Kate Johnson

MONTREAL — Patients with hypoglycemia at the time of hospitalization for community-acquired pneumonia have an increased risk of death, compared with patients with normoglycemia, according to a study reported at the World Diabetes Congress.

“Hypoglycemia is an easy-to-measure variable on admission, and should be a red flag to alert physicians to possible high-risk pneumonia patients,” said John-Michael Gamble, of the University of Alberta (Edmonton).

Because an influx of community-acquired pneumonia (CAP) cases resulting from pandemic influenza A(H1N1) is expected in hospital intensive care units, quick recognition of high-risk factors is particularly important, Mr. Gamble said in an interview.

His prospective study included 956 CAP patients admitted to six Edmonton hospitals between 2000 and 2002, for whom random venous blood glucose tests measured 6.1 mmol/L or lower.

Hypoglycemia was defined as a measurement less than 4.0 mmol/L, and normoglycemia was defined as a measurement between 4.0 mmol/L and 6.1 mmol/L.

The primary outcome of the study was in-hospital mortality. Secondary outcomes included 30-day and 1-year mortality. The mean age of the patients was 65 years, and 15% resided in nursing homes.

Hypoglycemia was present at hospital admission in 54 patients (6%); among those patients, fewer than half (46%) were previously diagnosed diabetes patients.

The mortality rate was significantly greater at all time points among patients with hypoglycemia at admission, compared with normoglycemic patients, Mr. Gamble reported.

The in-hospital and 30-day mortality rates were both 20% for patients with hypoglycemia at admission, compared with 9% and 10%, respectively, in those with normoglycemia.

Similarly, at 1 year, patients with hypoglycemia at admission had a 35% mortality rate, compared with 25% in those patients with normoglycemia.

In addition to adjusting for age, sex, comorbidities, medication, and nursing home residence, the study adjusted for pneumonia severity index (PSI), smoking status, presence of advance directives, previous pneumococcal vaccine, and direct admission to the ICU. Several additional sensitivity analyses included clinical markers of physiologic stress, exclusion of patients admitted to the ICU, and exclusion of patients with diabetes.

Whether high or low, blood glucose abnormalities in general “may serve as a marker for sicker patients,” commented Dr. Silvio Inzucchi, professor of medicine and clinical director of the section of endocrinology at Yale University, New Haven, Conn. Among nondiabetic patients, blood glucose abnormalities may be “particularly dangerous,” Dr. Inzucchi explained in a separate presentation at the meeting.

Endocrinologists and intensivists are facing a “pendulum swing” regarding inpatient glucose control, Dr. Inzucchi noted, in light of a recent publication suggesting “very surprisingly” that intensive versus conventional control of hyperglycemia is associated with a 15-fold increase in hypoglycemia and significantly higher mortality (27.5% versus 24.9%) (N. Engl. J. Med. 2009;360:1283–97).

As a result, Dr. Inzucchi helped draft the recent American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycemic Control, which recognizes the potential hypoglycemic risks of intensive control and recommends relaxing target blood glucose levels (Diabetes Care 2009;32:1344–5; Endocr. Pract. 2009;15:353–69).

“Specifically in the case of CAP, we need to look at the risks and benefits of treating admission hypoglycemia,” Mr. Gamble commented.

Mr. Gamble said he had no conflicts of interest. Dr. Inzucchi declared paid lecturing with Novo Nordisk, an advisory board agreement with Medtronic Inc., research sponsored by Eli Lilly Co., and CME program participation in which Sanofi-Aventis was a funding source.

MONTREAL — Patients with hypoglycemia at the time of hospitalization for community-acquired pneumonia have an increased risk of death, compared with patients with normoglycemia, according to a study reported at the World Diabetes Congress.

“Hypoglycemia is an easy-to-measure variable on admission, and should be a red flag to alert physicians to possible high-risk pneumonia patients,” said John-Michael Gamble, of the University of Alberta (Edmonton).

Because an influx of community-acquired pneumonia (CAP) cases resulting from pandemic influenza A(H1N1) is expected in hospital intensive care units, quick recognition of high-risk factors is particularly important, Mr. Gamble said in an interview.

His prospective study included 956 CAP patients admitted to six Edmonton hospitals between 2000 and 2002, for whom random venous blood glucose tests measured 6.1 mmol/L or lower.

Hypoglycemia was defined as a measurement less than 4.0 mmol/L, and normoglycemia was defined as a measurement between 4.0 mmol/L and 6.1 mmol/L.

The primary outcome of the study was in-hospital mortality. Secondary outcomes included 30-day and 1-year mortality. The mean age of the patients was 65 years, and 15% resided in nursing homes.

Hypoglycemia was present at hospital admission in 54 patients (6%); among those patients, fewer than half (46%) were previously diagnosed diabetes patients.

The mortality rate was significantly greater at all time points among patients with hypoglycemia at admission, compared with normoglycemic patients, Mr. Gamble reported.

The in-hospital and 30-day mortality rates were both 20% for patients with hypoglycemia at admission, compared with 9% and 10%, respectively, in those with normoglycemia.

Similarly, at 1 year, patients with hypoglycemia at admission had a 35% mortality rate, compared with 25% in those patients with normoglycemia.

In addition to adjusting for age, sex, comorbidities, medication, and nursing home residence, the study adjusted for pneumonia severity index (PSI), smoking status, presence of advance directives, previous pneumococcal vaccine, and direct admission to the ICU. Several additional sensitivity analyses included clinical markers of physiologic stress, exclusion of patients admitted to the ICU, and exclusion of patients with diabetes.

Whether high or low, blood glucose abnormalities in general “may serve as a marker for sicker patients,” commented Dr. Silvio Inzucchi, professor of medicine and clinical director of the section of endocrinology at Yale University, New Haven, Conn. Among nondiabetic patients, blood glucose abnormalities may be “particularly dangerous,” Dr. Inzucchi explained in a separate presentation at the meeting.

Endocrinologists and intensivists are facing a “pendulum swing” regarding inpatient glucose control, Dr. Inzucchi noted, in light of a recent publication suggesting “very surprisingly” that intensive versus conventional control of hyperglycemia is associated with a 15-fold increase in hypoglycemia and significantly higher mortality (27.5% versus 24.9%) (N. Engl. J. Med. 2009;360:1283–97).

As a result, Dr. Inzucchi helped draft the recent American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycemic Control, which recognizes the potential hypoglycemic risks of intensive control and recommends relaxing target blood glucose levels (Diabetes Care 2009;32:1344–5; Endocr. Pract. 2009;15:353–69).

“Specifically in the case of CAP, we need to look at the risks and benefits of treating admission hypoglycemia,” Mr. Gamble commented.

Mr. Gamble said he had no conflicts of interest. Dr. Inzucchi declared paid lecturing with Novo Nordisk, an advisory board agreement with Medtronic Inc., research sponsored by Eli Lilly Co., and CME program participation in which Sanofi-Aventis was a funding source.

MONTREAL — Patients with hypoglycemia at the time of hospitalization for community-acquired pneumonia have an increased risk of death, compared with patients with normoglycemia, according to a study reported at the World Diabetes Congress.

“Hypoglycemia is an easy-to-measure variable on admission, and should be a red flag to alert physicians to possible high-risk pneumonia patients,” said John-Michael Gamble, of the University of Alberta (Edmonton).

Because an influx of community-acquired pneumonia (CAP) cases resulting from pandemic influenza A(H1N1) is expected in hospital intensive care units, quick recognition of high-risk factors is particularly important, Mr. Gamble said in an interview.

His prospective study included 956 CAP patients admitted to six Edmonton hospitals between 2000 and 2002, for whom random venous blood glucose tests measured 6.1 mmol/L or lower.

Hypoglycemia was defined as a measurement less than 4.0 mmol/L, and normoglycemia was defined as a measurement between 4.0 mmol/L and 6.1 mmol/L.

The primary outcome of the study was in-hospital mortality. Secondary outcomes included 30-day and 1-year mortality. The mean age of the patients was 65 years, and 15% resided in nursing homes.

Hypoglycemia was present at hospital admission in 54 patients (6%); among those patients, fewer than half (46%) were previously diagnosed diabetes patients.

The mortality rate was significantly greater at all time points among patients with hypoglycemia at admission, compared with normoglycemic patients, Mr. Gamble reported.

The in-hospital and 30-day mortality rates were both 20% for patients with hypoglycemia at admission, compared with 9% and 10%, respectively, in those with normoglycemia.

Similarly, at 1 year, patients with hypoglycemia at admission had a 35% mortality rate, compared with 25% in those patients with normoglycemia.

In addition to adjusting for age, sex, comorbidities, medication, and nursing home residence, the study adjusted for pneumonia severity index (PSI), smoking status, presence of advance directives, previous pneumococcal vaccine, and direct admission to the ICU. Several additional sensitivity analyses included clinical markers of physiologic stress, exclusion of patients admitted to the ICU, and exclusion of patients with diabetes.

Whether high or low, blood glucose abnormalities in general “may serve as a marker for sicker patients,” commented Dr. Silvio Inzucchi, professor of medicine and clinical director of the section of endocrinology at Yale University, New Haven, Conn. Among nondiabetic patients, blood glucose abnormalities may be “particularly dangerous,” Dr. Inzucchi explained in a separate presentation at the meeting.

Endocrinologists and intensivists are facing a “pendulum swing” regarding inpatient glucose control, Dr. Inzucchi noted, in light of a recent publication suggesting “very surprisingly” that intensive versus conventional control of hyperglycemia is associated with a 15-fold increase in hypoglycemia and significantly higher mortality (27.5% versus 24.9%) (N. Engl. J. Med. 2009;360:1283–97).

As a result, Dr. Inzucchi helped draft the recent American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycemic Control, which recognizes the potential hypoglycemic risks of intensive control and recommends relaxing target blood glucose levels (Diabetes Care 2009;32:1344–5; Endocr. Pract. 2009;15:353–69).

“Specifically in the case of CAP, we need to look at the risks and benefits of treating admission hypoglycemia,” Mr. Gamble commented.

Mr. Gamble said he had no conflicts of interest. Dr. Inzucchi declared paid lecturing with Novo Nordisk, an advisory board agreement with Medtronic Inc., research sponsored by Eli Lilly Co., and CME program participation in which Sanofi-Aventis was a funding source.

