Sherry Boschert

SAN FRANCISCO — With only a handful of case reports in the medical literature, Raynaud phenomenon of the nipples isn't often a physician's first thought when a breast-feeding mother describes nipple pain.

However, if there are no signs of infection and no cracks or fissures on the nipples, consider this rare cause of nipple pain, especially if the woman has a history of Raynaud syndrome, Sharon R. Wiener said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The pain from this vasospasm of the nipples while breast-feeding usually is bilateral, severe, and a spasm-like throb. The nipple usually turns very white but may be blue, purple, or red, said Ms. Wiener, a certified nurse-midwife at the university.

This problem has been misdiagnosed as a candidal infection. Among 12 women in a 2004 case report who ultimately were diagnosed with Raynaud phenomenon of the nipples, 8 had been treated for candidiasis of the breast. Following them for 4 months and diligently taking detailed histories led to the correct diagnosis and treatment, she said.

A recent patient seen by Ms. Wiener said she had been diagnosed with Raynaud syndrome about 5 years before her pregnancy. She complained of episodes in which her nipples would become cold and then go into spasms for many hours.

“She was very concerned, appropriately, that she was going to have difficulty breast-feeding,” Ms. Wiener said.

Sending patients in whom you suspect this problem to a lactation consultant to identify poor latch can support the diagnosis. Alternatively, try applying a cold compress or ice to the nipple to see if it triggers the phenomenon.

It's important to prepare the woman for the effect this may have. “I've done this twice. In one case, I got a dramatic response,” she said. “I know this sounds horrible,” but it's preferable to prescribing treatment without a firm diagnosis.

The treatment of choice is the calcium channel blocker nifedipine, 5 mg b.i.d. for 2 weeks. “It's very quick acting” and a vasodilator, she said. “The handful that I have treated have responded very well and didn't need a repeat of the prescription. Why that is, I can't tell you.”

Raynaud phenomenon of the nipples has been associated with factors that restrict the blood vessels, including rheumatologic diseases, endocrine diseases, autoimmune diseases, cigarettes, and caffeine.

Advise the patient to avoid exposure to cold, vasoconstricting medications, nicotine, and caffeine. In mild cases, warm compresses or warm showers may suffice as treatment. Topical nitroglycerine appears to be effective treatment in half of cases.

SAN FRANCISCO — With only a handful of case reports in the medical literature, Raynaud phenomenon of the nipples isn't often a physician's first thought when a breast-feeding mother describes nipple pain.

However, if there are no signs of infection and no cracks or fissures on the nipples, consider this rare cause of nipple pain, especially if the woman has a history of Raynaud syndrome, Sharon R. Wiener said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The pain from this vasospasm of the nipples while breast-feeding usually is bilateral, severe, and a spasm-like throb. The nipple usually turns very white but may be blue, purple, or red, said Ms. Wiener, a certified nurse-midwife at the university.

This problem has been misdiagnosed as a candidal infection. Among 12 women in a 2004 case report who ultimately were diagnosed with Raynaud phenomenon of the nipples, 8 had been treated for candidiasis of the breast. Following them for 4 months and diligently taking detailed histories led to the correct diagnosis and treatment, she said.

A recent patient seen by Ms. Wiener said she had been diagnosed with Raynaud syndrome about 5 years before her pregnancy. She complained of episodes in which her nipples would become cold and then go into spasms for many hours.

“She was very concerned, appropriately, that she was going to have difficulty breast-feeding,” Ms. Wiener said.

Sending patients in whom you suspect this problem to a lactation consultant to identify poor latch can support the diagnosis. Alternatively, try applying a cold compress or ice to the nipple to see if it triggers the phenomenon.

It's important to prepare the woman for the effect this may have. “I've done this twice. In one case, I got a dramatic response,” she said. “I know this sounds horrible,” but it's preferable to prescribing treatment without a firm diagnosis.

The treatment of choice is the calcium channel blocker nifedipine, 5 mg b.i.d. for 2 weeks. “It's very quick acting” and a vasodilator, she said. “The handful that I have treated have responded very well and didn't need a repeat of the prescription. Why that is, I can't tell you.”

Raynaud phenomenon of the nipples has been associated with factors that restrict the blood vessels, including rheumatologic diseases, endocrine diseases, autoimmune diseases, cigarettes, and caffeine.

Advise the patient to avoid exposure to cold, vasoconstricting medications, nicotine, and caffeine. In mild cases, warm compresses or warm showers may suffice as treatment. Topical nitroglycerine appears to be effective treatment in half of cases.

SAN FRANCISCO — With only a handful of case reports in the medical literature, Raynaud phenomenon of the nipples isn't often a physician's first thought when a breast-feeding mother describes nipple pain.

However, if there are no signs of infection and no cracks or fissures on the nipples, consider this rare cause of nipple pain, especially if the woman has a history of Raynaud syndrome, Sharon R. Wiener said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The pain from this vasospasm of the nipples while breast-feeding usually is bilateral, severe, and a spasm-like throb. The nipple usually turns very white but may be blue, purple, or red, said Ms. Wiener, a certified nurse-midwife at the university.

This problem has been misdiagnosed as a candidal infection. Among 12 women in a 2004 case report who ultimately were diagnosed with Raynaud phenomenon of the nipples, 8 had been treated for candidiasis of the breast. Following them for 4 months and diligently taking detailed histories led to the correct diagnosis and treatment, she said.

A recent patient seen by Ms. Wiener said she had been diagnosed with Raynaud syndrome about 5 years before her pregnancy. She complained of episodes in which her nipples would become cold and then go into spasms for many hours.

“She was very concerned, appropriately, that she was going to have difficulty breast-feeding,” Ms. Wiener said.

Sending patients in whom you suspect this problem to a lactation consultant to identify poor latch can support the diagnosis. Alternatively, try applying a cold compress or ice to the nipple to see if it triggers the phenomenon.

It's important to prepare the woman for the effect this may have. “I've done this twice. In one case, I got a dramatic response,” she said. “I know this sounds horrible,” but it's preferable to prescribing treatment without a firm diagnosis.

The treatment of choice is the calcium channel blocker nifedipine, 5 mg b.i.d. for 2 weeks. “It's very quick acting” and a vasodilator, she said. “The handful that I have treated have responded very well and didn't need a repeat of the prescription. Why that is, I can't tell you.”

Raynaud phenomenon of the nipples has been associated with factors that restrict the blood vessels, including rheumatologic diseases, endocrine diseases, autoimmune diseases, cigarettes, and caffeine.

Advise the patient to avoid exposure to cold, vasoconstricting medications, nicotine, and caffeine. In mild cases, warm compresses or warm showers may suffice as treatment. Topical nitroglycerine appears to be effective treatment in half of cases.

SAN FRANCISCO – Children and adolescents with cancer showed greater adaptive skills and social skills than expected in healthy children, and certain adaptive styles help them thrive psychologically, separate speakers said at the annual meeting of the American Psychological Association.

A study of 172 children and teenagers with cancer looked at positive adjustment by measuring adaptability, social skills, and leadership. Results were compared with the same measures on a healthy sibling for 90 of the patients and with expected levels of these traits in healthy children.

Skills were assessed using the Revised Children's Manifest Anxiety Scale and the Behavioral Assessment System for Children-2.

Both the children with cancer and their siblings showed similar or lower levels of externalizing problems than would be expected in healthy controls. Children with cancer had higher composite scores for internalizing problems (anxiety, depression, and somatization), but their siblings had significantly lower composite scores, compared with expected rates, reported Melissa A. Alderfer, Ph.D., of Children's Hospital of Philadelphia.

Both the children with cancer and their siblings had greater adaptability and social skills than would be expected in conventional children. The siblings also showed more elevated levels of leadership than might be expected, but this trait was lower in children with cancer because of depressed leadership scores among children with brain tumors.

The children with cancer were 7–19 years of age and had been diagnosed between 44 days and 17 years prior to the study. Their siblings were 8–17 years old. Most (59%) of the children with cancer had leukemia, lymphoma, or blood disorders. A modest decline in positive adjustment was seen the further the cancer patient was from the time of diagnosis, Dr. Alderfer said.

Many previous studies have reported lower rates of depression in children with cancer, compared with healthy controls, Sean Phipps, Ph.D., said in a separate presentation. “The preponderance of evidence suggests that children with cancer are doing quite well” psychologically, said Dr. Phipps of St. Jude's Children's Research Hospital, Memphis, Tenn.

He and associates explored one of the possible reasons for this–each individual's style of coping or defense, termed adaptive style. In one study of 162 pediatric cancer patients and their parents, the parents and patients reported on their adaptive styles and levels of posttraumatic stress.

Children and parents who were identified as low anxious or repressors had less posttraumatic stress reported, compared with those who were identified as high anxious or defensive/high anxious (J. Pediatr. Psychol. 2006;31:298–309).

“These findings, in combination with the generally low levels of posttraumatic stress in the pediatric oncology population, raise questions about the utility of the posttraumatic stress model for understanding the experiences of children with cancer,” the investigators concluded.

A separate study in which Dr. Phipps was a coinvestigator assessed quality of life for 199 children with cancer and 108 healthy control children. The children with cancer and their parents reported better quality of life, compared with control children (Cancer 2006;106:2267–74).

Dr. Phipps wondered whether there is a downside to repressive adaptation. “I always thought so,” he said, which led him and his associates to conduct a separate study on the effects of adaptive style on somatic symptoms in children aged 7–18 years, including 120 children who had completed treatment for cancer at least 6 months earlier and 120 matched healthy controls.

Contrary to expectations, there were no significant differences between the cancer and control groups in self-reported somatic symptoms. Children who were identified as repressors were least likely to report somatic symptoms (Pediatr. Blood Cancer 2007;49:84–9).

“These results do not support the prevailing hypothesis that a repressive style may be a risk factor for psychosomatic illness,” the investigators reported.

Another study that hooked up physiologic monitoring devices to children with cancer found no relationship between measures of adaptive style and physiologic reactivity or short-term medical outcome, he added.

“Children with cancer are not only doing well, they're flourishing” psychologically, Dr. Phipps said.

SAN FRANCISCO – Children and adolescents with cancer showed greater adaptive skills and social skills than expected in healthy children, and certain adaptive styles help them thrive psychologically, separate speakers said at the annual meeting of the American Psychological Association.

A study of 172 children and teenagers with cancer looked at positive adjustment by measuring adaptability, social skills, and leadership. Results were compared with the same measures on a healthy sibling for 90 of the patients and with expected levels of these traits in healthy children.

Skills were assessed using the Revised Children's Manifest Anxiety Scale and the Behavioral Assessment System for Children-2.

Both the children with cancer and their siblings showed similar or lower levels of externalizing problems than would be expected in healthy controls. Children with cancer had higher composite scores for internalizing problems (anxiety, depression, and somatization), but their siblings had significantly lower composite scores, compared with expected rates, reported Melissa A. Alderfer, Ph.D., of Children's Hospital of Philadelphia.

Both the children with cancer and their siblings had greater adaptability and social skills than would be expected in conventional children. The siblings also showed more elevated levels of leadership than might be expected, but this trait was lower in children with cancer because of depressed leadership scores among children with brain tumors.

The children with cancer were 7–19 years of age and had been diagnosed between 44 days and 17 years prior to the study. Their siblings were 8–17 years old. Most (59%) of the children with cancer had leukemia, lymphoma, or blood disorders. A modest decline in positive adjustment was seen the further the cancer patient was from the time of diagnosis, Dr. Alderfer said.

Many previous studies have reported lower rates of depression in children with cancer, compared with healthy controls, Sean Phipps, Ph.D., said in a separate presentation. “The preponderance of evidence suggests that children with cancer are doing quite well” psychologically, said Dr. Phipps of St. Jude's Children's Research Hospital, Memphis, Tenn.

He and associates explored one of the possible reasons for this–each individual's style of coping or defense, termed adaptive style. In one study of 162 pediatric cancer patients and their parents, the parents and patients reported on their adaptive styles and levels of posttraumatic stress.

