Michele G. Sullivan

Systematic bias in the design of several underlying studies raises doubt over whether a serum proteomics test based on those studies can accurately identify ovarian cancer, two independent biostatisticians have argued.

The researchers, both of the University of Texas M.D. Anderson Cancer Research Center, Houston, have been unable to reproduce the high sensitivity and specificity rates reported in a 2003 study of the technique (J. Natl. Cancer Inst. 2005;97:307-9).

The problem, said Keith A. Baggerly, Ph.D., and Kevin R. Coombes, Ph.D., lies not in the fundamental concept—that cancer-shed proteins in serum may be able to identify patients who have even very early-stage cancer—but in the way the data sets were processed in both the 2003 study and the original 2002 National Cancer Institute (NCI) study upon which it was based.

“We're not saying proteomics doesn't work,” Dr. Baggerly said in an interview. “It may very well work. But these data sets can't be used to say this approach works.”

The method involves using mass spectroscopy to display proteins in serum as a series of peaks and valleys of varying strength. A computer-driven mathematical algorithm finds unique patterns expressed in the serum of patients with the disease. Several researchers are investigating proteomics' application in ovarian cancer, using different algorithms and spectrometers. All of the decoding work is being performed on three publicly available sets of spectral data, which were processed as part of the original proof-of-concept study by NCI researchers led by Emmanuel F. Petricoin III, M.D. (Lancet 2002;359:572-7).

Dr. Baggerly and Dr. Coombes reanalyzed the data used in a 2003 paper by Wei Zhu, Ph.D., and associates, of the State University of New York at Stony Brook. By using the same NCI data sets—samples from women with ovarian cancer, women with benign ovarian cysts, and healthy controls—but a new protein-recognition pattern, Dr. Zhu achieved perfect discrimination (100% sensitivity, 100% specificity) of patients with ovarian cancer, including early-stage disease, from normal controls (PNAS 2003;100:14666-71). Dr. Zhu's results were even better than those originally reported by Dr. Petricoin and colleagues in their 2002 study.

When Dr. Baggerly reanalyzed the Zhu data, he was unable to arrive at the same results. The Zhu study identified a pattern involving 18 protein peaks that separated controls from cancers. For Dr. Baggerly, the pattern resulted in significant accuracy in the first data set, which contained serum from all three groups, but not in the second data set, which contained only serum from cancer patients and healthy controls.

In the second data set, 13 of the 18 peak differences changed signs—that is, peaks associated with cancer in the first group were associated with controls in the second group, and peaks first associated with controls switched to cancers. “This reversal isn't consistent with a persistent difference between cancer samples and control samples,” Dr. Baggerly said.

The researchers then chose 18 random protein peaks from the same regions of spectral data as Dr. Zhu's peaks. The random peaks separated cancer samples from controls up to 56% of the time, depending on the strength of the signals used. Because the pattern of protein expression was inconsistent between the data sets, they concluded, the values did not represent biologically important changes in the serum of cancer patients.

The problem, Dr. Baggerly asserts, is that Dr. Zhu processed the serum samples in a nonrandomized way that the spectra were acquired in the initial study by Dr. Petricoin and his collegues.

“They ran all the controls on one day and all the cancers on the next day,” Dr. Baggerly said. “This is the worst kind of design when you are using a machine that can be subject to external factors,” such as changes in calibration or mechanical breakdown.

In fact, he said, a June 2004 study in which Dr. Petricoin participated also suffered from such a problem (Endoc. Relat. Cancer 2004;11:163-78). This study used a different mass spectrometer, which began to break down on day 3 of running the samples.

In a letter to the editor, Dr. Petricoin admitted the problem, but said, “We cannot detect whether the cancer data acquired on the previous day were convincingly negatively affected by the spectrometer failure.”

Dr. Baggerly contends that a better design involving randomizing sample processing would allow separation of differences due to biology from those due to external factors.

His failure to find reproducibility does not surprise Dr. Petricoin and his colleague, Lance A. Liotta, M.D., who participated in the 2002 and 2004 studies. Their commentary appears in the same journal. Each of the data sets, all of which are available without restriction online, was generated with different machines and methods to test those machines and methods.

“We would be surprised if the experimentally designed process changes between these two studies did not result in altered spectra. In fact, a goal of these experiments was to study the spectral alterations produced by changing the process,” they said.

Because serum proteomics is in its infancy, they wrote, there is no procedure to standardize intra- and inter-laboratory comparisons. Only after that standardization happens can well-designed, meaningful, and reproducible studies be conducted.

In the meantime, they concluded, researchers who wish to attempt such studies should keep open lines of communication with those who originally produced the data. “A meaningful analysis of reproducibility requires communication. … Without such communication, data can be misinterpreted; unwarranted, overextended conclusions can be drawn; and misinformation can be spread,” he said.

Additional research using meticulously designed studies is needed, Dr. Baggerly said. “If a test for ovarian cancer ever does come about from these data, I'd need to see a lot more studies before I'd send my mother out to get it.”

OvaCheck Unaffected, Developer Says

The serum proteomics study design debate won't affect the progress of OvaCheck, a proteomics test being developed as a screen for women at high risk for ovarian cancer, said Peter Levine, head of the Maryland firm developing the test.

“This is a purely academic debate,” said Mr. Levine, chief executive officer of Correlogic Systems Inc. “It has no bearing whatsoever on the state of the development of the technology today or on any of the other work researchers have been pursuing in this field.”

OvaCheck uses a sophisticated mathematical algorithm and mass spectroscopy to identify a specific pattern of serum proteins associated with even very early-stage ovarian cancers. The method was based on a 2002 National Cancer Institute (NCI) study, but it uses a different mass spectrometer and different spectral signals to identify cancer samples. Correlogic Systems is conducting validity testing on hundreds of samples but has not released any data on those tests.

The study design debate adds nothing to the development of proteomics technology because it focuses on outdated research, Mr. Levine said. “These studies are 2 and 3 years old,” he said. “Since then, scores of additional papers have been published on this technique and various other techniques.”

In fact, reanalyzing older studies may put forth the mistaken impression that serum proteomics has no future as a screening or diagnostic tool.

“The [NCI study] ushered in a revolution in the way we look at this biological data,” he said. “But it was just a proof-of-concept study. No one ever claimed it was a test for ovarian cancer.”

Many additional, more recent studies continue to expand on this original idea, including the research Correlogic Systems is performing, Mr. Levine said.

“We are refining our own technology as we go through the testing process, and that kind of research and development—tweaking the equipment and the process—goes on forever, as it should. Continuing to debate these early papers is like doing a thesis on the Wright brothers' first flight, when you already have a 747 that flies.”

OvaCheck, however, is still struggling through administrative processes at the Food and Drug Administration. Correlogic Systems hoped to license OvaCheck as a lab-developed test regulated under the Clinical Laboratory Improvement Amendments (CLIA). But the FDA determined last year that the software powering OvaCheck is a medical device covered by interstate commerce regulations and thus subject to FDA premarket review.

“We're still working with FDA on that issue and hope to have it resolved soon,” Mr Levine said.

Systematic bias in the design of several underlying studies raises doubt over whether a serum proteomics test based on those studies can accurately identify ovarian cancer, two independent biostatisticians have argued.

The researchers, both of the University of Texas M.D. Anderson Cancer Research Center, Houston, have been unable to reproduce the high sensitivity and specificity rates reported in a 2003 study of the technique (J. Natl. Cancer Inst. 2005;97:307-9).

The problem, said Keith A. Baggerly, Ph.D., and Kevin R. Coombes, Ph.D., lies not in the fundamental concept—that cancer-shed proteins in serum may be able to identify patients who have even very early-stage cancer—but in the way the data sets were processed in both the 2003 study and the original 2002 National Cancer Institute (NCI) study upon which it was based.

“We're not saying proteomics doesn't work,” Dr. Baggerly said in an interview. “It may very well work. But these data sets can't be used to say this approach works.”

The method involves using mass spectroscopy to display proteins in serum as a series of peaks and valleys of varying strength. A computer-driven mathematical algorithm finds unique patterns expressed in the serum of patients with the disease. Several researchers are investigating proteomics' application in ovarian cancer, using different algorithms and spectrometers. All of the decoding work is being performed on three publicly available sets of spectral data, which were processed as part of the original proof-of-concept study by NCI researchers led by Emmanuel F. Petricoin III, M.D. (Lancet 2002;359:572-7).

Dr. Baggerly and Dr. Coombes reanalyzed the data used in a 2003 paper by Wei Zhu, Ph.D., and associates, of the State University of New York at Stony Brook. By using the same NCI data sets—samples from women with ovarian cancer, women with benign ovarian cysts, and healthy controls—but a new protein-recognition pattern, Dr. Zhu achieved perfect discrimination (100% sensitivity, 100% specificity) of patients with ovarian cancer, including early-stage disease, from normal controls (PNAS 2003;100:14666-71). Dr. Zhu's results were even better than those originally reported by Dr. Petricoin and colleagues in their 2002 study.

When Dr. Baggerly reanalyzed the Zhu data, he was unable to arrive at the same results. The Zhu study identified a pattern involving 18 protein peaks that separated controls from cancers. For Dr. Baggerly, the pattern resulted in significant accuracy in the first data set, which contained serum from all three groups, but not in the second data set, which contained only serum from cancer patients and healthy controls.

In the second data set, 13 of the 18 peak differences changed signs—that is, peaks associated with cancer in the first group were associated with controls in the second group, and peaks first associated with controls switched to cancers. “This reversal isn't consistent with a persistent difference between cancer samples and control samples,” Dr. Baggerly said.

The researchers then chose 18 random protein peaks from the same regions of spectral data as Dr. Zhu's peaks. The random peaks separated cancer samples from controls up to 56% of the time, depending on the strength of the signals used. Because the pattern of protein expression was inconsistent between the data sets, they concluded, the values did not represent biologically important changes in the serum of cancer patients.

The problem, Dr. Baggerly asserts, is that Dr. Zhu processed the serum samples in a nonrandomized way that the spectra were acquired in the initial study by Dr. Petricoin and his collegues.

“They ran all the controls on one day and all the cancers on the next day,” Dr. Baggerly said. “This is the worst kind of design when you are using a machine that can be subject to external factors,” such as changes in calibration or mechanical breakdown.

In fact, he said, a June 2004 study in which Dr. Petricoin participated also suffered from such a problem (Endoc. Relat. Cancer 2004;11:163-78). This study used a different mass spectrometer, which began to break down on day 3 of running the samples.

In a letter to the editor, Dr. Petricoin admitted the problem, but said, “We cannot detect whether the cancer data acquired on the previous day were convincingly negatively affected by the spectrometer failure.”

Dr. Baggerly contends that a better design involving randomizing sample processing would allow separation of differences due to biology from those due to external factors.

His failure to find reproducibility does not surprise Dr. Petricoin and his colleague, Lance A. Liotta, M.D., who participated in the 2002 and 2004 studies. Their commentary appears in the same journal. Each of the data sets, all of which are available without restriction online, was generated with different machines and methods to test those machines and methods.

“We would be surprised if the experimentally designed process changes between these two studies did not result in altered spectra. In fact, a goal of these experiments was to study the spectral alterations produced by changing the process,” they said.

Because serum proteomics is in its infancy, they wrote, there is no procedure to standardize intra- and inter-laboratory comparisons. Only after that standardization happens can well-designed, meaningful, and reproducible studies be conducted.

In the meantime, they concluded, researchers who wish to attempt such studies should keep open lines of communication with those who originally produced the data. “A meaningful analysis of reproducibility requires communication. … Without such communication, data can be misinterpreted; unwarranted, overextended conclusions can be drawn; and misinformation can be spread,” he said.

Additional research using meticulously designed studies is needed, Dr. Baggerly said. “If a test for ovarian cancer ever does come about from these data, I'd need to see a lot more studies before I'd send my mother out to get it.”

OvaCheck Unaffected, Developer Says

The serum proteomics study design debate won't affect the progress of OvaCheck, a proteomics test being developed as a screen for women at high risk for ovarian cancer, said Peter Levine, head of the Maryland firm developing the test.

“This is a purely academic debate,” said Mr. Levine, chief executive officer of Correlogic Systems Inc. “It has no bearing whatsoever on the state of the development of the technology today or on any of the other work researchers have been pursuing in this field.”

