Sherry Boschert

SEATTLE — Blood tests on 507 patients seen in emergency departments for chest pain found resistance to aspirin in 20% of those with a history of heart failure and in 12% of those without heart failure, Dr. Lori B. Daniels reported in a poster presentation at the annual meeting of the Heart Failure Society of America.

“Physicians should be aware of the high rate of aspirin nonresponsiveness in patients with heart failure, because they may be susceptible to thrombotic events” even if treated with aspirin, and they may need other antithrombotic therapy, said Dr. Daniels of the University of California, San Diego, and her associates.

Aspirin prevents MI, stroke, or other vascular events by causing platelet dysfunction so that platelets do not aggregate. It irreversibly inhibits platelet cyclooxygenase, a key enzyme in prostaglandin synthesis, so platelets lose the capacity to synthesize thromboxane A2, an inducer of platelet aggregation with vasoconstrictive properties.

Between 8% and 18% of patients treated with aspirin, however, develop recurrent vascular events within 2 years, a phenomenon described as aspirin resistance “or perhaps, more accurately, as aspirin nonresponsiveness,” the investigators wrote.

They took blood samples from patients with suspected acute coronary syndromes seen at five medical centers. All were on outpatient aspirin therapy or were given an aspirin when they arrived at the emergency department. The 25% of patients with a history of heart failure were older than those without heart failure (62 vs. 58 years) and were more likely to be taking aspirin as an outpatient (81% vs. 60%), but the two groups did not differ by sex or body mass index.

Blood samples were tested using the Ultegra Rapid Platelet Function Assay on a Verify Now testing device. The Ultegra assay is a turbidimetric-based optical detection system that measures platelet-induced aggregation as an increase in light transmittance. Aspirin nonresponsiveness was defined as an “aspirin reaction unit” value of at least 550. Results showed a mean of 479 aspirin reaction units in patients with a history of heart failure, compared with 458 units in patients without heart failure. None of the investigators are associated with Accumetrix, which makes the Verify Now device.

Heart failure patients were more likely to have a history of hypertension (88% vs. 71%), coronary artery disease (65% vs. 32%), MI (55% vs. 23%), diabetes (49% vs. 28%), chronic renal insufficiency (28% vs. 6%), and tobacco use (63% vs. 51%), compared with non-heart failure patients. Those with heart failure averaged 4 years of aspirin use, compared with 2 years in patients without.

Patients withheart failure who do not respond to aspirin may be susceptible to thrombotic events. DR. DANIELS

SEATTLE — Blood tests on 507 patients seen in emergency departments for chest pain found resistance to aspirin in 20% of those with a history of heart failure and in 12% of those without heart failure, Dr. Lori B. Daniels reported in a poster presentation at the annual meeting of the Heart Failure Society of America.

“Physicians should be aware of the high rate of aspirin nonresponsiveness in patients with heart failure, because they may be susceptible to thrombotic events” even if treated with aspirin, and they may need other antithrombotic therapy, said Dr. Daniels of the University of California, San Diego, and her associates.

Aspirin prevents MI, stroke, or other vascular events by causing platelet dysfunction so that platelets do not aggregate. It irreversibly inhibits platelet cyclooxygenase, a key enzyme in prostaglandin synthesis, so platelets lose the capacity to synthesize thromboxane A2, an inducer of platelet aggregation with vasoconstrictive properties.

Between 8% and 18% of patients treated with aspirin, however, develop recurrent vascular events within 2 years, a phenomenon described as aspirin resistance “or perhaps, more accurately, as aspirin nonresponsiveness,” the investigators wrote.

They took blood samples from patients with suspected acute coronary syndromes seen at five medical centers. All were on outpatient aspirin therapy or were given an aspirin when they arrived at the emergency department. The 25% of patients with a history of heart failure were older than those without heart failure (62 vs. 58 years) and were more likely to be taking aspirin as an outpatient (81% vs. 60%), but the two groups did not differ by sex or body mass index.

Blood samples were tested using the Ultegra Rapid Platelet Function Assay on a Verify Now testing device. The Ultegra assay is a turbidimetric-based optical detection system that measures platelet-induced aggregation as an increase in light transmittance. Aspirin nonresponsiveness was defined as an “aspirin reaction unit” value of at least 550. Results showed a mean of 479 aspirin reaction units in patients with a history of heart failure, compared with 458 units in patients without heart failure. None of the investigators are associated with Accumetrix, which makes the Verify Now device.

Heart failure patients were more likely to have a history of hypertension (88% vs. 71%), coronary artery disease (65% vs. 32%), MI (55% vs. 23%), diabetes (49% vs. 28%), chronic renal insufficiency (28% vs. 6%), and tobacco use (63% vs. 51%), compared with non-heart failure patients. Those with heart failure averaged 4 years of aspirin use, compared with 2 years in patients without.

Patients withheart failure who do not respond to aspirin may be susceptible to thrombotic events. DR. DANIELS

SEATTLE — Blood tests on 507 patients seen in emergency departments for chest pain found resistance to aspirin in 20% of those with a history of heart failure and in 12% of those without heart failure, Dr. Lori B. Daniels reported in a poster presentation at the annual meeting of the Heart Failure Society of America.

“Physicians should be aware of the high rate of aspirin nonresponsiveness in patients with heart failure, because they may be susceptible to thrombotic events” even if treated with aspirin, and they may need other antithrombotic therapy, said Dr. Daniels of the University of California, San Diego, and her associates.

Aspirin prevents MI, stroke, or other vascular events by causing platelet dysfunction so that platelets do not aggregate. It irreversibly inhibits platelet cyclooxygenase, a key enzyme in prostaglandin synthesis, so platelets lose the capacity to synthesize thromboxane A2, an inducer of platelet aggregation with vasoconstrictive properties.

Between 8% and 18% of patients treated with aspirin, however, develop recurrent vascular events within 2 years, a phenomenon described as aspirin resistance “or perhaps, more accurately, as aspirin nonresponsiveness,” the investigators wrote.

They took blood samples from patients with suspected acute coronary syndromes seen at five medical centers. All were on outpatient aspirin therapy or were given an aspirin when they arrived at the emergency department. The 25% of patients with a history of heart failure were older than those without heart failure (62 vs. 58 years) and were more likely to be taking aspirin as an outpatient (81% vs. 60%), but the two groups did not differ by sex or body mass index.

Blood samples were tested using the Ultegra Rapid Platelet Function Assay on a Verify Now testing device. The Ultegra assay is a turbidimetric-based optical detection system that measures platelet-induced aggregation as an increase in light transmittance. Aspirin nonresponsiveness was defined as an “aspirin reaction unit” value of at least 550. Results showed a mean of 479 aspirin reaction units in patients with a history of heart failure, compared with 458 units in patients without heart failure. None of the investigators are associated with Accumetrix, which makes the Verify Now device.

Heart failure patients were more likely to have a history of hypertension (88% vs. 71%), coronary artery disease (65% vs. 32%), MI (55% vs. 23%), diabetes (49% vs. 28%), chronic renal insufficiency (28% vs. 6%), and tobacco use (63% vs. 51%), compared with non-heart failure patients. Those with heart failure averaged 4 years of aspirin use, compared with 2 years in patients without.

Patients withheart failure who do not respond to aspirin may be susceptible to thrombotic events. DR. DANIELS

SEATTLE — A 12-week study of sildenafil therapy in patients with heart failure due to left ventricular dysfunction and secondary pulmonary hypertension is continuing after an interim analysis found neither therapeutic futility nor overwhelming improvements in exercise capacity, Dr. Gregory Lewis said.

Speaking at the annual meeting of the Heart Failure Society of America, he did not give more specific results on exercise capacity changes in the 28 patients studied so far, but reported improvements in two secondary end points of the trial. In addition, there's no sign so far of any increase in adverse events related to the sildenafil therapy, said Dr. Lewis of Massachusetts General Hospital, Boston, and his associates.

He has no association with the company that makes sildenafil.

The double-blind study randomizes patients with New York Heart Association class III or IV systolic heart failure and secondary pulmonary hypertension to 12 weeks of placebo or oral sildenafil titrated up to 75 mg t.i.d. Twelve of 14 patients per group in the interim analysis completed the protocol.

At week 12, patients in the sildenafil group walked a mean 13% farther on the 6-minute walk test, a significant improvement compared with baseline and compared with the placebo group.

This result is consistent with a mean placebo-corrected 13% increase in the 6-minute walk distance demonstrated in the Sildenafil Citrate Therapy for Pulmonary Arterial Hypertension study, which gave similar doses of sildenafil to patients with idiopathic and other forms of pulmonary arterial hypertension unrelated to left ventricular systolic dysfunction (N. Engl. J. Med. 2005;353:2148–57).

In the current study, five patients in the sildenafil group improved their scores on the Minnesota Living with Heart Failure questionnaire, creating a significant difference in quality-of-life scores between the sildenafil and placebo groups at week 12.

The rates of adverse events did not differ significantly between the groups except in the number of hospitalizations for heart failure, for which there was one in the sildenafil group, and seven in five patients on placebo. The safety of chronic sildenafil therapy has not been studied extensively in this population before.

Dr. Lewis cautioned that the interim analysis rests on small numbers, and that results need to be validated in larger cohorts.

In an earlier study, Dr. Lewis and his associates found that acute administration of a single 50-mg oral dose of sildenafil lowered pulmonary arterial pressures, improved cardiac output, and increased exercise tolerance in patients with systolic heart failure and secondary pulmonary hypertension.

SEATTLE — A 12-week study of sildenafil therapy in patients with heart failure due to left ventricular dysfunction and secondary pulmonary hypertension is continuing after an interim analysis found neither therapeutic futility nor overwhelming improvements in exercise capacity, Dr. Gregory Lewis said.

Speaking at the annual meeting of the Heart Failure Society of America, he did not give more specific results on exercise capacity changes in the 28 patients studied so far, but reported improvements in two secondary end points of the trial. In addition, there's no sign so far of any increase in adverse events related to the sildenafil therapy, said Dr. Lewis of Massachusetts General Hospital, Boston, and his associates.

He has no association with the company that makes sildenafil.

The double-blind study randomizes patients with New York Heart Association class III or IV systolic heart failure and secondary pulmonary hypertension to 12 weeks of placebo or oral sildenafil titrated up to 75 mg t.i.d. Twelve of 14 patients per group in the interim analysis completed the protocol.

