Sherry Boschert

Reports of a high prevalence of low vitamin D levels in adolescents and children—and the potential multiorgan effects of vitamin D deficiency—have raised concerns and some confusion among physicians.

The alarm is prompting some to consider screening more teenagers and children for vitamin D deficiency, but physicians would do better to screen for proper nutrition to ensure vitamin D intake, suggested Dr. Jatinder Bhatia, chair of the committee on nutrition of the American Academy of Pediatrics (AAP). “If you can't get them to eat right, then do the testing.”

Dr. Bhatia, professor and chief of neonatology at the Medical College of Georgia, Augusta, said he heard little concern when the AAP updated its 2003 guidelines in 2008 to double the recommended daily intake of vitamin D to 400 IU. But recent studies have caused “a hue and cry” about low vitamin D levels, he added.

Other physicians interviewed for this article argued that physicians should focus on universal, empiric vitamin D supplementation. One expert suggested that the alarm may be unwarranted because the recent studies raise more questions than they answer. Everyone agreed that no one really knows how to define adequate vitamin D levels in adolescents and children, and that much more study is needed.

A report by a committee of the Institute of Medicine on what constitutes adequate intakes of vitamin D is expected to be released in the spring of 2010 and is “eagerly awaited,” said Dr. Frank Greer, professor of pediatrics at the University of Wisconsin, Madison, and a coauthor of the AAP's 2008 guidelines on vitamin D intake.

In the United States, N9% of U.S. children and adolescents (7.6 million people) have 25-hydroxyvitamin D (25[OH]D) deficiency and 61% (50.8 million) have insufficient 25(OH)D levels in serum tests, according to a study by Dr. Juhi Kumar and associates (Pediatrics 2009 Sept. 3; doi:10.1542/peds.2009-0051). Only 4% were taking daily vitamin D supplementation (400 IU).

The researchers calculated prevalence using data on 9,757 children and adolescents from the 2001-2004 National Health and Nutrition Examination Survey (NHANES), defining 25(OH)D deficiency as a serum level below 15 ng/mL and insufficiency as 15-29 ng/mL.

Evidence is accumulating that bone health may not be the only issue related to vitamin D levels. After adjustment for confounding variables, analyses of data on 6,275 of the NHANES participants found that deficiency in 25(OH)D was associated with more than a threefold increased risk for elevated parathyroid hormone levels, a more than doubled risk for higher systolic blood pressure, and reduced levels of serum calcium and HDL cholesterol, compared with children and adolescents whose 25(OH)D levels were at least 30 ng/mL, wrote Dr. Kumar of Albert Einstein College of Medicine, New York, and his colleagues.

A separate analysis of data on 3,528 adolescents from NHANES 2001-2004 found that those with low serum 25(OH)D levels (less than 15 ng/mL) had roughly a doubling in risk for hypertension and fasting hyperglycemia and nearly a quadrupled risk for metabolic syndrome, compared with adolescents with levels above 26 ng/mL, reported Jared P. Reis, Ph.D., of the National Heart, Lung, and Blood Institute, and his associates (Pediatrics 2009 Sept. 3; doi:10.1542/peds.2009-0213).

“These are staggering numbers” that are supported by smaller studies in the medical literature, said Dr. Catherine M. Gordon, director of the bone health program at Children's Hospital, Boston.

“We may eventually be at the point of saying that we need to universally screen vitamin D levels,” she said in an interview, but “I don't think we're quite there from a cost-effective standpoint. I do think that children should be universally supplemented, but that's a controversial point.”

It's hard to drink enough milk to get the recommended 400 IU of vitamin D daily, and most young people “are not real excited about eating mackerel or sardines” to get vitamin D, noted Dr. Gordon, who specializes in pediatric endocrinology and in adolescent medicine. “That pushes us to supplement.”

She recommended annual screening of vitamin D levels in children and adolescents at risk for vitamin D deficiency, including those who are obese, those who have problems that lead to malabsorption of vitamin D (such as cystic fibrosis or inflammatory bowel disease), and those who are taking medications that may increase vitamin D metabolism, such as anticonvulsants.

Dr. Greer, a neonatologist, also might screen African American infants who were exclusively breastfed and children whose families practice purdah, an Arabic cultural tradition of covering up before going outside.

There's a growing consensus that 25(OH)D levels of 20 ng/mL or lower constitute vitamin D deficiency in children and adults, Dr. Gordon said. “I'm a believer in trying to keep all of our levels above 30 ng/mL” because the extraskeletal benefits of vitamin D (on the immune system, cell proliferation, and more) are conferred at these higher levels. Levels of 21-30 ng/mL, then, might be considered insufficient. Patients in risk groups may need 800-2,000 IU/day of vitamin D to maintain good serum levels, she noted.

“The problem is, there are not any good guidelines on what a normal level should be,” Dr. Greer said. “In the wintertime, everybody in the United States has pretty low levels, but they go up in the summertime, and most of us don't get rickets.”

The AAP recommendation to consume at least 400 IU/day of vitamin D is based largely on studies of non-Hispanic white infants and may not be optimal for other races, he added. “Nobody has looked at large numbers of African American infants” and vitamin D.

Meanwhile, the “inflammatory” reports about vitamin D deficiency appearing in the medical literature “are driving people at the NIH [National Institutes of Health] Office of Dietary Supplements crazy,” Dr. Greer said.

The study investigators and physicians mentioned in this story reported having no potential conflicts of interest related to these topics.

Reports of a high prevalence of low vitamin D levels in adolescents and children—and the potential multiorgan effects of vitamin D deficiency—have raised concerns and some confusion among physicians.

The alarm is prompting some to consider screening more teenagers and children for vitamin D deficiency, but physicians would do better to screen for proper nutrition to ensure vitamin D intake, suggested Dr. Jatinder Bhatia, chair of the committee on nutrition of the American Academy of Pediatrics (AAP). “If you can't get them to eat right, then do the testing.”

Dr. Bhatia, professor and chief of neonatology at the Medical College of Georgia, Augusta, said he heard little concern when the AAP updated its 2003 guidelines in 2008 to double the recommended daily intake of vitamin D to 400 IU. But recent studies have caused “a hue and cry” about low vitamin D levels, he added.

Other physicians interviewed for this article argued that physicians should focus on universal, empiric vitamin D supplementation. One expert suggested that the alarm may be unwarranted because the recent studies raise more questions than they answer. Everyone agreed that no one really knows how to define adequate vitamin D levels in adolescents and children, and that much more study is needed.

A report by a committee of the Institute of Medicine on what constitutes adequate intakes of vitamin D is expected to be released in the spring of 2010 and is “eagerly awaited,” said Dr. Frank Greer, professor of pediatrics at the University of Wisconsin, Madison, and a coauthor of the AAP's 2008 guidelines on vitamin D intake.

In the United States, N9% of U.S. children and adolescents (7.6 million people) have 25-hydroxyvitamin D (25[OH]D) deficiency and 61% (50.8 million) have insufficient 25(OH)D levels in serum tests, according to a study by Dr. Juhi Kumar and associates (Pediatrics 2009 Sept. 3; doi:10.1542/peds.2009-0051). Only 4% were taking daily vitamin D supplementation (400 IU).

The researchers calculated prevalence using data on 9,757 children and adolescents from the 2001-2004 National Health and Nutrition Examination Survey (NHANES), defining 25(OH)D deficiency as a serum level below 15 ng/mL and insufficiency as 15-29 ng/mL.

Evidence is accumulating that bone health may not be the only issue related to vitamin D levels. After adjustment for confounding variables, analyses of data on 6,275 of the NHANES participants found that deficiency in 25(OH)D was associated with more than a threefold increased risk for elevated parathyroid hormone levels, a more than doubled risk for higher systolic blood pressure, and reduced levels of serum calcium and HDL cholesterol, compared with children and adolescents whose 25(OH)D levels were at least 30 ng/mL, wrote Dr. Kumar of Albert Einstein College of Medicine, New York, and his colleagues.

A separate analysis of data on 3,528 adolescents from NHANES 2001-2004 found that those with low serum 25(OH)D levels (less than 15 ng/mL) had roughly a doubling in risk for hypertension and fasting hyperglycemia and nearly a quadrupled risk for metabolic syndrome, compared with adolescents with levels above 26 ng/mL, reported Jared P. Reis, Ph.D., of the National Heart, Lung, and Blood Institute, and his associates (Pediatrics 2009 Sept. 3; doi:10.1542/peds.2009-0213).

“These are staggering numbers” that are supported by smaller studies in the medical literature, said Dr. Catherine M. Gordon, director of the bone health program at Children's Hospital, Boston.

“We may eventually be at the point of saying that we need to universally screen vitamin D levels,” she said in an interview, but “I don't think we're quite there from a cost-effective standpoint. I do think that children should be universally supplemented, but that's a controversial point.”

It's hard to drink enough milk to get the recommended 400 IU of vitamin D daily, and most young people “are not real excited about eating mackerel or sardines” to get vitamin D, noted Dr. Gordon, who specializes in pediatric endocrinology and in adolescent medicine. “That pushes us to supplement.”

She recommended annual screening of vitamin D levels in children and adolescents at risk for vitamin D deficiency, including those who are obese, those who have problems that lead to malabsorption of vitamin D (such as cystic fibrosis or inflammatory bowel disease), and those who are taking medications that may increase vitamin D metabolism, such as anticonvulsants.

Dr. Greer, a neonatologist, also might screen African American infants who were exclusively breastfed and children whose families practice purdah, an Arabic cultural tradition of covering up before going outside.

There's a growing consensus that 25(OH)D levels of 20 ng/mL or lower constitute vitamin D deficiency in children and adults, Dr. Gordon said. “I'm a believer in trying to keep all of our levels above 30 ng/mL” because the extraskeletal benefits of vitamin D (on the immune system, cell proliferation, and more) are conferred at these higher levels. Levels of 21-30 ng/mL, then, might be considered insufficient. Patients in risk groups may need 800-2,000 IU/day of vitamin D to maintain good serum levels, she noted.

“The problem is, there are not any good guidelines on what a normal level should be,” Dr. Greer said. “In the wintertime, everybody in the United States has pretty low levels, but they go up in the summertime, and most of us don't get rickets.”

The AAP recommendation to consume at least 400 IU/day of vitamin D is based largely on studies of non-Hispanic white infants and may not be optimal for other races, he added. “Nobody has looked at large numbers of African American infants” and vitamin D.

Meanwhile, the “inflammatory” reports about vitamin D deficiency appearing in the medical literature “are driving people at the NIH [National Institutes of Health] Office of Dietary Supplements crazy,” Dr. Greer said.

The study investigators and physicians mentioned in this story reported having no potential conflicts of interest related to these topics.

Reports of a high prevalence of low vitamin D levels in adolescents and children—and the potential multiorgan effects of vitamin D deficiency—have raised concerns and some confusion among physicians.

The alarm is prompting some to consider screening more teenagers and children for vitamin D deficiency, but physicians would do better to screen for proper nutrition to ensure vitamin D intake, suggested Dr. Jatinder Bhatia, chair of the committee on nutrition of the American Academy of Pediatrics (AAP). “If you can't get them to eat right, then do the testing.”

Dr. Bhatia, professor and chief of neonatology at the Medical College of Georgia, Augusta, said he heard little concern when the AAP updated its 2003 guidelines in 2008 to double the recommended daily intake of vitamin D to 400 IU. But recent studies have caused “a hue and cry” about low vitamin D levels, he added.

Other physicians interviewed for this article argued that physicians should focus on universal, empiric vitamin D supplementation. One expert suggested that the alarm may be unwarranted because the recent studies raise more questions than they answer. Everyone agreed that no one really knows how to define adequate vitamin D levels in adolescents and children, and that much more study is needed.

A report by a committee of the Institute of Medicine on what constitutes adequate intakes of vitamin D is expected to be released in the spring of 2010 and is “eagerly awaited,” said Dr. Frank Greer, professor of pediatrics at the University of Wisconsin, Madison, and a coauthor of the AAP's 2008 guidelines on vitamin D intake.