MONTREAL — Rheumatologists and general practitioners report significant variations in the way they manage patients with knee osteoarthritis, and in addition, their patient populations are also quite different, according to a French study sponsored by Wyeth Pharmaceuticals.

“This study identified variability in key aspects of management of knee OA as a function of medical specialty,” reported Dr. Pascal Richette of Hôpital Lariboisière, Paris, and colleagues in a poster at the World Congress on Osteoarthritis.

The study used a cross-sectional survey of 808 general practitioners and 134 rheumatologists, representing 1,570 and 251 patients respectively. Each physician completed a medical questionnaire for their two most recent patients who fulfilled criteria for knee OA as defined by the American College of Rheumatology.

The clinical profiles of patients varied considerably between the specialties, with patients in the care of general practitioners experiencing more pain than did patients under the care of a rheumatologist (49.8 vs. 46.2 on a 0-100 Visual Analog Scale). In addition, general practitioners reported that their patients' pain had been of longer duration than that of patients reported by the rheumatologists (7.9 vs. 6.8 years). Patients of general practitioners were also more likely to have a second joint affected by OA (71.2% vs. 63.7%).

In terms of prescribing practices, general practitioners prescribed symptomatic slow-acting drugs in OA significantly less frequently than did rheumatologists (39% vs. 45% of the time), the authors reported. Instead, general practitioners prescribed more low-dose, oral, and topical NSAIDs. The use of symptomatic slow-acting drugs in OA has been controversial because of conflicting data on the efficacy of these agents. This category of drugs includes nutritional supplements and medications designed to reduce the symptoms of OA over the long term.

In addition, intra-articular injection of steroids or hyaluronic acid was performed significantly less often by general practitioners (7.6% and 2.5% of the time, respectively) than by rheumatologists (31.5% and 46.2% of the time). Rheumatologists performed joint puncture significantly more frequently (18% vs. 4% of the time).

Rehabilitation and weight loss were prescribed more often by general practitioners (in 34% and 65% of cases, respectively) than by rheumatologists (in 22% and 51% of cases, respectively), whereas exercise was prescribed by 47% of rheumatologists vs. 34% of general practitioners.

General practitioners prescribed NSAIDs significantly more frequently and symptomatic slow-acting drugs in OA significantly less frequently than did rheumatologists.

The congress was sponsored by the Osteoarthritis Research Society International. There was no conflict of interest disclosure.

MONTREAL — Rheumatologists and general practitioners report significant variations in the way they manage patients with knee osteoarthritis, and in addition, their patient populations are also quite different, according to a French study sponsored by Wyeth Pharmaceuticals.

“This study identified variability in key aspects of management of knee OA as a function of medical specialty,” reported Dr. Pascal Richette of Hôpital Lariboisière, Paris, and colleagues in a poster at the World Congress on Osteoarthritis.

The study used a cross-sectional survey of 808 general practitioners and 134 rheumatologists, representing 1,570 and 251 patients respectively. Each physician completed a medical questionnaire for their two most recent patients who fulfilled criteria for knee OA as defined by the American College of Rheumatology.

The clinical profiles of patients varied considerably between the specialties, with patients in the care of general practitioners experiencing more pain than did patients under the care of a rheumatologist (49.8 vs. 46.2 on a 0-100 Visual Analog Scale). In addition, general practitioners reported that their patients' pain had been of longer duration than that of patients reported by the rheumatologists (7.9 vs. 6.8 years). Patients of general practitioners were also more likely to have a second joint affected by OA (71.2% vs. 63.7%).

In terms of prescribing practices, general practitioners prescribed symptomatic slow-acting drugs in OA significantly less frequently than did rheumatologists (39% vs. 45% of the time), the authors reported. Instead, general practitioners prescribed more low-dose, oral, and topical NSAIDs. The use of symptomatic slow-acting drugs in OA has been controversial because of conflicting data on the efficacy of these agents. This category of drugs includes nutritional supplements and medications designed to reduce the symptoms of OA over the long term.

In addition, intra-articular injection of steroids or hyaluronic acid was performed significantly less often by general practitioners (7.6% and 2.5% of the time, respectively) than by rheumatologists (31.5% and 46.2% of the time). Rheumatologists performed joint puncture significantly more frequently (18% vs. 4% of the time).

Rehabilitation and weight loss were prescribed more often by general practitioners (in 34% and 65% of cases, respectively) than by rheumatologists (in 22% and 51% of cases, respectively), whereas exercise was prescribed by 47% of rheumatologists vs. 34% of general practitioners.

General practitioners prescribed NSAIDs significantly more frequently and symptomatic slow-acting drugs in OA significantly less frequently than did rheumatologists.

The congress was sponsored by the Osteoarthritis Research Society International. There was no conflict of interest disclosure.

MONTREAL — Rheumatologists and general practitioners report significant variations in the way they manage patients with knee osteoarthritis, and in addition, their patient populations are also quite different, according to a French study sponsored by Wyeth Pharmaceuticals.

“This study identified variability in key aspects of management of knee OA as a function of medical specialty,” reported Dr. Pascal Richette of Hôpital Lariboisière, Paris, and colleagues in a poster at the World Congress on Osteoarthritis.

The study used a cross-sectional survey of 808 general practitioners and 134 rheumatologists, representing 1,570 and 251 patients respectively. Each physician completed a medical questionnaire for their two most recent patients who fulfilled criteria for knee OA as defined by the American College of Rheumatology.

The clinical profiles of patients varied considerably between the specialties, with patients in the care of general practitioners experiencing more pain than did patients under the care of a rheumatologist (49.8 vs. 46.2 on a 0-100 Visual Analog Scale). In addition, general practitioners reported that their patients' pain had been of longer duration than that of patients reported by the rheumatologists (7.9 vs. 6.8 years). Patients of general practitioners were also more likely to have a second joint affected by OA (71.2% vs. 63.7%).

In terms of prescribing practices, general practitioners prescribed symptomatic slow-acting drugs in OA significantly less frequently than did rheumatologists (39% vs. 45% of the time), the authors reported. Instead, general practitioners prescribed more low-dose, oral, and topical NSAIDs. The use of symptomatic slow-acting drugs in OA has been controversial because of conflicting data on the efficacy of these agents. This category of drugs includes nutritional supplements and medications designed to reduce the symptoms of OA over the long term.

In addition, intra-articular injection of steroids or hyaluronic acid was performed significantly less often by general practitioners (7.6% and 2.5% of the time, respectively) than by rheumatologists (31.5% and 46.2% of the time). Rheumatologists performed joint puncture significantly more frequently (18% vs. 4% of the time).

Rehabilitation and weight loss were prescribed more often by general practitioners (in 34% and 65% of cases, respectively) than by rheumatologists (in 22% and 51% of cases, respectively), whereas exercise was prescribed by 47% of rheumatologists vs. 34% of general practitioners.

General practitioners prescribed NSAIDs significantly more frequently and symptomatic slow-acting drugs in OA significantly less frequently than did rheumatologists.

The congress was sponsored by the Osteoarthritis Research Society International. There was no conflict of interest disclosure.

MONTREAL — The presence of bone marrow lesions in pain-free knees may be a marker for an increased risk of future osteoarthritis among people who participate in vigorous activity. However, it's not known whether a modified exercise program could reduce this risk, Dr. Anita Wluka said at the World Congress on Osteoarthritis.

“It's possible that we should be changing our recommendations from weight-bearing to non–weight-bearing physical activity in this group, but this warrants further investigation,” said Dr. Wluka of Monash University in Clayton, Victoria, Australia.

Dr. Wluka's findings were based on a subgroup analysis of people participating in the longitudinal Melbourne Collaborative Cohort (MCC) study, established in 1990 to assess the role of diet and lifestyle in the risk for cancer and diabetes. The original cohort included 41,500 people (aged 40-69 years). In 2002, the investigators expanded the outcomes of interest to include cardiovascular disease and metabolic syndrome.

In a subanalysis, her group identified 271 individuals (aged 50-79 years) who had no knee disease or pain at baseline and results from two magnetic resonance imaging scans taken 2 years apart. Cartilage volume and defects, as well as the presence of bone marrow lesions (BMLs), were assessed on MRI.

The degree of participation in vigorous physical activity was recorded when subjects first entered the larger MCC study (1990-94), and again around the time of the first MRI (2004).

Overall, the worsening of cartilage loss and defects was similar among all of the individuals from the first to the second MRI, regardless of their level of exercise, she said.

“These were not people who ran marathons. These were people who jogged, or danced, or played tennis for more than 20 minutes—enough to raise a sweat or become short of breath.”

The cohort was divided according to the presence (37 subjects) or absence (234 subjects) of BMLs on MRI. Among those with BMLs, the risk of medical knee cartilage defects and volume loss was much more pronounced among exercisers, compared with nonexercisers (odds ratio 3.4).

“This study identifies a subgroup—those with BML—who are more likely to have adverse outcomes with exercise,” she concluded. “It may be that the biomechanical properties of bones with BML are altered, and this alters the ability of cartilage to withstand normal or abnormal loading related to physical activity,” Dr. Wluka said.

Dr. Wluka said that her group chose to look at BMLs because they have been associated with pain and progression in patients with symptomatic OA. Even in clinically asymptomatic populations, BMLs have been associated with an increased prevalence of cartilage defects and loss, she said at the congress, which was sponsored by the Osteoarthritis Research Society International.

“I'm not suggesting everyone go out and get an MRI to see if they have BMLs, but looking at why people have BMLs might be helpful, and there might be noninvasive ways of identifying them,” she said in an interview.

Dr. Wluka said she had no conflicts of interest.

A bone marrow lesion, seen on MRI in this patient's knee, may signal an increased risk of OA with exercise.

Source Courtesy Dr. Anita Wluka

MONTREAL — The presence of bone marrow lesions in pain-free knees may be a marker for an increased risk of future osteoarthritis among people who participate in vigorous activity. However, it's not known whether a modified exercise program could reduce this risk, Dr. Anita Wluka said at the World Congress on Osteoarthritis.

“It's possible that we should be changing our recommendations from weight-bearing to non–weight-bearing physical activity in this group, but this warrants further investigation,” said Dr. Wluka of Monash University in Clayton, Victoria, Australia.