At week 12, patients in the sildenafil group walked a mean 13% farther on the 6-minute walk test, a significant improvement compared with baseline and compared with the placebo group.

This result is consistent with a mean placebo-corrected 13% increase in the 6-minute walk distance demonstrated in the Sildenafil Citrate Therapy for Pulmonary Arterial Hypertension study, which gave similar doses of sildenafil to patients with idiopathic and other forms of pulmonary arterial hypertension unrelated to left ventricular systolic dysfunction (N. Engl. J. Med. 2005;353:2148–57).

In the current study, five patients in the sildenafil group improved their scores on the Minnesota Living with Heart Failure questionnaire, creating a significant difference in quality-of-life scores between the sildenafil and placebo groups at week 12.

The rates of adverse events did not differ significantly between the groups except in the number of hospitalizations for heart failure, for which there was one in the sildenafil group, and seven in five patients on placebo. The safety of chronic sildenafil therapy has not been studied extensively in this population before.

Dr. Lewis cautioned that the interim analysis rests on small numbers, and that results need to be validated in larger cohorts.

In an earlier study, Dr. Lewis and his associates found that acute administration of a single 50-mg oral dose of sildenafil lowered pulmonary arterial pressures, improved cardiac output, and increased exercise tolerance in patients with systolic heart failure and secondary pulmonary hypertension.

SEATTLE — A 12-week study of sildenafil therapy in patients with heart failure due to left ventricular dysfunction and secondary pulmonary hypertension is continuing after an interim analysis found neither therapeutic futility nor overwhelming improvements in exercise capacity, Dr. Gregory Lewis said.

Speaking at the annual meeting of the Heart Failure Society of America, he did not give more specific results on exercise capacity changes in the 28 patients studied so far, but reported improvements in two secondary end points of the trial. In addition, there's no sign so far of any increase in adverse events related to the sildenafil therapy, said Dr. Lewis of Massachusetts General Hospital, Boston, and his associates.

He has no association with the company that makes sildenafil.

The double-blind study randomizes patients with New York Heart Association class III or IV systolic heart failure and secondary pulmonary hypertension to 12 weeks of placebo or oral sildenafil titrated up to 75 mg t.i.d. Twelve of 14 patients per group in the interim analysis completed the protocol.

At week 12, patients in the sildenafil group walked a mean 13% farther on the 6-minute walk test, a significant improvement compared with baseline and compared with the placebo group.

This result is consistent with a mean placebo-corrected 13% increase in the 6-minute walk distance demonstrated in the Sildenafil Citrate Therapy for Pulmonary Arterial Hypertension study, which gave similar doses of sildenafil to patients with idiopathic and other forms of pulmonary arterial hypertension unrelated to left ventricular systolic dysfunction (N. Engl. J. Med. 2005;353:2148–57).

In the current study, five patients in the sildenafil group improved their scores on the Minnesota Living with Heart Failure questionnaire, creating a significant difference in quality-of-life scores between the sildenafil and placebo groups at week 12.

The rates of adverse events did not differ significantly between the groups except in the number of hospitalizations for heart failure, for which there was one in the sildenafil group, and seven in five patients on placebo. The safety of chronic sildenafil therapy has not been studied extensively in this population before.

Dr. Lewis cautioned that the interim analysis rests on small numbers, and that results need to be validated in larger cohorts.

In an earlier study, Dr. Lewis and his associates found that acute administration of a single 50-mg oral dose of sildenafil lowered pulmonary arterial pressures, improved cardiac output, and increased exercise tolerance in patients with systolic heart failure and secondary pulmonary hypertension.

SAN FRANCISCO — Get ready to see more uninsured patients in emergency departments if states cut back Medicaid programs, Dr. Robert A. Lowe said at the annual meeting of the Society for Academic Emergency Medicine.

A study in Oregon confirmed the assumption that Medicaid cutbacks increase the proportion of patients without insurance among those seeking emergency care, said Dr. Lowe, director of the Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland.

The state's Medicaid program—the Oregon Health Plan—was “the crown jewel of Oregon health policy” in the early 1990s, but a state fiscal crisis led to cutbacks in 2003, he said. Enrollees who missed a premium payment for 1 month were locked out of the plan for 6 months. A new copayment of $50 for emergency department (ED) visits was added, and the scope of benefits shrank. Within 6 months of the policy changes, 50,000 people lost coverage.

An analysis of data from before and after the changes showed that the cutbacks produced an abrupt and sustained increase in the number of uninsured patients seeking emergency care, Dr. Lowe and his associates reported. In 10 urban EDs, the total number of visits remained relatively flat: 31,492 per month in 2002 and 31,910 per month in 2004. The number of patients covered by the Oregon Health Plan seen in the 10 EDs declined by 5,076 per year (from 7,964 per month in 2002 to 7,541 per month in 2004). The number of commercially insured patients seen fell by 12,144 per year (from 11,020 per month in 2002 to 10,008 per month in 2004). The number of uninsured patients seen in the 10 EDs rose by 18,348 per year (from 4,018 per month in 2002 to 5,547 per month in 2004).

Data from 25 of Oregon's 59 EDs, including 16 urban and 9 rural hospitals, showed increased numbers of uninsured patient visits in 2004 over those in 2003—differences that were statistically significant in 24 hospitals. The proportion of patients covered under the Oregon Health Plan or by commercial insurance fell significantly in 20 of the 25 EDs.

SAN FRANCISCO — Get ready to see more uninsured patients in emergency departments if states cut back Medicaid programs, Dr. Robert A. Lowe said at the annual meeting of the Society for Academic Emergency Medicine.

A study in Oregon confirmed the assumption that Medicaid cutbacks increase the proportion of patients without insurance among those seeking emergency care, said Dr. Lowe, director of the Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland.

The state's Medicaid program—the Oregon Health Plan—was “the crown jewel of Oregon health policy” in the early 1990s, but a state fiscal crisis led to cutbacks in 2003, he said. Enrollees who missed a premium payment for 1 month were locked out of the plan for 6 months. A new copayment of $50 for emergency department (ED) visits was added, and the scope of benefits shrank. Within 6 months of the policy changes, 50,000 people lost coverage.

An analysis of data from before and after the changes showed that the cutbacks produced an abrupt and sustained increase in the number of uninsured patients seeking emergency care, Dr. Lowe and his associates reported. In 10 urban EDs, the total number of visits remained relatively flat: 31,492 per month in 2002 and 31,910 per month in 2004. The number of patients covered by the Oregon Health Plan seen in the 10 EDs declined by 5,076 per year (from 7,964 per month in 2002 to 7,541 per month in 2004). The number of commercially insured patients seen fell by 12,144 per year (from 11,020 per month in 2002 to 10,008 per month in 2004). The number of uninsured patients seen in the 10 EDs rose by 18,348 per year (from 4,018 per month in 2002 to 5,547 per month in 2004).

Data from 25 of Oregon's 59 EDs, including 16 urban and 9 rural hospitals, showed increased numbers of uninsured patient visits in 2004 over those in 2003—differences that were statistically significant in 24 hospitals. The proportion of patients covered under the Oregon Health Plan or by commercial insurance fell significantly in 20 of the 25 EDs.

SAN FRANCISCO — Get ready to see more uninsured patients in emergency departments if states cut back Medicaid programs, Dr. Robert A. Lowe said at the annual meeting of the Society for Academic Emergency Medicine.

A study in Oregon confirmed the assumption that Medicaid cutbacks increase the proportion of patients without insurance among those seeking emergency care, said Dr. Lowe, director of the Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland.

The state's Medicaid program—the Oregon Health Plan—was “the crown jewel of Oregon health policy” in the early 1990s, but a state fiscal crisis led to cutbacks in 2003, he said. Enrollees who missed a premium payment for 1 month were locked out of the plan for 6 months. A new copayment of $50 for emergency department (ED) visits was added, and the scope of benefits shrank. Within 6 months of the policy changes, 50,000 people lost coverage.

An analysis of data from before and after the changes showed that the cutbacks produced an abrupt and sustained increase in the number of uninsured patients seeking emergency care, Dr. Lowe and his associates reported. In 10 urban EDs, the total number of visits remained relatively flat: 31,492 per month in 2002 and 31,910 per month in 2004. The number of patients covered by the Oregon Health Plan seen in the 10 EDs declined by 5,076 per year (from 7,964 per month in 2002 to 7,541 per month in 2004). The number of commercially insured patients seen fell by 12,144 per year (from 11,020 per month in 2002 to 10,008 per month in 2004). The number of uninsured patients seen in the 10 EDs rose by 18,348 per year (from 4,018 per month in 2002 to 5,547 per month in 2004).

Data from 25 of Oregon's 59 EDs, including 16 urban and 9 rural hospitals, showed increased numbers of uninsured patient visits in 2004 over those in 2003—differences that were statistically significant in 24 hospitals. The proportion of patients covered under the Oregon Health Plan or by commercial insurance fell significantly in 20 of the 25 EDs.

MONTEREY, CALIF. — Development of new treatments for Crohn's disease or ulcerative colitis has generally focused on immunomodulators, cytokine therapy, and other biotechnology, but lower-technology options are now being tried as well, Dr. Joshua R. Korzenik said.

Probiotics, parasites, and fecal transplants each have shown some positive results, although none are ready for prime time, Dr. Korzenik said at an update in gastroenterology and hepatology sponsored by the University of California, Davis.

▸ Probiotics. Most studies on the use of beneficial bacteria to treat inflammatory bowel disease have not supported this strategy, but one study of treating pouchitis produced interesting and positive results. Researchers are studying probiotics in the treatment of Crohn's disease and ulcerative colitis, said Dr. Korzenik, codirector of the Crohn's and Colitis Center at Massachusetts General Hospital, Boston.

The pouchitis study included 40 patients who were treated for ulcerative colitis with colectomy and an ileoanal anastomosis (or J-pouch) operation and subsequently developed a chronic inflammatory process, a problem that occurs in about 15% of J-pouches. Antibiotics can control the pouchitis, but long-term antibiotics are not ideal.