In the United States, N9% of U.S. children and adolescents (7.6 million people) have 25-hydroxyvitamin D (25[OH]D) deficiency and 61% (50.8 million) have insufficient 25(OH)D levels in serum tests, according to a study by Dr. Juhi Kumar and associates (Pediatrics 2009 Sept. 3; doi:10.1542/peds.2009-0051). Only 4% were taking daily vitamin D supplementation (400 IU).

The researchers calculated prevalence using data on 9,757 children and adolescents from the 2001-2004 National Health and Nutrition Examination Survey (NHANES), defining 25(OH)D deficiency as a serum level below 15 ng/mL and insufficiency as 15-29 ng/mL.

Evidence is accumulating that bone health may not be the only issue related to vitamin D levels. After adjustment for confounding variables, analyses of data on 6,275 of the NHANES participants found that deficiency in 25(OH)D was associated with more than a threefold increased risk for elevated parathyroid hormone levels, a more than doubled risk for higher systolic blood pressure, and reduced levels of serum calcium and HDL cholesterol, compared with children and adolescents whose 25(OH)D levels were at least 30 ng/mL, wrote Dr. Kumar of Albert Einstein College of Medicine, New York, and his colleagues.

A separate analysis of data on 3,528 adolescents from NHANES 2001-2004 found that those with low serum 25(OH)D levels (less than 15 ng/mL) had roughly a doubling in risk for hypertension and fasting hyperglycemia and nearly a quadrupled risk for metabolic syndrome, compared with adolescents with levels above 26 ng/mL, reported Jared P. Reis, Ph.D., of the National Heart, Lung, and Blood Institute, and his associates (Pediatrics 2009 Sept. 3; doi:10.1542/peds.2009-0213).

“These are staggering numbers” that are supported by smaller studies in the medical literature, said Dr. Catherine M. Gordon, director of the bone health program at Children's Hospital, Boston.

“We may eventually be at the point of saying that we need to universally screen vitamin D levels,” she said in an interview, but “I don't think we're quite there from a cost-effective standpoint. I do think that children should be universally supplemented, but that's a controversial point.”

It's hard to drink enough milk to get the recommended 400 IU of vitamin D daily, and most young people “are not real excited about eating mackerel or sardines” to get vitamin D, noted Dr. Gordon, who specializes in pediatric endocrinology and in adolescent medicine. “That pushes us to supplement.”

She recommended annual screening of vitamin D levels in children and adolescents at risk for vitamin D deficiency, including those who are obese, those who have problems that lead to malabsorption of vitamin D (such as cystic fibrosis or inflammatory bowel disease), and those who are taking medications that may increase vitamin D metabolism, such as anticonvulsants.

Dr. Greer, a neonatologist, also might screen African American infants who were exclusively breastfed and children whose families practice purdah, an Arabic cultural tradition of covering up before going outside.

There's a growing consensus that 25(OH)D levels of 20 ng/mL or lower constitute vitamin D deficiency in children and adults, Dr. Gordon said. “I'm a believer in trying to keep all of our levels above 30 ng/mL” because the extraskeletal benefits of vitamin D (on the immune system, cell proliferation, and more) are conferred at these higher levels. Levels of 21-30 ng/mL, then, might be considered insufficient. Patients in risk groups may need 800-2,000 IU/day of vitamin D to maintain good serum levels, she noted.

“The problem is, there are not any good guidelines on what a normal level should be,” Dr. Greer said. “In the wintertime, everybody in the United States has pretty low levels, but they go up in the summertime, and most of us don't get rickets.”

The AAP recommendation to consume at least 400 IU/day of vitamin D is based largely on studies of non-Hispanic white infants and may not be optimal for other races, he added. “Nobody has looked at large numbers of African American infants” and vitamin D.

Meanwhile, the “inflammatory” reports about vitamin D deficiency appearing in the medical literature “are driving people at the NIH [National Institutes of Health] Office of Dietary Supplements crazy,” Dr. Greer said.

The study investigators and physicians mentioned in this story reported having no potential conflicts of interest related to these topics.

SAN FRANCISCO — Postpartum mastitis and breast abscesses increasingly are being traced to community-associated infection with methicillin-resistant Staphylococcus aureus.

Fortunately, the risk of neonatal transmission or colonization in these cases is very low, and preliminary data suggest there's no increased risk of adverse neonatal outcomes even if the mother initially is given the wrong treatment for community-associated methicillin-resistant S. aureus (CA-MRSA), Dr. Natali Aziz said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

In general, as many as one in three breastfeeding women in the United States develop postpartum mastitis, with approximately 10% of these developing breast abscesses. Studies of breast milk cultures have found S. aureus present in 37%-50% of mastitis cases.

A case-control study of 48 cases of S. aureus–associated postpartum mastitis in 1998-2005 found that 17 (81%) of 21 cases that were resistant to methicillin occurred in 2005 (Emerg. Infect. Dis. 2007;13:298-301).

Genetic analyses also suggested that 20 of the 21 MRSA cases were due to community-acquired MRSA, which may reassure clinicians that mastitis associated with MRSA should be susceptible to oral antibiotics, added Dr. Aziz of the university.

What few data exist on postpartum MRSA infection suggest that most cases involve mastitis or soft tissue infection, and that mastitis commonly leads to abscesses, she said.

In the largest study to date of hospitalized women with puerperal mastitis, cultures from 35 women who had both mastitis and breast abscesses found that CA-MRSA was the most common organism in breast abscesses, with MRSA in approximately two-thirds of cases. MRSA was much less likely in 54 women who had mastitis alone, growing in only one culture. As in the smaller study, a majority of women with CA-MRSA did not receive an appropriate antibiotic, but empiric use of an ineffective antibiotic did not adversely affect outcomes (Obstet. Gynecol. 2008;112:533-7).

At San Francisco General Hospital in 2005, S. aureus was cultured in the breast milk of 8 of 15 cases of mastitis; only 2 had MRSA, but three women with breast abscesses all had MRSA, Dr. Aziz said.

The data so far suggest that clinicians can continue to treat routine cases of mastitis with conventional first-line medications, and that it's reasonable to start treatment for CA-MRSA before cultures are completed in patients with abscesses or recurrent failure on conventional mastitis therapy. Consider getting cultures for recurrent disease, in areas with a high prevalence of CA-MRSA, or in patients with risk factors for CA-MRSA. “Be aware of your local epidemiology for your antibiotic choice” for CA-MRSA, Dr. Aziz advised, and remember that abscesses with CA-MRSA usually will require adjunct drainage or aspiration.

Women whose breast milk is colonized with CA-MRSA without mastitis can continue to breastfeed or pump breast milk for term infants, but this may put preterm infants at higher risk of conjunctivitis, sepsis, or other problems, some case reports suggest.

It is not cost effective to universally screen for MRSA or to decolonize women with MRSA in obstetric populations, a recent decision-analysis study concluded (Obstet. Gynecol. 2009;113:983-91). Dr. Aziz said she has no conflicts of interest.

SAN FRANCISCO — Postpartum mastitis and breast abscesses increasingly are being traced to community-associated infection with methicillin-resistant Staphylococcus aureus.

Fortunately, the risk of neonatal transmission or colonization in these cases is very low, and preliminary data suggest there's no increased risk of adverse neonatal outcomes even if the mother initially is given the wrong treatment for community-associated methicillin-resistant S. aureus (CA-MRSA), Dr. Natali Aziz said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

In general, as many as one in three breastfeeding women in the United States develop postpartum mastitis, with approximately 10% of these developing breast abscesses. Studies of breast milk cultures have found S. aureus present in 37%-50% of mastitis cases.

A case-control study of 48 cases of S. aureus–associated postpartum mastitis in 1998-2005 found that 17 (81%) of 21 cases that were resistant to methicillin occurred in 2005 (Emerg. Infect. Dis. 2007;13:298-301).

Genetic analyses also suggested that 20 of the 21 MRSA cases were due to community-acquired MRSA, which may reassure clinicians that mastitis associated with MRSA should be susceptible to oral antibiotics, added Dr. Aziz of the university.

What few data exist on postpartum MRSA infection suggest that most cases involve mastitis or soft tissue infection, and that mastitis commonly leads to abscesses, she said.

In the largest study to date of hospitalized women with puerperal mastitis, cultures from 35 women who had both mastitis and breast abscesses found that CA-MRSA was the most common organism in breast abscesses, with MRSA in approximately two-thirds of cases. MRSA was much less likely in 54 women who had mastitis alone, growing in only one culture. As in the smaller study, a majority of women with CA-MRSA did not receive an appropriate antibiotic, but empiric use of an ineffective antibiotic did not adversely affect outcomes (Obstet. Gynecol. 2008;112:533-7).

At San Francisco General Hospital in 2005, S. aureus was cultured in the breast milk of 8 of 15 cases of mastitis; only 2 had MRSA, but three women with breast abscesses all had MRSA, Dr. Aziz said.

The data so far suggest that clinicians can continue to treat routine cases of mastitis with conventional first-line medications, and that it's reasonable to start treatment for CA-MRSA before cultures are completed in patients with abscesses or recurrent failure on conventional mastitis therapy. Consider getting cultures for recurrent disease, in areas with a high prevalence of CA-MRSA, or in patients with risk factors for CA-MRSA. “Be aware of your local epidemiology for your antibiotic choice” for CA-MRSA, Dr. Aziz advised, and remember that abscesses with CA-MRSA usually will require adjunct drainage or aspiration.

Women whose breast milk is colonized with CA-MRSA without mastitis can continue to breastfeed or pump breast milk for term infants, but this may put preterm infants at higher risk of conjunctivitis, sepsis, or other problems, some case reports suggest.

It is not cost effective to universally screen for MRSA or to decolonize women with MRSA in obstetric populations, a recent decision-analysis study concluded (Obstet. Gynecol. 2009;113:983-91). Dr. Aziz said she has no conflicts of interest.

SAN FRANCISCO — Postpartum mastitis and breast abscesses increasingly are being traced to community-associated infection with methicillin-resistant Staphylococcus aureus.

Fortunately, the risk of neonatal transmission or colonization in these cases is very low, and preliminary data suggest there's no increased risk of adverse neonatal outcomes even if the mother initially is given the wrong treatment for community-associated methicillin-resistant S. aureus (CA-MRSA), Dr. Natali Aziz said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

In general, as many as one in three breastfeeding women in the United States develop postpartum mastitis, with approximately 10% of these developing breast abscesses. Studies of breast milk cultures have found S. aureus present in 37%-50% of mastitis cases.

A case-control study of 48 cases of S. aureus–associated postpartum mastitis in 1998-2005 found that 17 (81%) of 21 cases that were resistant to methicillin occurred in 2005 (Emerg. Infect. Dis. 2007;13:298-301).

Genetic analyses also suggested that 20 of the 21 MRSA cases were due to community-acquired MRSA, which may reassure clinicians that mastitis associated with MRSA should be susceptible to oral antibiotics, added Dr. Aziz of the university.

What few data exist on postpartum MRSA infection suggest that most cases involve mastitis or soft tissue infection, and that mastitis commonly leads to abscesses, she said.

In the largest study to date of hospitalized women with puerperal mastitis, cultures from 35 women who had both mastitis and breast abscesses found that CA-MRSA was the most common organism in breast abscesses, with MRSA in approximately two-thirds of cases. MRSA was much less likely in 54 women who had mastitis alone, growing in only one culture. As in the smaller study, a majority of women with CA-MRSA did not receive an appropriate antibiotic, but empiric use of an ineffective antibiotic did not adversely affect outcomes (Obstet. Gynecol. 2008;112:533-7).

At San Francisco General Hospital in 2005, S. aureus was cultured in the breast milk of 8 of 15 cases of mastitis; only 2 had MRSA, but three women with breast abscesses all had MRSA, Dr. Aziz said.

The data so far suggest that clinicians can continue to treat routine cases of mastitis with conventional first-line medications, and that it's reasonable to start treatment for CA-MRSA before cultures are completed in patients with abscesses or recurrent failure on conventional mastitis therapy. Consider getting cultures for recurrent disease, in areas with a high prevalence of CA-MRSA, or in patients with risk factors for CA-MRSA. “Be aware of your local epidemiology for your antibiotic choice” for CA-MRSA, Dr. Aziz advised, and remember that abscesses with CA-MRSA usually will require adjunct drainage or aspiration.

