Doug Brunk

LAS VEGAS — Only 25% of Canadian gynecologists perform laparoscopic myomectomy, and 71% cite lack of appropriate training as the main barrier to performing the procedure.

These are the key findings from the first survey to address current Canadian practice patterns regarding laparoscopic myomectomy, Dr. Rose Kung said at the annual meeting of the AAGL.

In a study led by her associate, Dr. Grace Liu of the department of obstetrics and gynecology at Sunnybrook Health Sciences Centre, Toronto, the researchers distributed surveys to 1,257 members of the Society of Obstetricians and Gynaecologists of Canada in April 2007. Of the 485 respondents who practice gynecology, 462 (95%) perform surgery, 444 (92%) perform laparoscopic surgery, and 385 (79%) perform abdominal myomectomies, yet only 119 (25%) perform laparoscopic myomectomies. Of these 119 respondents, only 15 (13%) use this approach for the majority of their cases.

The top three deterrents to performing laparoscopic myomectomy reported by the 119 respondents who use the procedure were the presence of an intramural fibroid (81%), a fibroid greater than 5 cm in size (54%), and more than three fibroids (54%), said Dr. Kung, also of the Sunnybrook Health Sciences Centre.

Among the 485 respondents overall, fewer than half of the respondents (44%) said that they have referred patients to another gynecologist for laparoscopic myomectomy. The most common reason for not referring was uncertainty as to who would be performing the procedure (33%); other reasons given by those surveyed included insufficient evidence to support the procedure (30%), a belief that the complication rate is higher with the procedure (21%), and a preference for operating on their own patients (18%).

When the respondents were asked to compare their perceptions of laparoscopic myomectomy with abdominal myomectomy, the majority indicated they believe that laparoscopic myomectomy confers a faster recovery time, less adhesion formation, and a comparable myoma recurrence rate. Most respondents were unsure about whether there were differences in outcome between the two procedures in terms of blood loss, postprocedure fertility rate, and uterine rupture risk.

ELSEVIER GLOBAL MEDICAL NEWS

LAS VEGAS — Only 25% of Canadian gynecologists perform laparoscopic myomectomy, and 71% cite lack of appropriate training as the main barrier to performing the procedure.

These are the key findings from the first survey to address current Canadian practice patterns regarding laparoscopic myomectomy, Dr. Rose Kung said at the annual meeting of the AAGL.

In a study led by her associate, Dr. Grace Liu of the department of obstetrics and gynecology at Sunnybrook Health Sciences Centre, Toronto, the researchers distributed surveys to 1,257 members of the Society of Obstetricians and Gynaecologists of Canada in April 2007. Of the 485 respondents who practice gynecology, 462 (95%) perform surgery, 444 (92%) perform laparoscopic surgery, and 385 (79%) perform abdominal myomectomies, yet only 119 (25%) perform laparoscopic myomectomies. Of these 119 respondents, only 15 (13%) use this approach for the majority of their cases.

The top three deterrents to performing laparoscopic myomectomy reported by the 119 respondents who use the procedure were the presence of an intramural fibroid (81%), a fibroid greater than 5 cm in size (54%), and more than three fibroids (54%), said Dr. Kung, also of the Sunnybrook Health Sciences Centre.

Among the 485 respondents overall, fewer than half of the respondents (44%) said that they have referred patients to another gynecologist for laparoscopic myomectomy. The most common reason for not referring was uncertainty as to who would be performing the procedure (33%); other reasons given by those surveyed included insufficient evidence to support the procedure (30%), a belief that the complication rate is higher with the procedure (21%), and a preference for operating on their own patients (18%).

When the respondents were asked to compare their perceptions of laparoscopic myomectomy with abdominal myomectomy, the majority indicated they believe that laparoscopic myomectomy confers a faster recovery time, less adhesion formation, and a comparable myoma recurrence rate. Most respondents were unsure about whether there were differences in outcome between the two procedures in terms of blood loss, postprocedure fertility rate, and uterine rupture risk.

ELSEVIER GLOBAL MEDICAL NEWS

LAS VEGAS — Only 25% of Canadian gynecologists perform laparoscopic myomectomy, and 71% cite lack of appropriate training as the main barrier to performing the procedure.

These are the key findings from the first survey to address current Canadian practice patterns regarding laparoscopic myomectomy, Dr. Rose Kung said at the annual meeting of the AAGL.

In a study led by her associate, Dr. Grace Liu of the department of obstetrics and gynecology at Sunnybrook Health Sciences Centre, Toronto, the researchers distributed surveys to 1,257 members of the Society of Obstetricians and Gynaecologists of Canada in April 2007. Of the 485 respondents who practice gynecology, 462 (95%) perform surgery, 444 (92%) perform laparoscopic surgery, and 385 (79%) perform abdominal myomectomies, yet only 119 (25%) perform laparoscopic myomectomies. Of these 119 respondents, only 15 (13%) use this approach for the majority of their cases.

The top three deterrents to performing laparoscopic myomectomy reported by the 119 respondents who use the procedure were the presence of an intramural fibroid (81%), a fibroid greater than 5 cm in size (54%), and more than three fibroids (54%), said Dr. Kung, also of the Sunnybrook Health Sciences Centre.

Among the 485 respondents overall, fewer than half of the respondents (44%) said that they have referred patients to another gynecologist for laparoscopic myomectomy. The most common reason for not referring was uncertainty as to who would be performing the procedure (33%); other reasons given by those surveyed included insufficient evidence to support the procedure (30%), a belief that the complication rate is higher with the procedure (21%), and a preference for operating on their own patients (18%).

When the respondents were asked to compare their perceptions of laparoscopic myomectomy with abdominal myomectomy, the majority indicated they believe that laparoscopic myomectomy confers a faster recovery time, less adhesion formation, and a comparable myoma recurrence rate. Most respondents were unsure about whether there were differences in outcome between the two procedures in terms of blood loss, postprocedure fertility rate, and uterine rupture risk.

ELSEVIER GLOBAL MEDICAL NEWS

SAN DIEGO — The risk of neonatal morbidity, particularly of respiratory distress syndrome, is significantly higher for infants born between 34 and nearly 37 weeks' gestation than for those born at term, an analysis of Centers for Disease Control and Prevention data showed.

“We used to think that the lungs of a neonate are mature by 34 weeks, but we found out that's not always the case,” Dr. Amy Flick said in an interview during a poster session at the annual meeting of the Society for Maternal-Fetal Medicine. “If a neonate is [at] 34 weeks' gestational age and is fine, there should be no reason to deliver; you could be risking a bad outcome.”

To compare neonatal morbidity for infants born at 34–36.9 weeks' gestation with that for infants born at 37–42 weeks, and to compare pregnancy outcomes for women in the two groups, Dr. Flick and her associates analyzed data from the 2004 CDC national birth registry. The researchers performed a secondary analysis using 2004 National Center for Health Statistics birth statistical files.

Compared with women whose infants were born at term, the women who bore infants in the late preterm period had significantly higher rates of hypertension (1.8% vs. 0.8%), preeclampsia (7.8% vs. 3.2%), preterm premature rupture of membranes (5.1% vs. 1.2%), and diabetes (5.2% vs. 3.4%), said Dr. Flick of the department of obstetrics and gynecology at the University of Miami.

The risk of neonatal composite morbidity was significantly higher in the late preterm group than in infants born at term (8.9% vs. 3.3%). Logistic regression analysis revealed that infants in the late preterm group were also 5.3 times more likely to have respiratory distress syndrome, 3.7 times more likely to require assisted ventilation, and 1.6 times more likely to have a 5-minute Apgar score of less than 7.

The risks and benefits of even late preterm deliveries must be presented to patients in a comprehensive manner along with input from neonatologists, the investigators concluded. They also called for further studies, including longer follow-up of late preterm infants.

Dr. Flick acknowledged certain limitations of the study, including its retrospective design and the fact that data came from birth certificates.

SAN DIEGO — The risk of neonatal morbidity, particularly of respiratory distress syndrome, is significantly higher for infants born between 34 and nearly 37 weeks' gestation than for those born at term, an analysis of Centers for Disease Control and Prevention data showed.

“We used to think that the lungs of a neonate are mature by 34 weeks, but we found out that's not always the case,” Dr. Amy Flick said in an interview during a poster session at the annual meeting of the Society for Maternal-Fetal Medicine. “If a neonate is [at] 34 weeks' gestational age and is fine, there should be no reason to deliver; you could be risking a bad outcome.”

To compare neonatal morbidity for infants born at 34–36.9 weeks' gestation with that for infants born at 37–42 weeks, and to compare pregnancy outcomes for women in the two groups, Dr. Flick and her associates analyzed data from the 2004 CDC national birth registry. The researchers performed a secondary analysis using 2004 National Center for Health Statistics birth statistical files.

Compared with women whose infants were born at term, the women who bore infants in the late preterm period had significantly higher rates of hypertension (1.8% vs. 0.8%), preeclampsia (7.8% vs. 3.2%), preterm premature rupture of membranes (5.1% vs. 1.2%), and diabetes (5.2% vs. 3.4%), said Dr. Flick of the department of obstetrics and gynecology at the University of Miami.

The risk of neonatal composite morbidity was significantly higher in the late preterm group than in infants born at term (8.9% vs. 3.3%). Logistic regression analysis revealed that infants in the late preterm group were also 5.3 times more likely to have respiratory distress syndrome, 3.7 times more likely to require assisted ventilation, and 1.6 times more likely to have a 5-minute Apgar score of less than 7.

The risks and benefits of even late preterm deliveries must be presented to patients in a comprehensive manner along with input from neonatologists, the investigators concluded. They also called for further studies, including longer follow-up of late preterm infants.

Dr. Flick acknowledged certain limitations of the study, including its retrospective design and the fact that data came from birth certificates.

