Sherry Boschert

VANCOUVER, B.C. — There's no easy way to identify older women whose risk for human papillomavirus infection is low, so physicians should continue cervical screening unless the woman has tested negative consistently for the virus, Concepcion Diaz-Arrastia, M.D., and her associates advised in a poster presentation at the 22nd International Papillomavirus Conference.

Nineteen (11%) of 176 women older than 55 years tested positive for infection with high-risk or intermediate-risk types of the human papillomavirus (HPV) in a prospective, longitudinal study, they reported at the conference, sponsored by the University of California, San Francisco.

“High-risk HPV infection is not restricted to young women,” said Dr. Diaz-Arrastia of the University of Texas, Galveston, and her associates.

All the women completed a detailed medical and sexual history form and underwent a pelvic exam that included a liquid-based cervical sample and HPV test. The study found no clear social markers of risk for HPV infection in this group of older women, whose mean age was 67 years. “'Low risk' may be more difficult to establish in this age group,” the investigators concluded.

More than a third of the HPV-positive women said they had been sexually inactive for more than the past 5 years. There were no significant differences between the HPV-positive and HPV-negative women in terms of the traditional social risk factors for cervical neoplasia, including a history of first sexual activity before age 16, number of sexual partners in their lifetimes, presence of other sexually transmitted disease, history of sexual abuse, or smoking habits.

Pap smear results also did not correlate with risk for HPV infection. In the HPV-positive group, two women had atypical squamous cells of undetermined significance (ASC-US), and one woman had low-grade squamous intraepithelial lesions (LSIL). In the HPV-negative group, Pap results showed ASC-US in five women and LSIL in one woman. Stratified by race, 4% of 113 Hispanic women were HPV positive, as were 23% of 43 non-Hispanic white women and 25% of 20 African American women, the investigators reported.

VANCOUVER, B.C. — There's no easy way to identify older women whose risk for human papillomavirus infection is low, so physicians should continue cervical screening unless the woman has tested negative consistently for the virus, Concepcion Diaz-Arrastia, M.D., and her associates advised in a poster presentation at the 22nd International Papillomavirus Conference.

Nineteen (11%) of 176 women older than 55 years tested positive for infection with high-risk or intermediate-risk types of the human papillomavirus (HPV) in a prospective, longitudinal study, they reported at the conference, sponsored by the University of California, San Francisco.

“High-risk HPV infection is not restricted to young women,” said Dr. Diaz-Arrastia of the University of Texas, Galveston, and her associates.

All the women completed a detailed medical and sexual history form and underwent a pelvic exam that included a liquid-based cervical sample and HPV test. The study found no clear social markers of risk for HPV infection in this group of older women, whose mean age was 67 years. “'Low risk' may be more difficult to establish in this age group,” the investigators concluded.

More than a third of the HPV-positive women said they had been sexually inactive for more than the past 5 years. There were no significant differences between the HPV-positive and HPV-negative women in terms of the traditional social risk factors for cervical neoplasia, including a history of first sexual activity before age 16, number of sexual partners in their lifetimes, presence of other sexually transmitted disease, history of sexual abuse, or smoking habits.

Pap smear results also did not correlate with risk for HPV infection. In the HPV-positive group, two women had atypical squamous cells of undetermined significance (ASC-US), and one woman had low-grade squamous intraepithelial lesions (LSIL). In the HPV-negative group, Pap results showed ASC-US in five women and LSIL in one woman. Stratified by race, 4% of 113 Hispanic women were HPV positive, as were 23% of 43 non-Hispanic white women and 25% of 20 African American women, the investigators reported.

VANCOUVER, B.C. — There's no easy way to identify older women whose risk for human papillomavirus infection is low, so physicians should continue cervical screening unless the woman has tested negative consistently for the virus, Concepcion Diaz-Arrastia, M.D., and her associates advised in a poster presentation at the 22nd International Papillomavirus Conference.

Nineteen (11%) of 176 women older than 55 years tested positive for infection with high-risk or intermediate-risk types of the human papillomavirus (HPV) in a prospective, longitudinal study, they reported at the conference, sponsored by the University of California, San Francisco.

“High-risk HPV infection is not restricted to young women,” said Dr. Diaz-Arrastia of the University of Texas, Galveston, and her associates.

All the women completed a detailed medical and sexual history form and underwent a pelvic exam that included a liquid-based cervical sample and HPV test. The study found no clear social markers of risk for HPV infection in this group of older women, whose mean age was 67 years. “'Low risk' may be more difficult to establish in this age group,” the investigators concluded.

More than a third of the HPV-positive women said they had been sexually inactive for more than the past 5 years. There were no significant differences between the HPV-positive and HPV-negative women in terms of the traditional social risk factors for cervical neoplasia, including a history of first sexual activity before age 16, number of sexual partners in their lifetimes, presence of other sexually transmitted disease, history of sexual abuse, or smoking habits.

Pap smear results also did not correlate with risk for HPV infection. In the HPV-positive group, two women had atypical squamous cells of undetermined significance (ASC-US), and one woman had low-grade squamous intraepithelial lesions (LSIL). In the HPV-negative group, Pap results showed ASC-US in five women and LSIL in one woman. Stratified by race, 4% of 113 Hispanic women were HPV positive, as were 23% of 43 non-Hispanic white women and 25% of 20 African American women, the investigators reported.

SAN FRANCISCO — A group prenatal care program designed to empower pregnant women is spreading across the United States, Margaret Hutchison said at a meeting on antepartum and intrapartum management.

More than 60 sites offering prenatal care in 28 states have started CenteringPregnancy programs—mostly in public clinics, with some in HMOs and military clinics, said Ms. Hutchison, a certified nurse-midwife at San Francisco General Hospital, a teaching hospital of the University of California, which also sponsored the meeting.

Developed by a certified nurse-midwife and pilot-tested in 1993, the CenteringPregnancy model groups 8–12 women of similar gestational age for 10 facilitated 2-hour meetings starting at gestational weeks 12–16.

The groups usually meet monthly for the first 4 months and twice monthly after that. The women do self-care activities, such as measuring weight, taking blood pressure readings, and charting.

“This is an important part. It's not a group to just sit and talk,” Ms. Hutchison said. “Empowerment is the key.”

Sitting in a circle, the group discusses specific topics related to pregnancy and parenting, guided by “self-assessment sheets,” with the emphasis varying among core topics, such as smoking cessation or community building.

Ms. Hutchison said she started a CenteringPregnancy program at San Francisco General Hospital to help the many immigrant Hispanic females seen at her institution who seemed socially isolated. “I wanted them to have someone to call after we've sent them home with a baby,” she said.

Ms. Hutchison said she has no financial relationship with the nonprofit group that owns the program trademark, the Centering Pregnancy & Parenting Association Inc.

During group time, the women take turns having “mat time” with a health provider who conducts pregnancy risk assessments within the group space, sometimes on a floor mat that can be behind a screen if privacy is needed. Staying in the room to conduct assessments is important, she explained. Moving a woman into a separate room interrupts the group process and reasserts the traditional hierarchical relationship between providers and patients.

Because the program, which demands change from health care providers, is so different from traditional care—see box—it is not an easy one to implement. Billing has not been an issue, because the program fits into standard reimbursement systems, she said.

The program improved birth weights in a nonrandomized trial of 458 low-income women at two institutions. The women either participated in a CenteringPregnancy group or received traditional care, with the groups matched by age, race, parity, and date of delivery.

Average birth weight in the CenteringPregnancy group was 3,228 g—significantly higher than the average of 3,159 g in the control group. The CenteringPregnancy group showed a nonsignificant trend toward fewer low-birth-weight babies. In that study, 7% of babies born to the CenteringPregnancy group and 10% in the control group had low birth weights, defined as less than 500 g (Obstet. Gynecol. 2003;102[pt. 1]:1051–7).

A Comparison of Two Care Models

Traditional care

▸ Physical assessment is primary.

▸ Education is mostly one-on-one.

▸ Communication is didactic.

▸ Process of care is disempowering.

▸ Psychosocial support is incidental.

CenteringPregnancy care

▸ Physical assessment is just one aspect of care.

▸ Education is group-based and interactive.

▸ Communication is interactive and facilitated.

▸ Process of care is empowering.

▸ Psychosocial support and community-building are primary.

Source: Ms. Hutchison

SAN FRANCISCO — A group prenatal care program designed to empower pregnant women is spreading across the United States, Margaret Hutchison said at a meeting on antepartum and intrapartum management.

More than 60 sites offering prenatal care in 28 states have started CenteringPregnancy programs—mostly in public clinics, with some in HMOs and military clinics, said Ms. Hutchison, a certified nurse-midwife at San Francisco General Hospital, a teaching hospital of the University of California, which also sponsored the meeting.

Developed by a certified nurse-midwife and pilot-tested in 1993, the CenteringPregnancy model groups 8–12 women of similar gestational age for 10 facilitated 2-hour meetings starting at gestational weeks 12–16.

The groups usually meet monthly for the first 4 months and twice monthly after that. The women do self-care activities, such as measuring weight, taking blood pressure readings, and charting.

“This is an important part. It's not a group to just sit and talk,” Ms. Hutchison said. “Empowerment is the key.”

Sitting in a circle, the group discusses specific topics related to pregnancy and parenting, guided by “self-assessment sheets,” with the emphasis varying among core topics, such as smoking cessation or community building.

Ms. Hutchison said she started a CenteringPregnancy program at San Francisco General Hospital to help the many immigrant Hispanic females seen at her institution who seemed socially isolated. “I wanted them to have someone to call after we've sent them home with a baby,” she said.

Ms. Hutchison said she has no financial relationship with the nonprofit group that owns the program trademark, the Centering Pregnancy & Parenting Association Inc.

During group time, the women take turns having “mat time” with a health provider who conducts pregnancy risk assessments within the group space, sometimes on a floor mat that can be behind a screen if privacy is needed. Staying in the room to conduct assessments is important, she explained. Moving a woman into a separate room interrupts the group process and reasserts the traditional hierarchical relationship between providers and patients.

Because the program, which demands change from health care providers, is so different from traditional care—see box—it is not an easy one to implement. Billing has not been an issue, because the program fits into standard reimbursement systems, she said.

The program improved birth weights in a nonrandomized trial of 458 low-income women at two institutions. The women either participated in a CenteringPregnancy group or received traditional care, with the groups matched by age, race, parity, and date of delivery.

Average birth weight in the CenteringPregnancy group was 3,228 g—significantly higher than the average of 3,159 g in the control group. The CenteringPregnancy group showed a nonsignificant trend toward fewer low-birth-weight babies. In that study, 7% of babies born to the CenteringPregnancy group and 10% in the control group had low birth weights, defined as less than 500 g (Obstet. Gynecol. 2003;102[pt. 1]:1051–7).

A Comparison of Two Care Models

Traditional care

▸ Physical assessment is primary.

▸ Education is mostly one-on-one.

▸ Communication is didactic.

▸ Process of care is disempowering.

▸ Psychosocial support is incidental.

CenteringPregnancy care

▸ Physical assessment is just one aspect of care.

▸ Education is group-based and interactive.

▸ Communication is interactive and facilitated.