Women whose breast milk is colonized with CA-MRSA without mastitis can continue to breastfeed or pump breast milk for term infants, but this may put preterm infants at higher risk of conjunctivitis, sepsis, or other problems, some case reports suggest.

It is not cost effective to universally screen for MRSA or to decolonize women with MRSA in obstetric populations, a recent decision-analysis study concluded (Obstet. Gynecol. 2009;113:983-91). Dr. Aziz said she has no conflicts of interest.

SAN FRANCISCO — Empiric treatment with methotrexate for presumed ectopic pregnancy is a thing of the past, or should be, Dr. Amy “Meg” Autry said.

“You need to do a D&C before you treat with methotrexate” unless a definitive ectopic pregnancy is seen on ultrasound, she said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The D&C will help rule out ectopic pregnancy and avoid giving the chemotherapy drug to the 71% of women with indeterminate ultrasound results who actually have an intrauterine pregnancy, said Dr. Autry of the university.

Multiple studies support the need for doing a D&C before beginning methotrexate treatment, she noted. Besides the data that found chorionic villi in 71% of 245 women who underwent a D&C after indeterminate ultrasounds (Acad. Emerg. Med. 1999;6:1024-9), the results of a separate study of 112 women showed that a presumed diagnosis of ectopic pregnancy (without D&C results) was inaccurate in 38% of cases (Am. J. Obstet. Gynecol. 2002;100:505-10). Another study found that empiric treatment with methotrexate did not reduce complications or save money (Fertil. Steril. 2005;83:376-82). An endometrial Pipelle biopsy was not a sufficient substitute for a suction D&C to diagnose ectopic pregnancy in a separate, blinded prospective study of 32 patients (Am. J. Obstet. Gynecol. 2003;188:906-9).

The accumulated evidence is “compelling,” Dr. Autry said. “I would imagine for some of you in this room, this is practice changing, and I think you should change.”

In a separate practice-changing development, there is now “pretty good evidence to show that it's cost effective and tubal protective” to give methotrexate prophylactically to women scheduled for salpingostomies for ectopic pregnancy, Dr. Autry said.

When choosing surgery for ectopic pregnancy, she said she may take out the fallopian tube with the ectopic pregnancy but leave the other tube if it looks normal.

Salpingostomy is associated with persistent trophoblastic disease in 5%-20% of cases, however, without prophylactic methotrexate. Compared with no prophylaxis, giving methotrexate at the time of salpingostomy reduced the risk of tubal rupture (0.4% vs. 3.7%) or future procedures (1.9% vs. 4.7%) and lowered overall cost ($67.55 less on average), one study found (Fertil. Steril. 2001;76:1191-5). Patients with ectopic pregnancies who are most at risk for persistent trophoblastic tissue after salpingostomy are those with very early gestations, ectopic pregnancies less than 2 cm in size, or very high starting HCG levels, Dr. Autry said.

Dr. Autry said she has no conflicts of interest related to these topics.

'I would imagine for some of you … this is practice changing, and I think you should change.'

Source Dr. Autry

SAN FRANCISCO — Empiric treatment with methotrexate for presumed ectopic pregnancy is a thing of the past, or should be, Dr. Amy “Meg” Autry said.

“You need to do a D&C before you treat with methotrexate” unless a definitive ectopic pregnancy is seen on ultrasound, she said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The D&C will help rule out ectopic pregnancy and avoid giving the chemotherapy drug to the 71% of women with indeterminate ultrasound results who actually have an intrauterine pregnancy, said Dr. Autry of the university.

Multiple studies support the need for doing a D&C before beginning methotrexate treatment, she noted. Besides the data that found chorionic villi in 71% of 245 women who underwent a D&C after indeterminate ultrasounds (Acad. Emerg. Med. 1999;6:1024-9), the results of a separate study of 112 women showed that a presumed diagnosis of ectopic pregnancy (without D&C results) was inaccurate in 38% of cases (Am. J. Obstet. Gynecol. 2002;100:505-10). Another study found that empiric treatment with methotrexate did not reduce complications or save money (Fertil. Steril. 2005;83:376-82). An endometrial Pipelle biopsy was not a sufficient substitute for a suction D&C to diagnose ectopic pregnancy in a separate, blinded prospective study of 32 patients (Am. J. Obstet. Gynecol. 2003;188:906-9).

The accumulated evidence is “compelling,” Dr. Autry said. “I would imagine for some of you in this room, this is practice changing, and I think you should change.”

In a separate practice-changing development, there is now “pretty good evidence to show that it's cost effective and tubal protective” to give methotrexate prophylactically to women scheduled for salpingostomies for ectopic pregnancy, Dr. Autry said.

When choosing surgery for ectopic pregnancy, she said she may take out the fallopian tube with the ectopic pregnancy but leave the other tube if it looks normal.

Salpingostomy is associated with persistent trophoblastic disease in 5%-20% of cases, however, without prophylactic methotrexate. Compared with no prophylaxis, giving methotrexate at the time of salpingostomy reduced the risk of tubal rupture (0.4% vs. 3.7%) or future procedures (1.9% vs. 4.7%) and lowered overall cost ($67.55 less on average), one study found (Fertil. Steril. 2001;76:1191-5). Patients with ectopic pregnancies who are most at risk for persistent trophoblastic tissue after salpingostomy are those with very early gestations, ectopic pregnancies less than 2 cm in size, or very high starting HCG levels, Dr. Autry said.

Dr. Autry said she has no conflicts of interest related to these topics.

'I would imagine for some of you … this is practice changing, and I think you should change.'

Source Dr. Autry

SAN FRANCISCO — Empiric treatment with methotrexate for presumed ectopic pregnancy is a thing of the past, or should be, Dr. Amy “Meg” Autry said.

“You need to do a D&C before you treat with methotrexate” unless a definitive ectopic pregnancy is seen on ultrasound, she said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The D&C will help rule out ectopic pregnancy and avoid giving the chemotherapy drug to the 71% of women with indeterminate ultrasound results who actually have an intrauterine pregnancy, said Dr. Autry of the university.

Multiple studies support the need for doing a D&C before beginning methotrexate treatment, she noted. Besides the data that found chorionic villi in 71% of 245 women who underwent a D&C after indeterminate ultrasounds (Acad. Emerg. Med. 1999;6:1024-9), the results of a separate study of 112 women showed that a presumed diagnosis of ectopic pregnancy (without D&C results) was inaccurate in 38% of cases (Am. J. Obstet. Gynecol. 2002;100:505-10). Another study found that empiric treatment with methotrexate did not reduce complications or save money (Fertil. Steril. 2005;83:376-82). An endometrial Pipelle biopsy was not a sufficient substitute for a suction D&C to diagnose ectopic pregnancy in a separate, blinded prospective study of 32 patients (Am. J. Obstet. Gynecol. 2003;188:906-9).

The accumulated evidence is “compelling,” Dr. Autry said. “I would imagine for some of you in this room, this is practice changing, and I think you should change.”

In a separate practice-changing development, there is now “pretty good evidence to show that it's cost effective and tubal protective” to give methotrexate prophylactically to women scheduled for salpingostomies for ectopic pregnancy, Dr. Autry said.

When choosing surgery for ectopic pregnancy, she said she may take out the fallopian tube with the ectopic pregnancy but leave the other tube if it looks normal.

Salpingostomy is associated with persistent trophoblastic disease in 5%-20% of cases, however, without prophylactic methotrexate. Compared with no prophylaxis, giving methotrexate at the time of salpingostomy reduced the risk of tubal rupture (0.4% vs. 3.7%) or future procedures (1.9% vs. 4.7%) and lowered overall cost ($67.55 less on average), one study found (Fertil. Steril. 2001;76:1191-5). Patients with ectopic pregnancies who are most at risk for persistent trophoblastic tissue after salpingostomy are those with very early gestations, ectopic pregnancies less than 2 cm in size, or very high starting HCG levels, Dr. Autry said.

Dr. Autry said she has no conflicts of interest related to these topics.

'I would imagine for some of you … this is practice changing, and I think you should change.'

Source Dr. Autry

SAN FRANCISCO — During prenatal visits at the University of California, San Francisco, pregnant women meet not only with clinicians but with a new “Video Doctor” designed to help them stay fit and avoid excessive weight gain during pregnancy.

The women use a laptop and headphones in the clinic to view video clips of an actress who plays a physician and asks them about their diet and physical activities and then provides motivational counseling in an interactive format.

“This really is a nice adjunct to the counseling that we do in the clinic,” Dr. Naomi E. Stotland said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The Video Doctor program prints a “Provider Alert” sheet that the woman can bring to her clinician “so the clinician can see what's going on and reinforce the counseling,” said Dr. Stotland of the university.

She said she hopes the Video Doctor experiment will provide an effective, low-cost way of implementing basic strategies to limit excessive weight gain in pregnancy.

Recent studies suggest that working with a dietitian plus intensified monitoring and counseling by an ob.gyn. may reduce excessive weight gain in pregnancy in some populations, but these interventions are expensive and time consuming, she noted.

One randomized, controlled trial found that stepped-care behavioral interventions reduced excessive weight gain, compared with routine care, but only in women who had a normal body mass index before they became pregnant, she said.

Another study compared women who received provider counseling, plus a mailed patient-education newsletter, with historical controls and found that the intervention reduced the rate of excessive weight gain during pregnancy only in low-income women.

Most recently, investigators randomized 100 pregnant women to intensive dietary and lifestyle counseling or routine care with no extra counseling.

The intervention was similar to recommendations by the American College of Obstetricians and Gynecologists for routine weight gain monitoring and counseling.

Patients in the intervention group gained significantly less weight in pregnancy than did controls (29 vs. 36 pounds) but did not meet the primary outcome of a significant improvement in the percentage of women whose gestational weight gain fell within limits recommended by the Institute of Medicine (Am. J. Obstet. Gynecol. 2009;113:305-12).

“We have a long way to go,” Dr. Stotland said, “and these are kind of expensive things to implement. It's much, much more intensive counseling” than usual.

The Video Doctor may help with this, but a preliminary study showed only partial promise.

When used as a one-time intervention around the 20th week of pregnancy in a randomized, controlled trial, the Video Doctor was not associated with a difference in weight gain, but the women in the Video Doctor group did report better diets and physical activity behaviors and increased discussions about these topics at follow-up visits, Dr. Stotland said.

A new study will use a revised version of the Video Doctor that starts earlier in pregnancy and engages pregnant women in a serial fashion throughout pregnancy. The study also will incorporate other strategies such as self-monitoring of weight.

“We're hoping that as a package, this will reduce excessive weight gain in pregnancy, but we need to do more research,” she said.

A large proportion of U.S. women gain excessive weight during pregnancy.

In a recent study of nearly 53,000 women in the United States who gave birth to term singletons in 2004-2005, 42% of those who were normal weight at baseline and 64% of those who were overweight at baseline gained more pounds during pregnancy than were recommended in the 1990 Institute of Medicine guidelines.

Among women who were obese at baseline, 46% gained more than 25 pounds above the Institue of Medicine-recommended amount (Am. J. Obstet. Gynecol. 2009;200:271.e1-7).

The Institute of Medicine in May 2009 revised its recommendations for weight gain in pregnancy to add an upper limit to recommendations for pregnant women who are obese at baseline.

In a comparison of the Institute of Medicine guidelines with 2002-2003 data from the Pregnancy Risk Assessment Monitoring System, overweight women gained a median of 30 pounds during pregnancy, compared with 20 pounds recommended by the IOM, and obese women gained 25 pounds, compared with the recommended median of 15.5 pounds, the Institute of Medicine found.

Dr. Stotland reported that she has no conflicts of interest related to these topics.

'This really is a nice adjunct to the counseling that we do in the clinic.'

Source Dr. Stotland

A woman in a prenatal clinic connects with the Video Doctor for counseling on weight gain during pregnancy.