After bringing the patients' pouchitis into remission with antibiotics, researchers discontinued antibiotic therapy and randomized 20 patients to a potent probiotic called VSL#3, with another 20 patients assigned to placebo. The pouchitis returned in all patients on placebo by 5 months later, but 17 patients in the probiotic group remained in remission 9 months after starting therapy (Gastroenterology 2000;119:305).

Typical probiotics found in health food stores contain perhaps 1–20 billion bacteria. VSL#3, which is sold over the Internet, contains about 1.6 trillion bacteria, and patients in the study took three capsules per day. “You're still talking about relatively small potatoes,” compared with the 100 billion to 1 trillion bacteria in each gram of stool, Dr. Korzenik noted.

The VSL#3 treatment regimen costs about $12-$15 per day and is not covered by insurance.

▸ Parasites. Some researchers speculate that when the modern zeal for cleanliness eliminated helminth ova (infectious parasite eggs) from humans, this actually aided development of Crohn's disease and ulcerative colitis, he said, so that adding the ova back to the body might treat these diseases.

In one open-label study, 29 patients with active Crohn's disease took 2,500 Trichuris suis (pig whipworm) ova every 3 weeks for 24 weeks (Gut 2005;54:87–90).

The disease responded to the treatment in 79% of patients, and 72% of patients achieved remission. “The results are almost too good to be true, but it's very promising,” Dr. Korzenik said. “It's not Fear Factor, so you're not taking down a cup of writhing worms. You're really just drinking down the eggs.”

A separate placebo-controlled trial in patients with ulcerative colitis showed marginal benefit.

The ova are sold from Europe over the Internet as an expensive product called TSO. “I suggested it be called Ova the Counter,” he joked. The Food and Drug Administration is considering whether sales should be regulated. “It's not cheap, but it's very exciting as far as something that's very nontoxic and may actually have some benefit,” he said.

▸ Fecal transplants. Also called “human probiotics” because the implanted bacteria come from donor stool, this treatment is modeled after fecal enemas used to treat some patients with refractory Clostridium difficile infection in order to reestablish normal flora.

In one open-label study of six patients with longstanding ulcerative colitis who received daily infusions for 1 week, all had improvement in symptoms (J. Clin. Gastroenterol. 2003;37:42–7). “At this point, I would not recommend this at all, but it's very curious,” Dr. Korzenik said.

Conventional therapy for inflammatory bowel disease is generally antibiotics or aminosalicylates for mild disease, corticosteroids for moderate disease, and infliximab or surgery for severe disease. Several new cytokine therapies are likely to be approved in the next few years. “The fear is we may go from too little treatment to overtreating these patients,” he said.

MONTEREY, CALIF. — Development of new treatments for Crohn's disease or ulcerative colitis has generally focused on immunomodulators, cytokine therapy, and other biotechnology, but lower-technology options are now being tried as well, Dr. Joshua R. Korzenik said.

Probiotics, parasites, and fecal transplants each have shown some positive results, although none are ready for prime time, Dr. Korzenik said at an update in gastroenterology and hepatology sponsored by the University of California, Davis.

▸ Probiotics. Most studies on the use of beneficial bacteria to treat inflammatory bowel disease have not supported this strategy, but one study of treating pouchitis produced interesting and positive results. Researchers are studying probiotics in the treatment of Crohn's disease and ulcerative colitis, said Dr. Korzenik, codirector of the Crohn's and Colitis Center at Massachusetts General Hospital, Boston.

The pouchitis study included 40 patients who were treated for ulcerative colitis with colectomy and an ileoanal anastomosis (or J-pouch) operation and subsequently developed a chronic inflammatory process, a problem that occurs in about 15% of J-pouches. Antibiotics can control the pouchitis, but long-term antibiotics are not ideal.

After bringing the patients' pouchitis into remission with antibiotics, researchers discontinued antibiotic therapy and randomized 20 patients to a potent probiotic called VSL#3, with another 20 patients assigned to placebo. The pouchitis returned in all patients on placebo by 5 months later, but 17 patients in the probiotic group remained in remission 9 months after starting therapy (Gastroenterology 2000;119:305).

Typical probiotics found in health food stores contain perhaps 1–20 billion bacteria. VSL#3, which is sold over the Internet, contains about 1.6 trillion bacteria, and patients in the study took three capsules per day. “You're still talking about relatively small potatoes,” compared with the 100 billion to 1 trillion bacteria in each gram of stool, Dr. Korzenik noted.

The VSL#3 treatment regimen costs about $12-$15 per day and is not covered by insurance.

▸ Parasites. Some researchers speculate that when the modern zeal for cleanliness eliminated helminth ova (infectious parasite eggs) from humans, this actually aided development of Crohn's disease and ulcerative colitis, he said, so that adding the ova back to the body might treat these diseases.

In one open-label study, 29 patients with active Crohn's disease took 2,500 Trichuris suis (pig whipworm) ova every 3 weeks for 24 weeks (Gut 2005;54:87–90).

The disease responded to the treatment in 79% of patients, and 72% of patients achieved remission. “The results are almost too good to be true, but it's very promising,” Dr. Korzenik said. “It's not Fear Factor, so you're not taking down a cup of writhing worms. You're really just drinking down the eggs.”

A separate placebo-controlled trial in patients with ulcerative colitis showed marginal benefit.

The ova are sold from Europe over the Internet as an expensive product called TSO. “I suggested it be called Ova the Counter,” he joked. The Food and Drug Administration is considering whether sales should be regulated. “It's not cheap, but it's very exciting as far as something that's very nontoxic and may actually have some benefit,” he said.

▸ Fecal transplants. Also called “human probiotics” because the implanted bacteria come from donor stool, this treatment is modeled after fecal enemas used to treat some patients with refractory Clostridium difficile infection in order to reestablish normal flora.

In one open-label study of six patients with longstanding ulcerative colitis who received daily infusions for 1 week, all had improvement in symptoms (J. Clin. Gastroenterol. 2003;37:42–7). “At this point, I would not recommend this at all, but it's very curious,” Dr. Korzenik said.

Conventional therapy for inflammatory bowel disease is generally antibiotics or aminosalicylates for mild disease, corticosteroids for moderate disease, and infliximab or surgery for severe disease. Several new cytokine therapies are likely to be approved in the next few years. “The fear is we may go from too little treatment to overtreating these patients,” he said.

MONTEREY, CALIF. — Development of new treatments for Crohn's disease or ulcerative colitis has generally focused on immunomodulators, cytokine therapy, and other biotechnology, but lower-technology options are now being tried as well, Dr. Joshua R. Korzenik said.

Probiotics, parasites, and fecal transplants each have shown some positive results, although none are ready for prime time, Dr. Korzenik said at an update in gastroenterology and hepatology sponsored by the University of California, Davis.

▸ Probiotics. Most studies on the use of beneficial bacteria to treat inflammatory bowel disease have not supported this strategy, but one study of treating pouchitis produced interesting and positive results. Researchers are studying probiotics in the treatment of Crohn's disease and ulcerative colitis, said Dr. Korzenik, codirector of the Crohn's and Colitis Center at Massachusetts General Hospital, Boston.

The pouchitis study included 40 patients who were treated for ulcerative colitis with colectomy and an ileoanal anastomosis (or J-pouch) operation and subsequently developed a chronic inflammatory process, a problem that occurs in about 15% of J-pouches. Antibiotics can control the pouchitis, but long-term antibiotics are not ideal.

After bringing the patients' pouchitis into remission with antibiotics, researchers discontinued antibiotic therapy and randomized 20 patients to a potent probiotic called VSL#3, with another 20 patients assigned to placebo. The pouchitis returned in all patients on placebo by 5 months later, but 17 patients in the probiotic group remained in remission 9 months after starting therapy (Gastroenterology 2000;119:305).

Typical probiotics found in health food stores contain perhaps 1–20 billion bacteria. VSL#3, which is sold over the Internet, contains about 1.6 trillion bacteria, and patients in the study took three capsules per day. “You're still talking about relatively small potatoes,” compared with the 100 billion to 1 trillion bacteria in each gram of stool, Dr. Korzenik noted.

The VSL#3 treatment regimen costs about $12-$15 per day and is not covered by insurance.

▸ Parasites. Some researchers speculate that when the modern zeal for cleanliness eliminated helminth ova (infectious parasite eggs) from humans, this actually aided development of Crohn's disease and ulcerative colitis, he said, so that adding the ova back to the body might treat these diseases.

In one open-label study, 29 patients with active Crohn's disease took 2,500 Trichuris suis (pig whipworm) ova every 3 weeks for 24 weeks (Gut 2005;54:87–90).

The disease responded to the treatment in 79% of patients, and 72% of patients achieved remission. “The results are almost too good to be true, but it's very promising,” Dr. Korzenik said. “It's not Fear Factor, so you're not taking down a cup of writhing worms. You're really just drinking down the eggs.”

A separate placebo-controlled trial in patients with ulcerative colitis showed marginal benefit.

The ova are sold from Europe over the Internet as an expensive product called TSO. “I suggested it be called Ova the Counter,” he joked. The Food and Drug Administration is considering whether sales should be regulated. “It's not cheap, but it's very exciting as far as something that's very nontoxic and may actually have some benefit,” he said.

▸ Fecal transplants. Also called “human probiotics” because the implanted bacteria come from donor stool, this treatment is modeled after fecal enemas used to treat some patients with refractory Clostridium difficile infection in order to reestablish normal flora.

In one open-label study of six patients with longstanding ulcerative colitis who received daily infusions for 1 week, all had improvement in symptoms (J. Clin. Gastroenterol. 2003;37:42–7). “At this point, I would not recommend this at all, but it's very curious,” Dr. Korzenik said.

Conventional therapy for inflammatory bowel disease is generally antibiotics or aminosalicylates for mild disease, corticosteroids for moderate disease, and infliximab or surgery for severe disease. Several new cytokine therapies are likely to be approved in the next few years. “The fear is we may go from too little treatment to overtreating these patients,” he said.

MONTEREY, CALIF. — Clinically useful tests are on the horizon to detect changes in DNA that can alter health outcomes for patients with infectious diseases, Dr. Michael F. Murray said.

At the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology, he described helpful applications of new technology that should be available within the next 5 years or so, and some genetic testing that's being marketed now but is not clinically useful. Dr. Murray has no relationships with the companies that make the products he discussed.