SAN DIEGO — The risk of neonatal morbidity, particularly of respiratory distress syndrome, is significantly higher for infants born between 34 and nearly 37 weeks' gestation than for those born at term, an analysis of Centers for Disease Control and Prevention data showed.

“We used to think that the lungs of a neonate are mature by 34 weeks, but we found out that's not always the case,” Dr. Amy Flick said in an interview during a poster session at the annual meeting of the Society for Maternal-Fetal Medicine. “If a neonate is [at] 34 weeks' gestational age and is fine, there should be no reason to deliver; you could be risking a bad outcome.”

To compare neonatal morbidity for infants born at 34–36.9 weeks' gestation with that for infants born at 37–42 weeks, and to compare pregnancy outcomes for women in the two groups, Dr. Flick and her associates analyzed data from the 2004 CDC national birth registry. The researchers performed a secondary analysis using 2004 National Center for Health Statistics birth statistical files.

Compared with women whose infants were born at term, the women who bore infants in the late preterm period had significantly higher rates of hypertension (1.8% vs. 0.8%), preeclampsia (7.8% vs. 3.2%), preterm premature rupture of membranes (5.1% vs. 1.2%), and diabetes (5.2% vs. 3.4%), said Dr. Flick of the department of obstetrics and gynecology at the University of Miami.

The risk of neonatal composite morbidity was significantly higher in the late preterm group than in infants born at term (8.9% vs. 3.3%). Logistic regression analysis revealed that infants in the late preterm group were also 5.3 times more likely to have respiratory distress syndrome, 3.7 times more likely to require assisted ventilation, and 1.6 times more likely to have a 5-minute Apgar score of less than 7.

The risks and benefits of even late preterm deliveries must be presented to patients in a comprehensive manner along with input from neonatologists, the investigators concluded. They also called for further studies, including longer follow-up of late preterm infants.

Dr. Flick acknowledged certain limitations of the study, including its retrospective design and the fact that data came from birth certificates.

SAN DIEGO — Antioxidant vitamins C and E given prior to 17 weeks' gestation in nulliparous, low-risk women do not reduce the frequency of serious maternal and perinatal complications associated with pregnancy-related hypertension.

Nor do the vitamins reduce the diagnosis of preeclampsia, according to findings from a 5-year study of more than 10,000 women conducted by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network, Bethesda, Md.

In the randomized, placebo-controlled, double-blinded trial of low-risk nulliparous women, Dr. James M. Roberts and his colleagues at 16 centers in the United States allocated 10,154 women to daily treatment with 1,000 mg vitamin C and 400 IU vitamin E or placebo at 9–16 weeks' gestation.

The primary outcome was severe pregnancy-related hypertension (defined as a systolic blood pressure greater than 160 mm Hg or a diastolic pressure greater than 110 mm Hg), or mild pregnancy-related hypertension (defined as a blood pressure reading of greater than 140/90 mm Hg), with at least one of the following: renal or hepatic dysfunction, thrombocytopenia, eclampsia, indicated preterm delivery prior to 32 weeks' gestation, small for gestational age infant, stillbirth, or neonatal death up to discharge, Dr. Roberts explained at the annual meeting of the Society for Maternal-Fetal Medicine.

Dr. Roberts, professor of obstetrics, gynecology, and reproductive sciences at the Magee-Womens Research Institute at the University of Pittsburgh School of Medicine, reported that the women had a mean age of 24 years, their mean prepregnancy body mass index was 25 kg/m₂, 16% were smokers, 44% entered the trial by 13 weeks' gestation, and 77% entered the trial taking multivitamins.

Pregnancy outcome data were available on 9,969 women (4,993 in the vitamin treatment group and 4,976 in the placebo group). There were no significant differences between the treatment and control groups in terms of hypertension as a composite outcome (6.1% vs. 5.8%, respectively) or in the incidence of preeclampsia (7.2% vs. 6.7%).

The only difference in outcomes between the two groups was observed in the rate of gestational hypertension, which was 2.6% higher in the treatment group, compared with controls, though this difference was not statistically significant. Failing that, “everything was identical between the two groups,” including rates of admission to the neonatal intensive care unit, respiratory distress syndrome, and sepsis, Dr. Roberts said.

“Why doesn't antioxidant therapy reduce the frequency of preeclampsia or adverse outcomes?” he asked. One possibility is that not all women develop preeclampsia due to the same linkage between reduced placental perfusion and abnormal implantation. It may be that only a subset of women benefit from treatment to reduce oxidative stress. “This is an important possibility that we will be testing in another part of this study.” Dr. Roberts reported having no conflicts of interest to disclose.

Vitamins C and E did not reduce complications associated with pregnancy-related hypertension. DR. ROBERTS

SAN DIEGO — Antioxidant vitamins C and E given prior to 17 weeks' gestation in nulliparous, low-risk women do not reduce the frequency of serious maternal and perinatal complications associated with pregnancy-related hypertension.

Nor do the vitamins reduce the diagnosis of preeclampsia, according to findings from a 5-year study of more than 10,000 women conducted by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network, Bethesda, Md.

In the randomized, placebo-controlled, double-blinded trial of low-risk nulliparous women, Dr. James M. Roberts and his colleagues at 16 centers in the United States allocated 10,154 women to daily treatment with 1,000 mg vitamin C and 400 IU vitamin E or placebo at 9–16 weeks' gestation.

The primary outcome was severe pregnancy-related hypertension (defined as a systolic blood pressure greater than 160 mm Hg or a diastolic pressure greater than 110 mm Hg), or mild pregnancy-related hypertension (defined as a blood pressure reading of greater than 140/90 mm Hg), with at least one of the following: renal or hepatic dysfunction, thrombocytopenia, eclampsia, indicated preterm delivery prior to 32 weeks' gestation, small for gestational age infant, stillbirth, or neonatal death up to discharge, Dr. Roberts explained at the annual meeting of the Society for Maternal-Fetal Medicine.

Dr. Roberts, professor of obstetrics, gynecology, and reproductive sciences at the Magee-Womens Research Institute at the University of Pittsburgh School of Medicine, reported that the women had a mean age of 24 years, their mean prepregnancy body mass index was 25 kg/m₂, 16% were smokers, 44% entered the trial by 13 weeks' gestation, and 77% entered the trial taking multivitamins.

Pregnancy outcome data were available on 9,969 women (4,993 in the vitamin treatment group and 4,976 in the placebo group). There were no significant differences between the treatment and control groups in terms of hypertension as a composite outcome (6.1% vs. 5.8%, respectively) or in the incidence of preeclampsia (7.2% vs. 6.7%).

The only difference in outcomes between the two groups was observed in the rate of gestational hypertension, which was 2.6% higher in the treatment group, compared with controls, though this difference was not statistically significant. Failing that, “everything was identical between the two groups,” including rates of admission to the neonatal intensive care unit, respiratory distress syndrome, and sepsis, Dr. Roberts said.

“Why doesn't antioxidant therapy reduce the frequency of preeclampsia or adverse outcomes?” he asked. One possibility is that not all women develop preeclampsia due to the same linkage between reduced placental perfusion and abnormal implantation. It may be that only a subset of women benefit from treatment to reduce oxidative stress. “This is an important possibility that we will be testing in another part of this study.” Dr. Roberts reported having no conflicts of interest to disclose.

Vitamins C and E did not reduce complications associated with pregnancy-related hypertension. DR. ROBERTS

SAN DIEGO — Antioxidant vitamins C and E given prior to 17 weeks' gestation in nulliparous, low-risk women do not reduce the frequency of serious maternal and perinatal complications associated with pregnancy-related hypertension.

Nor do the vitamins reduce the diagnosis of preeclampsia, according to findings from a 5-year study of more than 10,000 women conducted by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network, Bethesda, Md.

In the randomized, placebo-controlled, double-blinded trial of low-risk nulliparous women, Dr. James M. Roberts and his colleagues at 16 centers in the United States allocated 10,154 women to daily treatment with 1,000 mg vitamin C and 400 IU vitamin E or placebo at 9–16 weeks' gestation.

The primary outcome was severe pregnancy-related hypertension (defined as a systolic blood pressure greater than 160 mm Hg or a diastolic pressure greater than 110 mm Hg), or mild pregnancy-related hypertension (defined as a blood pressure reading of greater than 140/90 mm Hg), with at least one of the following: renal or hepatic dysfunction, thrombocytopenia, eclampsia, indicated preterm delivery prior to 32 weeks' gestation, small for gestational age infant, stillbirth, or neonatal death up to discharge, Dr. Roberts explained at the annual meeting of the Society for Maternal-Fetal Medicine.

Dr. Roberts, professor of obstetrics, gynecology, and reproductive sciences at the Magee-Womens Research Institute at the University of Pittsburgh School of Medicine, reported that the women had a mean age of 24 years, their mean prepregnancy body mass index was 25 kg/m₂, 16% were smokers, 44% entered the trial by 13 weeks' gestation, and 77% entered the trial taking multivitamins.

Pregnancy outcome data were available on 9,969 women (4,993 in the vitamin treatment group and 4,976 in the placebo group). There were no significant differences between the treatment and control groups in terms of hypertension as a composite outcome (6.1% vs. 5.8%, respectively) or in the incidence of preeclampsia (7.2% vs. 6.7%).

The only difference in outcomes between the two groups was observed in the rate of gestational hypertension, which was 2.6% higher in the treatment group, compared with controls, though this difference was not statistically significant. Failing that, “everything was identical between the two groups,” including rates of admission to the neonatal intensive care unit, respiratory distress syndrome, and sepsis, Dr. Roberts said.