Children and parents who were identified as low anxious or repressors had less posttraumatic stress reported, compared with those who were identified as high anxious or defensive/high anxious (J. Pediatr. Psychol. 2006;31:298–309).

“These findings, in combination with the generally low levels of posttraumatic stress in the pediatric oncology population, raise questions about the utility of the posttraumatic stress model for understanding the experiences of children with cancer,” the investigators concluded.

A separate study in which Dr. Phipps was a coinvestigator assessed quality of life for 199 children with cancer and 108 healthy control children. The children with cancer and their parents reported better quality of life, compared with control children (Cancer 2006;106:2267–74).

Dr. Phipps wondered whether there is a downside to repressive adaptation. “I always thought so,” he said, which led him and his associates to conduct a separate study on the effects of adaptive style on somatic symptoms in children aged 7–18 years, including 120 children who had completed treatment for cancer at least 6 months earlier and 120 matched healthy controls.

Contrary to expectations, there were no significant differences between the cancer and control groups in self-reported somatic symptoms. Children who were identified as repressors were least likely to report somatic symptoms (Pediatr. Blood Cancer 2007;49:84–9).

“These results do not support the prevailing hypothesis that a repressive style may be a risk factor for psychosomatic illness,” the investigators reported.

Another study that hooked up physiologic monitoring devices to children with cancer found no relationship between measures of adaptive style and physiologic reactivity or short-term medical outcome, he added.

“Children with cancer are not only doing well, they're flourishing” psychologically, Dr. Phipps said.

SAN FRANCISCO – Children and adolescents with cancer showed greater adaptive skills and social skills than expected in healthy children, and certain adaptive styles help them thrive psychologically, separate speakers said at the annual meeting of the American Psychological Association.

A study of 172 children and teenagers with cancer looked at positive adjustment by measuring adaptability, social skills, and leadership. Results were compared with the same measures on a healthy sibling for 90 of the patients and with expected levels of these traits in healthy children.

Skills were assessed using the Revised Children's Manifest Anxiety Scale and the Behavioral Assessment System for Children-2.

Both the children with cancer and their siblings showed similar or lower levels of externalizing problems than would be expected in healthy controls. Children with cancer had higher composite scores for internalizing problems (anxiety, depression, and somatization), but their siblings had significantly lower composite scores, compared with expected rates, reported Melissa A. Alderfer, Ph.D., of Children's Hospital of Philadelphia.

Both the children with cancer and their siblings had greater adaptability and social skills than would be expected in conventional children. The siblings also showed more elevated levels of leadership than might be expected, but this trait was lower in children with cancer because of depressed leadership scores among children with brain tumors.

The children with cancer were 7–19 years of age and had been diagnosed between 44 days and 17 years prior to the study. Their siblings were 8–17 years old. Most (59%) of the children with cancer had leukemia, lymphoma, or blood disorders. A modest decline in positive adjustment was seen the further the cancer patient was from the time of diagnosis, Dr. Alderfer said.

Many previous studies have reported lower rates of depression in children with cancer, compared with healthy controls, Sean Phipps, Ph.D., said in a separate presentation. “The preponderance of evidence suggests that children with cancer are doing quite well” psychologically, said Dr. Phipps of St. Jude's Children's Research Hospital, Memphis, Tenn.

He and associates explored one of the possible reasons for this–each individual's style of coping or defense, termed adaptive style. In one study of 162 pediatric cancer patients and their parents, the parents and patients reported on their adaptive styles and levels of posttraumatic stress.

Children and parents who were identified as low anxious or repressors had less posttraumatic stress reported, compared with those who were identified as high anxious or defensive/high anxious (J. Pediatr. Psychol. 2006;31:298–309).

“These findings, in combination with the generally low levels of posttraumatic stress in the pediatric oncology population, raise questions about the utility of the posttraumatic stress model for understanding the experiences of children with cancer,” the investigators concluded.

A separate study in which Dr. Phipps was a coinvestigator assessed quality of life for 199 children with cancer and 108 healthy control children. The children with cancer and their parents reported better quality of life, compared with control children (Cancer 2006;106:2267–74).

Dr. Phipps wondered whether there is a downside to repressive adaptation. “I always thought so,” he said, which led him and his associates to conduct a separate study on the effects of adaptive style on somatic symptoms in children aged 7–18 years, including 120 children who had completed treatment for cancer at least 6 months earlier and 120 matched healthy controls.

Contrary to expectations, there were no significant differences between the cancer and control groups in self-reported somatic symptoms. Children who were identified as repressors were least likely to report somatic symptoms (Pediatr. Blood Cancer 2007;49:84–9).

“These results do not support the prevailing hypothesis that a repressive style may be a risk factor for psychosomatic illness,” the investigators reported.

Another study that hooked up physiologic monitoring devices to children with cancer found no relationship between measures of adaptive style and physiologic reactivity or short-term medical outcome, he added.

“Children with cancer are not only doing well, they're flourishing” psychologically, Dr. Phipps said.

LOS ANGELES — Taking cefdinir once instead of twice daily for 7 instead of 10 days successfully treated uncomplicated skin and skin structure infections in a small randomized study.

The study of 64 clinically evaluable patients who were randomized to treatment with one of two oral cephalosporins was not powered to endorse the shorter therapy conclusively. That would require thousands of patients, Dr. George J. Murakawa said at the annual meeting of the Society for Investigational Dermatology.

Previous studies, however, have proved the efficacy of treating uncomplicated skin and skin structure infections with either cephalexin 250 mg q.i.d. for 10 days or cefdinir 300 mg b.i.d. for 10 days. The current study randomized patients to the standard cephalexin regimen or two capsules of cefdinir (600 mg) once daily for 7 days.

The treatment cured the infections in 31 of 32 patients on cephalexin and 30 of 32 patients on cefdinir, said Dr. Murakawa of Michigan State University, East Lansing. Dr. Murakawa is a speaker for Abbott Laboratories, which markets cefdinir and funded this study.

"You don't necessarily need to use the standard 10-day course" of cefdinir, he said. "Once-daily doses worked very well. All patients cleared, even those with methicillin-resistant Staphylococcus aureus."

A physician in the audience said that the high rate of cure seen with cephalexin suggests that it, too, might work with fewer daily doses and a shorter course of therapy.

The infections included folliculitis (10 patients), abscesses (8), cellulitis (6), furuncle or carbuncle (13), impetigo (19), paronychia (2), and wound infection (6).

The treating physician was blinded to the medication, which was dispensed by a third party. Patients were asked not to disclose information about randomization. The physician incised and drained pustules. A specimen was collected from all patients for culture, and 50 grew out an organism.

Of 26 cultures that grew S. aureus, 7 were resistant to methicillin. All patients with S. aureus infection were cured in both treatment groups regardless of methicillin resistance, Dr. Murakawa said.

More patients were compliant with the cefdinir regimen than with cephalexin.

Bacterial skin infections are one of the most common problems seen by physicians, comprising 14% of all skin-related visits to internists, he noted.

LOS ANGELES — Taking cefdinir once instead of twice daily for 7 instead of 10 days successfully treated uncomplicated skin and skin structure infections in a small randomized study.

The study of 64 clinically evaluable patients who were randomized to treatment with one of two oral cephalosporins was not powered to endorse the shorter therapy conclusively. That would require thousands of patients, Dr. George J. Murakawa said at the annual meeting of the Society for Investigational Dermatology.

Previous studies, however, have proved the efficacy of treating uncomplicated skin and skin structure infections with either cephalexin 250 mg q.i.d. for 10 days or cefdinir 300 mg b.i.d. for 10 days. The current study randomized patients to the standard cephalexin regimen or two capsules of cefdinir (600 mg) once daily for 7 days.

The treatment cured the infections in 31 of 32 patients on cephalexin and 30 of 32 patients on cefdinir, said Dr. Murakawa of Michigan State University, East Lansing. Dr. Murakawa is a speaker for Abbott Laboratories, which markets cefdinir and funded this study.

"You don't necessarily need to use the standard 10-day course" of cefdinir, he said. "Once-daily doses worked very well. All patients cleared, even those with methicillin-resistant Staphylococcus aureus."

A physician in the audience said that the high rate of cure seen with cephalexin suggests that it, too, might work with fewer daily doses and a shorter course of therapy.

The infections included folliculitis (10 patients), abscesses (8), cellulitis (6), furuncle or carbuncle (13), impetigo (19), paronychia (2), and wound infection (6).

The treating physician was blinded to the medication, which was dispensed by a third party. Patients were asked not to disclose information about randomization. The physician incised and drained pustules. A specimen was collected from all patients for culture, and 50 grew out an organism.

Of 26 cultures that grew S. aureus, 7 were resistant to methicillin. All patients with S. aureus infection were cured in both treatment groups regardless of methicillin resistance, Dr. Murakawa said.

More patients were compliant with the cefdinir regimen than with cephalexin.

Bacterial skin infections are one of the most common problems seen by physicians, comprising 14% of all skin-related visits to internists, he noted.

LOS ANGELES — Taking cefdinir once instead of twice daily for 7 instead of 10 days successfully treated uncomplicated skin and skin structure infections in a small randomized study.

The study of 64 clinically evaluable patients who were randomized to treatment with one of two oral cephalosporins was not powered to endorse the shorter therapy conclusively. That would require thousands of patients, Dr. George J. Murakawa said at the annual meeting of the Society for Investigational Dermatology.

Previous studies, however, have proved the efficacy of treating uncomplicated skin and skin structure infections with either cephalexin 250 mg q.i.d. for 10 days or cefdinir 300 mg b.i.d. for 10 days. The current study randomized patients to the standard cephalexin regimen or two capsules of cefdinir (600 mg) once daily for 7 days.

The treatment cured the infections in 31 of 32 patients on cephalexin and 30 of 32 patients on cefdinir, said Dr. Murakawa of Michigan State University, East Lansing. Dr. Murakawa is a speaker for Abbott Laboratories, which markets cefdinir and funded this study.

"You don't necessarily need to use the standard 10-day course" of cefdinir, he said. "Once-daily doses worked very well. All patients cleared, even those with methicillin-resistant Staphylococcus aureus."

A physician in the audience said that the high rate of cure seen with cephalexin suggests that it, too, might work with fewer daily doses and a shorter course of therapy.

The infections included folliculitis (10 patients), abscesses (8), cellulitis (6), furuncle or carbuncle (13), impetigo (19), paronychia (2), and wound infection (6).

The treating physician was blinded to the medication, which was dispensed by a third party. Patients were asked not to disclose information about randomization. The physician incised and drained pustules. A specimen was collected from all patients for culture, and 50 grew out an organism.

Of 26 cultures that grew S. aureus, 7 were resistant to methicillin. All patients with S. aureus infection were cured in both treatment groups regardless of methicillin resistance, Dr. Murakawa said.

More patients were compliant with the cefdinir regimen than with cephalexin.

Bacterial skin infections are one of the most common problems seen by physicians, comprising 14% of all skin-related visits to internists, he noted.

SAN FRANCISCO – Don't assume the presence of twin-twin transfusion syndrome if you see discordant sizes and weights in a monochorionic twin pregnancy; consider unequal placental sharing and other potential causes, Dr. Vickie A. Feldstein said.

Sometimes called “selective intrauterine growth restriction,” unequal placental sharing occurs when twins who share one placenta don't divide the placental resources equally so that one twin gets less circulation and nutrition.

“Twins in utero, like twins on the outside, don't necessarily share well,” she said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Monochorionic twins typically get followed closely (at least every 2 weeks) in the last two trimesters because of the risk for twin-twin transfusion syndrome, which affects 15% of monochorionic twins and causes fetal death in up to 70% of cases if untreated.

Every ultrasound report from serial surveillance of monochorionic twins should include an estimate of percent weight discordance, said Dr. Feldstein, professor of clinical radiology and obstetrics, gynecology, and reproductive sciences at the university. To calculate percent weight discordance, take the estimated weight of the larger twin, subtract the estimated weight of the smaller twin, divide the sum by the weight of the larger twin, and multiply by 100.