Dr. Wluka's findings were based on a subgroup analysis of people participating in the longitudinal Melbourne Collaborative Cohort (MCC) study, established in 1990 to assess the role of diet and lifestyle in the risk for cancer and diabetes. The original cohort included 41,500 people (aged 40-69 years). In 2002, the investigators expanded the outcomes of interest to include cardiovascular disease and metabolic syndrome.

In a subanalysis, her group identified 271 individuals (aged 50-79 years) who had no knee disease or pain at baseline and results from two magnetic resonance imaging scans taken 2 years apart. Cartilage volume and defects, as well as the presence of bone marrow lesions (BMLs), were assessed on MRI.

The degree of participation in vigorous physical activity was recorded when subjects first entered the larger MCC study (1990-94), and again around the time of the first MRI (2004).

Overall, the worsening of cartilage loss and defects was similar among all of the individuals from the first to the second MRI, regardless of their level of exercise, she said.

“These were not people who ran marathons. These were people who jogged, or danced, or played tennis for more than 20 minutes—enough to raise a sweat or become short of breath.”

The cohort was divided according to the presence (37 subjects) or absence (234 subjects) of BMLs on MRI. Among those with BMLs, the risk of medical knee cartilage defects and volume loss was much more pronounced among exercisers, compared with nonexercisers (odds ratio 3.4).

“This study identifies a subgroup—those with BML—who are more likely to have adverse outcomes with exercise,” she concluded. “It may be that the biomechanical properties of bones with BML are altered, and this alters the ability of cartilage to withstand normal or abnormal loading related to physical activity,” Dr. Wluka said.

Dr. Wluka said that her group chose to look at BMLs because they have been associated with pain and progression in patients with symptomatic OA. Even in clinically asymptomatic populations, BMLs have been associated with an increased prevalence of cartilage defects and loss, she said at the congress, which was sponsored by the Osteoarthritis Research Society International.

“I'm not suggesting everyone go out and get an MRI to see if they have BMLs, but looking at why people have BMLs might be helpful, and there might be noninvasive ways of identifying them,” she said in an interview.

Dr. Wluka said she had no conflicts of interest.

A bone marrow lesion, seen on MRI in this patient's knee, may signal an increased risk of OA with exercise.

Source Courtesy Dr. Anita Wluka

MONTREAL — The presence of bone marrow lesions in pain-free knees may be a marker for an increased risk of future osteoarthritis among people who participate in vigorous activity. However, it's not known whether a modified exercise program could reduce this risk, Dr. Anita Wluka said at the World Congress on Osteoarthritis.

“It's possible that we should be changing our recommendations from weight-bearing to non–weight-bearing physical activity in this group, but this warrants further investigation,” said Dr. Wluka of Monash University in Clayton, Victoria, Australia.

Dr. Wluka's findings were based on a subgroup analysis of people participating in the longitudinal Melbourne Collaborative Cohort (MCC) study, established in 1990 to assess the role of diet and lifestyle in the risk for cancer and diabetes. The original cohort included 41,500 people (aged 40-69 years). In 2002, the investigators expanded the outcomes of interest to include cardiovascular disease and metabolic syndrome.

In a subanalysis, her group identified 271 individuals (aged 50-79 years) who had no knee disease or pain at baseline and results from two magnetic resonance imaging scans taken 2 years apart. Cartilage volume and defects, as well as the presence of bone marrow lesions (BMLs), were assessed on MRI.

The degree of participation in vigorous physical activity was recorded when subjects first entered the larger MCC study (1990-94), and again around the time of the first MRI (2004).

Overall, the worsening of cartilage loss and defects was similar among all of the individuals from the first to the second MRI, regardless of their level of exercise, she said.

“These were not people who ran marathons. These were people who jogged, or danced, or played tennis for more than 20 minutes—enough to raise a sweat or become short of breath.”

The cohort was divided according to the presence (37 subjects) or absence (234 subjects) of BMLs on MRI. Among those with BMLs, the risk of medical knee cartilage defects and volume loss was much more pronounced among exercisers, compared with nonexercisers (odds ratio 3.4).

“This study identifies a subgroup—those with BML—who are more likely to have adverse outcomes with exercise,” she concluded. “It may be that the biomechanical properties of bones with BML are altered, and this alters the ability of cartilage to withstand normal or abnormal loading related to physical activity,” Dr. Wluka said.

Dr. Wluka said that her group chose to look at BMLs because they have been associated with pain and progression in patients with symptomatic OA. Even in clinically asymptomatic populations, BMLs have been associated with an increased prevalence of cartilage defects and loss, she said at the congress, which was sponsored by the Osteoarthritis Research Society International.

“I'm not suggesting everyone go out and get an MRI to see if they have BMLs, but looking at why people have BMLs might be helpful, and there might be noninvasive ways of identifying them,” she said in an interview.

Dr. Wluka said she had no conflicts of interest.

A bone marrow lesion, seen on MRI in this patient's knee, may signal an increased risk of OA with exercise.

Source Courtesy Dr. Anita Wluka

MONTREAL — Almost one-fifth of patients with chronic knee osteoarthritis may have symptoms of neuropathic pain, requiring consideration of an alternative approach to their pain management, reported Dr. Jacqueline Hochman at the World Congress on Osteoarthritis.

“In clinical practice, neuropathic pain is generally not considered a feature of osteoarthritis, and among osteoarthritis researchers it is a novel concept,” she said in an interview. “But a growing body of literature suggests that one reason for treatment failure in osteoarthritis might be a mismatch between the current medications we're using and the underlying mechanisms of pain.”

Dr. Hochman, a rheumatologist at Women's College Hospital in Toronto, explained that current theories about pain point to the possible development of neuropathic pain as a result of the chronic, nociceptive stimulation associated with osteoarthritis.

“Most likely, central sensitization in osteoarthritis arises from chronic or recurrent stimulation of peripheral nociceptors, leading to modifications in the central nervous system that cause hyperexcitability in the spinal cord and, perhaps, supraspinal centers involved in the central transmission of pain,” Dr. Hochman said.

The diagnosis of neuropathic pain is a clinical one that is “based on a characteristic symptom profile that includes spontaneous sensations such as burning pain, numbness, and tingling, and evoked sensations such as sensitivity to light touch,” she said. In the presence of these symptoms, sensory abnormalities on physical examination, such as pinprick hyperalgesia and allodynia, can aid the diagnosis.

However, there is a paucity of data on symptoms of neuropathic pain in OA, Dr. Hochman said. Because symptoms “are going to lead our patients to seek medical care and alert their physicians to the possibility of underlying neuropathic mechanisms, it's important to know whether people with OA have symptoms of neuropathic pain.”

Therefore, in a group of 171 patients (median age, 76 years) with chronic, symptomatic knee osteoarthritis, she administered a modification of the painDETECT questionnaire (mPD-Q) that is designed to distinguish neuropathic from nociceptive pain.

Other study measures included biopsychosocial factors, such as depression, anxiety, pain catastrophizing, and sleepiness; sociodemographics; osteoarthritis severity; comorbid conditions; and medication use.

After the exclusion of the patients who had neurologic conditions (neuropathy, sciatica, shingles, postherpetic neuralgia, multiple sclerosis, stroke, and Parkinson's disease), the study identified 19% of the patients who had symptoms suggestive of neuropathic pain, Dr. Hochman reported.

On multivariate analysis, greater pain intensity and chronic hip or back pain with radiation down either leg (but not below the knee) were correlated with higher scores for neuropathic pain (odds ratio, 3.6).

“The subgroup of patients with neuropathic pain symptoms may benefit from further evaluation and possibly treatment for neuropathic pain,” she said.

Neuropathic pain medications include anticonvulsants such as gabapentin and pregabalin, and tricyclic antidepressants such as amitriptyline and nortriptyline, which are believed to “disrupt the central pain pathway and impact central reorganization at the higher spinal centers,” Dr. Hochman said. Antidepressants may also alleviate the depression, anxiety, and sleep disturbances that often accompany—and can also amplify—pain.

Dr. Roy Altman noted that Dr. Hochman is documenting something that many clinicians have long suspected, namely that neuropathic pain plays a role as a part of the pain syndrome in osteoarthritis as a consequence of central pain sensitization.

This information is useful in supporting the use of medications that are not typically considered for osteoarthritis. Since older studies have not documented the value of gabapentin and pregabolin in unselected patients with osteoarthritis, it appears that some benefit could be achieved in selected patients with symptoms compatible with neuropathic pain, according to Dr. Altman, professor of rheumatology at the University of California, Los Angeles.

Additional study of this selected population seems to be in order. Also, more recent research has suggested that in a more general population, serotonin norepinephrine reuptake inhibitors are of value in osteoarthritis, he added.

Dr. Hochman said that further research is needed to determine whether people with painful osteoarthritis who have symptoms of neuropathic pain respond better to neuropathic treatments vs. standard medications such as NSAIDs and acetaminophen. She said that there is little research to date to guide clinicians on whether to treat both nociceptive and neuropathic pain concomitantly, or whether treatment for neuropathic pain can be stopped if pain improves.

The congress was sponsored by the Osteoarthritis Research Society International.

Dr. Hochman said she had no conflicts of interest.

Many clinicians have long suspected that neuropathic pain plays a role as a part of the pain syndrome in OA.

Source DR. ALTMAN

MONTREAL — Almost one-fifth of patients with chronic knee osteoarthritis may have symptoms of neuropathic pain, requiring consideration of an alternative approach to their pain management, reported Dr. Jacqueline Hochman at the World Congress on Osteoarthritis.

“In clinical practice, neuropathic pain is generally not considered a feature of osteoarthritis, and among osteoarthritis researchers it is a novel concept,” she said in an interview. “But a growing body of literature suggests that one reason for treatment failure in osteoarthritis might be a mismatch between the current medications we're using and the underlying mechanisms of pain.”

Dr. Hochman, a rheumatologist at Women's College Hospital in Toronto, explained that current theories about pain point to the possible development of neuropathic pain as a result of the chronic, nociceptive stimulation associated with osteoarthritis.

