Sherry Boschert

SAN FRANCISCO — Don't reach for the vancomycin when you see uncomplicated cellulitis, because in most cases, empiric therapy is still needed to fight the β-hemolytic streptococci, Ramesh V. Nathan, M.D., said at the annual meeting of the Infectious Diseases Society of America.

Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) might be on the tips of everyone's tongues these days, but group A streptococci remain the cause of most cases of cellulitis that can't be cultured because the patients lack abscesses or wounds, Dr. Nathan explained in a poster presentation.

Serology results for 54 adult patients with uncomplicated cellulitis showed streptococcal antibodies in 45 (83%). In general, most soft tissue infections are caused by β-hemolytic streptococci or S. aureus, so the 9 cases (17%) with negative streptococcal serologies were presumed to be caused by S. aureus, said Dr. Nathan of the University of California, Los Angeles.

Traditionally, β-lactam antibiotics have been the mainstay of treatment for uncomplicated cellulitis because of their excellent activity against both organisms.

Older literature suggested that β-hemolytic streptococci caused most cases of uncomplicated cellulitis even after the emergence of MRSA, but it was unclear whether this had remained true, given the current epidemic of MRSA, Dr. Nathan said.

“Even in the era of community-acquired MRSA, β-hemolytic strep is still a very, very common cause of cellulitis. That means that for therapy, β-lactam antibiotics such as oxacillin or cefazolin are still going to be the most useful,” he said in an interview at the poster session.

Although serologies in most patients were positive for both antistreptolysin O and deoxyribonuclease B antibodies, indicating β-hemolytic streptococci infection, some were positive for just one or the other antibody. Both tests should be done for accurate diagnosis, he said.

The most common site of infection was the legs, followed by arms or hands, trunk, and face. Several comorbidities were highly associated with β-hemolytic streptococci infection: chronic lymphedema, cirrhosis, obesity, and recurrent cellulitis. No comorbidities were seen, however, in 16 patients—a significant proportion (30%) of the whole cohort.

Two patients with negative serologies were found to have group B streptococci by fortuitous blood cultures, Dr. Nathan added. Both patients had diabetes.

The proportion of β-hemolytic streptococci infections in diabetic patients may be underestimated because the usual antibody tests do not detect group B streptococci, he said. Even in the diabetic patients in the study, most infections were caused by β-hemolytic streptococci.

All patients with recurrent cellulitis who reported a previous cellulitis in the same limb had β-hemolytic streptococcal infection.

The study excluded patients with abscesses and significant ulcers or wounds that could be cultured.

It also excluded patients with infections that are more typically caused by a variety of etiologic agents and by polymicrobial infections including periorbital, perineal, and groin infections; diabetic foot ulcers; and infections originating from bite wounds or foreign bodies.

This infection, presumed to be MRSA, did not respond to treatment with doxycycline. Once group A streptococcus was diagnosed, the patient responded well to penicillin. Courtesy Dr. Arthur Jeng

SAN FRANCISCO — Don't reach for the vancomycin when you see uncomplicated cellulitis, because in most cases, empiric therapy is still needed to fight the β-hemolytic streptococci, Ramesh V. Nathan, M.D., said at the annual meeting of the Infectious Diseases Society of America.

Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) might be on the tips of everyone's tongues these days, but group A streptococci remain the cause of most cases of cellulitis that can't be cultured because the patients lack abscesses or wounds, Dr. Nathan explained in a poster presentation.

Serology results for 54 adult patients with uncomplicated cellulitis showed streptococcal antibodies in 45 (83%). In general, most soft tissue infections are caused by β-hemolytic streptococci or S. aureus, so the 9 cases (17%) with negative streptococcal serologies were presumed to be caused by S. aureus, said Dr. Nathan of the University of California, Los Angeles.

Traditionally, β-lactam antibiotics have been the mainstay of treatment for uncomplicated cellulitis because of their excellent activity against both organisms.

Older literature suggested that β-hemolytic streptococci caused most cases of uncomplicated cellulitis even after the emergence of MRSA, but it was unclear whether this had remained true, given the current epidemic of MRSA, Dr. Nathan said.

“Even in the era of community-acquired MRSA, β-hemolytic strep is still a very, very common cause of cellulitis. That means that for therapy, β-lactam antibiotics such as oxacillin or cefazolin are still going to be the most useful,” he said in an interview at the poster session.

Although serologies in most patients were positive for both antistreptolysin O and deoxyribonuclease B antibodies, indicating β-hemolytic streptococci infection, some were positive for just one or the other antibody. Both tests should be done for accurate diagnosis, he said.

The most common site of infection was the legs, followed by arms or hands, trunk, and face. Several comorbidities were highly associated with β-hemolytic streptococci infection: chronic lymphedema, cirrhosis, obesity, and recurrent cellulitis. No comorbidities were seen, however, in 16 patients—a significant proportion (30%) of the whole cohort.

Two patients with negative serologies were found to have group B streptococci by fortuitous blood cultures, Dr. Nathan added. Both patients had diabetes.

The proportion of β-hemolytic streptococci infections in diabetic patients may be underestimated because the usual antibody tests do not detect group B streptococci, he said. Even in the diabetic patients in the study, most infections were caused by β-hemolytic streptococci.

All patients with recurrent cellulitis who reported a previous cellulitis in the same limb had β-hemolytic streptococcal infection.

The study excluded patients with abscesses and significant ulcers or wounds that could be cultured.

It also excluded patients with infections that are more typically caused by a variety of etiologic agents and by polymicrobial infections including periorbital, perineal, and groin infections; diabetic foot ulcers; and infections originating from bite wounds or foreign bodies.

This infection, presumed to be MRSA, did not respond to treatment with doxycycline. Once group A streptococcus was diagnosed, the patient responded well to penicillin. Courtesy Dr. Arthur Jeng

SAN FRANCISCO — Don't reach for the vancomycin when you see uncomplicated cellulitis, because in most cases, empiric therapy is still needed to fight the β-hemolytic streptococci, Ramesh V. Nathan, M.D., said at the annual meeting of the Infectious Diseases Society of America.

Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) might be on the tips of everyone's tongues these days, but group A streptococci remain the cause of most cases of cellulitis that can't be cultured because the patients lack abscesses or wounds, Dr. Nathan explained in a poster presentation.

Serology results for 54 adult patients with uncomplicated cellulitis showed streptococcal antibodies in 45 (83%). In general, most soft tissue infections are caused by β-hemolytic streptococci or S. aureus, so the 9 cases (17%) with negative streptococcal serologies were presumed to be caused by S. aureus, said Dr. Nathan of the University of California, Los Angeles.

Traditionally, β-lactam antibiotics have been the mainstay of treatment for uncomplicated cellulitis because of their excellent activity against both organisms.

Older literature suggested that β-hemolytic streptococci caused most cases of uncomplicated cellulitis even after the emergence of MRSA, but it was unclear whether this had remained true, given the current epidemic of MRSA, Dr. Nathan said.

“Even in the era of community-acquired MRSA, β-hemolytic strep is still a very, very common cause of cellulitis. That means that for therapy, β-lactam antibiotics such as oxacillin or cefazolin are still going to be the most useful,” he said in an interview at the poster session.

Although serologies in most patients were positive for both antistreptolysin O and deoxyribonuclease B antibodies, indicating β-hemolytic streptococci infection, some were positive for just one or the other antibody. Both tests should be done for accurate diagnosis, he said.

The most common site of infection was the legs, followed by arms or hands, trunk, and face. Several comorbidities were highly associated with β-hemolytic streptococci infection: chronic lymphedema, cirrhosis, obesity, and recurrent cellulitis. No comorbidities were seen, however, in 16 patients—a significant proportion (30%) of the whole cohort.

Two patients with negative serologies were found to have group B streptococci by fortuitous blood cultures, Dr. Nathan added. Both patients had diabetes.

The proportion of β-hemolytic streptococci infections in diabetic patients may be underestimated because the usual antibody tests do not detect group B streptococci, he said. Even in the diabetic patients in the study, most infections were caused by β-hemolytic streptococci.

All patients with recurrent cellulitis who reported a previous cellulitis in the same limb had β-hemolytic streptococcal infection.

The study excluded patients with abscesses and significant ulcers or wounds that could be cultured.

It also excluded patients with infections that are more typically caused by a variety of etiologic agents and by polymicrobial infections including periorbital, perineal, and groin infections; diabetic foot ulcers; and infections originating from bite wounds or foreign bodies.

This infection, presumed to be MRSA, did not respond to treatment with doxycycline. Once group A streptococcus was diagnosed, the patient responded well to penicillin. Courtesy Dr. Arthur Jeng

SAN FRANCISCO — The incidence of pediatric hepatitis A took a nosedive since the introduction of a vaccine, Annemarie Wasley, Sc.D., reported at the annual meeting of the Infectious Diseases Society of America.

Now Hispanic children account for an increasing proportion of cases.

The Advisory Committee on Immunization Practices recommended in 1997 that people at high risk of getting hepatitis A (such as international travelers) get vaccinated, and in 1999 recommended routine childhood immunizations against hepatitis A in 17 states with high levels of the disease. Dr. Wasley of the Centers for Disease Control and Prevention, Atlanta, and her associates compared data from the National Notifiable Disease Surveillance System for 2004 with average rates in the prevaccine period of 1990–1997.

The national incidence of hepatitis A declined by 82% to 1.9/100,000 children aged 0–18 years old. “It's now at the lowest rate we've seen in more than 40 years of surveillance of this disease,” she said.

Incidence rates declined by 90% in the 17 states with recommendations for routine vaccination, compared with a decline of 68% in nonroutine vaccination states. In the prevaccine period, cases in the nonroutine vaccination states accounted for 27% of pediatric hepatitis A cases, compared with 68% of cases in 2004.

“The data support an important role for the vaccine in reducing hepatitis A incidence” and suggest that recommendations to expand routine hepatitis A vaccinations nationwide would further reduce pediatric rates of the disease, Dr. Wasley said.

For the first time, the incidence of hepatitis A in children is as low as, or lower than, rates in adults, she added.

The average annual number of U.S. pediatric hepatitis A cases dropped from 9,996 in 1990–1997 to 1,497 in 2004. The incidence declined in all races and ethnic groups in states with routine vaccination recommendations. Hepatitis A remained eight times more common in Hispanic children than in non-Hispanics, even though the incidence in states with routine vaccination recommendations declined by 94% in Hispanics in 2004, compared with the prevaccine period. In the states without recommendations for routine vaccination, pediatric hepatitis A incidence decreased by only 46% in Hispanics, compared with a 78% decline in non-Hispanics.

In 2004, 70 of every 100,000 Hispanic children had hepatitis A, “the highest rate of any demographic” in the study, she said. Hepatitis A in Hispanics accounted for 42% of all pediatric cases of the disease in the prevaccine period and 54% of all cases in 2004. Among Hispanic children, two-thirds of cases are in nonroutine vaccination states.

Although Hispanics constituted 5% of hepatitis A cases in nonroutine vaccination states in 1990–1997, they now account for nearly a third of pediatric cases in those states.