Source Courtesy Kristin Gerbert

SAN FRANCISCO — During prenatal visits at the University of California, San Francisco, pregnant women meet not only with clinicians but with a new “Video Doctor” designed to help them stay fit and avoid excessive weight gain during pregnancy.

The women use a laptop and headphones in the clinic to view video clips of an actress who plays a physician and asks them about their diet and physical activities and then provides motivational counseling in an interactive format.

“This really is a nice adjunct to the counseling that we do in the clinic,” Dr. Naomi E. Stotland said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The Video Doctor program prints a “Provider Alert” sheet that the woman can bring to her clinician “so the clinician can see what's going on and reinforce the counseling,” said Dr. Stotland of the university.

She said she hopes the Video Doctor experiment will provide an effective, low-cost way of implementing basic strategies to limit excessive weight gain in pregnancy.

Recent studies suggest that working with a dietitian plus intensified monitoring and counseling by an ob.gyn. may reduce excessive weight gain in pregnancy in some populations, but these interventions are expensive and time consuming, she noted.

One randomized, controlled trial found that stepped-care behavioral interventions reduced excessive weight gain, compared with routine care, but only in women who had a normal body mass index before they became pregnant, she said.

Another study compared women who received provider counseling, plus a mailed patient-education newsletter, with historical controls and found that the intervention reduced the rate of excessive weight gain during pregnancy only in low-income women.

Most recently, investigators randomized 100 pregnant women to intensive dietary and lifestyle counseling or routine care with no extra counseling.

The intervention was similar to recommendations by the American College of Obstetricians and Gynecologists for routine weight gain monitoring and counseling.

Patients in the intervention group gained significantly less weight in pregnancy than did controls (29 vs. 36 pounds) but did not meet the primary outcome of a significant improvement in the percentage of women whose gestational weight gain fell within limits recommended by the Institute of Medicine (Am. J. Obstet. Gynecol. 2009;113:305-12).

“We have a long way to go,” Dr. Stotland said, “and these are kind of expensive things to implement. It's much, much more intensive counseling” than usual.

The Video Doctor may help with this, but a preliminary study showed only partial promise.

When used as a one-time intervention around the 20th week of pregnancy in a randomized, controlled trial, the Video Doctor was not associated with a difference in weight gain, but the women in the Video Doctor group did report better diets and physical activity behaviors and increased discussions about these topics at follow-up visits, Dr. Stotland said.

A new study will use a revised version of the Video Doctor that starts earlier in pregnancy and engages pregnant women in a serial fashion throughout pregnancy. The study also will incorporate other strategies such as self-monitoring of weight.

“We're hoping that as a package, this will reduce excessive weight gain in pregnancy, but we need to do more research,” she said.

A large proportion of U.S. women gain excessive weight during pregnancy.

In a recent study of nearly 53,000 women in the United States who gave birth to term singletons in 2004-2005, 42% of those who were normal weight at baseline and 64% of those who were overweight at baseline gained more pounds during pregnancy than were recommended in the 1990 Institute of Medicine guidelines.

Among women who were obese at baseline, 46% gained more than 25 pounds above the Institue of Medicine-recommended amount (Am. J. Obstet. Gynecol. 2009;200:271.e1-7).

The Institute of Medicine in May 2009 revised its recommendations for weight gain in pregnancy to add an upper limit to recommendations for pregnant women who are obese at baseline.

In a comparison of the Institute of Medicine guidelines with 2002-2003 data from the Pregnancy Risk Assessment Monitoring System, overweight women gained a median of 30 pounds during pregnancy, compared with 20 pounds recommended by the IOM, and obese women gained 25 pounds, compared with the recommended median of 15.5 pounds, the Institute of Medicine found.

Dr. Stotland reported that she has no conflicts of interest related to these topics.

'This really is a nice adjunct to the counseling that we do in the clinic.'

Source Dr. Stotland

A woman in a prenatal clinic connects with the Video Doctor for counseling on weight gain during pregnancy.

Source Courtesy Kristin Gerbert

SAN FRANCISCO — During prenatal visits at the University of California, San Francisco, pregnant women meet not only with clinicians but with a new “Video Doctor” designed to help them stay fit and avoid excessive weight gain during pregnancy.

The women use a laptop and headphones in the clinic to view video clips of an actress who plays a physician and asks them about their diet and physical activities and then provides motivational counseling in an interactive format.

“This really is a nice adjunct to the counseling that we do in the clinic,” Dr. Naomi E. Stotland said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The Video Doctor program prints a “Provider Alert” sheet that the woman can bring to her clinician “so the clinician can see what's going on and reinforce the counseling,” said Dr. Stotland of the university.

She said she hopes the Video Doctor experiment will provide an effective, low-cost way of implementing basic strategies to limit excessive weight gain in pregnancy.

Recent studies suggest that working with a dietitian plus intensified monitoring and counseling by an ob.gyn. may reduce excessive weight gain in pregnancy in some populations, but these interventions are expensive and time consuming, she noted.

One randomized, controlled trial found that stepped-care behavioral interventions reduced excessive weight gain, compared with routine care, but only in women who had a normal body mass index before they became pregnant, she said.

Another study compared women who received provider counseling, plus a mailed patient-education newsletter, with historical controls and found that the intervention reduced the rate of excessive weight gain during pregnancy only in low-income women.

Most recently, investigators randomized 100 pregnant women to intensive dietary and lifestyle counseling or routine care with no extra counseling.

The intervention was similar to recommendations by the American College of Obstetricians and Gynecologists for routine weight gain monitoring and counseling.

Patients in the intervention group gained significantly less weight in pregnancy than did controls (29 vs. 36 pounds) but did not meet the primary outcome of a significant improvement in the percentage of women whose gestational weight gain fell within limits recommended by the Institute of Medicine (Am. J. Obstet. Gynecol. 2009;113:305-12).

“We have a long way to go,” Dr. Stotland said, “and these are kind of expensive things to implement. It's much, much more intensive counseling” than usual.

The Video Doctor may help with this, but a preliminary study showed only partial promise.

When used as a one-time intervention around the 20th week of pregnancy in a randomized, controlled trial, the Video Doctor was not associated with a difference in weight gain, but the women in the Video Doctor group did report better diets and physical activity behaviors and increased discussions about these topics at follow-up visits, Dr. Stotland said.

A new study will use a revised version of the Video Doctor that starts earlier in pregnancy and engages pregnant women in a serial fashion throughout pregnancy. The study also will incorporate other strategies such as self-monitoring of weight.

“We're hoping that as a package, this will reduce excessive weight gain in pregnancy, but we need to do more research,” she said.

A large proportion of U.S. women gain excessive weight during pregnancy.

In a recent study of nearly 53,000 women in the United States who gave birth to term singletons in 2004-2005, 42% of those who were normal weight at baseline and 64% of those who were overweight at baseline gained more pounds during pregnancy than were recommended in the 1990 Institute of Medicine guidelines.

Among women who were obese at baseline, 46% gained more than 25 pounds above the Institue of Medicine-recommended amount (Am. J. Obstet. Gynecol. 2009;200:271.e1-7).

The Institute of Medicine in May 2009 revised its recommendations for weight gain in pregnancy to add an upper limit to recommendations for pregnant women who are obese at baseline.

In a comparison of the Institute of Medicine guidelines with 2002-2003 data from the Pregnancy Risk Assessment Monitoring System, overweight women gained a median of 30 pounds during pregnancy, compared with 20 pounds recommended by the IOM, and obese women gained 25 pounds, compared with the recommended median of 15.5 pounds, the Institute of Medicine found.

Dr. Stotland reported that she has no conflicts of interest related to these topics.

'This really is a nice adjunct to the counseling that we do in the clinic.'

Source Dr. Stotland

A woman in a prenatal clinic connects with the Video Doctor for counseling on weight gain during pregnancy.

Source Courtesy Kristin Gerbert

Fortunately, the risk of neonatal transmission or colonization in these cases is very low, and preliminary data suggest there's no increased risk of adverse neonatal outcomes even if the mother initially is given the wrong treatment for community-associated methicillin-resistant S. aureus (CA-MRSA), Dr. Natali Aziz said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

In general, as many as one in three breastfeeding women in the United States develops postpartum mastitis, with approximately 10% of these developing breast abscesses. Studies of breast milk cultures have found S. aureus present in 37%-50% of mastitis cases.

A case-control study of 48 cases of S. aureus-associated postpartum mastitis in 1998-2005 found that 17 (81%) of 21 cases that were resistant to methicillin occurred in 2005 (Emerg. Infect. Dis. 2007;13:298-301).

Genetic analyses also suggested that 20 of the 21 MRSA cases were due to community-acquired MRSA, which may reassure clinicians that mastitis associated with MRSA should be susceptible to oral antibiotics, added Dr. Aziz of the university.

What few data exist on postpartum MRSA infection suggest that most cases involve mastitis or soft tissue infection, and that mastitis commonly leads to abscesses, she said. In one series of 10 postpartum MRSA infections, 4 affected the breast, 3 were associated with incisions, and 3 were in soft tissue. In another series of eight postpartum MRSA infections, half were in the breast, and three of these four cases progressed to abscesses.

The 21 cases of MRSA were less likely than the methicillin-susceptible cases to receive timely and appropriate treatment, but there were no significant differences in clinical outcomes in this small study, she noted.

In the largest study to date of hospitalized women with puerperal mastitis, cultures from 35 women who had both mastitis and breast abscesses found that CA-MRSA was the most common organism in breast abscesses, with MRSA in approximately two-thirds of cases. MRSA was much less likely in 54 women who had mastitis alone, growing in only one culture. As in the smaller study, a majority of women with CA-MRSA did not receive an appropriate antibiotic, but empiric use of an ineffective antibiotic did not adversely affect outcomes (Obstet. Gynecol. 2008;112:533-7).

At San Francisco General Hospital in 2005, S. aureus was cultured in the breast milk of 8 of 15 cases of mastitis; only 2 had MRSA, but three women with breast abscesses all had MRSA, Dr. Aziz said.

The data so far suggest that clinicians can continue to treat routine cases of mastitis with conventional first-line medications, and that it's reasonable to start treatment for CA-MRSA before cultures are completed in patients with abscesses or recurrent failure on conventional mastitis therapy. Consider getting cultures for recurrent disease, in areas with a high prevalence of CA-MRSA, or in patients with risk factors for CA-MRSA.

“Be aware of your local epidemiology for your antibiotic choice” for CA-MRSA, Dr. Aziz advised, and remember that abscesses with CA-MRSA usually will require adjunct drainage.

Women whose breast milk is colonized with CA-MRSA without mastitis can continue to breastfeed or pump breast milk for term infants, but this may put preterm infants at higher risk of conjunctivitis or other problems, case reports suggest.

It is not cost effective to universally screen for MRSA or to decolonize women with MRSA in obstetric populations, a recent decision-analysis study concluded (Obstet. Gynecol. 2009;113:983-91).

Dr. Aziz said she has no conflicts of interest.

Fortunately, the risk of neonatal transmission or colonization in these cases is very low, and preliminary data suggest there's no increased risk of adverse neonatal outcomes even if the mother initially is given the wrong treatment for community-associated methicillin-resistant S. aureus (CA-MRSA), Dr. Natali Aziz said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

In general, as many as one in three breastfeeding women in the United States develops postpartum mastitis, with approximately 10% of these developing breast abscesses. Studies of breast milk cultures have found S. aureus present in 37%-50% of mastitis cases.

A case-control study of 48 cases of S. aureus-associated postpartum mastitis in 1998-2005 found that 17 (81%) of 21 cases that were resistant to methicillin occurred in 2005 (Emerg. Infect. Dis. 2007;13:298-301).

Genetic analyses also suggested that 20 of the 21 MRSA cases were due to community-acquired MRSA, which may reassure clinicians that mastitis associated with MRSA should be susceptible to oral antibiotics, added Dr. Aziz of the university.

