, Los Angeles.

“Children with E. coli also tend to be afebrile vs. those with other forms of diarrhea, such as Shigella, who are often highly febrile. So, although they could have a fever, the absence of a fever would be another clue.” Despite being afebrile on presentation, about half of children with E. coli have a history of fever before presentation, she added.

In addition to elderly people, children younger than 5 years are the highest-risk group for E. coli infection. And although 2%–7% of adult E. coli infections result in hemolytic uremic syndrome (HUS), 15% of infected children are at risk for this potentially fatal complication, she said.

Avoidance of antibiotics is key in this population, based on a prospective study showing higher rates of HUS among E. coli-infected children receiving antibiotic therapy (56%), compared with those who did not receive antibiotics (8%)—a relative risk of 14 (N. Engl. J. Med. 2000;342:1930–6). The increased risk is likely due to the antibiotic's liberation of shiga toxin, she noted.

Antimotility agents should also be avoided, based on the theory that they keep the toxin in the intestine. Narcotic opioids should be avoided because they have an antimotility effect and can increase the risk of neurologic complications.

Aggressive fluid management offers nephroprotection and should be started as soon as possible, she said. “Oral rehydration is not enough—they need intravenous fluid resuscitation. We highly recommend they receive saline boluses … and then they should be carefully watched for early signs of HUS,” she said.

COLORADO SPRINGS – Trauma therapy should be an integral part of substance abuse recovery programs, because trauma is at the root of most addictions, Dolores J. Walker said at a symposium on addictive disorders sponsored by Psychotherapy Associates.

“Substance abuse comes with a package. If we want to be effective, we have to look beyond substance abuse in our therapy, and the integration of substance abuse and trauma has the best outcome,” said Ms. Walker, director of substance abuse services at Cedar Springs Behavioral Health System in Colorado Springs.

Statistics show that up to two-thirds of men and women in treatment for substance abuse report a history of trauma. Among alcoholic women, 90% report sexual abuse or violence as children, and 82% of adolescents in residential care report a history of trauma, she said.

“Clearly, these people are self-medicating. They are numbing out the trauma,” she said. “I sit with people every day who are desperate to restore their balance so they can have a life.”

Trauma can result from natural disasters, wars, near-death experiences, auto accidents, or acts of violence, but it can also result from seemingly more benign events, such as a significant relationship breakup, a medical procedure, the death of a pet, or being shunned, teased, or bullied, she said.

Addiction treatment programs that are trauma sensitive attempt to help patients address any unresolved issues regarding their traumatic history. It is the unresolved issues that will hamper addiction recovery, Ms. Walker said.

Because of the recognized risk of retraumatizing the patient, the initial phase of the program focuses on establishing trust and a feeling of safety, she said.

“Our job is to neutralize the memories and restore homeostasis, not to get them to relive the trauma. That only retraumatizes and revictimizes,” she said.

It is within this initial stage of establishing safety that patients begin their drug or alcohol detoxification program. The second stage focuses on trauma recovery, where patients “rewrite” the experience so they see themselves as a survivor rather than a victim.

“You have to enter the trauma area, not through the rational brain but through feeling,” Ms. Walker said, stressing that patients must be encouraged not to relive the trauma but to observe it from the safety of the present.

This empowers them to progress beyond victimization to survival of the experience. From this point, patients can then reconnect with the present and address their addiction, she said.

The addictive aftermath of trauma is being seen more frequently among military personnel with posttraumatic stress disorder (PTSD), according to Nancy Harrel, who is director of the Masters and Johnson Trauma-Based Disorders Program at Two Rivers Psychiatric Hospital, Kansas City, Mo.

“I think these guys are going to continue showing up in our offices, but they won't be saying they've got PTSD from their war experience,” she said in a separate presentation at the meeting. “Many … who I see have come through our dual diagnosis unit because they are using alcohol to cope.”

In the case of PTSD, alcohol is particularly effective at blocking flashbacks, she said. This makes the initial detoxification process particularly grueling. “We have to educate them that once they stop drinking, the original trauma behind their addiction will return,” Ms. Harrel said, adding that one of the first goals for these patients is to get them sleeping properly again.

Research suggests that military PTSD may be far more common among personnel deployed to Iraq than it is among those deployed to Afghanistan because of the much higher exposure to combat in Iraq, Ms. Walker said.

Up to 17% of those returning from Iraq met criteria for PTSD, compared with 11% of those returning from Afghanistan; and almost 12% of those deployed to Iraq were wounded, compared with 5% of those deployed to Afghanistan, she said at the meeting.