International travel is an important risk factor for hepatitis A disease, especially in Hispanic children, she said.

The proportion of cases attributed to exposure during international travel has increased over time, so that travel is now the most common risk factor. The rate of cases due to household contact with an infected person held steady, and the proportion of cases attributed to exposure to the disease in a child day-care setting decreased.

In 2004, 34% of children with hepatitis A had engaged in international travel, compared with 6% in the prevaccine period. Among Hispanic children with hepatitis A, 43% had traveled internationally, compared with 5% of non-Hispanic children with the disease. Almost all of the trips (97%) were to Central and South America.

The results show great progress in preventing hepatitis A with the vaccine, and highlight the need to reduce higher rates among Hispanic children, she said. “Improved hepatitis A vaccination of Hispanic children nationwide is needed to reduce this disparity, Dr. Wasley said.

SAN FRANCISCO — The incidence of pediatric hepatitis A took a nosedive since the introduction of a vaccine, Annemarie Wasley, Sc.D., reported at the annual meeting of the Infectious Diseases Society of America.

Now Hispanic children account for an increasing proportion of cases.

The Advisory Committee on Immunization Practices recommended in 1997 that people at high risk of getting hepatitis A (such as international travelers) get vaccinated, and in 1999 recommended routine childhood immunizations against hepatitis A in 17 states with high levels of the disease. Dr. Wasley of the Centers for Disease Control and Prevention, Atlanta, and her associates compared data from the National Notifiable Disease Surveillance System for 2004 with average rates in the prevaccine period of 1990–1997.

The national incidence of hepatitis A declined by 82% to 1.9/100,000 children aged 0–18 years old. “It's now at the lowest rate we've seen in more than 40 years of surveillance of this disease,” she said.

Incidence rates declined by 90% in the 17 states with recommendations for routine vaccination, compared with a decline of 68% in nonroutine vaccination states. In the prevaccine period, cases in the nonroutine vaccination states accounted for 27% of pediatric hepatitis A cases, compared with 68% of cases in 2004.

“The data support an important role for the vaccine in reducing hepatitis A incidence” and suggest that recommendations to expand routine hepatitis A vaccinations nationwide would further reduce pediatric rates of the disease, Dr. Wasley said.

For the first time, the incidence of hepatitis A in children is as low as, or lower than, rates in adults, she added.

The average annual number of U.S. pediatric hepatitis A cases dropped from 9,996 in 1990–1997 to 1,497 in 2004. The incidence declined in all races and ethnic groups in states with routine vaccination recommendations. Hepatitis A remained eight times more common in Hispanic children than in non-Hispanics, even though the incidence in states with routine vaccination recommendations declined by 94% in Hispanics in 2004, compared with the prevaccine period. In the states without recommendations for routine vaccination, pediatric hepatitis A incidence decreased by only 46% in Hispanics, compared with a 78% decline in non-Hispanics.

In 2004, 70 of every 100,000 Hispanic children had hepatitis A, “the highest rate of any demographic” in the study, she said. Hepatitis A in Hispanics accounted for 42% of all pediatric cases of the disease in the prevaccine period and 54% of all cases in 2004. Among Hispanic children, two-thirds of cases are in nonroutine vaccination states.

Although Hispanics constituted 5% of hepatitis A cases in nonroutine vaccination states in 1990–1997, they now account for nearly a third of pediatric cases in those states.

International travel is an important risk factor for hepatitis A disease, especially in Hispanic children, she said.

The proportion of cases attributed to exposure during international travel has increased over time, so that travel is now the most common risk factor. The rate of cases due to household contact with an infected person held steady, and the proportion of cases attributed to exposure to the disease in a child day-care setting decreased.

In 2004, 34% of children with hepatitis A had engaged in international travel, compared with 6% in the prevaccine period. Among Hispanic children with hepatitis A, 43% had traveled internationally, compared with 5% of non-Hispanic children with the disease. Almost all of the trips (97%) were to Central and South America.

The results show great progress in preventing hepatitis A with the vaccine, and highlight the need to reduce higher rates among Hispanic children, she said. “Improved hepatitis A vaccination of Hispanic children nationwide is needed to reduce this disparity, Dr. Wasley said.

SAN FRANCISCO — The incidence of pediatric hepatitis A took a nosedive since the introduction of a vaccine, Annemarie Wasley, Sc.D., reported at the annual meeting of the Infectious Diseases Society of America.

Now Hispanic children account for an increasing proportion of cases.

The Advisory Committee on Immunization Practices recommended in 1997 that people at high risk of getting hepatitis A (such as international travelers) get vaccinated, and in 1999 recommended routine childhood immunizations against hepatitis A in 17 states with high levels of the disease. Dr. Wasley of the Centers for Disease Control and Prevention, Atlanta, and her associates compared data from the National Notifiable Disease Surveillance System for 2004 with average rates in the prevaccine period of 1990–1997.

The national incidence of hepatitis A declined by 82% to 1.9/100,000 children aged 0–18 years old. “It's now at the lowest rate we've seen in more than 40 years of surveillance of this disease,” she said.

Incidence rates declined by 90% in the 17 states with recommendations for routine vaccination, compared with a decline of 68% in nonroutine vaccination states. In the prevaccine period, cases in the nonroutine vaccination states accounted for 27% of pediatric hepatitis A cases, compared with 68% of cases in 2004.

“The data support an important role for the vaccine in reducing hepatitis A incidence” and suggest that recommendations to expand routine hepatitis A vaccinations nationwide would further reduce pediatric rates of the disease, Dr. Wasley said.

For the first time, the incidence of hepatitis A in children is as low as, or lower than, rates in adults, she added.

The average annual number of U.S. pediatric hepatitis A cases dropped from 9,996 in 1990–1997 to 1,497 in 2004. The incidence declined in all races and ethnic groups in states with routine vaccination recommendations. Hepatitis A remained eight times more common in Hispanic children than in non-Hispanics, even though the incidence in states with routine vaccination recommendations declined by 94% in Hispanics in 2004, compared with the prevaccine period. In the states without recommendations for routine vaccination, pediatric hepatitis A incidence decreased by only 46% in Hispanics, compared with a 78% decline in non-Hispanics.

In 2004, 70 of every 100,000 Hispanic children had hepatitis A, “the highest rate of any demographic” in the study, she said. Hepatitis A in Hispanics accounted for 42% of all pediatric cases of the disease in the prevaccine period and 54% of all cases in 2004. Among Hispanic children, two-thirds of cases are in nonroutine vaccination states.

Although Hispanics constituted 5% of hepatitis A cases in nonroutine vaccination states in 1990–1997, they now account for nearly a third of pediatric cases in those states.

International travel is an important risk factor for hepatitis A disease, especially in Hispanic children, she said.

The proportion of cases attributed to exposure during international travel has increased over time, so that travel is now the most common risk factor. The rate of cases due to household contact with an infected person held steady, and the proportion of cases attributed to exposure to the disease in a child day-care setting decreased.

In 2004, 34% of children with hepatitis A had engaged in international travel, compared with 6% in the prevaccine period. Among Hispanic children with hepatitis A, 43% had traveled internationally, compared with 5% of non-Hispanic children with the disease. Almost all of the trips (97%) were to Central and South America.

The results show great progress in preventing hepatitis A with the vaccine, and highlight the need to reduce higher rates among Hispanic children, she said. “Improved hepatitis A vaccination of Hispanic children nationwide is needed to reduce this disparity, Dr. Wasley said.

SAN FRANCISCO — The same principles that keep commodities traders in business were used for the first time to predict disease, accurately forecasting influenza activity up to 6 weeks in advance, Philip M. Polgreen, M.D., said.

Instead of buying corn or soybean futures, a group of 61 health care providers in Iowa used an Internet site to trade information about influenza activity during last year's flu season. In this innovative pilot study, the investigators aggregated and analyzed the trades and compared them with later surveillance data on actual flu activity from the Centers for Disease Control and Prevention.

Results showed that the influenza “prediction market” provided useful forecasts of disease activity up to 6 weeks in advance, with accuracy increasing as the target week grew nearer, Dr. Polgreen said at the annual meeting of the Infectious Diseases Society of America.

Market forecasts made 2–3 weeks in advance matched the level of influenza activity later reported by the CDC 80% of the time, reported Dr. Polgreen of the University of Iowa, Iowa City, and his associates.

“Our data suggest that prediction markets can forecast influenza activity quickly, accurately, and inexpensively by aggregating the expert opinion of health care providers,” he said.

Even a 2-week warning of increased influenza activity would be helpful because it would allow time to vaccinate high-risk patients and health care providers and also would allow planning for increased hospital admissions, Dr. Polgreen said.

Historically, no accurate predictor of flu activity has been available. Although yearly influenza outbreaks are certain, the timing, severity, and strains are not known.

Outbreaks typically peak over 2–3 weeks and last for about 2–3 months. Vaccines must be administered early enough to provide protection (at least 2 weeks before exposure) but not too early, because their effectiveness wanes over time.

Prediction markets were used first in 1988 to forecast the winner of Iowa's presidential caucus, and have proved more accurate than Gallup polls. The method since has been used by Hewlett-Packard to forecast sales of its printers and by Eli Lilly & Co. to predict which drugs are most likely to advance through clinical trials.

About 30–60 active traders are needed for a prediction market to function. More are better, but the most important goal is to use traders who have solid information, such as primary care physicians, infectious disease specialists, pediatricians, emergency department physicians and nurses, epidemiologists, clinical microbiologists, public health officials, and pharmacists.

This year, the investigators will run an influenza prediction market for the full state of Iowa with about 100 traders.

How the Flu Market Worked

Each trader was given 100 “flu dollars” for trading on an interactive Web site that was accessible around the clock. Every even-numbered week during the flu season, the system introduced a new set of contracts, and traders bought or sold predictions of the level of flu activity that would occur 8 weeks after the contracts opened.

They chose from six levels of flu activity, which ranged from “no activity” through “widespread activity.” Trading could continue until the last day of the target week.

A clinical microbiologist who suddenly began seeing more respiratory cultures that tested positive for influenza might log on to the Web site and purchase shares for “widespread influenza activity” while also trying to sell shares for “little or no influenza activity,” Dr. Polgreen said.

The electronic interaction of all the traders led to a set of market prices that reflected the consensus probability for the future level of influenza activity.

When the CDC released its influenza surveillance report after the target week, traders who bought contracts correctly predicting the level of flu activity received 1 flu dollar per contract. All other contracts converted to a zero value.

At the end of the flu season, traders received $1 in educational grant money for every flu dollar they owned. The most successful trader amassed $213.

SAN FRANCISCO — The same principles that keep commodities traders in business were used for the first time to predict disease, accurately forecasting influenza activity up to 6 weeks in advance, Philip M. Polgreen, M.D., said.

Instead of buying corn or soybean futures, a group of 61 health care providers in Iowa used an Internet site to trade information about influenza activity during last year's flu season. In this innovative pilot study, the investigators aggregated and analyzed the trades and compared them with later surveillance data on actual flu activity from the Centers for Disease Control and Prevention.