An example of technology that will change how clinicians diagnose, treat, and prevent infectious diseases is the AmpliChip CYP450 assay. It uses polymerase chain reaction (PCR) tests and microarray analysis to detect 31 genetic polymorphisms in cytochrome P450 (particularly in two genes—CYP2D6 and CYP2C19). CYP450 is involved in the metabolism of many drugs.

The AmpliChip gives clinicians a report that predicts a patient's phenotype as a poor, intermediate, extensive, or ultrarapid metabolizer for CYP2D6 and a poor or extensive metabolizer for CYP2C19. This type of technology can be put to other uses as well, explained Dr. Murray, clinical chief of the division of genetics at Brigham and Women's Hospital, Boston.

“This is one of many competing platforms to use technology to rapidly understand the patient's genetics and then to make a clinical decision based on it,” Dr. Murray said. The technology is capable of delivering the report to a clinician within 8 hours of taking the blood sample, although no one currently has the system set up to deliver results that quickly, he added. Clinicians could then use that information to make clinical decisions without having to know a lot about genetics.

Dr. Murray described a case in which genomic medicine might have made a difference in management of pneumonia. A young woman treated in the emergency department with ceftriaxone for right upper lobe pneumonia was considered to be a low risk and sent home on an oral fluoroquinolone antibiotic.

After a day without fever, the patient got worse over the next few days before calling 911, febrile and confused. She was intubated in the field, developed acute respiratory distress syndrome, and died in the ICU 10 days later.

Theoretically, if a DNA analysis had been done on the patient the first time she came to the emergency department with pneumonia, it might have shown quickly that she had Streptococcus pneumoniae serotype 3 bacteremia, which is associated with a poor prognosis. PCR tests of the organism could have detected genotypic susceptibility to ceftriaxone and resistance to all quinolones.

DNA tests could also establish the patient's “host susceptibility profile,” Dr. Murray said. There are a lot of candidate genes for this profile, such as surfactant B. A polymorphism in surfactant B is associated with an increased need for mechanical ventilation in adults who present with community-acquired pneumonia.

If these tests had been done, the patient might not have been sent home from the emergency department. She could have been admitted, treated with IV antibiotics and aggressive respiratory therapy, and discharged 6 days later on an oral cephalosporin.

These applications of existing genetic technology aren't up and running yet, but “it's reasonable to think that at least in 10 years, probably more like 5, maybe less,” these tools will be available clinically, Dr. Murray said.

One currently available genetic test—the Otodx aminoglycoside hypersensitivity test—offers clinicians a means of detecting a common mutation associated with aminoglycoside-induced hearing loss. Results take 2 weeks, and the test costs about $250.

The marketing firm suggests that all patients being considered for aminoglycoside therapy get tested, but a 2-week wait is not clinically helpful, Dr. Murray said.

MONTEREY, CALIF. — Clinically useful tests are on the horizon to detect changes in DNA that can alter health outcomes for patients with infectious diseases, Dr. Michael F. Murray said.

At the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology, he described helpful applications of new technology that should be available within the next 5 years or so, and some genetic testing that's being marketed now but is not clinically useful. Dr. Murray has no relationships with the companies that make the products he discussed.

An example of technology that will change how clinicians diagnose, treat, and prevent infectious diseases is the AmpliChip CYP450 assay. It uses polymerase chain reaction (PCR) tests and microarray analysis to detect 31 genetic polymorphisms in cytochrome P450 (particularly in two genes—CYP2D6 and CYP2C19). CYP450 is involved in the metabolism of many drugs.

The AmpliChip gives clinicians a report that predicts a patient's phenotype as a poor, intermediate, extensive, or ultrarapid metabolizer for CYP2D6 and a poor or extensive metabolizer for CYP2C19. This type of technology can be put to other uses as well, explained Dr. Murray, clinical chief of the division of genetics at Brigham and Women's Hospital, Boston.

“This is one of many competing platforms to use technology to rapidly understand the patient's genetics and then to make a clinical decision based on it,” Dr. Murray said. The technology is capable of delivering the report to a clinician within 8 hours of taking the blood sample, although no one currently has the system set up to deliver results that quickly, he added. Clinicians could then use that information to make clinical decisions without having to know a lot about genetics.

Dr. Murray described a case in which genomic medicine might have made a difference in management of pneumonia. A young woman treated in the emergency department with ceftriaxone for right upper lobe pneumonia was considered to be a low risk and sent home on an oral fluoroquinolone antibiotic.

After a day without fever, the patient got worse over the next few days before calling 911, febrile and confused. She was intubated in the field, developed acute respiratory distress syndrome, and died in the ICU 10 days later.

Theoretically, if a DNA analysis had been done on the patient the first time she came to the emergency department with pneumonia, it might have shown quickly that she had Streptococcus pneumoniae serotype 3 bacteremia, which is associated with a poor prognosis. PCR tests of the organism could have detected genotypic susceptibility to ceftriaxone and resistance to all quinolones.

DNA tests could also establish the patient's “host susceptibility profile,” Dr. Murray said. There are a lot of candidate genes for this profile, such as surfactant B. A polymorphism in surfactant B is associated with an increased need for mechanical ventilation in adults who present with community-acquired pneumonia.

If these tests had been done, the patient might not have been sent home from the emergency department. She could have been admitted, treated with IV antibiotics and aggressive respiratory therapy, and discharged 6 days later on an oral cephalosporin.

These applications of existing genetic technology aren't up and running yet, but “it's reasonable to think that at least in 10 years, probably more like 5, maybe less,” these tools will be available clinically, Dr. Murray said.

One currently available genetic test—the Otodx aminoglycoside hypersensitivity test—offers clinicians a means of detecting a common mutation associated with aminoglycoside-induced hearing loss. Results take 2 weeks, and the test costs about $250.

The marketing firm suggests that all patients being considered for aminoglycoside therapy get tested, but a 2-week wait is not clinically helpful, Dr. Murray said.

MONTEREY, CALIF. — Clinically useful tests are on the horizon to detect changes in DNA that can alter health outcomes for patients with infectious diseases, Dr. Michael F. Murray said.

At the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology, he described helpful applications of new technology that should be available within the next 5 years or so, and some genetic testing that's being marketed now but is not clinically useful. Dr. Murray has no relationships with the companies that make the products he discussed.

An example of technology that will change how clinicians diagnose, treat, and prevent infectious diseases is the AmpliChip CYP450 assay. It uses polymerase chain reaction (PCR) tests and microarray analysis to detect 31 genetic polymorphisms in cytochrome P450 (particularly in two genes—CYP2D6 and CYP2C19). CYP450 is involved in the metabolism of many drugs.

The AmpliChip gives clinicians a report that predicts a patient's phenotype as a poor, intermediate, extensive, or ultrarapid metabolizer for CYP2D6 and a poor or extensive metabolizer for CYP2C19. This type of technology can be put to other uses as well, explained Dr. Murray, clinical chief of the division of genetics at Brigham and Women's Hospital, Boston.

“This is one of many competing platforms to use technology to rapidly understand the patient's genetics and then to make a clinical decision based on it,” Dr. Murray said. The technology is capable of delivering the report to a clinician within 8 hours of taking the blood sample, although no one currently has the system set up to deliver results that quickly, he added. Clinicians could then use that information to make clinical decisions without having to know a lot about genetics.

Dr. Murray described a case in which genomic medicine might have made a difference in management of pneumonia. A young woman treated in the emergency department with ceftriaxone for right upper lobe pneumonia was considered to be a low risk and sent home on an oral fluoroquinolone antibiotic.

After a day without fever, the patient got worse over the next few days before calling 911, febrile and confused. She was intubated in the field, developed acute respiratory distress syndrome, and died in the ICU 10 days later.

Theoretically, if a DNA analysis had been done on the patient the first time she came to the emergency department with pneumonia, it might have shown quickly that she had Streptococcus pneumoniae serotype 3 bacteremia, which is associated with a poor prognosis. PCR tests of the organism could have detected genotypic susceptibility to ceftriaxone and resistance to all quinolones.

DNA tests could also establish the patient's “host susceptibility profile,” Dr. Murray said. There are a lot of candidate genes for this profile, such as surfactant B. A polymorphism in surfactant B is associated with an increased need for mechanical ventilation in adults who present with community-acquired pneumonia.

If these tests had been done, the patient might not have been sent home from the emergency department. She could have been admitted, treated with IV antibiotics and aggressive respiratory therapy, and discharged 6 days later on an oral cephalosporin.

These applications of existing genetic technology aren't up and running yet, but “it's reasonable to think that at least in 10 years, probably more like 5, maybe less,” these tools will be available clinically, Dr. Murray said.

One currently available genetic test—the Otodx aminoglycoside hypersensitivity test—offers clinicians a means of detecting a common mutation associated with aminoglycoside-induced hearing loss. Results take 2 weeks, and the test costs about $250.

The marketing firm suggests that all patients being considered for aminoglycoside therapy get tested, but a 2-week wait is not clinically helpful, Dr. Murray said.

MONTEREY, CALIF. — By itself, chorioamnionitis does not justify an operative delivery even if the first stage of labor is prolonged, a retrospective study of 1,810 deliveries suggests.

Longer first-stage labor in pregnancies with chorioamnionitis was associated with a 60% increased risk for cesarean delivery and a 30% increased risk for meconium-stained amniotic fluid, a multivariate analysis found. The results showed no increase in risk for meconium aspiration syndrome with prolonged first-stage labor in pregnancies with chorioamnionitis, Dr. Natali Aziz said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

Chorioamnionitis in previous studies has been associated with significant adverse obstetric and neonatal outcomes including maternal blood loss and transfusions, endomyometritis, greater severity of lacerations, meconium aspiration syndrome, lower Apgar scores, neonatal sepsis, and other problems.

The current study found that the duration of first-stage labor in women with chorioamnionitis did not affect the risk of neonatal sequelae, “which was surprising to us,” said Dr. Aziz of the University of California, San Francisco.

The timing of delivery for patients with chorioamnionitis is controversial, she said. Her institution does not deliver based solely on the diagnosis of chorioamnionitis, but some other institutions do.