OvaCheck uses a sophisticated mathematical algorithm and mass spectroscopy to identify a specific pattern of serum proteins associated with even very early-stage ovarian cancers. The method was based on a 2002 National Cancer Institute (NCI) study, but it uses a different mass spectrometer and different spectral signals to identify cancer samples. Correlogic Systems is conducting validity testing on hundreds of samples but has not released any data on those tests.

The study design debate adds nothing to the development of proteomics technology because it focuses on outdated research, Mr. Levine said. “These studies are 2 and 3 years old,” he said. “Since then, scores of additional papers have been published on this technique and various other techniques.”

In fact, reanalyzing older studies may put forth the mistaken impression that serum proteomics has no future as a screening or diagnostic tool.

“The [NCI study] ushered in a revolution in the way we look at this biological data,” he said. “But it was just a proof-of-concept study. No one ever claimed it was a test for ovarian cancer.”

Many additional, more recent studies continue to expand on this original idea, including the research Correlogic Systems is performing, Mr. Levine said.

“We are refining our own technology as we go through the testing process, and that kind of research and development—tweaking the equipment and the process—goes on forever, as it should. Continuing to debate these early papers is like doing a thesis on the Wright brothers' first flight, when you already have a 747 that flies.”

OvaCheck, however, is still struggling through administrative processes at the Food and Drug Administration. Correlogic Systems hoped to license OvaCheck as a lab-developed test regulated under the Clinical Laboratory Improvement Amendments (CLIA). But the FDA determined last year that the software powering OvaCheck is a medical device covered by interstate commerce regulations and thus subject to FDA premarket review.

“We're still working with FDA on that issue and hope to have it resolved soon,” Mr Levine said.

Systematic bias in the design of several underlying studies raises doubt over whether a serum proteomics test based on those studies can accurately identify ovarian cancer, two independent biostatisticians have argued.

The researchers, both of the University of Texas M.D. Anderson Cancer Research Center, Houston, have been unable to reproduce the high sensitivity and specificity rates reported in a 2003 study of the technique (J. Natl. Cancer Inst. 2005;97:307-9).

The problem, said Keith A. Baggerly, Ph.D., and Kevin R. Coombes, Ph.D., lies not in the fundamental concept—that cancer-shed proteins in serum may be able to identify patients who have even very early-stage cancer—but in the way the data sets were processed in both the 2003 study and the original 2002 National Cancer Institute (NCI) study upon which it was based.

“We're not saying proteomics doesn't work,” Dr. Baggerly said in an interview. “It may very well work. But these data sets can't be used to say this approach works.”

The method involves using mass spectroscopy to display proteins in serum as a series of peaks and valleys of varying strength. A computer-driven mathematical algorithm finds unique patterns expressed in the serum of patients with the disease. Several researchers are investigating proteomics' application in ovarian cancer, using different algorithms and spectrometers. All of the decoding work is being performed on three publicly available sets of spectral data, which were processed as part of the original proof-of-concept study by NCI researchers led by Emmanuel F. Petricoin III, M.D. (Lancet 2002;359:572-7).

Dr. Baggerly and Dr. Coombes reanalyzed the data used in a 2003 paper by Wei Zhu, Ph.D., and associates, of the State University of New York at Stony Brook. By using the same NCI data sets—samples from women with ovarian cancer, women with benign ovarian cysts, and healthy controls—but a new protein-recognition pattern, Dr. Zhu achieved perfect discrimination (100% sensitivity, 100% specificity) of patients with ovarian cancer, including early-stage disease, from normal controls (PNAS 2003;100:14666-71). Dr. Zhu's results were even better than those originally reported by Dr. Petricoin and colleagues in their 2002 study.

When Dr. Baggerly reanalyzed the Zhu data, he was unable to arrive at the same results. The Zhu study identified a pattern involving 18 protein peaks that separated controls from cancers. For Dr. Baggerly, the pattern resulted in significant accuracy in the first data set, which contained serum from all three groups, but not in the second data set, which contained only serum from cancer patients and healthy controls.

In the second data set, 13 of the 18 peak differences changed signs—that is, peaks associated with cancer in the first group were associated with controls in the second group, and peaks first associated with controls switched to cancers. “This reversal isn't consistent with a persistent difference between cancer samples and control samples,” Dr. Baggerly said.

The researchers then chose 18 random protein peaks from the same regions of spectral data as Dr. Zhu's peaks. The random peaks separated cancer samples from controls up to 56% of the time, depending on the strength of the signals used. Because the pattern of protein expression was inconsistent between the data sets, they concluded, the values did not represent biologically important changes in the serum of cancer patients.

The problem, Dr. Baggerly asserts, is that Dr. Zhu processed the serum samples in a nonrandomized way that the spectra were acquired in the initial study by Dr. Petricoin and his collegues.

“They ran all the controls on one day and all the cancers on the next day,” Dr. Baggerly said. “This is the worst kind of design when you are using a machine that can be subject to external factors,” such as changes in calibration or mechanical breakdown.

In fact, he said, a June 2004 study in which Dr. Petricoin participated also suffered from such a problem (Endoc. Relat. Cancer 2004;11:163-78). This study used a different mass spectrometer, which began to break down on day 3 of running the samples.

In a letter to the editor, Dr. Petricoin admitted the problem, but said, “We cannot detect whether the cancer data acquired on the previous day were convincingly negatively affected by the spectrometer failure.”

Dr. Baggerly contends that a better design involving randomizing sample processing would allow separation of differences due to biology from those due to external factors.

His failure to find reproducibility does not surprise Dr. Petricoin and his colleague, Lance A. Liotta, M.D., who participated in the 2002 and 2004 studies. Their commentary appears in the same journal. Each of the data sets, all of which are available without restriction online, was generated with different machines and methods to test those machines and methods.

“We would be surprised if the experimentally designed process changes between these two studies did not result in altered spectra. In fact, a goal of these experiments was to study the spectral alterations produced by changing the process,” they said.

Because serum proteomics is in its infancy, they wrote, there is no procedure to standardize intra- and inter-laboratory comparisons. Only after that standardization happens can well-designed, meaningful, and reproducible studies be conducted.

In the meantime, they concluded, researchers who wish to attempt such studies should keep open lines of communication with those who originally produced the data. “A meaningful analysis of reproducibility requires communication. … Without such communication, data can be misinterpreted; unwarranted, overextended conclusions can be drawn; and misinformation can be spread,” he said.

Additional research using meticulously designed studies is needed, Dr. Baggerly said. “If a test for ovarian cancer ever does come about from these data, I'd need to see a lot more studies before I'd send my mother out to get it.”

OvaCheck Unaffected, Developer Says

The serum proteomics study design debate won't affect the progress of OvaCheck, a proteomics test being developed as a screen for women at high risk for ovarian cancer, said Peter Levine, head of the Maryland firm developing the test.

“This is a purely academic debate,” said Mr. Levine, chief executive officer of Correlogic Systems Inc. “It has no bearing whatsoever on the state of the development of the technology today or on any of the other work researchers have been pursuing in this field.”

OvaCheck uses a sophisticated mathematical algorithm and mass spectroscopy to identify a specific pattern of serum proteins associated with even very early-stage ovarian cancers. The method was based on a 2002 National Cancer Institute (NCI) study, but it uses a different mass spectrometer and different spectral signals to identify cancer samples. Correlogic Systems is conducting validity testing on hundreds of samples but has not released any data on those tests.

The study design debate adds nothing to the development of proteomics technology because it focuses on outdated research, Mr. Levine said. “These studies are 2 and 3 years old,” he said. “Since then, scores of additional papers have been published on this technique and various other techniques.”

In fact, reanalyzing older studies may put forth the mistaken impression that serum proteomics has no future as a screening or diagnostic tool.

“The [NCI study] ushered in a revolution in the way we look at this biological data,” he said. “But it was just a proof-of-concept study. No one ever claimed it was a test for ovarian cancer.”

Many additional, more recent studies continue to expand on this original idea, including the research Correlogic Systems is performing, Mr. Levine said.

“We are refining our own technology as we go through the testing process, and that kind of research and development—tweaking the equipment and the process—goes on forever, as it should. Continuing to debate these early papers is like doing a thesis on the Wright brothers' first flight, when you already have a 747 that flies.”

OvaCheck, however, is still struggling through administrative processes at the Food and Drug Administration. Correlogic Systems hoped to license OvaCheck as a lab-developed test regulated under the Clinical Laboratory Improvement Amendments (CLIA). But the FDA determined last year that the software powering OvaCheck is a medical device covered by interstate commerce regulations and thus subject to FDA premarket review.

“We're still working with FDA on that issue and hope to have it resolved soon,” Mr Levine said.

Teens who take a sexual abstinence pledge delay their sexual debut for a few years, but they have just as many sexually transmitted infections as nonpledgers, probably because they are more likely to engage in noncoital sex and aren't as likely to use a condom during any sexual activity.

Hannah Brückner, Ph.D., and Peter Bearman, Ph.D., said their findings might put a new spin on programs that stress abstinence as the only way to avoid STDs and pregnancy. “The all-or-nothing approach … may create additional barriers to knowledge and protection for adolescents. For example, the emphasis on virginity may encourage adolescents to limit their sexual activity to noncoital behaviors, which may nevertheless expose them to risks of infection” (J. Adolesc. Health 2005;36:271-8).

Health care behavior by pledgers further complicates the problem, they noted. “It is important to know that pledgers are less likely than nonpledgers to be tested for STDs and to have ever seen a doctor because they are worried about an STD,” said the investigators of Yale University, New Haven, Conn., and Columbia University, New York.

The researchers extracted data gathered from 2001 to 2002, during the third wave of the National Longitudinal Study of Adolescent Health. During this wave, respondents were age 18-24 years. A total of 11,471 respondents provided urine samples for STD testing (chlamydia, gonorrhea, and trichomoniasis). An additional 3,317 sexually active female respondents were randomly selected for human papilloma virus (HPV) testing.

Pledge status was collected from all three waves of the survey. Nonpledgers reported no abstinence pledge during any of the waves. Consistent pledgers reported pledging during all waves or pledging for the first time during wave 3. Inconsistent pledgers reported pledging during an early wave but not a subsequent wave.

Most of the group (80%) were nonpledgers. Only 7% were consistent pledgers; 13% were inconsistent pledgers.

Consistent and inconsistent pledgers delayed their time to first coitus by several years, compared with nonpledgers. Among nonpledgers, 75% reported first intercourse by age 18. Inconsistent pledgers reached the 75th percentile by age 20, and consistent pledgers by age 24.

Male pledgers delayed intercourse the longest. By age 25, 25% of consistent male pledgers were still virgins, compared with 15% of inconsistent pledgers and 7% of nonpledgers. By age 25, 21% of female consistent pledgers were still virgins, compared with 10% of inconsistent pledgers and 6% of nonpledgers.

Delaying first intercourse had no significant effect on STD incidence in the groups, however.

About 6.9% of nonpledgers, 6.4% of inconsistent pledgers, and 4.6% of the consistent pledgers tested positive for trichomoniasis, chlamydia, and/or gonorrhea.

For HPV infection, the rates were 26.5% among nonpledgers, 28.5% among inconsistent pledgers, and 26.7% among consistent pledgers.

Pledgers did have fewer sexual partners than nonpledgers (average of 1.5 partners vs. 2.4 partners), and were not exposed as long to STD risk. However, they were more likely to engage in noncoital sexual contact.

About 3% of respondents reported oral sex but no vaginal sex. About 2% of nonpledgers fell into that group, compared with 13% of consistent pledgers and 5% of inconsistent pledgers. About 0.7% of nonpledgers reported anal sex but not vaginal sex, compared with 1.2% of pledgers.

About 1% of male nonpledgers reported anal, but not vaginal, sex, compared with 3% of male inconsistent pledgers and 4% of male consistent pledgers.

Condom use during these experiences was very low for all respondents: Only 4% reported using a condom during oral sex, and about 30% reported using one for anal sex.

“The combination of low condom use and overrepresentation of pledgers [in noncoital sex] provides some support for the hypothesis that this behavioral pattern is associated with greater than expected STD acquisition among pledgers, although the numbers are small and provide an insufficient basis from which to make inference,” the authors said.

Teens who take a sexual abstinence pledge delay their sexual debut for a few years, but they have just as many sexually transmitted infections as nonpledgers, probably because they are more likely to engage in noncoital sex and aren't as likely to use a condom during any sexual activity.