Results showed that the influenza “prediction market” provided useful forecasts of disease activity up to 6 weeks in advance, with accuracy increasing as the target week grew nearer, Dr. Polgreen said at the annual meeting of the Infectious Diseases Society of America.

Market forecasts made 2–3 weeks in advance matched the level of influenza activity later reported by the CDC 80% of the time, reported Dr. Polgreen of the University of Iowa, Iowa City, and his associates.

“Our data suggest that prediction markets can forecast influenza activity quickly, accurately, and inexpensively by aggregating the expert opinion of health care providers,” he said.

Even a 2-week warning of increased influenza activity would be helpful because it would allow time to vaccinate high-risk patients and health care providers and also would allow planning for increased hospital admissions, Dr. Polgreen said.

Historically, no accurate predictor of flu activity has been available. Although yearly influenza outbreaks are certain, the timing, severity, and strains are not known.

Outbreaks typically peak over 2–3 weeks and last for about 2–3 months. Vaccines must be administered early enough to provide protection (at least 2 weeks before exposure) but not too early, because their effectiveness wanes over time.

Prediction markets were used first in 1988 to forecast the winner of Iowa's presidential caucus, and have proved more accurate than Gallup polls. The method since has been used by Hewlett-Packard to forecast sales of its printers and by Eli Lilly & Co. to predict which drugs are most likely to advance through clinical trials.

About 30–60 active traders are needed for a prediction market to function. More are better, but the most important goal is to use traders who have solid information, such as primary care physicians, infectious disease specialists, pediatricians, emergency department physicians and nurses, epidemiologists, clinical microbiologists, public health officials, and pharmacists.

This year, the investigators will run an influenza prediction market for the full state of Iowa with about 100 traders.

How the Flu Market Worked

Each trader was given 100 “flu dollars” for trading on an interactive Web site that was accessible around the clock. Every even-numbered week during the flu season, the system introduced a new set of contracts, and traders bought or sold predictions of the level of flu activity that would occur 8 weeks after the contracts opened.

They chose from six levels of flu activity, which ranged from “no activity” through “widespread activity.” Trading could continue until the last day of the target week.

A clinical microbiologist who suddenly began seeing more respiratory cultures that tested positive for influenza might log on to the Web site and purchase shares for “widespread influenza activity” while also trying to sell shares for “little or no influenza activity,” Dr. Polgreen said.

The electronic interaction of all the traders led to a set of market prices that reflected the consensus probability for the future level of influenza activity.

When the CDC released its influenza surveillance report after the target week, traders who bought contracts correctly predicting the level of flu activity received 1 flu dollar per contract. All other contracts converted to a zero value.

At the end of the flu season, traders received $1 in educational grant money for every flu dollar they owned. The most successful trader amassed $213.

SAN FRANCISCO — The same principles that keep commodities traders in business were used for the first time to predict disease, accurately forecasting influenza activity up to 6 weeks in advance, Philip M. Polgreen, M.D., said.

Instead of buying corn or soybean futures, a group of 61 health care providers in Iowa used an Internet site to trade information about influenza activity during last year's flu season. In this innovative pilot study, the investigators aggregated and analyzed the trades and compared them with later surveillance data on actual flu activity from the Centers for Disease Control and Prevention.

Results showed that the influenza “prediction market” provided useful forecasts of disease activity up to 6 weeks in advance, with accuracy increasing as the target week grew nearer, Dr. Polgreen said at the annual meeting of the Infectious Diseases Society of America.

Market forecasts made 2–3 weeks in advance matched the level of influenza activity later reported by the CDC 80% of the time, reported Dr. Polgreen of the University of Iowa, Iowa City, and his associates.

“Our data suggest that prediction markets can forecast influenza activity quickly, accurately, and inexpensively by aggregating the expert opinion of health care providers,” he said.

Even a 2-week warning of increased influenza activity would be helpful because it would allow time to vaccinate high-risk patients and health care providers and also would allow planning for increased hospital admissions, Dr. Polgreen said.

Historically, no accurate predictor of flu activity has been available. Although yearly influenza outbreaks are certain, the timing, severity, and strains are not known.

Outbreaks typically peak over 2–3 weeks and last for about 2–3 months. Vaccines must be administered early enough to provide protection (at least 2 weeks before exposure) but not too early, because their effectiveness wanes over time.

Prediction markets were used first in 1988 to forecast the winner of Iowa's presidential caucus, and have proved more accurate than Gallup polls. The method since has been used by Hewlett-Packard to forecast sales of its printers and by Eli Lilly & Co. to predict which drugs are most likely to advance through clinical trials.

About 30–60 active traders are needed for a prediction market to function. More are better, but the most important goal is to use traders who have solid information, such as primary care physicians, infectious disease specialists, pediatricians, emergency department physicians and nurses, epidemiologists, clinical microbiologists, public health officials, and pharmacists.

This year, the investigators will run an influenza prediction market for the full state of Iowa with about 100 traders.

How the Flu Market Worked

Each trader was given 100 “flu dollars” for trading on an interactive Web site that was accessible around the clock. Every even-numbered week during the flu season, the system introduced a new set of contracts, and traders bought or sold predictions of the level of flu activity that would occur 8 weeks after the contracts opened.

They chose from six levels of flu activity, which ranged from “no activity” through “widespread activity.” Trading could continue until the last day of the target week.

A clinical microbiologist who suddenly began seeing more respiratory cultures that tested positive for influenza might log on to the Web site and purchase shares for “widespread influenza activity” while also trying to sell shares for “little or no influenza activity,” Dr. Polgreen said.

The electronic interaction of all the traders led to a set of market prices that reflected the consensus probability for the future level of influenza activity.

When the CDC released its influenza surveillance report after the target week, traders who bought contracts correctly predicting the level of flu activity received 1 flu dollar per contract. All other contracts converted to a zero value.

At the end of the flu season, traders received $1 in educational grant money for every flu dollar they owned. The most successful trader amassed $213.

VANCOUVER, B.C. — Low-grade squamous intraepithelial lesions were likely to regress in women older than 30 years who were not infected with types of human papillomavirus associated with a high risk for cervical cancer, a longitudinal study found.

Of 412 women with untreated cervical low-grade squamous intraepithelial lesions (L-SIL), only women who tested positive for high-risk human papillomavirus (HPV) developed cervical intraepithelial neoplasia grades 2 or 3 (CIN 2/3) during 2 years of follow-up, Christine C. Clavel, Ph.D., said at the 22nd International Papillomavirus Conference.

HPV testing is approved in the United States to help triage women with Pap results showing atypical squamous cells of undetermined significance, or as an adjunct to Pap smears for screening women older than age 30. The study suggests that it also might be helpful by allowing a longer interval between follow-ups in women with L-SIL and a negative HPV test, said Dr. Clavel of the University of Reims (France) Hospital Center.

At baseline, 87% of the 412 women and 80% of those older than 35 years tested positive for high-risk HPV types. Colposcopy and biopsies found 21 cases of CIN 2/3 at baseline and an additional 12 cases during the 2-year follow-up, all in women who initially tested positive for high-risk HPV, she said at the conference, sponsored by the University of California, San Francisco.

Half of the high-risk HPV infections cleared over a median of 9 months in the cohort as a whole and in the subset of women older than 35 years. Cytologic lesions cleared over time in 66% of the total cohort and in 68% of women older than 35.

“There was a significant correlation observed between an initial negative high-risk HPV test, the regression of cytologic lesions, and the absence of CIN 2/3 in follow-up,” Dr. Clavel said.

Women with L-SIL who test negative for high-risk HPV might safely be followed 12 months later by repeat cytology and HPV testing, she said. This would include approximately 13% of all women with L-SIL, 20% of these over age 35 with L-SIL, or 24% of women over age 45 with L-SIL. In women older than 45 years, misclassification of L-SIL increases and leads to a decrease in detection of L-SIL at colposcopy, she noted.

Using HPV testing plus Pap smears to follow HPV-negative women with L-SIL could significantly decrease the number of women sent to colposcopy, compared with follow-up using cytology alone, Dr. Clavel said.

VANCOUVER, B.C. — Low-grade squamous intraepithelial lesions were likely to regress in women older than 30 years who were not infected with types of human papillomavirus associated with a high risk for cervical cancer, a longitudinal study found.

Of 412 women with untreated cervical low-grade squamous intraepithelial lesions (L-SIL), only women who tested positive for high-risk human papillomavirus (HPV) developed cervical intraepithelial neoplasia grades 2 or 3 (CIN 2/3) during 2 years of follow-up, Christine C. Clavel, Ph.D., said at the 22nd International Papillomavirus Conference.

HPV testing is approved in the United States to help triage women with Pap results showing atypical squamous cells of undetermined significance, or as an adjunct to Pap smears for screening women older than age 30. The study suggests that it also might be helpful by allowing a longer interval between follow-ups in women with L-SIL and a negative HPV test, said Dr. Clavel of the University of Reims (France) Hospital Center.

At baseline, 87% of the 412 women and 80% of those older than 35 years tested positive for high-risk HPV types. Colposcopy and biopsies found 21 cases of CIN 2/3 at baseline and an additional 12 cases during the 2-year follow-up, all in women who initially tested positive for high-risk HPV, she said at the conference, sponsored by the University of California, San Francisco.

Half of the high-risk HPV infections cleared over a median of 9 months in the cohort as a whole and in the subset of women older than 35 years. Cytologic lesions cleared over time in 66% of the total cohort and in 68% of women older than 35.

“There was a significant correlation observed between an initial negative high-risk HPV test, the regression of cytologic lesions, and the absence of CIN 2/3 in follow-up,” Dr. Clavel said.

Women with L-SIL who test negative for high-risk HPV might safely be followed 12 months later by repeat cytology and HPV testing, she said. This would include approximately 13% of all women with L-SIL, 20% of these over age 35 with L-SIL, or 24% of women over age 45 with L-SIL. In women older than 45 years, misclassification of L-SIL increases and leads to a decrease in detection of L-SIL at colposcopy, she noted.

Using HPV testing plus Pap smears to follow HPV-negative women with L-SIL could significantly decrease the number of women sent to colposcopy, compared with follow-up using cytology alone, Dr. Clavel said.

VANCOUVER, B.C. — Low-grade squamous intraepithelial lesions were likely to regress in women older than 30 years who were not infected with types of human papillomavirus associated with a high risk for cervical cancer, a longitudinal study found.

Of 412 women with untreated cervical low-grade squamous intraepithelial lesions (L-SIL), only women who tested positive for high-risk human papillomavirus (HPV) developed cervical intraepithelial neoplasia grades 2 or 3 (CIN 2/3) during 2 years of follow-up, Christine C. Clavel, Ph.D., said at the 22nd International Papillomavirus Conference.

HPV testing is approved in the United States to help triage women with Pap results showing atypical squamous cells of undetermined significance, or as an adjunct to Pap smears for screening women older than age 30. The study suggests that it also might be helpful by allowing a longer interval between follow-ups in women with L-SIL and a negative HPV test, said Dr. Clavel of the University of Reims (France) Hospital Center.