“Most likely, central sensitization in osteoarthritis arises from chronic or recurrent stimulation of peripheral nociceptors, leading to modifications in the central nervous system that cause hyperexcitability in the spinal cord and, perhaps, supraspinal centers involved in the central transmission of pain,” Dr. Hochman said.

The diagnosis of neuropathic pain is a clinical one that is “based on a characteristic symptom profile that includes spontaneous sensations such as burning pain, numbness, and tingling, and evoked sensations such as sensitivity to light touch,” she said. In the presence of these symptoms, sensory abnormalities on physical examination, such as pinprick hyperalgesia and allodynia, can aid the diagnosis.

However, there is a paucity of data on symptoms of neuropathic pain in OA, Dr. Hochman said. Because symptoms “are going to lead our patients to seek medical care and alert their physicians to the possibility of underlying neuropathic mechanisms, it's important to know whether people with OA have symptoms of neuropathic pain.”

Therefore, in a group of 171 patients (median age, 76 years) with chronic, symptomatic knee osteoarthritis, she administered a modification of the painDETECT questionnaire (mPD-Q) that is designed to distinguish neuropathic from nociceptive pain.

Other study measures included biopsychosocial factors, such as depression, anxiety, pain catastrophizing, and sleepiness; sociodemographics; osteoarthritis severity; comorbid conditions; and medication use.

After the exclusion of the patients who had neurologic conditions (neuropathy, sciatica, shingles, postherpetic neuralgia, multiple sclerosis, stroke, and Parkinson's disease), the study identified 19% of the patients who had symptoms suggestive of neuropathic pain, Dr. Hochman reported.

On multivariate analysis, greater pain intensity and chronic hip or back pain with radiation down either leg (but not below the knee) were correlated with higher scores for neuropathic pain (odds ratio, 3.6).

“The subgroup of patients with neuropathic pain symptoms may benefit from further evaluation and possibly treatment for neuropathic pain,” she said.

Neuropathic pain medications include anticonvulsants such as gabapentin and pregabalin, and tricyclic antidepressants such as amitriptyline and nortriptyline, which are believed to “disrupt the central pain pathway and impact central reorganization at the higher spinal centers,” Dr. Hochman said. Antidepressants may also alleviate the depression, anxiety, and sleep disturbances that often accompany—and can also amplify—pain.

Dr. Roy Altman noted that Dr. Hochman is documenting something that many clinicians have long suspected, namely that neuropathic pain plays a role as a part of the pain syndrome in osteoarthritis as a consequence of central pain sensitization.

This information is useful in supporting the use of medications that are not typically considered for osteoarthritis. Since older studies have not documented the value of gabapentin and pregabolin in unselected patients with osteoarthritis, it appears that some benefit could be achieved in selected patients with symptoms compatible with neuropathic pain, according to Dr. Altman, professor of rheumatology at the University of California, Los Angeles.

Additional study of this selected population seems to be in order. Also, more recent research has suggested that in a more general population, serotonin norepinephrine reuptake inhibitors are of value in osteoarthritis, he added.

Dr. Hochman said that further research is needed to determine whether people with painful osteoarthritis who have symptoms of neuropathic pain respond better to neuropathic treatments vs. standard medications such as NSAIDs and acetaminophen. She said that there is little research to date to guide clinicians on whether to treat both nociceptive and neuropathic pain concomitantly, or whether treatment for neuropathic pain can be stopped if pain improves.

The congress was sponsored by the Osteoarthritis Research Society International.

Dr. Hochman said she had no conflicts of interest.

Many clinicians have long suspected that neuropathic pain plays a role as a part of the pain syndrome in OA.

Source DR. ALTMAN

MONTREAL — Almost one-fifth of patients with chronic knee osteoarthritis may have symptoms of neuropathic pain, requiring consideration of an alternative approach to their pain management, reported Dr. Jacqueline Hochman at the World Congress on Osteoarthritis.

“In clinical practice, neuropathic pain is generally not considered a feature of osteoarthritis, and among osteoarthritis researchers it is a novel concept,” she said in an interview. “But a growing body of literature suggests that one reason for treatment failure in osteoarthritis might be a mismatch between the current medications we're using and the underlying mechanisms of pain.”

Dr. Hochman, a rheumatologist at Women's College Hospital in Toronto, explained that current theories about pain point to the possible development of neuropathic pain as a result of the chronic, nociceptive stimulation associated with osteoarthritis.

“Most likely, central sensitization in osteoarthritis arises from chronic or recurrent stimulation of peripheral nociceptors, leading to modifications in the central nervous system that cause hyperexcitability in the spinal cord and, perhaps, supraspinal centers involved in the central transmission of pain,” Dr. Hochman said.

The diagnosis of neuropathic pain is a clinical one that is “based on a characteristic symptom profile that includes spontaneous sensations such as burning pain, numbness, and tingling, and evoked sensations such as sensitivity to light touch,” she said. In the presence of these symptoms, sensory abnormalities on physical examination, such as pinprick hyperalgesia and allodynia, can aid the diagnosis.

However, there is a paucity of data on symptoms of neuropathic pain in OA, Dr. Hochman said. Because symptoms “are going to lead our patients to seek medical care and alert their physicians to the possibility of underlying neuropathic mechanisms, it's important to know whether people with OA have symptoms of neuropathic pain.”

Therefore, in a group of 171 patients (median age, 76 years) with chronic, symptomatic knee osteoarthritis, she administered a modification of the painDETECT questionnaire (mPD-Q) that is designed to distinguish neuropathic from nociceptive pain.

Other study measures included biopsychosocial factors, such as depression, anxiety, pain catastrophizing, and sleepiness; sociodemographics; osteoarthritis severity; comorbid conditions; and medication use.

After the exclusion of the patients who had neurologic conditions (neuropathy, sciatica, shingles, postherpetic neuralgia, multiple sclerosis, stroke, and Parkinson's disease), the study identified 19% of the patients who had symptoms suggestive of neuropathic pain, Dr. Hochman reported.

On multivariate analysis, greater pain intensity and chronic hip or back pain with radiation down either leg (but not below the knee) were correlated with higher scores for neuropathic pain (odds ratio, 3.6).

“The subgroup of patients with neuropathic pain symptoms may benefit from further evaluation and possibly treatment for neuropathic pain,” she said.

Neuropathic pain medications include anticonvulsants such as gabapentin and pregabalin, and tricyclic antidepressants such as amitriptyline and nortriptyline, which are believed to “disrupt the central pain pathway and impact central reorganization at the higher spinal centers,” Dr. Hochman said. Antidepressants may also alleviate the depression, anxiety, and sleep disturbances that often accompany—and can also amplify—pain.

Dr. Roy Altman noted that Dr. Hochman is documenting something that many clinicians have long suspected, namely that neuropathic pain plays a role as a part of the pain syndrome in osteoarthritis as a consequence of central pain sensitization.

This information is useful in supporting the use of medications that are not typically considered for osteoarthritis. Since older studies have not documented the value of gabapentin and pregabolin in unselected patients with osteoarthritis, it appears that some benefit could be achieved in selected patients with symptoms compatible with neuropathic pain, according to Dr. Altman, professor of rheumatology at the University of California, Los Angeles.

Additional study of this selected population seems to be in order. Also, more recent research has suggested that in a more general population, serotonin norepinephrine reuptake inhibitors are of value in osteoarthritis, he added.

Dr. Hochman said that further research is needed to determine whether people with painful osteoarthritis who have symptoms of neuropathic pain respond better to neuropathic treatments vs. standard medications such as NSAIDs and acetaminophen. She said that there is little research to date to guide clinicians on whether to treat both nociceptive and neuropathic pain concomitantly, or whether treatment for neuropathic pain can be stopped if pain improves.

The congress was sponsored by the Osteoarthritis Research Society International.

Dr. Hochman said she had no conflicts of interest.

Many clinicians have long suspected that neuropathic pain plays a role as a part of the pain syndrome in OA.

Source DR. ALTMAN

AMSTERDAM — Two drugs that inhibit uterine contractions might provide a novel approach to improving implantation rates in patients undergoing IVF, according to early research reported at the annual meeting of the European Society of Human Reproduction and Embryology.

“Contractions of the uterus are more frequent in IVF cycles compared to normal menstrual cycles, and a higher frequency of contractions around the time of embryo transfer is associated with a more negative impact on pregnancy outcomes,” reported Dr. Christophe Blockeel of the center for reproductive medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium.

“We've learned that uterine contractions are actually in many cases expelling somewhere between 15% to 50% of embryos after transfer,” commented Roger Pierson, Ph.D., a collaborator in the study, and professor of obstetrics, gynecology, and reproductive sciences at the University of Saskatchewan (Sask).

“Regardless of which catheter you use, or whether or not you use ultrasound, you are still irritating the uterus and it doesn't matter how gentle you are, some women are going to respond with advanced uterine contractions,” he said in an interview.

The study, which was conducted in oocyte donors and was funded by Ferring Pharmaceuticals, examined the effect of the selective oxytocin antagonist barusiban and the mixed oxytocin/vasopressin antagonist atosiban versus placebo on luteal phase uterine contractions.

The study participants were 125 oocyte donors who had undergone controlled ovarian stimulation, oocyte retrieval, and luteal phase supplementation with progeste progesterone. Women were randomized to either barusiban (41 women, IV bolus 9 mg, IV infusion 2.16 mg/h); atosiban (42 women, IV bolus 6.75 mg, IV infusion 18 mg/h); or placebo on day 2 after oocyte retrieval.

Transvaginal ultrasounds lasting at least 5 minutes were obtained after retrieval on day 1, 14 times on day 2 (pretreatment, 8 times before mock embryo transfer, 3 times after mock embryo transfer, and 2 times post infusion), and on Day 5.

With both medications, the frequency of uterine contractions remained stable during the first 2 days after retrieval, followed by a significant decrease noted in both treatment groups that lasted for about 3 hours.

“These medications are quite short acting, so they need to be administered an hour or two before transfer just to get the uterus settled to facilitate implantation,” explained Dr. Pierson, who is also a consultant for Ferring.

Without the control medication the frequency of uterine contractions can be as high as 6 or 7 per minute after embryo transfer, he said, adding that the ideal is somewhere around 1 to 1.5 contractions per minute.