“Why doesn't antioxidant therapy reduce the frequency of preeclampsia or adverse outcomes?” he asked. One possibility is that not all women develop preeclampsia due to the same linkage between reduced placental perfusion and abnormal implantation. It may be that only a subset of women benefit from treatment to reduce oxidative stress. “This is an important possibility that we will be testing in another part of this study.” Dr. Roberts reported having no conflicts of interest to disclose.

Vitamins C and E did not reduce complications associated with pregnancy-related hypertension. DR. ROBERTS

SAN DIEGO — A single dose of intramuscular oxytocin achieved a significant reduction in the rate of placental retention in second-trimester medical termination, and was associated with a significant reduction in postpartum blood loss, results from a randomized, single-center study showed.

“Intramuscular oxytocin is a reasonable choice as a prophylactic ecbolic for the third stage [of labor] following second-trimester medical pregnancy termination,” Dr. Jan E. Dickinson said at the annual meeting of the Society for Maternal-Fetal Medicine.

Placental retention is a frequent complication of prostaglandin pregnancy termination, occurring 30%-40% of the time, said Dr. Dickinson, associate professor of maternal-fetal medicine at the University of Western Australia School of Women's and Infants' Health, Crawley. Potential complications of placental retention include increased blood loss, infectious morbidity, operative complications, and increased requirement for blood transfusion.

However, current protocols for third-stage management vary, so she and her associates conducted a study intended to develop a third-stage management protocol that would minimize the incidence of placental retention and associated complications among 251 women undergoing pregnancy termination at the university with intravaginal misoprostol at 14–24 weeks. They randomized the women to one of three management strategies: 83 women to receive 10 units of intramuscular oxytocin after delivery of the fetus (group 1); 83 women to receive 600 mcg oral misoprostol after delivery of the fetus (group 2); and 85 women to receive no additional medication after delivery of the fetus (group 3).

The primary outcome was incidence of failure of placental expulsion within 60 minutes of fetal delivery, with the need for operative removal.

Dr. Dickinson, who had no conflicts to disclose, reported that there were no significant differences between the three groups in terms of maternal age (mean, 31 years), race (93% white), parity (mean, one), prior uterine surgery (mean, 20%), median gestational age at study recruitment (19 weeks), or duration of termination (mean, 17 hours). The researchers did observe a significant difference between the groups in the incidence of placental retention (10% in group 1, 29% in group 2, and 31% in group 3). Logistic regression analysis of placental retention rates revealed that the odds ratio between groups 1 and 3 was significant (OR, 0.24), but between groups 2 and 3 it was not (OR, 0.92). Calculated blood loss was significantly lower in group 1 compared with the other groups (100 mL vs. 200 mL in groups 2 and 3). There were no significant differences among groups 1, 2, and 3 in terms of duration of hospital stay (30 hours, 33 hours, and 29 hours, respectively), readmission (7%, 4%, and 9%), or need for curettage (4%, 2%, and 6%).

In a later interview, Dr. Dickinson said that for centers and countries with limited access to hospital facilities, this protocol “potentially offers a simple and effective means to management of the third stage and improved safety for women with pregnancy loss in the second trimester.”

SAN DIEGO — A single dose of intramuscular oxytocin achieved a significant reduction in the rate of placental retention in second-trimester medical termination, and was associated with a significant reduction in postpartum blood loss, results from a randomized, single-center study showed.

“Intramuscular oxytocin is a reasonable choice as a prophylactic ecbolic for the third stage [of labor] following second-trimester medical pregnancy termination,” Dr. Jan E. Dickinson said at the annual meeting of the Society for Maternal-Fetal Medicine.

Placental retention is a frequent complication of prostaglandin pregnancy termination, occurring 30%-40% of the time, said Dr. Dickinson, associate professor of maternal-fetal medicine at the University of Western Australia School of Women's and Infants' Health, Crawley. Potential complications of placental retention include increased blood loss, infectious morbidity, operative complications, and increased requirement for blood transfusion.

However, current protocols for third-stage management vary, so she and her associates conducted a study intended to develop a third-stage management protocol that would minimize the incidence of placental retention and associated complications among 251 women undergoing pregnancy termination at the university with intravaginal misoprostol at 14–24 weeks. They randomized the women to one of three management strategies: 83 women to receive 10 units of intramuscular oxytocin after delivery of the fetus (group 1); 83 women to receive 600 mcg oral misoprostol after delivery of the fetus (group 2); and 85 women to receive no additional medication after delivery of the fetus (group 3).

The primary outcome was incidence of failure of placental expulsion within 60 minutes of fetal delivery, with the need for operative removal.

Dr. Dickinson, who had no conflicts to disclose, reported that there were no significant differences between the three groups in terms of maternal age (mean, 31 years), race (93% white), parity (mean, one), prior uterine surgery (mean, 20%), median gestational age at study recruitment (19 weeks), or duration of termination (mean, 17 hours). The researchers did observe a significant difference between the groups in the incidence of placental retention (10% in group 1, 29% in group 2, and 31% in group 3). Logistic regression analysis of placental retention rates revealed that the odds ratio between groups 1 and 3 was significant (OR, 0.24), but between groups 2 and 3 it was not (OR, 0.92). Calculated blood loss was significantly lower in group 1 compared with the other groups (100 mL vs. 200 mL in groups 2 and 3). There were no significant differences among groups 1, 2, and 3 in terms of duration of hospital stay (30 hours, 33 hours, and 29 hours, respectively), readmission (7%, 4%, and 9%), or need for curettage (4%, 2%, and 6%).

In a later interview, Dr. Dickinson said that for centers and countries with limited access to hospital facilities, this protocol “potentially offers a simple and effective means to management of the third stage and improved safety for women with pregnancy loss in the second trimester.”

SAN DIEGO — A single dose of intramuscular oxytocin achieved a significant reduction in the rate of placental retention in second-trimester medical termination, and was associated with a significant reduction in postpartum blood loss, results from a randomized, single-center study showed.

“Intramuscular oxytocin is a reasonable choice as a prophylactic ecbolic for the third stage [of labor] following second-trimester medical pregnancy termination,” Dr. Jan E. Dickinson said at the annual meeting of the Society for Maternal-Fetal Medicine.

Placental retention is a frequent complication of prostaglandin pregnancy termination, occurring 30%-40% of the time, said Dr. Dickinson, associate professor of maternal-fetal medicine at the University of Western Australia School of Women's and Infants' Health, Crawley. Potential complications of placental retention include increased blood loss, infectious morbidity, operative complications, and increased requirement for blood transfusion.

However, current protocols for third-stage management vary, so she and her associates conducted a study intended to develop a third-stage management protocol that would minimize the incidence of placental retention and associated complications among 251 women undergoing pregnancy termination at the university with intravaginal misoprostol at 14–24 weeks. They randomized the women to one of three management strategies: 83 women to receive 10 units of intramuscular oxytocin after delivery of the fetus (group 1); 83 women to receive 600 mcg oral misoprostol after delivery of the fetus (group 2); and 85 women to receive no additional medication after delivery of the fetus (group 3).

The primary outcome was incidence of failure of placental expulsion within 60 minutes of fetal delivery, with the need for operative removal.

Dr. Dickinson, who had no conflicts to disclose, reported that there were no significant differences between the three groups in terms of maternal age (mean, 31 years), race (93% white), parity (mean, one), prior uterine surgery (mean, 20%), median gestational age at study recruitment (19 weeks), or duration of termination (mean, 17 hours). The researchers did observe a significant difference between the groups in the incidence of placental retention (10% in group 1, 29% in group 2, and 31% in group 3). Logistic regression analysis of placental retention rates revealed that the odds ratio between groups 1 and 3 was significant (OR, 0.24), but between groups 2 and 3 it was not (OR, 0.92). Calculated blood loss was significantly lower in group 1 compared with the other groups (100 mL vs. 200 mL in groups 2 and 3). There were no significant differences among groups 1, 2, and 3 in terms of duration of hospital stay (30 hours, 33 hours, and 29 hours, respectively), readmission (7%, 4%, and 9%), or need for curettage (4%, 2%, and 6%).

In a later interview, Dr. Dickinson said that for centers and countries with limited access to hospital facilities, this protocol “potentially offers a simple and effective means to management of the third stage and improved safety for women with pregnancy loss in the second trimester.”

SAN DIEGO — Women who acquire HIV perinatally have pregnancy outcomes that are on a par with those who acquire HIV later in life, results from a small single-center study suggest.

“This is a relatively new group of young mothers, and not much is known about how they do in pregnancy,” Dr. Tania Kasdaglis said in an interview during a poster session at the annual meeting of the Society for Maternal-Fetal Medicine. Many may assume “that perinatally infected HIV patients might have poorer pregnancy outcomes because they have had HIV longer or because their immune systems have been tried since they were born, but in fact they do very well.”

She and her colleagues in the department of obstetrics, gynecology, and reproductive sciences at the University of Maryland, Baltimore, studied women receiving prenatal care at the university's HIV clinic between 1997 and 2008. On a 1:1 basis they matched perinatally infected women with those who acquired the disease after childhood for age, race, and prepregnancy body mass index. Both groups had access to prenatal care, were on highly active antiretroviral therapy, had their CD4 counts and viral loads monitored, and were delivered at the university's medical center.

Among these women, 11 perinatally infected patients with 13 continuing pregnancies were studied. Cases were similar to controls in terms of mean age (18.7 years vs. 19 years), prepregnancy body mass index (27.7 kg/m₂ vs. 27.3 kg/m₂); third-trimester viral load (1,688 copies/mL vs. 10,548 copies/mL); third-trimester CD4 counts (391 vs. 410 cells/mcL); gestational age at delivery (38.3 weeks vs. 39 weeks), and birth weight percentile (32.1% vs. 39.4%). Although the viral load was not significantly different between the two groups, it was lower among perinatally infected women, suggesting that this group of women may be more compliant with highly active antiretroviral therapy (HAART) compared with controls, said Dr. Kasdaglis, a first-year maternal-fetal medicine fellow at the university.