If the discordance “is more than 15%, we're a little bit attentive,” she said. Discordance of 20% or more is cause for concern.

A 20% discordance may stabilize, with the twins following their own growth charts and ending up healthy but slightly different sizes. “This is one of the reasons I never refer to these as identical twins,” she noted.

If the discordance continues to increase, however, look for the cord insertion sites by ultrasound. With unequal placental sharing, typically the larger twin has a central cord insertion, and the smaller twin has a marginal cord insertion.

“If you do Dopplers of the cords of these twins, in general the twin with the better piece of placenta and central cord has normal umbilical artery Dopplers, and the smaller growth-restricted twin tends to have higher-resistance Dopplers from very early on,” Dr. Feldstein said.

If the smaller twin starts to fall off of its growth chart, early delivery may be in order.

All monochorionic twins have connections between arteries, veins, or an artery in one twin and a vein in the other. An artery in one twin draining into a vein of the other, bringing oxygenated blood to its sibling, is definitive for twin-twin transfusion syndrome. An artery-to-artery connection is protective for twin-twin transfusion syndrome. The difference affects how the patient should be counseled.

A diagnosis of twin-twin transfusion syndrome requires not just discordant sizes/weights but also the presence of polyhydramnios in one fetal sac and oligohydramnios in the other. The variability of twin-twin transfusion syndrome cases in age of onset, severity, acuity, and degree of discordance in size, weight, and amniotic fluid volumes can make it hard to recognize.

Unequal placental sharing and twin-twin transfusion syndrome can occur separately or concurrently. “I think of monochorionic placentas like snowflakes. They're all different, and anatomy is crucial,” she said.

If one twin has oligohydramnios and the other has normal amniotic fluid volume, it may be a case of unequal placental sharing, or there may be a more common problem such as a renal anomaly or rupture of membranes.

“We have a fair number of patients referred in for 'twin-twin transfusion syndrome,' and it turns out that one twin has ruptured membranes and there isn't twin-twin transfusion syndrome at all,” Dr. Mary E. Norton said in a joint presentation with Dr. Feldstein. “It's important to think about the common things that can cause oligohydramnios,” said Dr. Norton, director of perinatal medicine and genetics and professor of obstetrics, gynecology, and reproductive sciences at UCSF.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO – Don't assume the presence of twin-twin transfusion syndrome if you see discordant sizes and weights in a monochorionic twin pregnancy; consider unequal placental sharing and other potential causes, Dr. Vickie A. Feldstein said.

Sometimes called “selective intrauterine growth restriction,” unequal placental sharing occurs when twins who share one placenta don't divide the placental resources equally so that one twin gets less circulation and nutrition.

“Twins in utero, like twins on the outside, don't necessarily share well,” she said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Monochorionic twins typically get followed closely (at least every 2 weeks) in the last two trimesters because of the risk for twin-twin transfusion syndrome, which affects 15% of monochorionic twins and causes fetal death in up to 70% of cases if untreated.

Every ultrasound report from serial surveillance of monochorionic twins should include an estimate of percent weight discordance, said Dr. Feldstein, professor of clinical radiology and obstetrics, gynecology, and reproductive sciences at the university. To calculate percent weight discordance, take the estimated weight of the larger twin, subtract the estimated weight of the smaller twin, divide the sum by the weight of the larger twin, and multiply by 100.

If the discordance “is more than 15%, we're a little bit attentive,” she said. Discordance of 20% or more is cause for concern.

A 20% discordance may stabilize, with the twins following their own growth charts and ending up healthy but slightly different sizes. “This is one of the reasons I never refer to these as identical twins,” she noted.

If the discordance continues to increase, however, look for the cord insertion sites by ultrasound. With unequal placental sharing, typically the larger twin has a central cord insertion, and the smaller twin has a marginal cord insertion.

“If you do Dopplers of the cords of these twins, in general the twin with the better piece of placenta and central cord has normal umbilical artery Dopplers, and the smaller growth-restricted twin tends to have higher-resistance Dopplers from very early on,” Dr. Feldstein said.

If the smaller twin starts to fall off of its growth chart, early delivery may be in order.

All monochorionic twins have connections between arteries, veins, or an artery in one twin and a vein in the other. An artery in one twin draining into a vein of the other, bringing oxygenated blood to its sibling, is definitive for twin-twin transfusion syndrome. An artery-to-artery connection is protective for twin-twin transfusion syndrome. The difference affects how the patient should be counseled.

A diagnosis of twin-twin transfusion syndrome requires not just discordant sizes/weights but also the presence of polyhydramnios in one fetal sac and oligohydramnios in the other. The variability of twin-twin transfusion syndrome cases in age of onset, severity, acuity, and degree of discordance in size, weight, and amniotic fluid volumes can make it hard to recognize.

Unequal placental sharing and twin-twin transfusion syndrome can occur separately or concurrently. “I think of monochorionic placentas like snowflakes. They're all different, and anatomy is crucial,” she said.

If one twin has oligohydramnios and the other has normal amniotic fluid volume, it may be a case of unequal placental sharing, or there may be a more common problem such as a renal anomaly or rupture of membranes.

“We have a fair number of patients referred in for 'twin-twin transfusion syndrome,' and it turns out that one twin has ruptured membranes and there isn't twin-twin transfusion syndrome at all,” Dr. Mary E. Norton said in a joint presentation with Dr. Feldstein. “It's important to think about the common things that can cause oligohydramnios,” said Dr. Norton, director of perinatal medicine and genetics and professor of obstetrics, gynecology, and reproductive sciences at UCSF.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO – Don't assume the presence of twin-twin transfusion syndrome if you see discordant sizes and weights in a monochorionic twin pregnancy; consider unequal placental sharing and other potential causes, Dr. Vickie A. Feldstein said.

Sometimes called “selective intrauterine growth restriction,” unequal placental sharing occurs when twins who share one placenta don't divide the placental resources equally so that one twin gets less circulation and nutrition.

“Twins in utero, like twins on the outside, don't necessarily share well,” she said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Monochorionic twins typically get followed closely (at least every 2 weeks) in the last two trimesters because of the risk for twin-twin transfusion syndrome, which affects 15% of monochorionic twins and causes fetal death in up to 70% of cases if untreated.

Every ultrasound report from serial surveillance of monochorionic twins should include an estimate of percent weight discordance, said Dr. Feldstein, professor of clinical radiology and obstetrics, gynecology, and reproductive sciences at the university. To calculate percent weight discordance, take the estimated weight of the larger twin, subtract the estimated weight of the smaller twin, divide the sum by the weight of the larger twin, and multiply by 100.

If the discordance “is more than 15%, we're a little bit attentive,” she said. Discordance of 20% or more is cause for concern.

A 20% discordance may stabilize, with the twins following their own growth charts and ending up healthy but slightly different sizes. “This is one of the reasons I never refer to these as identical twins,” she noted.

If the discordance continues to increase, however, look for the cord insertion sites by ultrasound. With unequal placental sharing, typically the larger twin has a central cord insertion, and the smaller twin has a marginal cord insertion.

“If you do Dopplers of the cords of these twins, in general the twin with the better piece of placenta and central cord has normal umbilical artery Dopplers, and the smaller growth-restricted twin tends to have higher-resistance Dopplers from very early on,” Dr. Feldstein said.

If the smaller twin starts to fall off of its growth chart, early delivery may be in order.

All monochorionic twins have connections between arteries, veins, or an artery in one twin and a vein in the other. An artery in one twin draining into a vein of the other, bringing oxygenated blood to its sibling, is definitive for twin-twin transfusion syndrome. An artery-to-artery connection is protective for twin-twin transfusion syndrome. The difference affects how the patient should be counseled.

A diagnosis of twin-twin transfusion syndrome requires not just discordant sizes/weights but also the presence of polyhydramnios in one fetal sac and oligohydramnios in the other. The variability of twin-twin transfusion syndrome cases in age of onset, severity, acuity, and degree of discordance in size, weight, and amniotic fluid volumes can make it hard to recognize.

Unequal placental sharing and twin-twin transfusion syndrome can occur separately or concurrently. “I think of monochorionic placentas like snowflakes. They're all different, and anatomy is crucial,” she said.

If one twin has oligohydramnios and the other has normal amniotic fluid volume, it may be a case of unequal placental sharing, or there may be a more common problem such as a renal anomaly or rupture of membranes.

“We have a fair number of patients referred in for 'twin-twin transfusion syndrome,' and it turns out that one twin has ruptured membranes and there isn't twin-twin transfusion syndrome at all,” Dr. Mary E. Norton said in a joint presentation with Dr. Feldstein. “It's important to think about the common things that can cause oligohydramnios,” said Dr. Norton, director of perinatal medicine and genetics and professor of obstetrics, gynecology, and reproductive sciences at UCSF.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO – With only a handful of case reports in the medical literature, Raynaud's phenomenon of the nipples isn't the first thing that physicians think of when a breast-feeding mother complains of nipple pain.

If there are no signs of infection and no cracks or fissures on the nipples, consider this rare cause of nipple pain, especially if the woman has a history of Raynaud's syndrome, Sharon R. Wiener said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The pain from this vasospasm of the nipples while breast-feeding usually is bilateral, severe, and a spasm-like throb. The nipple usually turns very white but may be blue, purple, or red, said Ms. Wiener, a certified nurse-midwife at the university.

This problem has been misdiagnosed as a candidal infection. Among 12 women in a 2004 case report who ultimately were diagnosed with Raynaud's phenomenon of the nipples, 8 had been treated for candidiasis of the breast. Following them for 4 months and diligently taking detailed histories led to the correct diagnosis and treatment, she said.

A recent patient seen by Ms. Wiener said she had been diagnosed with Raynaud's syndrome about 5 years before her pregnancy. She complained of episodes in which her nipples would become cold and then go into spasms for many hours. “She was very concerned, appropriately, that she was going to have difficulty breast-feeding,” Ms. Wiener said.

Sending patients in whom you suspect this problem to a lactation consultant to identify poor latch can support the diagnosis. Alternatively, try applying a cold compress or ice to the nipple to see if it triggers the phenomenon.

It's important to prepare the woman for the effect this may have. “I've done this twice. In one case, I got a dramatic response,” she said. “I know this sounds horrible,” but it's preferable to prescribing treatment without a firm diagnosis.

The treatment of choice is the calcium channel blocker nifedipine, 5 mg b.i.d. for 2 weeks. “It's very quick acting” and a vasodilator, she said. “The handful that I have treated have responded very well and didn't need a repeat of the prescription. Why that is, I can't tell you.”

Raynaud's phenomenon of the nipples has been associated with factors that restrict the blood vessels, including rheumatologic diseases, endocrine diseases, autoimmune diseases, cigarettes, and caffeine.

Advise the patient to avoid exposure to cold, vasoconstricting medications, nicotine, and caffeine. In mild cases, warm compresses or warm showers may suffice as treatment. Topical nitroglycerine appears to be effective treatment in half of all cases.

SAN FRANCISCO – With only a handful of case reports in the medical literature, Raynaud's phenomenon of the nipples isn't the first thing that physicians think of when a breast-feeding mother complains of nipple pain.

If there are no signs of infection and no cracks or fissures on the nipples, consider this rare cause of nipple pain, especially if the woman has a history of Raynaud's syndrome, Sharon R. Wiener said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The pain from this vasospasm of the nipples while breast-feeding usually is bilateral, severe, and a spasm-like throb. The nipple usually turns very white but may be blue, purple, or red, said Ms. Wiener, a certified nurse-midwife at the university.

This problem has been misdiagnosed as a candidal infection. Among 12 women in a 2004 case report who ultimately were diagnosed with Raynaud's phenomenon of the nipples, 8 had been treated for candidiasis of the breast. Following them for 4 months and diligently taking detailed histories led to the correct diagnosis and treatment, she said.

