Kate Johnson

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Emergency on-call coverage from specialist physicians is “unraveling” at hospitals across the country, resulting in delayed treatment, patient transfers, permanent injuries, and even death, according to a study from the Center for Studying Health System Change, a nonpartisan policy research group in Washington.

While the problem is predominantly an issue for hospital emergency departments, it also is becoming increasingly problematic for inpatients who need urgent specialty care, according to the report. The findings are based on 2007 data from 12 nationally representative communities: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; Northern New Jersey; Orange County, Calif; Phoenix; Seattle; and Syracuse, N.Y.

The picture is particularly grim given the fact that overall ED utilization rates have risen by 7% in the past decade, from 36.9 to 39.6 visits per 100 people, according to the report. While insured people account for the vast majority of ED visits, “the proportion of visits by uninsured people is rising at a relatively higher rate,” the study's authors wrote.

Citing a 2006 paper from the American College of Emergency Physicians, the study reported that 73% of emergency departments in the United States report inadequate on-call coverage by specialist physicians. In particularly short supply are orthopedic surgeons, neurosurgeons, plastic surgeons, trauma surgeons, hand surgeons, obstetrician-gynecologists, neurologists, ophthalmologists, and dermatologists. While an actual shortage of such physicians may sometimes be to blame, “physician unwillingness to take call appears to be a more pressing issue for many hospitals,” the study authors stated.

Although unwillingness to accept on-call duty is largely influenced by quality of life issues, the requirement to provide on-call coverage has traditionally been mandated by hospitals under the Emergency Medical Treatment and Labor Act. However, many specialists are now shifting their practices away from the hospital setting, and are no longer obligated by medical staff privileges, noted the report's authors.

Many physicians also believe payment for on-call care is inadequate, especially when they are caring for uninsured patients. Specialists are also concerned that providing emergency care may increase their exposure to medical liability and drive up the cost of their malpractice premiums, according to the report.

As a result, adverse patient outcomes are reported. One study found that 21% of patient deaths or permanent injuries related to ED treatment delays are attributed to lack of specialists' availability, noted the report. Complete lack of access to specialty care in some EDs is forcing either travel or transfer of patients. And for the physicians who continue to provide on-call coverage, increasing workload and decreasing morale may put patients further at risk.

“It's not a surprise that we're having this problem—it's a surprise to me that we have any on-call specialists at all,” Dr. Todd Taylor, previously an emergency physician and speaker for the ACEP Council, said in an interview. Dr. Taylor left clinical medicine last summer to work in the computer industry, he said, because the risks of liability were more than he could justify.

For Dr. Taylor, it is these very liability risks that are at the root of the current on-call crisis. “The liability issue has become the overriding barrier to physicians being willing to put themselves at risk,” he said.

More troubling than the lack of emergency on-call specialists, he added, is the lack of emergency physicians in general—a newer phenomenon reported earlier this year in the 2007 Daniel Stern & Associates Emergency Medicine Compensation and Benefits Survey.

“This has applied to on-call specialists for years, but the phenomenon is now spreading to core emergency physicians, who are increasingly seeking alternative careers,” Dr. Taylor said, noting that 30% of the study's respondents said they were considering leaving medicine because of the malpractice climate. “That's what's different now compared to 2 or 3 years ago.”

Emergency on-call coverage from specialist physicians is “unraveling” at hospitals across the country, resulting in delayed treatment, patient transfers, permanent injuries, and even death, according to a study from the Center for Studying Health System Change, a nonpartisan policy research group in Washington.

While the problem is predominantly an issue for hospital emergency departments, it also is becoming increasingly problematic for inpatients who need urgent specialty care, according to the report. The findings are based on 2007 data from 12 nationally representative communities: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; Northern New Jersey; Orange County, Calif; Phoenix; Seattle; and Syracuse, N.Y.

The picture is particularly grim given the fact that overall ED utilization rates have risen by 7% in the past decade, from 36.9 to 39.6 visits per 100 people, according to the report. While insured people account for the vast majority of ED visits, “the proportion of visits by uninsured people is rising at a relatively higher rate,” the study's authors wrote.

Citing a 2006 paper from the American College of Emergency Physicians, the study reported that 73% of emergency departments in the United States report inadequate on-call coverage by specialist physicians. In particularly short supply are orthopedic surgeons, neurosurgeons, plastic surgeons, trauma surgeons, hand surgeons, obstetrician-gynecologists, neurologists, ophthalmologists, and dermatologists. While an actual shortage of such physicians may sometimes be to blame, “physician unwillingness to take call appears to be a more pressing issue for many hospitals,” the study authors stated.