“This is a very new approach to improving implantation and quite different,” he explained. While atosiban is already used to treat preterm labor, barusiban was specifically developed to treat uterine contractions in IVF, and another similar medication is being developed by the company.

“Both barusiban and atosiban are very well tolerated drugs; however, toxicology tests are still needed before we can use these drugs in patients undergoing embryo transfer rather than donors,” Dr. Blockeel said. Optimal dosing also needs further investigation.

AMSTERDAM — Two drugs that inhibit uterine contractions might provide a novel approach to improving implantation rates in patients undergoing IVF, according to early research reported at the annual meeting of the European Society of Human Reproduction and Embryology.

“Contractions of the uterus are more frequent in IVF cycles compared to normal menstrual cycles, and a higher frequency of contractions around the time of embryo transfer is associated with a more negative impact on pregnancy outcomes,” reported Dr. Christophe Blockeel of the center for reproductive medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium.

“We've learned that uterine contractions are actually in many cases expelling somewhere between 15% to 50% of embryos after transfer,” commented Roger Pierson, Ph.D., a collaborator in the study, and professor of obstetrics, gynecology, and reproductive sciences at the University of Saskatchewan (Sask).

“Regardless of which catheter you use, or whether or not you use ultrasound, you are still irritating the uterus and it doesn't matter how gentle you are, some women are going to respond with advanced uterine contractions,” he said in an interview.

The study, which was conducted in oocyte donors and was funded by Ferring Pharmaceuticals, examined the effect of the selective oxytocin antagonist barusiban and the mixed oxytocin/vasopressin antagonist atosiban versus placebo on luteal phase uterine contractions.

The study participants were 125 oocyte donors who had undergone controlled ovarian stimulation, oocyte retrieval, and luteal phase supplementation with progeste progesterone. Women were randomized to either barusiban (41 women, IV bolus 9 mg, IV infusion 2.16 mg/h); atosiban (42 women, IV bolus 6.75 mg, IV infusion 18 mg/h); or placebo on day 2 after oocyte retrieval.

Transvaginal ultrasounds lasting at least 5 minutes were obtained after retrieval on day 1, 14 times on day 2 (pretreatment, 8 times before mock embryo transfer, 3 times after mock embryo transfer, and 2 times post infusion), and on Day 5.

With both medications, the frequency of uterine contractions remained stable during the first 2 days after retrieval, followed by a significant decrease noted in both treatment groups that lasted for about 3 hours.

“These medications are quite short acting, so they need to be administered an hour or two before transfer just to get the uterus settled to facilitate implantation,” explained Dr. Pierson, who is also a consultant for Ferring.

Without the control medication the frequency of uterine contractions can be as high as 6 or 7 per minute after embryo transfer, he said, adding that the ideal is somewhere around 1 to 1.5 contractions per minute.

“This is a very new approach to improving implantation and quite different,” he explained. While atosiban is already used to treat preterm labor, barusiban was specifically developed to treat uterine contractions in IVF, and another similar medication is being developed by the company.

“Both barusiban and atosiban are very well tolerated drugs; however, toxicology tests are still needed before we can use these drugs in patients undergoing embryo transfer rather than donors,” Dr. Blockeel said. Optimal dosing also needs further investigation.

AMSTERDAM — Two drugs that inhibit uterine contractions might provide a novel approach to improving implantation rates in patients undergoing IVF, according to early research reported at the annual meeting of the European Society of Human Reproduction and Embryology.

“Contractions of the uterus are more frequent in IVF cycles compared to normal menstrual cycles, and a higher frequency of contractions around the time of embryo transfer is associated with a more negative impact on pregnancy outcomes,” reported Dr. Christophe Blockeel of the center for reproductive medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium.

“We've learned that uterine contractions are actually in many cases expelling somewhere between 15% to 50% of embryos after transfer,” commented Roger Pierson, Ph.D., a collaborator in the study, and professor of obstetrics, gynecology, and reproductive sciences at the University of Saskatchewan (Sask).

“Regardless of which catheter you use, or whether or not you use ultrasound, you are still irritating the uterus and it doesn't matter how gentle you are, some women are going to respond with advanced uterine contractions,” he said in an interview.

The study, which was conducted in oocyte donors and was funded by Ferring Pharmaceuticals, examined the effect of the selective oxytocin antagonist barusiban and the mixed oxytocin/vasopressin antagonist atosiban versus placebo on luteal phase uterine contractions.

The study participants were 125 oocyte donors who had undergone controlled ovarian stimulation, oocyte retrieval, and luteal phase supplementation with progeste progesterone. Women were randomized to either barusiban (41 women, IV bolus 9 mg, IV infusion 2.16 mg/h); atosiban (42 women, IV bolus 6.75 mg, IV infusion 18 mg/h); or placebo on day 2 after oocyte retrieval.

Transvaginal ultrasounds lasting at least 5 minutes were obtained after retrieval on day 1, 14 times on day 2 (pretreatment, 8 times before mock embryo transfer, 3 times after mock embryo transfer, and 2 times post infusion), and on Day 5.

With both medications, the frequency of uterine contractions remained stable during the first 2 days after retrieval, followed by a significant decrease noted in both treatment groups that lasted for about 3 hours.

“These medications are quite short acting, so they need to be administered an hour or two before transfer just to get the uterus settled to facilitate implantation,” explained Dr. Pierson, who is also a consultant for Ferring.

Without the control medication the frequency of uterine contractions can be as high as 6 or 7 per minute after embryo transfer, he said, adding that the ideal is somewhere around 1 to 1.5 contractions per minute.

“This is a very new approach to improving implantation and quite different,” he explained. While atosiban is already used to treat preterm labor, barusiban was specifically developed to treat uterine contractions in IVF, and another similar medication is being developed by the company.

“Both barusiban and atosiban are very well tolerated drugs; however, toxicology tests are still needed before we can use these drugs in patients undergoing embryo transfer rather than donors,” Dr. Blockeel said. Optimal dosing also needs further investigation.

AMSTERDAM — Vitrified ovarian tissue yields a greater number of viable oocytes after thaw and transplant, compared with tissue that is frozen using conventional techniques, according to data presented at the European Society of Human Reproduction and Embryology.

“Both ischemic loss from cortical transplantation and oocyte loss from freezing can be prevented with ultrathin grafts and vitrification,” said Dr. Sherman Silber, director of the Infertility Center of St. Louis.

In fact, oocyte viability from transplanted vitrified ovarian tissue is similar to that of fresh transplants, he said.

In one study, Dr. Silber compared oocyte viability in 14 young cancer patients who had received ovarian tissue transplants after either vitrification (n = 8) or conventional freezing (n = 6). He compared his results with those of nine patients who had received fresh ovarian tissue transplanted from their identical twins.

Oocyte viability was similar in the twin patients who had received fresh tissue and cancer patients who had received vitrified tissue, but was significantly decreased in cancer patients who had received conventionally frozen tissue, he reported.

“We found that 91.9% of the fresh oocytes were viable, compared with 88.9% of those vitrified. However, slow freezing resulted in a 56% loss of viability,” he said.

Ovarian function returned in all patients regardless of whether they had received fresh tissue or tissue frozen by either method, emphasized Dr. Silber. All patients regained a normal ovarian cycle 4-5 months after transplant.

Dr. Silber's data point to the superiority of vitrification over conventional freezing, in terms of oocyte viability. However, another paper presented at the meeting suggests vitrification may result in abnormal expression of a gene known as GAPDH (glyceraldehyde 3-phosphate dehydrogenase). In an in vitro study of human ovarian tissue, “we detected drastically reduced levels of GAPDH-gene expression in ovarian tissue after vitrification, compared with conventional freezing,” reported Vladimir Isachenko, Ph.D., of the University of Ulm (Germany).

“This is a housekeeping gene,” he explained in an interview. “If there is no expression of this gene, or expression is decreased, it will eventually result in cell death,” he said.

Studies to date show no indication of abnormalities in children conceived from vitrified ovarian tissue or oocytes, commented Dr. Silber.

But abnormal gene expression could have very subtle effects that might also not become evident until adulthood, Dr. Isachenko explained. He suggested that the mechanism by which vitrification might alter gene expression might be the direct contact of tissue with liquid nitrogen. Based on his findings, his laboratory no longer uses vitrification.

Oocyte viability from transplanted vitrified ovarian tissue is similar to that of fresh transplants.

Source Dr. Silber

AMSTERDAM — Vitrified ovarian tissue yields a greater number of viable oocytes after thaw and transplant, compared with tissue that is frozen using conventional techniques, according to data presented at the European Society of Human Reproduction and Embryology.

“Both ischemic loss from cortical transplantation and oocyte loss from freezing can be prevented with ultrathin grafts and vitrification,” said Dr. Sherman Silber, director of the Infertility Center of St. Louis.

In fact, oocyte viability from transplanted vitrified ovarian tissue is similar to that of fresh transplants, he said.

In one study, Dr. Silber compared oocyte viability in 14 young cancer patients who had received ovarian tissue transplants after either vitrification (n = 8) or conventional freezing (n = 6). He compared his results with those of nine patients who had received fresh ovarian tissue transplanted from their identical twins.

Oocyte viability was similar in the twin patients who had received fresh tissue and cancer patients who had received vitrified tissue, but was significantly decreased in cancer patients who had received conventionally frozen tissue, he reported.

“We found that 91.9% of the fresh oocytes were viable, compared with 88.9% of those vitrified. However, slow freezing resulted in a 56% loss of viability,” he said.

Ovarian function returned in all patients regardless of whether they had received fresh tissue or tissue frozen by either method, emphasized Dr. Silber. All patients regained a normal ovarian cycle 4-5 months after transplant.

Dr. Silber's data point to the superiority of vitrification over conventional freezing, in terms of oocyte viability. However, another paper presented at the meeting suggests vitrification may result in abnormal expression of a gene known as GAPDH (glyceraldehyde 3-phosphate dehydrogenase). In an in vitro study of human ovarian tissue, “we detected drastically reduced levels of GAPDH-gene expression in ovarian tissue after vitrification, compared with conventional freezing,” reported Vladimir Isachenko, Ph.D., of the University of Ulm (Germany).

“This is a housekeeping gene,” he explained in an interview. “If there is no expression of this gene, or expression is decreased, it will eventually result in cell death,” he said.