▸ Process of care is empowering.

▸ Psychosocial support and community-building are primary.

Source: Ms. Hutchison

SAN FRANCISCO — A group prenatal care program designed to empower pregnant women is spreading across the United States, Margaret Hutchison said at a meeting on antepartum and intrapartum management.

More than 60 sites offering prenatal care in 28 states have started CenteringPregnancy programs—mostly in public clinics, with some in HMOs and military clinics, said Ms. Hutchison, a certified nurse-midwife at San Francisco General Hospital, a teaching hospital of the University of California, which also sponsored the meeting.

Developed by a certified nurse-midwife and pilot-tested in 1993, the CenteringPregnancy model groups 8–12 women of similar gestational age for 10 facilitated 2-hour meetings starting at gestational weeks 12–16.

The groups usually meet monthly for the first 4 months and twice monthly after that. The women do self-care activities, such as measuring weight, taking blood pressure readings, and charting.

“This is an important part. It's not a group to just sit and talk,” Ms. Hutchison said. “Empowerment is the key.”

Sitting in a circle, the group discusses specific topics related to pregnancy and parenting, guided by “self-assessment sheets,” with the emphasis varying among core topics, such as smoking cessation or community building.

Ms. Hutchison said she started a CenteringPregnancy program at San Francisco General Hospital to help the many immigrant Hispanic females seen at her institution who seemed socially isolated. “I wanted them to have someone to call after we've sent them home with a baby,” she said.

Ms. Hutchison said she has no financial relationship with the nonprofit group that owns the program trademark, the Centering Pregnancy & Parenting Association Inc.

During group time, the women take turns having “mat time” with a health provider who conducts pregnancy risk assessments within the group space, sometimes on a floor mat that can be behind a screen if privacy is needed. Staying in the room to conduct assessments is important, she explained. Moving a woman into a separate room interrupts the group process and reasserts the traditional hierarchical relationship between providers and patients.

Because the program, which demands change from health care providers, is so different from traditional care—see box—it is not an easy one to implement. Billing has not been an issue, because the program fits into standard reimbursement systems, she said.

The program improved birth weights in a nonrandomized trial of 458 low-income women at two institutions. The women either participated in a CenteringPregnancy group or received traditional care, with the groups matched by age, race, parity, and date of delivery.

Average birth weight in the CenteringPregnancy group was 3,228 g—significantly higher than the average of 3,159 g in the control group. The CenteringPregnancy group showed a nonsignificant trend toward fewer low-birth-weight babies. In that study, 7% of babies born to the CenteringPregnancy group and 10% in the control group had low birth weights, defined as less than 500 g (Obstet. Gynecol. 2003;102[pt. 1]:1051–7).

A Comparison of Two Care Models

Traditional care

▸ Physical assessment is primary.

▸ Education is mostly one-on-one.

▸ Communication is didactic.

▸ Process of care is disempowering.

▸ Psychosocial support is incidental.

CenteringPregnancy care

▸ Physical assessment is just one aspect of care.

▸ Education is group-based and interactive.

▸ Communication is interactive and facilitated.

▸ Process of care is empowering.

▸ Psychosocial support and community-building are primary.

Source: Ms. Hutchison

SAN FRANCISCO — A new computerized tool helps pregnant women decide whether they want invasive prenatal testing, Miriam Kuppermann, Ph.D., said at an antepartum and intrapartum management meeting sponsored by the University of California, San Francisco.

In a randomized, controlled trial, 496 pregnant women seen at three institutions in the San Francisco Bay area used the computerized decision-assistance tool or viewed a computer version of age-appropriate brochures the state requires clinicians give to all pregnant women. Both were available in English and Spanish. Investigators assessed the impact of the tool or the brochures in three follow-up interviews.

“We do emphasize throughout that the goal of our program is neither to get women to test nor to get them not to test. The goal is to help them make an informed decision that is consistent with their own preferences and values,” Dr. Kupperman said.

Immediately after the computer session, 75% of women using the decision-assistance tool correctly estimated their risk for having a baby with Down syndrome, compared with 5% of women in the control group. A significant difference in knowledge persisted in the second follow-up interview 2 weeks later.

The state pamphlets do not provide an individual's risk for Down syndrome, so the difference in knowledge between groups is not too surprising, but it's nevertheless encouraging to see that a high percentage of women understood their risk for trisomy 21 after using the computerized tool, Dr. Kuppermann said.

Immediately after the computer session, about 50% of women in the intervention group correctly estimated their risk for miscarriage related to prenatal testing, compared with 20% of women in the control group.

The third follow-up interview, conducted at 30 weeks' gestation after any decisions about prenatal testing were made, found that women in the intervention group had less uncertainty about their decisions, reported fewer factors contributing to uncertainty, and had less decisional conflict, meaning they were more comfortable with their decisions.

Women in the intervention group were more likely to undergo invasive prenatal testing, compared with the control group. Women in this group who entered the study wanting to undergo invasive testing were more likely to change their minds and not be tested. Women who came in with little inclination to be tested were more likely to change their minds and undergo testing.

“So it's working in both directions, which makes me feel good that it's not a biased tool,” she said. “We believe that our tool does lead to more informed decisions that better reflect underlying preferences.”

The computerized tool first reassures women that most babies are born healthy, but it notes that 3%–4% will have a birth defect and that Down syndrome is one of the defects that can be detected by testing.

The woman enters her age, answers questions about other risk factors, and then receives an individualized risk presentation. For example, a 36-year-old woman's mid-trimester risk for carrying a fetus affected by trisomy 21 is about 4 in 1,000, so the computer might show her a photo of 1,000 balls, 4 of which are highlighted yellow to represent the risk.

In a “values clarification exercise,” the woman answers questions about various aspects of testing scenarios to elicit their value to her, ranging from “absolutely critical” to “not at all important.” Based on the woman's responses, the program suggests testing strategies that might fit her values and risks, and it gives summaries of strategies she chooses. “Again, there's no absolute recommendation,” Dr. Kuppermann said.

She and her associates now are modifying the tool to include first-trimester screening and testing strategies and models for other genetic tests for prenatal disorders besides Down syndrome.

The tool should be ready for clinical use in 2006, she said.

SAN FRANCISCO — A new computerized tool helps pregnant women decide whether they want invasive prenatal testing, Miriam Kuppermann, Ph.D., said at an antepartum and intrapartum management meeting sponsored by the University of California, San Francisco.

In a randomized, controlled trial, 496 pregnant women seen at three institutions in the San Francisco Bay area used the computerized decision-assistance tool or viewed a computer version of age-appropriate brochures the state requires clinicians give to all pregnant women. Both were available in English and Spanish. Investigators assessed the impact of the tool or the brochures in three follow-up interviews.

“We do emphasize throughout that the goal of our program is neither to get women to test nor to get them not to test. The goal is to help them make an informed decision that is consistent with their own preferences and values,” Dr. Kupperman said.

Immediately after the computer session, 75% of women using the decision-assistance tool correctly estimated their risk for having a baby with Down syndrome, compared with 5% of women in the control group. A significant difference in knowledge persisted in the second follow-up interview 2 weeks later.

The state pamphlets do not provide an individual's risk for Down syndrome, so the difference in knowledge between groups is not too surprising, but it's nevertheless encouraging to see that a high percentage of women understood their risk for trisomy 21 after using the computerized tool, Dr. Kuppermann said.

Immediately after the computer session, about 50% of women in the intervention group correctly estimated their risk for miscarriage related to prenatal testing, compared with 20% of women in the control group.

The third follow-up interview, conducted at 30 weeks' gestation after any decisions about prenatal testing were made, found that women in the intervention group had less uncertainty about their decisions, reported fewer factors contributing to uncertainty, and had less decisional conflict, meaning they were more comfortable with their decisions.

Women in the intervention group were more likely to undergo invasive prenatal testing, compared with the control group. Women in this group who entered the study wanting to undergo invasive testing were more likely to change their minds and not be tested. Women who came in with little inclination to be tested were more likely to change their minds and undergo testing.

“So it's working in both directions, which makes me feel good that it's not a biased tool,” she said. “We believe that our tool does lead to more informed decisions that better reflect underlying preferences.”

The computerized tool first reassures women that most babies are born healthy, but it notes that 3%–4% will have a birth defect and that Down syndrome is one of the defects that can be detected by testing.

The woman enters her age, answers questions about other risk factors, and then receives an individualized risk presentation. For example, a 36-year-old woman's mid-trimester risk for carrying a fetus affected by trisomy 21 is about 4 in 1,000, so the computer might show her a photo of 1,000 balls, 4 of which are highlighted yellow to represent the risk.

In a “values clarification exercise,” the woman answers questions about various aspects of testing scenarios to elicit their value to her, ranging from “absolutely critical” to “not at all important.” Based on the woman's responses, the program suggests testing strategies that might fit her values and risks, and it gives summaries of strategies she chooses. “Again, there's no absolute recommendation,” Dr. Kuppermann said.

She and her associates now are modifying the tool to include first-trimester screening and testing strategies and models for other genetic tests for prenatal disorders besides Down syndrome.

The tool should be ready for clinical use in 2006, she said.

SAN FRANCISCO — A new computerized tool helps pregnant women decide whether they want invasive prenatal testing, Miriam Kuppermann, Ph.D., said at an antepartum and intrapartum management meeting sponsored by the University of California, San Francisco.

In a randomized, controlled trial, 496 pregnant women seen at three institutions in the San Francisco Bay area used the computerized decision-assistance tool or viewed a computer version of age-appropriate brochures the state requires clinicians give to all pregnant women. Both were available in English and Spanish. Investigators assessed the impact of the tool or the brochures in three follow-up interviews.

“We do emphasize throughout that the goal of our program is neither to get women to test nor to get them not to test. The goal is to help them make an informed decision that is consistent with their own preferences and values,” Dr. Kupperman said.

Immediately after the computer session, 75% of women using the decision-assistance tool correctly estimated their risk for having a baby with Down syndrome, compared with 5% of women in the control group. A significant difference in knowledge persisted in the second follow-up interview 2 weeks later.

The state pamphlets do not provide an individual's risk for Down syndrome, so the difference in knowledge between groups is not too surprising, but it's nevertheless encouraging to see that a high percentage of women understood their risk for trisomy 21 after using the computerized tool, Dr. Kuppermann said.

Immediately after the computer session, about 50% of women in the intervention group correctly estimated their risk for miscarriage related to prenatal testing, compared with 20% of women in the control group.

The third follow-up interview, conducted at 30 weeks' gestation after any decisions about prenatal testing were made, found that women in the intervention group had less uncertainty about their decisions, reported fewer factors contributing to uncertainty, and had less decisional conflict, meaning they were more comfortable with their decisions.

Women in the intervention group were more likely to undergo invasive prenatal testing, compared with the control group. Women in this group who entered the study wanting to undergo invasive testing were more likely to change their minds and not be tested. Women who came in with little inclination to be tested were more likely to change their minds and undergo testing.

“So it's working in both directions, which makes me feel good that it's not a biased tool,” she said. “We believe that our tool does lead to more informed decisions that better reflect underlying preferences.”