Although unwillingness to accept on-call duty is largely influenced by quality of life issues, the requirement to provide on-call coverage has traditionally been mandated by hospitals under the Emergency Medical Treatment and Labor Act. However, many specialists are now shifting their practices away from the hospital setting, and are no longer obligated by medical staff privileges, noted the report's authors.

Many physicians also believe payment for on-call care is inadequate, especially when they are caring for uninsured patients. Specialists are also concerned that providing emergency care may increase their exposure to medical liability and drive up the cost of their malpractice premiums, according to the report.

As a result, adverse patient outcomes are reported. One study found that 21% of patient deaths or permanent injuries related to ED treatment delays are attributed to lack of specialists' availability, noted the report. Complete lack of access to specialty care in some EDs is forcing either travel or transfer of patients. And for the physicians who continue to provide on-call coverage, increasing workload and decreasing morale may put patients further at risk.

“It's not a surprise that we're having this problem—it's a surprise to me that we have any on-call specialists at all,” Dr. Todd Taylor, previously an emergency physician and speaker for the ACEP Council, said in an interview. Dr. Taylor left clinical medicine last summer to work in the computer industry, he said, because the risks of liability were more than he could justify.

For Dr. Taylor, it is these very liability risks that are at the root of the current on-call crisis. “The liability issue has become the overriding barrier to physicians being willing to put themselves at risk,” he said.

More troubling than the lack of emergency on-call specialists, he added, is the lack of emergency physicians in general—a newer phenomenon reported earlier this year in the 2007 Daniel Stern & Associates Emergency Medicine Compensation and Benefits Survey.

“This has applied to on-call specialists for years, but the phenomenon is now spreading to core emergency physicians, who are increasingly seeking alternative careers,” Dr. Taylor said, noting that 30% of the study's respondents said they were considering leaving medicine because of the malpractice climate. “That's what's different now compared to 2 or 3 years ago.”

Emergency on-call coverage from specialist physicians is “unraveling” at hospitals across the country, resulting in delayed treatment, patient transfers, permanent injuries, and even death, according to a study from the Center for Studying Health System Change, a nonpartisan policy research group in Washington.

While the problem is predominantly an issue for hospital emergency departments, it also is becoming increasingly problematic for inpatients who need urgent specialty care, according to the report. The findings are based on 2007 data from 12 nationally representative communities: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; Northern New Jersey; Orange County, Calif; Phoenix; Seattle; and Syracuse, N.Y.

The picture is particularly grim given the fact that overall ED utilization rates have risen by 7% in the past decade, from 36.9 to 39.6 visits per 100 people, according to the report. While insured people account for the vast majority of ED visits, “the proportion of visits by uninsured people is rising at a relatively higher rate,” the study's authors wrote.

Citing a 2006 paper from the American College of Emergency Physicians, the study reported that 73% of emergency departments in the United States report inadequate on-call coverage by specialist physicians. In particularly short supply are orthopedic surgeons, neurosurgeons, plastic surgeons, trauma surgeons, hand surgeons, obstetrician-gynecologists, neurologists, ophthalmologists, and dermatologists. While an actual shortage of such physicians may sometimes be to blame, “physician unwillingness to take call appears to be a more pressing issue for many hospitals,” the study authors stated.

Although unwillingness to accept on-call duty is largely influenced by quality of life issues, the requirement to provide on-call coverage has traditionally been mandated by hospitals under the Emergency Medical Treatment and Labor Act. However, many specialists are now shifting their practices away from the hospital setting, and are no longer obligated by medical staff privileges, noted the report's authors.

Many physicians also believe payment for on-call care is inadequate, especially when they are caring for uninsured patients. Specialists are also concerned that providing emergency care may increase their exposure to medical liability and drive up the cost of their malpractice premiums, according to the report.

As a result, adverse patient outcomes are reported. One study found that 21% of patient deaths or permanent injuries related to ED treatment delays are attributed to lack of specialists' availability, noted the report. Complete lack of access to specialty care in some EDs is forcing either travel or transfer of patients. And for the physicians who continue to provide on-call coverage, increasing workload and decreasing morale may put patients further at risk.