Studies to date show no indication of abnormalities in children conceived from vitrified ovarian tissue or oocytes, commented Dr. Silber.

But abnormal gene expression could have very subtle effects that might also not become evident until adulthood, Dr. Isachenko explained. He suggested that the mechanism by which vitrification might alter gene expression might be the direct contact of tissue with liquid nitrogen. Based on his findings, his laboratory no longer uses vitrification.

Oocyte viability from transplanted vitrified ovarian tissue is similar to that of fresh transplants.

Source Dr. Silber

AMSTERDAM — Vitrified ovarian tissue yields a greater number of viable oocytes after thaw and transplant, compared with tissue that is frozen using conventional techniques, according to data presented at the European Society of Human Reproduction and Embryology.

“Both ischemic loss from cortical transplantation and oocyte loss from freezing can be prevented with ultrathin grafts and vitrification,” said Dr. Sherman Silber, director of the Infertility Center of St. Louis.

In fact, oocyte viability from transplanted vitrified ovarian tissue is similar to that of fresh transplants, he said.

In one study, Dr. Silber compared oocyte viability in 14 young cancer patients who had received ovarian tissue transplants after either vitrification (n = 8) or conventional freezing (n = 6). He compared his results with those of nine patients who had received fresh ovarian tissue transplanted from their identical twins.

Oocyte viability was similar in the twin patients who had received fresh tissue and cancer patients who had received vitrified tissue, but was significantly decreased in cancer patients who had received conventionally frozen tissue, he reported.

“We found that 91.9% of the fresh oocytes were viable, compared with 88.9% of those vitrified. However, slow freezing resulted in a 56% loss of viability,” he said.

Ovarian function returned in all patients regardless of whether they had received fresh tissue or tissue frozen by either method, emphasized Dr. Silber. All patients regained a normal ovarian cycle 4-5 months after transplant.

Dr. Silber's data point to the superiority of vitrification over conventional freezing, in terms of oocyte viability. However, another paper presented at the meeting suggests vitrification may result in abnormal expression of a gene known as GAPDH (glyceraldehyde 3-phosphate dehydrogenase). In an in vitro study of human ovarian tissue, “we detected drastically reduced levels of GAPDH-gene expression in ovarian tissue after vitrification, compared with conventional freezing,” reported Vladimir Isachenko, Ph.D., of the University of Ulm (Germany).

“This is a housekeeping gene,” he explained in an interview. “If there is no expression of this gene, or expression is decreased, it will eventually result in cell death,” he said.

Studies to date show no indication of abnormalities in children conceived from vitrified ovarian tissue or oocytes, commented Dr. Silber.

But abnormal gene expression could have very subtle effects that might also not become evident until adulthood, Dr. Isachenko explained. He suggested that the mechanism by which vitrification might alter gene expression might be the direct contact of tissue with liquid nitrogen. Based on his findings, his laboratory no longer uses vitrification.

Oocyte viability from transplanted vitrified ovarian tissue is similar to that of fresh transplants.

Source Dr. Silber

MONTREAL — Mycoplasma genitalium is likely an underrecognized cause of some cases of cervicitis, but the role of the physician in screening for and treating this organism remains unclear, according to Dr. Harold Wiesenfeld of Magee-Womens Hospital and the University of Pittsburgh.

Dr. Wiesenfeld outlined his work showing a link between M. genitalium and subclinical pelvic inflammatory disease, as well as more recent findings implicating the organism in cervicitis, at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

“Many cases, perhaps most cases, of cervicitis occur in women who are negative for the traditional pathogens known to cause cervicitis, such as Neisseria gonorrhoeae and Chlamydia trachomatis,” he said in an interview. “Our findings may explain the etiology of cervicitis in some women.”

His study of 524 women at risk for lower genital tract infection and undergoing testing for sexually transmitted disease found elevated polymorphonuclear leukocytes (PMNs), a microscopic marker for cervical inflammation, in 22% of the women. M. genitalium was identified in 8% of the overall cohort, but occurred more frequently among those with elevated PMNs compared with those without (37% vs. 21%). In fact, among all women with elevated PMNs, M. genitalium was the most common pathogen “eclipsing the more traditionally recognized cervicitis organisms,” Dr. Wiesenfeld said.

In contrast, only 32% of those with elevated PMNs had C. trachomatis, 22% had N. gonorrhoeae, 22% had bacterial vaginosis, and 21% had Trichomonas vaginalis.

After logistic regression, infection with M. genitalium was independently associated with elevated PMNs, with an odds ratio of 2.5, he said.

“As there is an independent association between M. genitalium and cervical inflammation, it is likely that M. genitalium is the cause of a true cervical infection rather than just a colonizing organism,” Dr. Wiesenfeld said. “I would not expect a colonizing organism to cause a cervical inflammatory response.”

In order to rule out confounding STDs, the analysis was then restricted to 345 women who had tested negative for gonorrhea, chlamydia, and Trichomonas species. Eight percent of this cohort tested positive for M. genitalium, and 46% of this group had elevated PMNs compared with the 18 women who had no STD infections.

“After controlling for age, M. genitalium infection was independently associated with elevated PMNs with an odds ratio of 4.7,” he said. Only a minority of women had clinical signs of cervicitis, and there were no clinical differences between those who tested positive or negative for M. genitalium.

The findings shed new light on the contributions of M. genitalium to cervicitis, but “at this point I do not think that these findings will change the routine management of cervicitis,” Dr. Wiesenfeld said.

MONTREAL — Mycoplasma genitalium is likely an underrecognized cause of some cases of cervicitis, but the role of the physician in screening for and treating this organism remains unclear, according to Dr. Harold Wiesenfeld of Magee-Womens Hospital and the University of Pittsburgh.

Dr. Wiesenfeld outlined his work showing a link between M. genitalium and subclinical pelvic inflammatory disease, as well as more recent findings implicating the organism in cervicitis, at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

“Many cases, perhaps most cases, of cervicitis occur in women who are negative for the traditional pathogens known to cause cervicitis, such as Neisseria gonorrhoeae and Chlamydia trachomatis,” he said in an interview. “Our findings may explain the etiology of cervicitis in some women.”

His study of 524 women at risk for lower genital tract infection and undergoing testing for sexually transmitted disease found elevated polymorphonuclear leukocytes (PMNs), a microscopic marker for cervical inflammation, in 22% of the women. M. genitalium was identified in 8% of the overall cohort, but occurred more frequently among those with elevated PMNs compared with those without (37% vs. 21%). In fact, among all women with elevated PMNs, M. genitalium was the most common pathogen “eclipsing the more traditionally recognized cervicitis organisms,” Dr. Wiesenfeld said.

In contrast, only 32% of those with elevated PMNs had C. trachomatis, 22% had N. gonorrhoeae, 22% had bacterial vaginosis, and 21% had Trichomonas vaginalis.

After logistic regression, infection with M. genitalium was independently associated with elevated PMNs, with an odds ratio of 2.5, he said.

“As there is an independent association between M. genitalium and cervical inflammation, it is likely that M. genitalium is the cause of a true cervical infection rather than just a colonizing organism,” Dr. Wiesenfeld said. “I would not expect a colonizing organism to cause a cervical inflammatory response.”

In order to rule out confounding STDs, the analysis was then restricted to 345 women who had tested negative for gonorrhea, chlamydia, and Trichomonas species. Eight percent of this cohort tested positive for M. genitalium, and 46% of this group had elevated PMNs compared with the 18 women who had no STD infections.

“After controlling for age, M. genitalium infection was independently associated with elevated PMNs with an odds ratio of 4.7,” he said. Only a minority of women had clinical signs of cervicitis, and there were no clinical differences between those who tested positive or negative for M. genitalium.

The findings shed new light on the contributions of M. genitalium to cervicitis, but “at this point I do not think that these findings will change the routine management of cervicitis,” Dr. Wiesenfeld said.

MONTREAL — Mycoplasma genitalium is likely an underrecognized cause of some cases of cervicitis, but the role of the physician in screening for and treating this organism remains unclear, according to Dr. Harold Wiesenfeld of Magee-Womens Hospital and the University of Pittsburgh.

Dr. Wiesenfeld outlined his work showing a link between M. genitalium and subclinical pelvic inflammatory disease, as well as more recent findings implicating the organism in cervicitis, at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

“Many cases, perhaps most cases, of cervicitis occur in women who are negative for the traditional pathogens known to cause cervicitis, such as Neisseria gonorrhoeae and Chlamydia trachomatis,” he said in an interview. “Our findings may explain the etiology of cervicitis in some women.”

His study of 524 women at risk for lower genital tract infection and undergoing testing for sexually transmitted disease found elevated polymorphonuclear leukocytes (PMNs), a microscopic marker for cervical inflammation, in 22% of the women. M. genitalium was identified in 8% of the overall cohort, but occurred more frequently among those with elevated PMNs compared with those without (37% vs. 21%). In fact, among all women with elevated PMNs, M. genitalium was the most common pathogen “eclipsing the more traditionally recognized cervicitis organisms,” Dr. Wiesenfeld said.

In contrast, only 32% of those with elevated PMNs had C. trachomatis, 22% had N. gonorrhoeae, 22% had bacterial vaginosis, and 21% had Trichomonas vaginalis.

After logistic regression, infection with M. genitalium was independently associated with elevated PMNs, with an odds ratio of 2.5, he said.

“As there is an independent association between M. genitalium and cervical inflammation, it is likely that M. genitalium is the cause of a true cervical infection rather than just a colonizing organism,” Dr. Wiesenfeld said. “I would not expect a colonizing organism to cause a cervical inflammatory response.”

In order to rule out confounding STDs, the analysis was then restricted to 345 women who had tested negative for gonorrhea, chlamydia, and Trichomonas species. Eight percent of this cohort tested positive for M. genitalium, and 46% of this group had elevated PMNs compared with the 18 women who had no STD infections.

“After controlling for age, M. genitalium infection was independently associated with elevated PMNs with an odds ratio of 4.7,” he said. Only a minority of women had clinical signs of cervicitis, and there were no clinical differences between those who tested positive or negative for M. genitalium.