COLORADO SPRINGS – Trauma therapy should be an integral part of substance abuse recovery programs, because trauma is at the root of most addictions, Dolores J. Walker said at a symposium on addictive disorders sponsored by Psychotherapy Associates.

“Substance abuse comes with a package. If we want to be effective, we have to look beyond substance abuse in our therapy, and the integration of substance abuse and trauma has the best outcome,” said Ms. Walker, director of substance abuse services at Cedar Springs Behavioral Health System in Colorado Springs.

Statistics show that up to two-thirds of men and women in treatment for substance abuse report a history of trauma. Among alcoholic women, 90% report sexual abuse or violence as children, and 82% of adolescents in residential care report a history of trauma, she said.

“Clearly, these people are self-medicating. They are numbing out the trauma,” she said. “I sit with people every day who are desperate to restore their balance so they can have a life.”

Trauma can result from natural disasters, wars, near-death experiences, auto accidents, or acts of violence, but it can also result from seemingly more benign events, such as a significant relationship breakup, a medical procedure, the death of a pet, or being shunned, teased, or bullied, she said.

Addiction treatment programs that are trauma sensitive attempt to help patients address any unresolved issues regarding their traumatic history. It is the unresolved issues that will hamper addiction recovery, Ms. Walker said.

Because of the recognized risk of retraumatizing the patient, the initial phase of the program focuses on establishing trust and a feeling of safety, she said.

“Our job is to neutralize the memories and restore homeostasis, not to get them to relive the trauma. That only retraumatizes and revictimizes,” she said.

It is within this initial stage of establishing safety that patients begin their drug or alcohol detoxification program. The second stage focuses on trauma recovery, where patients “rewrite” the experience so they see themselves as a survivor rather than a victim.

“You have to enter the trauma area, not through the rational brain but through feeling,” Ms. Walker said, stressing that patients must be encouraged not to relive the trauma but to observe it from the safety of the present.

This empowers them to progress beyond victimization to survival of the experience. From this point, patients can then reconnect with the present and address their addiction, she said.

The addictive aftermath of trauma is being seen more frequently among military personnel with posttraumatic stress disorder (PTSD), according to Nancy Harrel, who is director of the Masters and Johnson Trauma-Based Disorders Program at Two Rivers Psychiatric Hospital, Kansas City, Mo.

“I think these guys are going to continue showing up in our offices, but they won't be saying they've got PTSD from their war experience,” she said in a separate presentation at the meeting. “Many … who I see have come through our dual diagnosis unit because they are using alcohol to cope.”

In the case of PTSD, alcohol is particularly effective at blocking flashbacks, she said. This makes the initial detoxification process particularly grueling. “We have to educate them that once they stop drinking, the original trauma behind their addiction will return,” Ms. Harrel said, adding that one of the first goals for these patients is to get them sleeping properly again.

Research suggests that military PTSD may be far more common among personnel deployed to Iraq than it is among those deployed to Afghanistan because of the much higher exposure to combat in Iraq, Ms. Walker said.

Up to 17% of those returning from Iraq met criteria for PTSD, compared with 11% of those returning from Afghanistan; and almost 12% of those deployed to Iraq were wounded, compared with 5% of those deployed to Afghanistan, she said at the meeting.

COLORADO SPRINGS – Trauma therapy should be an integral part of substance abuse recovery programs, because trauma is at the root of most addictions, Dolores J. Walker said at a symposium on addictive disorders sponsored by Psychotherapy Associates.

“Substance abuse comes with a package. If we want to be effective, we have to look beyond substance abuse in our therapy, and the integration of substance abuse and trauma has the best outcome,” said Ms. Walker, director of substance abuse services at Cedar Springs Behavioral Health System in Colorado Springs.

Statistics show that up to two-thirds of men and women in treatment for substance abuse report a history of trauma. Among alcoholic women, 90% report sexual abuse or violence as children, and 82% of adolescents in residential care report a history of trauma, she said.

“Clearly, these people are self-medicating. They are numbing out the trauma,” she said. “I sit with people every day who are desperate to restore their balance so they can have a life.”

Trauma can result from natural disasters, wars, near-death experiences, auto accidents, or acts of violence, but it can also result from seemingly more benign events, such as a significant relationship breakup, a medical procedure, the death of a pet, or being shunned, teased, or bullied, she said.