Hannah Brückner, Ph.D., and Peter Bearman, Ph.D., said their findings might put a new spin on programs that stress abstinence as the only way to avoid STDs and pregnancy. “The all-or-nothing approach … may create additional barriers to knowledge and protection for adolescents. For example, the emphasis on virginity may encourage adolescents to limit their sexual activity to noncoital behaviors, which may nevertheless expose them to risks of infection” (J. Adolesc. Health 2005;36:271-8).

Health care behavior by pledgers further complicates the problem, they noted. “It is important to know that pledgers are less likely than nonpledgers to be tested for STDs and to have ever seen a doctor because they are worried about an STD,” said the investigators of Yale University, New Haven, Conn., and Columbia University, New York.

The researchers extracted data gathered from 2001 to 2002, during the third wave of the National Longitudinal Study of Adolescent Health. During this wave, respondents were age 18-24 years. A total of 11,471 respondents provided urine samples for STD testing (chlamydia, gonorrhea, and trichomoniasis). An additional 3,317 sexually active female respondents were randomly selected for human papilloma virus (HPV) testing.

Pledge status was collected from all three waves of the survey. Nonpledgers reported no abstinence pledge during any of the waves. Consistent pledgers reported pledging during all waves or pledging for the first time during wave 3. Inconsistent pledgers reported pledging during an early wave but not a subsequent wave.

Most of the group (80%) were nonpledgers. Only 7% were consistent pledgers; 13% were inconsistent pledgers.

Consistent and inconsistent pledgers delayed their time to first coitus by several years, compared with nonpledgers. Among nonpledgers, 75% reported first intercourse by age 18. Inconsistent pledgers reached the 75th percentile by age 20, and consistent pledgers by age 24.

Male pledgers delayed intercourse the longest. By age 25, 25% of consistent male pledgers were still virgins, compared with 15% of inconsistent pledgers and 7% of nonpledgers. By age 25, 21% of female consistent pledgers were still virgins, compared with 10% of inconsistent pledgers and 6% of nonpledgers.

Delaying first intercourse had no significant effect on STD incidence in the groups, however.

About 6.9% of nonpledgers, 6.4% of inconsistent pledgers, and 4.6% of the consistent pledgers tested positive for trichomoniasis, chlamydia, and/or gonorrhea.

For HPV infection, the rates were 26.5% among nonpledgers, 28.5% among inconsistent pledgers, and 26.7% among consistent pledgers.

Pledgers did have fewer sexual partners than nonpledgers (average of 1.5 partners vs. 2.4 partners), and were not exposed as long to STD risk. However, they were more likely to engage in noncoital sexual contact.

About 3% of respondents reported oral sex but no vaginal sex. About 2% of nonpledgers fell into that group, compared with 13% of consistent pledgers and 5% of inconsistent pledgers. About 0.7% of nonpledgers reported anal sex but not vaginal sex, compared with 1.2% of pledgers.

About 1% of male nonpledgers reported anal, but not vaginal, sex, compared with 3% of male inconsistent pledgers and 4% of male consistent pledgers.

Condom use during these experiences was very low for all respondents: Only 4% reported using a condom during oral sex, and about 30% reported using one for anal sex.

“The combination of low condom use and overrepresentation of pledgers [in noncoital sex] provides some support for the hypothesis that this behavioral pattern is associated with greater than expected STD acquisition among pledgers, although the numbers are small and provide an insufficient basis from which to make inference,” the authors said.

Teens who take a sexual abstinence pledge delay their sexual debut for a few years, but they have just as many sexually transmitted infections as nonpledgers, probably because they are more likely to engage in noncoital sex and aren't as likely to use a condom during any sexual activity.

Hannah Brückner, Ph.D., and Peter Bearman, Ph.D., said their findings might put a new spin on programs that stress abstinence as the only way to avoid STDs and pregnancy. “The all-or-nothing approach … may create additional barriers to knowledge and protection for adolescents. For example, the emphasis on virginity may encourage adolescents to limit their sexual activity to noncoital behaviors, which may nevertheless expose them to risks of infection” (J. Adolesc. Health 2005;36:271-8).

Health care behavior by pledgers further complicates the problem, they noted. “It is important to know that pledgers are less likely than nonpledgers to be tested for STDs and to have ever seen a doctor because they are worried about an STD,” said the investigators of Yale University, New Haven, Conn., and Columbia University, New York.

The researchers extracted data gathered from 2001 to 2002, during the third wave of the National Longitudinal Study of Adolescent Health. During this wave, respondents were age 18-24 years. A total of 11,471 respondents provided urine samples for STD testing (chlamydia, gonorrhea, and trichomoniasis). An additional 3,317 sexually active female respondents were randomly selected for human papilloma virus (HPV) testing.

Pledge status was collected from all three waves of the survey. Nonpledgers reported no abstinence pledge during any of the waves. Consistent pledgers reported pledging during all waves or pledging for the first time during wave 3. Inconsistent pledgers reported pledging during an early wave but not a subsequent wave.

Most of the group (80%) were nonpledgers. Only 7% were consistent pledgers; 13% were inconsistent pledgers.

Consistent and inconsistent pledgers delayed their time to first coitus by several years, compared with nonpledgers. Among nonpledgers, 75% reported first intercourse by age 18. Inconsistent pledgers reached the 75th percentile by age 20, and consistent pledgers by age 24.

Male pledgers delayed intercourse the longest. By age 25, 25% of consistent male pledgers were still virgins, compared with 15% of inconsistent pledgers and 7% of nonpledgers. By age 25, 21% of female consistent pledgers were still virgins, compared with 10% of inconsistent pledgers and 6% of nonpledgers.

Delaying first intercourse had no significant effect on STD incidence in the groups, however.

About 6.9% of nonpledgers, 6.4% of inconsistent pledgers, and 4.6% of the consistent pledgers tested positive for trichomoniasis, chlamydia, and/or gonorrhea.

For HPV infection, the rates were 26.5% among nonpledgers, 28.5% among inconsistent pledgers, and 26.7% among consistent pledgers.

Pledgers did have fewer sexual partners than nonpledgers (average of 1.5 partners vs. 2.4 partners), and were not exposed as long to STD risk. However, they were more likely to engage in noncoital sexual contact.

About 3% of respondents reported oral sex but no vaginal sex. About 2% of nonpledgers fell into that group, compared with 13% of consistent pledgers and 5% of inconsistent pledgers. About 0.7% of nonpledgers reported anal sex but not vaginal sex, compared with 1.2% of pledgers.

About 1% of male nonpledgers reported anal, but not vaginal, sex, compared with 3% of male inconsistent pledgers and 4% of male consistent pledgers.

Condom use during these experiences was very low for all respondents: Only 4% reported using a condom during oral sex, and about 30% reported using one for anal sex.

“The combination of low condom use and overrepresentation of pledgers [in noncoital sex] provides some support for the hypothesis that this behavioral pattern is associated with greater than expected STD acquisition among pledgers, although the numbers are small and provide an insufficient basis from which to make inference,” the authors said.

The oral pathogen Actinomyces naeslundii appears to be associated with shorter gestation resulting in preterm low birth weight, while oral Lactobacillus casei is associated with longer gestation and higher birth weight.

Increased levels of A. naeslundii could account for as much as 4%-6% of preterm low-birth-weight babies, although more research is necessary to confirm causality, said Ananda P. Dasanayake, D.D.S., of the New York University College of Dentistry, and his colleagues (J. Periodontol. 2005;76:171-7).

The epidemiologic study offers one more tantalizing glimpse at the interrelationship between oral health and systemic disease, and points up the importance of dental care during pregnancy.

“It is advisable to tell patients to seek dental care during pregnancy,” Dr. Dasanayake said in an interview. “If they have chronic periodontal disease, that can be treated—usually mechanically, by scaling and root planing, but sometimes with combination therapy that includes antibiotics.”

Dr. Dasanayake and his colleagues compared the presence of oral bacteria during the third trimester and at delivery with pregnancy outcomes in 297 primigravidas. The women's mean age was 20 years; 93% were African American. About 85% had at least a high school education. Saliva samples were obtained by expectoration after chewing on sterile paraffin wax.

Samples were tested for A. naeslundii, L. casei, Streptococcus mutans, Streptococcus sobrinus, Streptococcus sanguinus, and Lactobacillus acidophilus.

Most of the women (67%) had normal vaginal deliveries. The average infant birth weight was 3,200 g and average gestational age was 39 weeks. There were 26 low-birth-weight deliveries and 28 preterm deliveries.

In a multivariate analysis, the only bacteria significantly associated with pregnancy outcomes were A. naeslundii and L. casei.

Increasing numbers of A. naeslundii were significantly associated with preterm low birth weight.

For every one-unit increase in A. naeslundii levels, there was a 60-g decrease in birth weight and a 0.17-week decrease in gestational age.

L. casei was associated with increasing gestational age.

Each unit increase in L. casei was associated with a 0.13-week increase in gestational age.

The connection between oral bacteria and preterm birth is biologically plausible, Dr. Dasanayake said.

Infections trigger inflammation and increase cytokines, which in turn can increase prostaglandins and lead to cervical dilation and uterine contraction.

Conversely, oral L. casei—which is associated with the incidence of dental caries—can have a protective effect by colonizing the vagina (migrating via elimination), where it suppresses the growth of pathogenic bacteria and inhibits bacterial vaginosis.

Because of the epidemiologic nature of the study, he said, it was not possible to separate the actual effect of either bacterial level from other contributing factors, such as drug and alcohol use or smoking.

However, two ongoing randomized controlled trials, one in South America and one in the United States, may give more specific information.

“In these studies, pregnant women are randomized into two groups—one group has their periodontal disease treated during pregnancy and one group has it treated after pregnancy,” Dr. Dasanayake said.

He added that several studies, including one of his own, have failed to find any association between oral bacteria and pregnancy outcome.

His study was performed in Sri Lanka with women who did not use tobacco, alcohol, or drugs because of cultural taboos and very low socioeconomic status. No association was seen in this group of women.

The oral pathogen Actinomyces naeslundii appears to be associated with shorter gestation resulting in preterm low birth weight, while oral Lactobacillus casei is associated with longer gestation and higher birth weight.

Increased levels of A. naeslundii could account for as much as 4%-6% of preterm low-birth-weight babies, although more research is necessary to confirm causality, said Ananda P. Dasanayake, D.D.S., of the New York University College of Dentistry, and his colleagues (J. Periodontol. 2005;76:171-7).

The epidemiologic study offers one more tantalizing glimpse at the interrelationship between oral health and systemic disease, and points up the importance of dental care during pregnancy.

“It is advisable to tell patients to seek dental care during pregnancy,” Dr. Dasanayake said in an interview. “If they have chronic periodontal disease, that can be treated—usually mechanically, by scaling and root planing, but sometimes with combination therapy that includes antibiotics.”

Dr. Dasanayake and his colleagues compared the presence of oral bacteria during the third trimester and at delivery with pregnancy outcomes in 297 primigravidas. The women's mean age was 20 years; 93% were African American. About 85% had at least a high school education. Saliva samples were obtained by expectoration after chewing on sterile paraffin wax.

Samples were tested for A. naeslundii, L. casei, Streptococcus mutans, Streptococcus sobrinus, Streptococcus sanguinus, and Lactobacillus acidophilus.

Most of the women (67%) had normal vaginal deliveries. The average infant birth weight was 3,200 g and average gestational age was 39 weeks. There were 26 low-birth-weight deliveries and 28 preterm deliveries.

In a multivariate analysis, the only bacteria significantly associated with pregnancy outcomes were A. naeslundii and L. casei.

Increasing numbers of A. naeslundii were significantly associated with preterm low birth weight.

For every one-unit increase in A. naeslundii levels, there was a 60-g decrease in birth weight and a 0.17-week decrease in gestational age.

L. casei was associated with increasing gestational age.

Each unit increase in L. casei was associated with a 0.13-week increase in gestational age.

The connection between oral bacteria and preterm birth is biologically plausible, Dr. Dasanayake said.

Infections trigger inflammation and increase cytokines, which in turn can increase prostaglandins and lead to cervical dilation and uterine contraction.

Conversely, oral L. casei—which is associated with the incidence of dental caries—can have a protective effect by colonizing the vagina (migrating via elimination), where it suppresses the growth of pathogenic bacteria and inhibits bacterial vaginosis.

Because of the epidemiologic nature of the study, he said, it was not possible to separate the actual effect of either bacterial level from other contributing factors, such as drug and alcohol use or smoking.

However, two ongoing randomized controlled trials, one in South America and one in the United States, may give more specific information.