A recent patient seen by Ms. Wiener said she had been diagnosed with Raynaud's syndrome about 5 years before her pregnancy. She complained of episodes in which her nipples would become cold and then go into spasms for many hours. “She was very concerned, appropriately, that she was going to have difficulty breast-feeding,” Ms. Wiener said.

Sending patients in whom you suspect this problem to a lactation consultant to identify poor latch can support the diagnosis. Alternatively, try applying a cold compress or ice to the nipple to see if it triggers the phenomenon.

It's important to prepare the woman for the effect this may have. “I've done this twice. In one case, I got a dramatic response,” she said. “I know this sounds horrible,” but it's preferable to prescribing treatment without a firm diagnosis.

The treatment of choice is the calcium channel blocker nifedipine, 5 mg b.i.d. for 2 weeks. “It's very quick acting” and a vasodilator, she said. “The handful that I have treated have responded very well and didn't need a repeat of the prescription. Why that is, I can't tell you.”

Raynaud's phenomenon of the nipples has been associated with factors that restrict the blood vessels, including rheumatologic diseases, endocrine diseases, autoimmune diseases, cigarettes, and caffeine.

Advise the patient to avoid exposure to cold, vasoconstricting medications, nicotine, and caffeine. In mild cases, warm compresses or warm showers may suffice as treatment. Topical nitroglycerine appears to be effective treatment in half of all cases.

SAN FRANCISCO – With only a handful of case reports in the medical literature, Raynaud's phenomenon of the nipples isn't the first thing that physicians think of when a breast-feeding mother complains of nipple pain.

If there are no signs of infection and no cracks or fissures on the nipples, consider this rare cause of nipple pain, especially if the woman has a history of Raynaud's syndrome, Sharon R. Wiener said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The pain from this vasospasm of the nipples while breast-feeding usually is bilateral, severe, and a spasm-like throb. The nipple usually turns very white but may be blue, purple, or red, said Ms. Wiener, a certified nurse-midwife at the university.

This problem has been misdiagnosed as a candidal infection. Among 12 women in a 2004 case report who ultimately were diagnosed with Raynaud's phenomenon of the nipples, 8 had been treated for candidiasis of the breast. Following them for 4 months and diligently taking detailed histories led to the correct diagnosis and treatment, she said.

A recent patient seen by Ms. Wiener said she had been diagnosed with Raynaud's syndrome about 5 years before her pregnancy. She complained of episodes in which her nipples would become cold and then go into spasms for many hours. “She was very concerned, appropriately, that she was going to have difficulty breast-feeding,” Ms. Wiener said.

Sending patients in whom you suspect this problem to a lactation consultant to identify poor latch can support the diagnosis. Alternatively, try applying a cold compress or ice to the nipple to see if it triggers the phenomenon.

It's important to prepare the woman for the effect this may have. “I've done this twice. In one case, I got a dramatic response,” she said. “I know this sounds horrible,” but it's preferable to prescribing treatment without a firm diagnosis.

The treatment of choice is the calcium channel blocker nifedipine, 5 mg b.i.d. for 2 weeks. “It's very quick acting” and a vasodilator, she said. “The handful that I have treated have responded very well and didn't need a repeat of the prescription. Why that is, I can't tell you.”

Raynaud's phenomenon of the nipples has been associated with factors that restrict the blood vessels, including rheumatologic diseases, endocrine diseases, autoimmune diseases, cigarettes, and caffeine.

Advise the patient to avoid exposure to cold, vasoconstricting medications, nicotine, and caffeine. In mild cases, warm compresses or warm showers may suffice as treatment. Topical nitroglycerine appears to be effective treatment in half of all cases.

LOS ANGELES — Two studies on psoriasis presented at the annual meeting of the Society for Investigative Dermatology show an association between the disease and increased mortality, and an increased risk for hypertension, heart disease, and diabetes.

In the first study, severe psoriasis was an independent predictor of death and increased patients' mortality risk by 50%, compared with normal control patients' risk, in a cohort study of more than 713,000 patients. No increased risk for death was seen in patients with mild psoriasis, however, compared with controls, Shanu Kohli Kurd said at the meeting. Ms. Kurd and her associates derived the 50% greater mortality risk for severe psoriasis after adjusting for the effects of age and gender.

Patients with severe psoriasis should receive comprehensive health assessments to try to reduce their risk of death, suggested Ms. Kurd, a clinical research fellow in dermatology at the University of Pennsylvania, Philadelphia, and her associates. Multiple comorbidities that have been associated with psoriasis may increase mortality, but even after adjusting for the effects of major comorbidities, the risk of death was 40% higher in patients with severe psoriasis, compared with controls.

Severe psoriasis was defined as disease requiring systemic therapy; mild psoriasis did not require such therapy. Data drawn from the General Practice Research Database, compiled in the United Kingdom from 1987 to 2002, accounted for 3,951 patients with severe psoriasis, 133,568 patients with mild psoriasis, and up to 5 control patients for each psoriasis patient, seen in the same practices in the same time periods.

The overall incidence of death was 12 patients per 1,000 patient-years in each of three other groups: the mild psoriasis group, the 560,358 controls for the mild psoriasis group, and the 15,075 controls for the severe psoriasis group. In patients with severe psoriasis, however, overall incidence of death was 21 patients per 1,000 patient-years, Ms. Kurd reported.

The relative risk of death was greatest for younger patients with severe psoriasis, and was not affected by gender. At age 35 years, patients with severe psoriasis were 2.5 times more likely to die, compared with control patients. By age 95 years, severe psoriasis incurred only a 10% increased relative risk of death. The increased relative risk of death persisted in analyses that excluded patients with concomitant psoriatic arthritis or rheumatologic disease.

The median age of death for patients with severe psoriasis was 74 years in males and 75 years in females, compared with 77 years in males and 81 years in females in the control group.

The study was funded in part by Centocor Inc., which markets infliximab.

The second study found increased rates of hypertension, heart disease, and diabetes in patients with psoriasis, compared with the general population, said Dr. Wayne P. Gulliver. He and his associate at a medical research organization in St. John's, Nfld., analyzed data from the province of Newfoundland and Labrador, where the population has a high prevalence of psoriasis linked to two genetic markers for psoriasis (HLA-Cw6 and tumor necrosis factor-α238).

Surveys of 100 patients with mild to moderate psoriasis and 100 patients with severe psoriasis—all older than age 50 years—found hypertension in 25% of the mild to moderate group and 21% of the severe psoriasis group, compared with 14% of the general population aged 30–64 years.

Heart disease had been diagnosed in 14% of the mild to moderate group, 10% of the severe psoriasis group, and 4% of the general population. Diabetes was present in 10% of the mild to moderate group, 12% of the severe psoriasis group, and 4% of the general population.

Records on 169 separate patients with psoriasis who had died showed that they lived 10 years fewer, on average, compared with the average life span in Canada. Cardiovascular or genitourinary disease was more likely to be the immediate cause of death in the psoriasis group, compared with death statistics in Newfoundland and Labrador.

In the psoriasis deaths, 44% were caused by cardiovascular disease, compared with 36% in the general population. Genitourinary disease was the cause of 3% of deaths in the psoriasis group and none in the general population. The study was funded in part by Merck Serono S.A., which markets efalizumab in Europe.

LOS ANGELES — Two studies on psoriasis presented at the annual meeting of the Society for Investigative Dermatology show an association between the disease and increased mortality, and an increased risk for hypertension, heart disease, and diabetes.

In the first study, severe psoriasis was an independent predictor of death and increased patients' mortality risk by 50%, compared with normal control patients' risk, in a cohort study of more than 713,000 patients. No increased risk for death was seen in patients with mild psoriasis, however, compared with controls, Shanu Kohli Kurd said at the meeting. Ms. Kurd and her associates derived the 50% greater mortality risk for severe psoriasis after adjusting for the effects of age and gender.

Patients with severe psoriasis should receive comprehensive health assessments to try to reduce their risk of death, suggested Ms. Kurd, a clinical research fellow in dermatology at the University of Pennsylvania, Philadelphia, and her associates. Multiple comorbidities that have been associated with psoriasis may increase mortality, but even after adjusting for the effects of major comorbidities, the risk of death was 40% higher in patients with severe psoriasis, compared with controls.

Severe psoriasis was defined as disease requiring systemic therapy; mild psoriasis did not require such therapy. Data drawn from the General Practice Research Database, compiled in the United Kingdom from 1987 to 2002, accounted for 3,951 patients with severe psoriasis, 133,568 patients with mild psoriasis, and up to 5 control patients for each psoriasis patient, seen in the same practices in the same time periods.

The overall incidence of death was 12 patients per 1,000 patient-years in each of three other groups: the mild psoriasis group, the 560,358 controls for the mild psoriasis group, and the 15,075 controls for the severe psoriasis group. In patients with severe psoriasis, however, overall incidence of death was 21 patients per 1,000 patient-years, Ms. Kurd reported.

The relative risk of death was greatest for younger patients with severe psoriasis, and was not affected by gender. At age 35 years, patients with severe psoriasis were 2.5 times more likely to die, compared with control patients. By age 95 years, severe psoriasis incurred only a 10% increased relative risk of death. The increased relative risk of death persisted in analyses that excluded patients with concomitant psoriatic arthritis or rheumatologic disease.

The median age of death for patients with severe psoriasis was 74 years in males and 75 years in females, compared with 77 years in males and 81 years in females in the control group.

The study was funded in part by Centocor Inc., which markets infliximab.

The second study found increased rates of hypertension, heart disease, and diabetes in patients with psoriasis, compared with the general population, said Dr. Wayne P. Gulliver. He and his associate at a medical research organization in St. John's, Nfld., analyzed data from the province of Newfoundland and Labrador, where the population has a high prevalence of psoriasis linked to two genetic markers for psoriasis (HLA-Cw6 and tumor necrosis factor-α238).

Surveys of 100 patients with mild to moderate psoriasis and 100 patients with severe psoriasis—all older than age 50 years—found hypertension in 25% of the mild to moderate group and 21% of the severe psoriasis group, compared with 14% of the general population aged 30–64 years.

Heart disease had been diagnosed in 14% of the mild to moderate group, 10% of the severe psoriasis group, and 4% of the general population. Diabetes was present in 10% of the mild to moderate group, 12% of the severe psoriasis group, and 4% of the general population.

Records on 169 separate patients with psoriasis who had died showed that they lived 10 years fewer, on average, compared with the average life span in Canada. Cardiovascular or genitourinary disease was more likely to be the immediate cause of death in the psoriasis group, compared with death statistics in Newfoundland and Labrador.

In the psoriasis deaths, 44% were caused by cardiovascular disease, compared with 36% in the general population. Genitourinary disease was the cause of 3% of deaths in the psoriasis group and none in the general population. The study was funded in part by Merck Serono S.A., which markets efalizumab in Europe.

LOS ANGELES — Two studies on psoriasis presented at the annual meeting of the Society for Investigative Dermatology show an association between the disease and increased mortality, and an increased risk for hypertension, heart disease, and diabetes.

In the first study, severe psoriasis was an independent predictor of death and increased patients' mortality risk by 50%, compared with normal control patients' risk, in a cohort study of more than 713,000 patients. No increased risk for death was seen in patients with mild psoriasis, however, compared with controls, Shanu Kohli Kurd said at the meeting. Ms. Kurd and her associates derived the 50% greater mortality risk for severe psoriasis after adjusting for the effects of age and gender.

Patients with severe psoriasis should receive comprehensive health assessments to try to reduce their risk of death, suggested Ms. Kurd, a clinical research fellow in dermatology at the University of Pennsylvania, Philadelphia, and her associates. Multiple comorbidities that have been associated with psoriasis may increase mortality, but even after adjusting for the effects of major comorbidities, the risk of death was 40% higher in patients with severe psoriasis, compared with controls.