“It's not a surprise that we're having this problem—it's a surprise to me that we have any on-call specialists at all,” Dr. Todd Taylor, previously an emergency physician and speaker for the ACEP Council, said in an interview. Dr. Taylor left clinical medicine last summer to work in the computer industry, he said, because the risks of liability were more than he could justify.

For Dr. Taylor, it is these very liability risks that are at the root of the current on-call crisis. “The liability issue has become the overriding barrier to physicians being willing to put themselves at risk,” he said.

More troubling than the lack of emergency on-call specialists, he added, is the lack of emergency physicians in general—a newer phenomenon reported earlier this year in the 2007 Daniel Stern & Associates Emergency Medicine Compensation and Benefits Survey.

“This has applied to on-call specialists for years, but the phenomenon is now spreading to core emergency physicians, who are increasingly seeking alternative careers,” Dr. Taylor said, noting that 30% of the study's respondents said they were considering leaving medicine because of the malpractice climate. “That's what's different now compared to 2 or 3 years ago.”

MONTREAL — For patients with adhesive small bowel obstruction, a water-soluble contrast medium produces significantly better outcomes than conservative treatment, according to a study presented at a meeting sponsored by the International Society of Surgery.

“Gastrografin [meglumine diatrizoate] has been shown to shift fluid, dilute intestinal contents, and decrease edema in the intestinal wall, facilitating motility,” said Dr. Salomone Di Saverio of the emergency surgery unit at S. Orsola-Malpighi University Hospital in Bologna, Italy.

The reported operative rate for adhesive small bowel obstruction (ASBO) ranges from 27% to 42%, said Dr. Di Saverio. Although emergency surgery is mandatory in the case of total occlusion or when strangulation is suspected, partial occlusion is an indication for conservative treatment consisting of an NPO (nil per os) diet, nasogastric tube suction, and intravenous fluid resuscitation with the correction of electrolyte imbalance, he said in an interview.

In a multicenter, prospective study, Dr. Di Saverio compared conservative treatment to Gastrografin (GG) treatment in 76 patients with ASBO. Half of the patients were randomized to each arm of the study. The mean age of the patients was 68 years in the conservative treatment group, and 64 years in the GG group.

All patients were evaluated radiologically within 36 hours of treatment initiation. Patients in the GG group who had no evidence of GG in their bowel at 36 hours were considered to have a full obstruction and underwent emergency laparotomy, whereas patients with GG in the bowel but persistent symptoms at 36 hours were considered to have partial obstruction and were switched to conservative treatment. Patients in the conservative treatment group who had persistent obstruction at 36 hours were continued on conservative therapy for an additional 36 hours and then reevaluated.

A total of 31 patients in the GG group (82%) had resolution of their obstruction in a mean time of 6.5 hours, whereas the remaining 7 patients (18%) ultimately underwent surgery. One patient needed bowel resection for strangulation, said Dr. Di Saverio. In contrast, only 21 patients (55%) in the conservative treatment group responded to initial conservative therapy, and the remaining 17 (45%) needed surgery, including 2 patients who had bowel resections for strangulation.

The significant difference in surgery rate (18% in the GG group vs. 45% in the conservative treatment group) was mirrored in the difference in time to symptom resolution (6.5 hours vs. 43 hours, respectively), and the length of hospital stay (4.6 days vs. 7.8 days).

Complications such as bowel strangulation and resection were higher in the conservative treatment group (5% vs. 2.5%), but this difference was not significant, said Dr. Di Saverio. During a mean follow-up period of 20 months, there was no significant difference in relapse rate.

Dr. Di Saverio declared no conflict of interest with regard to Gastrografin.

Gastrografin is shown here in a patient with complete bowel obstruction.

This ultrasound of the same patient shows the resolved bowel obstruction. Photos courtesy Dr. Salomone Di Saverio

MONTREAL — For patients with adhesive small bowel obstruction, a water-soluble contrast medium produces significantly better outcomes than conservative treatment, according to a study presented at a meeting sponsored by the International Society of Surgery.

“Gastrografin [meglumine diatrizoate] has been shown to shift fluid, dilute intestinal contents, and decrease edema in the intestinal wall, facilitating motility,” said Dr. Salomone Di Saverio of the emergency surgery unit at S. Orsola-Malpighi University Hospital in Bologna, Italy.

The reported operative rate for adhesive small bowel obstruction (ASBO) ranges from 27% to 42%, said Dr. Di Saverio. Although emergency surgery is mandatory in the case of total occlusion or when strangulation is suspected, partial occlusion is an indication for conservative treatment consisting of an NPO (nil per os) diet, nasogastric tube suction, and intravenous fluid resuscitation with the correction of electrolyte imbalance, he said in an interview.