“In these studies, pregnant women are randomized into two groups—one group has their periodontal disease treated during pregnancy and one group has it treated after pregnancy,” Dr. Dasanayake said.

He added that several studies, including one of his own, have failed to find any association between oral bacteria and pregnancy outcome.

His study was performed in Sri Lanka with women who did not use tobacco, alcohol, or drugs because of cultural taboos and very low socioeconomic status. No association was seen in this group of women.

The oral pathogen Actinomyces naeslundii appears to be associated with shorter gestation resulting in preterm low birth weight, while oral Lactobacillus casei is associated with longer gestation and higher birth weight.

Increased levels of A. naeslundii could account for as much as 4%-6% of preterm low-birth-weight babies, although more research is necessary to confirm causality, said Ananda P. Dasanayake, D.D.S., of the New York University College of Dentistry, and his colleagues (J. Periodontol. 2005;76:171-7).

The epidemiologic study offers one more tantalizing glimpse at the interrelationship between oral health and systemic disease, and points up the importance of dental care during pregnancy.

“It is advisable to tell patients to seek dental care during pregnancy,” Dr. Dasanayake said in an interview. “If they have chronic periodontal disease, that can be treated—usually mechanically, by scaling and root planing, but sometimes with combination therapy that includes antibiotics.”

Dr. Dasanayake and his colleagues compared the presence of oral bacteria during the third trimester and at delivery with pregnancy outcomes in 297 primigravidas. The women's mean age was 20 years; 93% were African American. About 85% had at least a high school education. Saliva samples were obtained by expectoration after chewing on sterile paraffin wax.

Samples were tested for A. naeslundii, L. casei, Streptococcus mutans, Streptococcus sobrinus, Streptococcus sanguinus, and Lactobacillus acidophilus.

Most of the women (67%) had normal vaginal deliveries. The average infant birth weight was 3,200 g and average gestational age was 39 weeks. There were 26 low-birth-weight deliveries and 28 preterm deliveries.

In a multivariate analysis, the only bacteria significantly associated with pregnancy outcomes were A. naeslundii and L. casei.

Increasing numbers of A. naeslundii were significantly associated with preterm low birth weight.

For every one-unit increase in A. naeslundii levels, there was a 60-g decrease in birth weight and a 0.17-week decrease in gestational age.

L. casei was associated with increasing gestational age.

Each unit increase in L. casei was associated with a 0.13-week increase in gestational age.

The connection between oral bacteria and preterm birth is biologically plausible, Dr. Dasanayake said.

Infections trigger inflammation and increase cytokines, which in turn can increase prostaglandins and lead to cervical dilation and uterine contraction.

Conversely, oral L. casei—which is associated with the incidence of dental caries—can have a protective effect by colonizing the vagina (migrating via elimination), where it suppresses the growth of pathogenic bacteria and inhibits bacterial vaginosis.

Because of the epidemiologic nature of the study, he said, it was not possible to separate the actual effect of either bacterial level from other contributing factors, such as drug and alcohol use or smoking.

However, two ongoing randomized controlled trials, one in South America and one in the United States, may give more specific information.

“In these studies, pregnant women are randomized into two groups—one group has their periodontal disease treated during pregnancy and one group has it treated after pregnancy,” Dr. Dasanayake said.

He added that several studies, including one of his own, have failed to find any association between oral bacteria and pregnancy outcome.

His study was performed in Sri Lanka with women who did not use tobacco, alcohol, or drugs because of cultural taboos and very low socioeconomic status. No association was seen in this group of women.

Magnetic resonance imaging is an effective means of diagnosing acute abdominal and pelvic pain in pregnant patients, and it avoids fetal exposure to the radiation of a computerized axial tomography exam, Katherine Birchard, M.D., and her colleagues reported.

Although there have been no documented cases of MRI causing adverse effects to the fetus, MRI scans should be used in pregnant patients only when the benefits clearly outweigh the risks, the researchers said. “However, we should stress that the single greatest factor in morbidity and mortality of the pregnant patient is delay in diagnosis,” reported Dr. Birchard of the University of North Carolina, and associates (AJR Am. J. Roentgenol. 2005;184:452-8).

The researchers retrospectively analyzed all MRI studies of 29 pregnant patients referred to their facility from 2002 to 2004 for evaluation of acute abdominal or pelvic pain. The patients' mean age was 25 years (18-35 years), and mean gestational age was 23 weeks (10-36 weeks). Most of the patients (22) did not have gadolinium administered.

Every patient underwent fetal sonography before any other imaging. Six also underwent complete abdominal sonographic examination before the MRI, which was the imaging exam used in 23 patients.

MRI identified appendiceal abscess (1 case), appendicitis (2 cases), intraabdominal and rectus muscle abscess (1), pancreatitis (1), and ulcerative colitis (1). MRI also showed Crohn's disease with diffuse peritoneal inflammation (1), intussusception (1), bilateral adrenal hemorrhage (1), pyelonephritis (2), hydronephrosis (1), uterine fibroid degeneration (2), degeneration and torsion of a subserosal uterine fibroid (1), simple ovarian cysts (1), and ovarian torsion (1). The other 12 examinations were normal.

The MRI results were congruent with follow-up medical records in 28 of the 29 patients and accurately described the disease process in all except one patient. This patient was at 18 weeks' gestation and complained of acute right lower quadrant pain. The MRI identified multiple ovarian cysts, but a laparoscopy 1 month later showed a torsed right ovary with multiple cysts. When examined retrospectively, the MRI did not show this finding.

“We believe this is due to the fact that the ovary was largely cystic, and therefore, edematous tissue was not seen,” the researchers said. They cautioned that ovarian torsion occurs more commonly during pregnancy, and this condition should be considered during every evaluation of an adnexal mass in a pregnant patient.

Magnetic resonance imaging is an effective means of diagnosing acute abdominal and pelvic pain in pregnant patients, and it avoids fetal exposure to the radiation of a computerized axial tomography exam, Katherine Birchard, M.D., and her colleagues reported.

Although there have been no documented cases of MRI causing adverse effects to the fetus, MRI scans should be used in pregnant patients only when the benefits clearly outweigh the risks, the researchers said. “However, we should stress that the single greatest factor in morbidity and mortality of the pregnant patient is delay in diagnosis,” reported Dr. Birchard of the University of North Carolina, and associates (AJR Am. J. Roentgenol. 2005;184:452-8).

The researchers retrospectively analyzed all MRI studies of 29 pregnant patients referred to their facility from 2002 to 2004 for evaluation of acute abdominal or pelvic pain. The patients' mean age was 25 years (18-35 years), and mean gestational age was 23 weeks (10-36 weeks). Most of the patients (22) did not have gadolinium administered.

Every patient underwent fetal sonography before any other imaging. Six also underwent complete abdominal sonographic examination before the MRI, which was the imaging exam used in 23 patients.

MRI identified appendiceal abscess (1 case), appendicitis (2 cases), intraabdominal and rectus muscle abscess (1), pancreatitis (1), and ulcerative colitis (1). MRI also showed Crohn's disease with diffuse peritoneal inflammation (1), intussusception (1), bilateral adrenal hemorrhage (1), pyelonephritis (2), hydronephrosis (1), uterine fibroid degeneration (2), degeneration and torsion of a subserosal uterine fibroid (1), simple ovarian cysts (1), and ovarian torsion (1). The other 12 examinations were normal.

The MRI results were congruent with follow-up medical records in 28 of the 29 patients and accurately described the disease process in all except one patient. This patient was at 18 weeks' gestation and complained of acute right lower quadrant pain. The MRI identified multiple ovarian cysts, but a laparoscopy 1 month later showed a torsed right ovary with multiple cysts. When examined retrospectively, the MRI did not show this finding.

“We believe this is due to the fact that the ovary was largely cystic, and therefore, edematous tissue was not seen,” the researchers said. They cautioned that ovarian torsion occurs more commonly during pregnancy, and this condition should be considered during every evaluation of an adnexal mass in a pregnant patient.

Magnetic resonance imaging is an effective means of diagnosing acute abdominal and pelvic pain in pregnant patients, and it avoids fetal exposure to the radiation of a computerized axial tomography exam, Katherine Birchard, M.D., and her colleagues reported.

Although there have been no documented cases of MRI causing adverse effects to the fetus, MRI scans should be used in pregnant patients only when the benefits clearly outweigh the risks, the researchers said. “However, we should stress that the single greatest factor in morbidity and mortality of the pregnant patient is delay in diagnosis,” reported Dr. Birchard of the University of North Carolina, and associates (AJR Am. J. Roentgenol. 2005;184:452-8).

The researchers retrospectively analyzed all MRI studies of 29 pregnant patients referred to their facility from 2002 to 2004 for evaluation of acute abdominal or pelvic pain. The patients' mean age was 25 years (18-35 years), and mean gestational age was 23 weeks (10-36 weeks). Most of the patients (22) did not have gadolinium administered.

Every patient underwent fetal sonography before any other imaging. Six also underwent complete abdominal sonographic examination before the MRI, which was the imaging exam used in 23 patients.

MRI identified appendiceal abscess (1 case), appendicitis (2 cases), intraabdominal and rectus muscle abscess (1), pancreatitis (1), and ulcerative colitis (1). MRI also showed Crohn's disease with diffuse peritoneal inflammation (1), intussusception (1), bilateral adrenal hemorrhage (1), pyelonephritis (2), hydronephrosis (1), uterine fibroid degeneration (2), degeneration and torsion of a subserosal uterine fibroid (1), simple ovarian cysts (1), and ovarian torsion (1). The other 12 examinations were normal.

The MRI results were congruent with follow-up medical records in 28 of the 29 patients and accurately described the disease process in all except one patient. This patient was at 18 weeks' gestation and complained of acute right lower quadrant pain. The MRI identified multiple ovarian cysts, but a laparoscopy 1 month later showed a torsed right ovary with multiple cysts. When examined retrospectively, the MRI did not show this finding.

“We believe this is due to the fact that the ovary was largely cystic, and therefore, edematous tissue was not seen,” the researchers said. They cautioned that ovarian torsion occurs more commonly during pregnancy, and this condition should be considered during every evaluation of an adnexal mass in a pregnant patient.

All pregnant women should undergo screening for Toxoplasma gondii infection once each trimester, and all newborns should be screened for congenital toxoplasmosis, Kenneth M. Boyer, M.D., and colleagues have recommended.

Even a thorough history fails to identify about half of pregnant women who have an acute infection, according to Dr. Boyer of Rush University Medical Center, Chicago. Only a serologic screening process would identify all infected women and newborns in time to administer the treatment necessary to prevent neurologic sequelae of the illness in these infants (Am. J. Obstet. Gynecol. 2005;192:564-71).

“It is difficult to imagine that any informed mother or father would choose not to include this screening in their prenatal care, considering that almost all untreated infants who are infected … in utero experience ophthalmologic and/or neurologic disease, and that treatment of the fetus and infant clearly reduces these risks,” they said.

The researchers retrospectively analyzed the medical records of 131 infants and children with congenital toxoplasmosis who were referred to the Chicago Collaborative Treatment Trial. The study focused on demographic data and the mothers' understanding of factors surrounding their exposure to the parasite.

Women were questioned about their exposure during pregnancy to cats, cat litter, gardening, and sandboxes. They also were questioned about their consumption of raw or undercooked meat, eggs, or unpasteurized milk; the nature and timing of their exposure; and any illness during pregnancy that was compatible with infection, especially prolonged fever, night sweats, myalgia, headache, and lymphadenopathy.

Most of the women (75%) could recall a conceivable exposure, but only 39% specifically recalled exposure to cat litter or raw meat dishes. One-quarter of the women could not identify any possible exposure to cats or raw or undercooked foods.

More than half (52%) could not recall an infectious illness of any kind during pregnancy. Almost half (48%) noted an illness that might have been caused by the parasite; 27% recalled fever or night sweats and 23% recalled lymphadenopathy.

Ten of the women had serologic testing for toxoplasmosis before delivery. Three of those were living in France at the time, where such testing is part of routine obstetric care. Each of the remaining seven women had compatible illness or identified risk factors.

One woman was tested because an ultrasound noted ascites in her twin fetuses. Three were tested because their physicians were looking for the cause of the illness, and three were tested as part of routine obstetric care.