Severe psoriasis was defined as disease requiring systemic therapy; mild psoriasis did not require such therapy. Data drawn from the General Practice Research Database, compiled in the United Kingdom from 1987 to 2002, accounted for 3,951 patients with severe psoriasis, 133,568 patients with mild psoriasis, and up to 5 control patients for each psoriasis patient, seen in the same practices in the same time periods.

The overall incidence of death was 12 patients per 1,000 patient-years in each of three other groups: the mild psoriasis group, the 560,358 controls for the mild psoriasis group, and the 15,075 controls for the severe psoriasis group. In patients with severe psoriasis, however, overall incidence of death was 21 patients per 1,000 patient-years, Ms. Kurd reported.

The relative risk of death was greatest for younger patients with severe psoriasis, and was not affected by gender. At age 35 years, patients with severe psoriasis were 2.5 times more likely to die, compared with control patients. By age 95 years, severe psoriasis incurred only a 10% increased relative risk of death. The increased relative risk of death persisted in analyses that excluded patients with concomitant psoriatic arthritis or rheumatologic disease.

The median age of death for patients with severe psoriasis was 74 years in males and 75 years in females, compared with 77 years in males and 81 years in females in the control group.

The study was funded in part by Centocor Inc., which markets infliximab.

The second study found increased rates of hypertension, heart disease, and diabetes in patients with psoriasis, compared with the general population, said Dr. Wayne P. Gulliver. He and his associate at a medical research organization in St. John's, Nfld., analyzed data from the province of Newfoundland and Labrador, where the population has a high prevalence of psoriasis linked to two genetic markers for psoriasis (HLA-Cw6 and tumor necrosis factor-α238).

Surveys of 100 patients with mild to moderate psoriasis and 100 patients with severe psoriasis—all older than age 50 years—found hypertension in 25% of the mild to moderate group and 21% of the severe psoriasis group, compared with 14% of the general population aged 30–64 years.

Heart disease had been diagnosed in 14% of the mild to moderate group, 10% of the severe psoriasis group, and 4% of the general population. Diabetes was present in 10% of the mild to moderate group, 12% of the severe psoriasis group, and 4% of the general population.

Records on 169 separate patients with psoriasis who had died showed that they lived 10 years fewer, on average, compared with the average life span in Canada. Cardiovascular or genitourinary disease was more likely to be the immediate cause of death in the psoriasis group, compared with death statistics in Newfoundland and Labrador.

In the psoriasis deaths, 44% were caused by cardiovascular disease, compared with 36% in the general population. Genitourinary disease was the cause of 3% of deaths in the psoriasis group and none in the general population. The study was funded in part by Merck Serono S.A., which markets efalizumab in Europe.

SAN FRANCISCO — Giving a rapid HIV test to a woman in labor can help prevent transmission to the newborn, but it's just the first step, Dr. Deborah Cohan said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

A recent study of labor and delivery suites in Illinois hospitals found that all had rapid HIV tests available but only a small percentage had adequate supplies of intravenous zidovudine (AZT) to give to mothers with positive results. “They were ready, but not quite ready,” said Dr. Cohan of the university and medical director of the Bay Area Perinatal AIDS Center.

The key to managing positive rapid HIV tests in labor is to be prepared, stressed Dr. Cohan. Providers of health care should have easy access to a written protocol and to HIV consultants. The Centers for Disease Control and Prevention's free Perinatal HIV Hotline can provide both and is reachable around the clock at 888-448-8765, she said.

Hospital pharmacies should stock adequate supplies of antiretrovirals for use on labor and delivery wards—not only AZT in both intravenous and liquid formulations so that both the mother and the baby can be treated, but also oral nevirapine in 200-mg doses. Patient education materials should be handy as well.

When a rapid HIV test reads positive, “Often people think, 'Oh, I need to tell the mother,' but you need to tell the pharmacy first,” Dr. Cohan advised. Alert the pharmacy about the need for antiretroviral therapy and think about the best mode of delivery for this patient. Alert the patient's nurse, and then tell the patient about the positive result and your recommendations for treatment and delivery.

All positive results should be treated as true positives because “there's no way to guess which might be false positives,” she noted. A 66% rate of transmission for an HIV-positive mother to the newborn can be reduced to less than a 10% risk with intrapartum and/or neonatal antiretroviral therapy. “It's probably less than a 5% risk” with therapy, she said.

Start maternal antiretroviral therapy, and alert your pediatric colleagues to decide on a neonatal regimen. “The Perinatal Hotline can help with this as well,” Dr. Cohan added.

To minimize risk of vertical transmission, reduce the duration of rupture of membranes or labor, avoid fetal scalp electrodes or fetal scalp sampling, avoid forceps and vacuum deliveries if possible, and don't do an episiotomy if you can avoid it to reduce the baby's exposure to maternal blood.

A cesarean section is indicated if the pregnancy is at 38 weeks' gestation with no ruptured membranes and no labor, and you can initiate maternal antiretroviral therapy before the C-section. Giving antiretrovirals 3–4 hours before C-section allows time for adequate drug levels in the mother and in umbilical cord blood.

If a woman comes in prior to 38 weeks to rule out labor, and she's not in labor and the membranes are intact but a rapid HIV test is positive, consider hospitalizing her to give intravenous antiretroviral therapy and then deliver by C-section at 38 weeks, Dr. Cohan suggested.

“We've had very good luck at getting the viral load substantially lower even after just a few days of antiretrovirals,” she said.

Six rapid HIV tests have been approved that give same-day results. All require confirmatory testing for diagnosis. The rapid tests are useful for women in labor who have had no prenatal care or who did not get an HIV test during their prenatal care. Numerous studies have shown rapid HIV testing in labor is cost-effective, Dr. Cohan said.

It's a good idea to evaluate the prenatal HIV testing rate at your institution, she suggested. At San Francisco General Hospital, where Dr. Cohan practices, “we thought we were doing fine” until a study showed they were testing only 52% of pregnant women for HIV.

The hospital lost its dedicated HIV test counselor because of budget cuts, “which felt like a huge tragedy at the time” but turned out to be beneficial, she said. Incorporating HIV testing into nurses' routine intake procedures boosted the prenatal testing rate to 93%.

SAN FRANCISCO — Giving a rapid HIV test to a woman in labor can help prevent transmission to the newborn, but it's just the first step, Dr. Deborah Cohan said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

A recent study of labor and delivery suites in Illinois hospitals found that all had rapid HIV tests available but only a small percentage had adequate supplies of intravenous zidovudine (AZT) to give to mothers with positive results. “They were ready, but not quite ready,” said Dr. Cohan of the university and medical director of the Bay Area Perinatal AIDS Center.

The key to managing positive rapid HIV tests in labor is to be prepared, stressed Dr. Cohan. Providers of health care should have easy access to a written protocol and to HIV consultants. The Centers for Disease Control and Prevention's free Perinatal HIV Hotline can provide both and is reachable around the clock at 888-448-8765, she said.

Hospital pharmacies should stock adequate supplies of antiretrovirals for use on labor and delivery wards—not only AZT in both intravenous and liquid formulations so that both the mother and the baby can be treated, but also oral nevirapine in 200-mg doses. Patient education materials should be handy as well.

When a rapid HIV test reads positive, “Often people think, 'Oh, I need to tell the mother,' but you need to tell the pharmacy first,” Dr. Cohan advised. Alert the pharmacy about the need for antiretroviral therapy and think about the best mode of delivery for this patient. Alert the patient's nurse, and then tell the patient about the positive result and your recommendations for treatment and delivery.

All positive results should be treated as true positives because “there's no way to guess which might be false positives,” she noted. A 66% rate of transmission for an HIV-positive mother to the newborn can be reduced to less than a 10% risk with intrapartum and/or neonatal antiretroviral therapy. “It's probably less than a 5% risk” with therapy, she said.

Start maternal antiretroviral therapy, and alert your pediatric colleagues to decide on a neonatal regimen. “The Perinatal Hotline can help with this as well,” Dr. Cohan added.

To minimize risk of vertical transmission, reduce the duration of rupture of membranes or labor, avoid fetal scalp electrodes or fetal scalp sampling, avoid forceps and vacuum deliveries if possible, and don't do an episiotomy if you can avoid it to reduce the baby's exposure to maternal blood.

A cesarean section is indicated if the pregnancy is at 38 weeks' gestation with no ruptured membranes and no labor, and you can initiate maternal antiretroviral therapy before the C-section. Giving antiretrovirals 3–4 hours before C-section allows time for adequate drug levels in the mother and in umbilical cord blood.

If a woman comes in prior to 38 weeks to rule out labor, and she's not in labor and the membranes are intact but a rapid HIV test is positive, consider hospitalizing her to give intravenous antiretroviral therapy and then deliver by C-section at 38 weeks, Dr. Cohan suggested.

“We've had very good luck at getting the viral load substantially lower even after just a few days of antiretrovirals,” she said.

Six rapid HIV tests have been approved that give same-day results. All require confirmatory testing for diagnosis. The rapid tests are useful for women in labor who have had no prenatal care or who did not get an HIV test during their prenatal care. Numerous studies have shown rapid HIV testing in labor is cost-effective, Dr. Cohan said.

It's a good idea to evaluate the prenatal HIV testing rate at your institution, she suggested. At San Francisco General Hospital, where Dr. Cohan practices, “we thought we were doing fine” until a study showed they were testing only 52% of pregnant women for HIV.

The hospital lost its dedicated HIV test counselor because of budget cuts, “which felt like a huge tragedy at the time” but turned out to be beneficial, she said. Incorporating HIV testing into nurses' routine intake procedures boosted the prenatal testing rate to 93%.

SAN FRANCISCO — Giving a rapid HIV test to a woman in labor can help prevent transmission to the newborn, but it's just the first step, Dr. Deborah Cohan said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

A recent study of labor and delivery suites in Illinois hospitals found that all had rapid HIV tests available but only a small percentage had adequate supplies of intravenous zidovudine (AZT) to give to mothers with positive results. “They were ready, but not quite ready,” said Dr. Cohan of the university and medical director of the Bay Area Perinatal AIDS Center.

The key to managing positive rapid HIV tests in labor is to be prepared, stressed Dr. Cohan. Providers of health care should have easy access to a written protocol and to HIV consultants. The Centers for Disease Control and Prevention's free Perinatal HIV Hotline can provide both and is reachable around the clock at 888-448-8765, she said.

Hospital pharmacies should stock adequate supplies of antiretrovirals for use on labor and delivery wards—not only AZT in both intravenous and liquid formulations so that both the mother and the baby can be treated, but also oral nevirapine in 200-mg doses. Patient education materials should be handy as well.

When a rapid HIV test reads positive, “Often people think, 'Oh, I need to tell the mother,' but you need to tell the pharmacy first,” Dr. Cohan advised. Alert the pharmacy about the need for antiretroviral therapy and think about the best mode of delivery for this patient. Alert the patient's nurse, and then tell the patient about the positive result and your recommendations for treatment and delivery.

All positive results should be treated as true positives because “there's no way to guess which might be false positives,” she noted. A 66% rate of transmission for an HIV-positive mother to the newborn can be reduced to less than a 10% risk with intrapartum and/or neonatal antiretroviral therapy. “It's probably less than a 5% risk” with therapy, she said.

Start maternal antiretroviral therapy, and alert your pediatric colleagues to decide on a neonatal regimen. “The Perinatal Hotline can help with this as well,” Dr. Cohan added.

To minimize risk of vertical transmission, reduce the duration of rupture of membranes or labor, avoid fetal scalp electrodes or fetal scalp sampling, avoid forceps and vacuum deliveries if possible, and don't do an episiotomy if you can avoid it to reduce the baby's exposure to maternal blood.

A cesarean section is indicated if the pregnancy is at 38 weeks' gestation with no ruptured membranes and no labor, and you can initiate maternal antiretroviral therapy before the C-section. Giving antiretrovirals 3–4 hours before C-section allows time for adequate drug levels in the mother and in umbilical cord blood.