At baseline, 87% of the 412 women and 80% of those older than 35 years tested positive for high-risk HPV types. Colposcopy and biopsies found 21 cases of CIN 2/3 at baseline and an additional 12 cases during the 2-year follow-up, all in women who initially tested positive for high-risk HPV, she said at the conference, sponsored by the University of California, San Francisco.

Half of the high-risk HPV infections cleared over a median of 9 months in the cohort as a whole and in the subset of women older than 35 years. Cytologic lesions cleared over time in 66% of the total cohort and in 68% of women older than 35.

“There was a significant correlation observed between an initial negative high-risk HPV test, the regression of cytologic lesions, and the absence of CIN 2/3 in follow-up,” Dr. Clavel said.

Women with L-SIL who test negative for high-risk HPV might safely be followed 12 months later by repeat cytology and HPV testing, she said. This would include approximately 13% of all women with L-SIL, 20% of these over age 35 with L-SIL, or 24% of women over age 45 with L-SIL. In women older than 45 years, misclassification of L-SIL increases and leads to a decrease in detection of L-SIL at colposcopy, she noted.

Using HPV testing plus Pap smears to follow HPV-negative women with L-SIL could significantly decrease the number of women sent to colposcopy, compared with follow-up using cytology alone, Dr. Clavel said.

SAN FRANCISCO — Patients receiving bone densitometry should be counseled about their T and the z scores, Steven T. Harris, M.D., advised at a meeting on osteoporosis sponsored by the University of California, San Francisco.

The T score compares the patient's bone mineral density with the mean peak bone density of a 30-year-old person of the same sex and is expressed as a number of standard deviations above or below the young person's density, said Dr. Harris of the university.

The z score compares the patient's bone mineral density with mean peak density for someone the same age, and helps give patients some perspective. “In my consultative practice over the years, I've seen many, many, many patients who have been terrified by being told that they have osteoporosis at age 78 by comparing them to that 30-year-old, and yet who feel reassured when you show them where they are relative to their peers,” he said.

Sharing both score types helps give patients a more accurate picture of their bone health. A 55-year-old woman with a z score of −2 has bone density around the lower limits of normal for her age, but her T score would be −3.2 in comparison with a young adult. That patient can be reassured that she's similar to her peers, but should be persuaded that “there is an issue here that needs to be addressed,” he said.

That said, the patient with a T score above −2.5 (the cutoff for osteoporosis) can still have a clinical diagnosis of osteoporosis if other factors are present such as atraumatic vertebral fractures.

Getting a z score can be especially motivating because those patients who are abnormal, compared with their peers, need the greatest attention to possible secondary causes of low bone density. “If you see an abnormal z score, it makes you worry that much more about something very unusual going on in that particular patient,” Dr. Harris said.

Patients should also be warned that first bone density measurements give a snapshot of the skeleton's current state. But a low T score does not identify the cause of the low bone density, and the patient should not be labeled osteoporosis automatically, he added. Density reports can have a fairly wide margin of error on first-time measurements. In addition, bone density measurements often vary by a few percentage points when done by different machines. Whenever possible, follow-up scans should be performed with the same machine, he advised.

Vitamin D deficiency leading to reduced osteomalacia can produce a low T score that can improve dramatically once the vitamin deficiency is corrected. Celiac disease with malabsorption can lead to a low T score.

Individual T scores for L1-L4 on spinal densitometry are usually aggregated for diagnostic purposes instead of using the individual results for vertebral bodies. The best and worst scores for individual vertebrae should be within one standard deviation of each other. If not, one should suspect an imaging artifact. In these cases, usually the “best” T score is spurious, Dr. Harris said.

It's important to not just read the densitometry report but to look at the scan, he added. A spine with scoliosis, for example, will have changes in facet joints that make the accuracy of densitometry problematic.

Whiteness seen on the L3 and L4 sections of a spinal scan may be due to facet joint sclerosis, skewing density readings. The aggregation of L1-L4 measurements in one such patient produced a T score of −1.7, suggestive of osteopenia. Excluding the L3-L4 measurements, however, the T score was −2.9, in the range of osteoporosis, he said.

On hip scans, check to make sure the hip was imaged in the correct position, with the femoral shaft straight up and down and with sufficient internal rotation on the leg so that little or none of the lesser trochanter is visible.

SAN FRANCISCO — Patients receiving bone densitometry should be counseled about their T and the z scores, Steven T. Harris, M.D., advised at a meeting on osteoporosis sponsored by the University of California, San Francisco.

The T score compares the patient's bone mineral density with the mean peak bone density of a 30-year-old person of the same sex and is expressed as a number of standard deviations above or below the young person's density, said Dr. Harris of the university.

The z score compares the patient's bone mineral density with mean peak density for someone the same age, and helps give patients some perspective. “In my consultative practice over the years, I've seen many, many, many patients who have been terrified by being told that they have osteoporosis at age 78 by comparing them to that 30-year-old, and yet who feel reassured when you show them where they are relative to their peers,” he said.

Sharing both score types helps give patients a more accurate picture of their bone health. A 55-year-old woman with a z score of −2 has bone density around the lower limits of normal for her age, but her T score would be −3.2 in comparison with a young adult. That patient can be reassured that she's similar to her peers, but should be persuaded that “there is an issue here that needs to be addressed,” he said.

That said, the patient with a T score above −2.5 (the cutoff for osteoporosis) can still have a clinical diagnosis of osteoporosis if other factors are present such as atraumatic vertebral fractures.

Getting a z score can be especially motivating because those patients who are abnormal, compared with their peers, need the greatest attention to possible secondary causes of low bone density. “If you see an abnormal z score, it makes you worry that much more about something very unusual going on in that particular patient,” Dr. Harris said.

Patients should also be warned that first bone density measurements give a snapshot of the skeleton's current state. But a low T score does not identify the cause of the low bone density, and the patient should not be labeled osteoporosis automatically, he added. Density reports can have a fairly wide margin of error on first-time measurements. In addition, bone density measurements often vary by a few percentage points when done by different machines. Whenever possible, follow-up scans should be performed with the same machine, he advised.

Vitamin D deficiency leading to reduced osteomalacia can produce a low T score that can improve dramatically once the vitamin deficiency is corrected. Celiac disease with malabsorption can lead to a low T score.

Individual T scores for L1-L4 on spinal densitometry are usually aggregated for diagnostic purposes instead of using the individual results for vertebral bodies. The best and worst scores for individual vertebrae should be within one standard deviation of each other. If not, one should suspect an imaging artifact. In these cases, usually the “best” T score is spurious, Dr. Harris said.

It's important to not just read the densitometry report but to look at the scan, he added. A spine with scoliosis, for example, will have changes in facet joints that make the accuracy of densitometry problematic.

Whiteness seen on the L3 and L4 sections of a spinal scan may be due to facet joint sclerosis, skewing density readings. The aggregation of L1-L4 measurements in one such patient produced a T score of −1.7, suggestive of osteopenia. Excluding the L3-L4 measurements, however, the T score was −2.9, in the range of osteoporosis, he said.

On hip scans, check to make sure the hip was imaged in the correct position, with the femoral shaft straight up and down and with sufficient internal rotation on the leg so that little or none of the lesser trochanter is visible.

SAN FRANCISCO — Patients receiving bone densitometry should be counseled about their T and the z scores, Steven T. Harris, M.D., advised at a meeting on osteoporosis sponsored by the University of California, San Francisco.

The T score compares the patient's bone mineral density with the mean peak bone density of a 30-year-old person of the same sex and is expressed as a number of standard deviations above or below the young person's density, said Dr. Harris of the university.

The z score compares the patient's bone mineral density with mean peak density for someone the same age, and helps give patients some perspective. “In my consultative practice over the years, I've seen many, many, many patients who have been terrified by being told that they have osteoporosis at age 78 by comparing them to that 30-year-old, and yet who feel reassured when you show them where they are relative to their peers,” he said.

Sharing both score types helps give patients a more accurate picture of their bone health. A 55-year-old woman with a z score of −2 has bone density around the lower limits of normal for her age, but her T score would be −3.2 in comparison with a young adult. That patient can be reassured that she's similar to her peers, but should be persuaded that “there is an issue here that needs to be addressed,” he said.

That said, the patient with a T score above −2.5 (the cutoff for osteoporosis) can still have a clinical diagnosis of osteoporosis if other factors are present such as atraumatic vertebral fractures.

Getting a z score can be especially motivating because those patients who are abnormal, compared with their peers, need the greatest attention to possible secondary causes of low bone density. “If you see an abnormal z score, it makes you worry that much more about something very unusual going on in that particular patient,” Dr. Harris said.

Patients should also be warned that first bone density measurements give a snapshot of the skeleton's current state. But a low T score does not identify the cause of the low bone density, and the patient should not be labeled osteoporosis automatically, he added. Density reports can have a fairly wide margin of error on first-time measurements. In addition, bone density measurements often vary by a few percentage points when done by different machines. Whenever possible, follow-up scans should be performed with the same machine, he advised.

Vitamin D deficiency leading to reduced osteomalacia can produce a low T score that can improve dramatically once the vitamin deficiency is corrected. Celiac disease with malabsorption can lead to a low T score.

Individual T scores for L1-L4 on spinal densitometry are usually aggregated for diagnostic purposes instead of using the individual results for vertebral bodies. The best and worst scores for individual vertebrae should be within one standard deviation of each other. If not, one should suspect an imaging artifact. In these cases, usually the “best” T score is spurious, Dr. Harris said.

It's important to not just read the densitometry report but to look at the scan, he added. A spine with scoliosis, for example, will have changes in facet joints that make the accuracy of densitometry problematic.

Whiteness seen on the L3 and L4 sections of a spinal scan may be due to facet joint sclerosis, skewing density readings. The aggregation of L1-L4 measurements in one such patient produced a T score of −1.7, suggestive of osteopenia. Excluding the L3-L4 measurements, however, the T score was −2.9, in the range of osteoporosis, he said.

On hip scans, check to make sure the hip was imaged in the correct position, with the femoral shaft straight up and down and with sufficient internal rotation on the leg so that little or none of the lesser trochanter is visible.

SAN DIEGO — Hydrothermal ablation stopped persistent uterine hemorrhage in six women with large submucosal intrauterine myomas, Herbert A. Goldfarb, M.D., said at an international congress of the Society of Laparoendoscopic Surgeons.

These six patients traditionally would have required a transfusion and hysterectomy. Hydrothermal ablation (HTA) offers a more conservative approach, according to Dr. Goldfarb of New York University. Dr. Goldfarb also said he has no relationship with the company that makes the HTA system.

More than 3 million women in the United States complain of abnormal uterine bleeding each year. Approximately 25% of the 600,000 hysterectomies performed annually in this country are done to treat uterine bleeding, most commonly due to benign causes.

The six women treated with HTA by Dr. Goldfarb were severely anemic. Medical therapy with GnRH agonists and later with norethindrone acetate had failed to stop their bleeding.

“I've always used norethindrone acetate as the one stopgap that could stop women from bleeding,” but it didn't work in these cases, Dr. Goldfarb said. None of the women could have undergone hysterectomy or myomectomy without a blood transfusion.