Since only three women were tested as part of an investigation of an infectious illness, it is apparent that many physicians do not consider toxoplasmosis as a possible cause of these nonspecific symptoms during pregnancy, the authors noted. “This observation points out the importance of greater recognition by obstetricians of the pediatric implications of maternal infection and infectious symptoms during pregnancy.”

The only way to prevent or detect a higher proportion of infants with congenital infection is by systematic serologic screening, they concluded, adding that cost analyses should be performed before any decision making occurs. However, the potentially devastating lifelong effects of congenital toxoplasmosis, and the recognized benefits of early identification and treatment, make a compelling case for systematic screening, the researchers said.

Additionally, they noted, congenital toxoplasmosis is more common than many genetic and metabolic diseases, such as phenylketonuria, congenital hypothyroidism, and congenital adrenal hyperplasia, for which mandatory neonatal screening already exists.

The American College of Obstetricians and Gynecologists recommends routine toxoplasmosis screening only in HIV-positive pregnant women. Routine screening also may be justifiable in women who are cat owners, the college says.

ACOG does not recommend routine screening for every pregnant woman, because there is a low incidence of seropositivity in the United States. Countries such as France and Austria, which have mandated screening, have high rates of seropositivity among their populations.

Serologic screening in pregnant women may yield equivocal results because IgM antibodies to the parasite can persist for long periods, according to ACOG.

All pregnant women should undergo screening for Toxoplasma gondii infection once each trimester, and all newborns should be screened for congenital toxoplasmosis, Kenneth M. Boyer, M.D., and colleagues have recommended.

Even a thorough history fails to identify about half of pregnant women who have an acute infection, according to Dr. Boyer of Rush University Medical Center, Chicago. Only a serologic screening process would identify all infected women and newborns in time to administer the treatment necessary to prevent neurologic sequelae of the illness in these infants (Am. J. Obstet. Gynecol. 2005;192:564-71).

“It is difficult to imagine that any informed mother or father would choose not to include this screening in their prenatal care, considering that almost all untreated infants who are infected … in utero experience ophthalmologic and/or neurologic disease, and that treatment of the fetus and infant clearly reduces these risks,” they said.

The researchers retrospectively analyzed the medical records of 131 infants and children with congenital toxoplasmosis who were referred to the Chicago Collaborative Treatment Trial. The study focused on demographic data and the mothers' understanding of factors surrounding their exposure to the parasite.

Women were questioned about their exposure during pregnancy to cats, cat litter, gardening, and sandboxes. They also were questioned about their consumption of raw or undercooked meat, eggs, or unpasteurized milk; the nature and timing of their exposure; and any illness during pregnancy that was compatible with infection, especially prolonged fever, night sweats, myalgia, headache, and lymphadenopathy.

Most of the women (75%) could recall a conceivable exposure, but only 39% specifically recalled exposure to cat litter or raw meat dishes. One-quarter of the women could not identify any possible exposure to cats or raw or undercooked foods.

More than half (52%) could not recall an infectious illness of any kind during pregnancy. Almost half (48%) noted an illness that might have been caused by the parasite; 27% recalled fever or night sweats and 23% recalled lymphadenopathy.

Ten of the women had serologic testing for toxoplasmosis before delivery. Three of those were living in France at the time, where such testing is part of routine obstetric care. Each of the remaining seven women had compatible illness or identified risk factors.

One woman was tested because an ultrasound noted ascites in her twin fetuses. Three were tested because their physicians were looking for the cause of the illness, and three were tested as part of routine obstetric care.

Since only three women were tested as part of an investigation of an infectious illness, it is apparent that many physicians do not consider toxoplasmosis as a possible cause of these nonspecific symptoms during pregnancy, the authors noted. “This observation points out the importance of greater recognition by obstetricians of the pediatric implications of maternal infection and infectious symptoms during pregnancy.”

The only way to prevent or detect a higher proportion of infants with congenital infection is by systematic serologic screening, they concluded, adding that cost analyses should be performed before any decision making occurs. However, the potentially devastating lifelong effects of congenital toxoplasmosis, and the recognized benefits of early identification and treatment, make a compelling case for systematic screening, the researchers said.

Additionally, they noted, congenital toxoplasmosis is more common than many genetic and metabolic diseases, such as phenylketonuria, congenital hypothyroidism, and congenital adrenal hyperplasia, for which mandatory neonatal screening already exists.

The American College of Obstetricians and Gynecologists recommends routine toxoplasmosis screening only in HIV-positive pregnant women. Routine screening also may be justifiable in women who are cat owners, the college says.

ACOG does not recommend routine screening for every pregnant woman, because there is a low incidence of seropositivity in the United States. Countries such as France and Austria, which have mandated screening, have high rates of seropositivity among their populations.

Serologic screening in pregnant women may yield equivocal results because IgM antibodies to the parasite can persist for long periods, according to ACOG.

All pregnant women should undergo screening for Toxoplasma gondii infection once each trimester, and all newborns should be screened for congenital toxoplasmosis, Kenneth M. Boyer, M.D., and colleagues have recommended.

Even a thorough history fails to identify about half of pregnant women who have an acute infection, according to Dr. Boyer of Rush University Medical Center, Chicago. Only a serologic screening process would identify all infected women and newborns in time to administer the treatment necessary to prevent neurologic sequelae of the illness in these infants (Am. J. Obstet. Gynecol. 2005;192:564-71).

“It is difficult to imagine that any informed mother or father would choose not to include this screening in their prenatal care, considering that almost all untreated infants who are infected … in utero experience ophthalmologic and/or neurologic disease, and that treatment of the fetus and infant clearly reduces these risks,” they said.

The researchers retrospectively analyzed the medical records of 131 infants and children with congenital toxoplasmosis who were referred to the Chicago Collaborative Treatment Trial. The study focused on demographic data and the mothers' understanding of factors surrounding their exposure to the parasite.

Women were questioned about their exposure during pregnancy to cats, cat litter, gardening, and sandboxes. They also were questioned about their consumption of raw or undercooked meat, eggs, or unpasteurized milk; the nature and timing of their exposure; and any illness during pregnancy that was compatible with infection, especially prolonged fever, night sweats, myalgia, headache, and lymphadenopathy.

Most of the women (75%) could recall a conceivable exposure, but only 39% specifically recalled exposure to cat litter or raw meat dishes. One-quarter of the women could not identify any possible exposure to cats or raw or undercooked foods.

More than half (52%) could not recall an infectious illness of any kind during pregnancy. Almost half (48%) noted an illness that might have been caused by the parasite; 27% recalled fever or night sweats and 23% recalled lymphadenopathy.

Ten of the women had serologic testing for toxoplasmosis before delivery. Three of those were living in France at the time, where such testing is part of routine obstetric care. Each of the remaining seven women had compatible illness or identified risk factors.

One woman was tested because an ultrasound noted ascites in her twin fetuses. Three were tested because their physicians were looking for the cause of the illness, and three were tested as part of routine obstetric care.

Since only three women were tested as part of an investigation of an infectious illness, it is apparent that many physicians do not consider toxoplasmosis as a possible cause of these nonspecific symptoms during pregnancy, the authors noted. “This observation points out the importance of greater recognition by obstetricians of the pediatric implications of maternal infection and infectious symptoms during pregnancy.”

The only way to prevent or detect a higher proportion of infants with congenital infection is by systematic serologic screening, they concluded, adding that cost analyses should be performed before any decision making occurs. However, the potentially devastating lifelong effects of congenital toxoplasmosis, and the recognized benefits of early identification and treatment, make a compelling case for systematic screening, the researchers said.

Additionally, they noted, congenital toxoplasmosis is more common than many genetic and metabolic diseases, such as phenylketonuria, congenital hypothyroidism, and congenital adrenal hyperplasia, for which mandatory neonatal screening already exists.

The American College of Obstetricians and Gynecologists recommends routine toxoplasmosis screening only in HIV-positive pregnant women. Routine screening also may be justifiable in women who are cat owners, the college says.

ACOG does not recommend routine screening for every pregnant woman, because there is a low incidence of seropositivity in the United States. Countries such as France and Austria, which have mandated screening, have high rates of seropositivity among their populations.

Serologic screening in pregnant women may yield equivocal results because IgM antibodies to the parasite can persist for long periods, according to ACOG.

WHITE SULPHUR SPRINGS, W. VA. — Most abnormal cervical cytology in adolescent women will be low-grade squamous intraepithelial lesions, and will regress to normal by the follow-up exam, Andrea Wininger, M.D., said at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

Her retrospective chart review included 217 abnormal Pap smears among women aged 13-17 years. Low-grade squamous intraepithelial lesions (LSIL) were seen in 57%, atypical squamous cells of undetermined significance (ASCUS) in 30%, high-grade squamous intraepithelial lesions (HSIL) in 7%, and atypical squamous cells in which HSIL cannot be excluded (ASC-H) in 5.5%.

Regression was high among all abnormal smears. By the follow-up exam, (mean 11 months later) 65% of LSIL, 67% of ASCUS, 57% of ASC-H, and 55% of HSIL had regressed. Of the 129 women (60%) who returned for their follow-up exam, 64% had normal cytology.

Rates of progression were low, said Dr. Wininger of the University of South Carolina, Columbia. Only 2.4% of ASCUS progressed to HSIL and 7% of LSIL progressed to HSIL.

That's good news for these young women, many of whom can be managed conservatively. But getting them to return for that critical follow-up isn't easy. “Forty percent didn't come back for their second smear, which is a very high rate of noncompliance, and this is one of the factors that puts this group at high risk for cervical dysplasia,” she said.

The tendency toward noncompliance, plus a proclivity for high-risk sexual behavior, makes early education about sexual health a must. “Early, aggressive education for these patients is critical to get them to understand the relationship between risky sexual behavior and sexually transmitted infections.”

She also recommended routine screening for sexually transmitted disease among all adolescents who have abnormal cytology, as her study found a significant association between chlamydia infection and progressing abnormal cytology. But she found no association between abnormal cytology and gonorrhea, trichomoniasis, genital warts, Candida, or bacterial vaginosis.

WHITE SULPHUR SPRINGS, W. VA. — Most abnormal cervical cytology in adolescent women will be low-grade squamous intraepithelial lesions, and will regress to normal by the follow-up exam, Andrea Wininger, M.D., said at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

Her retrospective chart review included 217 abnormal Pap smears among women aged 13-17 years. Low-grade squamous intraepithelial lesions (LSIL) were seen in 57%, atypical squamous cells of undetermined significance (ASCUS) in 30%, high-grade squamous intraepithelial lesions (HSIL) in 7%, and atypical squamous cells in which HSIL cannot be excluded (ASC-H) in 5.5%.

Regression was high among all abnormal smears. By the follow-up exam, (mean 11 months later) 65% of LSIL, 67% of ASCUS, 57% of ASC-H, and 55% of HSIL had regressed. Of the 129 women (60%) who returned for their follow-up exam, 64% had normal cytology.

Rates of progression were low, said Dr. Wininger of the University of South Carolina, Columbia. Only 2.4% of ASCUS progressed to HSIL and 7% of LSIL progressed to HSIL.

That's good news for these young women, many of whom can be managed conservatively. But getting them to return for that critical follow-up isn't easy. “Forty percent didn't come back for their second smear, which is a very high rate of noncompliance, and this is one of the factors that puts this group at high risk for cervical dysplasia,” she said.

The tendency toward noncompliance, plus a proclivity for high-risk sexual behavior, makes early education about sexual health a must. “Early, aggressive education for these patients is critical to get them to understand the relationship between risky sexual behavior and sexually transmitted infections.”

She also recommended routine screening for sexually transmitted disease among all adolescents who have abnormal cytology, as her study found a significant association between chlamydia infection and progressing abnormal cytology. But she found no association between abnormal cytology and gonorrhea, trichomoniasis, genital warts, Candida, or bacterial vaginosis.

WHITE SULPHUR SPRINGS, W. VA. — Most abnormal cervical cytology in adolescent women will be low-grade squamous intraepithelial lesions, and will regress to normal by the follow-up exam, Andrea Wininger, M.D., said at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

Her retrospective chart review included 217 abnormal Pap smears among women aged 13-17 years. Low-grade squamous intraepithelial lesions (LSIL) were seen in 57%, atypical squamous cells of undetermined significance (ASCUS) in 30%, high-grade squamous intraepithelial lesions (HSIL) in 7%, and atypical squamous cells in which HSIL cannot be excluded (ASC-H) in 5.5%.