The study findings show that “perinatally infected HIV patients have good pregnancy outcomes that do not differ from [those of] women who acquire HIV later in life and have access to the same level of prenatal care,” concluded Dr. Kasdaglis, who reported having no conflicts of interest.

'Perinatally infected HIV pregnant patients have good pregnancy outcomes' in this small study. DR. KASDAGLIS

SAN DIEGO — Women who acquire HIV perinatally have pregnancy outcomes that are on a par with those who acquire HIV later in life, results from a small single-center study suggest.

“This is a relatively new group of young mothers, and not much is known about how they do in pregnancy,” Dr. Tania Kasdaglis said in an interview during a poster session at the annual meeting of the Society for Maternal-Fetal Medicine. Many may assume “that perinatally infected HIV patients might have poorer pregnancy outcomes because they have had HIV longer or because their immune systems have been tried since they were born, but in fact they do very well.”

She and her colleagues in the department of obstetrics, gynecology, and reproductive sciences at the University of Maryland, Baltimore, studied women receiving prenatal care at the university's HIV clinic between 1997 and 2008. On a 1:1 basis they matched perinatally infected women with those who acquired the disease after childhood for age, race, and prepregnancy body mass index. Both groups had access to prenatal care, were on highly active antiretroviral therapy, had their CD4 counts and viral loads monitored, and were delivered at the university's medical center.

Among these women, 11 perinatally infected patients with 13 continuing pregnancies were studied. Cases were similar to controls in terms of mean age (18.7 years vs. 19 years), prepregnancy body mass index (27.7 kg/m₂ vs. 27.3 kg/m₂); third-trimester viral load (1,688 copies/mL vs. 10,548 copies/mL); third-trimester CD4 counts (391 vs. 410 cells/mcL); gestational age at delivery (38.3 weeks vs. 39 weeks), and birth weight percentile (32.1% vs. 39.4%). Although the viral load was not significantly different between the two groups, it was lower among perinatally infected women, suggesting that this group of women may be more compliant with highly active antiretroviral therapy (HAART) compared with controls, said Dr. Kasdaglis, a first-year maternal-fetal medicine fellow at the university.

The study findings show that “perinatally infected HIV patients have good pregnancy outcomes that do not differ from [those of] women who acquire HIV later in life and have access to the same level of prenatal care,” concluded Dr. Kasdaglis, who reported having no conflicts of interest.

'Perinatally infected HIV pregnant patients have good pregnancy outcomes' in this small study. DR. KASDAGLIS

SAN DIEGO — Women who acquire HIV perinatally have pregnancy outcomes that are on a par with those who acquire HIV later in life, results from a small single-center study suggest.

“This is a relatively new group of young mothers, and not much is known about how they do in pregnancy,” Dr. Tania Kasdaglis said in an interview during a poster session at the annual meeting of the Society for Maternal-Fetal Medicine. Many may assume “that perinatally infected HIV patients might have poorer pregnancy outcomes because they have had HIV longer or because their immune systems have been tried since they were born, but in fact they do very well.”

She and her colleagues in the department of obstetrics, gynecology, and reproductive sciences at the University of Maryland, Baltimore, studied women receiving prenatal care at the university's HIV clinic between 1997 and 2008. On a 1:1 basis they matched perinatally infected women with those who acquired the disease after childhood for age, race, and prepregnancy body mass index. Both groups had access to prenatal care, were on highly active antiretroviral therapy, had their CD4 counts and viral loads monitored, and were delivered at the university's medical center.

Among these women, 11 perinatally infected patients with 13 continuing pregnancies were studied. Cases were similar to controls in terms of mean age (18.7 years vs. 19 years), prepregnancy body mass index (27.7 kg/m₂ vs. 27.3 kg/m₂); third-trimester viral load (1,688 copies/mL vs. 10,548 copies/mL); third-trimester CD4 counts (391 vs. 410 cells/mcL); gestational age at delivery (38.3 weeks vs. 39 weeks), and birth weight percentile (32.1% vs. 39.4%). Although the viral load was not significantly different between the two groups, it was lower among perinatally infected women, suggesting that this group of women may be more compliant with highly active antiretroviral therapy (HAART) compared with controls, said Dr. Kasdaglis, a first-year maternal-fetal medicine fellow at the university.

The study findings show that “perinatally infected HIV patients have good pregnancy outcomes that do not differ from [those of] women who acquire HIV later in life and have access to the same level of prenatal care,” concluded Dr. Kasdaglis, who reported having no conflicts of interest.

'Perinatally infected HIV pregnant patients have good pregnancy outcomes' in this small study. DR. KASDAGLIS

SAN DIEGO — No junior high or high school athlete who sustains a concussion in contact sports should be allowed to return to play that same day, because on average, simple concussions have recognizable deficits 8 days after the injury, according to Dr. Suraj Achar.

Concussion “is a serious brain injury that has been underrecognized and undertreated,” Dr. Achar said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. “Parents, coaches, trainers, and doctors should resist the temptation to let the kids go back on the field.”

In 2008, the National Football League mandated that team physicians forbid players to resume the game on the day of a concussive injury, and Dr. Achar believes a similar standard of care is appropriate for young athletes.

In football, an estimated 10% of college players and 20% of high school players in the United States sustain concussive injuries each season (JAMA 1999;282:958–63), yet about 80% of cases are never reported, either because they are missed by nonmedically trained observers or because the athlete resists being pulled onto the sidelines and may not recognize the seriousness of what happened, explained Dr. Achar of the department of sports medicine at the University of California, San Diego.

He noted that younger children are more susceptible to concussions, compared with their older counterparts, for reasons that remain unclear. Yet maybe one in four concussions have long-term manifestations. Single concussions may lead to changes in mental and physical functioning for 30-plus years, Dr. Achar said.

A widely used diagnostic instrument is the standardized assessment of concussion (SAC) system, which tabulates a summary of total scores in orientation, immediate memory, concentration, delayed recall, strength and coordination, and exertional maneuvers. An athlete who scores even 1 point less than the optimal 30 points is considered to have suffered a concussion.

A study of male college and high school athletes found that the SAC had sensitivity of 94% and a specificity of 76% (J. Intl. Neuropsychol. Soc. 2001;7:693–702). Neuroimaging tests usually are not ordered after a concussion because the results tend to be normal. Deficits generally are functional, not structural, said Dr. Achar, who practices family and sports medicine in La Jolla, Calif.

A consensus paper on concussion in sport, classified concussions as either simple—meaning that symptoms resolve in 7–10 days with no obvious sequelae, no intervention is required, and neurologic testing is negative—or complex, meaning that symptoms persist after 7 days and worsen with exertion, prolonged loss of consciousness and cognitive impairment occur, and the patient has a history of multiple concussive injuries (Br. J. Sports Med. 2005;39:196–204). “You need a multidisciplinary team to care for these patients,” said Dr. Achar, who had no potential conflicts of interest to disclose.

In minors, “concussive symptoms can last up to 3 weeks. With sophisticated computer testing, neurologic deficits rarely resolve before 8 days after the injury. We want to completely rest them.”

The path for return to play begins with light aerobic exercise, followed gradually by sport-specific exercises such as skating in hockey or running in soccer, with progressive addition of resistance training. Finally, noncontact training drills and full-contact training drills may be resumed, and the athlete may return to play after medical clearance.

If any postconcussive symptoms occur, the consensus guidelines recommend that the patient drop back to the previous asymptomatic level and try to progress again after 24 hours.

'Parents, coaches, trainers, and doctors should resist the temptation to let the kids go back on the field.' DR. ACHAR

SAN DIEGO — No junior high or high school athlete who sustains a concussion in contact sports should be allowed to return to play that same day, because on average, simple concussions have recognizable deficits 8 days after the injury, according to Dr. Suraj Achar.

Concussion “is a serious brain injury that has been underrecognized and undertreated,” Dr. Achar said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. “Parents, coaches, trainers, and doctors should resist the temptation to let the kids go back on the field.”

In 2008, the National Football League mandated that team physicians forbid players to resume the game on the day of a concussive injury, and Dr. Achar believes a similar standard of care is appropriate for young athletes.

In football, an estimated 10% of college players and 20% of high school players in the United States sustain concussive injuries each season (JAMA 1999;282:958–63), yet about 80% of cases are never reported, either because they are missed by nonmedically trained observers or because the athlete resists being pulled onto the sidelines and may not recognize the seriousness of what happened, explained Dr. Achar of the department of sports medicine at the University of California, San Diego.

He noted that younger children are more susceptible to concussions, compared with their older counterparts, for reasons that remain unclear. Yet maybe one in four concussions have long-term manifestations. Single concussions may lead to changes in mental and physical functioning for 30-plus years, Dr. Achar said.

A widely used diagnostic instrument is the standardized assessment of concussion (SAC) system, which tabulates a summary of total scores in orientation, immediate memory, concentration, delayed recall, strength and coordination, and exertional maneuvers. An athlete who scores even 1 point less than the optimal 30 points is considered to have suffered a concussion.

A study of male college and high school athletes found that the SAC had sensitivity of 94% and a specificity of 76% (J. Intl. Neuropsychol. Soc. 2001;7:693–702). Neuroimaging tests usually are not ordered after a concussion because the results tend to be normal. Deficits generally are functional, not structural, said Dr. Achar, who practices family and sports medicine in La Jolla, Calif.

A consensus paper on concussion in sport, classified concussions as either simple—meaning that symptoms resolve in 7–10 days with no obvious sequelae, no intervention is required, and neurologic testing is negative—or complex, meaning that symptoms persist after 7 days and worsen with exertion, prolonged loss of consciousness and cognitive impairment occur, and the patient has a history of multiple concussive injuries (Br. J. Sports Med. 2005;39:196–204). “You need a multidisciplinary team to care for these patients,” said Dr. Achar, who had no potential conflicts of interest to disclose.