The computerized tool first reassures women that most babies are born healthy, but it notes that 3%–4% will have a birth defect and that Down syndrome is one of the defects that can be detected by testing.

The woman enters her age, answers questions about other risk factors, and then receives an individualized risk presentation. For example, a 36-year-old woman's mid-trimester risk for carrying a fetus affected by trisomy 21 is about 4 in 1,000, so the computer might show her a photo of 1,000 balls, 4 of which are highlighted yellow to represent the risk.

In a “values clarification exercise,” the woman answers questions about various aspects of testing scenarios to elicit their value to her, ranging from “absolutely critical” to “not at all important.” Based on the woman's responses, the program suggests testing strategies that might fit her values and risks, and it gives summaries of strategies she chooses. “Again, there's no absolute recommendation,” Dr. Kuppermann said.

She and her associates now are modifying the tool to include first-trimester screening and testing strategies and models for other genetic tests for prenatal disorders besides Down syndrome.

The tool should be ready for clinical use in 2006, she said.

SAN FRANCISCO — First-trimester screening for aneuploidy may soon become the standard of care, Robert H. Ball, M.D., predicted at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

There is sufficient evidence to support the incorporation of first-trimester testing into practice, and the focus now should be on the most effective way to implement this, according to a consensus statement produced at a workshop sponsored by the National Institute of Child Health and Human Development in December 2004.

At least seven studies have shown that detection of aneuploidy can be improved by analyzing a combination of risk factors in the first trimester: maternal age, nuchal translucency measured on ultrasound, and serum testing for β-HCG and PAPP-A.

Women at risk may be offered more definitive testing earlier in pregnancy with this approach, or results of negative first-trimester screens can be integrated with second-trimester serum screening for improved aneuploidy detection in the second trimester.

“This is a big deal, no doubt about it,” said Dr. Ball, a perinatologist at UCSF Children's Hospital. Most nuchal translucency screens will be done in prenatal diagnostic centers, not in physician offices.

Dr. Ball presented data at the meeting from the First and Second Trimester Evaluation of Risk for Aneuploidy (FASTER) trial, in which he was an investigator. The results have been accepted for publication in the New England Journal of Medicine.

The study obtained follow-up information for 37,002 births, from an impressive 97% of the women who enrolled and underwent first- and second-trimester screening. Aneuploidy detection rates improved when first-trimester serum screening was added to nuchal translucency measurement, compared with using nuchal translucency alone to assess risk. Detection improved further when these first-trimester results were integrated with second-trimester serum screening.

The study's size provided the power to analyze subgroups, including results based on the gestational week of screening. The best time for first-trimester screening was week 11: When screening was performed at that time, detection rates were 73% with nuchal translucency alone and 93% with the combined nuchal translucency/serum screen. After integrating the combined first-trimester screen with second-trimester screening, the detection rate was 98%.

First trimester screening may pose scheduling problems, he predicted. “That's sort of a logistical nightmare, if you think about it,” because physicians will be scrambling to get patients into prenatal diagnostic centers before the 11-week window passes, he said. “I can imagine people suing because they didn't get in for their nuchal translucency screening and they have a Down syndrome kid” that might have been detected earlier.

In hopes that the integrated first- and second-trimester screening strategies might obviate the need for genetic sonograms, investigators analyzed the FASTER data with and without genetic sonogram results. They found that the likelihood of aneuploidy greatly increased with identification of at least one genetic marker on ultrasound. Genetic ultrasound results improved the overall 84% detection rate for aneuploidy using first-trimester screening alone and decreased the false-positive rate.

“Much to my chagrin, having a genetic sonogram after you've had a bucket load of other tests is actually going to be useful,” Dr. Ball said.

SAN FRANCISCO — First-trimester screening for aneuploidy may soon become the standard of care, Robert H. Ball, M.D., predicted at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

There is sufficient evidence to support the incorporation of first-trimester testing into practice, and the focus now should be on the most effective way to implement this, according to a consensus statement produced at a workshop sponsored by the National Institute of Child Health and Human Development in December 2004.

At least seven studies have shown that detection of aneuploidy can be improved by analyzing a combination of risk factors in the first trimester: maternal age, nuchal translucency measured on ultrasound, and serum testing for β-HCG and PAPP-A.

Women at risk may be offered more definitive testing earlier in pregnancy with this approach, or results of negative first-trimester screens can be integrated with second-trimester serum screening for improved aneuploidy detection in the second trimester.

“This is a big deal, no doubt about it,” said Dr. Ball, a perinatologist at UCSF Children's Hospital. Most nuchal translucency screens will be done in prenatal diagnostic centers, not in physician offices.

Dr. Ball presented data at the meeting from the First and Second Trimester Evaluation of Risk for Aneuploidy (FASTER) trial, in which he was an investigator. The results have been accepted for publication in the New England Journal of Medicine.

The study obtained follow-up information for 37,002 births, from an impressive 97% of the women who enrolled and underwent first- and second-trimester screening. Aneuploidy detection rates improved when first-trimester serum screening was added to nuchal translucency measurement, compared with using nuchal translucency alone to assess risk. Detection improved further when these first-trimester results were integrated with second-trimester serum screening.

The study's size provided the power to analyze subgroups, including results based on the gestational week of screening. The best time for first-trimester screening was week 11: When screening was performed at that time, detection rates were 73% with nuchal translucency alone and 93% with the combined nuchal translucency/serum screen. After integrating the combined first-trimester screen with second-trimester screening, the detection rate was 98%.

First trimester screening may pose scheduling problems, he predicted. “That's sort of a logistical nightmare, if you think about it,” because physicians will be scrambling to get patients into prenatal diagnostic centers before the 11-week window passes, he said. “I can imagine people suing because they didn't get in for their nuchal translucency screening and they have a Down syndrome kid” that might have been detected earlier.

In hopes that the integrated first- and second-trimester screening strategies might obviate the need for genetic sonograms, investigators analyzed the FASTER data with and without genetic sonogram results. They found that the likelihood of aneuploidy greatly increased with identification of at least one genetic marker on ultrasound. Genetic ultrasound results improved the overall 84% detection rate for aneuploidy using first-trimester screening alone and decreased the false-positive rate.

“Much to my chagrin, having a genetic sonogram after you've had a bucket load of other tests is actually going to be useful,” Dr. Ball said.

SAN FRANCISCO — First-trimester screening for aneuploidy may soon become the standard of care, Robert H. Ball, M.D., predicted at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

There is sufficient evidence to support the incorporation of first-trimester testing into practice, and the focus now should be on the most effective way to implement this, according to a consensus statement produced at a workshop sponsored by the National Institute of Child Health and Human Development in December 2004.

At least seven studies have shown that detection of aneuploidy can be improved by analyzing a combination of risk factors in the first trimester: maternal age, nuchal translucency measured on ultrasound, and serum testing for β-HCG and PAPP-A.

Women at risk may be offered more definitive testing earlier in pregnancy with this approach, or results of negative first-trimester screens can be integrated with second-trimester serum screening for improved aneuploidy detection in the second trimester.

“This is a big deal, no doubt about it,” said Dr. Ball, a perinatologist at UCSF Children's Hospital. Most nuchal translucency screens will be done in prenatal diagnostic centers, not in physician offices.

Dr. Ball presented data at the meeting from the First and Second Trimester Evaluation of Risk for Aneuploidy (FASTER) trial, in which he was an investigator. The results have been accepted for publication in the New England Journal of Medicine.

The study obtained follow-up information for 37,002 births, from an impressive 97% of the women who enrolled and underwent first- and second-trimester screening. Aneuploidy detection rates improved when first-trimester serum screening was added to nuchal translucency measurement, compared with using nuchal translucency alone to assess risk. Detection improved further when these first-trimester results were integrated with second-trimester serum screening.

The study's size provided the power to analyze subgroups, including results based on the gestational week of screening. The best time for first-trimester screening was week 11: When screening was performed at that time, detection rates were 73% with nuchal translucency alone and 93% with the combined nuchal translucency/serum screen. After integrating the combined first-trimester screen with second-trimester screening, the detection rate was 98%.

First trimester screening may pose scheduling problems, he predicted. “That's sort of a logistical nightmare, if you think about it,” because physicians will be scrambling to get patients into prenatal diagnostic centers before the 11-week window passes, he said. “I can imagine people suing because they didn't get in for their nuchal translucency screening and they have a Down syndrome kid” that might have been detected earlier.

In hopes that the integrated first- and second-trimester screening strategies might obviate the need for genetic sonograms, investigators analyzed the FASTER data with and without genetic sonogram results. They found that the likelihood of aneuploidy greatly increased with identification of at least one genetic marker on ultrasound. Genetic ultrasound results improved the overall 84% detection rate for aneuploidy using first-trimester screening alone and decreased the false-positive rate.

“Much to my chagrin, having a genetic sonogram after you've had a bucket load of other tests is actually going to be useful,” Dr. Ball said.

SAN FRANCISCO — In the general ob.gyn. practice of Amy Meg Autry, M.D., visits with pregnant patients have evolved from giving equal time to examination and counseling to about 2% to examination and 98% to counseling.

Dr. Autry of the University of California, San Francisco, researched answers to some of women's most common safety concerns regarding pregnancy and offered an overview of her findings at a meeting on antepartum and intrapartum management sponsored by the university:

▸ Fish. While eating fish can be good for maternal cardiovascular health and fetal growth and development, fish accumulate methyl mercury in their muscles from industrial pollution, which may cause neurotoxic symptoms in neonates that resemble cerebral palsy.

Only one retrospective study has found severe neurotoxic effects in children born to Japanese women who ate a steady diet of fish with high levels of mercury, even though the mothers showed minimal or no effects of mercury ingestion. Three other studies found neurologic effects in Japanese adults who ate a similar toxic-fish diet or Iraqi adults who ate grain that had been pretreated with mercury.

Two prospective studies produced conflicting results. In one, a diet high in whale blubber was associated with delays in attention, memory, and small-motor function in serial testing of children through age 6 in the Faeroe Islands of Norway. A separate study of residents of the Seychelles Islands who ate 12 meals of fish per week found that they had mercury levels 10–20 times higher than average levels in U.S. residents, yet this exposure produced no long-term neurologic effects. Other prospective studies are ongoing.

A 2004 joint advisory for consumers issued by the Environmental Protection Agency and the Food and Drug Administration recommended that pregnant women not eat shark, swordfish, king mackerel, or tilefish, because they are high in mercury. The advisory emphasized the positive benefits of fish and stated that pregnant women may eat up to 12 ounces (two average meals) per week of fish low in mercury, such as salmon, shrimp, pollack, and catfish. Canned light tuna has less mercury than albacore tuna. For local fish, consult local and tribal advisories that apply to your area, or limit ingestion to 6 ounces per week.

▸ Cheese and hot dogs. One third of an estimated 1,500 cases of listeriosis each year in the United States are in pregnant women. They are more susceptible to the infection due to compromised immune systems. One in five pregnant women with listeriosis experiences a spontaneous abortion or stillbirth.

Although cases of listeriosis in pregnancy are rare and sporadic, it's prudent to avoid high-risk foods such as hot dogs or luncheon meats, unless they've been reheated to steaming. Avoid soft cheeses, refrigerated patés or meat spreads, unpasteurized milk, and raw or undercooked meats.