In a multicenter, prospective study, Dr. Di Saverio compared conservative treatment to Gastrografin (GG) treatment in 76 patients with ASBO. Half of the patients were randomized to each arm of the study. The mean age of the patients was 68 years in the conservative treatment group, and 64 years in the GG group.

All patients were evaluated radiologically within 36 hours of treatment initiation. Patients in the GG group who had no evidence of GG in their bowel at 36 hours were considered to have a full obstruction and underwent emergency laparotomy, whereas patients with GG in the bowel but persistent symptoms at 36 hours were considered to have partial obstruction and were switched to conservative treatment. Patients in the conservative treatment group who had persistent obstruction at 36 hours were continued on conservative therapy for an additional 36 hours and then reevaluated.

A total of 31 patients in the GG group (82%) had resolution of their obstruction in a mean time of 6.5 hours, whereas the remaining 7 patients (18%) ultimately underwent surgery. One patient needed bowel resection for strangulation, said Dr. Di Saverio. In contrast, only 21 patients (55%) in the conservative treatment group responded to initial conservative therapy, and the remaining 17 (45%) needed surgery, including 2 patients who had bowel resections for strangulation.

The significant difference in surgery rate (18% in the GG group vs. 45% in the conservative treatment group) was mirrored in the difference in time to symptom resolution (6.5 hours vs. 43 hours, respectively), and the length of hospital stay (4.6 days vs. 7.8 days).

Complications such as bowel strangulation and resection were higher in the conservative treatment group (5% vs. 2.5%), but this difference was not significant, said Dr. Di Saverio. During a mean follow-up period of 20 months, there was no significant difference in relapse rate.

Dr. Di Saverio declared no conflict of interest with regard to Gastrografin.

Gastrografin is shown here in a patient with complete bowel obstruction.

This ultrasound of the same patient shows the resolved bowel obstruction. Photos courtesy Dr. Salomone Di Saverio

MONTREAL — For patients with adhesive small bowel obstruction, a water-soluble contrast medium produces significantly better outcomes than conservative treatment, according to a study presented at a meeting sponsored by the International Society of Surgery.

“Gastrografin [meglumine diatrizoate] has been shown to shift fluid, dilute intestinal contents, and decrease edema in the intestinal wall, facilitating motility,” said Dr. Salomone Di Saverio of the emergency surgery unit at S. Orsola-Malpighi University Hospital in Bologna, Italy.

The reported operative rate for adhesive small bowel obstruction (ASBO) ranges from 27% to 42%, said Dr. Di Saverio. Although emergency surgery is mandatory in the case of total occlusion or when strangulation is suspected, partial occlusion is an indication for conservative treatment consisting of an NPO (nil per os) diet, nasogastric tube suction, and intravenous fluid resuscitation with the correction of electrolyte imbalance, he said in an interview.

In a multicenter, prospective study, Dr. Di Saverio compared conservative treatment to Gastrografin (GG) treatment in 76 patients with ASBO. Half of the patients were randomized to each arm of the study. The mean age of the patients was 68 years in the conservative treatment group, and 64 years in the GG group.

All patients were evaluated radiologically within 36 hours of treatment initiation. Patients in the GG group who had no evidence of GG in their bowel at 36 hours were considered to have a full obstruction and underwent emergency laparotomy, whereas patients with GG in the bowel but persistent symptoms at 36 hours were considered to have partial obstruction and were switched to conservative treatment. Patients in the conservative treatment group who had persistent obstruction at 36 hours were continued on conservative therapy for an additional 36 hours and then reevaluated.

A total of 31 patients in the GG group (82%) had resolution of their obstruction in a mean time of 6.5 hours, whereas the remaining 7 patients (18%) ultimately underwent surgery. One patient needed bowel resection for strangulation, said Dr. Di Saverio. In contrast, only 21 patients (55%) in the conservative treatment group responded to initial conservative therapy, and the remaining 17 (45%) needed surgery, including 2 patients who had bowel resections for strangulation.

The significant difference in surgery rate (18% in the GG group vs. 45% in the conservative treatment group) was mirrored in the difference in time to symptom resolution (6.5 hours vs. 43 hours, respectively), and the length of hospital stay (4.6 days vs. 7.8 days).