Regression was high among all abnormal smears. By the follow-up exam, (mean 11 months later) 65% of LSIL, 67% of ASCUS, 57% of ASC-H, and 55% of HSIL had regressed. Of the 129 women (60%) who returned for their follow-up exam, 64% had normal cytology.

Rates of progression were low, said Dr. Wininger of the University of South Carolina, Columbia. Only 2.4% of ASCUS progressed to HSIL and 7% of LSIL progressed to HSIL.

That's good news for these young women, many of whom can be managed conservatively. But getting them to return for that critical follow-up isn't easy. “Forty percent didn't come back for their second smear, which is a very high rate of noncompliance, and this is one of the factors that puts this group at high risk for cervical dysplasia,” she said.

The tendency toward noncompliance, plus a proclivity for high-risk sexual behavior, makes early education about sexual health a must. “Early, aggressive education for these patients is critical to get them to understand the relationship between risky sexual behavior and sexually transmitted infections.”

She also recommended routine screening for sexually transmitted disease among all adolescents who have abnormal cytology, as her study found a significant association between chlamydia infection and progressing abnormal cytology. But she found no association between abnormal cytology and gonorrhea, trichomoniasis, genital warts, Candida, or bacterial vaginosis.

NEW ORLEANS — A thorough skin exam should always include an examination of the vulva, because many skin conditions can affect the genitals and cause everything from transient discomfort to loss of anatomical structures, Lynette J. Margesson, M.D., said at the annual meeting of the American Academy of Dermatology.

Women have very little education about their vulvar health and thus, tend to ascribe every bout of itching to candidiasis. They usually will not offer information about genital discomfort. “As a result, women suffer with undiagnosed symptoms, waste millions on antifungals, and endure vulvar pain and dyspareunia. Instead of seeking help, they hide and scratch,” said Dr. Margesson, a dermatologist from Manchester, N.H.

“Imagine the rash somewhere else on the skin,” she advised. This can help ease any discomfort either the patient or physician might feel about a vulvar exam.

She described 10 “vulvar traps” to avoid:

Missing the missing bits—check for what's not there. Lichen sclerosis and lichen planus can both eventually cause scarring of the labia and clitoris, and marked introital stenosis. Dyspareunia is usual. “These poor women can completely lose their labia and clitoris,” Dr. Margesson said. “Don't let that happen to your patient.”

Mistaking the normal for abnormal. Dermatologists aren't gynecologists and might not be familiar with benign variances in vulvar anatomy. Sebaceous hyperplasia can be confused with an unusual rash or neoplasm. Characterized by variably sized yellow papules on the labia minora, sebaceous hyperplasia is a benign condition that doesn't require treatment.

In vulvar papillomatosis, papillae can cover the entire mucosal surface of the labia minora. Labial hypertrophy is a normal size variant and doesn't require treatment, unless the affected labia interfere with sexual function or other activities, or are irritated by clothing.

Not looking closely enough. It's easy to miss signs of herpes simplex infection (HSV), because women are often asymptomatic carriers. The typical simplex pustules may be hidden or missed in a confusing background of ulcers, erosions, and/or fissures. However, HSV is the most common cause of vulvar ulcers, so patients with unexplained symptoms or lesions should be tested.

Mistreating simple problems, such as candidiasis. Don't diagnose candidiasis over the phone, Dr. Margesson stressed. Candida infections complicate all vulvar skin problems, especially lichen planus, lichen sclerosis, and lichen simplex chronicus. Scratching further irritates the skin and some over-the-counter (OTC) antipruritics can cause contact dermatitis. “Persistent candida” may occur because the yeast is a resistant strain or because the symptoms are actually from a contact dermatitis to the topicals being used. Culture on Sabouraud's medium to identify resistant strains, and be prepared for an extended course of treatment—perhaps as long as 6 months.

Missing contact dermatitis. Faced with vulvar pruritus of any etiology, women tend to slather on OTC medications that can cause severe contact dermatitis. This frequent problem is another complication for vulvar dermatoses, Dr. Margesson said. “Women often consider their vulva 'dirty' and scrub it unnecessarily with soap or cleansers.” Urinary incontinence can complicate the problem, so hygiene counseling is important. Topical benzocaine can cause a severe, ulcerated contact dermatitis.

Misusing or misunderstanding topical steroids. Adequate courses of superpotent topical steroids are usually necessary to control vulvar inflammation from lichen sclerosis and lichen planus. Less potent steroids will not be effective. “Patient education is critical,” she said. The vulva is relatively steroid-resistant, whereas the perineal areas are steroid-sensitive. Women should be told exactly where to put the topicals, how much to apply, and for how long. All women on topical steroids should be seen at regular intervals.

“Everything white is lichen sclerosis.” Several vulvar conditions mimic the white plaques of lichen sclerosis, including lichen planus, lichen simplex chronicus, mucus membrane pemphigoid, vulvar intraepithelial neoplasia, and vitiligo. “Biopsy is essential to confirm diagnosis,” Dr. Margesson said.

Inadequate follow-up. Because women may be reluctant to share vulvar symptoms, and dermatologists may be reluctant to examine the area, problems may go untreated. Some serious vulvar disorders, such as lichen sclerosis, lichen planus, and even malignancy, may be asymptomatic.

Missing concomitant disease. “Look for more than one problem,” she said. One condition can predispose to another, and women may present with several at once. The most commonly missed concomitant vulvar disorders are candidiasis, contact dermatitis, HSV, atrophy, and cancer.

Not checking on compliance. This is another important reason to examine the vulva. Noncompliance generally arises from ignorance or miscommunication. Women may be afraid of using potent steroids and ignorant of exactly where to apply them. There may also be psychosocial issues. “Some women … may be getting a secondary gain by using their condition as a way of avoiding sex,” Dr. Margesson said.

NEW ORLEANS — A thorough skin exam should always include an examination of the vulva, because many skin conditions can affect the genitals and cause everything from transient discomfort to loss of anatomical structures, Lynette J. Margesson, M.D., said at the annual meeting of the American Academy of Dermatology.

Women have very little education about their vulvar health and thus, tend to ascribe every bout of itching to candidiasis. They usually will not offer information about genital discomfort. “As a result, women suffer with undiagnosed symptoms, waste millions on antifungals, and endure vulvar pain and dyspareunia. Instead of seeking help, they hide and scratch,” said Dr. Margesson, a dermatologist from Manchester, N.H.

“Imagine the rash somewhere else on the skin,” she advised. This can help ease any discomfort either the patient or physician might feel about a vulvar exam.

She described 10 “vulvar traps” to avoid:

Missing the missing bits—check for what's not there. Lichen sclerosis and lichen planus can both eventually cause scarring of the labia and clitoris, and marked introital stenosis. Dyspareunia is usual. “These poor women can completely lose their labia and clitoris,” Dr. Margesson said. “Don't let that happen to your patient.”

Mistaking the normal for abnormal. Dermatologists aren't gynecologists and might not be familiar with benign variances in vulvar anatomy. Sebaceous hyperplasia can be confused with an unusual rash or neoplasm. Characterized by variably sized yellow papules on the labia minora, sebaceous hyperplasia is a benign condition that doesn't require treatment.

In vulvar papillomatosis, papillae can cover the entire mucosal surface of the labia minora. Labial hypertrophy is a normal size variant and doesn't require treatment, unless the affected labia interfere with sexual function or other activities, or are irritated by clothing.

Not looking closely enough. It's easy to miss signs of herpes simplex infection (HSV), because women are often asymptomatic carriers. The typical simplex pustules may be hidden or missed in a confusing background of ulcers, erosions, and/or fissures. However, HSV is the most common cause of vulvar ulcers, so patients with unexplained symptoms or lesions should be tested.

Mistreating simple problems, such as candidiasis. Don't diagnose candidiasis over the phone, Dr. Margesson stressed. Candida infections complicate all vulvar skin problems, especially lichen planus, lichen sclerosis, and lichen simplex chronicus. Scratching further irritates the skin and some over-the-counter (OTC) antipruritics can cause contact dermatitis. “Persistent candida” may occur because the yeast is a resistant strain or because the symptoms are actually from a contact dermatitis to the topicals being used. Culture on Sabouraud's medium to identify resistant strains, and be prepared for an extended course of treatment—perhaps as long as 6 months.

Missing contact dermatitis. Faced with vulvar pruritus of any etiology, women tend to slather on OTC medications that can cause severe contact dermatitis. This frequent problem is another complication for vulvar dermatoses, Dr. Margesson said. “Women often consider their vulva 'dirty' and scrub it unnecessarily with soap or cleansers.” Urinary incontinence can complicate the problem, so hygiene counseling is important. Topical benzocaine can cause a severe, ulcerated contact dermatitis.

Misusing or misunderstanding topical steroids. Adequate courses of superpotent topical steroids are usually necessary to control vulvar inflammation from lichen sclerosis and lichen planus. Less potent steroids will not be effective. “Patient education is critical,” she said. The vulva is relatively steroid-resistant, whereas the perineal areas are steroid-sensitive. Women should be told exactly where to put the topicals, how much to apply, and for how long. All women on topical steroids should be seen at regular intervals.

“Everything white is lichen sclerosis.” Several vulvar conditions mimic the white plaques of lichen sclerosis, including lichen planus, lichen simplex chronicus, mucus membrane pemphigoid, vulvar intraepithelial neoplasia, and vitiligo. “Biopsy is essential to confirm diagnosis,” Dr. Margesson said.

Inadequate follow-up. Because women may be reluctant to share vulvar symptoms, and dermatologists may be reluctant to examine the area, problems may go untreated. Some serious vulvar disorders, such as lichen sclerosis, lichen planus, and even malignancy, may be asymptomatic.

Missing concomitant disease. “Look for more than one problem,” she said. One condition can predispose to another, and women may present with several at once. The most commonly missed concomitant vulvar disorders are candidiasis, contact dermatitis, HSV, atrophy, and cancer.

Not checking on compliance. This is another important reason to examine the vulva. Noncompliance generally arises from ignorance or miscommunication. Women may be afraid of using potent steroids and ignorant of exactly where to apply them. There may also be psychosocial issues. “Some women … may be getting a secondary gain by using their condition as a way of avoiding sex,” Dr. Margesson said.

NEW ORLEANS — A thorough skin exam should always include an examination of the vulva, because many skin conditions can affect the genitals and cause everything from transient discomfort to loss of anatomical structures, Lynette J. Margesson, M.D., said at the annual meeting of the American Academy of Dermatology.

Women have very little education about their vulvar health and thus, tend to ascribe every bout of itching to candidiasis. They usually will not offer information about genital discomfort. “As a result, women suffer with undiagnosed symptoms, waste millions on antifungals, and endure vulvar pain and dyspareunia. Instead of seeking help, they hide and scratch,” said Dr. Margesson, a dermatologist from Manchester, N.H.

“Imagine the rash somewhere else on the skin,” she advised. This can help ease any discomfort either the patient or physician might feel about a vulvar exam.

She described 10 “vulvar traps” to avoid:

Missing the missing bits—check for what's not there. Lichen sclerosis and lichen planus can both eventually cause scarring of the labia and clitoris, and marked introital stenosis. Dyspareunia is usual. “These poor women can completely lose their labia and clitoris,” Dr. Margesson said. “Don't let that happen to your patient.”

Mistaking the normal for abnormal. Dermatologists aren't gynecologists and might not be familiar with benign variances in vulvar anatomy. Sebaceous hyperplasia can be confused with an unusual rash or neoplasm. Characterized by variably sized yellow papules on the labia minora, sebaceous hyperplasia is a benign condition that doesn't require treatment.

In vulvar papillomatosis, papillae can cover the entire mucosal surface of the labia minora. Labial hypertrophy is a normal size variant and doesn't require treatment, unless the affected labia interfere with sexual function or other activities, or are irritated by clothing.

Not looking closely enough. It's easy to miss signs of herpes simplex infection (HSV), because women are often asymptomatic carriers. The typical simplex pustules may be hidden or missed in a confusing background of ulcers, erosions, and/or fissures. However, HSV is the most common cause of vulvar ulcers, so patients with unexplained symptoms or lesions should be tested.

Mistreating simple problems, such as candidiasis. Don't diagnose candidiasis over the phone, Dr. Margesson stressed. Candida infections complicate all vulvar skin problems, especially lichen planus, lichen sclerosis, and lichen simplex chronicus. Scratching further irritates the skin and some over-the-counter (OTC) antipruritics can cause contact dermatitis. “Persistent candida” may occur because the yeast is a resistant strain or because the symptoms are actually from a contact dermatitis to the topicals being used. Culture on Sabouraud's medium to identify resistant strains, and be prepared for an extended course of treatment—perhaps as long as 6 months.