▸ Caffeine. No data substantiate concerns about adverse pregnancy effects caused by light to moderate caffeine consumption.

Many studies that suggested caffeine may raise the risk for low birth weight, spontaneous abortion, congenital anomalies, or conception delays are poorly designed and demonstrate study bias, she said. Most of these studies were confounded by an association between caffeine intake and cigarette smoking.

▸ Alcohol. Multiple small studies show deleterious effects of drinking even small amounts of alcohol during pregnancy. A 2002 study that followed children from birth to age 6, for example, found persistently smaller head circumferences, height, and weight in children of women who had less than one drink per day. A 2001 study found more aggressive behavior in children of mothers who had one drink per week during pregnancy.

▸ Hot tubs. Animal data suggest that maternal hyperthermia (a body temperature of 102°F) may lead to first-trimester spontaneous abortion or neural tube defects. A very poorly designed study in human subjects, which was published in 2003, found a higher rate of first-trimester losses in women who used a hot tub more than weekly within 4 weeks of their last menstrual period. A 2005 metaanalysis of 42 studies suggested an 86% increase in risk for neural tube defects if the mother used a hot tub, sauna, or electric blanket and developed a fever.

On average, a pregnant woman's core body temperature will reach 102°F after 15 minutes of soaking in 102°F water or 10 minutes in 106°F water.

Skip hot tubs in the first trimester, and limit soaking times or water temperature after that, Dr. Autry advised.

▸ Exercise. Getting hot from exercise is okay; there's no evidence that hyperthermia from exercise is teratogenic, she said. Even exercise at high altitudes appears safe.

Exercise helps prevent gestational diabetes and decreases the risk for postpartum depression. Avoid standing still, supine activities, sports that cause falling or heavy contact, and scuba diving, which can cause decompression sickness in the fetus.

▸ Hair dye. All attempts to find an association between hair dye and teratogenic effects or cancer have washed out. Dye if you want to, Dr. Autry said.

SAN FRANCISCO — In the general ob.gyn. practice of Amy Meg Autry, M.D., visits with pregnant patients have evolved from giving equal time to examination and counseling to about 2% to examination and 98% to counseling.

Dr. Autry of the University of California, San Francisco, researched answers to some of women's most common safety concerns regarding pregnancy and offered an overview of her findings at a meeting on antepartum and intrapartum management sponsored by the university:

▸ Fish. While eating fish can be good for maternal cardiovascular health and fetal growth and development, fish accumulate methyl mercury in their muscles from industrial pollution, which may cause neurotoxic symptoms in neonates that resemble cerebral palsy.

Only one retrospective study has found severe neurotoxic effects in children born to Japanese women who ate a steady diet of fish with high levels of mercury, even though the mothers showed minimal or no effects of mercury ingestion. Three other studies found neurologic effects in Japanese adults who ate a similar toxic-fish diet or Iraqi adults who ate grain that had been pretreated with mercury.

Two prospective studies produced conflicting results. In one, a diet high in whale blubber was associated with delays in attention, memory, and small-motor function in serial testing of children through age 6 in the Faeroe Islands of Norway. A separate study of residents of the Seychelles Islands who ate 12 meals of fish per week found that they had mercury levels 10–20 times higher than average levels in U.S. residents, yet this exposure produced no long-term neurologic effects. Other prospective studies are ongoing.

A 2004 joint advisory for consumers issued by the Environmental Protection Agency and the Food and Drug Administration recommended that pregnant women not eat shark, swordfish, king mackerel, or tilefish, because they are high in mercury. The advisory emphasized the positive benefits of fish and stated that pregnant women may eat up to 12 ounces (two average meals) per week of fish low in mercury, such as salmon, shrimp, pollack, and catfish. Canned light tuna has less mercury than albacore tuna. For local fish, consult local and tribal advisories that apply to your area, or limit ingestion to 6 ounces per week.

▸ Cheese and hot dogs. One third of an estimated 1,500 cases of listeriosis each year in the United States are in pregnant women. They are more susceptible to the infection due to compromised immune systems. One in five pregnant women with listeriosis experiences a spontaneous abortion or stillbirth.

Although cases of listeriosis in pregnancy are rare and sporadic, it's prudent to avoid high-risk foods such as hot dogs or luncheon meats, unless they've been reheated to steaming. Avoid soft cheeses, refrigerated patés or meat spreads, unpasteurized milk, and raw or undercooked meats.

▸ Caffeine. No data substantiate concerns about adverse pregnancy effects caused by light to moderate caffeine consumption.

Many studies that suggested caffeine may raise the risk for low birth weight, spontaneous abortion, congenital anomalies, or conception delays are poorly designed and demonstrate study bias, she said. Most of these studies were confounded by an association between caffeine intake and cigarette smoking.

▸ Alcohol. Multiple small studies show deleterious effects of drinking even small amounts of alcohol during pregnancy. A 2002 study that followed children from birth to age 6, for example, found persistently smaller head circumferences, height, and weight in children of women who had less than one drink per day. A 2001 study found more aggressive behavior in children of mothers who had one drink per week during pregnancy.

▸ Hot tubs. Animal data suggest that maternal hyperthermia (a body temperature of 102°F) may lead to first-trimester spontaneous abortion or neural tube defects. A very poorly designed study in human subjects, which was published in 2003, found a higher rate of first-trimester losses in women who used a hot tub more than weekly within 4 weeks of their last menstrual period. A 2005 metaanalysis of 42 studies suggested an 86% increase in risk for neural tube defects if the mother used a hot tub, sauna, or electric blanket and developed a fever.

On average, a pregnant woman's core body temperature will reach 102°F after 15 minutes of soaking in 102°F water or 10 minutes in 106°F water.

Skip hot tubs in the first trimester, and limit soaking times or water temperature after that, Dr. Autry advised.

▸ Exercise. Getting hot from exercise is okay; there's no evidence that hyperthermia from exercise is teratogenic, she said. Even exercise at high altitudes appears safe.

Exercise helps prevent gestational diabetes and decreases the risk for postpartum depression. Avoid standing still, supine activities, sports that cause falling or heavy contact, and scuba diving, which can cause decompression sickness in the fetus.

▸ Hair dye. All attempts to find an association between hair dye and teratogenic effects or cancer have washed out. Dye if you want to, Dr. Autry said.

SAN FRANCISCO — In the general ob.gyn. practice of Amy Meg Autry, M.D., visits with pregnant patients have evolved from giving equal time to examination and counseling to about 2% to examination and 98% to counseling.

Dr. Autry of the University of California, San Francisco, researched answers to some of women's most common safety concerns regarding pregnancy and offered an overview of her findings at a meeting on antepartum and intrapartum management sponsored by the university:

▸ Fish. While eating fish can be good for maternal cardiovascular health and fetal growth and development, fish accumulate methyl mercury in their muscles from industrial pollution, which may cause neurotoxic symptoms in neonates that resemble cerebral palsy.

Only one retrospective study has found severe neurotoxic effects in children born to Japanese women who ate a steady diet of fish with high levels of mercury, even though the mothers showed minimal or no effects of mercury ingestion. Three other studies found neurologic effects in Japanese adults who ate a similar toxic-fish diet or Iraqi adults who ate grain that had been pretreated with mercury.

Two prospective studies produced conflicting results. In one, a diet high in whale blubber was associated with delays in attention, memory, and small-motor function in serial testing of children through age 6 in the Faeroe Islands of Norway. A separate study of residents of the Seychelles Islands who ate 12 meals of fish per week found that they had mercury levels 10–20 times higher than average levels in U.S. residents, yet this exposure produced no long-term neurologic effects. Other prospective studies are ongoing.

A 2004 joint advisory for consumers issued by the Environmental Protection Agency and the Food and Drug Administration recommended that pregnant women not eat shark, swordfish, king mackerel, or tilefish, because they are high in mercury. The advisory emphasized the positive benefits of fish and stated that pregnant women may eat up to 12 ounces (two average meals) per week of fish low in mercury, such as salmon, shrimp, pollack, and catfish. Canned light tuna has less mercury than albacore tuna. For local fish, consult local and tribal advisories that apply to your area, or limit ingestion to 6 ounces per week.

▸ Cheese and hot dogs. One third of an estimated 1,500 cases of listeriosis each year in the United States are in pregnant women. They are more susceptible to the infection due to compromised immune systems. One in five pregnant women with listeriosis experiences a spontaneous abortion or stillbirth.

Although cases of listeriosis in pregnancy are rare and sporadic, it's prudent to avoid high-risk foods such as hot dogs or luncheon meats, unless they've been reheated to steaming. Avoid soft cheeses, refrigerated patés or meat spreads, unpasteurized milk, and raw or undercooked meats.

▸ Caffeine. No data substantiate concerns about adverse pregnancy effects caused by light to moderate caffeine consumption.

Many studies that suggested caffeine may raise the risk for low birth weight, spontaneous abortion, congenital anomalies, or conception delays are poorly designed and demonstrate study bias, she said. Most of these studies were confounded by an association between caffeine intake and cigarette smoking.

▸ Alcohol. Multiple small studies show deleterious effects of drinking even small amounts of alcohol during pregnancy. A 2002 study that followed children from birth to age 6, for example, found persistently smaller head circumferences, height, and weight in children of women who had less than one drink per day. A 2001 study found more aggressive behavior in children of mothers who had one drink per week during pregnancy.

▸ Hot tubs. Animal data suggest that maternal hyperthermia (a body temperature of 102°F) may lead to first-trimester spontaneous abortion or neural tube defects. A very poorly designed study in human subjects, which was published in 2003, found a higher rate of first-trimester losses in women who used a hot tub more than weekly within 4 weeks of their last menstrual period. A 2005 metaanalysis of 42 studies suggested an 86% increase in risk for neural tube defects if the mother used a hot tub, sauna, or electric blanket and developed a fever.

On average, a pregnant woman's core body temperature will reach 102°F after 15 minutes of soaking in 102°F water or 10 minutes in 106°F water.

Skip hot tubs in the first trimester, and limit soaking times or water temperature after that, Dr. Autry advised.

▸ Exercise. Getting hot from exercise is okay; there's no evidence that hyperthermia from exercise is teratogenic, she said. Even exercise at high altitudes appears safe.

Exercise helps prevent gestational diabetes and decreases the risk for postpartum depression. Avoid standing still, supine activities, sports that cause falling or heavy contact, and scuba diving, which can cause decompression sickness in the fetus.

▸ Hair dye. All attempts to find an association between hair dye and teratogenic effects or cancer have washed out. Dye if you want to, Dr. Autry said.

KOHALA COAST, HAWAII — Attack hyperkeratotic scabies both topically and systemically or your treatment will fail, Timothy G. Berger, M.D., said at a conference sponsored by the Center for Bio-Medical Communications Inc.

He divides patients with scabies into two categories to guide management—those with a low burden or a high burden of disease. For the typical patient with a low burden, two applications of permethrin 5% cream a week apart will cure 95% of cases.

But a double whammy usually is needed for patients with a high burden of disease—those with crusted or hyperkeratotic scabies, AIDS and scabies, or scabies acquired while in a long-term care facility or prison, said Dr. Berger of the University of California, San Francisco.