Complications such as bowel strangulation and resection were higher in the conservative treatment group (5% vs. 2.5%), but this difference was not significant, said Dr. Di Saverio. During a mean follow-up period of 20 months, there was no significant difference in relapse rate.

Dr. Di Saverio declared no conflict of interest with regard to Gastrografin.

Gastrografin is shown here in a patient with complete bowel obstruction.

This ultrasound of the same patient shows the resolved bowel obstruction. Photos courtesy Dr. Salomone Di Saverio

Family physician Patrice Ranger estimates that she sees about 10 depressed patients a week at the student health services clinic at the Simon Fraser University campus in Burnaby, B.C. That's about 10% of her practice.

However, she can help a fair number of those patients by encouraging self-management techniques that involve just one or two office visits and often no medication. “Whether it's mild, moderate, or severe depression, there's always room for this type of tool—perhaps as a sole treatment in a mild depression, or as an adjunctive tool in more moderate or severe depression,” she said in an interview.

Supported self-management draws on the principles of cognitive-behavioral therapy (CBT) and is based on the premise that patients can actively participate in their own depression treatment by using techniques to change attitude and behavior. The approach is guided by a workbook or an online interactive program that teaches skills for combating the negative thought patterns that contribute to depression.

Self-management is overseen by a coach or supporter who is often a health care provider, but also can be a family member or friend, said Dan Bilsker, Ph.D., a psychologist at the university who developed the workbook Dr. Ranger uses.

Self-management of depression—also known as guided self-management—is becoming a standard component of the mental health care system in the United Kingdom and Australia, Dr. Bilsker said. “It's as low cost as any intervention gets; it's low risk, user friendly, and evidence based.”

Yet not much is known about it, nor is it widely used in the United States, even though it fits “with the emerging paradigm of collaborative health care and serves to maximize the impact of an existing health care system by extending the reach of primary care,” he said in an interview.

And it is ideal for a primary care setting. “Primary care is carrying the burden of most intervention for depression. [Most] people with depression see only a primary care physician and have no contact at any point with the psychiatric system.”

Given the time constraints and patient load of most primary care physicians, medication is often the treatment of choice for depression, although there is little evidence to support its benefit in minor depression, Dr. Bilsker said. Supported self-management, on the other hand, is an initial treatment that is as time efficient as medication, with a more favorable risk profile. “It gives an alternative [and] leaves open the option of the physician adding medication later.”

Dr. Ranger said she advises the approach to most of her patients as a first step. “You don't just give it to them and send them away. [They] come back within 2 weeks to discuss how they're feeling.”

Even if she decides that medication is needed, she retains the self-management techniques as an important part of the treatment. “This is one way of learning skills that can help over your lifetime. The medicine may be needed for the here and now or for a longer time, but that's only part of the treatment. The other part is looking at a person's skills and thought processes. People can learn that they have some control with very practical things such as goal setting and self-care.”

Dr. Bilsker noted that the supported self-management approach is also attractive to patients. “Studies show that many people want to be actively involved. They don't always want to hand it over to a professional. This is part of an overall shift in the management of all chronic diseases … to give the patient[s] tools, training, and support so they are a part of their recovery process.”

The workbook can be downloaded, for free, by going to www.carmha.ca/publications/resources/asw/SCDPAntidepressantSkills.pdf

Family physician Patrice Ranger estimates that she sees about 10 depressed patients a week at the student health services clinic at the Simon Fraser University campus in Burnaby, B.C. That's about 10% of her practice.

However, she can help a fair number of those patients by encouraging self-management techniques that involve just one or two office visits and often no medication. “Whether it's mild, moderate, or severe depression, there's always room for this type of tool—perhaps as a sole treatment in a mild depression, or as an adjunctive tool in more moderate or severe depression,” she said in an interview.

Supported self-management draws on the principles of cognitive-behavioral therapy (CBT) and is based on the premise that patients can actively participate in their own depression treatment by using techniques to change attitude and behavior. The approach is guided by a workbook or an online interactive program that teaches skills for combating the negative thought patterns that contribute to depression.

Self-management is overseen by a coach or supporter who is often a health care provider, but also can be a family member or friend, said Dan Bilsker, Ph.D., a psychologist at the university who developed the workbook Dr. Ranger uses.

Self-management of depression—also known as guided self-management—is becoming a standard component of the mental health care system in the United Kingdom and Australia, Dr. Bilsker said. “It's as low cost as any intervention gets; it's low risk, user friendly, and evidence based.”