Instead, HTA stopped the hemorrhaging in all six women by circulating saline solution heated to 90° C in the uterus for 10 minutes.

The hydrothermal ablation procedure can be directly visualized. Dr. Goldfarb noted that this gives it an advantage over some other techniques used for uterine ablation.

After the hemorrhaging was stopped and hemoglobin levels improved, some of the women went on to have a hysterectomy. Other women refused hysterectomy and have been followed without further surgery. No long-term data are available yet on the latter group of women.

Hydrothermal ablation “doesn't necessarily replace hysterectomy” but it can prevent the need for transfusion and emergency hysterectomy, Dr. Goldfarb told physicians at the meeting. “It's safe, quick, and effective, and it gives you time to decide how you want to treat this patient,” he said.

One physician who attended the meeting said that he had had success in stopping uterine hemorrhaging in similar cases by using the NovaSure system, which ablates the uterus via a bipolar electrode.

SAN DIEGO — Hydrothermal ablation stopped persistent uterine hemorrhage in six women with large submucosal intrauterine myomas, Herbert A. Goldfarb, M.D., said at an international congress of the Society of Laparoendoscopic Surgeons.

These six patients traditionally would have required a transfusion and hysterectomy. Hydrothermal ablation (HTA) offers a more conservative approach, according to Dr. Goldfarb of New York University. Dr. Goldfarb also said he has no relationship with the company that makes the HTA system.

More than 3 million women in the United States complain of abnormal uterine bleeding each year. Approximately 25% of the 600,000 hysterectomies performed annually in this country are done to treat uterine bleeding, most commonly due to benign causes.

The six women treated with HTA by Dr. Goldfarb were severely anemic. Medical therapy with GnRH agonists and later with norethindrone acetate had failed to stop their bleeding.

“I've always used norethindrone acetate as the one stopgap that could stop women from bleeding,” but it didn't work in these cases, Dr. Goldfarb said. None of the women could have undergone hysterectomy or myomectomy without a blood transfusion.

Instead, HTA stopped the hemorrhaging in all six women by circulating saline solution heated to 90° C in the uterus for 10 minutes.

The hydrothermal ablation procedure can be directly visualized. Dr. Goldfarb noted that this gives it an advantage over some other techniques used for uterine ablation.

After the hemorrhaging was stopped and hemoglobin levels improved, some of the women went on to have a hysterectomy. Other women refused hysterectomy and have been followed without further surgery. No long-term data are available yet on the latter group of women.

Hydrothermal ablation “doesn't necessarily replace hysterectomy” but it can prevent the need for transfusion and emergency hysterectomy, Dr. Goldfarb told physicians at the meeting. “It's safe, quick, and effective, and it gives you time to decide how you want to treat this patient,” he said.

One physician who attended the meeting said that he had had success in stopping uterine hemorrhaging in similar cases by using the NovaSure system, which ablates the uterus via a bipolar electrode.

SAN DIEGO — Hydrothermal ablation stopped persistent uterine hemorrhage in six women with large submucosal intrauterine myomas, Herbert A. Goldfarb, M.D., said at an international congress of the Society of Laparoendoscopic Surgeons.

These six patients traditionally would have required a transfusion and hysterectomy. Hydrothermal ablation (HTA) offers a more conservative approach, according to Dr. Goldfarb of New York University. Dr. Goldfarb also said he has no relationship with the company that makes the HTA system.

More than 3 million women in the United States complain of abnormal uterine bleeding each year. Approximately 25% of the 600,000 hysterectomies performed annually in this country are done to treat uterine bleeding, most commonly due to benign causes.

The six women treated with HTA by Dr. Goldfarb were severely anemic. Medical therapy with GnRH agonists and later with norethindrone acetate had failed to stop their bleeding.

“I've always used norethindrone acetate as the one stopgap that could stop women from bleeding,” but it didn't work in these cases, Dr. Goldfarb said. None of the women could have undergone hysterectomy or myomectomy without a blood transfusion.

Instead, HTA stopped the hemorrhaging in all six women by circulating saline solution heated to 90° C in the uterus for 10 minutes.

The hydrothermal ablation procedure can be directly visualized. Dr. Goldfarb noted that this gives it an advantage over some other techniques used for uterine ablation.

After the hemorrhaging was stopped and hemoglobin levels improved, some of the women went on to have a hysterectomy. Other women refused hysterectomy and have been followed without further surgery. No long-term data are available yet on the latter group of women.

Hydrothermal ablation “doesn't necessarily replace hysterectomy” but it can prevent the need for transfusion and emergency hysterectomy, Dr. Goldfarb told physicians at the meeting. “It's safe, quick, and effective, and it gives you time to decide how you want to treat this patient,” he said.

One physician who attended the meeting said that he had had success in stopping uterine hemorrhaging in similar cases by using the NovaSure system, which ablates the uterus via a bipolar electrode.

SAN DIEGO — Laparoscopic supracervical hysterectomies can be done safely on an outpatient basis, a review of 190 cases suggests, Stefanos Chandakas, M.D., reported.

The surgeries were performed over a 14-month period by a two-surgeon team at Princess Royal University Hospital, London, where subtotal hysterectomies have been the norm since 2001. Patients underwent the hysterectomies to treat endometriosis (22%), menorrhagia (66%), and endometrial pathology (12%). All had failed medical therapy.

Patients lost an estimated 200 mL of blood on average, ranging from 50 to 2,000 mL. Less than 100 mL of blood was lost in 74% of cases, estimated Dr. Chandakas of the hospital, and his associates.

There were no significant intraoperative complications, vascular injuries, or nerve or ureter injuries. The average length of stay was 8 hours, and 94% of patients were discharged in less than 24 hours.

Postoperative complications included bladder infection or dysfunction in 2%, deep vein thrombosis in less than 1%, and paralytic ileus in one patient. Minimal cyclic bleeding occurred in 1% of patients. That's better than complication rates of 1%–10% reported in the literature, perhaps “because we spend 3–5 minutes coagulating the cervical canal” during the surgery, he said. One patient required reoperation for an intraabdominal abscess.

Compared with total abdominal hysterectomy or total vaginal hysterectomy, laparoscopic supracervical hysterectomy is “a much safer and easier operation to do,” Dr. Chandakas said.

Patients ranged in age from 33 to 53 years, with uterine sizes of 8–41 weeks and uterine weights of 36–325 g. The procedure took 125 minutes when first adopted by Dr. Chandakas' institution, but in recent years 80% of laparoscopic supracervical hysterectomies have averaged 40–45 minutes. The main reason for the longer surgical times was difficulty with the morcellator. Operating times decreased when the surgeons switched to disposable morcellators, he noted.

The team performed laparoscopic supracervical hysterectomy using PlasmaKinetic energy for tissue dissection and coagulation and a 12-mm morcellator to remove dissected organs. U.S. physicians in the audience said that surgeons in this country are just starting to use this approach.

“In the last 3–4 years, we can see a trend of supracervical hysterectomies coming back and becoming more and more widespread both in the U.K. and in the U.S.,” Dr. Chandakas said. The laparoscopic approach to supracervical hysterectomies is newer and easier, he added.

Concerns have been expressed in the literature that subtotal hysterectomies to treat malignancies may leave patients with higher risk compared with total hysterectomies, because the cervix remains intact. There is no evidence, however, that total hysterectomies decrease mortality from cervical cancer. It's the Pap screening that reduces mortality, he noted.

SAN DIEGO — Laparoscopic supracervical hysterectomies can be done safely on an outpatient basis, a review of 190 cases suggests, Stefanos Chandakas, M.D., reported.

The surgeries were performed over a 14-month period by a two-surgeon team at Princess Royal University Hospital, London, where subtotal hysterectomies have been the norm since 2001. Patients underwent the hysterectomies to treat endometriosis (22%), menorrhagia (66%), and endometrial pathology (12%). All had failed medical therapy.

Patients lost an estimated 200 mL of blood on average, ranging from 50 to 2,000 mL. Less than 100 mL of blood was lost in 74% of cases, estimated Dr. Chandakas of the hospital, and his associates.

There were no significant intraoperative complications, vascular injuries, or nerve or ureter injuries. The average length of stay was 8 hours, and 94% of patients were discharged in less than 24 hours.

Postoperative complications included bladder infection or dysfunction in 2%, deep vein thrombosis in less than 1%, and paralytic ileus in one patient. Minimal cyclic bleeding occurred in 1% of patients. That's better than complication rates of 1%–10% reported in the literature, perhaps “because we spend 3–5 minutes coagulating the cervical canal” during the surgery, he said. One patient required reoperation for an intraabdominal abscess.

Compared with total abdominal hysterectomy or total vaginal hysterectomy, laparoscopic supracervical hysterectomy is “a much safer and easier operation to do,” Dr. Chandakas said.

Patients ranged in age from 33 to 53 years, with uterine sizes of 8–41 weeks and uterine weights of 36–325 g. The procedure took 125 minutes when first adopted by Dr. Chandakas' institution, but in recent years 80% of laparoscopic supracervical hysterectomies have averaged 40–45 minutes. The main reason for the longer surgical times was difficulty with the morcellator. Operating times decreased when the surgeons switched to disposable morcellators, he noted.

The team performed laparoscopic supracervical hysterectomy using PlasmaKinetic energy for tissue dissection and coagulation and a 12-mm morcellator to remove dissected organs. U.S. physicians in the audience said that surgeons in this country are just starting to use this approach.

“In the last 3–4 years, we can see a trend of supracervical hysterectomies coming back and becoming more and more widespread both in the U.K. and in the U.S.,” Dr. Chandakas said. The laparoscopic approach to supracervical hysterectomies is newer and easier, he added.

Concerns have been expressed in the literature that subtotal hysterectomies to treat malignancies may leave patients with higher risk compared with total hysterectomies, because the cervix remains intact. There is no evidence, however, that total hysterectomies decrease mortality from cervical cancer. It's the Pap screening that reduces mortality, he noted.

SAN DIEGO — Laparoscopic supracervical hysterectomies can be done safely on an outpatient basis, a review of 190 cases suggests, Stefanos Chandakas, M.D., reported.

The surgeries were performed over a 14-month period by a two-surgeon team at Princess Royal University Hospital, London, where subtotal hysterectomies have been the norm since 2001. Patients underwent the hysterectomies to treat endometriosis (22%), menorrhagia (66%), and endometrial pathology (12%). All had failed medical therapy.

Patients lost an estimated 200 mL of blood on average, ranging from 50 to 2,000 mL. Less than 100 mL of blood was lost in 74% of cases, estimated Dr. Chandakas of the hospital, and his associates.

There were no significant intraoperative complications, vascular injuries, or nerve or ureter injuries. The average length of stay was 8 hours, and 94% of patients were discharged in less than 24 hours.

Postoperative complications included bladder infection or dysfunction in 2%, deep vein thrombosis in less than 1%, and paralytic ileus in one patient. Minimal cyclic bleeding occurred in 1% of patients. That's better than complication rates of 1%–10% reported in the literature, perhaps “because we spend 3–5 minutes coagulating the cervical canal” during the surgery, he said. One patient required reoperation for an intraabdominal abscess.