Addiction treatment programs that are trauma sensitive attempt to help patients address any unresolved issues regarding their traumatic history. It is the unresolved issues that will hamper addiction recovery, Ms. Walker said.

Because of the recognized risk of retraumatizing the patient, the initial phase of the program focuses on establishing trust and a feeling of safety, she said.

“Our job is to neutralize the memories and restore homeostasis, not to get them to relive the trauma. That only retraumatizes and revictimizes,” she said.

It is within this initial stage of establishing safety that patients begin their drug or alcohol detoxification program. The second stage focuses on trauma recovery, where patients “rewrite” the experience so they see themselves as a survivor rather than a victim.

“You have to enter the trauma area, not through the rational brain but through feeling,” Ms. Walker said, stressing that patients must be encouraged not to relive the trauma but to observe it from the safety of the present.

This empowers them to progress beyond victimization to survival of the experience. From this point, patients can then reconnect with the present and address their addiction, she said.

The addictive aftermath of trauma is being seen more frequently among military personnel with posttraumatic stress disorder (PTSD), according to Nancy Harrel, who is director of the Masters and Johnson Trauma-Based Disorders Program at Two Rivers Psychiatric Hospital, Kansas City, Mo.

“I think these guys are going to continue showing up in our offices, but they won't be saying they've got PTSD from their war experience,” she said in a separate presentation at the meeting. “Many … who I see have come through our dual diagnosis unit because they are using alcohol to cope.”

In the case of PTSD, alcohol is particularly effective at blocking flashbacks, she said. This makes the initial detoxification process particularly grueling. “We have to educate them that once they stop drinking, the original trauma behind their addiction will return,” Ms. Harrel said, adding that one of the first goals for these patients is to get them sleeping properly again.

Research suggests that military PTSD may be far more common among personnel deployed to Iraq than it is among those deployed to Afghanistan because of the much higher exposure to combat in Iraq, Ms. Walker said.

Up to 17% of those returning from Iraq met criteria for PTSD, compared with 11% of those returning from Afghanistan; and almost 12% of those deployed to Iraq were wounded, compared with 5% of those deployed to Afghanistan, she said at the meeting.

CHICAGO — The “D test” is a critical second-step test when methicillin-resistant Staphylococcus aureus cultures come back showing erythromycin resistance and clindamycin susceptibility, according to Dr. Jeffrey Starke.

“It should be automatic—every hospital in the country should know about this test. If you are not running it, you have to start,” cautioned Dr. Starke, professor and vice chairman of pediatrics at Baylor College of Medicine, and infection control officer at Texas Children's Hospital, in Houston.

As the number of methicillin-resistant Staphylococcus aureus (MRSA) infections has escalated to epidemic proportions at Texas Children's Hospital, discordance in the bacteria's response to erythromycin and clindamycin has become a red flag for the organism's potential to develop “inducible resistance” to clindamycin, Dr. Starke said at a meeting sponsored by the American College of Emergency Physicians.

“If it's erythromycin and clindamycin susceptible initially, or resistant to both initially, there is no issue,” he explained. “But it's when there is discordance—when it shows erythromycin resistance but clindamycin susceptibility—that this test needs to be done.”

The clindamycin disk induction test, or D test, will determine if the organism is truly susceptible to clindamycin, or whether there is a risk of inducible clindamycin resistance, he said. “When an isolate has inducible clindamycin resistance, treatment failures often occur when clindamycin is used—especially if the infection is serious or deep-seated,” Dr. Starke said.

The current epidemic of community-acquired MRSA infection differs from the traditional disease in terms of both the risk factors and the aggressiveness of the infection, he said.

“Patients are almost exclusively normal hosts,” he said, listing current risk factors as race (African Americans have significantly increased risk, compared with whites), prior infections, infected household contacts, day care, and competitive athletics.

Unlike the traditional MRSA involvement of skin and soft tissue (and sometimes muscle, bone, or joints), current infections can involve all these areas simultaneously and continue to progress. “We are seeing a large number of complicated necrotizing pneumonias and empyemas, we are seeing S. aureus meningitis, sepsis, and septic venous thrombosis,” he said. “If you are not seeing this yet, it is coming,” he warned.

In the case of such deep, acute involvement, the role of surgical intervention is equal to, if not more important than, that of antibiotics, Dr. Starke emphasized.

“My overall message is to be surgically aggressive—you need to drain the pus,” he said.