The investigators analyzed outcomes by comparing women with chorioamnionitis whose first stage of labor lasted less than 12 hours (39% of cases), 12–24 hours (48%), or 24 hours or longer (13%). The results “support continued efforts to achieve a vaginal delivery if other obstetrical indications permit, even in the setting of a prolonged course of labor and intraamniotic infection,” Dr. Aziz said. “Much of the maternal morbidity in our data was due to operative delivery in itself.”

An initial univariate analysis found that a longer first-stage labor was associated with worse maternal and obstetric outcomes, but “not as much as we expected,” she said. Risks for postpartum hemorrhage, C-section, endomyometritis, and operative vaginal delivery increased with longer labors.

Postpartum hemorrhage and endomyometritis, however, can be associated with cesarean delivery, so the investigators conducted a multivariate analysis that controlled for the effects of potential confounders, including cesarean delivery. That analysis found associations only between longer labor and increased risks for cesarean delivery or meconium-stained amniotic fluid.

They then conducted a second multivariate analysis that did not control for the effects of cesarean delivery. Some researchers have speculated that cesarean delivery may be a causal pathway that leads from chorioamnionitis to adverse perinatal outcomes, and so controlling for cesarean delivery might mask any effects of prolonged labor on chorioamnionitis and neonatal outcomes, Dr. Aziz and her associates reasoned.

In the analysis that did not control for cesarean delivery, the only other significant association with increased duration of first-stage labor was a 20% increased risk for postpartum hemorrhage. There was a trend toward greater need for blood transfusion with prolonged first-stage labor in pregnancies with chorioamnionitis. “We've demonstrated that the increasing duration of first-stage labor was associated with increased maternal morbidity, and in turn with operative delivery and thereby postpartum hemorrhage, but not with neonatal morbidity,” she said.

One physician in the audience commented, “I think these are very encouraging and reassuring data.”

Prolonged first-stage labor in pregnancies with chorioamnionitis also was associated with a significantly decreased risk for an umbilical artery base excess greater than 12 mmol/L, which puzzled the investigators. This may be due to fetal indications causing the delivery, Dr. Aziz said.

MONTEREY, CALIF. — By itself, chorioamnionitis does not justify an operative delivery even if the first stage of labor is prolonged, a retrospective study of 1,810 deliveries suggests.

Longer first-stage labor in pregnancies with chorioamnionitis was associated with a 60% increased risk for cesarean delivery and a 30% increased risk for meconium-stained amniotic fluid, a multivariate analysis found. The results showed no increase in risk for meconium aspiration syndrome with prolonged first-stage labor in pregnancies with chorioamnionitis, Dr. Natali Aziz said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

Chorioamnionitis in previous studies has been associated with significant adverse obstetric and neonatal outcomes including maternal blood loss and transfusions, endomyometritis, greater severity of lacerations, meconium aspiration syndrome, lower Apgar scores, neonatal sepsis, and other problems.

The current study found that the duration of first-stage labor in women with chorioamnionitis did not affect the risk of neonatal sequelae, “which was surprising to us,” said Dr. Aziz of the University of California, San Francisco.

The timing of delivery for patients with chorioamnionitis is controversial, she said. Her institution does not deliver based solely on the diagnosis of chorioamnionitis, but some other institutions do.

The investigators analyzed outcomes by comparing women with chorioamnionitis whose first stage of labor lasted less than 12 hours (39% of cases), 12–24 hours (48%), or 24 hours or longer (13%). The results “support continued efforts to achieve a vaginal delivery if other obstetrical indications permit, even in the setting of a prolonged course of labor and intraamniotic infection,” Dr. Aziz said. “Much of the maternal morbidity in our data was due to operative delivery in itself.”

An initial univariate analysis found that a longer first-stage labor was associated with worse maternal and obstetric outcomes, but “not as much as we expected,” she said. Risks for postpartum hemorrhage, C-section, endomyometritis, and operative vaginal delivery increased with longer labors.

Postpartum hemorrhage and endomyometritis, however, can be associated with cesarean delivery, so the investigators conducted a multivariate analysis that controlled for the effects of potential confounders, including cesarean delivery. That analysis found associations only between longer labor and increased risks for cesarean delivery or meconium-stained amniotic fluid.

They then conducted a second multivariate analysis that did not control for the effects of cesarean delivery. Some researchers have speculated that cesarean delivery may be a causal pathway that leads from chorioamnionitis to adverse perinatal outcomes, and so controlling for cesarean delivery might mask any effects of prolonged labor on chorioamnionitis and neonatal outcomes, Dr. Aziz and her associates reasoned.

In the analysis that did not control for cesarean delivery, the only other significant association with increased duration of first-stage labor was a 20% increased risk for postpartum hemorrhage. There was a trend toward greater need for blood transfusion with prolonged first-stage labor in pregnancies with chorioamnionitis. “We've demonstrated that the increasing duration of first-stage labor was associated with increased maternal morbidity, and in turn with operative delivery and thereby postpartum hemorrhage, but not with neonatal morbidity,” she said.

One physician in the audience commented, “I think these are very encouraging and reassuring data.”

Prolonged first-stage labor in pregnancies with chorioamnionitis also was associated with a significantly decreased risk for an umbilical artery base excess greater than 12 mmol/L, which puzzled the investigators. This may be due to fetal indications causing the delivery, Dr. Aziz said.

MONTEREY, CALIF. — By itself, chorioamnionitis does not justify an operative delivery even if the first stage of labor is prolonged, a retrospective study of 1,810 deliveries suggests.

Longer first-stage labor in pregnancies with chorioamnionitis was associated with a 60% increased risk for cesarean delivery and a 30% increased risk for meconium-stained amniotic fluid, a multivariate analysis found. The results showed no increase in risk for meconium aspiration syndrome with prolonged first-stage labor in pregnancies with chorioamnionitis, Dr. Natali Aziz said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

Chorioamnionitis in previous studies has been associated with significant adverse obstetric and neonatal outcomes including maternal blood loss and transfusions, endomyometritis, greater severity of lacerations, meconium aspiration syndrome, lower Apgar scores, neonatal sepsis, and other problems.

The current study found that the duration of first-stage labor in women with chorioamnionitis did not affect the risk of neonatal sequelae, “which was surprising to us,” said Dr. Aziz of the University of California, San Francisco.

The timing of delivery for patients with chorioamnionitis is controversial, she said. Her institution does not deliver based solely on the diagnosis of chorioamnionitis, but some other institutions do.

The investigators analyzed outcomes by comparing women with chorioamnionitis whose first stage of labor lasted less than 12 hours (39% of cases), 12–24 hours (48%), or 24 hours or longer (13%). The results “support continued efforts to achieve a vaginal delivery if other obstetrical indications permit, even in the setting of a prolonged course of labor and intraamniotic infection,” Dr. Aziz said. “Much of the maternal morbidity in our data was due to operative delivery in itself.”

An initial univariate analysis found that a longer first-stage labor was associated with worse maternal and obstetric outcomes, but “not as much as we expected,” she said. Risks for postpartum hemorrhage, C-section, endomyometritis, and operative vaginal delivery increased with longer labors.

Postpartum hemorrhage and endomyometritis, however, can be associated with cesarean delivery, so the investigators conducted a multivariate analysis that controlled for the effects of potential confounders, including cesarean delivery. That analysis found associations only between longer labor and increased risks for cesarean delivery or meconium-stained amniotic fluid.

They then conducted a second multivariate analysis that did not control for the effects of cesarean delivery. Some researchers have speculated that cesarean delivery may be a causal pathway that leads from chorioamnionitis to adverse perinatal outcomes, and so controlling for cesarean delivery might mask any effects of prolonged labor on chorioamnionitis and neonatal outcomes, Dr. Aziz and her associates reasoned.

In the analysis that did not control for cesarean delivery, the only other significant association with increased duration of first-stage labor was a 20% increased risk for postpartum hemorrhage. There was a trend toward greater need for blood transfusion with prolonged first-stage labor in pregnancies with chorioamnionitis. “We've demonstrated that the increasing duration of first-stage labor was associated with increased maternal morbidity, and in turn with operative delivery and thereby postpartum hemorrhage, but not with neonatal morbidity,” she said.

One physician in the audience commented, “I think these are very encouraging and reassuring data.”

Prolonged first-stage labor in pregnancies with chorioamnionitis also was associated with a significantly decreased risk for an umbilical artery base excess greater than 12 mmol/L, which puzzled the investigators. This may be due to fetal indications causing the delivery, Dr. Aziz said.

Imagine losing access to telephones, the Internet, and fax lines during a disaster, and trying to treat patients with nothing but a scratchy two-way radio to connect you with people and institutions outside your office.

It's so last century, and so avoidable, yet that's what happens after natural or man-made disasters, said Dr. Ronald C. Merrell. Physicians should plan ahead to maintain telecommunications so that they can practice medicine independently of emergency operation centers in such situations, he advised.

After terrorists destroyed the World Trade Center in New York in 2001, the dust was so thick that it interfered with satellite communications and cell phones. After a tsunami decimated parts of Southeast Asia in 2004, and after Hurricane Katrina hit the U.S. Gulf Coast in 2005, many physicians lost phone lines and were stuck with more primitive modes of communication, like ham radios.

“That's technology we've had since the Second World War. It's fine, but we need to find a way to access the Internet. It's hard to practice medicine over a radio,” said Dr. Merrell, director of the Medical Informatics and Technology Applications Consortium (MITAC) at Virginia Commonwealth University, Richmond, and an ACS Fellow. MITAC is a research center sponsored by the National Aeronautic and Space Administration (NASA).

The medical needs of refugees from a disaster aren't necessarily what you might expect. Dr. Merrell and two colleagues from MITAC responded to a call from NASA after Hurricane Katrina to help an occupational medicine office at a NASA facility about 34 miles from the Mississippi coast. The office and its one physician had lost most communication with the outside world. Hundreds of people needed medical care, and within days the numbers grew to 4,000.

Many patients were on complex regimens of medicine, but their pills had washed away in the storm. One group of mentally ill patients from an assisted living facility had lost antipsychotic medication. Others had lost refrigeration and no longer had insulin.

Telemedicine teams in other parts of the country were eager to help, but the Mississippi facility had no good way to let them know what to send.

Dr. Merrell and his team set up a satellite telephone, a computer satellite dish, and other equipment that gave them 65 kilobytes of transmission speed. Phone calls were transmitted via a French satellite to Paris and back to the United States. The team even brought solar panels to provide power if needed, but they were able to use electricity from the NASA facility.