Compared with total abdominal hysterectomy or total vaginal hysterectomy, laparoscopic supracervical hysterectomy is “a much safer and easier operation to do,” Dr. Chandakas said.

Patients ranged in age from 33 to 53 years, with uterine sizes of 8–41 weeks and uterine weights of 36–325 g. The procedure took 125 minutes when first adopted by Dr. Chandakas' institution, but in recent years 80% of laparoscopic supracervical hysterectomies have averaged 40–45 minutes. The main reason for the longer surgical times was difficulty with the morcellator. Operating times decreased when the surgeons switched to disposable morcellators, he noted.

The team performed laparoscopic supracervical hysterectomy using PlasmaKinetic energy for tissue dissection and coagulation and a 12-mm morcellator to remove dissected organs. U.S. physicians in the audience said that surgeons in this country are just starting to use this approach.

“In the last 3–4 years, we can see a trend of supracervical hysterectomies coming back and becoming more and more widespread both in the U.K. and in the U.S.,” Dr. Chandakas said. The laparoscopic approach to supracervical hysterectomies is newer and easier, he added.

Concerns have been expressed in the literature that subtotal hysterectomies to treat malignancies may leave patients with higher risk compared with total hysterectomies, because the cervix remains intact. There is no evidence, however, that total hysterectomies decrease mortality from cervical cancer. It's the Pap screening that reduces mortality, he noted.

SAN DIEGO — The rate of surgical complications with laparoscopic hysterectomy is similar whether the procedure is performed for benign or cancerous conditions, Ali Mahdavi, M.D., said at an international congress of the Society of Laparoendoscopic Surgeons.

Laparoscopic hysterectomy in 74 women with gynecologic cancers required more surgical time and longer hospitalization, compared with laparoscopic hysterectomy in 85 women with benign gynecologic conditions, a retrospective review of consecutive cases found.

There were no significant differences between groups, however, in estimated blood loss, rate of procedures converted to laparotomy, and intraoperative bowel or bladder injuries, said Dr. Mahdavi, a gynecologic oncologist at the University of California, Irvine.

“Laparoscopic procedures for gynecologic cancers are complicated and technically demanding procedures,” but appear to be safe when done by experienced surgeons, Dr. Mahdavi said. “Operators who decide to proceed with laparoscopic hysterectomy for gynecologic cancers should not only be trained gynecologic oncologists, but should [also] have extensive operative laparoscopy skills.”

The study won first prize among scientific papers on gynecology presented at the meeting.

All hysterectomies were performed by the same group of surgeons, assisted by residents and fellows, using standard techniques and the same preoperative care for all patients. The study analyzed data from patient admission up to 30 days following discharge after surgery.

Women in the cancer group were older than the women with benign conditions (a mean age of 57 and 51 years, respectively) and had a larger mean body mass index (28 vs. 24 kg/m

Mean operating times were 253 minutes in the cancer group and 188 minutes in the benign conditions group. Patients remained hospitalized for 3.5 days in the cancer group, significantly longer than the 2.5 days in the benign conditions group.

Although the mean estimated blood loss did not differ significantly (201 and 184 mL, respectively), the rate of transfusion was significantly lower in the cancer group. Two women in the cancer group and four in the benign conditions group required transfusion.

A significantly higher rate of postoperative fever in the cancer group (four cases, compared with two in the benign conditions group) was not associated with major morbidity, however, Dr. Mahdavi noted.

Two surgeries in each group were converted to laparotomy. One patient in the cancer group suffered an intraoperative bladder injury. There were no bowel injuries or wound infections.

Laparoscopic hysterectomy is a relatively new approach to managing gynecologic cancers, and questions have been raised about perioperative complications and long-term outcomes, compared with abdominal or vaginal hysterectomies.

The results support retrospective studies suggesting the feasibility and safety of laparoscopic hysterectomy for gynecologic cancers, he said. Randomized, controlled trials comparing different hysterectomy routes may never be performed for some gynecologic cancers because the number of patients needed for such trials could not be attained, Dr. Mahdavi said.

In the current study, women in the cancer group had malignancies of the endometrium (49 patients), cervix (15), ovary (7), vagina (1), or other areas (2).

Women in the control group underwent laparoscopic hysterectomy for symptomatic uterine myomas (18 patients), benign adnexal masses (33), pelvic endometriosis (10), and other benign conditions (24), including genital prolapse, cervical dysplasia, and endometrial hyperplasia.

Most patients in the cancer group underwent cancer staging procedures such as lymphadenectomy in addition to hysterectomy, which contributed to operating time, he said.

Other additional procedures in the cancer group included salpingo-oophorectomy, sigmoidoscopy, and cystoscopy. Additional procedures in the control group included salpingo-oophorectomy, colpopexy, urethropexy, cystoscopy, appendectomy, and anterior or posterior colporrhaphy.

In the cancer group, 46 underwent laparoscopic-assisted vaginal hysterectomy, 24 had a total laparoscopic radical hysterectomy, and 2 each underwent total laparoscopic hysterectomy or laparoscopic supracervical hysterectomy.

In the control group, 59 patients had a laparoscopic vaginal hysterectomy, 15 underwent total laparoscopic hysterectomy, and 11 had a laparoscopic supracervical hysterectomy.

SAN DIEGO — The rate of surgical complications with laparoscopic hysterectomy is similar whether the procedure is performed for benign or cancerous conditions, Ali Mahdavi, M.D., said at an international congress of the Society of Laparoendoscopic Surgeons.

Laparoscopic hysterectomy in 74 women with gynecologic cancers required more surgical time and longer hospitalization, compared with laparoscopic hysterectomy in 85 women with benign gynecologic conditions, a retrospective review of consecutive cases found.

There were no significant differences between groups, however, in estimated blood loss, rate of procedures converted to laparotomy, and intraoperative bowel or bladder injuries, said Dr. Mahdavi, a gynecologic oncologist at the University of California, Irvine.

“Laparoscopic procedures for gynecologic cancers are complicated and technically demanding procedures,” but appear to be safe when done by experienced surgeons, Dr. Mahdavi said. “Operators who decide to proceed with laparoscopic hysterectomy for gynecologic cancers should not only be trained gynecologic oncologists, but should [also] have extensive operative laparoscopy skills.”

The study won first prize among scientific papers on gynecology presented at the meeting.

All hysterectomies were performed by the same group of surgeons, assisted by residents and fellows, using standard techniques and the same preoperative care for all patients. The study analyzed data from patient admission up to 30 days following discharge after surgery.

Women in the cancer group were older than the women with benign conditions (a mean age of 57 and 51 years, respectively) and had a larger mean body mass index (28 vs. 24 kg/m

Mean operating times were 253 minutes in the cancer group and 188 minutes in the benign conditions group. Patients remained hospitalized for 3.5 days in the cancer group, significantly longer than the 2.5 days in the benign conditions group.

Although the mean estimated blood loss did not differ significantly (201 and 184 mL, respectively), the rate of transfusion was significantly lower in the cancer group. Two women in the cancer group and four in the benign conditions group required transfusion.

A significantly higher rate of postoperative fever in the cancer group (four cases, compared with two in the benign conditions group) was not associated with major morbidity, however, Dr. Mahdavi noted.

Two surgeries in each group were converted to laparotomy. One patient in the cancer group suffered an intraoperative bladder injury. There were no bowel injuries or wound infections.

Laparoscopic hysterectomy is a relatively new approach to managing gynecologic cancers, and questions have been raised about perioperative complications and long-term outcomes, compared with abdominal or vaginal hysterectomies.

The results support retrospective studies suggesting the feasibility and safety of laparoscopic hysterectomy for gynecologic cancers, he said. Randomized, controlled trials comparing different hysterectomy routes may never be performed for some gynecologic cancers because the number of patients needed for such trials could not be attained, Dr. Mahdavi said.

In the current study, women in the cancer group had malignancies of the endometrium (49 patients), cervix (15), ovary (7), vagina (1), or other areas (2).

Women in the control group underwent laparoscopic hysterectomy for symptomatic uterine myomas (18 patients), benign adnexal masses (33), pelvic endometriosis (10), and other benign conditions (24), including genital prolapse, cervical dysplasia, and endometrial hyperplasia.

Most patients in the cancer group underwent cancer staging procedures such as lymphadenectomy in addition to hysterectomy, which contributed to operating time, he said.

Other additional procedures in the cancer group included salpingo-oophorectomy, sigmoidoscopy, and cystoscopy. Additional procedures in the control group included salpingo-oophorectomy, colpopexy, urethropexy, cystoscopy, appendectomy, and anterior or posterior colporrhaphy.

In the cancer group, 46 underwent laparoscopic-assisted vaginal hysterectomy, 24 had a total laparoscopic radical hysterectomy, and 2 each underwent total laparoscopic hysterectomy or laparoscopic supracervical hysterectomy.

In the control group, 59 patients had a laparoscopic vaginal hysterectomy, 15 underwent total laparoscopic hysterectomy, and 11 had a laparoscopic supracervical hysterectomy.

SAN DIEGO — The rate of surgical complications with laparoscopic hysterectomy is similar whether the procedure is performed for benign or cancerous conditions, Ali Mahdavi, M.D., said at an international congress of the Society of Laparoendoscopic Surgeons.

Laparoscopic hysterectomy in 74 women with gynecologic cancers required more surgical time and longer hospitalization, compared with laparoscopic hysterectomy in 85 women with benign gynecologic conditions, a retrospective review of consecutive cases found.

There were no significant differences between groups, however, in estimated blood loss, rate of procedures converted to laparotomy, and intraoperative bowel or bladder injuries, said Dr. Mahdavi, a gynecologic oncologist at the University of California, Irvine.

“Laparoscopic procedures for gynecologic cancers are complicated and technically demanding procedures,” but appear to be safe when done by experienced surgeons, Dr. Mahdavi said. “Operators who decide to proceed with laparoscopic hysterectomy for gynecologic cancers should not only be trained gynecologic oncologists, but should [also] have extensive operative laparoscopy skills.”

The study won first prize among scientific papers on gynecology presented at the meeting.

All hysterectomies were performed by the same group of surgeons, assisted by residents and fellows, using standard techniques and the same preoperative care for all patients. The study analyzed data from patient admission up to 30 days following discharge after surgery.

Women in the cancer group were older than the women with benign conditions (a mean age of 57 and 51 years, respectively) and had a larger mean body mass index (28 vs. 24 kg/m

Mean operating times were 253 minutes in the cancer group and 188 minutes in the benign conditions group. Patients remained hospitalized for 3.5 days in the cancer group, significantly longer than the 2.5 days in the benign conditions group.

Although the mean estimated blood loss did not differ significantly (201 and 184 mL, respectively), the rate of transfusion was significantly lower in the cancer group. Two women in the cancer group and four in the benign conditions group required transfusion.

A significantly higher rate of postoperative fever in the cancer group (four cases, compared with two in the benign conditions group) was not associated with major morbidity, however, Dr. Mahdavi noted.