What few data exist on postpartum MRSA infection suggest that most cases involve mastitis or soft tissue infection, and that mastitis commonly leads to abscesses, she said. In one series of 10 postpartum MRSA infections, 4 affected the breast, 3 were associated with incisions, and 3 were in soft tissue. In another series of eight postpartum MRSA infections, half were in the breast, and three of these four cases progressed to abscesses.

The 21 cases of MRSA were less likely than the methicillin-susceptible cases to receive timely and appropriate treatment, but there were no significant differences in clinical outcomes in this small study, she noted.

In the largest study to date of hospitalized women with puerperal mastitis, cultures from 35 women who had both mastitis and breast abscesses found that CA-MRSA was the most common organism in breast abscesses, with MRSA in approximately two-thirds of cases. MRSA was much less likely in 54 women who had mastitis alone, growing in only one culture. As in the smaller study, a majority of women with CA-MRSA did not receive an appropriate antibiotic, but empiric use of an ineffective antibiotic did not adversely affect outcomes (Obstet. Gynecol. 2008;112:533-7).

At San Francisco General Hospital in 2005, S. aureus was cultured in the breast milk of 8 of 15 cases of mastitis; only 2 had MRSA, but three women with breast abscesses all had MRSA, Dr. Aziz said.

The data so far suggest that clinicians can continue to treat routine cases of mastitis with conventional first-line medications, and that it's reasonable to start treatment for CA-MRSA before cultures are completed in patients with abscesses or recurrent failure on conventional mastitis therapy. Consider getting cultures for recurrent disease, in areas with a high prevalence of CA-MRSA, or in patients with risk factors for CA-MRSA.

“Be aware of your local epidemiology for your antibiotic choice” for CA-MRSA, Dr. Aziz advised, and remember that abscesses with CA-MRSA usually will require adjunct drainage.

Women whose breast milk is colonized with CA-MRSA without mastitis can continue to breastfeed or pump breast milk for term infants, but this may put preterm infants at higher risk of conjunctivitis or other problems, case reports suggest.

It is not cost effective to universally screen for MRSA or to decolonize women with MRSA in obstetric populations, a recent decision-analysis study concluded (Obstet. Gynecol. 2009;113:983-91).

Dr. Aziz said she has no conflicts of interest.

Fortunately, the risk of neonatal transmission or colonization in these cases is very low, and preliminary data suggest there's no increased risk of adverse neonatal outcomes even if the mother initially is given the wrong treatment for community-associated methicillin-resistant S. aureus (CA-MRSA), Dr. Natali Aziz said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

In general, as many as one in three breastfeeding women in the United States develops postpartum mastitis, with approximately 10% of these developing breast abscesses. Studies of breast milk cultures have found S. aureus present in 37%-50% of mastitis cases.

A case-control study of 48 cases of S. aureus-associated postpartum mastitis in 1998-2005 found that 17 (81%) of 21 cases that were resistant to methicillin occurred in 2005 (Emerg. Infect. Dis. 2007;13:298-301).

Genetic analyses also suggested that 20 of the 21 MRSA cases were due to community-acquired MRSA, which may reassure clinicians that mastitis associated with MRSA should be susceptible to oral antibiotics, added Dr. Aziz of the university.

What few data exist on postpartum MRSA infection suggest that most cases involve mastitis or soft tissue infection, and that mastitis commonly leads to abscesses, she said. In one series of 10 postpartum MRSA infections, 4 affected the breast, 3 were associated with incisions, and 3 were in soft tissue. In another series of eight postpartum MRSA infections, half were in the breast, and three of these four cases progressed to abscesses.

The 21 cases of MRSA were less likely than the methicillin-susceptible cases to receive timely and appropriate treatment, but there were no significant differences in clinical outcomes in this small study, she noted.

In the largest study to date of hospitalized women with puerperal mastitis, cultures from 35 women who had both mastitis and breast abscesses found that CA-MRSA was the most common organism in breast abscesses, with MRSA in approximately two-thirds of cases. MRSA was much less likely in 54 women who had mastitis alone, growing in only one culture. As in the smaller study, a majority of women with CA-MRSA did not receive an appropriate antibiotic, but empiric use of an ineffective antibiotic did not adversely affect outcomes (Obstet. Gynecol. 2008;112:533-7).

At San Francisco General Hospital in 2005, S. aureus was cultured in the breast milk of 8 of 15 cases of mastitis; only 2 had MRSA, but three women with breast abscesses all had MRSA, Dr. Aziz said.

The data so far suggest that clinicians can continue to treat routine cases of mastitis with conventional first-line medications, and that it's reasonable to start treatment for CA-MRSA before cultures are completed in patients with abscesses or recurrent failure on conventional mastitis therapy. Consider getting cultures for recurrent disease, in areas with a high prevalence of CA-MRSA, or in patients with risk factors for CA-MRSA.

“Be aware of your local epidemiology for your antibiotic choice” for CA-MRSA, Dr. Aziz advised, and remember that abscesses with CA-MRSA usually will require adjunct drainage.

Women whose breast milk is colonized with CA-MRSA without mastitis can continue to breastfeed or pump breast milk for term infants, but this may put preterm infants at higher risk of conjunctivitis or other problems, case reports suggest.

It is not cost effective to universally screen for MRSA or to decolonize women with MRSA in obstetric populations, a recent decision-analysis study concluded (Obstet. Gynecol. 2009;113:983-91).

Dr. Aziz said she has no conflicts of interest.

SAN FRANCISCO – Teenagers and their parents favor the idea of routine mental health screening for adolescents who come to emergency departments, but don't think it necessarily applies to them, a survey of 604 people found.

The 299 patients aged 13-17 years and 305 parents who accompanied them completed a two-page questionnaire in 3-5 minutes while waiting for the adolescent to receive emergency care in a large Midwestern hospital.

Emergency departments (EDs) could be excellent places for mental health screening and intervention during long wait times, Roisin O'Mara and her associates suggested in a poster presentation at the annual conference of the American Society of Suicidology. Previous studies suggest that ED visits provide “teachable moments” when adolescents may be receptive to interventions, said Ms. O'Mara of the University of Michigan, Ann Arbor.

Among the adolescents surveyed, 93%-94% felt that it is somewhat important or extremely important to screen teenagers in the ED for depression, anxiety, alcohol misuse, drug misuse, or suicide risk. Among adults surveyed, 96%-99% agreed that screening teens for these are somewhat or extremely important. Screening for behavioral problems or dating violence was thought to be somewhat or extremely important by 87%-89% of adolescents and 96%-97% of adults.

When asked if ED staff should ask all teens about these problems as part of routine care, 57% of adolescents and 69% of adults agreed or strongly agreed, a statistically significant difference between the youths and their parents/guardians. However, when asked if they would take a mental health screening (or allow their teen to take one) if it were offered that day, only 42% of adolescents and 49% of adults agreed or strongly agreed.

“This seems to reflect an attitude of, 'Yes, it is a good idea, but not necessarily for me or my teen',” Ms. O'Mara noted.

The top concern expressed about mental health screening in the ED was worry about privacy (72% of teens, 63% of adults). Any effort to start such screening should address this concern, the investigators suggested.

The adolescents also were significantly more likely than were the adults to say that a screening is unnecessary because they know they don't have these mental health problems (61%) and to say that they worry about what other people would think of them if they did have these problems (53%). Among adults, 44% were “sure” their teen didn't have mental health problems and only 19% worried about what people might think.

It's encouraging that stigma doesn't seem to be a problem among the parents and/or guardians, but a focus on stigma reduction among adolescents still is needed, Ms. O'Mara said.

Sixty percent of teens and 62% of adults said the adolescent was in too much pain and distress in the ED to have a mental health screening. Worries about how long it might take were reported by 57% and 46%, respectively. In 49% of teens and 37% of adults, a mental health screening was deemed unnecessary because the teen was already getting help for mental health problems.

A far lower proportion of adolescents (79%), compared with adults (90%), said a brochure on any of these mental health problems would be helpful. More helpful would be a chance to speak with a mental health professional while in the ED (95% of teens and 98% of adults) or information on where to go for further help (96% of teens and 100% of adults).

Large numbers of adolescents come to EDs each year, especially in low-income, medically underserved areas. Mental health screening may be especially helpful in detecting young males at risk of suicide who typically don't surface in other health care settings. “The ED setting has been underutilized in such interventions,” Ms. O'Mara said.

The adolescents were nearly equally split between males and females, and were accompanied mainly by their mothers or female adult guardians. Both the youths and adults were predominantly white.

SAN FRANCISCO – Teenagers and their parents favor the idea of routine mental health screening for adolescents who come to emergency departments, but don't think it necessarily applies to them, a survey of 604 people found.

The 299 patients aged 13-17 years and 305 parents who accompanied them completed a two-page questionnaire in 3-5 minutes while waiting for the adolescent to receive emergency care in a large Midwestern hospital.

Emergency departments (EDs) could be excellent places for mental health screening and intervention during long wait times, Roisin O'Mara and her associates suggested in a poster presentation at the annual conference of the American Society of Suicidology. Previous studies suggest that ED visits provide “teachable moments” when adolescents may be receptive to interventions, said Ms. O'Mara of the University of Michigan, Ann Arbor.

Among the adolescents surveyed, 93%-94% felt that it is somewhat important or extremely important to screen teenagers in the ED for depression, anxiety, alcohol misuse, drug misuse, or suicide risk. Among adults surveyed, 96%-99% agreed that screening teens for these are somewhat or extremely important. Screening for behavioral problems or dating violence was thought to be somewhat or extremely important by 87%-89% of adolescents and 96%-97% of adults.

When asked if ED staff should ask all teens about these problems as part of routine care, 57% of adolescents and 69% of adults agreed or strongly agreed, a statistically significant difference between the youths and their parents/guardians. However, when asked if they would take a mental health screening (or allow their teen to take one) if it were offered that day, only 42% of adolescents and 49% of adults agreed or strongly agreed.

“This seems to reflect an attitude of, 'Yes, it is a good idea, but not necessarily for me or my teen',” Ms. O'Mara noted.

The top concern expressed about mental health screening in the ED was worry about privacy (72% of teens, 63% of adults). Any effort to start such screening should address this concern, the investigators suggested.

The adolescents also were significantly more likely than were the adults to say that a screening is unnecessary because they know they don't have these mental health problems (61%) and to say that they worry about what other people would think of them if they did have these problems (53%). Among adults, 44% were “sure” their teen didn't have mental health problems and only 19% worried about what people might think.

It's encouraging that stigma doesn't seem to be a problem among the parents and/or guardians, but a focus on stigma reduction among adolescents still is needed, Ms. O'Mara said.

Sixty percent of teens and 62% of adults said the adolescent was in too much pain and distress in the ED to have a mental health screening. Worries about how long it might take were reported by 57% and 46%, respectively. In 49% of teens and 37% of adults, a mental health screening was deemed unnecessary because the teen was already getting help for mental health problems.

A far lower proportion of adolescents (79%), compared with adults (90%), said a brochure on any of these mental health problems would be helpful. More helpful would be a chance to speak with a mental health professional while in the ED (95% of teens and 98% of adults) or information on where to go for further help (96% of teens and 100% of adults).

Large numbers of adolescents come to EDs each year, especially in low-income, medically underserved areas. Mental health screening may be especially helpful in detecting young males at risk of suicide who typically don't surface in other health care settings. “The ED setting has been underutilized in such interventions,” Ms. O'Mara said.

The adolescents were nearly equally split between males and females, and were accompanied mainly by their mothers or female adult guardians. Both the youths and adults were predominantly white.

SAN FRANCISCO – Teenagers and their parents favor the idea of routine mental health screening for adolescents who come to emergency departments, but don't think it necessarily applies to them, a survey of 604 people found.

The 299 patients aged 13-17 years and 305 parents who accompanied them completed a two-page questionnaire in 3-5 minutes while waiting for the adolescent to receive emergency care in a large Midwestern hospital.

Emergency departments (EDs) could be excellent places for mental health screening and intervention during long wait times, Roisin O'Mara and her associates suggested in a poster presentation at the annual conference of the American Society of Suicidology. Previous studies suggest that ED visits provide “teachable moments” when adolescents may be receptive to interventions, said Ms. O'Mara of the University of Michigan, Ann Arbor.