He prefers to use these two categories because patients with a high burden of disease may present with multiple papules instead of crusts, but need the combination therapy used for crusted scabies.

The combination treatment consists of weekly applications of permethrin 5% cream for 3–6 weeks plus ivermectin 200 mcg/kg every 2 weeks for two (or occasionally three) doses. The patient should show improvement by 3 weeks and continue to gradually improve.

Don't try to save a buck by skimping on the ivermectin, Dr. Berger warned. Don't round down the dose but, rather, give the full dose of ivermectin (usually 12–18 mg), and allow plenty of time to treat. In appropriate doses, the combination therapy has never failed him.

In a typical case, a family brought in an 87-year-old woman who had had 6 months of severe itching, though no one else in the family was itching.

The patient had failed treatment with multiple courses of permethrin, systemic steroids, and other medications.

She had a widespread papular eruption on her trunk, proximal extremities, and face, showing focal plaques, some of which were markedly hyperkeratotic, Dr. Berger said.

“The British describe this as looking like a fine white sand on the skin. That's exactly what it looks like,” Dr. Berger said.

Her history was a tip-off: After a hip replacement 9 months earlier, she had spent time in a long-term care facility for rehabilitation. Scrapings of lesions on the soles of her feet were loaded with scabies mites and feces.

Don't be dissuaded from suspecting scabies just because a patient has failed permethrin treatment or family members seem unaffected, Dr. Berger advised.

Treat the whole family, but not necessarily immediately. Family members who are affected get immediate treatment, but otherwise Dr. Berger waits to treat the family until the primary patient has been treated, so that the patient is no longer infectious.

High-burden cases often involve the scalp, so instruct patients to apply permethrin to the scalp too, he advised. Ivermectin won't help scabies involving the nail plate, so consider more aggressive treatments for nail scabies.

Ivermectin is secreted in sebum, he noted, which is one reason monotherapy may not work in the elderly, children, malnourished patients, or people with Down syndrome, all of whom make less sebum.

Immunosuppression plus neural disease puts patients at risk for crusted scabies, one reason that people with AIDS or Down syndrome are at higher risk for crusted scabies, he said.

KOHALA COAST, HAWAII — Attack hyperkeratotic scabies both topically and systemically or your treatment will fail, Timothy G. Berger, M.D., said at a conference sponsored by the Center for Bio-Medical Communications Inc.

He divides patients with scabies into two categories to guide management—those with a low burden or a high burden of disease. For the typical patient with a low burden, two applications of permethrin 5% cream a week apart will cure 95% of cases.

But a double whammy usually is needed for patients with a high burden of disease—those with crusted or hyperkeratotic scabies, AIDS and scabies, or scabies acquired while in a long-term care facility or prison, said Dr. Berger of the University of California, San Francisco.

He prefers to use these two categories because patients with a high burden of disease may present with multiple papules instead of crusts, but need the combination therapy used for crusted scabies.

The combination treatment consists of weekly applications of permethrin 5% cream for 3–6 weeks plus ivermectin 200 mcg/kg every 2 weeks for two (or occasionally three) doses. The patient should show improvement by 3 weeks and continue to gradually improve.

Don't try to save a buck by skimping on the ivermectin, Dr. Berger warned. Don't round down the dose but, rather, give the full dose of ivermectin (usually 12–18 mg), and allow plenty of time to treat. In appropriate doses, the combination therapy has never failed him.

In a typical case, a family brought in an 87-year-old woman who had had 6 months of severe itching, though no one else in the family was itching.

The patient had failed treatment with multiple courses of permethrin, systemic steroids, and other medications.

She had a widespread papular eruption on her trunk, proximal extremities, and face, showing focal plaques, some of which were markedly hyperkeratotic, Dr. Berger said.

“The British describe this as looking like a fine white sand on the skin. That's exactly what it looks like,” Dr. Berger said.

Her history was a tip-off: After a hip replacement 9 months earlier, she had spent time in a long-term care facility for rehabilitation. Scrapings of lesions on the soles of her feet were loaded with scabies mites and feces.

Don't be dissuaded from suspecting scabies just because a patient has failed permethrin treatment or family members seem unaffected, Dr. Berger advised.

Treat the whole family, but not necessarily immediately. Family members who are affected get immediate treatment, but otherwise Dr. Berger waits to treat the family until the primary patient has been treated, so that the patient is no longer infectious.

High-burden cases often involve the scalp, so instruct patients to apply permethrin to the scalp too, he advised. Ivermectin won't help scabies involving the nail plate, so consider more aggressive treatments for nail scabies.

Ivermectin is secreted in sebum, he noted, which is one reason monotherapy may not work in the elderly, children, malnourished patients, or people with Down syndrome, all of whom make less sebum.

Immunosuppression plus neural disease puts patients at risk for crusted scabies, one reason that people with AIDS or Down syndrome are at higher risk for crusted scabies, he said.

KOHALA COAST, HAWAII — Attack hyperkeratotic scabies both topically and systemically or your treatment will fail, Timothy G. Berger, M.D., said at a conference sponsored by the Center for Bio-Medical Communications Inc.

He divides patients with scabies into two categories to guide management—those with a low burden or a high burden of disease. For the typical patient with a low burden, two applications of permethrin 5% cream a week apart will cure 95% of cases.

But a double whammy usually is needed for patients with a high burden of disease—those with crusted or hyperkeratotic scabies, AIDS and scabies, or scabies acquired while in a long-term care facility or prison, said Dr. Berger of the University of California, San Francisco.

He prefers to use these two categories because patients with a high burden of disease may present with multiple papules instead of crusts, but need the combination therapy used for crusted scabies.

The combination treatment consists of weekly applications of permethrin 5% cream for 3–6 weeks plus ivermectin 200 mcg/kg every 2 weeks for two (or occasionally three) doses. The patient should show improvement by 3 weeks and continue to gradually improve.

Don't try to save a buck by skimping on the ivermectin, Dr. Berger warned. Don't round down the dose but, rather, give the full dose of ivermectin (usually 12–18 mg), and allow plenty of time to treat. In appropriate doses, the combination therapy has never failed him.

In a typical case, a family brought in an 87-year-old woman who had had 6 months of severe itching, though no one else in the family was itching.

The patient had failed treatment with multiple courses of permethrin, systemic steroids, and other medications.

She had a widespread papular eruption on her trunk, proximal extremities, and face, showing focal plaques, some of which were markedly hyperkeratotic, Dr. Berger said.

“The British describe this as looking like a fine white sand on the skin. That's exactly what it looks like,” Dr. Berger said.

Her history was a tip-off: After a hip replacement 9 months earlier, she had spent time in a long-term care facility for rehabilitation. Scrapings of lesions on the soles of her feet were loaded with scabies mites and feces.

Don't be dissuaded from suspecting scabies just because a patient has failed permethrin treatment or family members seem unaffected, Dr. Berger advised.

Treat the whole family, but not necessarily immediately. Family members who are affected get immediate treatment, but otherwise Dr. Berger waits to treat the family until the primary patient has been treated, so that the patient is no longer infectious.

High-burden cases often involve the scalp, so instruct patients to apply permethrin to the scalp too, he advised. Ivermectin won't help scabies involving the nail plate, so consider more aggressive treatments for nail scabies.

Ivermectin is secreted in sebum, he noted, which is one reason monotherapy may not work in the elderly, children, malnourished patients, or people with Down syndrome, all of whom make less sebum.

Immunosuppression plus neural disease puts patients at risk for crusted scabies, one reason that people with AIDS or Down syndrome are at higher risk for crusted scabies, he said.

VANCOUVER, B.C. — Incorporating testing for human papillomavirus into cervical screening practices for women older than 30 years may take more effort than one would think, Walter Kinney, M.D., said at the 22nd International Papillomavirus Conference.

He described the first 123,909 HPV tests performed within the Kaiser Permanente system on women over age 30 who also had satisfactory results from cytology performed at the same time. Kaiser announced its “co-testing” policy of Pap smears plus HPV tests for women over age 30 in 2002.

“We told the lab to anticipate a tidal wave of specimens. That didn't happen,” said Dr. Kinney of the Permanente Medical Group, Sacramento. “You can't just buy the reagent, announce the guidelines, turn on the machine, and expect this to happen.”

Kaiser officials set about figuring out what to do to get clinicians and patients to accept HPV testing. “This was a humbling process that went on for a couple of years” but led to excellent acceptance rates by physicians and patients, he said at the meeting, sponsored by the University of California, San Francisco.

Between May 2003 and August 2004, 85%–93% of appropriate patients underwent cotesting at Kaiser facilities, with the exception of one facility that posted a 70% cotesting rate.

This compares with results of a 2005 survey of 185 ob.gyns. randomly selected from the American Medical Association database in which only 33% said they would offer cotesting, despite recommendations for its use by the American College of Obstetricians and Gynecologists and the American Cancer Society (Am. J. Obstet. Gynecol. 2005;192:414–21).

Kaiser gained wider acceptance of cotesting by addressing issues related to staff, patients, and clinicians. For staff, training on how and why to do HPV testing is critical. “They have to think it's something they would choose for themselves,” and they need to know how to talk with patients about it, Dr. Kinney said. “Sometimes the patients believe the staff a lot more than they believe you.”

Kaiser created a specimen-handling policy and flowcharts for cotesting, posted summary sheets, obtained new color-coded order forms and color-coded specimen bins, and redesigned its “Pap books” to track results and patient responses.

Patients should be informed about cotesting before the clinician arrives in the exam room, he said.

One way to do this is to have a medical assistant give the patient written materials after taking her blood pressure. Have information sheets handy, as well as brochures. For patients with abnormal test results, have available brochures explaining their condition.

What the clinician says to the patient about cotesting is important too. A poll of 350 Kaiser patients and 37 physicians asking why the patient did or did not have cotesting found that physicians believed both their words and printed materials were important. Patients, on the other hand, felt that what mattered most was whether physicians said cotesting is a good idea and that they would choose testing themselves.

Give clinicians the education and tools they need to know what to say to patients about cotesting, and how to say it. Steps include conferences and guidelines, sample messages or scripts, and handouts on frequently asked questions.

In the Kaiser study, only 5.3% of the first 123,909 cotests were HPV positive. Of these, 3.7% had negative Pap tests.

The rate of HPV positivity dropped by half after age 39, from 9% in 30- to 39-year-olds to 5% of 40- to 49-year-olds. HPV positivity rates decreased with age to a low of 3% in women in their 60s, then crept up a bit over time, he said.

The lead investigator in studying the HPV data was Barbara Fetterman, Ph.D., of the Permanente Medical Group, Oakland, Calif.

VANCOUVER, B.C. — Incorporating testing for human papillomavirus into cervical screening practices for women older than 30 years may take more effort than one would think, Walter Kinney, M.D., said at the 22nd International Papillomavirus Conference.

He described the first 123,909 HPV tests performed within the Kaiser Permanente system on women over age 30 who also had satisfactory results from cytology performed at the same time. Kaiser announced its “co-testing” policy of Pap smears plus HPV tests for women over age 30 in 2002.