If a woman comes in prior to 38 weeks to rule out labor, and she's not in labor and the membranes are intact but a rapid HIV test is positive, consider hospitalizing her to give intravenous antiretroviral therapy and then deliver by C-section at 38 weeks, Dr. Cohan suggested.

“We've had very good luck at getting the viral load substantially lower even after just a few days of antiretrovirals,” she said.

Six rapid HIV tests have been approved that give same-day results. All require confirmatory testing for diagnosis. The rapid tests are useful for women in labor who have had no prenatal care or who did not get an HIV test during their prenatal care. Numerous studies have shown rapid HIV testing in labor is cost-effective, Dr. Cohan said.

It's a good idea to evaluate the prenatal HIV testing rate at your institution, she suggested. At San Francisco General Hospital, where Dr. Cohan practices, “we thought we were doing fine” until a study showed they were testing only 52% of pregnant women for HIV.

The hospital lost its dedicated HIV test counselor because of budget cuts, “which felt like a huge tragedy at the time” but turned out to be beneficial, she said. Incorporating HIV testing into nurses' routine intake procedures boosted the prenatal testing rate to 93%.

The need to measure free thyroxine levels has diminished in the past 2 decades, but it's still a frequently ordered test and may be an important one for some patient populations, especially pregnant women.

There's no consensus, however, on how to measure free thyroxine (T₄). Efforts are underway to standardize free T₄ testing amid some controversy over whether this is scientifically feasible—or medically necessary.

Results of free T₄ assays vary according to which immunoassay is used and which laboratory processes it.

The available immunoassays “all have problems,” says Dr. James D. Faix, director of clinical chemistry and immunology at Stanford (Calif.) University. “If your goal is to accurately measure the free T₄, they probably all fail at that, but they may be clinically useful in terms of estimating the free T₄.”

Improvements in measuring thyroid stimulating hormone (TSH) in the 1980s and early 1990s expanded the usefulness of TSH tests from detection of elevated TSH levels to include detection of suppressed TSH levels associated with hyperthyroidism. For many clinicians, TSH became a single-test screen of thyroid function, and the use of free T₄ tests to detect or monitor hyperthyroidism declined.

The test frequently still gets ordered today to verify hyperthyroidism in a patient with low TSH results, even though its usefulness is questioned by some.

Primary care physicians may get along fine using just TSH tests, “but for a thyroid clinic, we routinely get both” tests, said Dr. Francis S. Greenspan, chief of the thyroid clinic at the University of California, San Francisco. “Most textbooks recommend this combination to evaluate patients who have thyroid disease.”

If a patient's TSH level is suppressed, for example, a treating clinician wants to know if that's due to a slight rise in circulating hormone or a significant rise, to help determine the need for aggressive therapy, he said.

Free T₄ immunoassays aren't reliable in subgroups of patients with disturbances in binding proteins, Dr. Carole Spencer noted.

“These free T₄ immunoassays will give spuriously misleading values in just those conditions where you'd like to have an accurate free T₄, in conditions like pregnancy and nonthyroidal illnesses” that affect some hospitalized patients, said Dr. Spencer, who is professor of medicine at the University of Southern California, Los Angeles.

A recent study by Dr. Jerald Nelson and associates at Loma Linda (Calif.) University reported that a free T₄ immunoassay measured total T₄, not free T₄ (Clin. Chem. 2007;53:911–5). Further studies found that the same is true of the other free T₄ immunoassays, he said.

Dr. Nelson's findings call to mind previous unsuccessful efforts by the American Thyroid Association to get the immunoassay manufacturers to call them free T₄ estimate tests, “to alert physicians that they weren't the real McCoy. They were merely estimate tests and could be erroneous at times,” Dr. Spencer said. “These new studies of Dr. Nelson shockingly show that these immunoassays are just glorified T₄ tests and can be very misleading.”

Dr. Faix cautioned that physicians should “continue to be skeptical” about the tests. “People who rely on free T₄ to confirm abnormal TSH results need to be aware that the problems with free T₄ testing have not been solved.”

Dr. Faix is a member of the Working Group on Standardization of Thyroid Function Tests commissioned by the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC). The working group is one of several launched by the IFCC to respond to a European Union directive to standardize all laboratory testing.

So far, it's unclear to the group whether it's feasible to set a gold standard for measuring free T₄ (see sidebar), he said. In addition, some U.S. physicians think that the European mandate for standardizing all tests is overreaching, and shouldn't include free T₄.

The effort could pay off, however, especially for pregnant women, Dr. Faix said.

Women with subclinical hypothyroidism develop clinical thyroid disease during pregnancy, creating risks for the fetus if they go without therapy. Because pregnancy increases levels of thyroid binding proteins, a free T₄ immunoassay to confirm an abnormal TSH level in pregnancy “is not as reliable because of these biological changes,” he said. “A better standardized method for ascertaining the thyroid function status during pregnancy would be helpful.”

Using the immunoassays, free T₄ readings go lower and lower as gestation progresses and vary by the test used. Up to 65% of pregnant women will have low free T₄ values by the third trimester according to one immunoassay, but only about 15% of pregnant women have that result using a different one, Dr. Spencer said.

The more accurate reference methods, however, show that a small increase in free T₄ levels in the first trimester of pregnancy subsequently returns to prepregnancy levels without the “grossly low” values seen with immunoassays.

The free T₄ immunoassays “basically shouldn't be used in pregnancy,” she said. A TSH test is an appropriate biosensor of endogenous free T₄ during pregnancy. “That's what we're trying to encourage physicians to use rather than these free T₄ immunoassays,” she added.

New studies show that these immunoassays are 'just glorified T₄ tests and can be very misleading.' Dr. Spencer

In pregnancy, a free T₄ immunoassay to confirm an abnormal TSH level is not as reliable. DR. FAIX

Measuring Free T₄ Is Challenging

Only a tiny fraction of the total T₄ that's present in the blood is free and not bound to plasma proteins—usually about 1 ng/DL. Accurately measuring this tiny percentage has proved challenging over the years.

Most available immunoassays use a one-step “labeled analogue” method or a one-step “labeled antibody” method, but some use a two-step “back-titration” method of measuring free T₄. “There continues to be evidence of significant discrepancies between these different approaches,” Dr. Faix said.

The IFCC working group proposes a reference method against which free T₄ tests should be compared—a new approach using direct equilibrium dialysis combined with tandem mass spectrometry. A pilot project that used frozen sera to compare this method with the three commercially available immunoassays found significant differences in results between the proposed reference method and the three immunoassays.

The reference method isn't practical for clinical laboratories, and operates very differently than the immunoassays, so it probably won't help improve the current assays, Dr. Spencer said. Standardizing a reference test for free T₄ may be a good academic exercise, but “I'm not sure how much of an impact it's going to have.”

The need to measure free thyroxine levels has diminished in the past 2 decades, but it's still a frequently ordered test and may be an important one for some patient populations, especially pregnant women.

There's no consensus, however, on how to measure free thyroxine (T₄). Efforts are underway to standardize free T₄ testing amid some controversy over whether this is scientifically feasible—or medically necessary.

Results of free T₄ assays vary according to which immunoassay is used and which laboratory processes it.

The available immunoassays “all have problems,” says Dr. James D. Faix, director of clinical chemistry and immunology at Stanford (Calif.) University. “If your goal is to accurately measure the free T₄, they probably all fail at that, but they may be clinically useful in terms of estimating the free T₄.”

Improvements in measuring thyroid stimulating hormone (TSH) in the 1980s and early 1990s expanded the usefulness of TSH tests from detection of elevated TSH levels to include detection of suppressed TSH levels associated with hyperthyroidism. For many clinicians, TSH became a single-test screen of thyroid function, and the use of free T₄ tests to detect or monitor hyperthyroidism declined.

The test frequently still gets ordered today to verify hyperthyroidism in a patient with low TSH results, even though its usefulness is questioned by some.

Primary care physicians may get along fine using just TSH tests, “but for a thyroid clinic, we routinely get both” tests, said Dr. Francis S. Greenspan, chief of the thyroid clinic at the University of California, San Francisco. “Most textbooks recommend this combination to evaluate patients who have thyroid disease.”

If a patient's TSH level is suppressed, for example, a treating clinician wants to know if that's due to a slight rise in circulating hormone or a significant rise, to help determine the need for aggressive therapy, he said.

Free T₄ immunoassays aren't reliable in subgroups of patients with disturbances in binding proteins, Dr. Carole Spencer noted.

“These free T₄ immunoassays will give spuriously misleading values in just those conditions where you'd like to have an accurate free T₄, in conditions like pregnancy and nonthyroidal illnesses” that affect some hospitalized patients, said Dr. Spencer, who is professor of medicine at the University of Southern California, Los Angeles.

A recent study by Dr. Jerald Nelson and associates at Loma Linda (Calif.) University reported that a free T₄ immunoassay measured total T₄, not free T₄ (Clin. Chem. 2007;53:911–5). Further studies found that the same is true of the other free T₄ immunoassays, he said.

Dr. Nelson's findings call to mind previous unsuccessful efforts by the American Thyroid Association to get the immunoassay manufacturers to call them free T₄ estimate tests, “to alert physicians that they weren't the real McCoy. They were merely estimate tests and could be erroneous at times,” Dr. Spencer said. “These new studies of Dr. Nelson shockingly show that these immunoassays are just glorified T₄ tests and can be very misleading.”

Dr. Faix cautioned that physicians should “continue to be skeptical” about the tests. “People who rely on free T₄ to confirm abnormal TSH results need to be aware that the problems with free T₄ testing have not been solved.”

Dr. Faix is a member of the Working Group on Standardization of Thyroid Function Tests commissioned by the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC). The working group is one of several launched by the IFCC to respond to a European Union directive to standardize all laboratory testing.

So far, it's unclear to the group whether it's feasible to set a gold standard for measuring free T₄ (see sidebar), he said. In addition, some U.S. physicians think that the European mandate for standardizing all tests is overreaching, and shouldn't include free T₄.

The effort could pay off, however, especially for pregnant women, Dr. Faix said.

Women with subclinical hypothyroidism develop clinical thyroid disease during pregnancy, creating risks for the fetus if they go without therapy. Because pregnancy increases levels of thyroid binding proteins, a free T₄ immunoassay to confirm an abnormal TSH level in pregnancy “is not as reliable because of these biological changes,” he said. “A better standardized method for ascertaining the thyroid function status during pregnancy would be helpful.”

Using the immunoassays, free T₄ readings go lower and lower as gestation progresses and vary by the test used. Up to 65% of pregnant women will have low free T₄ values by the third trimester according to one immunoassay, but only about 15% of pregnant women have that result using a different one, Dr. Spencer said.

The more accurate reference methods, however, show that a small increase in free T₄ levels in the first trimester of pregnancy subsequently returns to prepregnancy levels without the “grossly low” values seen with immunoassays.

The free T₄ immunoassays “basically shouldn't be used in pregnancy,” she said. A TSH test is an appropriate biosensor of endogenous free T₄ during pregnancy. “That's what we're trying to encourage physicians to use rather than these free T₄ immunoassays,” she added.

New studies show that these immunoassays are 'just glorified T₄ tests and can be very misleading.' Dr. Spencer

In pregnancy, a free T₄ immunoassay to confirm an abnormal TSH level is not as reliable. DR. FAIX

Measuring Free T₄ Is Challenging

Only a tiny fraction of the total T₄ that's present in the blood is free and not bound to plasma proteins—usually about 1 ng/DL. Accurately measuring this tiny percentage has proved challenging over the years.

Most available immunoassays use a one-step “labeled analogue” method or a one-step “labeled antibody” method, but some use a two-step “back-titration” method of measuring free T₄. “There continues to be evidence of significant discrepancies between these different approaches,” Dr. Faix said.

The IFCC working group proposes a reference method against which free T₄ tests should be compared—a new approach using direct equilibrium dialysis combined with tandem mass spectrometry. A pilot project that used frozen sera to compare this method with the three commercially available immunoassays found significant differences in results between the proposed reference method and the three immunoassays.