Among the adolescents surveyed, 93%-94% felt that it is somewhat important or extremely important to screen teenagers in the ED for depression, anxiety, alcohol misuse, drug misuse, or suicide risk. Among adults surveyed, 96%-99% agreed that screening teens for these are somewhat or extremely important. Screening for behavioral problems or dating violence was thought to be somewhat or extremely important by 87%-89% of adolescents and 96%-97% of adults.

When asked if ED staff should ask all teens about these problems as part of routine care, 57% of adolescents and 69% of adults agreed or strongly agreed, a statistically significant difference between the youths and their parents/guardians. However, when asked if they would take a mental health screening (or allow their teen to take one) if it were offered that day, only 42% of adolescents and 49% of adults agreed or strongly agreed.

“This seems to reflect an attitude of, 'Yes, it is a good idea, but not necessarily for me or my teen',” Ms. O'Mara noted.

The top concern expressed about mental health screening in the ED was worry about privacy (72% of teens, 63% of adults). Any effort to start such screening should address this concern, the investigators suggested.

The adolescents also were significantly more likely than were the adults to say that a screening is unnecessary because they know they don't have these mental health problems (61%) and to say that they worry about what other people would think of them if they did have these problems (53%). Among adults, 44% were “sure” their teen didn't have mental health problems and only 19% worried about what people might think.

It's encouraging that stigma doesn't seem to be a problem among the parents and/or guardians, but a focus on stigma reduction among adolescents still is needed, Ms. O'Mara said.

Sixty percent of teens and 62% of adults said the adolescent was in too much pain and distress in the ED to have a mental health screening. Worries about how long it might take were reported by 57% and 46%, respectively. In 49% of teens and 37% of adults, a mental health screening was deemed unnecessary because the teen was already getting help for mental health problems.

A far lower proportion of adolescents (79%), compared with adults (90%), said a brochure on any of these mental health problems would be helpful. More helpful would be a chance to speak with a mental health professional while in the ED (95% of teens and 98% of adults) or information on where to go for further help (96% of teens and 100% of adults).

Large numbers of adolescents come to EDs each year, especially in low-income, medically underserved areas. Mental health screening may be especially helpful in detecting young males at risk of suicide who typically don't surface in other health care settings. “The ED setting has been underutilized in such interventions,” Ms. O'Mara said.

The adolescents were nearly equally split between males and females, and were accompanied mainly by their mothers or female adult guardians. Both the youths and adults were predominantly white.

Family members and friends who take care of adults needing help managing diabetes are most likely to seek information from a physician, followed closely by the Internet, an online survey of 1,002 caregivers suggests.

The take-home message for physicians is that they are truly critical to caregivers' ability to help people manage their diabetes and they need to make conversations with caregivers a priority “no matter how little time they have,” said Paula Correa, director of the Hormone Foundation, which conducted the survey along with the National Alliance for Caregiving. Eli Lilly & Co., which markets drugs for diabetes, funded the survey.

According to the caregivers, patients struggle most with diet and exercise (listed by 54% of respondents), followed by the medical management of diabetes (49%).

The survey, conducted in April 2009, is the first of its kind to focus on the needs of unpaid caregivers of people with diabetes, as opposed to paid home care aides or workers in assisted living facilities, Ms. Correa added. The results are available at www.hormone.org/Public/diabetes_caregiver.cfm

A total of 89% of respondents said they get diabetes care information from physicians. The Internet is a source of diabetes care information for 69% of respondents. (See box.).

Frustration in trying to find reliable information on the Internet was reported by 63% of respondents. Frustration also was expressed by 49% from having to wade through commercial content on the Internet, 37% said they get too many search results, and 33% had difficulty finding information specific to their needs.

The Hormone Foundation, the public education affiliate of the Endocrine Society, indicated that it plans to incorporate the findings in the development of a new Web site called Diabetes Caregiver Central to provide unpaid caregivers with the resources they need in one location. The site is slated to launch by the end of 2010.

Although caregivers as a whole scored 74 out of a total score of 100 on a five-question quiz of diabetes knowledge, they showed confusion about hemoglobin A_1c goals. Only 40% could identify the recommended HbA_1c levels, and 51% were unsure.

Only 25% said they felt “informed” about diabetes and its potential complications when they first started taking care of a person with diabetes.

In the areas of diet and exercise, 59% reported that the person with diabetes either cannot or will not exercise, and 50% said the person does not want to follow a healthy diet. Consistent maintenance of blood sugar levels at targets was a significant issue for 43%, and 43% reported episodes of hypoglycemia requiring immediate action. Respondents said the person with diabetes was depressed in 45% of cases, and 40% said the person experiences memory loss, confusion, or symptoms of Alzheimer's disease.

Forty-one percent said they were having great difficulty managing diabetes plus other medical problems, and 37% reported difficulty managing blood sugar levels and preventing hypoglycemia. Dealing with insurance forms and reimbursements was a difficult issue for 26%. Twenty percent of respondents said that it is very difficult “communicating with the physicians who treat my loved one's diabetes,” yet only 3% wanted more information on how to communicate with the physician or the loved one.

More information on diet and exercise issues was desired by 26% of respondents, 17% wanted more information on medical issues, 13% requested more information on medications, and 12% sought additional help understanding blood sugar management.

Source ELSEVIER GLOBAL MEDICAL NEWS

Family members and friends who take care of adults needing help managing diabetes are most likely to seek information from a physician, followed closely by the Internet, an online survey of 1,002 caregivers suggests.

The take-home message for physicians is that they are truly critical to caregivers' ability to help people manage their diabetes and they need to make conversations with caregivers a priority “no matter how little time they have,” said Paula Correa, director of the Hormone Foundation, which conducted the survey along with the National Alliance for Caregiving. Eli Lilly & Co., which markets drugs for diabetes, funded the survey.

According to the caregivers, patients struggle most with diet and exercise (listed by 54% of respondents), followed by the medical management of diabetes (49%).

The survey, conducted in April 2009, is the first of its kind to focus on the needs of unpaid caregivers of people with diabetes, as opposed to paid home care aides or workers in assisted living facilities, Ms. Correa added. The results are available at www.hormone.org/Public/diabetes_caregiver.cfm

A total of 89% of respondents said they get diabetes care information from physicians. The Internet is a source of diabetes care information for 69% of respondents. (See box.).

Frustration in trying to find reliable information on the Internet was reported by 63% of respondents. Frustration also was expressed by 49% from having to wade through commercial content on the Internet, 37% said they get too many search results, and 33% had difficulty finding information specific to their needs.

The Hormone Foundation, the public education affiliate of the Endocrine Society, indicated that it plans to incorporate the findings in the development of a new Web site called Diabetes Caregiver Central to provide unpaid caregivers with the resources they need in one location. The site is slated to launch by the end of 2010.

Although caregivers as a whole scored 74 out of a total score of 100 on a five-question quiz of diabetes knowledge, they showed confusion about hemoglobin A_1c goals. Only 40% could identify the recommended HbA_1c levels, and 51% were unsure.

Only 25% said they felt “informed” about diabetes and its potential complications when they first started taking care of a person with diabetes.

In the areas of diet and exercise, 59% reported that the person with diabetes either cannot or will not exercise, and 50% said the person does not want to follow a healthy diet. Consistent maintenance of blood sugar levels at targets was a significant issue for 43%, and 43% reported episodes of hypoglycemia requiring immediate action. Respondents said the person with diabetes was depressed in 45% of cases, and 40% said the person experiences memory loss, confusion, or symptoms of Alzheimer's disease.

Forty-one percent said they were having great difficulty managing diabetes plus other medical problems, and 37% reported difficulty managing blood sugar levels and preventing hypoglycemia. Dealing with insurance forms and reimbursements was a difficult issue for 26%. Twenty percent of respondents said that it is very difficult “communicating with the physicians who treat my loved one's diabetes,” yet only 3% wanted more information on how to communicate with the physician or the loved one.

More information on diet and exercise issues was desired by 26% of respondents, 17% wanted more information on medical issues, 13% requested more information on medications, and 12% sought additional help understanding blood sugar management.

Source ELSEVIER GLOBAL MEDICAL NEWS

Family members and friends who take care of adults needing help managing diabetes are most likely to seek information from a physician, followed closely by the Internet, an online survey of 1,002 caregivers suggests.

The take-home message for physicians is that they are truly critical to caregivers' ability to help people manage their diabetes and they need to make conversations with caregivers a priority “no matter how little time they have,” said Paula Correa, director of the Hormone Foundation, which conducted the survey along with the National Alliance for Caregiving. Eli Lilly & Co., which markets drugs for diabetes, funded the survey.

According to the caregivers, patients struggle most with diet and exercise (listed by 54% of respondents), followed by the medical management of diabetes (49%).

The survey, conducted in April 2009, is the first of its kind to focus on the needs of unpaid caregivers of people with diabetes, as opposed to paid home care aides or workers in assisted living facilities, Ms. Correa added. The results are available at www.hormone.org/Public/diabetes_caregiver.cfm

A total of 89% of respondents said they get diabetes care information from physicians. The Internet is a source of diabetes care information for 69% of respondents. (See box.).

Frustration in trying to find reliable information on the Internet was reported by 63% of respondents. Frustration also was expressed by 49% from having to wade through commercial content on the Internet, 37% said they get too many search results, and 33% had difficulty finding information specific to their needs.

The Hormone Foundation, the public education affiliate of the Endocrine Society, indicated that it plans to incorporate the findings in the development of a new Web site called Diabetes Caregiver Central to provide unpaid caregivers with the resources they need in one location. The site is slated to launch by the end of 2010.

Although caregivers as a whole scored 74 out of a total score of 100 on a five-question quiz of diabetes knowledge, they showed confusion about hemoglobin A_1c goals. Only 40% could identify the recommended HbA_1c levels, and 51% were unsure.

Only 25% said they felt “informed” about diabetes and its potential complications when they first started taking care of a person with diabetes.

In the areas of diet and exercise, 59% reported that the person with diabetes either cannot or will not exercise, and 50% said the person does not want to follow a healthy diet. Consistent maintenance of blood sugar levels at targets was a significant issue for 43%, and 43% reported episodes of hypoglycemia requiring immediate action. Respondents said the person with diabetes was depressed in 45% of cases, and 40% said the person experiences memory loss, confusion, or symptoms of Alzheimer's disease.

Forty-one percent said they were having great difficulty managing diabetes plus other medical problems, and 37% reported difficulty managing blood sugar levels and preventing hypoglycemia. Dealing with insurance forms and reimbursements was a difficult issue for 26%. Twenty percent of respondents said that it is very difficult “communicating with the physicians who treat my loved one's diabetes,” yet only 3% wanted more information on how to communicate with the physician or the loved one.

More information on diet and exercise issues was desired by 26% of respondents, 17% wanted more information on medical issues, 13% requested more information on medications, and 12% sought additional help understanding blood sugar management.

Source ELSEVIER GLOBAL MEDICAL NEWS

Counting hemangiomas is one way to identify higher risk when managing infantile hemangiomas, which are tremendously heterogeneous, according to Dr. Ilona J. Frieden.

For example, having more than five infantile hemangiomas increases the risk of having liver hemangiomas, she explained at a women's and pediatric dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

Infantile hemangiomas reach 80% of their maximum size at a mean age of 3 months, a study of more than 1,000 patients found (Pediatrics 2008;122:360-7). By 5 months, 80% have finished growing, highlighting the importance of early referral to a specialist.

Hemangiomas in the periocular region, airway, or liver can cause some of the greatest potential medical morbidities, noted Dr. Frieden, director of pediatric dermatology at the University of California, San Francisco. The risk of permanent disfigurement is a common reason for treatment, and this is particularly true for hemangiomas involving the central face, nasal tip, ear, glabella, cheek, and perioral area.

Localized hemangiomas—those that are spatially confined and often appear to arise from a central focal point—are of less concern than segmental ones, though localized lesions can cause problems if they grow large enough.

Segmental hemangiomas—those that affect a broad anatomic region or a recognized developmental unit such as an entire ear or that seem dermatomal—are significantly more likely to develop complications and to need treatment, compared with localized lesions, she noted.