“We told the lab to anticipate a tidal wave of specimens. That didn't happen,” said Dr. Kinney of the Permanente Medical Group, Sacramento. “You can't just buy the reagent, announce the guidelines, turn on the machine, and expect this to happen.”

Kaiser officials set about figuring out what to do to get clinicians and patients to accept HPV testing. “This was a humbling process that went on for a couple of years” but led to excellent acceptance rates by physicians and patients, he said at the meeting, sponsored by the University of California, San Francisco.

Between May 2003 and August 2004, 85%–93% of appropriate patients underwent cotesting at Kaiser facilities, with the exception of one facility that posted a 70% cotesting rate.

This compares with results of a 2005 survey of 185 ob.gyns. randomly selected from the American Medical Association database in which only 33% said they would offer cotesting, despite recommendations for its use by the American College of Obstetricians and Gynecologists and the American Cancer Society (Am. J. Obstet. Gynecol. 2005;192:414–21).

Kaiser gained wider acceptance of cotesting by addressing issues related to staff, patients, and clinicians. For staff, training on how and why to do HPV testing is critical. “They have to think it's something they would choose for themselves,” and they need to know how to talk with patients about it, Dr. Kinney said. “Sometimes the patients believe the staff a lot more than they believe you.”

Kaiser created a specimen-handling policy and flowcharts for cotesting, posted summary sheets, obtained new color-coded order forms and color-coded specimen bins, and redesigned its “Pap books” to track results and patient responses.

Patients should be informed about cotesting before the clinician arrives in the exam room, he said.

One way to do this is to have a medical assistant give the patient written materials after taking her blood pressure. Have information sheets handy, as well as brochures. For patients with abnormal test results, have available brochures explaining their condition.

What the clinician says to the patient about cotesting is important too. A poll of 350 Kaiser patients and 37 physicians asking why the patient did or did not have cotesting found that physicians believed both their words and printed materials were important. Patients, on the other hand, felt that what mattered most was whether physicians said cotesting is a good idea and that they would choose testing themselves.

Give clinicians the education and tools they need to know what to say to patients about cotesting, and how to say it. Steps include conferences and guidelines, sample messages or scripts, and handouts on frequently asked questions.

In the Kaiser study, only 5.3% of the first 123,909 cotests were HPV positive. Of these, 3.7% had negative Pap tests.

The rate of HPV positivity dropped by half after age 39, from 9% in 30- to 39-year-olds to 5% of 40- to 49-year-olds. HPV positivity rates decreased with age to a low of 3% in women in their 60s, then crept up a bit over time, he said.

The lead investigator in studying the HPV data was Barbara Fetterman, Ph.D., of the Permanente Medical Group, Oakland, Calif.

VANCOUVER, B.C. — Incorporating testing for human papillomavirus into cervical screening practices for women older than 30 years may take more effort than one would think, Walter Kinney, M.D., said at the 22nd International Papillomavirus Conference.

He described the first 123,909 HPV tests performed within the Kaiser Permanente system on women over age 30 who also had satisfactory results from cytology performed at the same time. Kaiser announced its “co-testing” policy of Pap smears plus HPV tests for women over age 30 in 2002.

“We told the lab to anticipate a tidal wave of specimens. That didn't happen,” said Dr. Kinney of the Permanente Medical Group, Sacramento. “You can't just buy the reagent, announce the guidelines, turn on the machine, and expect this to happen.”

Kaiser officials set about figuring out what to do to get clinicians and patients to accept HPV testing. “This was a humbling process that went on for a couple of years” but led to excellent acceptance rates by physicians and patients, he said at the meeting, sponsored by the University of California, San Francisco.

Between May 2003 and August 2004, 85%–93% of appropriate patients underwent cotesting at Kaiser facilities, with the exception of one facility that posted a 70% cotesting rate.

This compares with results of a 2005 survey of 185 ob.gyns. randomly selected from the American Medical Association database in which only 33% said they would offer cotesting, despite recommendations for its use by the American College of Obstetricians and Gynecologists and the American Cancer Society (Am. J. Obstet. Gynecol. 2005;192:414–21).

Kaiser gained wider acceptance of cotesting by addressing issues related to staff, patients, and clinicians. For staff, training on how and why to do HPV testing is critical. “They have to think it's something they would choose for themselves,” and they need to know how to talk with patients about it, Dr. Kinney said. “Sometimes the patients believe the staff a lot more than they believe you.”

Kaiser created a specimen-handling policy and flowcharts for cotesting, posted summary sheets, obtained new color-coded order forms and color-coded specimen bins, and redesigned its “Pap books” to track results and patient responses.

Patients should be informed about cotesting before the clinician arrives in the exam room, he said.

One way to do this is to have a medical assistant give the patient written materials after taking her blood pressure. Have information sheets handy, as well as brochures. For patients with abnormal test results, have available brochures explaining their condition.

What the clinician says to the patient about cotesting is important too. A poll of 350 Kaiser patients and 37 physicians asking why the patient did or did not have cotesting found that physicians believed both their words and printed materials were important. Patients, on the other hand, felt that what mattered most was whether physicians said cotesting is a good idea and that they would choose testing themselves.

Give clinicians the education and tools they need to know what to say to patients about cotesting, and how to say it. Steps include conferences and guidelines, sample messages or scripts, and handouts on frequently asked questions.

In the Kaiser study, only 5.3% of the first 123,909 cotests were HPV positive. Of these, 3.7% had negative Pap tests.

The rate of HPV positivity dropped by half after age 39, from 9% in 30- to 39-year-olds to 5% of 40- to 49-year-olds. HPV positivity rates decreased with age to a low of 3% in women in their 60s, then crept up a bit over time, he said.

The lead investigator in studying the HPV data was Barbara Fetterman, Ph.D., of the Permanente Medical Group, Oakland, Calif.

SAN FRANCISCO — None of the newer biomarkers being evaluated as possible predictors of cardiovascular risk have been studied enough to be considered ready for clinical use, Michael H. Alderman, M.D., said at the annual meeting of the American Society of Hypertension.

Conventional risk factors such as blood pressure, insulin resistance, diabetes, obesity, lipids, and family history account for 50% of cardiovascular risk, so any biomarkers that could further gauge risk would be useful. A biomarker is a substance that can be measured precisely in serum or urine and is related to subsequent occurrence of cardiovascular disease—such as cholesterol, said Dr. Alderman of Albert Einstein College of Medicine, New York.

A handful of newer, more precise biomarkers appear to be more intimately associated with the development of cardiovascular disease and look like they will be useful. These include C-reactive protein, neurocytokines, and uric acid. So far, however, there is “suggestive, but for the most part not yet convincing, evidence that these new biomarkers add to the predictive value already contained in the markers that we have,” Dr. Alderman said at a press briefing during the meeting, where he gave a summary of reports on the newer biomarkers.

To be useful, a new risk marker would have to make a contribution beyond what's obtained from conventional risk markers. “I don't think that's been formally tested” with the newer biomarkers, he said.

Tests for the new risk marker would have to be reproducible at different times and in different populations, and would have to define an important amount, or proportion, of risk. Lastly, an assay for the biomarker would need to be feasible and cost effective when applied to a population.

“Those kinds of questions have been asked of blood pressure screening and cholesterol screening, but haven't been asked of cytokines,” for example, he said.

Dr. Alderman said he believes that uric acid is an independent risk factor for cardiovascular events, particularly in hypertensive patients, but the data supporting this are inconsistent. Other data showing that uric acid is predictive of elevated blood pressure may be more interesting and useful, he said.

SAN FRANCISCO — None of the newer biomarkers being evaluated as possible predictors of cardiovascular risk have been studied enough to be considered ready for clinical use, Michael H. Alderman, M.D., said at the annual meeting of the American Society of Hypertension.

Conventional risk factors such as blood pressure, insulin resistance, diabetes, obesity, lipids, and family history account for 50% of cardiovascular risk, so any biomarkers that could further gauge risk would be useful. A biomarker is a substance that can be measured precisely in serum or urine and is related to subsequent occurrence of cardiovascular disease—such as cholesterol, said Dr. Alderman of Albert Einstein College of Medicine, New York.

A handful of newer, more precise biomarkers appear to be more intimately associated with the development of cardiovascular disease and look like they will be useful. These include C-reactive protein, neurocytokines, and uric acid. So far, however, there is “suggestive, but for the most part not yet convincing, evidence that these new biomarkers add to the predictive value already contained in the markers that we have,” Dr. Alderman said at a press briefing during the meeting, where he gave a summary of reports on the newer biomarkers.

To be useful, a new risk marker would have to make a contribution beyond what's obtained from conventional risk markers. “I don't think that's been formally tested” with the newer biomarkers, he said.

Tests for the new risk marker would have to be reproducible at different times and in different populations, and would have to define an important amount, or proportion, of risk. Lastly, an assay for the biomarker would need to be feasible and cost effective when applied to a population.

“Those kinds of questions have been asked of blood pressure screening and cholesterol screening, but haven't been asked of cytokines,” for example, he said.

Dr. Alderman said he believes that uric acid is an independent risk factor for cardiovascular events, particularly in hypertensive patients, but the data supporting this are inconsistent. Other data showing that uric acid is predictive of elevated blood pressure may be more interesting and useful, he said.

SAN FRANCISCO — None of the newer biomarkers being evaluated as possible predictors of cardiovascular risk have been studied enough to be considered ready for clinical use, Michael H. Alderman, M.D., said at the annual meeting of the American Society of Hypertension.

Conventional risk factors such as blood pressure, insulin resistance, diabetes, obesity, lipids, and family history account for 50% of cardiovascular risk, so any biomarkers that could further gauge risk would be useful. A biomarker is a substance that can be measured precisely in serum or urine and is related to subsequent occurrence of cardiovascular disease—such as cholesterol, said Dr. Alderman of Albert Einstein College of Medicine, New York.

A handful of newer, more precise biomarkers appear to be more intimately associated with the development of cardiovascular disease and look like they will be useful. These include C-reactive protein, neurocytokines, and uric acid. So far, however, there is “suggestive, but for the most part not yet convincing, evidence that these new biomarkers add to the predictive value already contained in the markers that we have,” Dr. Alderman said at a press briefing during the meeting, where he gave a summary of reports on the newer biomarkers.

To be useful, a new risk marker would have to make a contribution beyond what's obtained from conventional risk markers. “I don't think that's been formally tested” with the newer biomarkers, he said.

Tests for the new risk marker would have to be reproducible at different times and in different populations, and would have to define an important amount, or proportion, of risk. Lastly, an assay for the biomarker would need to be feasible and cost effective when applied to a population.

“Those kinds of questions have been asked of blood pressure screening and cholesterol screening, but haven't been asked of cytokines,” for example, he said.

Dr. Alderman said he believes that uric acid is an independent risk factor for cardiovascular events, particularly in hypertensive patients, but the data supporting this are inconsistent. Other data showing that uric acid is predictive of elevated blood pressure may be more interesting and useful, he said.

SAN FRANCISCO — In the general ob.gyn. practice of Amy Meg Autry, M.D., visits with pregnant patients have evolved from giving equal time to examination and counseling to about 2% to examination and 98% to counseling.