The system allowed them to order medications, connect with other medical facilities, and coordinate transfers of patients to more stable environments.

Because telemedicine isn't part of the usual disaster preparedness infrastructure, deploying the specialized equipment and then training people to practice telemedicine is time-consuming, which limits the amount of help it can provide, Dr. Merrell noted. Physicians would be wise to assess the disaster plans for their clinics or hospitals and advocate for redundant telecommunications capabilities.

“Medicine has to have a fairly independent and broadband interface” separate from acute emergency response efforts to serve patients well in a crisis, he said.

Having equipment and trained personnel in place made a huge difference when a devastating earthquake struck Pakistan in October 2005, Dr. Merrell said, noting that it may have been the first time that telemedicine formed the core of a successful medical response to a tragedy.

Under a grant from the U.S. Agency for International Development, Dr. Merrell and Dr. Azhar Rafiq of Virginia Commonwealth University had traveled to Pakistan about a month before the earthquake to help establish two telemedicine training facilities in Rawalpindi, just outside the capital of Islamabad. The telemedicine facilities were to enable communications with two primary care clinics in the rural Punjab area for a more integrated health system.

When the earthquake hit, “We were in touch with them within 12 hours” thanks to the telemedicine programs, he said. The Rawalpindi medical facility was the first fully intact medical site encountered by people fleeing the mountainous areas, where the earthquake had leveled brick hospitals and killed almost all of the medical workers. Soon Rawalpindi's 1,500 beds were in demand for 6,000 patients.

Telecommunications kept the facility from being overwhelmed. Medical students volunteered for brief training in telemedicine and hiked into the mountains with backpacks containing satellite phones, digital cameras, laptop computers, and mobile power sources. From the mountains they informed the hospital at Rawalpindi and other facilities about which patients were headed their way and what would be needed. The students also transmitted medical records and photographs.

After reconstructive surgery at the Rawalpindi medical facility, patients were sent back to tent facilities in the mountains to recover. Surgeons were even able to send patients with complex orthopedic repairs to the mountains, knowing that staff would be able to telecommunicate about the patients' status and any postsurgical problems that arose.

“They never did overwhelm the hospital,” Dr. Merrell said. “They were able to use telecommunications to move patients down out of the mountains for definitive care and get them out and back to the mountains in a fraction of the usual time—in about 48 hours.”

Dr. Merrell and Dr. Rafiq returned to Pakistan in January 2006 to help assess the surgical systems and telemedicine facilities as the country moved from its post-earthquake crisis phase to a reconstruction phase. Telemedicine will continue to help Pakistani medical workers use their time most efficiently and make health care more integrated.

Dr. Merrell, left, with Dr. Khan and Dr. Gilani, outside the clinic in Rawalpindi following last year's earthquake in Pakistan. Courtesy Dr. Ronald C. Merrell

Imagine losing access to telephones, the Internet, and fax lines during a disaster, and trying to treat patients with nothing but a scratchy two-way radio to connect you with people and institutions outside your office.

It's so last century, and so avoidable, yet that's what happens after natural or man-made disasters, said Dr. Ronald C. Merrell. Physicians should plan ahead to maintain telecommunications so that they can practice medicine independently of emergency operation centers in such situations, he advised.

After terrorists destroyed the World Trade Center in New York in 2001, the dust was so thick that it interfered with satellite communications and cell phones. After a tsunami decimated parts of Southeast Asia in 2004, and after Hurricane Katrina hit the U.S. Gulf Coast in 2005, many physicians lost phone lines and were stuck with more primitive modes of communication, like ham radios.

“That's technology we've had since the Second World War. It's fine, but we need to find a way to access the Internet. It's hard to practice medicine over a radio,” said Dr. Merrell, director of the Medical Informatics and Technology Applications Consortium (MITAC) at Virginia Commonwealth University, Richmond, and an ACS Fellow. MITAC is a research center sponsored by the National Aeronautic and Space Administration (NASA).

The medical needs of refugees from a disaster aren't necessarily what you might expect. Dr. Merrell and two colleagues from MITAC responded to a call from NASA after Hurricane Katrina to help an occupational medicine office at a NASA facility about 34 miles from the Mississippi coast. The office and its one physician had lost most communication with the outside world. Hundreds of people needed medical care, and within days the numbers grew to 4,000.

Many patients were on complex regimens of medicine, but their pills had washed away in the storm. One group of mentally ill patients from an assisted living facility had lost antipsychotic medication. Others had lost refrigeration and no longer had insulin.

Telemedicine teams in other parts of the country were eager to help, but the Mississippi facility had no good way to let them know what to send.

Dr. Merrell and his team set up a satellite telephone, a computer satellite dish, and other equipment that gave them 65 kilobytes of transmission speed. Phone calls were transmitted via a French satellite to Paris and back to the United States. The team even brought solar panels to provide power if needed, but they were able to use electricity from the NASA facility.

The system allowed them to order medications, connect with other medical facilities, and coordinate transfers of patients to more stable environments.

Because telemedicine isn't part of the usual disaster preparedness infrastructure, deploying the specialized equipment and then training people to practice telemedicine is time-consuming, which limits the amount of help it can provide, Dr. Merrell noted. Physicians would be wise to assess the disaster plans for their clinics or hospitals and advocate for redundant telecommunications capabilities.

“Medicine has to have a fairly independent and broadband interface” separate from acute emergency response efforts to serve patients well in a crisis, he said.

Having equipment and trained personnel in place made a huge difference when a devastating earthquake struck Pakistan in October 2005, Dr. Merrell said, noting that it may have been the first time that telemedicine formed the core of a successful medical response to a tragedy.

Under a grant from the U.S. Agency for International Development, Dr. Merrell and Dr. Azhar Rafiq of Virginia Commonwealth University had traveled to Pakistan about a month before the earthquake to help establish two telemedicine training facilities in Rawalpindi, just outside the capital of Islamabad. The telemedicine facilities were to enable communications with two primary care clinics in the rural Punjab area for a more integrated health system.

When the earthquake hit, “We were in touch with them within 12 hours” thanks to the telemedicine programs, he said. The Rawalpindi medical facility was the first fully intact medical site encountered by people fleeing the mountainous areas, where the earthquake had leveled brick hospitals and killed almost all of the medical workers. Soon Rawalpindi's 1,500 beds were in demand for 6,000 patients.

Telecommunications kept the facility from being overwhelmed. Medical students volunteered for brief training in telemedicine and hiked into the mountains with backpacks containing satellite phones, digital cameras, laptop computers, and mobile power sources. From the mountains they informed the hospital at Rawalpindi and other facilities about which patients were headed their way and what would be needed. The students also transmitted medical records and photographs.

After reconstructive surgery at the Rawalpindi medical facility, patients were sent back to tent facilities in the mountains to recover. Surgeons were even able to send patients with complex orthopedic repairs to the mountains, knowing that staff would be able to telecommunicate about the patients' status and any postsurgical problems that arose.

“They never did overwhelm the hospital,” Dr. Merrell said. “They were able to use telecommunications to move patients down out of the mountains for definitive care and get them out and back to the mountains in a fraction of the usual time—in about 48 hours.”

Dr. Merrell and Dr. Rafiq returned to Pakistan in January 2006 to help assess the surgical systems and telemedicine facilities as the country moved from its post-earthquake crisis phase to a reconstruction phase. Telemedicine will continue to help Pakistani medical workers use their time most efficiently and make health care more integrated.

Dr. Merrell, left, with Dr. Khan and Dr. Gilani, outside the clinic in Rawalpindi following last year's earthquake in Pakistan. Courtesy Dr. Ronald C. Merrell

Imagine losing access to telephones, the Internet, and fax lines during a disaster, and trying to treat patients with nothing but a scratchy two-way radio to connect you with people and institutions outside your office.

It's so last century, and so avoidable, yet that's what happens after natural or man-made disasters, said Dr. Ronald C. Merrell. Physicians should plan ahead to maintain telecommunications so that they can practice medicine independently of emergency operation centers in such situations, he advised.

After terrorists destroyed the World Trade Center in New York in 2001, the dust was so thick that it interfered with satellite communications and cell phones. After a tsunami decimated parts of Southeast Asia in 2004, and after Hurricane Katrina hit the U.S. Gulf Coast in 2005, many physicians lost phone lines and were stuck with more primitive modes of communication, like ham radios.

“That's technology we've had since the Second World War. It's fine, but we need to find a way to access the Internet. It's hard to practice medicine over a radio,” said Dr. Merrell, director of the Medical Informatics and Technology Applications Consortium (MITAC) at Virginia Commonwealth University, Richmond, and an ACS Fellow. MITAC is a research center sponsored by the National Aeronautic and Space Administration (NASA).

The medical needs of refugees from a disaster aren't necessarily what you might expect. Dr. Merrell and two colleagues from MITAC responded to a call from NASA after Hurricane Katrina to help an occupational medicine office at a NASA facility about 34 miles from the Mississippi coast. The office and its one physician had lost most communication with the outside world. Hundreds of people needed medical care, and within days the numbers grew to 4,000.

Many patients were on complex regimens of medicine, but their pills had washed away in the storm. One group of mentally ill patients from an assisted living facility had lost antipsychotic medication. Others had lost refrigeration and no longer had insulin.

Telemedicine teams in other parts of the country were eager to help, but the Mississippi facility had no good way to let them know what to send.

Dr. Merrell and his team set up a satellite telephone, a computer satellite dish, and other equipment that gave them 65 kilobytes of transmission speed. Phone calls were transmitted via a French satellite to Paris and back to the United States. The team even brought solar panels to provide power if needed, but they were able to use electricity from the NASA facility.

The system allowed them to order medications, connect with other medical facilities, and coordinate transfers of patients to more stable environments.

Because telemedicine isn't part of the usual disaster preparedness infrastructure, deploying the specialized equipment and then training people to practice telemedicine is time-consuming, which limits the amount of help it can provide, Dr. Merrell noted. Physicians would be wise to assess the disaster plans for their clinics or hospitals and advocate for redundant telecommunications capabilities.

“Medicine has to have a fairly independent and broadband interface” separate from acute emergency response efforts to serve patients well in a crisis, he said.