Two surgeries in each group were converted to laparotomy. One patient in the cancer group suffered an intraoperative bladder injury. There were no bowel injuries or wound infections.

Laparoscopic hysterectomy is a relatively new approach to managing gynecologic cancers, and questions have been raised about perioperative complications and long-term outcomes, compared with abdominal or vaginal hysterectomies.

The results support retrospective studies suggesting the feasibility and safety of laparoscopic hysterectomy for gynecologic cancers, he said. Randomized, controlled trials comparing different hysterectomy routes may never be performed for some gynecologic cancers because the number of patients needed for such trials could not be attained, Dr. Mahdavi said.

In the current study, women in the cancer group had malignancies of the endometrium (49 patients), cervix (15), ovary (7), vagina (1), or other areas (2).

Women in the control group underwent laparoscopic hysterectomy for symptomatic uterine myomas (18 patients), benign adnexal masses (33), pelvic endometriosis (10), and other benign conditions (24), including genital prolapse, cervical dysplasia, and endometrial hyperplasia.

Most patients in the cancer group underwent cancer staging procedures such as lymphadenectomy in addition to hysterectomy, which contributed to operating time, he said.

Other additional procedures in the cancer group included salpingo-oophorectomy, sigmoidoscopy, and cystoscopy. Additional procedures in the control group included salpingo-oophorectomy, colpopexy, urethropexy, cystoscopy, appendectomy, and anterior or posterior colporrhaphy.

In the cancer group, 46 underwent laparoscopic-assisted vaginal hysterectomy, 24 had a total laparoscopic radical hysterectomy, and 2 each underwent total laparoscopic hysterectomy or laparoscopic supracervical hysterectomy.

In the control group, 59 patients had a laparoscopic vaginal hysterectomy, 15 underwent total laparoscopic hysterectomy, and 11 had a laparoscopic supracervical hysterectomy.

SAN DIEGO — Laparoscopic management for ectopic pregnancy was safely undertaken in 12 women who were in shock, Mark Erian, M.D., reported at an international congress of the Society of Laparoendoscopic Surgeons.

He reviewed records of 12 patients with clinical hypovolemic shock due to a ruptured fallopian tube ectopic pregnancy who were treated laparoscopically in one gynecology unit where minimally invasive surgery is the norm. All patients survived and were successfully treated, said Dr. Erian of Royal Brisbane and Women's Hospital, Brisbane, Australia.

The report of the 12 cases was coauthored by Glenda McLaren, M.D., of the University of Queensland, which is in Brisbane.

Laparoscopic management is the mainstay for women with ectopic pregnancy who are not in shock, and it should still be even when shock occurs, Dr. Erian said. His unit has successfully treated an additional 5 cases of ectopic pregnancy in women with hypovolemic shock since the original series of 12 cases, he added.

The original 12 cases were seen over a period of approximately 4 years, the researchers said. Such cases are relatively rare. Some of these patients had been airlifted by helicopter to the hospital from other parts of Australia.

The patients had a mean age of 21 years (ranging from 15 to 43 years), and all had been amenorrheic for a mean of 7 weeks except two patients for whom the latest normal menstrual period was unknown. Serum β-HCG measurements showed a mean value of 4,850 IU/L. Symptoms and findings of a pelvic examination usually pointed to ectopic pregnancy. Preoperative ultrasound scans showed no intrauterine gestations or excessive peritoneal fluid, and usually showed an adnexal mass with heterogenic echogenicity.

Urgent resuscitation measures, including blood transfusion, stabilized each patient's hemodynamic status. After placing the patient in an exaggerated Trendelenburg's position with a 15− to 25-degree tilt, Dr. Erian performed laparoscopy via a left upper quadrant abdominal approach.

“I always ask the anesthetist to pass a nasogastric or an orogastric tube to make sure that when I pass my first trocar, I'm not going to find myself right inside the stomach,” he noted.

A four-portal entry technique and video laparoscopy allowed maximum access and maneuverability of instruments. In nearly every case, the pelvic organs were bathed with blood, requiring copious irrigation with warm Hartmann's or Ringer's solution and suction for adequate visualization.

The first step in management was to stop the bleeding from the ruptured fallopian tube by using monopolar coagulation diathermy, followed by controlled salpingostomy to remove the ectopic pregnancy. The specimen was sent for histologic examination to confirm the diagnosis. A negative suction drainage apparatus was placed in the pouch of Douglas and left in the pelvis for 6–8 hours following surgery.

After surgery, patients were given prescriptions for a few weeks' worth of iron supplements if needed, and β-HCG values were monitored at least weekly until they fell to nonpregnant levels.

Estimated blood loss averaged 1.8 L. Surgical treatment lasted a mean of 29 minutes. Serum β-HCG levels dropped to nonpregnant levels in 4–6 weeks in all except one patient whose β-HCG level fell but did plateau at 1,800 IU/L for 10 days.

That patient then was readmitted and given a course of methotrexate and folinic acid. Her serum β-HCG level declined to a nonpregnant level 4 weeks later.

No cases reportedly required laparotomy.

Severe intraperitoneal hemorrhage occurs as a result of a ruptured ectopic pregnancy.

This vantage point shows right broad ligament varicosities.

Broad ligament varicosities are shown after laparoscopic suturing is performed. Photos courtesy Dr. Mark Erian

SAN DIEGO — Laparoscopic management for ectopic pregnancy was safely undertaken in 12 women who were in shock, Mark Erian, M.D., reported at an international congress of the Society of Laparoendoscopic Surgeons.

He reviewed records of 12 patients with clinical hypovolemic shock due to a ruptured fallopian tube ectopic pregnancy who were treated laparoscopically in one gynecology unit where minimally invasive surgery is the norm. All patients survived and were successfully treated, said Dr. Erian of Royal Brisbane and Women's Hospital, Brisbane, Australia.

The report of the 12 cases was coauthored by Glenda McLaren, M.D., of the University of Queensland, which is in Brisbane.

Laparoscopic management is the mainstay for women with ectopic pregnancy who are not in shock, and it should still be even when shock occurs, Dr. Erian said. His unit has successfully treated an additional 5 cases of ectopic pregnancy in women with hypovolemic shock since the original series of 12 cases, he added.

The original 12 cases were seen over a period of approximately 4 years, the researchers said. Such cases are relatively rare. Some of these patients had been airlifted by helicopter to the hospital from other parts of Australia.

The patients had a mean age of 21 years (ranging from 15 to 43 years), and all had been amenorrheic for a mean of 7 weeks except two patients for whom the latest normal menstrual period was unknown. Serum β-HCG measurements showed a mean value of 4,850 IU/L. Symptoms and findings of a pelvic examination usually pointed to ectopic pregnancy. Preoperative ultrasound scans showed no intrauterine gestations or excessive peritoneal fluid, and usually showed an adnexal mass with heterogenic echogenicity.

Urgent resuscitation measures, including blood transfusion, stabilized each patient's hemodynamic status. After placing the patient in an exaggerated Trendelenburg's position with a 15− to 25-degree tilt, Dr. Erian performed laparoscopy via a left upper quadrant abdominal approach.

“I always ask the anesthetist to pass a nasogastric or an orogastric tube to make sure that when I pass my first trocar, I'm not going to find myself right inside the stomach,” he noted.

A four-portal entry technique and video laparoscopy allowed maximum access and maneuverability of instruments. In nearly every case, the pelvic organs were bathed with blood, requiring copious irrigation with warm Hartmann's or Ringer's solution and suction for adequate visualization.

The first step in management was to stop the bleeding from the ruptured fallopian tube by using monopolar coagulation diathermy, followed by controlled salpingostomy to remove the ectopic pregnancy. The specimen was sent for histologic examination to confirm the diagnosis. A negative suction drainage apparatus was placed in the pouch of Douglas and left in the pelvis for 6–8 hours following surgery.

After surgery, patients were given prescriptions for a few weeks' worth of iron supplements if needed, and β-HCG values were monitored at least weekly until they fell to nonpregnant levels.

Estimated blood loss averaged 1.8 L. Surgical treatment lasted a mean of 29 minutes. Serum β-HCG levels dropped to nonpregnant levels in 4–6 weeks in all except one patient whose β-HCG level fell but did plateau at 1,800 IU/L for 10 days.

That patient then was readmitted and given a course of methotrexate and folinic acid. Her serum β-HCG level declined to a nonpregnant level 4 weeks later.

No cases reportedly required laparotomy.

Severe intraperitoneal hemorrhage occurs as a result of a ruptured ectopic pregnancy.

This vantage point shows right broad ligament varicosities.

Broad ligament varicosities are shown after laparoscopic suturing is performed. Photos courtesy Dr. Mark Erian

SAN DIEGO — Laparoscopic management for ectopic pregnancy was safely undertaken in 12 women who were in shock, Mark Erian, M.D., reported at an international congress of the Society of Laparoendoscopic Surgeons.

He reviewed records of 12 patients with clinical hypovolemic shock due to a ruptured fallopian tube ectopic pregnancy who were treated laparoscopically in one gynecology unit where minimally invasive surgery is the norm. All patients survived and were successfully treated, said Dr. Erian of Royal Brisbane and Women's Hospital, Brisbane, Australia.

The report of the 12 cases was coauthored by Glenda McLaren, M.D., of the University of Queensland, which is in Brisbane.

Laparoscopic management is the mainstay for women with ectopic pregnancy who are not in shock, and it should still be even when shock occurs, Dr. Erian said. His unit has successfully treated an additional 5 cases of ectopic pregnancy in women with hypovolemic shock since the original series of 12 cases, he added.

The original 12 cases were seen over a period of approximately 4 years, the researchers said. Such cases are relatively rare. Some of these patients had been airlifted by helicopter to the hospital from other parts of Australia.

The patients had a mean age of 21 years (ranging from 15 to 43 years), and all had been amenorrheic for a mean of 7 weeks except two patients for whom the latest normal menstrual period was unknown. Serum β-HCG measurements showed a mean value of 4,850 IU/L. Symptoms and findings of a pelvic examination usually pointed to ectopic pregnancy. Preoperative ultrasound scans showed no intrauterine gestations or excessive peritoneal fluid, and usually showed an adnexal mass with heterogenic echogenicity.

Urgent resuscitation measures, including blood transfusion, stabilized each patient's hemodynamic status. After placing the patient in an exaggerated Trendelenburg's position with a 15− to 25-degree tilt, Dr. Erian performed laparoscopy via a left upper quadrant abdominal approach.

“I always ask the anesthetist to pass a nasogastric or an orogastric tube to make sure that when I pass my first trocar, I'm not going to find myself right inside the stomach,” he noted.

A four-portal entry technique and video laparoscopy allowed maximum access and maneuverability of instruments. In nearly every case, the pelvic organs were bathed with blood, requiring copious irrigation with warm Hartmann's or Ringer's solution and suction for adequate visualization.

The first step in management was to stop the bleeding from the ruptured fallopian tube by using monopolar coagulation diathermy, followed by controlled salpingostomy to remove the ectopic pregnancy. The specimen was sent for histologic examination to confirm the diagnosis. A negative suction drainage apparatus was placed in the pouch of Douglas and left in the pelvis for 6–8 hours following surgery.