The findings shed new light on the contributions of M. genitalium to cervicitis, but “at this point I do not think that these findings will change the routine management of cervicitis,” Dr. Wiesenfeld said.

MONTREAL — Expedited partner treatment, also known as patient-delivered partner therapy, could substantially reduce costs and morbidity from sexually transmitted diseases if it were allowed in all states, according to Dr. Margaret Villers.

The practice allows physicians who are treating patients with sexually transmitted diseases to either provide treatment, or write a prescription for their patients' partners without requiring the partners to come into the office.

Although the Centers for Disease Control and Prevention has encouraged expedited partner treatment (EPT) since 2006, it is explicitly legal in only 19 states, and “in multiple states and localities, there are legal barriers which may prevent universal implementation,” Dr. Villers said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology. (For a map showing the legal status of EPT in each state, visit www.cdc.gov/std/ept/legal/default.htm

“The South Carolina statute very much mirrors the other states where it's prohibited in the sense that if you do not see a patient—if you've never met them, if you have not examined them, and if you do not have an ongoing relationship with them—then you are not allowed to prescribe a medication for them,” explained Dr. Villers of the Medical University of South Carolina, Charleston.

In a cost-utility model examining the potential impact of EPT in 11 states where it was illegal in 2007 (one state, North Dakota, has since made the practice legal), she estimated there would be a cost savings of almost $6 million and the prevention of more than 2,000 cases of Chlamydia trachomatis and Neisseria gonorrhoeae annually.

Using estimates of disease prevalence, treatment failure, costs, and quality-adjusted life years, EPT would have resulted in 984 fewer cases of chlamydia (rather than the actual 196,819 cases) and 1,280 fewer cases of gonorrhea (rather than the actual 56,585 cases). This reduction in disease would have resulted in a net savings of $1,671,387 for chlamydia and $4,163,534 for gonorrhea, and a combined gain of 453 quality-adjusted life years.

Currently, in the 19 U.S. states where EPT is explicitly legal, “there are state statutes that either allow for the provision of a prescription in general or specifically for the treatment of STDs only,” she said. But there are 21 states where the laws are “somewhat murky. Either there are no laws, which means that presumably you can go ahead and provide this treatment” or there's nothing prohibiting treatment. She said that approximately 1 year ago the American Bar Association sent an open letter to all members encouraging states and localities to pass statutes that might decrease barriers to the implementation of EPT.

“Improved clarification of the legal status of EPT, whether it is a state law which only allows the prescription of medications for STDS or whether it is a broader general law, might actually make this type of treatment more acceptable to physicians,” she said in an interview.

However, she said that both legal and clinical concerns are barriers to EPT. “Research studies have shown that there are few risks to partners who receive EPT and there are significant benefits. I think if the legal status of EPT was clarified, it would be much easier to educate physicians about its benefits,” she said, noting that the logical places to prescribe EPT are health departments, which are usually state administered.

Dr. Villers noted that her study probably underestimates the benefits of EPT because it is based on the assumption that the infected patient was female, and was confined to the 3-month period following her treatment. Also we did not take into account multiple sexual partners, and we only looked at direct medical costs, not indirect costs, such as time off from work.

MONTREAL — Expedited partner treatment, also known as patient-delivered partner therapy, could substantially reduce costs and morbidity from sexually transmitted diseases if it were allowed in all states, according to Dr. Margaret Villers.

The practice allows physicians who are treating patients with sexually transmitted diseases to either provide treatment, or write a prescription for their patients' partners without requiring the partners to come into the office.

Although the Centers for Disease Control and Prevention has encouraged expedited partner treatment (EPT) since 2006, it is explicitly legal in only 19 states, and “in multiple states and localities, there are legal barriers which may prevent universal implementation,” Dr. Villers said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology. (For a map showing the legal status of EPT in each state, visit www.cdc.gov/std/ept/legal/default.htm

“The South Carolina statute very much mirrors the other states where it's prohibited in the sense that if you do not see a patient—if you've never met them, if you have not examined them, and if you do not have an ongoing relationship with them—then you are not allowed to prescribe a medication for them,” explained Dr. Villers of the Medical University of South Carolina, Charleston.

In a cost-utility model examining the potential impact of EPT in 11 states where it was illegal in 2007 (one state, North Dakota, has since made the practice legal), she estimated there would be a cost savings of almost $6 million and the prevention of more than 2,000 cases of Chlamydia trachomatis and Neisseria gonorrhoeae annually.

Using estimates of disease prevalence, treatment failure, costs, and quality-adjusted life years, EPT would have resulted in 984 fewer cases of chlamydia (rather than the actual 196,819 cases) and 1,280 fewer cases of gonorrhea (rather than the actual 56,585 cases). This reduction in disease would have resulted in a net savings of $1,671,387 for chlamydia and $4,163,534 for gonorrhea, and a combined gain of 453 quality-adjusted life years.

Currently, in the 19 U.S. states where EPT is explicitly legal, “there are state statutes that either allow for the provision of a prescription in general or specifically for the treatment of STDs only,” she said. But there are 21 states where the laws are “somewhat murky. Either there are no laws, which means that presumably you can go ahead and provide this treatment” or there's nothing prohibiting treatment. She said that approximately 1 year ago the American Bar Association sent an open letter to all members encouraging states and localities to pass statutes that might decrease barriers to the implementation of EPT.

“Improved clarification of the legal status of EPT, whether it is a state law which only allows the prescription of medications for STDS or whether it is a broader general law, might actually make this type of treatment more acceptable to physicians,” she said in an interview.

However, she said that both legal and clinical concerns are barriers to EPT. “Research studies have shown that there are few risks to partners who receive EPT and there are significant benefits. I think if the legal status of EPT was clarified, it would be much easier to educate physicians about its benefits,” she said, noting that the logical places to prescribe EPT are health departments, which are usually state administered.

Dr. Villers noted that her study probably underestimates the benefits of EPT because it is based on the assumption that the infected patient was female, and was confined to the 3-month period following her treatment. Also we did not take into account multiple sexual partners, and we only looked at direct medical costs, not indirect costs, such as time off from work.

MONTREAL — Expedited partner treatment, also known as patient-delivered partner therapy, could substantially reduce costs and morbidity from sexually transmitted diseases if it were allowed in all states, according to Dr. Margaret Villers.

The practice allows physicians who are treating patients with sexually transmitted diseases to either provide treatment, or write a prescription for their patients' partners without requiring the partners to come into the office.

Although the Centers for Disease Control and Prevention has encouraged expedited partner treatment (EPT) since 2006, it is explicitly legal in only 19 states, and “in multiple states and localities, there are legal barriers which may prevent universal implementation,” Dr. Villers said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology. (For a map showing the legal status of EPT in each state, visit www.cdc.gov/std/ept/legal/default.htm

“The South Carolina statute very much mirrors the other states where it's prohibited in the sense that if you do not see a patient—if you've never met them, if you have not examined them, and if you do not have an ongoing relationship with them—then you are not allowed to prescribe a medication for them,” explained Dr. Villers of the Medical University of South Carolina, Charleston.

In a cost-utility model examining the potential impact of EPT in 11 states where it was illegal in 2007 (one state, North Dakota, has since made the practice legal), she estimated there would be a cost savings of almost $6 million and the prevention of more than 2,000 cases of Chlamydia trachomatis and Neisseria gonorrhoeae annually.

Using estimates of disease prevalence, treatment failure, costs, and quality-adjusted life years, EPT would have resulted in 984 fewer cases of chlamydia (rather than the actual 196,819 cases) and 1,280 fewer cases of gonorrhea (rather than the actual 56,585 cases). This reduction in disease would have resulted in a net savings of $1,671,387 for chlamydia and $4,163,534 for gonorrhea, and a combined gain of 453 quality-adjusted life years.

Currently, in the 19 U.S. states where EPT is explicitly legal, “there are state statutes that either allow for the provision of a prescription in general or specifically for the treatment of STDs only,” she said. But there are 21 states where the laws are “somewhat murky. Either there are no laws, which means that presumably you can go ahead and provide this treatment” or there's nothing prohibiting treatment. She said that approximately 1 year ago the American Bar Association sent an open letter to all members encouraging states and localities to pass statutes that might decrease barriers to the implementation of EPT.

“Improved clarification of the legal status of EPT, whether it is a state law which only allows the prescription of medications for STDS or whether it is a broader general law, might actually make this type of treatment more acceptable to physicians,” she said in an interview.

However, she said that both legal and clinical concerns are barriers to EPT. “Research studies have shown that there are few risks to partners who receive EPT and there are significant benefits. I think if the legal status of EPT was clarified, it would be much easier to educate physicians about its benefits,” she said, noting that the logical places to prescribe EPT are health departments, which are usually state administered.

Dr. Villers noted that her study probably underestimates the benefits of EPT because it is based on the assumption that the infected patient was female, and was confined to the 3-month period following her treatment. Also we did not take into account multiple sexual partners, and we only looked at direct medical costs, not indirect costs, such as time off from work.

MONTREAL — Women who have not yet established prenatal care have a significantly higher rate of acute pyelonephritis before 12 weeks of gestation compared with women who already have an obstetric provider by 12 weeks, based on results of a retrospective study.

“Many providers do not see patients early in the first trimester, because they often like to ensure there is an established pregnancy. But we would encourage them to have patients present as early as possible, at least for labs and urine screening,” said Dr. Mollie Ann McDonnold, who presented her findings at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology (IDSOG).

Her retrospective study examined 254 consecutive hospital admissions for acute pyelonephritis in pregnancy between January 2004 and June 2007. Overall, there were 29 cases (11%) occurring before 12 weeks' gestation, and 60 cases (24%) before 16 weeks' gestation.

Among women who had already established prenatal care (219), most infections occurred later in pregnancy, with only 5% of cases occurring before 12 weeks, and 16% occurring prior to 16 weeks of gestation. However, among women without prenatal care (35), 51% of cases presented prior to 12 weeks and 74% occurred prior to 16 weeks of gestation.

“These results were expected as it is not common to establish prenatal care prior to 12 weeks,” said Dr. McDonnold of Brown University, Providence, R.I.

There were no differences in age, ethnicity, parity, length of hospital stay, presence or degree of fever, or heart rate at admission between women with or without established prenatal care.