Residual skin changes are more likely if the infantile hemangioma is pedunculated or there is a sharp drop-off or steep slope to the lesion. Thin plaques and lesions with a gradual slope to normal skin have a better prognosis.

Ulceration, which is the most common complication of hemangiomas, occurs at a median age of 4 months. It is more likely in hemangiomas that are segmental (33%, versus 7% localized), and in hemangiomas on the lower lip (30%), neck (25%), and anogenital area (50%), Dr. Frieden noted.

The tremendous heterogeneity of infantile hemangiomas can complicate parental peace of mind when a worried parent turns to the Internet for information. Internet postings tend to emphasize worst cases, and parents lack the context for interpreting the information they find, so it is important to be proactive and discuss this with them, she advised.

Dr. Frieden is a consultant to Pierre Fabre Laboratories, which is conducting trials of propranolol as a treatment for hemangiomas. SDEF and this news organization are owned by Elsevier.

Having more than five infantile hemangiomas increases the risk of having liver hemangiomas.

Source Dr. Frieden

Ulceration is more likely in hemangiomas that are segmental, and in those that occur on the lower lip, neck, and anogenital area.

Source Courtesy Dr. Ilona J. Frieden

Counting hemangiomas is one way to identify higher risk when managing infantile hemangiomas, which are tremendously heterogeneous, according to Dr. Ilona J. Frieden.

For example, having more than five infantile hemangiomas increases the risk of having liver hemangiomas, she explained at a women's and pediatric dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

Infantile hemangiomas reach 80% of their maximum size at a mean age of 3 months, a study of more than 1,000 patients found (Pediatrics 2008;122:360-7). By 5 months, 80% have finished growing, highlighting the importance of early referral to a specialist.

Hemangiomas in the periocular region, airway, or liver can cause some of the greatest potential medical morbidities, noted Dr. Frieden, director of pediatric dermatology at the University of California, San Francisco. The risk of permanent disfigurement is a common reason for treatment, and this is particularly true for hemangiomas involving the central face, nasal tip, ear, glabella, cheek, and perioral area.

Localized hemangiomas—those that are spatially confined and often appear to arise from a central focal point—are of less concern than segmental ones, though localized lesions can cause problems if they grow large enough.

Segmental hemangiomas—those that affect a broad anatomic region or a recognized developmental unit such as an entire ear or that seem dermatomal—are significantly more likely to develop complications and to need treatment, compared with localized lesions, she noted.

Residual skin changes are more likely if the infantile hemangioma is pedunculated or there is a sharp drop-off or steep slope to the lesion. Thin plaques and lesions with a gradual slope to normal skin have a better prognosis.

Ulceration, which is the most common complication of hemangiomas, occurs at a median age of 4 months. It is more likely in hemangiomas that are segmental (33%, versus 7% localized), and in hemangiomas on the lower lip (30%), neck (25%), and anogenital area (50%), Dr. Frieden noted.

The tremendous heterogeneity of infantile hemangiomas can complicate parental peace of mind when a worried parent turns to the Internet for information. Internet postings tend to emphasize worst cases, and parents lack the context for interpreting the information they find, so it is important to be proactive and discuss this with them, she advised.

Dr. Frieden is a consultant to Pierre Fabre Laboratories, which is conducting trials of propranolol as a treatment for hemangiomas. SDEF and this news organization are owned by Elsevier.

Having more than five infantile hemangiomas increases the risk of having liver hemangiomas.

Source Dr. Frieden

Ulceration is more likely in hemangiomas that are segmental, and in those that occur on the lower lip, neck, and anogenital area.

Source Courtesy Dr. Ilona J. Frieden

Counting hemangiomas is one way to identify higher risk when managing infantile hemangiomas, which are tremendously heterogeneous, according to Dr. Ilona J. Frieden.

For example, having more than five infantile hemangiomas increases the risk of having liver hemangiomas, she explained at a women's and pediatric dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

Infantile hemangiomas reach 80% of their maximum size at a mean age of 3 months, a study of more than 1,000 patients found (Pediatrics 2008;122:360-7). By 5 months, 80% have finished growing, highlighting the importance of early referral to a specialist.

Hemangiomas in the periocular region, airway, or liver can cause some of the greatest potential medical morbidities, noted Dr. Frieden, director of pediatric dermatology at the University of California, San Francisco. The risk of permanent disfigurement is a common reason for treatment, and this is particularly true for hemangiomas involving the central face, nasal tip, ear, glabella, cheek, and perioral area.

Localized hemangiomas—those that are spatially confined and often appear to arise from a central focal point—are of less concern than segmental ones, though localized lesions can cause problems if they grow large enough.

Segmental hemangiomas—those that affect a broad anatomic region or a recognized developmental unit such as an entire ear or that seem dermatomal—are significantly more likely to develop complications and to need treatment, compared with localized lesions, she noted.

Residual skin changes are more likely if the infantile hemangioma is pedunculated or there is a sharp drop-off or steep slope to the lesion. Thin plaques and lesions with a gradual slope to normal skin have a better prognosis.

Ulceration, which is the most common complication of hemangiomas, occurs at a median age of 4 months. It is more likely in hemangiomas that are segmental (33%, versus 7% localized), and in hemangiomas on the lower lip (30%), neck (25%), and anogenital area (50%), Dr. Frieden noted.

The tremendous heterogeneity of infantile hemangiomas can complicate parental peace of mind when a worried parent turns to the Internet for information. Internet postings tend to emphasize worst cases, and parents lack the context for interpreting the information they find, so it is important to be proactive and discuss this with them, she advised.

Dr. Frieden is a consultant to Pierre Fabre Laboratories, which is conducting trials of propranolol as a treatment for hemangiomas. SDEF and this news organization are owned by Elsevier.

Having more than five infantile hemangiomas increases the risk of having liver hemangiomas.

Source Dr. Frieden

Ulceration is more likely in hemangiomas that are segmental, and in those that occur on the lower lip, neck, and anogenital area.

Source Courtesy Dr. Ilona J. Frieden

Pregnant women with mild glucose intolerance have a significantly increased—though still small—risk of developing cardiovascular disease later on, an analysis of data on 435,696 Canadian women suggested.

Compared with pregnant women who were thought to have normal glucose tolerance, the risk for developing cardiovascular disease during a median of 12 years after pregnancy increased by 19% in women with presumed hyperglycemia but not gestational diabetes, and by 66% in women with gestational diabetes, reported Dr. Ravi Retnakaran and Dr. Baiju R. Shah, both of the University of Toronto.

The absolute risk for cardiovascular disease increased by 0.05% to an absolute rate of 2.3/10,000 person-years in women with presumed hyperglycemia but not gestational diabetes, and by 0.16% to an absolute rate of 4.2/10,000 person-years in women with gestational diabetes, compared with a rate of 1.9/10,000 person-years in women presumed to have normal glucose tolerance.

The study was published online in the Canadian Medical Association Journal (2009 [doi:10.1503/cmaj.090569

The population-based cohort study followed women with no history of pregestational diabetes who gave birth between April 1994 and March 1998. The investigators did not have access to laboratory glucose values, but used the Canadian Health System's administrative database to identify three groups of pregnant women.

A “normal” group of 349,977 women had an oral glucose challenge test but received no further testing, suggesting normal results. A mild glucose intolerance group of 71,831 women had two glucose tests on the same day, and so presumably had hyperglycemia on the glucose challenge followed by a glucose tolerance test, but were excluded from having gestational diabetes based on an algorithm analogous to one used by the Ontario Diabetes Database. The third group of 13,888 women had both tests and were thought to have gestational diabetes based on the algorithm.

The analyses adjusted for the effects of age, year of delivery, location of residence (rural vs. urban), income, comorbidity, preexisting hypertension, and gestational hypertension.

Previous studies have shown that gestational diabetes is associated with an increased risk of later cardiovascular disease. This study raises the possibility that hyperglycemia without gestational diabetes also may be associated with subsequent cardiovascular disease, the authors noted.

When the results were adjusted for the later development of diabetes, the mild gestational hyperglycemia no longer was significantly associated with an increased risk for cardiovascular disease. Given the low underlying cardiovascular risk of this young cohort and the long time generally needed to develop macrovascular disease in patients with type 2 diabetes, however, it seems most likely that vascular disease develops in parallel with diabetes instead of necessarily following it, they added.

In an editorial, Dr. J. Kennedy Cruickshank and Dr. Moulinath Banerjee, both of the University of Manchester (England), said that the findings add weight to the “common soil” hypothesis that vessel damage and hyperglycemia have a common cause (CMAJ 2009 [doi:10.1503/cmaj.091396

Perhaps type 2 diabetes no longer can be defined as “just” hyperglycemia, and the definition should include earlier blood vessel damage in addition to or instead of glycemia, they suggested. That might help explain what they called the failure of intensive glycemic control regimens to reduce mortality or improve cardiovascular event rates.

Dr. Cruickshank and Dr. Banerjee suggested that diabetes research focused on insulin resistance may have been misdirected, and that the next generation of diabetes treatments should focus on the blood vessel.

All of the physicians mentioned in this article declared having no conflicts of interest related to these topics.

Pregnant women with mild glucose intolerance have a significantly increased—though still small—risk of developing cardiovascular disease later on, an analysis of data on 435,696 Canadian women suggested.

Compared with pregnant women who were thought to have normal glucose tolerance, the risk for developing cardiovascular disease during a median of 12 years after pregnancy increased by 19% in women with presumed hyperglycemia but not gestational diabetes, and by 66% in women with gestational diabetes, reported Dr. Ravi Retnakaran and Dr. Baiju R. Shah, both of the University of Toronto.

The absolute risk for cardiovascular disease increased by 0.05% to an absolute rate of 2.3/10,000 person-years in women with presumed hyperglycemia but not gestational diabetes, and by 0.16% to an absolute rate of 4.2/10,000 person-years in women with gestational diabetes, compared with a rate of 1.9/10,000 person-years in women presumed to have normal glucose tolerance.

The study was published online in the Canadian Medical Association Journal (2009 [doi:10.1503/cmaj.090569

The population-based cohort study followed women with no history of pregestational diabetes who gave birth between April 1994 and March 1998. The investigators did not have access to laboratory glucose values, but used the Canadian Health System's administrative database to identify three groups of pregnant women.

A “normal” group of 349,977 women had an oral glucose challenge test but received no further testing, suggesting normal results. A mild glucose intolerance group of 71,831 women had two glucose tests on the same day, and so presumably had hyperglycemia on the glucose challenge followed by a glucose tolerance test, but were excluded from having gestational diabetes based on an algorithm analogous to one used by the Ontario Diabetes Database. The third group of 13,888 women had both tests and were thought to have gestational diabetes based on the algorithm.

The analyses adjusted for the effects of age, year of delivery, location of residence (rural vs. urban), income, comorbidity, preexisting hypertension, and gestational hypertension.

Previous studies have shown that gestational diabetes is associated with an increased risk of later cardiovascular disease. This study raises the possibility that hyperglycemia without gestational diabetes also may be associated with subsequent cardiovascular disease, the authors noted.

When the results were adjusted for the later development of diabetes, the mild gestational hyperglycemia no longer was significantly associated with an increased risk for cardiovascular disease. Given the low underlying cardiovascular risk of this young cohort and the long time generally needed to develop macrovascular disease in patients with type 2 diabetes, however, it seems most likely that vascular disease develops in parallel with diabetes instead of necessarily following it, they added.

In an editorial, Dr. J. Kennedy Cruickshank and Dr. Moulinath Banerjee, both of the University of Manchester (England), said that the findings add weight to the “common soil” hypothesis that vessel damage and hyperglycemia have a common cause (CMAJ 2009 [doi:10.1503/cmaj.091396

Perhaps type 2 diabetes no longer can be defined as “just” hyperglycemia, and the definition should include earlier blood vessel damage in addition to or instead of glycemia, they suggested. That might help explain what they called the failure of intensive glycemic control regimens to reduce mortality or improve cardiovascular event rates.