In minors, “concussive symptoms can last up to 3 weeks. With sophisticated computer testing, neurologic deficits rarely resolve before 8 days after the injury. We want to completely rest them.”

The path for return to play begins with light aerobic exercise, followed gradually by sport-specific exercises such as skating in hockey or running in soccer, with progressive addition of resistance training. Finally, noncontact training drills and full-contact training drills may be resumed, and the athlete may return to play after medical clearance.

If any postconcussive symptoms occur, the consensus guidelines recommend that the patient drop back to the previous asymptomatic level and try to progress again after 24 hours.

'Parents, coaches, trainers, and doctors should resist the temptation to let the kids go back on the field.' DR. ACHAR

SAN DIEGO — No junior high or high school athlete who sustains a concussion in contact sports should be allowed to return to play that same day, because on average, simple concussions have recognizable deficits 8 days after the injury, according to Dr. Suraj Achar.

Concussion “is a serious brain injury that has been underrecognized and undertreated,” Dr. Achar said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. “Parents, coaches, trainers, and doctors should resist the temptation to let the kids go back on the field.”

In 2008, the National Football League mandated that team physicians forbid players to resume the game on the day of a concussive injury, and Dr. Achar believes a similar standard of care is appropriate for young athletes.

In football, an estimated 10% of college players and 20% of high school players in the United States sustain concussive injuries each season (JAMA 1999;282:958–63), yet about 80% of cases are never reported, either because they are missed by nonmedically trained observers or because the athlete resists being pulled onto the sidelines and may not recognize the seriousness of what happened, explained Dr. Achar of the department of sports medicine at the University of California, San Diego.

He noted that younger children are more susceptible to concussions, compared with their older counterparts, for reasons that remain unclear. Yet maybe one in four concussions have long-term manifestations. Single concussions may lead to changes in mental and physical functioning for 30-plus years, Dr. Achar said.

A widely used diagnostic instrument is the standardized assessment of concussion (SAC) system, which tabulates a summary of total scores in orientation, immediate memory, concentration, delayed recall, strength and coordination, and exertional maneuvers. An athlete who scores even 1 point less than the optimal 30 points is considered to have suffered a concussion.

A study of male college and high school athletes found that the SAC had sensitivity of 94% and a specificity of 76% (J. Intl. Neuropsychol. Soc. 2001;7:693–702). Neuroimaging tests usually are not ordered after a concussion because the results tend to be normal. Deficits generally are functional, not structural, said Dr. Achar, who practices family and sports medicine in La Jolla, Calif.

A consensus paper on concussion in sport, classified concussions as either simple—meaning that symptoms resolve in 7–10 days with no obvious sequelae, no intervention is required, and neurologic testing is negative—or complex, meaning that symptoms persist after 7 days and worsen with exertion, prolonged loss of consciousness and cognitive impairment occur, and the patient has a history of multiple concussive injuries (Br. J. Sports Med. 2005;39:196–204). “You need a multidisciplinary team to care for these patients,” said Dr. Achar, who had no potential conflicts of interest to disclose.

In minors, “concussive symptoms can last up to 3 weeks. With sophisticated computer testing, neurologic deficits rarely resolve before 8 days after the injury. We want to completely rest them.”

The path for return to play begins with light aerobic exercise, followed gradually by sport-specific exercises such as skating in hockey or running in soccer, with progressive addition of resistance training. Finally, noncontact training drills and full-contact training drills may be resumed, and the athlete may return to play after medical clearance.

If any postconcussive symptoms occur, the consensus guidelines recommend that the patient drop back to the previous asymptomatic level and try to progress again after 24 hours.

'Parents, coaches, trainers, and doctors should resist the temptation to let the kids go back on the field.' DR. ACHAR

SAN DIEGO — No junior high or high school athlete who sustains a concussion in contact sports should be allowed to return to play that same day, because on average, simple concussions have recognizable deficits 8 days after the injury, according to Dr. Suraj Achar.

Concussion “is a serious brain injury that has been underrecognized and undertreated,” Dr. Achar said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. “Parents, coaches, trainers, and doctors should resist the temptation to let the kids go back on the field.”

In 2008, the National Football League mandated that team physicians forbid players to resume the game on the day of a concussive injury, and this should be the standard of care for all young athletes, said Dr. Achar of the department of sports medicine at the University of California, San Diego.

He noted that younger children are more susceptible to concussions, compared with their older counterparts, for reasons that remain unclear. Yet maybe one in four concussions have long-term manifestations. Single concussions may lead to changes in mental and physical functioning for 30-plus years, he said.

A widely used diagnostic instrument is the standardized assessment of concussion (SAC) system, which tabulates a summary of total scores in orientation, immediate memory, concentration, and delayed recall. An athlete who scores even 1 point less than the optimal 30 points is considered to have suffered a concussion. Other components of the system involve neurologic screening, including recollection of the injury and tests of strength and coordination, as well as exertional maneuvers such as a 40-yard dash, sit-ups, push-ups, and knee bends.

A study of male college and high school athletes found that the SAC had sensitivity of 94% and a specificity of 76% (J. Intl. Neuropsychol. Soc. 2001;7:693–702). Neuroimaging tests usually are not ordered after a concussion because the results tend to be normal. Deficits generally are functional, not structural. “Sometimes we do CT imaging when there is a prolonged disturbance of consciousness and in those with worsening symptoms and, for sure, we do CT imaging when there are focal neurologic symptoms,” said Dr. Achar, who practices family and sports medicine in La Jolla, Calif. There are no good data about the benefit of MRI for evaluation of concussion.

A consensus paper on concussion in sport, classified concussions as either simple—meaning that symptoms resolve in 7–10 days with no obvious sequelae, no intervention is required, and neurologic testing is negative—or complex—meaning that symptoms persist after 7 days and worsen with exertion, prolonged loss of consciousness and cognitive impairment occur, and the patient has a history of multiple concussive injuries (Br. J. Sports Med. 2005;39:196–204). “You need a multidisciplinary team to care for these patients,” Dr. Achar said.

In minors, “concussive symptoms can last up to 3 weeks. With sophisticated computer testing, neurologic deficits rarely resolve before 8 days after the injury. We want to completely rest them. That means even brain rest until they're completely asymptomatic.”

The path for return to play begins with light aerobic exercise such as walking or stationary cycling, followed gradually by sport-specific exercises such as skating in hockey or running in soccer, with progressive addition of resistance training. Finally, noncontact training drills and full-contact training drills may be resumed, and the athlete may return to play after medical clearance.

Dr. Achar had no conflicts to disclose.

Single concussions may lead to changes in mental and physical functioning for 30-plus years. DR. ACHAR

SAN DIEGO — No junior high or high school athlete who sustains a concussion in contact sports should be allowed to return to play that same day, because on average, simple concussions have recognizable deficits 8 days after the injury, according to Dr. Suraj Achar.

Concussion “is a serious brain injury that has been underrecognized and undertreated,” Dr. Achar said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. “Parents, coaches, trainers, and doctors should resist the temptation to let the kids go back on the field.”

In 2008, the National Football League mandated that team physicians forbid players to resume the game on the day of a concussive injury, and this should be the standard of care for all young athletes, said Dr. Achar of the department of sports medicine at the University of California, San Diego.

He noted that younger children are more susceptible to concussions, compared with their older counterparts, for reasons that remain unclear. Yet maybe one in four concussions have long-term manifestations. Single concussions may lead to changes in mental and physical functioning for 30-plus years, he said.

A widely used diagnostic instrument is the standardized assessment of concussion (SAC) system, which tabulates a summary of total scores in orientation, immediate memory, concentration, and delayed recall. An athlete who scores even 1 point less than the optimal 30 points is considered to have suffered a concussion. Other components of the system involve neurologic screening, including recollection of the injury and tests of strength and coordination, as well as exertional maneuvers such as a 40-yard dash, sit-ups, push-ups, and knee bends.

A study of male college and high school athletes found that the SAC had sensitivity of 94% and a specificity of 76% (J. Intl. Neuropsychol. Soc. 2001;7:693–702). Neuroimaging tests usually are not ordered after a concussion because the results tend to be normal. Deficits generally are functional, not structural. “Sometimes we do CT imaging when there is a prolonged disturbance of consciousness and in those with worsening symptoms and, for sure, we do CT imaging when there are focal neurologic symptoms,” said Dr. Achar, who practices family and sports medicine in La Jolla, Calif. There are no good data about the benefit of MRI for evaluation of concussion.

A consensus paper on concussion in sport, classified concussions as either simple—meaning that symptoms resolve in 7–10 days with no obvious sequelae, no intervention is required, and neurologic testing is negative—or complex—meaning that symptoms persist after 7 days and worsen with exertion, prolonged loss of consciousness and cognitive impairment occur, and the patient has a history of multiple concussive injuries (Br. J. Sports Med. 2005;39:196–204). “You need a multidisciplinary team to care for these patients,” Dr. Achar said.

In minors, “concussive symptoms can last up to 3 weeks. With sophisticated computer testing, neurologic deficits rarely resolve before 8 days after the injury. We want to completely rest them. That means even brain rest until they're completely asymptomatic.”

The path for return to play begins with light aerobic exercise such as walking or stationary cycling, followed gradually by sport-specific exercises such as skating in hockey or running in soccer, with progressive addition of resistance training. Finally, noncontact training drills and full-contact training drills may be resumed, and the athlete may return to play after medical clearance.

Dr. Achar had no conflicts to disclose.

Single concussions may lead to changes in mental and physical functioning for 30-plus years. DR. ACHAR

SAN DIEGO — No junior high or high school athlete who sustains a concussion in contact sports should be allowed to return to play that same day, because on average, simple concussions have recognizable deficits 8 days after the injury, according to Dr. Suraj Achar.