Missing contact dermatitis. Faced with vulvar pruritus of any etiology, women tend to slather on OTC medications that can cause severe contact dermatitis. This frequent problem is another complication for vulvar dermatoses, Dr. Margesson said. “Women often consider their vulva 'dirty' and scrub it unnecessarily with soap or cleansers.” Urinary incontinence can complicate the problem, so hygiene counseling is important. Topical benzocaine can cause a severe, ulcerated contact dermatitis.

Misusing or misunderstanding topical steroids. Adequate courses of superpotent topical steroids are usually necessary to control vulvar inflammation from lichen sclerosis and lichen planus. Less potent steroids will not be effective. “Patient education is critical,” she said. The vulva is relatively steroid-resistant, whereas the perineal areas are steroid-sensitive. Women should be told exactly where to put the topicals, how much to apply, and for how long. All women on topical steroids should be seen at regular intervals.

“Everything white is lichen sclerosis.” Several vulvar conditions mimic the white plaques of lichen sclerosis, including lichen planus, lichen simplex chronicus, mucus membrane pemphigoid, vulvar intraepithelial neoplasia, and vitiligo. “Biopsy is essential to confirm diagnosis,” Dr. Margesson said.

Inadequate follow-up. Because women may be reluctant to share vulvar symptoms, and dermatologists may be reluctant to examine the area, problems may go untreated. Some serious vulvar disorders, such as lichen sclerosis, lichen planus, and even malignancy, may be asymptomatic.

Missing concomitant disease. “Look for more than one problem,” she said. One condition can predispose to another, and women may present with several at once. The most commonly missed concomitant vulvar disorders are candidiasis, contact dermatitis, HSV, atrophy, and cancer.

Not checking on compliance. This is another important reason to examine the vulva. Noncompliance generally arises from ignorance or miscommunication. Women may be afraid of using potent steroids and ignorant of exactly where to apply them. There may also be psychosocial issues. “Some women … may be getting a secondary gain by using their condition as a way of avoiding sex,” Dr. Margesson said.

A program that integrates cognitive therapy with spiritual awareness and healing has proved beneficial to female survivors of childhood sexual abuse, significantly decreasing symptom scores in all patients in a small pilot study.

The 8-week program of manualized, individual sessions offers the kind of experience many abuse survivors never encounter though they may spend years in therapy—a way to explore how sexual abuse has shaped their spirituality and how that spirituality has shaped their mental and emotional health.

The link between spirituality and health has long been recognized, said Nichole Murray-Swank, Ph.D., who created the program. Just as positive spirituality is associated with better mental health, negative spirituality is associated with poorer mental health. Many abuse survivors carry extremely negative spiritual images; these very persistent thought patterns can impede healing, said Dr. Murray-Swank, a clinical psychologist at Loyola College in Maryland, Columbia.

At the core of these images is the survivor's belief that she is utterly worthless, irredeemably damaged, and undeserving of love or happiness, Dr. Murray-Swank said. These feelings form the basis of crippling shame, sexual dysfunction, poor body image, anger, and emotional isolation. They can also exacerbate depression and posttraumatic stress disorder.

Dr. Murray-Swank's pilot program, “Solace for the Soul: A Journey Towards Wholeness,” asks clients to work through these thoughts and images. The program is nondenominational, although it is theistic, she said in an interview. In Ohio, where the pilot study was conducted, most clients subscribed to a monotheistic, paternal image of God. But the program does not specify this image. “By 'theistic,' we mean that it describes a creative force, whether people understand that to be nature, or energy, or a deity,” Dr. Murray-Swank said.

Each session focuses on a specific aspect of spirituality and its relationship to childhood sexual abuse: feelings of abandonment by God and associated anger; connecting with the spiritual; letting go of shame; seeing the body as a beautiful creation; and seeing sexuality as a sacred, life-affirming way of connecting to others.

Dr. Murray-Swank's first group consisted of four adult women who had experienced long-standing sexual abuse—including penetration—by their father or stepfather, beginning in prepubescence. The women were referred from mental health agencies after they learned about the program and expressed an interest in joining. All of them had serious, chronic mental illness: one had bipolar disorder; one had borderline personality disorder and depression; and two had chronic, serious depression. All had severe PTSD.

The women filled out five questionnaires at baseline, after session 4, at the end of the intervention, and at 1 or 2 months' follow-up (Brief Symptom Inventory, Trauma Symptom Checklist-40, Brief Measure of Religious Coping, God Image Scale, and Religious Concepts Survey). They also kept daily symptom logs measuring psychological and spiritual distress, positive and negative coping, self-worth, sexual problems, trauma symptoms, and body image.

By the last measurement, all of the patients experienced decreases in the Brief Symptom Inventory, with the most symptomatic patient making the largest improvement (dropping from 80 to 15 on the scale). One patient dropped from 55 to 35, one from 45 to 34, and the last from 15 to almost 0. The largest improvements were seen in depression and anxiety symptoms.

Dr. Murray-Swank said the work was challenging to all the women. The most difficult sessions were those that concerned sexuality and body image. “When I asked them to write positive things about their body, some were unable to give even one answer.”

Some of the women experienced intermittent increases in their sexual symptom scores during the sessions. This wasn't a surprise, Dr. Murray-Swank said. “It's not fun doing these things. Healing is difficult, and it might even be more painful during the process.”

Additional research is ongoing and may find a permanent home, the Center for the Study of Spirituality, Trauma, Loss, and Violence to be located at Loyola College in Maryland and focus on the importance of spirituality in healing, clinical programs, and provide education and training.

While acknowledging that these brief interventions cannot completely heal survivors of sexual abuse, she does think they can be an important adjunct to other therapy.

A program that integrates cognitive therapy with spiritual awareness and healing has proved beneficial to female survivors of childhood sexual abuse, significantly decreasing symptom scores in all patients in a small pilot study.

The 8-week program of manualized, individual sessions offers the kind of experience many abuse survivors never encounter though they may spend years in therapy—a way to explore how sexual abuse has shaped their spirituality and how that spirituality has shaped their mental and emotional health.

The link between spirituality and health has long been recognized, said Nichole Murray-Swank, Ph.D., who created the program. Just as positive spirituality is associated with better mental health, negative spirituality is associated with poorer mental health. Many abuse survivors carry extremely negative spiritual images; these very persistent thought patterns can impede healing, said Dr. Murray-Swank, a clinical psychologist at Loyola College in Maryland, Columbia.

At the core of these images is the survivor's belief that she is utterly worthless, irredeemably damaged, and undeserving of love or happiness, Dr. Murray-Swank said. These feelings form the basis of crippling shame, sexual dysfunction, poor body image, anger, and emotional isolation. They can also exacerbate depression and posttraumatic stress disorder.

Dr. Murray-Swank's pilot program, “Solace for the Soul: A Journey Towards Wholeness,” asks clients to work through these thoughts and images. The program is nondenominational, although it is theistic, she said in an interview. In Ohio, where the pilot study was conducted, most clients subscribed to a monotheistic, paternal image of God. But the program does not specify this image. “By 'theistic,' we mean that it describes a creative force, whether people understand that to be nature, or energy, or a deity,” Dr. Murray-Swank said.

Each session focuses on a specific aspect of spirituality and its relationship to childhood sexual abuse: feelings of abandonment by God and associated anger; connecting with the spiritual; letting go of shame; seeing the body as a beautiful creation; and seeing sexuality as a sacred, life-affirming way of connecting to others.

Dr. Murray-Swank's first group consisted of four adult women who had experienced long-standing sexual abuse—including penetration—by their father or stepfather, beginning in prepubescence. The women were referred from mental health agencies after they learned about the program and expressed an interest in joining. All of them had serious, chronic mental illness: one had bipolar disorder; one had borderline personality disorder and depression; and two had chronic, serious depression. All had severe PTSD.

The women filled out five questionnaires at baseline, after session 4, at the end of the intervention, and at 1 or 2 months' follow-up (Brief Symptom Inventory, Trauma Symptom Checklist-40, Brief Measure of Religious Coping, God Image Scale, and Religious Concepts Survey). They also kept daily symptom logs measuring psychological and spiritual distress, positive and negative coping, self-worth, sexual problems, trauma symptoms, and body image.

By the last measurement, all of the patients experienced decreases in the Brief Symptom Inventory, with the most symptomatic patient making the largest improvement (dropping from 80 to 15 on the scale). One patient dropped from 55 to 35, one from 45 to 34, and the last from 15 to almost 0. The largest improvements were seen in depression and anxiety symptoms.

Dr. Murray-Swank said the work was challenging to all the women. The most difficult sessions were those that concerned sexuality and body image. “When I asked them to write positive things about their body, some were unable to give even one answer.”

Some of the women experienced intermittent increases in their sexual symptom scores during the sessions. This wasn't a surprise, Dr. Murray-Swank said. “It's not fun doing these things. Healing is difficult, and it might even be more painful during the process.”

Additional research is ongoing and may find a permanent home, the Center for the Study of Spirituality, Trauma, Loss, and Violence to be located at Loyola College in Maryland and focus on the importance of spirituality in healing, clinical programs, and provide education and training.

While acknowledging that these brief interventions cannot completely heal survivors of sexual abuse, she does think they can be an important adjunct to other therapy.

A program that integrates cognitive therapy with spiritual awareness and healing has proved beneficial to female survivors of childhood sexual abuse, significantly decreasing symptom scores in all patients in a small pilot study.

The 8-week program of manualized, individual sessions offers the kind of experience many abuse survivors never encounter though they may spend years in therapy—a way to explore how sexual abuse has shaped their spirituality and how that spirituality has shaped their mental and emotional health.

The link between spirituality and health has long been recognized, said Nichole Murray-Swank, Ph.D., who created the program. Just as positive spirituality is associated with better mental health, negative spirituality is associated with poorer mental health. Many abuse survivors carry extremely negative spiritual images; these very persistent thought patterns can impede healing, said Dr. Murray-Swank, a clinical psychologist at Loyola College in Maryland, Columbia.

At the core of these images is the survivor's belief that she is utterly worthless, irredeemably damaged, and undeserving of love or happiness, Dr. Murray-Swank said. These feelings form the basis of crippling shame, sexual dysfunction, poor body image, anger, and emotional isolation. They can also exacerbate depression and posttraumatic stress disorder.

Dr. Murray-Swank's pilot program, “Solace for the Soul: A Journey Towards Wholeness,” asks clients to work through these thoughts and images. The program is nondenominational, although it is theistic, she said in an interview. In Ohio, where the pilot study was conducted, most clients subscribed to a monotheistic, paternal image of God. But the program does not specify this image. “By 'theistic,' we mean that it describes a creative force, whether people understand that to be nature, or energy, or a deity,” Dr. Murray-Swank said.

Each session focuses on a specific aspect of spirituality and its relationship to childhood sexual abuse: feelings of abandonment by God and associated anger; connecting with the spiritual; letting go of shame; seeing the body as a beautiful creation; and seeing sexuality as a sacred, life-affirming way of connecting to others.

Dr. Murray-Swank's first group consisted of four adult women who had experienced long-standing sexual abuse—including penetration—by their father or stepfather, beginning in prepubescence. The women were referred from mental health agencies after they learned about the program and expressed an interest in joining. All of them had serious, chronic mental illness: one had bipolar disorder; one had borderline personality disorder and depression; and two had chronic, serious depression. All had severe PTSD.

The women filled out five questionnaires at baseline, after session 4, at the end of the intervention, and at 1 or 2 months' follow-up (Brief Symptom Inventory, Trauma Symptom Checklist-40, Brief Measure of Religious Coping, God Image Scale, and Religious Concepts Survey). They also kept daily symptom logs measuring psychological and spiritual distress, positive and negative coping, self-worth, sexual problems, trauma symptoms, and body image.

By the last measurement, all of the patients experienced decreases in the Brief Symptom Inventory, with the most symptomatic patient making the largest improvement (dropping from 80 to 15 on the scale). One patient dropped from 55 to 35, one from 45 to 34, and the last from 15 to almost 0. The largest improvements were seen in depression and anxiety symptoms.

Dr. Murray-Swank said the work was challenging to all the women. The most difficult sessions were those that concerned sexuality and body image. “When I asked them to write positive things about their body, some were unable to give even one answer.”