Dr. Cruickshank and Dr. Banerjee suggested that diabetes research focused on insulin resistance may have been misdirected, and that the next generation of diabetes treatments should focus on the blood vessel.

All of the physicians mentioned in this article declared having no conflicts of interest related to these topics.

Pregnant women with mild glucose intolerance have a significantly increased—though still small—risk of developing cardiovascular disease later on, an analysis of data on 435,696 Canadian women suggested.

Compared with pregnant women who were thought to have normal glucose tolerance, the risk for developing cardiovascular disease during a median of 12 years after pregnancy increased by 19% in women with presumed hyperglycemia but not gestational diabetes, and by 66% in women with gestational diabetes, reported Dr. Ravi Retnakaran and Dr. Baiju R. Shah, both of the University of Toronto.

The absolute risk for cardiovascular disease increased by 0.05% to an absolute rate of 2.3/10,000 person-years in women with presumed hyperglycemia but not gestational diabetes, and by 0.16% to an absolute rate of 4.2/10,000 person-years in women with gestational diabetes, compared with a rate of 1.9/10,000 person-years in women presumed to have normal glucose tolerance.

The study was published online in the Canadian Medical Association Journal (2009 [doi:10.1503/cmaj.090569

The population-based cohort study followed women with no history of pregestational diabetes who gave birth between April 1994 and March 1998. The investigators did not have access to laboratory glucose values, but used the Canadian Health System's administrative database to identify three groups of pregnant women.

A “normal” group of 349,977 women had an oral glucose challenge test but received no further testing, suggesting normal results. A mild glucose intolerance group of 71,831 women had two glucose tests on the same day, and so presumably had hyperglycemia on the glucose challenge followed by a glucose tolerance test, but were excluded from having gestational diabetes based on an algorithm analogous to one used by the Ontario Diabetes Database. The third group of 13,888 women had both tests and were thought to have gestational diabetes based on the algorithm.

The analyses adjusted for the effects of age, year of delivery, location of residence (rural vs. urban), income, comorbidity, preexisting hypertension, and gestational hypertension.

Previous studies have shown that gestational diabetes is associated with an increased risk of later cardiovascular disease. This study raises the possibility that hyperglycemia without gestational diabetes also may be associated with subsequent cardiovascular disease, the authors noted.

When the results were adjusted for the later development of diabetes, the mild gestational hyperglycemia no longer was significantly associated with an increased risk for cardiovascular disease. Given the low underlying cardiovascular risk of this young cohort and the long time generally needed to develop macrovascular disease in patients with type 2 diabetes, however, it seems most likely that vascular disease develops in parallel with diabetes instead of necessarily following it, they added.

In an editorial, Dr. J. Kennedy Cruickshank and Dr. Moulinath Banerjee, both of the University of Manchester (England), said that the findings add weight to the “common soil” hypothesis that vessel damage and hyperglycemia have a common cause (CMAJ 2009 [doi:10.1503/cmaj.091396

Perhaps type 2 diabetes no longer can be defined as “just” hyperglycemia, and the definition should include earlier blood vessel damage in addition to or instead of glycemia, they suggested. That might help explain what they called the failure of intensive glycemic control regimens to reduce mortality or improve cardiovascular event rates.

Dr. Cruickshank and Dr. Banerjee suggested that diabetes research focused on insulin resistance may have been misdirected, and that the next generation of diabetes treatments should focus on the blood vessel.

All of the physicians mentioned in this article declared having no conflicts of interest related to these topics.

Family members and friends who take care of adults needing help managing diabetes are most likely to seek information from a physician, followed closely by the Internet, an online survey of 1,002 caregivers suggests.

The take-home message for physicians is that they are truly critical to caregivers' ability to help people manage their diabetes and they need to make conversations with caregivers a priority “no matter how little time they have,” said Paula Correa, director of the Hormone Foundation, which conducted the survey along with the National Alliance for Caregiving.

Eli Lilly & Co., which markets drugs for diabetes, funded the survey.

According to caregivers, patients struggle most with diet and exercise (listed by 54% of respondents), followed by the medical management of diabetes (49%).

The survey, conducted in April 2009, is the first of its kind to focus on the needs of unpaid caregivers of people with diabetes, as opposed to paid home care aides or workers in assisted living facilities, Ms. Correa added. The results, released last month, are available at www.hormone.org/Public/diabetes_caregiver.cfm

A total of 89% of respondents said they get diabetes care information from physicians. The Internet is a source of diabetes care information for 69% of respondents (see chart).

Frustration in trying to find reliable information on the Internet was reported by 63% of respondents. Frustration also was expressed by 49% from having to wade through commercial content on the Internet, and 37% said they get too many search results. Thirty-three percent had difficulty finding information on the Internet that was specific to their needs.

The Hormone Foundation, the public education affiliate of The Endocrine Society, indicated that it plans to incorporate the findings in the development of a new Web site, Diabetes Caregiver Central, to provide unpaid caregivers with the resources they need in a one-stop location. The site is slated to launch by the end of 2010.

Caregivers as a whole scored 74 out of a total score of 100 on a five-question quiz of diabetes knowledge, but they showed confusion about hemoglobin A_1c goals. Only 40% could identify the recommended HbA_1c levels, and 51% were unsure.

Only 25% said they felt “informed” about diabetes and its potential complications when they first started taking care of a person with diabetes.

In the areas of diet and exercise, 59% reported that the person with diabetes either cannot or will not exercise, and 50% said the person does not want to follow a healthy diet. Consistent maintenance of blood sugar levels at targets was a significant issue for 43%, and 43% reported episodes of hypoglycemia requiring immediate action. Respondents said the person with diabetes was depressed in 45% of cases, and 40% said the person experiences memory loss, confusion, or symptoms of Alzheimer's disease.

Forty-one percent said they were having great difficulty managing diabetes plus other medical problems, and 37% reported difficulty managing blood sugar levels and preventing hypoglycemia. Dealing with insurance forms and reimbursements was a difficult issue for 26%. Twenty percent of respondents said that it is very difficult “communicating with the physicians who treat my loved one's diabetes,” yet only 3% wanted more information on how to communicate with the physician or the loved one.

More information on diet and exercise issues was desired by 26% of respondents, 17% wanted more information on medical issues, 13% requested more information on medications, and 12% sought additional help understanding blood sugar management.

Source ELSEVIER GLOBAL MEDICAL NEWS

Family members and friends who take care of adults needing help managing diabetes are most likely to seek information from a physician, followed closely by the Internet, an online survey of 1,002 caregivers suggests.

The take-home message for physicians is that they are truly critical to caregivers' ability to help people manage their diabetes and they need to make conversations with caregivers a priority “no matter how little time they have,” said Paula Correa, director of the Hormone Foundation, which conducted the survey along with the National Alliance for Caregiving.

Eli Lilly & Co., which markets drugs for diabetes, funded the survey.

According to caregivers, patients struggle most with diet and exercise (listed by 54% of respondents), followed by the medical management of diabetes (49%).

The survey, conducted in April 2009, is the first of its kind to focus on the needs of unpaid caregivers of people with diabetes, as opposed to paid home care aides or workers in assisted living facilities, Ms. Correa added. The results, released last month, are available at www.hormone.org/Public/diabetes_caregiver.cfm

A total of 89% of respondents said they get diabetes care information from physicians. The Internet is a source of diabetes care information for 69% of respondents (see chart).

Frustration in trying to find reliable information on the Internet was reported by 63% of respondents. Frustration also was expressed by 49% from having to wade through commercial content on the Internet, and 37% said they get too many search results. Thirty-three percent had difficulty finding information on the Internet that was specific to their needs.

The Hormone Foundation, the public education affiliate of The Endocrine Society, indicated that it plans to incorporate the findings in the development of a new Web site, Diabetes Caregiver Central, to provide unpaid caregivers with the resources they need in a one-stop location. The site is slated to launch by the end of 2010.

Caregivers as a whole scored 74 out of a total score of 100 on a five-question quiz of diabetes knowledge, but they showed confusion about hemoglobin A_1c goals. Only 40% could identify the recommended HbA_1c levels, and 51% were unsure.

Only 25% said they felt “informed” about diabetes and its potential complications when they first started taking care of a person with diabetes.

In the areas of diet and exercise, 59% reported that the person with diabetes either cannot or will not exercise, and 50% said the person does not want to follow a healthy diet. Consistent maintenance of blood sugar levels at targets was a significant issue for 43%, and 43% reported episodes of hypoglycemia requiring immediate action. Respondents said the person with diabetes was depressed in 45% of cases, and 40% said the person experiences memory loss, confusion, or symptoms of Alzheimer's disease.

Forty-one percent said they were having great difficulty managing diabetes plus other medical problems, and 37% reported difficulty managing blood sugar levels and preventing hypoglycemia. Dealing with insurance forms and reimbursements was a difficult issue for 26%. Twenty percent of respondents said that it is very difficult “communicating with the physicians who treat my loved one's diabetes,” yet only 3% wanted more information on how to communicate with the physician or the loved one.

More information on diet and exercise issues was desired by 26% of respondents, 17% wanted more information on medical issues, 13% requested more information on medications, and 12% sought additional help understanding blood sugar management.

Source ELSEVIER GLOBAL MEDICAL NEWS

Family members and friends who take care of adults needing help managing diabetes are most likely to seek information from a physician, followed closely by the Internet, an online survey of 1,002 caregivers suggests.

The take-home message for physicians is that they are truly critical to caregivers' ability to help people manage their diabetes and they need to make conversations with caregivers a priority “no matter how little time they have,” said Paula Correa, director of the Hormone Foundation, which conducted the survey along with the National Alliance for Caregiving.

Eli Lilly & Co., which markets drugs for diabetes, funded the survey.

According to caregivers, patients struggle most with diet and exercise (listed by 54% of respondents), followed by the medical management of diabetes (49%).

The survey, conducted in April 2009, is the first of its kind to focus on the needs of unpaid caregivers of people with diabetes, as opposed to paid home care aides or workers in assisted living facilities, Ms. Correa added. The results, released last month, are available at www.hormone.org/Public/diabetes_caregiver.cfm

A total of 89% of respondents said they get diabetes care information from physicians. The Internet is a source of diabetes care information for 69% of respondents (see chart).

Frustration in trying to find reliable information on the Internet was reported by 63% of respondents. Frustration also was expressed by 49% from having to wade through commercial content on the Internet, and 37% said they get too many search results. Thirty-three percent had difficulty finding information on the Internet that was specific to their needs.

The Hormone Foundation, the public education affiliate of The Endocrine Society, indicated that it plans to incorporate the findings in the development of a new Web site, Diabetes Caregiver Central, to provide unpaid caregivers with the resources they need in a one-stop location. The site is slated to launch by the end of 2010.

Caregivers as a whole scored 74 out of a total score of 100 on a five-question quiz of diabetes knowledge, but they showed confusion about hemoglobin A_1c goals. Only 40% could identify the recommended HbA_1c levels, and 51% were unsure.

Only 25% said they felt “informed” about diabetes and its potential complications when they first started taking care of a person with diabetes.

In the areas of diet and exercise, 59% reported that the person with diabetes either cannot or will not exercise, and 50% said the person does not want to follow a healthy diet. Consistent maintenance of blood sugar levels at targets was a significant issue for 43%, and 43% reported episodes of hypoglycemia requiring immediate action. Respondents said the person with diabetes was depressed in 45% of cases, and 40% said the person experiences memory loss, confusion, or symptoms of Alzheimer's disease.

Forty-one percent said they were having great difficulty managing diabetes plus other medical problems, and 37% reported difficulty managing blood sugar levels and preventing hypoglycemia. Dealing with insurance forms and reimbursements was a difficult issue for 26%. Twenty percent of respondents said that it is very difficult “communicating with the physicians who treat my loved one's diabetes,” yet only 3% wanted more information on how to communicate with the physician or the loved one.

More information on diet and exercise issues was desired by 26% of respondents, 17% wanted more information on medical issues, 13% requested more information on medications, and 12% sought additional help understanding blood sugar management.

Source ELSEVIER GLOBAL MEDICAL NEWS