Yet not much is known about it, nor is it widely used in the United States, even though it fits “with the emerging paradigm of collaborative health care and serves to maximize the impact of an existing health care system by extending the reach of primary care,” he said in an interview.

And it is ideal for a primary care setting. “Primary care is carrying the burden of most intervention for depression. [Most] people with depression see only a primary care physician and have no contact at any point with the psychiatric system.”

Given the time constraints and patient load of most primary care physicians, medication is often the treatment of choice for depression, although there is little evidence to support its benefit in minor depression, Dr. Bilsker said. Supported self-management, on the other hand, is an initial treatment that is as time efficient as medication, with a more favorable risk profile. “It gives an alternative [and] leaves open the option of the physician adding medication later.”

Dr. Ranger said she advises the approach to most of her patients as a first step. “You don't just give it to them and send them away. [They] come back within 2 weeks to discuss how they're feeling.”

Even if she decides that medication is needed, she retains the self-management techniques as an important part of the treatment. “This is one way of learning skills that can help over your lifetime. The medicine may be needed for the here and now or for a longer time, but that's only part of the treatment. The other part is looking at a person's skills and thought processes. People can learn that they have some control with very practical things such as goal setting and self-care.”

Dr. Bilsker noted that the supported self-management approach is also attractive to patients. “Studies show that many people want to be actively involved. They don't always want to hand it over to a professional. This is part of an overall shift in the management of all chronic diseases … to give the patient[s] tools, training, and support so they are a part of their recovery process.”

The workbook can be downloaded, for free, by going to www.carmha.ca/publications/resources/asw/SCDPAntidepressantSkills.pdf

Family physician Patrice Ranger estimates that she sees about 10 depressed patients a week at the student health services clinic at the Simon Fraser University campus in Burnaby, B.C. That's about 10% of her practice.

However, she can help a fair number of those patients by encouraging self-management techniques that involve just one or two office visits and often no medication. “Whether it's mild, moderate, or severe depression, there's always room for this type of tool—perhaps as a sole treatment in a mild depression, or as an adjunctive tool in more moderate or severe depression,” she said in an interview.

Supported self-management draws on the principles of cognitive-behavioral therapy (CBT) and is based on the premise that patients can actively participate in their own depression treatment by using techniques to change attitude and behavior. The approach is guided by a workbook or an online interactive program that teaches skills for combating the negative thought patterns that contribute to depression.

Self-management is overseen by a coach or supporter who is often a health care provider, but also can be a family member or friend, said Dan Bilsker, Ph.D., a psychologist at the university who developed the workbook Dr. Ranger uses.

Self-management of depression—also known as guided self-management—is becoming a standard component of the mental health care system in the United Kingdom and Australia, Dr. Bilsker said. “It's as low cost as any intervention gets; it's low risk, user friendly, and evidence based.”

Yet not much is known about it, nor is it widely used in the United States, even though it fits “with the emerging paradigm of collaborative health care and serves to maximize the impact of an existing health care system by extending the reach of primary care,” he said in an interview.

And it is ideal for a primary care setting. “Primary care is carrying the burden of most intervention for depression. [Most] people with depression see only a primary care physician and have no contact at any point with the psychiatric system.”

Given the time constraints and patient load of most primary care physicians, medication is often the treatment of choice for depression, although there is little evidence to support its benefit in minor depression, Dr. Bilsker said. Supported self-management, on the other hand, is an initial treatment that is as time efficient as medication, with a more favorable risk profile. “It gives an alternative [and] leaves open the option of the physician adding medication later.”

Dr. Ranger said she advises the approach to most of her patients as a first step. “You don't just give it to them and send them away. [They] come back within 2 weeks to discuss how they're feeling.”

Even if she decides that medication is needed, she retains the self-management techniques as an important part of the treatment. “This is one way of learning skills that can help over your lifetime. The medicine may be needed for the here and now or for a longer time, but that's only part of the treatment. The other part is looking at a person's skills and thought processes. People can learn that they have some control with very practical things such as goal setting and self-care.”

Dr. Bilsker noted that the supported self-management approach is also attractive to patients. “Studies show that many people want to be actively involved. They don't always want to hand it over to a professional. This is part of an overall shift in the management of all chronic diseases … to give the patient[s] tools, training, and support so they are a part of their recovery process.”

The workbook can be downloaded, for free, by going to www.carmha.ca/publications/resources/asw/SCDPAntidepressantSkills.pdf