Dr. Autry of the University of California, San Francisco, researched answers to some of their most common safety concerns regarding pregnancy and offered an overview of her findings at a meeting on antepartum and intrapartum management sponsored by the university:

▸ Fish. While eating fish can be good for maternal cardiovascular health and fetal growth and development, fish accumulate methyl mercury in their muscles from industrial pollution, which may cause neurotoxic symptoms in neonates that resemble cerebral palsy.

Only one retrospective study has found severe neurotoxic effects in children born to Japanese women who ate a steady diet of fish with high levels of mercury, even though the mothers showed minimal or no effects of mercury ingestion. Three other studies found neurologic effects in Japanese adults who ate a similar toxic-fish diet or Iraqi adults who ate grain that had been pretreated with mercury.

Two prospective studies produced conflicting results. In one, a diet high in whale blubber was associated with delays in attention, memory, and small-motor function in serial testing of children through age 6 in the Faeroe Islands of Norway. A separate study of residents of the Seychelles Islands who ate 12 meals of fish per week found that they had mercury levels 10–20 times higher than average levels in U.S. residents, yet this exposure produced no long-term neurologic effects. Other prospective studies are ongoing.

A 2004 joint advisory for consumers issued by the Environmental Protection Agency and the Food and Drug Administration recommended that pregnant women not eat shark, swordfish, king mackerel, or tilefish, because they are high in mercury.

The advisory emphasized the positive benefits of fish and stated that pregnant women may eat up to 12 ounces (two average meals) per week of fish low in mercury, such as salmon, shrimp, pollack, and catfish. Canned light tuna has less mercury than albacore tuna. For local fish, consult local and tribal advisories that apply to your area, or limit ingestion to 6 ounces per week.

▸ Cheese and hot dogs. One-third of an estimated 1,500 cases of listeriosis each year in the United States are in pregnant women. They are more susceptible to the infection due to compromised immune systems. One in five pregnant women with listeriosis experiences a spontaneous abortion or stillbirth.

Although cases of listeriosis in pregnancy are rare and sporadic, it's prudent to avoid high-risk foods such as hot dogs or luncheon meats, unless they've been reheated to steaming. Avoid soft cheeses, refrigerated patés or meat spreads, unpasteurized milk, and raw or undercooked meats.

▸ Caffeine. No data substantiate concerns about adverse pregnancy effects caused by light to moderate caffeine consumption.

Many studies that suggested caffeine may raise the risk for low birth weight, spontaneous abortion, congenital anomalies, or conception delays are poorly designed and demonstrate study bias, she said. Most of these studies were confounded by an association between caffeine intake and cigarette smoking.

▸ Alcohol. Multiple small studies show deleterious effects of drinking even small amounts of alcohol during pregnancy. A 2002 study that followed children from birth to age 6, for example, found persistently smaller head circumferences, height, and weight in children of women who had less than one drink per day during pregnancy. A 2001 study found more aggressive behavior in children of mothers who had one drink per week during pregnancy.

▸ Hot tubs. Animal data suggest that maternal hyperthermia (a body temperature of 102 degrees) may lead to first-trimester spontaneous abortion or neural tube defects. A very poorly designed study in human subjects, which was published in 2003, found a higher rate of first-trimester losses in women who used a hot tub more than weekly within 4 weeks of their last menstrual period. A 2005 metaanalysis of 42 studies suggested an 86% increase in risk for neural tube defects if the mother used a hot tub, sauna, or electric blanket and developed a fever.

On average, a pregnant woman's core body temperature will reach 102 degrees after 15 minutes of soaking in 102-degree water or 10 minutes in 106-degree water.

Skip hot tubs in the first trimester, and limit soaking times or water temperature after that, Dr. Autry advised.

▸ Exercise. Getting hot from exercise is okay; there's no evidence that hyperthermia from exercise is teratogenic, she said. Even exercise at high altitudes appears safe.

Exercise helps prevent gestational diabetes and decreases the risk for postpartum depression. Avoid standing still, supine activities, sports that cause falling or heavy contact, and scuba diving, which can cause decompression sickness in the fetus.

▸ Hair dye. All attempts to find an association between hair dye and teratogenic effects or cancer have washed out. Dye if you want to, Dr. Autry said.

SAN FRANCISCO — In the general ob.gyn. practice of Amy Meg Autry, M.D., visits with pregnant patients have evolved from giving equal time to examination and counseling to about 2% to examination and 98% to counseling.

Dr. Autry of the University of California, San Francisco, researched answers to some of their most common safety concerns regarding pregnancy and offered an overview of her findings at a meeting on antepartum and intrapartum management sponsored by the university:

▸ Fish. While eating fish can be good for maternal cardiovascular health and fetal growth and development, fish accumulate methyl mercury in their muscles from industrial pollution, which may cause neurotoxic symptoms in neonates that resemble cerebral palsy.

Only one retrospective study has found severe neurotoxic effects in children born to Japanese women who ate a steady diet of fish with high levels of mercury, even though the mothers showed minimal or no effects of mercury ingestion. Three other studies found neurologic effects in Japanese adults who ate a similar toxic-fish diet or Iraqi adults who ate grain that had been pretreated with mercury.

Two prospective studies produced conflicting results. In one, a diet high in whale blubber was associated with delays in attention, memory, and small-motor function in serial testing of children through age 6 in the Faeroe Islands of Norway. A separate study of residents of the Seychelles Islands who ate 12 meals of fish per week found that they had mercury levels 10–20 times higher than average levels in U.S. residents, yet this exposure produced no long-term neurologic effects. Other prospective studies are ongoing.

A 2004 joint advisory for consumers issued by the Environmental Protection Agency and the Food and Drug Administration recommended that pregnant women not eat shark, swordfish, king mackerel, or tilefish, because they are high in mercury.

The advisory emphasized the positive benefits of fish and stated that pregnant women may eat up to 12 ounces (two average meals) per week of fish low in mercury, such as salmon, shrimp, pollack, and catfish. Canned light tuna has less mercury than albacore tuna. For local fish, consult local and tribal advisories that apply to your area, or limit ingestion to 6 ounces per week.

▸ Cheese and hot dogs. One-third of an estimated 1,500 cases of listeriosis each year in the United States are in pregnant women. They are more susceptible to the infection due to compromised immune systems. One in five pregnant women with listeriosis experiences a spontaneous abortion or stillbirth.

Although cases of listeriosis in pregnancy are rare and sporadic, it's prudent to avoid high-risk foods such as hot dogs or luncheon meats, unless they've been reheated to steaming. Avoid soft cheeses, refrigerated patés or meat spreads, unpasteurized milk, and raw or undercooked meats.

▸ Caffeine. No data substantiate concerns about adverse pregnancy effects caused by light to moderate caffeine consumption.

Many studies that suggested caffeine may raise the risk for low birth weight, spontaneous abortion, congenital anomalies, or conception delays are poorly designed and demonstrate study bias, she said. Most of these studies were confounded by an association between caffeine intake and cigarette smoking.

▸ Alcohol. Multiple small studies show deleterious effects of drinking even small amounts of alcohol during pregnancy. A 2002 study that followed children from birth to age 6, for example, found persistently smaller head circumferences, height, and weight in children of women who had less than one drink per day during pregnancy. A 2001 study found more aggressive behavior in children of mothers who had one drink per week during pregnancy.

▸ Hot tubs. Animal data suggest that maternal hyperthermia (a body temperature of 102 degrees) may lead to first-trimester spontaneous abortion or neural tube defects. A very poorly designed study in human subjects, which was published in 2003, found a higher rate of first-trimester losses in women who used a hot tub more than weekly within 4 weeks of their last menstrual period. A 2005 metaanalysis of 42 studies suggested an 86% increase in risk for neural tube defects if the mother used a hot tub, sauna, or electric blanket and developed a fever.

On average, a pregnant woman's core body temperature will reach 102 degrees after 15 minutes of soaking in 102-degree water or 10 minutes in 106-degree water.

Skip hot tubs in the first trimester, and limit soaking times or water temperature after that, Dr. Autry advised.

▸ Exercise. Getting hot from exercise is okay; there's no evidence that hyperthermia from exercise is teratogenic, she said. Even exercise at high altitudes appears safe.

Exercise helps prevent gestational diabetes and decreases the risk for postpartum depression. Avoid standing still, supine activities, sports that cause falling or heavy contact, and scuba diving, which can cause decompression sickness in the fetus.

▸ Hair dye. All attempts to find an association between hair dye and teratogenic effects or cancer have washed out. Dye if you want to, Dr. Autry said.

SAN FRANCISCO — In the general ob.gyn. practice of Amy Meg Autry, M.D., visits with pregnant patients have evolved from giving equal time to examination and counseling to about 2% to examination and 98% to counseling.

Dr. Autry of the University of California, San Francisco, researched answers to some of their most common safety concerns regarding pregnancy and offered an overview of her findings at a meeting on antepartum and intrapartum management sponsored by the university:

▸ Fish. While eating fish can be good for maternal cardiovascular health and fetal growth and development, fish accumulate methyl mercury in their muscles from industrial pollution, which may cause neurotoxic symptoms in neonates that resemble cerebral palsy.

Only one retrospective study has found severe neurotoxic effects in children born to Japanese women who ate a steady diet of fish with high levels of mercury, even though the mothers showed minimal or no effects of mercury ingestion. Three other studies found neurologic effects in Japanese adults who ate a similar toxic-fish diet or Iraqi adults who ate grain that had been pretreated with mercury.

Two prospective studies produced conflicting results. In one, a diet high in whale blubber was associated with delays in attention, memory, and small-motor function in serial testing of children through age 6 in the Faeroe Islands of Norway. A separate study of residents of the Seychelles Islands who ate 12 meals of fish per week found that they had mercury levels 10–20 times higher than average levels in U.S. residents, yet this exposure produced no long-term neurologic effects. Other prospective studies are ongoing.

A 2004 joint advisory for consumers issued by the Environmental Protection Agency and the Food and Drug Administration recommended that pregnant women not eat shark, swordfish, king mackerel, or tilefish, because they are high in mercury.

The advisory emphasized the positive benefits of fish and stated that pregnant women may eat up to 12 ounces (two average meals) per week of fish low in mercury, such as salmon, shrimp, pollack, and catfish. Canned light tuna has less mercury than albacore tuna. For local fish, consult local and tribal advisories that apply to your area, or limit ingestion to 6 ounces per week.

▸ Cheese and hot dogs. One-third of an estimated 1,500 cases of listeriosis each year in the United States are in pregnant women. They are more susceptible to the infection due to compromised immune systems. One in five pregnant women with listeriosis experiences a spontaneous abortion or stillbirth.

Although cases of listeriosis in pregnancy are rare and sporadic, it's prudent to avoid high-risk foods such as hot dogs or luncheon meats, unless they've been reheated to steaming. Avoid soft cheeses, refrigerated patés or meat spreads, unpasteurized milk, and raw or undercooked meats.

▸ Caffeine. No data substantiate concerns about adverse pregnancy effects caused by light to moderate caffeine consumption.

Many studies that suggested caffeine may raise the risk for low birth weight, spontaneous abortion, congenital anomalies, or conception delays are poorly designed and demonstrate study bias, she said. Most of these studies were confounded by an association between caffeine intake and cigarette smoking.