CHICAGO — The “D test” is a critical second-step test when methicillin-resistant Staphylococcus aureus cultures come back showing erythromycin resistance and clindamycin susceptibility, according to Dr. Jeffrey Starke.

“It should be automatic—every hospital in the country should know about this test. If you are not running it, you have to start,” cautioned Dr. Starke, professor and vice chairman of pediatrics at Baylor College of Medicine, and infection control officer at Texas Children's Hospital, in Houston.

As the number of methicillin-resistant Staphylococcus aureus (MRSA) infections has escalated to epidemic proportions at Texas Children's Hospital, discordance in the bacteria's response to erythromycin and clindamycin has become a red flag for the organism's potential to develop “inducible resistance” to clindamycin, Dr. Starke said at a meeting sponsored by the American College of Emergency Physicians.

“If it's erythromycin and clindamycin susceptible initially, or resistant to both initially, there is no issue,” he explained. “But it's when there is discordance—when it shows erythromycin resistance but clindamycin susceptibility—that this test needs to be done.”

The clindamycin disk induction test, or D test, will determine if the organism is truly susceptible to clindamycin, or whether there is a risk of inducible clindamycin resistance, he said. “When an isolate has inducible clindamycin resistance, treatment failures often occur when clindamycin is used—especially if the infection is serious or deep-seated,” Dr. Starke said.

The current epidemic of community-acquired MRSA infection differs from the traditional disease in terms of both the risk factors and the aggressiveness of the infection, he said.

“Patients are almost exclusively normal hosts,” he said, listing current risk factors as race (African Americans have significantly increased risk, compared with whites), prior infections, infected household contacts, day care, and competitive athletics.

Unlike the traditional MRSA involvement of skin and soft tissue (and sometimes muscle, bone, or joints), current infections can involve all these areas simultaneously and continue to progress. “We are seeing a large number of complicated necrotizing pneumonias and empyemas, we are seeing S. aureus meningitis, sepsis, and septic venous thrombosis,” he said. “If you are not seeing this yet, it is coming,” he warned.

In the case of such deep, acute involvement, the role of surgical intervention is equal to, if not more important than, that of antibiotics, Dr. Starke emphasized.

“My overall message is to be surgically aggressive—you need to drain the pus,” he said.

CHICAGO — The “D test” is a critical second-step test when methicillin-resistant Staphylococcus aureus cultures come back showing erythromycin resistance and clindamycin susceptibility, according to Dr. Jeffrey Starke.

“It should be automatic—every hospital in the country should know about this test. If you are not running it, you have to start,” cautioned Dr. Starke, professor and vice chairman of pediatrics at Baylor College of Medicine, and infection control officer at Texas Children's Hospital, in Houston.

As the number of methicillin-resistant Staphylococcus aureus (MRSA) infections has escalated to epidemic proportions at Texas Children's Hospital, discordance in the bacteria's response to erythromycin and clindamycin has become a red flag for the organism's potential to develop “inducible resistance” to clindamycin, Dr. Starke said at a meeting sponsored by the American College of Emergency Physicians.

“If it's erythromycin and clindamycin susceptible initially, or resistant to both initially, there is no issue,” he explained. “But it's when there is discordance—when it shows erythromycin resistance but clindamycin susceptibility—that this test needs to be done.”

The clindamycin disk induction test, or D test, will determine if the organism is truly susceptible to clindamycin, or whether there is a risk of inducible clindamycin resistance, he said. “When an isolate has inducible clindamycin resistance, treatment failures often occur when clindamycin is used—especially if the infection is serious or deep-seated,” Dr. Starke said.

The current epidemic of community-acquired MRSA infection differs from the traditional disease in terms of both the risk factors and the aggressiveness of the infection, he said.

“Patients are almost exclusively normal hosts,” he said, listing current risk factors as race (African Americans have significantly increased risk, compared with whites), prior infections, infected household contacts, day care, and competitive athletics.

Unlike the traditional MRSA involvement of skin and soft tissue (and sometimes muscle, bone, or joints), current infections can involve all these areas simultaneously and continue to progress. “We are seeing a large number of complicated necrotizing pneumonias and empyemas, we are seeing S. aureus meningitis, sepsis, and septic venous thrombosis,” he said. “If you are not seeing this yet, it is coming,” he warned.

In the case of such deep, acute involvement, the role of surgical intervention is equal to, if not more important than, that of antibiotics, Dr. Starke emphasized.

“My overall message is to be surgically aggressive—you need to drain the pus,” he said.