The reference method isn't practical for clinical laboratories, and operates very differently than the immunoassays, so it probably won't help improve the current assays, Dr. Spencer said. Standardizing a reference test for free T₄ may be a good academic exercise, but “I'm not sure how much of an impact it's going to have.”

The need to measure free thyroxine levels has diminished in the past 2 decades, but it's still a frequently ordered test and may be an important one for some patient populations, especially pregnant women.

There's no consensus, however, on how to measure free thyroxine (T₄). Efforts are underway to standardize free T₄ testing amid some controversy over whether this is scientifically feasible—or medically necessary.

Results of free T₄ assays vary according to which immunoassay is used and which laboratory processes it.

The available immunoassays “all have problems,” says Dr. James D. Faix, director of clinical chemistry and immunology at Stanford (Calif.) University. “If your goal is to accurately measure the free T₄, they probably all fail at that, but they may be clinically useful in terms of estimating the free T₄.”

Improvements in measuring thyroid stimulating hormone (TSH) in the 1980s and early 1990s expanded the usefulness of TSH tests from detection of elevated TSH levels to include detection of suppressed TSH levels associated with hyperthyroidism. For many clinicians, TSH became a single-test screen of thyroid function, and the use of free T₄ tests to detect or monitor hyperthyroidism declined.

The test frequently still gets ordered today to verify hyperthyroidism in a patient with low TSH results, even though its usefulness is questioned by some.

Primary care physicians may get along fine using just TSH tests, “but for a thyroid clinic, we routinely get both” tests, said Dr. Francis S. Greenspan, chief of the thyroid clinic at the University of California, San Francisco. “Most textbooks recommend this combination to evaluate patients who have thyroid disease.”

If a patient's TSH level is suppressed, for example, a treating clinician wants to know if that's due to a slight rise in circulating hormone or a significant rise, to help determine the need for aggressive therapy, he said.

Free T₄ immunoassays aren't reliable in subgroups of patients with disturbances in binding proteins, Dr. Carole Spencer noted.

“These free T₄ immunoassays will give spuriously misleading values in just those conditions where you'd like to have an accurate free T₄, in conditions like pregnancy and nonthyroidal illnesses” that affect some hospitalized patients, said Dr. Spencer, who is professor of medicine at the University of Southern California, Los Angeles.

A recent study by Dr. Jerald Nelson and associates at Loma Linda (Calif.) University reported that a free T₄ immunoassay measured total T₄, not free T₄ (Clin. Chem. 2007;53:911–5). Further studies found that the same is true of the other free T₄ immunoassays, he said.

Dr. Nelson's findings call to mind previous unsuccessful efforts by the American Thyroid Association to get the immunoassay manufacturers to call them free T₄ estimate tests, “to alert physicians that they weren't the real McCoy. They were merely estimate tests and could be erroneous at times,” Dr. Spencer said. “These new studies of Dr. Nelson shockingly show that these immunoassays are just glorified T₄ tests and can be very misleading.”

Dr. Faix cautioned that physicians should “continue to be skeptical” about the tests. “People who rely on free T₄ to confirm abnormal TSH results need to be aware that the problems with free T₄ testing have not been solved.”

Dr. Faix is a member of the Working Group on Standardization of Thyroid Function Tests commissioned by the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC). The working group is one of several launched by the IFCC to respond to a European Union directive to standardize all laboratory testing.

So far, it's unclear to the group whether it's feasible to set a gold standard for measuring free T₄ (see sidebar), he said. In addition, some U.S. physicians think that the European mandate for standardizing all tests is overreaching, and shouldn't include free T₄.

The effort could pay off, however, especially for pregnant women, Dr. Faix said.

Women with subclinical hypothyroidism develop clinical thyroid disease during pregnancy, creating risks for the fetus if they go without therapy. Because pregnancy increases levels of thyroid binding proteins, a free T₄ immunoassay to confirm an abnormal TSH level in pregnancy “is not as reliable because of these biological changes,” he said. “A better standardized method for ascertaining the thyroid function status during pregnancy would be helpful.”

Using the immunoassays, free T₄ readings go lower and lower as gestation progresses and vary by the test used. Up to 65% of pregnant women will have low free T₄ values by the third trimester according to one immunoassay, but only about 15% of pregnant women have that result using a different one, Dr. Spencer said.

The more accurate reference methods, however, show that a small increase in free T₄ levels in the first trimester of pregnancy subsequently returns to prepregnancy levels without the “grossly low” values seen with immunoassays.

The free T₄ immunoassays “basically shouldn't be used in pregnancy,” she said. A TSH test is an appropriate biosensor of endogenous free T₄ during pregnancy. “That's what we're trying to encourage physicians to use rather than these free T₄ immunoassays,” she added.

New studies show that these immunoassays are 'just glorified T₄ tests and can be very misleading.' Dr. Spencer

In pregnancy, a free T₄ immunoassay to confirm an abnormal TSH level is not as reliable. DR. FAIX

Measuring Free T₄ Is Challenging

Only a tiny fraction of the total T₄ that's present in the blood is free and not bound to plasma proteins—usually about 1 ng/DL. Accurately measuring this tiny percentage has proved challenging over the years.

Most available immunoassays use a one-step “labeled analogue” method or a one-step “labeled antibody” method, but some use a two-step “back-titration” method of measuring free T₄. “There continues to be evidence of significant discrepancies between these different approaches,” Dr. Faix said.

The IFCC working group proposes a reference method against which free T₄ tests should be compared—a new approach using direct equilibrium dialysis combined with tandem mass spectrometry. A pilot project that used frozen sera to compare this method with the three commercially available immunoassays found significant differences in results between the proposed reference method and the three immunoassays.

The reference method isn't practical for clinical laboratories, and operates very differently than the immunoassays, so it probably won't help improve the current assays, Dr. Spencer said. Standardizing a reference test for free T₄ may be a good academic exercise, but “I'm not sure how much of an impact it's going to have.”

SAN FRANCISCO – Giving a rapid HIV test to a woman in labor can help prevent transmission to the newborn, but it's just the first step, Dr. Deborah Cohan said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

A recent study of labor-and-delivery suites in Illinois hospitals found that all had rapid HIV tests available but only a small percentage had adequate supplies of intravenous zidovudine (AZT) to give to mothers with positive results. “They were ready, but not quite ready,” said Dr. Cohan.

The key to managing positive rapid HIV tests in labor is to be prepared, she stressed. Health care providers should have easy access to a written protocol and to HIV consultants. The Centers for Disease Control and Prevention's free Perinatal HIV Hotline can provide both and is reachable around the clock at 888-448-8765, said Dr. Cohan, medical director of the Bay Area Perinatal AIDS Center.

Hospital pharmacies should stock adequate supplies of antiretrovirals for use on labor-and-delivery wards–not only AZT in both intravenous and liquid formulations so that both the mother and the baby can be treated, but also oral nevirapine in 200-mg doses. Patient education materials should be handy as well.

When a rapid HIV test reads positive, “Often people think, 'Oh, I need to tell the mother,' but you need to tell the pharmacy first,” Dr. Cohan advised. Alert the pharmacy about the need for antiretroviral therapy and think about the best mode of delivery for this patient. Alert the patient's nurse, and then tell the patient about the positive result and your recommendations for treatment and delivery.

All positive results should be treated as true positives because “there's no way to guess which might be false positives,” she noted. A 66% rate of transmission for an HIV-positive mother to the newborn can be reduced to less than a 10% risk with intrapartum and/or neonatal antiretroviral therapy. “It's probably less than a 5% risk” with therapy, she said. Start maternal antiretroviral therapy, and alert your pediatric colleagues to decide on a neonatal regimen. “The Perinatal Hotline can help with this as well,” Dr. Cohan added.

To minimize risk of vertical transmission, reduce the duration of rupture of membranes or labor, avoid fetal scalp electrodes or fetal scalp sampling, avoid forceps and vacuum deliveries if possible, and avoid an episiotomy if you can, to reduce the baby's exposure to maternal blood.

A cesarean section is indicated if the pregnancy is at 38 weeks' gestation with no ruptured membranes and no labor, and you can initiate maternal antiretroviral therapy before the procedure. Giving antiretrovirals 3-4 hours before C-section allows time for adequate drug levels in the mother and in umbilical cord blood.

If a woman comes in prior to 38 weeks to rule out labor, and she's not in labor and the membranes are intact but a rapid HIV test is positive, consider hospitalizing her to give intravenous antiretroviral therapy and then deliver by C-section at 38 weeks, Dr. Cohan suggested.

“We've had very good luck at getting the viral load substantially lower even after just a few days of antiretrovirals,” she said.

Six rapid HIV tests have been approved that give same-day results. All require confirmatory testing for diagnosis. The rapid tests are useful for women in labor who have had no prenatal care or who did not get an HIV test during their prenatal care. Numerous studies have shown rapid HIV testing in labor is cost-effective, Dr. Cohan said.

It's a good idea to evaluate the prenatal HIV testing rate at your institution, she suggested. At San Francisco General Hospital, where Dr. Cohan practices, “we thought we were doing fine” until a study showed they were testing only 52% of pregnant women for HIV.

The hospital lost its dedicated HIV test counselor because of budget cuts, but incorporating HIV testing into nurses' routine intake procedures actually boosted the prenatal testing rate to 93%.

SAN FRANCISCO – Giving a rapid HIV test to a woman in labor can help prevent transmission to the newborn, but it's just the first step, Dr. Deborah Cohan said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

A recent study of labor-and-delivery suites in Illinois hospitals found that all had rapid HIV tests available but only a small percentage had adequate supplies of intravenous zidovudine (AZT) to give to mothers with positive results. “They were ready, but not quite ready,” said Dr. Cohan.

The key to managing positive rapid HIV tests in labor is to be prepared, she stressed. Health care providers should have easy access to a written protocol and to HIV consultants. The Centers for Disease Control and Prevention's free Perinatal HIV Hotline can provide both and is reachable around the clock at 888-448-8765, said Dr. Cohan, medical director of the Bay Area Perinatal AIDS Center.

Hospital pharmacies should stock adequate supplies of antiretrovirals for use on labor-and-delivery wards–not only AZT in both intravenous and liquid formulations so that both the mother and the baby can be treated, but also oral nevirapine in 200-mg doses. Patient education materials should be handy as well.

When a rapid HIV test reads positive, “Often people think, 'Oh, I need to tell the mother,' but you need to tell the pharmacy first,” Dr. Cohan advised. Alert the pharmacy about the need for antiretroviral therapy and think about the best mode of delivery for this patient. Alert the patient's nurse, and then tell the patient about the positive result and your recommendations for treatment and delivery.

All positive results should be treated as true positives because “there's no way to guess which might be false positives,” she noted. A 66% rate of transmission for an HIV-positive mother to the newborn can be reduced to less than a 10% risk with intrapartum and/or neonatal antiretroviral therapy. “It's probably less than a 5% risk” with therapy, she said. Start maternal antiretroviral therapy, and alert your pediatric colleagues to decide on a neonatal regimen. “The Perinatal Hotline can help with this as well,” Dr. Cohan added.

To minimize risk of vertical transmission, reduce the duration of rupture of membranes or labor, avoid fetal scalp electrodes or fetal scalp sampling, avoid forceps and vacuum deliveries if possible, and avoid an episiotomy if you can, to reduce the baby's exposure to maternal blood.

A cesarean section is indicated if the pregnancy is at 38 weeks' gestation with no ruptured membranes and no labor, and you can initiate maternal antiretroviral therapy before the procedure. Giving antiretrovirals 3-4 hours before C-section allows time for adequate drug levels in the mother and in umbilical cord blood.

If a woman comes in prior to 38 weeks to rule out labor, and she's not in labor and the membranes are intact but a rapid HIV test is positive, consider hospitalizing her to give intravenous antiretroviral therapy and then deliver by C-section at 38 weeks, Dr. Cohan suggested.