Having equipment and trained personnel in place made a huge difference when a devastating earthquake struck Pakistan in October 2005, Dr. Merrell said, noting that it may have been the first time that telemedicine formed the core of a successful medical response to a tragedy.

Under a grant from the U.S. Agency for International Development, Dr. Merrell and Dr. Azhar Rafiq of Virginia Commonwealth University had traveled to Pakistan about a month before the earthquake to help establish two telemedicine training facilities in Rawalpindi, just outside the capital of Islamabad. The telemedicine facilities were to enable communications with two primary care clinics in the rural Punjab area for a more integrated health system.

When the earthquake hit, “We were in touch with them within 12 hours” thanks to the telemedicine programs, he said. The Rawalpindi medical facility was the first fully intact medical site encountered by people fleeing the mountainous areas, where the earthquake had leveled brick hospitals and killed almost all of the medical workers. Soon Rawalpindi's 1,500 beds were in demand for 6,000 patients.

Telecommunications kept the facility from being overwhelmed. Medical students volunteered for brief training in telemedicine and hiked into the mountains with backpacks containing satellite phones, digital cameras, laptop computers, and mobile power sources. From the mountains they informed the hospital at Rawalpindi and other facilities about which patients were headed their way and what would be needed. The students also transmitted medical records and photographs.

After reconstructive surgery at the Rawalpindi medical facility, patients were sent back to tent facilities in the mountains to recover. Surgeons were even able to send patients with complex orthopedic repairs to the mountains, knowing that staff would be able to telecommunicate about the patients' status and any postsurgical problems that arose.

“They never did overwhelm the hospital,” Dr. Merrell said. “They were able to use telecommunications to move patients down out of the mountains for definitive care and get them out and back to the mountains in a fraction of the usual time—in about 48 hours.”

Dr. Merrell and Dr. Rafiq returned to Pakistan in January 2006 to help assess the surgical systems and telemedicine facilities as the country moved from its post-earthquake crisis phase to a reconstruction phase. Telemedicine will continue to help Pakistani medical workers use their time most efficiently and make health care more integrated.

Dr. Merrell, left, with Dr. Khan and Dr. Gilani, outside the clinic in Rawalpindi following last year's earthquake in Pakistan. Courtesy Dr. Ronald C. Merrell

MONTEREY, CALIF. — Multiple doses of tenofovir produced much higher drug concentrations in fetuses, compared with other antiretrovirals taken by pregnant women with HIV, Dr. Kim A. Boggess said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

Few data exist on the fetal effects of antiretroviral regimens for HIV, and those few mostly look at single doses. The current study of eight HIV-infected women who had been on antiretrovirals for at least 26 weeks had them take their usual doses of antiretroviral medications on the day before and the day of a scheduled prelabor cesarean delivery. They also received intravenous zidovudine 4 hours before delivery to reduce the risk of vertical transmission.

Blood samples taken from the mother and mixed umbilical venous/arterial blood before administration of zidovudine and afterward (a mean of 16 hours after their last dose of usual antiretrovirals) found that tenofovir accumulates within the fetal compartment, said Dr. Boggess of the University of North Carolina, Chapel Hill, and her associates.

Results showed levels of tenofovir in umbilical cord blood were six times levels in maternal blood, nine times higher than reported following a single dose of tenofovir. Umbilical:maternal ratios for other antiretrovirals were similar to concentrations reported for single doses.

Three of the eight women were taking tenofovir (Viread), two women were on nelfinavir (Viracept), six were taking Kaletra (lopinavir/ritonavir), and all were exposed to Combivir (lamivudine/zidovudine) in their antiretroviral regimens.

Dr. Boggess has no affiliation with any of the companies that make these drugs.

The implications of tenofovir accumulating in the fetal compartment are unclear; it could be both helpful and harmful. Higher concentrations of an antiretroviral may help reduce the risk of vertical transmission of HIV from women who cannot undergo cesarean delivery, but also may cause more adverse side effects.

The infants are being followed, some with x-rays, to monitor potential bone changes from exposure to antiretrovirals, a concern raised by studies in monkeys.

Approximately 1,800 children are infected with HIV daily worldwide, usually via pregnancy or breast-feeding. Higher fetal antiretroviral concentrations might be especially useful in areas of the world where access to C-sections is limited, Dr. Boggess said.

MONTEREY, CALIF. — Multiple doses of tenofovir produced much higher drug concentrations in fetuses, compared with other antiretrovirals taken by pregnant women with HIV, Dr. Kim A. Boggess said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

Few data exist on the fetal effects of antiretroviral regimens for HIV, and those few mostly look at single doses. The current study of eight HIV-infected women who had been on antiretrovirals for at least 26 weeks had them take their usual doses of antiretroviral medications on the day before and the day of a scheduled prelabor cesarean delivery. They also received intravenous zidovudine 4 hours before delivery to reduce the risk of vertical transmission.

Blood samples taken from the mother and mixed umbilical venous/arterial blood before administration of zidovudine and afterward (a mean of 16 hours after their last dose of usual antiretrovirals) found that tenofovir accumulates within the fetal compartment, said Dr. Boggess of the University of North Carolina, Chapel Hill, and her associates.

Results showed levels of tenofovir in umbilical cord blood were six times levels in maternal blood, nine times higher than reported following a single dose of tenofovir. Umbilical:maternal ratios for other antiretrovirals were similar to concentrations reported for single doses.

Three of the eight women were taking tenofovir (Viread), two women were on nelfinavir (Viracept), six were taking Kaletra (lopinavir/ritonavir), and all were exposed to Combivir (lamivudine/zidovudine) in their antiretroviral regimens.

Dr. Boggess has no affiliation with any of the companies that make these drugs.

The implications of tenofovir accumulating in the fetal compartment are unclear; it could be both helpful and harmful. Higher concentrations of an antiretroviral may help reduce the risk of vertical transmission of HIV from women who cannot undergo cesarean delivery, but also may cause more adverse side effects.

The infants are being followed, some with x-rays, to monitor potential bone changes from exposure to antiretrovirals, a concern raised by studies in monkeys.

Approximately 1,800 children are infected with HIV daily worldwide, usually via pregnancy or breast-feeding. Higher fetal antiretroviral concentrations might be especially useful in areas of the world where access to C-sections is limited, Dr. Boggess said.

MONTEREY, CALIF. — Multiple doses of tenofovir produced much higher drug concentrations in fetuses, compared with other antiretrovirals taken by pregnant women with HIV, Dr. Kim A. Boggess said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

Few data exist on the fetal effects of antiretroviral regimens for HIV, and those few mostly look at single doses. The current study of eight HIV-infected women who had been on antiretrovirals for at least 26 weeks had them take their usual doses of antiretroviral medications on the day before and the day of a scheduled prelabor cesarean delivery. They also received intravenous zidovudine 4 hours before delivery to reduce the risk of vertical transmission.

Blood samples taken from the mother and mixed umbilical venous/arterial blood before administration of zidovudine and afterward (a mean of 16 hours after their last dose of usual antiretrovirals) found that tenofovir accumulates within the fetal compartment, said Dr. Boggess of the University of North Carolina, Chapel Hill, and her associates.

Results showed levels of tenofovir in umbilical cord blood were six times levels in maternal blood, nine times higher than reported following a single dose of tenofovir. Umbilical:maternal ratios for other antiretrovirals were similar to concentrations reported for single doses.

Three of the eight women were taking tenofovir (Viread), two women were on nelfinavir (Viracept), six were taking Kaletra (lopinavir/ritonavir), and all were exposed to Combivir (lamivudine/zidovudine) in their antiretroviral regimens.

Dr. Boggess has no affiliation with any of the companies that make these drugs.

The implications of tenofovir accumulating in the fetal compartment are unclear; it could be both helpful and harmful. Higher concentrations of an antiretroviral may help reduce the risk of vertical transmission of HIV from women who cannot undergo cesarean delivery, but also may cause more adverse side effects.

The infants are being followed, some with x-rays, to monitor potential bone changes from exposure to antiretrovirals, a concern raised by studies in monkeys.

Approximately 1,800 children are infected with HIV daily worldwide, usually via pregnancy or breast-feeding. Higher fetal antiretroviral concentrations might be especially useful in areas of the world where access to C-sections is limited, Dr. Boggess said.

MONTEREY, CALIF. — Two (2%) of 98 pregnant women being admitted for labor or a scheduled C-section were colonized with methicillin-resistant Staphylococcus aureus in a pilot study, Dr. Richard H. Beigi reported in a poster presentation at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

The results of the study are consistent with a 2%–4% colonization rate for methicillin-resistant S. aureus (MRSA) found in some populations, though higher rates have been seen in select populations. These are among the first data on MRSA in women entering labor and delivery wards, said Dr. Beigi, who performed the study at MetroHealth Medical Center, Cleveland, and now is at Magee-Women's Hospital, Pittsburgh.

“It emphasizes the fact that we need to have very good hand hygiene,” he said in an interview at the poster session. The study was funded by Steris Corp., which makes a hand hygiene product.

The 2% rate provides a baseline for comparisons as the incidence of MRSA is tracked in labor and delivery over time. Ongoing surveillance is warranted given the increasing rates of MRSA in other specialties and the limited number of effective drug treatments for complications of MRSA infection, said Dr. Beigi and his associates.

Of the 96 women, 21 (22%) had S. aureus detected in samples from the anterior nares. Two (10%) of the 21 with S. aureus had MRSA. One of the women with MRSA worked in a hospital, and the other had no contact with a hospital or hospital workers as a potential source for her MRSA colonization.

Eight (38%) of the 21 isolates with S. aureus demonstrated inducible clindamycin resistance, and one of these was a strain with MRSA. The clinical implications of this are unclear, but MRSA plus clindamycin resistance would further narrow choices for therapy.

In a subset of 28 women who also had cultures obtained from the outer third of the vagina, 23 (82%) had concordant findings, meaning that if they were positive or negative for S. aureus in one anatomical site, they had the same result at the other site.

Six postpartum infections potentially were attributable to S. aureus–two cases of mastitis and four wound infections after C-section. Postpartum infection rates were twice as high in women with S. aureus (10%), compared with uncolonized women (5%), but the difference was not statistically significant. A larger study might show a significant difference in infection rates, Dr. Beigi suggested.