▸ Alcohol. Multiple small studies show deleterious effects of drinking even small amounts of alcohol during pregnancy. A 2002 study that followed children from birth to age 6, for example, found persistently smaller head circumferences, height, and weight in children of women who had less than one drink per day during pregnancy. A 2001 study found more aggressive behavior in children of mothers who had one drink per week during pregnancy.

▸ Hot tubs. Animal data suggest that maternal hyperthermia (a body temperature of 102 degrees) may lead to first-trimester spontaneous abortion or neural tube defects. A very poorly designed study in human subjects, which was published in 2003, found a higher rate of first-trimester losses in women who used a hot tub more than weekly within 4 weeks of their last menstrual period. A 2005 metaanalysis of 42 studies suggested an 86% increase in risk for neural tube defects if the mother used a hot tub, sauna, or electric blanket and developed a fever.

On average, a pregnant woman's core body temperature will reach 102 degrees after 15 minutes of soaking in 102-degree water or 10 minutes in 106-degree water.

Skip hot tubs in the first trimester, and limit soaking times or water temperature after that, Dr. Autry advised.

▸ Exercise. Getting hot from exercise is okay; there's no evidence that hyperthermia from exercise is teratogenic, she said. Even exercise at high altitudes appears safe.

Exercise helps prevent gestational diabetes and decreases the risk for postpartum depression. Avoid standing still, supine activities, sports that cause falling or heavy contact, and scuba diving, which can cause decompression sickness in the fetus.

▸ Hair dye. All attempts to find an association between hair dye and teratogenic effects or cancer have washed out. Dye if you want to, Dr. Autry said.

SAN FRANCISCO — A new computerized tool helps pregnant women decide whether they want invasive prenatal testing, Miriam Kuppermann, Ph.D., said during a meeting on antepartum and intrapartum management, sponsored by the University of California, San Francisco.

The tool should be ready for clinical use in 2006, said Dr. Kuppermann of the university.

In a randomized, controlled trial, 496 pregnant women seen at three institutions in the San Francisco Bay area used the computerized decision-assistance tool or viewed a computer version of age-appropriate brochures that the state requires clinicians to give to all pregnant women. Both were available in English and Spanish. Investigators assessed the impact of the tool or the brochures during three follow-up interviews.

“We do emphasize throughout that the goal of our program is neither to get women to test nor to get them not to test. The goal is to help them make an informed decision that is consistent with their own preferences and values,” she said.

Immediately after the computer session, 75% of women using the decision-assistance tool correctly estimated their risk for having a baby with Down syndrome, compared with 5% of women in the control group. A significant difference in knowledge persisted in the second follow-up interview 2 weeks later.

The state pamphlets do not provide an individual's risk for Down syndrome, so the difference in knowledge between groups is not too surprising, but it's nevertheless encouraging to see that a high percentage of women understood their risk for trisomy 21 after using the computerized tool, Dr. Kuppermann said.

Immediately after the computer session, about 50% of women in the intervention group correctly estimated their risk for miscarriage related to prenatal testing, compared with 20% of women in the control group.

This difference in knowledge between groups also persisted 2 weeks later, she said.

The third follow-up interview, conducted at 30 weeks' gestation after any decisions about prenatal testing were made, found that women in the intervention group had less uncertainty about their decisions, reported fewer factors contributing to uncertainty, and had less decisional conflict, meaning they were more comfortable with their decisions.

Women in the intervention group were more likely to undergo invasive prenatal testing, compared with the control group. Women in this group who entered the study very inclined to undergo invasive testing were more likely to change their minds during the study and not be tested, Dr. Kupperman said.

Women who came in with little inclination to be tested were more likely to change their minds and undergo testing.

“So it's working in both directions, which makes me feel good that it's not a biased tool,” she said. “We believe that our tool does lead to more informed decisions that better reflect underlying preferences.”

The computerized tool first reassures women that most babies are born healthy, but it notes that 3%–4% will have a birth defect and that Down syndrome is one of the defects that can be detected by prenatal testing.

The woman enters her age, answers questions about other risk factors, and then receives an individualized risk presentation. For example, a 36-year-old woman's mid-trimester risk for carrying a fetus affected by trisomy 21 is about 4 in 1,000, so the computer might show her a photo of 1,000 balls, 4 of which are highlighted yellow to represent the risk.

In a “values clarification exercise,” the woman answers questions about various aspects of testing scenarios to elicit their value to her, ranging from “absolutely critical” to “not at all important.” Based on the woman's responses, the program suggests testing strategies that might fit her values and risks, and it gives summaries of strategies she chooses. “Again, there's no absolute recommendation,” Dr. Kuppermann said.

She and her associates now are modifying the tool to include first-trimester screening and testing strategies and models for other genetic tests for prenatal disorders besides Down syndrome. They also are creating a low-literacy version of the tool that relies less on text.

SAN FRANCISCO — A new computerized tool helps pregnant women decide whether they want invasive prenatal testing, Miriam Kuppermann, Ph.D., said during a meeting on antepartum and intrapartum management, sponsored by the University of California, San Francisco.

The tool should be ready for clinical use in 2006, said Dr. Kuppermann of the university.

In a randomized, controlled trial, 496 pregnant women seen at three institutions in the San Francisco Bay area used the computerized decision-assistance tool or viewed a computer version of age-appropriate brochures that the state requires clinicians to give to all pregnant women. Both were available in English and Spanish. Investigators assessed the impact of the tool or the brochures during three follow-up interviews.

“We do emphasize throughout that the goal of our program is neither to get women to test nor to get them not to test. The goal is to help them make an informed decision that is consistent with their own preferences and values,” she said.

Immediately after the computer session, 75% of women using the decision-assistance tool correctly estimated their risk for having a baby with Down syndrome, compared with 5% of women in the control group. A significant difference in knowledge persisted in the second follow-up interview 2 weeks later.

The state pamphlets do not provide an individual's risk for Down syndrome, so the difference in knowledge between groups is not too surprising, but it's nevertheless encouraging to see that a high percentage of women understood their risk for trisomy 21 after using the computerized tool, Dr. Kuppermann said.

Immediately after the computer session, about 50% of women in the intervention group correctly estimated their risk for miscarriage related to prenatal testing, compared with 20% of women in the control group.

This difference in knowledge between groups also persisted 2 weeks later, she said.

The third follow-up interview, conducted at 30 weeks' gestation after any decisions about prenatal testing were made, found that women in the intervention group had less uncertainty about their decisions, reported fewer factors contributing to uncertainty, and had less decisional conflict, meaning they were more comfortable with their decisions.

Women in the intervention group were more likely to undergo invasive prenatal testing, compared with the control group. Women in this group who entered the study very inclined to undergo invasive testing were more likely to change their minds during the study and not be tested, Dr. Kupperman said.

Women who came in with little inclination to be tested were more likely to change their minds and undergo testing.

“So it's working in both directions, which makes me feel good that it's not a biased tool,” she said. “We believe that our tool does lead to more informed decisions that better reflect underlying preferences.”

The computerized tool first reassures women that most babies are born healthy, but it notes that 3%–4% will have a birth defect and that Down syndrome is one of the defects that can be detected by prenatal testing.

The woman enters her age, answers questions about other risk factors, and then receives an individualized risk presentation. For example, a 36-year-old woman's mid-trimester risk for carrying a fetus affected by trisomy 21 is about 4 in 1,000, so the computer might show her a photo of 1,000 balls, 4 of which are highlighted yellow to represent the risk.

In a “values clarification exercise,” the woman answers questions about various aspects of testing scenarios to elicit their value to her, ranging from “absolutely critical” to “not at all important.” Based on the woman's responses, the program suggests testing strategies that might fit her values and risks, and it gives summaries of strategies she chooses. “Again, there's no absolute recommendation,” Dr. Kuppermann said.

She and her associates now are modifying the tool to include first-trimester screening and testing strategies and models for other genetic tests for prenatal disorders besides Down syndrome. They also are creating a low-literacy version of the tool that relies less on text.

SAN FRANCISCO — A new computerized tool helps pregnant women decide whether they want invasive prenatal testing, Miriam Kuppermann, Ph.D., said during a meeting on antepartum and intrapartum management, sponsored by the University of California, San Francisco.

The tool should be ready for clinical use in 2006, said Dr. Kuppermann of the university.

In a randomized, controlled trial, 496 pregnant women seen at three institutions in the San Francisco Bay area used the computerized decision-assistance tool or viewed a computer version of age-appropriate brochures that the state requires clinicians to give to all pregnant women. Both were available in English and Spanish. Investigators assessed the impact of the tool or the brochures during three follow-up interviews.

“We do emphasize throughout that the goal of our program is neither to get women to test nor to get them not to test. The goal is to help them make an informed decision that is consistent with their own preferences and values,” she said.

Immediately after the computer session, 75% of women using the decision-assistance tool correctly estimated their risk for having a baby with Down syndrome, compared with 5% of women in the control group. A significant difference in knowledge persisted in the second follow-up interview 2 weeks later.

The state pamphlets do not provide an individual's risk for Down syndrome, so the difference in knowledge between groups is not too surprising, but it's nevertheless encouraging to see that a high percentage of women understood their risk for trisomy 21 after using the computerized tool, Dr. Kuppermann said.

Immediately after the computer session, about 50% of women in the intervention group correctly estimated their risk for miscarriage related to prenatal testing, compared with 20% of women in the control group.

This difference in knowledge between groups also persisted 2 weeks later, she said.

The third follow-up interview, conducted at 30 weeks' gestation after any decisions about prenatal testing were made, found that women in the intervention group had less uncertainty about their decisions, reported fewer factors contributing to uncertainty, and had less decisional conflict, meaning they were more comfortable with their decisions.

Women in the intervention group were more likely to undergo invasive prenatal testing, compared with the control group. Women in this group who entered the study very inclined to undergo invasive testing were more likely to change their minds during the study and not be tested, Dr. Kupperman said.

Women who came in with little inclination to be tested were more likely to change their minds and undergo testing.

“So it's working in both directions, which makes me feel good that it's not a biased tool,” she said. “We believe that our tool does lead to more informed decisions that better reflect underlying preferences.”

The computerized tool first reassures women that most babies are born healthy, but it notes that 3%–4% will have a birth defect and that Down syndrome is one of the defects that can be detected by prenatal testing.

The woman enters her age, answers questions about other risk factors, and then receives an individualized risk presentation. For example, a 36-year-old woman's mid-trimester risk for carrying a fetus affected by trisomy 21 is about 4 in 1,000, so the computer might show her a photo of 1,000 balls, 4 of which are highlighted yellow to represent the risk.

In a “values clarification exercise,” the woman answers questions about various aspects of testing scenarios to elicit their value to her, ranging from “absolutely critical” to “not at all important.” Based on the woman's responses, the program suggests testing strategies that might fit her values and risks, and it gives summaries of strategies she chooses. “Again, there's no absolute recommendation,” Dr. Kuppermann said.

She and her associates now are modifying the tool to include first-trimester screening and testing strategies and models for other genetic tests for prenatal disorders besides Down syndrome. They also are creating a low-literacy version of the tool that relies less on text.