“We've had very good luck at getting the viral load substantially lower even after just a few days of antiretrovirals,” she said.

Six rapid HIV tests have been approved that give same-day results. All require confirmatory testing for diagnosis. The rapid tests are useful for women in labor who have had no prenatal care or who did not get an HIV test during their prenatal care. Numerous studies have shown rapid HIV testing in labor is cost-effective, Dr. Cohan said.

It's a good idea to evaluate the prenatal HIV testing rate at your institution, she suggested. At San Francisco General Hospital, where Dr. Cohan practices, “we thought we were doing fine” until a study showed they were testing only 52% of pregnant women for HIV.

The hospital lost its dedicated HIV test counselor because of budget cuts, but incorporating HIV testing into nurses' routine intake procedures actually boosted the prenatal testing rate to 93%.

SAN FRANCISCO – Giving a rapid HIV test to a woman in labor can help prevent transmission to the newborn, but it's just the first step, Dr. Deborah Cohan said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

A recent study of labor-and-delivery suites in Illinois hospitals found that all had rapid HIV tests available but only a small percentage had adequate supplies of intravenous zidovudine (AZT) to give to mothers with positive results. “They were ready, but not quite ready,” said Dr. Cohan.

The key to managing positive rapid HIV tests in labor is to be prepared, she stressed. Health care providers should have easy access to a written protocol and to HIV consultants. The Centers for Disease Control and Prevention's free Perinatal HIV Hotline can provide both and is reachable around the clock at 888-448-8765, said Dr. Cohan, medical director of the Bay Area Perinatal AIDS Center.

Hospital pharmacies should stock adequate supplies of antiretrovirals for use on labor-and-delivery wards–not only AZT in both intravenous and liquid formulations so that both the mother and the baby can be treated, but also oral nevirapine in 200-mg doses. Patient education materials should be handy as well.

When a rapid HIV test reads positive, “Often people think, 'Oh, I need to tell the mother,' but you need to tell the pharmacy first,” Dr. Cohan advised. Alert the pharmacy about the need for antiretroviral therapy and think about the best mode of delivery for this patient. Alert the patient's nurse, and then tell the patient about the positive result and your recommendations for treatment and delivery.

All positive results should be treated as true positives because “there's no way to guess which might be false positives,” she noted. A 66% rate of transmission for an HIV-positive mother to the newborn can be reduced to less than a 10% risk with intrapartum and/or neonatal antiretroviral therapy. “It's probably less than a 5% risk” with therapy, she said. Start maternal antiretroviral therapy, and alert your pediatric colleagues to decide on a neonatal regimen. “The Perinatal Hotline can help with this as well,” Dr. Cohan added.

To minimize risk of vertical transmission, reduce the duration of rupture of membranes or labor, avoid fetal scalp electrodes or fetal scalp sampling, avoid forceps and vacuum deliveries if possible, and avoid an episiotomy if you can, to reduce the baby's exposure to maternal blood.

A cesarean section is indicated if the pregnancy is at 38 weeks' gestation with no ruptured membranes and no labor, and you can initiate maternal antiretroviral therapy before the procedure. Giving antiretrovirals 3-4 hours before C-section allows time for adequate drug levels in the mother and in umbilical cord blood.

If a woman comes in prior to 38 weeks to rule out labor, and she's not in labor and the membranes are intact but a rapid HIV test is positive, consider hospitalizing her to give intravenous antiretroviral therapy and then deliver by C-section at 38 weeks, Dr. Cohan suggested.

“We've had very good luck at getting the viral load substantially lower even after just a few days of antiretrovirals,” she said.

Six rapid HIV tests have been approved that give same-day results. All require confirmatory testing for diagnosis. The rapid tests are useful for women in labor who have had no prenatal care or who did not get an HIV test during their prenatal care. Numerous studies have shown rapid HIV testing in labor is cost-effective, Dr. Cohan said.

It's a good idea to evaluate the prenatal HIV testing rate at your institution, she suggested. At San Francisco General Hospital, where Dr. Cohan practices, “we thought we were doing fine” until a study showed they were testing only 52% of pregnant women for HIV.

The hospital lost its dedicated HIV test counselor because of budget cuts, but incorporating HIV testing into nurses' routine intake procedures actually boosted the prenatal testing rate to 93%.

LOS ANGELES — A review of data on 281 psoriasis patients found that those who began smoking after psoriasis onset developed psoriatic arthritis later than did nonsmokers or people who smoked before their psoriasis appeared.

Previous data suggest that psoriatic arthritis typically occurs approximately 10 years after the onset of psoriasis. In this study, the interval between diagnoses of psoriasis and psoriatic arthritis was 13 years in nonsmokers, 8 years in people who smoked before developing psoriasis, and 23 years in people who began smoking after their psoriasis diagnosis, Dr. Tina Rakkhit said.

That “dramatically longer time” to the development of joint disease in people who take up smoking after developing psoriasis “is consistent with the notion that the biology of psoriasis can be modulated by smoking activity,” she said at the annual meeting of the Society for Investigational Dermatology.

Of course, that doesn't mean that physicians should advocate smoking in patients with psoriasis.

The health hazards of smoking are well known. If the physiologic underpinnings of these findings can be elucidated, however, this may lead to preventive therapies for psoriatic arthritis without the toxicities of smoking, said Dr. Rakkhit, a dermatologic research fellow at the University of Utah, Salt Lake City.

“Our data support the concept that agents without such detrimental effects could be used to delay and possibly prevent the onset of this significant comorbid state,” Dr. Rakkhit and her associates concluded.

The data came from the 812-person Utah Psoriasis Initiative, a prospective, phenotypic database.

The study excluded patients who developed psoriatic arthritis before being diagnosed with psoriasis, which generally accounts for 15% of people with the joint disease.

Because the Utah Psoriasis Initiative does not collect data on measures of joint disease, the investigators could not tell whether the delayed psoriatic arthritis was less or more severe than earlier-appearing joint disease.

Compared with the general population of Utah, 13% of whom smoke, 36% of the study cohort smoked at the time of their psoriasis diagnosis. In the United States, 20% of the population smokes.

Psoriatic arthritis appeared in nonsmokers at an average age of 26 years and in smokers at age 29 in the current study. Patients were diagnosed with psoriatic arthritis at an average age of 36 if they never smoked and at age 42 if they ever smoked.

The findings add to the intriguing medical literature on the relationships between smoking and inflammatory diseases. Other studies suggest that heavier smokers develop rheumatoid arthritis later, Dr. Rakkhit noted. Crohn's disease appears earlier in smokers, and patients who undergo surgical correction for Crohn's disease are more likely to have recurrent disease. The opposite is seen with ulcerative colitis, which mainly is a disease of nonsmokers and former smokers. Among patients undergoing immunosuppressive therapies, a shorter duration is more likely to suffice in smokers than in nonsmokers.

LOS ANGELES — A review of data on 281 psoriasis patients found that those who began smoking after psoriasis onset developed psoriatic arthritis later than did nonsmokers or people who smoked before their psoriasis appeared.

Previous data suggest that psoriatic arthritis typically occurs approximately 10 years after the onset of psoriasis. In this study, the interval between diagnoses of psoriasis and psoriatic arthritis was 13 years in nonsmokers, 8 years in people who smoked before developing psoriasis, and 23 years in people who began smoking after their psoriasis diagnosis, Dr. Tina Rakkhit said.

That “dramatically longer time” to the development of joint disease in people who take up smoking after developing psoriasis “is consistent with the notion that the biology of psoriasis can be modulated by smoking activity,” she said at the annual meeting of the Society for Investigational Dermatology.

Of course, that doesn't mean that physicians should advocate smoking in patients with psoriasis.

The health hazards of smoking are well known. If the physiologic underpinnings of these findings can be elucidated, however, this may lead to preventive therapies for psoriatic arthritis without the toxicities of smoking, said Dr. Rakkhit, a dermatologic research fellow at the University of Utah, Salt Lake City.

“Our data support the concept that agents without such detrimental effects could be used to delay and possibly prevent the onset of this significant comorbid state,” Dr. Rakkhit and her associates concluded.

The data came from the 812-person Utah Psoriasis Initiative, a prospective, phenotypic database.

The study excluded patients who developed psoriatic arthritis before being diagnosed with psoriasis, which generally accounts for 15% of people with the joint disease.

Because the Utah Psoriasis Initiative does not collect data on measures of joint disease, the investigators could not tell whether the delayed psoriatic arthritis was less or more severe than earlier-appearing joint disease.

Compared with the general population of Utah, 13% of whom smoke, 36% of the study cohort smoked at the time of their psoriasis diagnosis. In the United States, 20% of the population smokes.

Psoriatic arthritis appeared in nonsmokers at an average age of 26 years and in smokers at age 29 in the current study. Patients were diagnosed with psoriatic arthritis at an average age of 36 if they never smoked and at age 42 if they ever smoked.

The findings add to the intriguing medical literature on the relationships between smoking and inflammatory diseases. Other studies suggest that heavier smokers develop rheumatoid arthritis later, Dr. Rakkhit noted. Crohn's disease appears earlier in smokers, and patients who undergo surgical correction for Crohn's disease are more likely to have recurrent disease. The opposite is seen with ulcerative colitis, which mainly is a disease of nonsmokers and former smokers. Among patients undergoing immunosuppressive therapies, a shorter duration is more likely to suffice in smokers than in nonsmokers.

LOS ANGELES — A review of data on 281 psoriasis patients found that those who began smoking after psoriasis onset developed psoriatic arthritis later than did nonsmokers or people who smoked before their psoriasis appeared.

Previous data suggest that psoriatic arthritis typically occurs approximately 10 years after the onset of psoriasis. In this study, the interval between diagnoses of psoriasis and psoriatic arthritis was 13 years in nonsmokers, 8 years in people who smoked before developing psoriasis, and 23 years in people who began smoking after their psoriasis diagnosis, Dr. Tina Rakkhit said.

That “dramatically longer time” to the development of joint disease in people who take up smoking after developing psoriasis “is consistent with the notion that the biology of psoriasis can be modulated by smoking activity,” she said at the annual meeting of the Society for Investigational Dermatology.

Of course, that doesn't mean that physicians should advocate smoking in patients with psoriasis.

The health hazards of smoking are well known. If the physiologic underpinnings of these findings can be elucidated, however, this may lead to preventive therapies for psoriatic arthritis without the toxicities of smoking, said Dr. Rakkhit, a dermatologic research fellow at the University of Utah, Salt Lake City.

“Our data support the concept that agents without such detrimental effects could be used to delay and possibly prevent the onset of this significant comorbid state,” Dr. Rakkhit and her associates concluded.

The data came from the 812-person Utah Psoriasis Initiative, a prospective, phenotypic database.

The study excluded patients who developed psoriatic arthritis before being diagnosed with psoriasis, which generally accounts for 15% of people with the joint disease.

Because the Utah Psoriasis Initiative does not collect data on measures of joint disease, the investigators could not tell whether the delayed psoriatic arthritis was less or more severe than earlier-appearing joint disease.

Compared with the general population of Utah, 13% of whom smoke, 36% of the study cohort smoked at the time of their psoriasis diagnosis. In the United States, 20% of the population smokes.

Psoriatic arthritis appeared in nonsmokers at an average age of 26 years and in smokers at age 29 in the current study. Patients were diagnosed with psoriatic arthritis at an average age of 36 if they never smoked and at age 42 if they ever smoked.

The findings add to the intriguing medical literature on the relationships between smoking and inflammatory diseases. Other studies suggest that heavier smokers develop rheumatoid arthritis later, Dr. Rakkhit noted. Crohn's disease appears earlier in smokers, and patients who undergo surgical correction for Crohn's disease are more likely to have recurrent disease. The opposite is seen with ulcerative colitis, which mainly is a disease of nonsmokers and former smokers. Among patients undergoing immunosuppressive therapies, a shorter duration is more likely to suffice in smokers than in nonsmokers.