Concussion “is a serious brain injury that has been underrecognized and undertreated,” Dr. Achar said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. “Parents, coaches, trainers, and doctors should resist the temptation to let the kids go back on the field.”

In 2008, the National Football League mandated that team physicians forbid players to resume the game on the day of a concussive injury, and this should be the standard of care for all young athletes, said Dr. Achar of the department of sports medicine at the University of California, San Diego.

He noted that younger children are more susceptible to concussions, compared with their older counterparts, for reasons that remain unclear. Yet maybe one in four concussions have long-term manifestations. Single concussions may lead to changes in mental and physical functioning for 30-plus years, he said.

A widely used diagnostic instrument is the standardized assessment of concussion (SAC) system, which tabulates a summary of total scores in orientation, immediate memory, concentration, and delayed recall. An athlete who scores even 1 point less than the optimal 30 points is considered to have suffered a concussion. Other components of the system involve neurologic screening, including recollection of the injury and tests of strength and coordination, as well as exertional maneuvers such as a 40-yard dash, sit-ups, push-ups, and knee bends.

A study of male college and high school athletes found that the SAC had sensitivity of 94% and a specificity of 76% (J. Intl. Neuropsychol. Soc. 2001;7:693–702). Neuroimaging tests usually are not ordered after a concussion because the results tend to be normal. Deficits generally are functional, not structural. “Sometimes we do CT imaging when there is a prolonged disturbance of consciousness and in those with worsening symptoms and, for sure, we do CT imaging when there are focal neurologic symptoms,” said Dr. Achar, who practices family and sports medicine in La Jolla, Calif. There are no good data about the benefit of MRI for evaluation of concussion.

A consensus paper on concussion in sport, classified concussions as either simple—meaning that symptoms resolve in 7–10 days with no obvious sequelae, no intervention is required, and neurologic testing is negative—or complex—meaning that symptoms persist after 7 days and worsen with exertion, prolonged loss of consciousness and cognitive impairment occur, and the patient has a history of multiple concussive injuries (Br. J. Sports Med. 2005;39:196–204). “You need a multidisciplinary team to care for these patients,” Dr. Achar said.

In minors, “concussive symptoms can last up to 3 weeks. With sophisticated computer testing, neurologic deficits rarely resolve before 8 days after the injury. We want to completely rest them. That means even brain rest until they're completely asymptomatic.”

The path for return to play begins with light aerobic exercise such as walking or stationary cycling, followed gradually by sport-specific exercises such as skating in hockey or running in soccer, with progressive addition of resistance training. Finally, noncontact training drills and full-contact training drills may be resumed, and the athlete may return to play after medical clearance.

Dr. Achar had no conflicts to disclose.

Single concussions may lead to changes in mental and physical functioning for 30-plus years. DR. ACHAR

SAN DIEGO — It's important to recognize femoral acetabular impingement in young athletes because increasing evidence suggests that children and adolescents with the condition may require total hip replacements later in life, according to Dr. Eric W. Edmonds.

Femoral acetabular impingement “may be related to slipped capital femoral epiphysis injuries, which usually occur in overweight children, but we think there is a more athletic body habitus in which the femoral head slowly creeps back because of athletic endeavors, he said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. The head and neck of the femur are offset from each other, so it becomes prominent on the front side and causes impingement as the child brings the hip up into flexion.

This can occur from a slight slip, known as a Cam impingement, or from a Pincer impingement, in which the acetabular cup is rotated back from where it should be. The majority of children with femoral acetabular impingement have a mix of these two types, said Dr. Edmonds, an orthopedic surgeon with the pediatric orthopedic and scoliosis center at Rady Children's Hospital, San Diego.

The first line of defense is conservative management with physical therapy such as Pilates and core training. If a femoral head doesn't look normal on x-ray, Dr. Edmonds said he orders an MRI with an arthrogram, because evaluation of the labrum inside the hip requires an intraarticular injection by the radiologist.

Another lower-extremity injury seen in young athletes is an avulsion fracture, which rarely requires surgical intervention. The best therapy is to protect from weight bearing and allow the athlete to return to sports as symptoms improve. Some athletes will develop hypertrophic ossifications at the fracture site.

Common problems that occur in young athletes who suffer avulsion fractures include avulsion of the sartorius muscle, the rectus femoris muscle, and the hamstrings.

Young athletes need to perform regular stretching exercises to maintain flexibility, he stressed. There are strong associations between quadriceps inflexibility and anterior knee pain, hamstring inflexibility and patellofemoral pain, and gastroc-soleus muscle inflexibility and calcaneal apophysitis, Dr. Edmonds said.

He estimated that 60% of young athletes referred to him have poor flexibility. He measures the flexibility of the hamstrings, the gastroc-soleus muscle, and the quadriceps with these three tests:

▸ Popliteal angle test (hamstrings). With the patient supine, the clinician measures the angle created at the knee using the thigh and the calf as the two vectors. The clinician maintains the hip flexion at 90 degrees while attempting to bring the knee straight. “In athletes younger than age 18, [the leg] should easily be raised up to 180 degrees with the knee extended, but I see a lot of kids with lower marks,” Dr. Edmonds said.

▸ Ankle dorsiflexion (gastroc-soleus). With the patient supine, measure the dorsiflexion of the ankle while the knee is extended. The gastroc-soleus muscle “should go 15–20 degrees past neutral with the knee extended,” he explained.

▸ Prone knee flexion (quadriceps). For this test the patient lies on his stomach and straightens his legs. The clinician then bends the knee and brings the heel as close as possible toward the buttock. “It should easily push down so that the heel touches their buttock, no matter how big their buttock is,” he said.

Dr. Edmonds said he had no conflicts to disclose.

Lack of offset between the femoral head and neck may indicate a Cam lesion. COURTESY DR. ERIC W. EDMONDS

SAN DIEGO — It's important to recognize femoral acetabular impingement in young athletes because increasing evidence suggests that children and adolescents with the condition may require total hip replacements later in life, according to Dr. Eric W. Edmonds.

Femoral acetabular impingement “may be related to slipped capital femoral epiphysis injuries, which usually occur in overweight children, but we think there is a more athletic body habitus in which the femoral head slowly creeps back because of athletic endeavors, he said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. The head and neck of the femur are offset from each other, so it becomes prominent on the front side and causes impingement as the child brings the hip up into flexion.

This can occur from a slight slip, known as a Cam impingement, or from a Pincer impingement, in which the acetabular cup is rotated back from where it should be. The majority of children with femoral acetabular impingement have a mix of these two types, said Dr. Edmonds, an orthopedic surgeon with the pediatric orthopedic and scoliosis center at Rady Children's Hospital, San Diego.

The first line of defense is conservative management with physical therapy such as Pilates and core training. If a femoral head doesn't look normal on x-ray, Dr. Edmonds said he orders an MRI with an arthrogram, because evaluation of the labrum inside the hip requires an intraarticular injection by the radiologist.

Another lower-extremity injury seen in young athletes is an avulsion fracture, which rarely requires surgical intervention. The best therapy is to protect from weight bearing and allow the athlete to return to sports as symptoms improve. Some athletes will develop hypertrophic ossifications at the fracture site.

Common problems that occur in young athletes who suffer avulsion fractures include avulsion of the sartorius muscle, the rectus femoris muscle, and the hamstrings.

Young athletes need to perform regular stretching exercises to maintain flexibility, he stressed. There are strong associations between quadriceps inflexibility and anterior knee pain, hamstring inflexibility and patellofemoral pain, and gastroc-soleus muscle inflexibility and calcaneal apophysitis, Dr. Edmonds said.

He estimated that 60% of young athletes referred to him have poor flexibility. He measures the flexibility of the hamstrings, the gastroc-soleus muscle, and the quadriceps with these three tests:

▸ Popliteal angle test (hamstrings). With the patient supine, the clinician measures the angle created at the knee using the thigh and the calf as the two vectors. The clinician maintains the hip flexion at 90 degrees while attempting to bring the knee straight. “In athletes younger than age 18, [the leg] should easily be raised up to 180 degrees with the knee extended, but I see a lot of kids with lower marks,” Dr. Edmonds said.

▸ Ankle dorsiflexion (gastroc-soleus). With the patient supine, measure the dorsiflexion of the ankle while the knee is extended. The gastroc-soleus muscle “should go 15–20 degrees past neutral with the knee extended,” he explained.

▸ Prone knee flexion (quadriceps). For this test the patient lies on his stomach and straightens his legs. The clinician then bends the knee and brings the heel as close as possible toward the buttock. “It should easily push down so that the heel touches their buttock, no matter how big their buttock is,” he said.

Dr. Edmonds said he had no conflicts to disclose.

Lack of offset between the femoral head and neck may indicate a Cam lesion. COURTESY DR. ERIC W. EDMONDS

SAN DIEGO — It's important to recognize femoral acetabular impingement in young athletes because increasing evidence suggests that children and adolescents with the condition may require total hip replacements later in life, according to Dr. Eric W. Edmonds.

Femoral acetabular impingement “may be related to slipped capital femoral epiphysis injuries, which usually occur in overweight children, but we think there is a more athletic body habitus in which the femoral head slowly creeps back because of athletic endeavors, he said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. The head and neck of the femur are offset from each other, so it becomes prominent on the front side and causes impingement as the child brings the hip up into flexion.

This can occur from a slight slip, known as a Cam impingement, or from a Pincer impingement, in which the acetabular cup is rotated back from where it should be. The majority of children with femoral acetabular impingement have a mix of these two types, said Dr. Edmonds, an orthopedic surgeon with the pediatric orthopedic and scoliosis center at Rady Children's Hospital, San Diego.