MONTEREY, CALIF. — Two (2%) of 98 pregnant women being admitted for labor or a scheduled C-section were colonized with methicillin-resistant Staphylococcus aureus in a pilot study, Dr. Richard H. Beigi reported in a poster presentation at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

The results of the study are consistent with a 2%–4% colonization rate for methicillin-resistant S. aureus (MRSA) found in some populations, though higher rates have been seen in select populations. These are among the first data on MRSA in women entering labor and delivery wards, said Dr. Beigi, who performed the study at MetroHealth Medical Center, Cleveland, and now is at Magee-Women's Hospital, Pittsburgh.

“It emphasizes the fact that we need to have very good hand hygiene,” he said in an interview at the poster session. The study was funded by Steris Corp., which makes a hand hygiene product.

The 2% rate provides a baseline for comparisons as the incidence of MRSA is tracked in labor and delivery over time. Ongoing surveillance is warranted given the increasing rates of MRSA in other specialties and the limited number of effective drug treatments for complications of MRSA infection, said Dr. Beigi and his associates.

Of the 96 women, 21 (22%) had S. aureus detected in samples from the anterior nares. Two (10%) of the 21 with S. aureus had MRSA. One of the women with MRSA worked in a hospital, and the other had no contact with a hospital or hospital workers as a potential source for her MRSA colonization.

Eight (38%) of the 21 isolates with S. aureus demonstrated inducible clindamycin resistance, and one of these was a strain with MRSA. The clinical implications of this are unclear, but MRSA plus clindamycin resistance would further narrow choices for therapy.

In a subset of 28 women who also had cultures obtained from the outer third of the vagina, 23 (82%) had concordant findings, meaning that if they were positive or negative for S. aureus in one anatomical site, they had the same result at the other site.

Six postpartum infections potentially were attributable to S. aureus–two cases of mastitis and four wound infections after C-section. Postpartum infection rates were twice as high in women with S. aureus (10%), compared with uncolonized women (5%), but the difference was not statistically significant. A larger study might show a significant difference in infection rates, Dr. Beigi suggested.

MONTEREY, CALIF. — Two (2%) of 98 pregnant women being admitted for labor or a scheduled C-section were colonized with methicillin-resistant Staphylococcus aureus in a pilot study, Dr. Richard H. Beigi reported in a poster presentation at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

The results of the study are consistent with a 2%–4% colonization rate for methicillin-resistant S. aureus (MRSA) found in some populations, though higher rates have been seen in select populations. These are among the first data on MRSA in women entering labor and delivery wards, said Dr. Beigi, who performed the study at MetroHealth Medical Center, Cleveland, and now is at Magee-Women's Hospital, Pittsburgh.

“It emphasizes the fact that we need to have very good hand hygiene,” he said in an interview at the poster session. The study was funded by Steris Corp., which makes a hand hygiene product.

The 2% rate provides a baseline for comparisons as the incidence of MRSA is tracked in labor and delivery over time. Ongoing surveillance is warranted given the increasing rates of MRSA in other specialties and the limited number of effective drug treatments for complications of MRSA infection, said Dr. Beigi and his associates.

Of the 96 women, 21 (22%) had S. aureus detected in samples from the anterior nares. Two (10%) of the 21 with S. aureus had MRSA. One of the women with MRSA worked in a hospital, and the other had no contact with a hospital or hospital workers as a potential source for her MRSA colonization.

Eight (38%) of the 21 isolates with S. aureus demonstrated inducible clindamycin resistance, and one of these was a strain with MRSA. The clinical implications of this are unclear, but MRSA plus clindamycin resistance would further narrow choices for therapy.

In a subset of 28 women who also had cultures obtained from the outer third of the vagina, 23 (82%) had concordant findings, meaning that if they were positive or negative for S. aureus in one anatomical site, they had the same result at the other site.

Six postpartum infections potentially were attributable to S. aureus–two cases of mastitis and four wound infections after C-section. Postpartum infection rates were twice as high in women with S. aureus (10%), compared with uncolonized women (5%), but the difference was not statistically significant. A larger study might show a significant difference in infection rates, Dr. Beigi suggested.

MONTEREY, CALIF. — Cefazolin remained an effective empiric therapy for antepartum pyelonephritis over the last 14 years, Dr. Soldrea Roberts said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

A retrospective study compared data on 136 women with antepartum pyelonephritis who were treated at one institution in two time periods, 1992–1993 and 2004–2006. Records revealed positive cultures in 76%, and 89% of these were caused by gram-negative isolates, found in 47 women in the earlier period and 46 in the later period.

Rates of multidrug resistant organisms causing antepartum pyelonephritis were not significantly different between periods but trended upward, from 32% of isolates in 1992–1993 to 43% in 2004–2006. Multidrug resistance was defined as resistance to at least 3 of an average of 10 antimicrobials tested per isolate.

E. coli caused more than 70% of cases. High rates of ampicillin-resistant E. coli were seen in both time periods—51% of cases in 1992–1993 and 54% of cases in 2004–2006—which confirms the inadequacy of ampicillin for empiric therapy of antepartum pyelonephritis, according to Dr. Roberts of Case Western Reserve University, Cleveland, Ohio, and her associates.

E. coli resistance to trimethoprim-sulfamethoxazole increased significantly from 5% of isolates in the earlier years to 23% in the later years, consistent with trends toward greater trimethoprim-sulfamethoxazole resistance in lower urinary tract infections over this time period. Only 5% of E. coli isolates were resistant to cefazolin in 1992–1993 and all isolates in 2004–2006 were susceptible to cefazolin despite concerns about the emergence of multidrug-resistant gram-negative rods over the past two decades, Dr. Roberts said.

The study was 80% powered to detect a 30% increase in multidrug-resistant isolates between the two time periods.

The likelihood of multidrug resistance was not affected by having a history of antepartum pyelonephritis.

Clinical outcomes did not differ significantly between the two time periods. The average length of hospitalization was 3 days in both periods and did not differ between women with or without multidrug-resistant organisms. Antibiotic regimens were changed during hospitalization in 13% in the earlier period and 11% in the later period. In 1992–1993, 96% of the women delivered at term, compared with 65% in 2004–2006.

MONTEREY, CALIF. — Cefazolin remained an effective empiric therapy for antepartum pyelonephritis over the last 14 years, Dr. Soldrea Roberts said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

A retrospective study compared data on 136 women with antepartum pyelonephritis who were treated at one institution in two time periods, 1992–1993 and 2004–2006. Records revealed positive cultures in 76%, and 89% of these were caused by gram-negative isolates, found in 47 women in the earlier period and 46 in the later period.

Rates of multidrug resistant organisms causing antepartum pyelonephritis were not significantly different between periods but trended upward, from 32% of isolates in 1992–1993 to 43% in 2004–2006. Multidrug resistance was defined as resistance to at least 3 of an average of 10 antimicrobials tested per isolate.

E. coli caused more than 70% of cases. High rates of ampicillin-resistant E. coli were seen in both time periods—51% of cases in 1992–1993 and 54% of cases in 2004–2006—which confirms the inadequacy of ampicillin for empiric therapy of antepartum pyelonephritis, according to Dr. Roberts of Case Western Reserve University, Cleveland, Ohio, and her associates.

E. coli resistance to trimethoprim-sulfamethoxazole increased significantly from 5% of isolates in the earlier years to 23% in the later years, consistent with trends toward greater trimethoprim-sulfamethoxazole resistance in lower urinary tract infections over this time period. Only 5% of E. coli isolates were resistant to cefazolin in 1992–1993 and all isolates in 2004–2006 were susceptible to cefazolin despite concerns about the emergence of multidrug-resistant gram-negative rods over the past two decades, Dr. Roberts said.

The study was 80% powered to detect a 30% increase in multidrug-resistant isolates between the two time periods.

The likelihood of multidrug resistance was not affected by having a history of antepartum pyelonephritis.

Clinical outcomes did not differ significantly between the two time periods. The average length of hospitalization was 3 days in both periods and did not differ between women with or without multidrug-resistant organisms. Antibiotic regimens were changed during hospitalization in 13% in the earlier period and 11% in the later period. In 1992–1993, 96% of the women delivered at term, compared with 65% in 2004–2006.

MONTEREY, CALIF. — Cefazolin remained an effective empiric therapy for antepartum pyelonephritis over the last 14 years, Dr. Soldrea Roberts said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

A retrospective study compared data on 136 women with antepartum pyelonephritis who were treated at one institution in two time periods, 1992–1993 and 2004–2006. Records revealed positive cultures in 76%, and 89% of these were caused by gram-negative isolates, found in 47 women in the earlier period and 46 in the later period.

Rates of multidrug resistant organisms causing antepartum pyelonephritis were not significantly different between periods but trended upward, from 32% of isolates in 1992–1993 to 43% in 2004–2006. Multidrug resistance was defined as resistance to at least 3 of an average of 10 antimicrobials tested per isolate.

E. coli caused more than 70% of cases. High rates of ampicillin-resistant E. coli were seen in both time periods—51% of cases in 1992–1993 and 54% of cases in 2004–2006—which confirms the inadequacy of ampicillin for empiric therapy of antepartum pyelonephritis, according to Dr. Roberts of Case Western Reserve University, Cleveland, Ohio, and her associates.

E. coli resistance to trimethoprim-sulfamethoxazole increased significantly from 5% of isolates in the earlier years to 23% in the later years, consistent with trends toward greater trimethoprim-sulfamethoxazole resistance in lower urinary tract infections over this time period. Only 5% of E. coli isolates were resistant to cefazolin in 1992–1993 and all isolates in 2004–2006 were susceptible to cefazolin despite concerns about the emergence of multidrug-resistant gram-negative rods over the past two decades, Dr. Roberts said.

The study was 80% powered to detect a 30% increase in multidrug-resistant isolates between the two time periods.

The likelihood of multidrug resistance was not affected by having a history of antepartum pyelonephritis.

Clinical outcomes did not differ significantly between the two time periods. The average length of hospitalization was 3 days in both periods and did not differ between women with or without multidrug-resistant organisms. Antibiotic regimens were changed during hospitalization in 13% in the earlier period and 11% in the later period. In 1992–1993, 96% of the women delivered at term, compared with 65% in 2004–2006.