After surgery, patients were given prescriptions for a few weeks' worth of iron supplements if needed, and β-HCG values were monitored at least weekly until they fell to nonpregnant levels.

Estimated blood loss averaged 1.8 L. Surgical treatment lasted a mean of 29 minutes. Serum β-HCG levels dropped to nonpregnant levels in 4–6 weeks in all except one patient whose β-HCG level fell but did plateau at 1,800 IU/L for 10 days.

That patient then was readmitted and given a course of methotrexate and folinic acid. Her serum β-HCG level declined to a nonpregnant level 4 weeks later.

No cases reportedly required laparotomy.

Severe intraperitoneal hemorrhage occurs as a result of a ruptured ectopic pregnancy.

This vantage point shows right broad ligament varicosities.

Broad ligament varicosities are shown after laparoscopic suturing is performed. Photos courtesy Dr. Mark Erian

SAN FRANCISCO — Two phase II clinical studies of a combination vaccine suggest that it is safe and immunogenic, investigators reported in poster presentations at the annual meeting of the Infectious Diseases Society of America.

An open study of 3,022 healthy infants found comparable immunogenicity and safety results among four lots of the Pentacel vaccine, which is used to immunize against diphtheria, tetanus, pertussis, polio, and Haemophilus influenzae type b (Hib), reported Kathryn M. Edwards, M.D.

Seroresponse and seroprotection rates were immunogenic with vaccine from all four lots despite coadministration with pneumococcal conjugate (Prevnar) vaccine. In some previous reports, Prevnar vaccine was associated with interference with coadministered pertussis or Hib vaccines, said Dr. Edwards, professor of pediatrics at Vanderbilt University, Nashville, Tenn. She has received funding from Sanofi and from Aventis-Sofitel, part of the Sanofi-Aventis Group, which makes the vaccine. Her associates in the study were employed by Sanofi Pasteur Inc.

Sanofi-Aventis has applied to the Food and Drug Administration for licensing to market Pentacel in the United States. If approved, the four-dose series of Pentacel could reduce the number of recommended childhood vaccine injections by two. Pentacel is licensed for pediatric use in nine countries.

In the current study, the largest single study of Pentacel vaccine in the United States, healthy infants at 23 clinical centers received concomitant Pentacel and Prevnar vaccines at 2, 4, and 6 months of age. They previously had received hepatitis B vaccine, with second and third doses of that vaccine given at 2 and 6 months of age.

Systemic reactions within 3 days of Pentacel vaccination included fever in 11%–20% of infants, fussiness in 60%–71%, and crying in 35%–45%. Two of three serious adverse events that were temporally associated with vaccination were considered to be possibly related to the vaccine.

One 2-month-old developed a hypotonic hyporesponsive episode (HHE) that began 2 hours after the first dose and lasted 8 hours. The infant recovered without treatment, had no sequelae, and received no further doses. This is the first episode of HHE reported in more than 16,000 doses of Pentacel administered so far, Dr. Edwards noted. Another 2-month-old had about eight afebrile seizure episodes 3 days after the first dose, each lasting less than 1 minute. The child was hospitalized for a day and was discharged after normal brain imaging and EEG results. Exam results 2 weeks later were normal. A febrile seizure in a third child with acute otitis media was considered unrelated to the vaccine.

A separate study presented at the meeting extended previous results from a randomized, controlled, multicenter study that found comparable safety and immunogenicity among three doses of Pentacel vaccine; individual administration of vaccines for polio and Hib; and a combination vaccine for diphtheria, tetanus, and acellular pertussis (DTaP).

The current data looked at a fourth dose of Pentacel vaccine in 430 infants or separate administration of the Hib and DTaP vaccines in 419 infants at 15 months of age. The protocol criteria were met by 371 in the Pentacel group and 349 in the control group. The vaccines were coadministered with three doses of Prevnar vaccine and two doses of hepatitis B vaccine in the first part of the study.

Immune responses to each antigen remained comparable between the Pentacel vaccine group and the control group after the 15-month doses in the second part of the study, reported Fernando Noriega, M.D., of Sanofi Pasteur, Swiftwater, Penn., and his associates.

There were no serious adverse events related to the vaccine and no reports of HHE. The investigators found no clinically relevant differences between the safety profiles of the Pentacel vaccine and the DTaP vaccine, Dr. Noriega said.

SAN FRANCISCO — Two phase II clinical studies of a combination vaccine suggest that it is safe and immunogenic, investigators reported in poster presentations at the annual meeting of the Infectious Diseases Society of America.

An open study of 3,022 healthy infants found comparable immunogenicity and safety results among four lots of the Pentacel vaccine, which is used to immunize against diphtheria, tetanus, pertussis, polio, and Haemophilus influenzae type b (Hib), reported Kathryn M. Edwards, M.D.

Seroresponse and seroprotection rates were immunogenic with vaccine from all four lots despite coadministration with pneumococcal conjugate (Prevnar) vaccine. In some previous reports, Prevnar vaccine was associated with interference with coadministered pertussis or Hib vaccines, said Dr. Edwards, professor of pediatrics at Vanderbilt University, Nashville, Tenn. She has received funding from Sanofi and from Aventis-Sofitel, part of the Sanofi-Aventis Group, which makes the vaccine. Her associates in the study were employed by Sanofi Pasteur Inc.

Sanofi-Aventis has applied to the Food and Drug Administration for licensing to market Pentacel in the United States. If approved, the four-dose series of Pentacel could reduce the number of recommended childhood vaccine injections by two. Pentacel is licensed for pediatric use in nine countries.

In the current study, the largest single study of Pentacel vaccine in the United States, healthy infants at 23 clinical centers received concomitant Pentacel and Prevnar vaccines at 2, 4, and 6 months of age. They previously had received hepatitis B vaccine, with second and third doses of that vaccine given at 2 and 6 months of age.

Systemic reactions within 3 days of Pentacel vaccination included fever in 11%–20% of infants, fussiness in 60%–71%, and crying in 35%–45%. Two of three serious adverse events that were temporally associated with vaccination were considered to be possibly related to the vaccine.

One 2-month-old developed a hypotonic hyporesponsive episode (HHE) that began 2 hours after the first dose and lasted 8 hours. The infant recovered without treatment, had no sequelae, and received no further doses. This is the first episode of HHE reported in more than 16,000 doses of Pentacel administered so far, Dr. Edwards noted. Another 2-month-old had about eight afebrile seizure episodes 3 days after the first dose, each lasting less than 1 minute. The child was hospitalized for a day and was discharged after normal brain imaging and EEG results. Exam results 2 weeks later were normal. A febrile seizure in a third child with acute otitis media was considered unrelated to the vaccine.

A separate study presented at the meeting extended previous results from a randomized, controlled, multicenter study that found comparable safety and immunogenicity among three doses of Pentacel vaccine; individual administration of vaccines for polio and Hib; and a combination vaccine for diphtheria, tetanus, and acellular pertussis (DTaP).

The current data looked at a fourth dose of Pentacel vaccine in 430 infants or separate administration of the Hib and DTaP vaccines in 419 infants at 15 months of age. The protocol criteria were met by 371 in the Pentacel group and 349 in the control group. The vaccines were coadministered with three doses of Prevnar vaccine and two doses of hepatitis B vaccine in the first part of the study.

Immune responses to each antigen remained comparable between the Pentacel vaccine group and the control group after the 15-month doses in the second part of the study, reported Fernando Noriega, M.D., of Sanofi Pasteur, Swiftwater, Penn., and his associates.

There were no serious adverse events related to the vaccine and no reports of HHE. The investigators found no clinically relevant differences between the safety profiles of the Pentacel vaccine and the DTaP vaccine, Dr. Noriega said.

SAN FRANCISCO — Two phase II clinical studies of a combination vaccine suggest that it is safe and immunogenic, investigators reported in poster presentations at the annual meeting of the Infectious Diseases Society of America.

An open study of 3,022 healthy infants found comparable immunogenicity and safety results among four lots of the Pentacel vaccine, which is used to immunize against diphtheria, tetanus, pertussis, polio, and Haemophilus influenzae type b (Hib), reported Kathryn M. Edwards, M.D.

Seroresponse and seroprotection rates were immunogenic with vaccine from all four lots despite coadministration with pneumococcal conjugate (Prevnar) vaccine. In some previous reports, Prevnar vaccine was associated with interference with coadministered pertussis or Hib vaccines, said Dr. Edwards, professor of pediatrics at Vanderbilt University, Nashville, Tenn. She has received funding from Sanofi and from Aventis-Sofitel, part of the Sanofi-Aventis Group, which makes the vaccine. Her associates in the study were employed by Sanofi Pasteur Inc.

Sanofi-Aventis has applied to the Food and Drug Administration for licensing to market Pentacel in the United States. If approved, the four-dose series of Pentacel could reduce the number of recommended childhood vaccine injections by two. Pentacel is licensed for pediatric use in nine countries.

In the current study, the largest single study of Pentacel vaccine in the United States, healthy infants at 23 clinical centers received concomitant Pentacel and Prevnar vaccines at 2, 4, and 6 months of age. They previously had received hepatitis B vaccine, with second and third doses of that vaccine given at 2 and 6 months of age.

Systemic reactions within 3 days of Pentacel vaccination included fever in 11%–20% of infants, fussiness in 60%–71%, and crying in 35%–45%. Two of three serious adverse events that were temporally associated with vaccination were considered to be possibly related to the vaccine.

One 2-month-old developed a hypotonic hyporesponsive episode (HHE) that began 2 hours after the first dose and lasted 8 hours. The infant recovered without treatment, had no sequelae, and received no further doses. This is the first episode of HHE reported in more than 16,000 doses of Pentacel administered so far, Dr. Edwards noted. Another 2-month-old had about eight afebrile seizure episodes 3 days after the first dose, each lasting less than 1 minute. The child was hospitalized for a day and was discharged after normal brain imaging and EEG results. Exam results 2 weeks later were normal. A febrile seizure in a third child with acute otitis media was considered unrelated to the vaccine.

A separate study presented at the meeting extended previous results from a randomized, controlled, multicenter study that found comparable safety and immunogenicity among three doses of Pentacel vaccine; individual administration of vaccines for polio and Hib; and a combination vaccine for diphtheria, tetanus, and acellular pertussis (DTaP).

The current data looked at a fourth dose of Pentacel vaccine in 430 infants or separate administration of the Hib and DTaP vaccines in 419 infants at 15 months of age. The protocol criteria were met by 371 in the Pentacel group and 349 in the control group. The vaccines were coadministered with three doses of Prevnar vaccine and two doses of hepatitis B vaccine in the first part of the study.

Immune responses to each antigen remained comparable between the Pentacel vaccine group and the control group after the 15-month doses in the second part of the study, reported Fernando Noriega, M.D., of Sanofi Pasteur, Swiftwater, Penn., and his associates.

There were no serious adverse events related to the vaccine and no reports of HHE. The investigators found no clinically relevant differences between the safety profiles of the Pentacel vaccine and the DTaP vaccine, Dr. Noriega said.