The first line of defense is conservative management with physical therapy such as Pilates and core training. If a femoral head doesn't look normal on x-ray, Dr. Edmonds said he orders an MRI with an arthrogram, because evaluation of the labrum inside the hip requires an intraarticular injection by the radiologist.

Another lower-extremity injury seen in young athletes is an avulsion fracture, which rarely requires surgical intervention. The best therapy is to protect from weight bearing and allow the athlete to return to sports as symptoms improve. Some athletes will develop hypertrophic ossifications at the fracture site.

Common problems that occur in young athletes who suffer avulsion fractures include avulsion of the sartorius muscle, the rectus femoris muscle, and the hamstrings.

Young athletes need to perform regular stretching exercises to maintain flexibility, he stressed. There are strong associations between quadriceps inflexibility and anterior knee pain, hamstring inflexibility and patellofemoral pain, and gastroc-soleus muscle inflexibility and calcaneal apophysitis, Dr. Edmonds said.

He estimated that 60% of young athletes referred to him have poor flexibility. He measures the flexibility of the hamstrings, the gastroc-soleus muscle, and the quadriceps with these three tests:

▸ Popliteal angle test (hamstrings). With the patient supine, the clinician measures the angle created at the knee using the thigh and the calf as the two vectors. The clinician maintains the hip flexion at 90 degrees while attempting to bring the knee straight. “In athletes younger than age 18, [the leg] should easily be raised up to 180 degrees with the knee extended, but I see a lot of kids with lower marks,” Dr. Edmonds said.

▸ Ankle dorsiflexion (gastroc-soleus). With the patient supine, measure the dorsiflexion of the ankle while the knee is extended. The gastroc-soleus muscle “should go 15–20 degrees past neutral with the knee extended,” he explained.

▸ Prone knee flexion (quadriceps). For this test the patient lies on his stomach and straightens his legs. The clinician then bends the knee and brings the heel as close as possible toward the buttock. “It should easily push down so that the heel touches their buttock, no matter how big their buttock is,” he said.

Dr. Edmonds said he had no conflicts to disclose.

Lack of offset between the femoral head and neck may indicate a Cam lesion. COURTESY DR. ERIC W. EDMONDS

SAN DIEGO — Clindamycin and trimethoprim-sulfamethoxazole are the most commonly used agents to treat community-acquired methicillin-resistant Staphylococcus aureus on an outpatient basis, but neither is perfect, according to one expert.

“The issue with clindamycin is that if you have big loads of bacteria, inducible resistance can develop,” Dr. Alice L. Pong said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. “So even though the bug might be susceptible on paper, over time it might develop resistance.”

Other strikes against clindamycin include its poor palatability—“most kids will throw it up,” she said—and the potential for gastrointestinal side effects, especially vomiting and diarrhea.

The recommended dosage is 20–40 mg/kg per day IV divided every 6–8 hours, and 10–30 mg/kg per day orally divided every 6–8 hours.

Trimethoprim-sulfamethoxazole is more convenient than clindamycin because it requires twice-a-day administration, and “it doesn't taste too bad,” said Dr. Pong of the division of infectious diseases at Rady Children's Hospital, San Diego. However, it's not effective for group A streptococci, “so if you don't have a culture and you don't know whether it's group A streptococci or S. aureus, you might run into trouble.”

There are limited data regarding trimethoprim-sulfamethoxazole's efficacy in treating MRSA, but “in many cases it probably works as well as anything else,” Dr. Pong said.

The recommended dosage is 8–12 mg/kg per day trimethoprim/40–60 mg/kg per day sulfamethoxazole given every 12 hours.

Doxycycline is another outpatient option for treating MRSA, “and it works well for acne, too,” she said. Approved for use in children aged 8 years and older, it has limited efficacy against group A streptococci.

The recommended dosage is 2–4 mg/kg per day given every 12 hours.

Rifampin is yet another treatment option, but it cannot be used alone as rapid resistance will ensue. The recommended dosage is 10–20 mg/kg per day IV or orally every 12–24 hours.

Quinolones such as levofloxacin are widely used for the treatment of MRSA in adults but are not approved for use in children in this situation.

Dr. Pong said that she and her colleagues have used quinolones for treating MRSA in children “only in situations where there is no other antibiotic available.”

Linezolid, a member of the new oxazolidinone class of drugs, is an expensive treatment option that is active at the ribosomal binding site of the bacterial cell.

“If you're going to give it for a prolonged period of time, you need to watch the complete blood count because linezolid can cause bone marrow suppression,” Dr. Pong warned. “But it works pretty well.

We occasionally put kids on this as a drug when they are discharged home from the hospital and they've improved on vancomycin or when their organism comes back as resistant to clindamycin and trimethoprim-sulfamethoxazole,” Dr. Pong continued.

Practical ways to decrease antibiotic resistance, she said, include avoiding unnecessary use of antibiotics, removing foreign devices as soon as possible, preventing transmission of resistant organisms, and practicing good infection control, especially hand washing.

Dr. Pong reported that she had no financial conflicts to disclose.

SAN DIEGO — Clindamycin and trimethoprim-sulfamethoxazole are the most commonly used agents to treat community-acquired methicillin-resistant Staphylococcus aureus on an outpatient basis, but neither is perfect, according to one expert.

“The issue with clindamycin is that if you have big loads of bacteria, inducible resistance can develop,” Dr. Alice L. Pong said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. “So even though the bug might be susceptible on paper, over time it might develop resistance.”

Other strikes against clindamycin include its poor palatability—“most kids will throw it up,” she said—and the potential for gastrointestinal side effects, especially vomiting and diarrhea.

The recommended dosage is 20–40 mg/kg per day IV divided every 6–8 hours, and 10–30 mg/kg per day orally divided every 6–8 hours.

Trimethoprim-sulfamethoxazole is more convenient than clindamycin because it requires twice-a-day administration, and “it doesn't taste too bad,” said Dr. Pong of the division of infectious diseases at Rady Children's Hospital, San Diego. However, it's not effective for group A streptococci, “so if you don't have a culture and you don't know whether it's group A streptococci or S. aureus, you might run into trouble.”

There are limited data regarding trimethoprim-sulfamethoxazole's efficacy in treating MRSA, but “in many cases it probably works as well as anything else,” Dr. Pong said.

The recommended dosage is 8–12 mg/kg per day trimethoprim/40–60 mg/kg per day sulfamethoxazole given every 12 hours.

Doxycycline is another outpatient option for treating MRSA, “and it works well for acne, too,” she said. Approved for use in children aged 8 years and older, it has limited efficacy against group A streptococci.

The recommended dosage is 2–4 mg/kg per day given every 12 hours.

Rifampin is yet another treatment option, but it cannot be used alone as rapid resistance will ensue. The recommended dosage is 10–20 mg/kg per day IV or orally every 12–24 hours.

Quinolones such as levofloxacin are widely used for the treatment of MRSA in adults but are not approved for use in children in this situation.

Dr. Pong said that she and her colleagues have used quinolones for treating MRSA in children “only in situations where there is no other antibiotic available.”

Linezolid, a member of the new oxazolidinone class of drugs, is an expensive treatment option that is active at the ribosomal binding site of the bacterial cell.

“If you're going to give it for a prolonged period of time, you need to watch the complete blood count because linezolid can cause bone marrow suppression,” Dr. Pong warned. “But it works pretty well.

We occasionally put kids on this as a drug when they are discharged home from the hospital and they've improved on vancomycin or when their organism comes back as resistant to clindamycin and trimethoprim-sulfamethoxazole,” Dr. Pong continued.

Practical ways to decrease antibiotic resistance, she said, include avoiding unnecessary use of antibiotics, removing foreign devices as soon as possible, preventing transmission of resistant organisms, and practicing good infection control, especially hand washing.

Dr. Pong reported that she had no financial conflicts to disclose.

SAN DIEGO — Clindamycin and trimethoprim-sulfamethoxazole are the most commonly used agents to treat community-acquired methicillin-resistant Staphylococcus aureus on an outpatient basis, but neither is perfect, according to one expert.

“The issue with clindamycin is that if you have big loads of bacteria, inducible resistance can develop,” Dr. Alice L. Pong said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. “So even though the bug might be susceptible on paper, over time it might develop resistance.”

Other strikes against clindamycin include its poor palatability—“most kids will throw it up,” she said—and the potential for gastrointestinal side effects, especially vomiting and diarrhea.

The recommended dosage is 20–40 mg/kg per day IV divided every 6–8 hours, and 10–30 mg/kg per day orally divided every 6–8 hours.

Trimethoprim-sulfamethoxazole is more convenient than clindamycin because it requires twice-a-day administration, and “it doesn't taste too bad,” said Dr. Pong of the division of infectious diseases at Rady Children's Hospital, San Diego. However, it's not effective for group A streptococci, “so if you don't have a culture and you don't know whether it's group A streptococci or S. aureus, you might run into trouble.”

There are limited data regarding trimethoprim-sulfamethoxazole's efficacy in treating MRSA, but “in many cases it probably works as well as anything else,” Dr. Pong said.

The recommended dosage is 8–12 mg/kg per day trimethoprim/40–60 mg/kg per day sulfamethoxazole given every 12 hours.

Doxycycline is another outpatient option for treating MRSA, “and it works well for acne, too,” she said. Approved for use in children aged 8 years and older, it has limited efficacy against group A streptococci.

The recommended dosage is 2–4 mg/kg per day given every 12 hours.

Rifampin is yet another treatment option, but it cannot be used alone as rapid resistance will ensue. The recommended dosage is 10–20 mg/kg per day IV or orally every 12–24 hours.

Quinolones such as levofloxacin are widely used for the treatment of MRSA in adults but are not approved for use in children in this situation.

Dr. Pong said that she and her colleagues have used quinolones for treating MRSA in children “only in situations where there is no other antibiotic available.”