Some of the women experienced intermittent increases in their sexual symptom scores during the sessions. This wasn't a surprise, Dr. Murray-Swank said. “It's not fun doing these things. Healing is difficult, and it might even be more painful during the process.”

Additional research is ongoing and may find a permanent home, the Center for the Study of Spirituality, Trauma, Loss, and Violence to be located at Loyola College in Maryland and focus on the importance of spirituality in healing, clinical programs, and provide education and training.

While acknowledging that these brief interventions cannot completely heal survivors of sexual abuse, she does think they can be an important adjunct to other therapy.

A biopsy showed a superficial and deep, perivascular, atypical mononuclear cell infiltrate with CD68, CD43, and myeloperoxidase positivity. A complete blood count revealed leukocytosis with monocytosis and immature granulocytes. A bone marrow biopsy showed acute myelomonocytic leukemia.

The patient received aggressive multiagent chemotherapy. After a disease-free period of 8 months, he subsequently developed a transient erythematous, macular eruption that prompted a repeat work-up. He was diagnosed with a relapse of his leukemia and is currently undergoing treatments with the monoclonal antibody, gemtuzumab ozogamicin.

“Leukemia cutis occurs in a significant minority of patients who have been previously diagnosed with leukemia or in whom the work-up for systemic illness has already begun,” said Adrian Guevara, M.D., who presented this case in a poster session at the annual meeting of the American Academy of Dermatology, “but only rarely is it the presenting sign of a myeloproliferative or myelodysplastic state in an otherwise asymptomatic patient.”

The lesions are the result of an infiltration of neoplastic cells into the epidermis and dermis; they occur in about 30% of leukemia patients. They most frequently appear as nonspecific, firm or rubbery papules, nodules, or plaques, which can range from flesh-colored to plum-colored. They can masquerade as other skin diseases including erythema nodosum, mycosis fungoides, erythema annulare centrifugum, urticaria, psoriasis, stasis dermatitis, and chilblains, said Dr. Guevara, a resident at the University of Oklahoma, Oklahoma City.

Early biopsy can provide critical information. For this patient, the skin biopsy was the first clue to underlying malignancy.

An early cutaneous manifestation such as this is usually a marker for advanced disease with involvement of other organs including meninges, Dr. Guevara noted.

A biopsy showed a superficial and deep, perivascular, atypical mononuclear cell infiltrate with CD68, CD43, and myeloperoxidase positivity. A complete blood count revealed leukocytosis with monocytosis and immature granulocytes. A bone marrow biopsy showed acute myelomonocytic leukemia.

The patient received aggressive multiagent chemotherapy. After a disease-free period of 8 months, he subsequently developed a transient erythematous, macular eruption that prompted a repeat work-up. He was diagnosed with a relapse of his leukemia and is currently undergoing treatments with the monoclonal antibody, gemtuzumab ozogamicin.

“Leukemia cutis occurs in a significant minority of patients who have been previously diagnosed with leukemia or in whom the work-up for systemic illness has already begun,” said Adrian Guevara, M.D., who presented this case in a poster session at the annual meeting of the American Academy of Dermatology, “but only rarely is it the presenting sign of a myeloproliferative or myelodysplastic state in an otherwise asymptomatic patient.”

The lesions are the result of an infiltration of neoplastic cells into the epidermis and dermis; they occur in about 30% of leukemia patients. They most frequently appear as nonspecific, firm or rubbery papules, nodules, or plaques, which can range from flesh-colored to plum-colored. They can masquerade as other skin diseases including erythema nodosum, mycosis fungoides, erythema annulare centrifugum, urticaria, psoriasis, stasis dermatitis, and chilblains, said Dr. Guevara, a resident at the University of Oklahoma, Oklahoma City.

Early biopsy can provide critical information. For this patient, the skin biopsy was the first clue to underlying malignancy.

An early cutaneous manifestation such as this is usually a marker for advanced disease with involvement of other organs including meninges, Dr. Guevara noted.

A biopsy showed a superficial and deep, perivascular, atypical mononuclear cell infiltrate with CD68, CD43, and myeloperoxidase positivity. A complete blood count revealed leukocytosis with monocytosis and immature granulocytes. A bone marrow biopsy showed acute myelomonocytic leukemia.

The patient received aggressive multiagent chemotherapy. After a disease-free period of 8 months, he subsequently developed a transient erythematous, macular eruption that prompted a repeat work-up. He was diagnosed with a relapse of his leukemia and is currently undergoing treatments with the monoclonal antibody, gemtuzumab ozogamicin.

“Leukemia cutis occurs in a significant minority of patients who have been previously diagnosed with leukemia or in whom the work-up for systemic illness has already begun,” said Adrian Guevara, M.D., who presented this case in a poster session at the annual meeting of the American Academy of Dermatology, “but only rarely is it the presenting sign of a myeloproliferative or myelodysplastic state in an otherwise asymptomatic patient.”

The lesions are the result of an infiltration of neoplastic cells into the epidermis and dermis; they occur in about 30% of leukemia patients. They most frequently appear as nonspecific, firm or rubbery papules, nodules, or plaques, which can range from flesh-colored to plum-colored. They can masquerade as other skin diseases including erythema nodosum, mycosis fungoides, erythema annulare centrifugum, urticaria, psoriasis, stasis dermatitis, and chilblains, said Dr. Guevara, a resident at the University of Oklahoma, Oklahoma City.

Early biopsy can provide critical information. For this patient, the skin biopsy was the first clue to underlying malignancy.

An early cutaneous manifestation such as this is usually a marker for advanced disease with involvement of other organs including meninges, Dr. Guevara noted.

Knowledge and attitudes about the flu vaccine—especially about its safety and side effects—are the biggest influences in parents' decisions about whether to vaccinate, Sharon G. Humiston, M.D., and her colleagues reported.

The finding may come as a surprise to physicians who view the logistics and cost are the biggest factors, said Dr. Humiston of the University of Rochester (N.Y.), and her associates (Arch. Pediatr. Adolesc. Med. 2005;159:108-12).

“Although health care providers surveyed previously emphasized practicality and convenience, our findings suggest that improving those factors for caregivers is not likely to substantially enhance immunization rates,” they wrote. “Provider time and resources might be better directed at educational and safety concerns.”

The researchers surveyed 153 caregivers of children aged 6-23 months, who presented for care at an ambulatory pediatric clinic or pediatric emergency department. The survey was conducted during the summer of 2003.

Clinic respondents were more likely to be Hispanic or another minority, have lower household incomes, and less education than ED respondents.

Of the entire group, 78% said they intended to have their children vaccinated for the flu that season. But fewer (61%) believed that influenza is serious enough to have all children aged 6-23 months vaccinated. Almost half (49%) believed that the vaccine could cause the flu, 56% said vomiting was a main symptom of the flu, and 63% believed that many babies with the flu need to be hospitalized.

Safety of the vaccine was the most common primary concern (46%). If they had fewer safety concerns, 73% of caregivers said they probably would have their children vaccinated. Prevention of otitis media also was a big issue, with 85% saying they probably would get the vaccine if it prevented OM.

Far fewer caregivers expressed concerns about the number of vaccines a child must have (13.7%), the cost (6.5%), or the number of doctor visits required (4.6%).

Most (68%) said they would get the vaccine if it cost $10-$20, and 51% said they probably would get it even if the cost was more than $20. Extra doctor visits weren't a big concern; 70% reported they probably would still get the vaccine even if it meant another trip. In fact, 94% said a doctor's office or clinic was their first choice of vaccination location. Only 3% said they preferred a public health clinic, 2% said they preferred a school, and 1% said they preferred a grocery store.

The only demographic variable associated with intent to vaccinate was education: Those with a high school education or less were more likely to vaccinate than were those with higher education. The low impact of demographics on intent to vaccinate “might also be attributable to the degree to which parents' concerns and motivations help them overcome barriers imposed by their social locations,” the authors wrote.

Knowledge and attitudes about the flu vaccine—especially about its safety and side effects—are the biggest influences in parents' decisions about whether to vaccinate, Sharon G. Humiston, M.D., and her colleagues reported.

The finding may come as a surprise to physicians who view the logistics and cost are the biggest factors, said Dr. Humiston of the University of Rochester (N.Y.), and her associates (Arch. Pediatr. Adolesc. Med. 2005;159:108-12).

“Although health care providers surveyed previously emphasized practicality and convenience, our findings suggest that improving those factors for caregivers is not likely to substantially enhance immunization rates,” they wrote. “Provider time and resources might be better directed at educational and safety concerns.”

The researchers surveyed 153 caregivers of children aged 6-23 months, who presented for care at an ambulatory pediatric clinic or pediatric emergency department. The survey was conducted during the summer of 2003.

Clinic respondents were more likely to be Hispanic or another minority, have lower household incomes, and less education than ED respondents.

Of the entire group, 78% said they intended to have their children vaccinated for the flu that season. But fewer (61%) believed that influenza is serious enough to have all children aged 6-23 months vaccinated. Almost half (49%) believed that the vaccine could cause the flu, 56% said vomiting was a main symptom of the flu, and 63% believed that many babies with the flu need to be hospitalized.

Safety of the vaccine was the most common primary concern (46%). If they had fewer safety concerns, 73% of caregivers said they probably would have their children vaccinated. Prevention of otitis media also was a big issue, with 85% saying they probably would get the vaccine if it prevented OM.

Far fewer caregivers expressed concerns about the number of vaccines a child must have (13.7%), the cost (6.5%), or the number of doctor visits required (4.6%).

Most (68%) said they would get the vaccine if it cost $10-$20, and 51% said they probably would get it even if the cost was more than $20. Extra doctor visits weren't a big concern; 70% reported they probably would still get the vaccine even if it meant another trip. In fact, 94% said a doctor's office or clinic was their first choice of vaccination location. Only 3% said they preferred a public health clinic, 2% said they preferred a school, and 1% said they preferred a grocery store.

The only demographic variable associated with intent to vaccinate was education: Those with a high school education or less were more likely to vaccinate than were those with higher education. The low impact of demographics on intent to vaccinate “might also be attributable to the degree to which parents' concerns and motivations help them overcome barriers imposed by their social locations,” the authors wrote.

Knowledge and attitudes about the flu vaccine—especially about its safety and side effects—are the biggest influences in parents' decisions about whether to vaccinate, Sharon G. Humiston, M.D., and her colleagues reported.

The finding may come as a surprise to physicians who view the logistics and cost are the biggest factors, said Dr. Humiston of the University of Rochester (N.Y.), and her associates (Arch. Pediatr. Adolesc. Med. 2005;159:108-12).

“Although health care providers surveyed previously emphasized practicality and convenience, our findings suggest that improving those factors for caregivers is not likely to substantially enhance immunization rates,” they wrote. “Provider time and resources might be better directed at educational and safety concerns.”

The researchers surveyed 153 caregivers of children aged 6-23 months, who presented for care at an ambulatory pediatric clinic or pediatric emergency department. The survey was conducted during the summer of 2003.

Clinic respondents were more likely to be Hispanic or another minority, have lower household incomes, and less education than ED respondents.

Of the entire group, 78% said they intended to have their children vaccinated for the flu that season. But fewer (61%) believed that influenza is serious enough to have all children aged 6-23 months vaccinated. Almost half (49%) believed that the vaccine could cause the flu, 56% said vomiting was a main symptom of the flu, and 63% believed that many babies with the flu need to be hospitalized.

Safety of the vaccine was the most common primary concern (46%). If they had fewer safety concerns, 73% of caregivers said they probably would have their children vaccinated. Prevention of otitis media also was a big issue, with 85% saying they probably would get the vaccine if it prevented OM.

Far fewer caregivers expressed concerns about the number of vaccines a child must have (13.7%), the cost (6.5%), or the number of doctor visits required (4.6%).

Most (68%) said they would get the vaccine if it cost $10-$20, and 51% said they probably would get it even if the cost was more than $20. Extra doctor visits weren't a big concern; 70% reported they probably would still get the vaccine even if it meant another trip. In fact, 94% said a doctor's office or clinic was their first choice of vaccination location. Only 3% said they preferred a public health clinic, 2% said they preferred a school, and 1% said they preferred a grocery store.

The only demographic variable associated with intent to vaccinate was education: Those with a high school education or less were more likely to vaccinate than were those with higher education. The low impact of demographics on intent to vaccinate “might also be attributable to the degree to which parents' concerns and motivations help them overcome barriers imposed by their social locations,” the authors wrote.