Linezolid, a member of the new oxazolidinone class of drugs, is an expensive treatment option that is active at the ribosomal binding site of the bacterial cell.

“If you're going to give it for a prolonged period of time, you need to watch the complete blood count because linezolid can cause bone marrow suppression,” Dr. Pong warned. “But it works pretty well.

We occasionally put kids on this as a drug when they are discharged home from the hospital and they've improved on vancomycin or when their organism comes back as resistant to clindamycin and trimethoprim-sulfamethoxazole,” Dr. Pong continued.

Practical ways to decrease antibiotic resistance, she said, include avoiding unnecessary use of antibiotics, removing foreign devices as soon as possible, preventing transmission of resistant organisms, and practicing good infection control, especially hand washing.

Dr. Pong reported that she had no financial conflicts to disclose.

SAN DIEGO — The prevalence of abnormal ankle-brachial index, plasma fibrinogen, and C-reactive protein is surprisingly high among adults with no known history of heart disease, according to results from a large national study.

The finding sheds new light on predicting one's risk for cardiovascular disease, lead investigator Timothy P. Murphy said in an interview in advance of the annual meeting of the Society of Interventional Radiology, where the study was presented.

“We have some very potent medical treatments that can help people avoid heart attacks, stroke, and coronary-related death,” said Dr. Murphy, an interventional radiologist and director of the vascular disease research center at Rhode Island Hospital, Providence. “The question is, who should get those intensive medical therapies and who should not? The medical therapies have side effects and they're also expensive. Not everyone can take them.”

Previous studies have shown that a low ankle-brachial index (ABI), elevated plasma fibrinogen, and elevated C-reactive protein (CRP) are associated with a higher risk of cardiovascular disease, but no comparable data have been reported for the prevalence of abnormal ABI, fibrinogen, and CRP in populations not considered at high risk for cardiovascular events.

Dr. Murphy and his associates analyzed data from a cohort of 6,292 men and women aged 40 years and older who participated in the 1999–2004 National Health and Nutrition Examination Survey (NHANES) and who had no known history of heart disease, stroke, diabetes, or atherosclerotic vascular disease. The main goal was to identify the proportion of study participants with an abnormal ABI (defined as less than 0.9 in either leg); elevated plasma fibrinogen (defined as 400 mg/dL or higher), and elevated CRP (defined as greater than 3 mg/L) whose risk for cardiovascular disease was considered to be low or intermediate based on a Framingham risk score of less than 20%.

Of the 6,292 subjects, 91% had a Framingham risk score of less than 20%. Of these, 3% had a low ABI, which translates into about 2.1 million Americans. In addition, 16.9% had elevated fibrinogen and 38.8% had elevated CRP. Dr. Murphy noted that 45% of these subjects had abnormal readings in at least one of the three conditions.

“Maybe we should do screening ABIs before we write off intensive medical therapy for all low- and intermediate-risk people,” he commented. “The proposal to use ABI as a screening tool is appealing because there are a number of interventional radiologists, vascular surgeons, and vascular internists using it for that purpose already. … We need to get the word out about this to the primary care community, because that's where most of the patients are.”

He noted that ABI is likely a more specific screening test than serum fibrinogen or CRP because it detects already-established atherosclerotic disease, and added that it remains unclear what happens when physicians begin intensive medical therapy in patients found to have a low ABI. “It's not known if you can reduce the increased risk of cardiovascular disease at that point,” Dr. Murphy said. “We think it's likely, but this study does not address that.”

He estimated that fewer than 5% of primary care physicians use ABI as a screening tool for cardiovascular disease. “It might take 15–20 minutes to do an ABI,” he said. “The problem is, Medicare doesn't reimburse ABI as a screening test in asymptomatic patients. If a patient has symptoms they would be indicated for the ABI and that could be reimbursed.”

Dr. Murphy said that he had no conflicts to disclose.

SAN DIEGO — The prevalence of abnormal ankle-brachial index, plasma fibrinogen, and C-reactive protein is surprisingly high among adults with no known history of heart disease, according to results from a large national study.

The finding sheds new light on predicting one's risk for cardiovascular disease, lead investigator Timothy P. Murphy said in an interview in advance of the annual meeting of the Society of Interventional Radiology, where the study was presented.

“We have some very potent medical treatments that can help people avoid heart attacks, stroke, and coronary-related death,” said Dr. Murphy, an interventional radiologist and director of the vascular disease research center at Rhode Island Hospital, Providence. “The question is, who should get those intensive medical therapies and who should not? The medical therapies have side effects and they're also expensive. Not everyone can take them.”

Previous studies have shown that a low ankle-brachial index (ABI), elevated plasma fibrinogen, and elevated C-reactive protein (CRP) are associated with a higher risk of cardiovascular disease, but no comparable data have been reported for the prevalence of abnormal ABI, fibrinogen, and CRP in populations not considered at high risk for cardiovascular events.

Dr. Murphy and his associates analyzed data from a cohort of 6,292 men and women aged 40 years and older who participated in the 1999–2004 National Health and Nutrition Examination Survey (NHANES) and who had no known history of heart disease, stroke, diabetes, or atherosclerotic vascular disease. The main goal was to identify the proportion of study participants with an abnormal ABI (defined as less than 0.9 in either leg); elevated plasma fibrinogen (defined as 400 mg/dL or higher), and elevated CRP (defined as greater than 3 mg/L) whose risk for cardiovascular disease was considered to be low or intermediate based on a Framingham risk score of less than 20%.

Of the 6,292 subjects, 91% had a Framingham risk score of less than 20%. Of these, 3% had a low ABI, which translates into about 2.1 million Americans. In addition, 16.9% had elevated fibrinogen and 38.8% had elevated CRP. Dr. Murphy noted that 45% of these subjects had abnormal readings in at least one of the three conditions.

“Maybe we should do screening ABIs before we write off intensive medical therapy for all low- and intermediate-risk people,” he commented. “The proposal to use ABI as a screening tool is appealing because there are a number of interventional radiologists, vascular surgeons, and vascular internists using it for that purpose already. … We need to get the word out about this to the primary care community, because that's where most of the patients are.”

He noted that ABI is likely a more specific screening test than serum fibrinogen or CRP because it detects already-established atherosclerotic disease, and added that it remains unclear what happens when physicians begin intensive medical therapy in patients found to have a low ABI. “It's not known if you can reduce the increased risk of cardiovascular disease at that point,” Dr. Murphy said. “We think it's likely, but this study does not address that.”

He estimated that fewer than 5% of primary care physicians use ABI as a screening tool for cardiovascular disease. “It might take 15–20 minutes to do an ABI,” he said. “The problem is, Medicare doesn't reimburse ABI as a screening test in asymptomatic patients. If a patient has symptoms they would be indicated for the ABI and that could be reimbursed.”

Dr. Murphy said that he had no conflicts to disclose.

SAN DIEGO — The prevalence of abnormal ankle-brachial index, plasma fibrinogen, and C-reactive protein is surprisingly high among adults with no known history of heart disease, according to results from a large national study.

The finding sheds new light on predicting one's risk for cardiovascular disease, lead investigator Timothy P. Murphy said in an interview in advance of the annual meeting of the Society of Interventional Radiology, where the study was presented.

“We have some very potent medical treatments that can help people avoid heart attacks, stroke, and coronary-related death,” said Dr. Murphy, an interventional radiologist and director of the vascular disease research center at Rhode Island Hospital, Providence. “The question is, who should get those intensive medical therapies and who should not? The medical therapies have side effects and they're also expensive. Not everyone can take them.”

Previous studies have shown that a low ankle-brachial index (ABI), elevated plasma fibrinogen, and elevated C-reactive protein (CRP) are associated with a higher risk of cardiovascular disease, but no comparable data have been reported for the prevalence of abnormal ABI, fibrinogen, and CRP in populations not considered at high risk for cardiovascular events.

Dr. Murphy and his associates analyzed data from a cohort of 6,292 men and women aged 40 years and older who participated in the 1999–2004 National Health and Nutrition Examination Survey (NHANES) and who had no known history of heart disease, stroke, diabetes, or atherosclerotic vascular disease. The main goal was to identify the proportion of study participants with an abnormal ABI (defined as less than 0.9 in either leg); elevated plasma fibrinogen (defined as 400 mg/dL or higher), and elevated CRP (defined as greater than 3 mg/L) whose risk for cardiovascular disease was considered to be low or intermediate based on a Framingham risk score of less than 20%.

Of the 6,292 subjects, 91% had a Framingham risk score of less than 20%. Of these, 3% had a low ABI, which translates into about 2.1 million Americans. In addition, 16.9% had elevated fibrinogen and 38.8% had elevated CRP. Dr. Murphy noted that 45% of these subjects had abnormal readings in at least one of the three conditions.

“Maybe we should do screening ABIs before we write off intensive medical therapy for all low- and intermediate-risk people,” he commented. “The proposal to use ABI as a screening tool is appealing because there are a number of interventional radiologists, vascular surgeons, and vascular internists using it for that purpose already. … We need to get the word out about this to the primary care community, because that's where most of the patients are.”

He noted that ABI is likely a more specific screening test than serum fibrinogen or CRP because it detects already-established atherosclerotic disease, and added that it remains unclear what happens when physicians begin intensive medical therapy in patients found to have a low ABI. “It's not known if you can reduce the increased risk of cardiovascular disease at that point,” Dr. Murphy said. “We think it's likely, but this study does not address that.”

He estimated that fewer than 5% of primary care physicians use ABI as a screening tool for cardiovascular disease. “It might take 15–20 minutes to do an ABI,” he said. “The problem is, Medicare doesn't reimburse ABI as a screening test in asymptomatic patients. If a patient has symptoms they would be indicated for the ABI and that could be reimbursed.”

Dr. Murphy said that he had no conflicts to disclose.