However, there was a statistically significant difference in insurance between the groups. While 57% of women with no prenatal care had no insurance, only 1.6% of women with prenatal care were in this situation. And 24% of women with prenatal care had private insurance, compared with just 2.4% of women without prenatal care.

“I think this is an extremely important observation,” commented Dr. Michael Gravett, president of IDSOG and professor of obstetrics and gynecology at the University of Washington in Seattle.

“The trend in prenatal care is that since we now do a lot of prenatal diagnosis, we frequently defer initiation of care and labs until about 12 or 13 weeks. This is a reminder that common things occur more commonly and we tend to overlook them. This is a caution to see women earlier at least for urinalysis,” the physician said.

MONTREAL — Women who have not yet established prenatal care have a significantly higher rate of acute pyelonephritis before 12 weeks of gestation compared with women who already have an obstetric provider by 12 weeks, based on results of a retrospective study.

“Many providers do not see patients early in the first trimester, because they often like to ensure there is an established pregnancy. But we would encourage them to have patients present as early as possible, at least for labs and urine screening,” said Dr. Mollie Ann McDonnold, who presented her findings at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology (IDSOG).

Her retrospective study examined 254 consecutive hospital admissions for acute pyelonephritis in pregnancy between January 2004 and June 2007. Overall, there were 29 cases (11%) occurring before 12 weeks' gestation, and 60 cases (24%) before 16 weeks' gestation.

Among women who had already established prenatal care (219), most infections occurred later in pregnancy, with only 5% of cases occurring before 12 weeks, and 16% occurring prior to 16 weeks of gestation. However, among women without prenatal care (35), 51% of cases presented prior to 12 weeks and 74% occurred prior to 16 weeks of gestation.

“These results were expected as it is not common to establish prenatal care prior to 12 weeks,” said Dr. McDonnold of Brown University, Providence, R.I.

There were no differences in age, ethnicity, parity, length of hospital stay, presence or degree of fever, or heart rate at admission between women with or without established prenatal care.

However, there was a statistically significant difference in insurance between the groups. While 57% of women with no prenatal care had no insurance, only 1.6% of women with prenatal care were in this situation. And 24% of women with prenatal care had private insurance, compared with just 2.4% of women without prenatal care.

“I think this is an extremely important observation,” commented Dr. Michael Gravett, president of IDSOG and professor of obstetrics and gynecology at the University of Washington in Seattle.

“The trend in prenatal care is that since we now do a lot of prenatal diagnosis, we frequently defer initiation of care and labs until about 12 or 13 weeks. This is a reminder that common things occur more commonly and we tend to overlook them. This is a caution to see women earlier at least for urinalysis,” the physician said.

MONTREAL — Women who have not yet established prenatal care have a significantly higher rate of acute pyelonephritis before 12 weeks of gestation compared with women who already have an obstetric provider by 12 weeks, based on results of a retrospective study.

“Many providers do not see patients early in the first trimester, because they often like to ensure there is an established pregnancy. But we would encourage them to have patients present as early as possible, at least for labs and urine screening,” said Dr. Mollie Ann McDonnold, who presented her findings at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology (IDSOG).

Her retrospective study examined 254 consecutive hospital admissions for acute pyelonephritis in pregnancy between January 2004 and June 2007. Overall, there were 29 cases (11%) occurring before 12 weeks' gestation, and 60 cases (24%) before 16 weeks' gestation.

Among women who had already established prenatal care (219), most infections occurred later in pregnancy, with only 5% of cases occurring before 12 weeks, and 16% occurring prior to 16 weeks of gestation. However, among women without prenatal care (35), 51% of cases presented prior to 12 weeks and 74% occurred prior to 16 weeks of gestation.

“These results were expected as it is not common to establish prenatal care prior to 12 weeks,” said Dr. McDonnold of Brown University, Providence, R.I.

There were no differences in age, ethnicity, parity, length of hospital stay, presence or degree of fever, or heart rate at admission between women with or without established prenatal care.

However, there was a statistically significant difference in insurance between the groups. While 57% of women with no prenatal care had no insurance, only 1.6% of women with prenatal care were in this situation. And 24% of women with prenatal care had private insurance, compared with just 2.4% of women without prenatal care.

“I think this is an extremely important observation,” commented Dr. Michael Gravett, president of IDSOG and professor of obstetrics and gynecology at the University of Washington in Seattle.

“The trend in prenatal care is that since we now do a lot of prenatal diagnosis, we frequently defer initiation of care and labs until about 12 or 13 weeks. This is a reminder that common things occur more commonly and we tend to overlook them. This is a caution to see women earlier at least for urinalysis,” the physician said.

MONTREAL — Although bacteriuria in early pregnancy has been associated with pyelonephritis and preterm delivery, the same is not true for polymicrobial urine cultures or “mixed flora,” said Dr. Amber Naresh of Magee-Women's Hospital, Pittsburgh.

“Urine cultures with polymicrobial growth in the first half of pregnancy are essentially the same as negative cultures as far as these pregnancy outcomes are concerned,” Dr. Naresh said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

Her retrospective cohort study, carried out between 2004 and 2007, compared 449 women with polymicrobial urine cultures and 375 women with negative urine cultures, all at less than 20 weeks' gestation. Polymicrobial growth was defined as mixed flora of more than 100,000 colony forming units per milliliter.

Admissions for pyelonephritis were identified by ICD-9 codes, and gestational age at delivery was determined from a research registry.

The rates of pyelonephritis were the same in the women with polymicrobial growth and those with a negative urine culture (0.22% and 0%). Similarly, preterm delivery at less than 37 weeks' gestation occurred in 18% of women with polymicrobial growth and 16% of those with negative urine cultures, and delivery at less than 34 weeks occurred in 6% and 5%, respectively, Dr. Naresh reported.

There were no differences between the groups in maternal age, race, socioeconomic status, and tobacco use, but women with polymicrobial growth had higher rates of group B streptococcal (GBS) infection (41% vs. 32%). “Put another way, women with GBS were more likely to have polymicrobial growth than women who were GBS negative,” she said, adding that those with vaginal GBS may “have a higher bacterial load in the vagina and are therefore more prone to having contamination of their urine specimen.”

Women with polymicrobial growth also were more likely to have had a previous preterm birth (8.7%), compared with women with negative urine cultures (1.3%). “Unfortunately, I don't have an explanation for this, especially since there is no association between polymicrobial growth and preterm delivery in the current pregnancy,” she said.

The mean date of collection of urine was 12.3 weeks of gestation in the polymicrobial group and 11.6 weeks in those with negative cultures. “It's questionable whether this has any clinical significance, although it clearly has statistical significance.”

Practices vary among obstetric providers regarding the management of polymicrobial growth in urine cultures. “Some practitioners routinely repeat the culture—at least that's a very common practice at my institution. They feel that that the polymicrobes may themselves be pathogenic, or may be covering up a monomicrobial infection. Others regard it essentially as a negative result, and still others might treat with antibiotics,” Dr. Naresh said.

“I believe these cultures likely represent contamination, and I feel I can safely recommend that they do not have to be repeated,” she said.

MONTREAL — Although bacteriuria in early pregnancy has been associated with pyelonephritis and preterm delivery, the same is not true for polymicrobial urine cultures or “mixed flora,” said Dr. Amber Naresh of Magee-Women's Hospital, Pittsburgh.

“Urine cultures with polymicrobial growth in the first half of pregnancy are essentially the same as negative cultures as far as these pregnancy outcomes are concerned,” Dr. Naresh said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

Her retrospective cohort study, carried out between 2004 and 2007, compared 449 women with polymicrobial urine cultures and 375 women with negative urine cultures, all at less than 20 weeks' gestation. Polymicrobial growth was defined as mixed flora of more than 100,000 colony forming units per milliliter.

Admissions for pyelonephritis were identified by ICD-9 codes, and gestational age at delivery was determined from a research registry.

The rates of pyelonephritis were the same in the women with polymicrobial growth and those with a negative urine culture (0.22% and 0%). Similarly, preterm delivery at less than 37 weeks' gestation occurred in 18% of women with polymicrobial growth and 16% of those with negative urine cultures, and delivery at less than 34 weeks occurred in 6% and 5%, respectively, Dr. Naresh reported.

There were no differences between the groups in maternal age, race, socioeconomic status, and tobacco use, but women with polymicrobial growth had higher rates of group B streptococcal (GBS) infection (41% vs. 32%). “Put another way, women with GBS were more likely to have polymicrobial growth than women who were GBS negative,” she said, adding that those with vaginal GBS may “have a higher bacterial load in the vagina and are therefore more prone to having contamination of their urine specimen.”

Women with polymicrobial growth also were more likely to have had a previous preterm birth (8.7%), compared with women with negative urine cultures (1.3%). “Unfortunately, I don't have an explanation for this, especially since there is no association between polymicrobial growth and preterm delivery in the current pregnancy,” she said.

The mean date of collection of urine was 12.3 weeks of gestation in the polymicrobial group and 11.6 weeks in those with negative cultures. “It's questionable whether this has any clinical significance, although it clearly has statistical significance.”

Practices vary among obstetric providers regarding the management of polymicrobial growth in urine cultures. “Some practitioners routinely repeat the culture—at least that's a very common practice at my institution. They feel that that the polymicrobes may themselves be pathogenic, or may be covering up a monomicrobial infection. Others regard it essentially as a negative result, and still others might treat with antibiotics,” Dr. Naresh said.

“I believe these cultures likely represent contamination, and I feel I can safely recommend that they do not have to be repeated,” she said.

MONTREAL — Although bacteriuria in early pregnancy has been associated with pyelonephritis and preterm delivery, the same is not true for polymicrobial urine cultures or “mixed flora,” said Dr. Amber Naresh of Magee-Women's Hospital, Pittsburgh.

“Urine cultures with polymicrobial growth in the first half of pregnancy are essentially the same as negative cultures as far as these pregnancy outcomes are concerned,” Dr. Naresh said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

Her retrospective cohort study, carried out between 2004 and 2007, compared 449 women with polymicrobial urine cultures and 375 women with negative urine cultures, all at less than 20 weeks' gestation. Polymicrobial growth was defined as mixed flora of more than 100,000 colony forming units per milliliter.

Admissions for pyelonephritis were identified by ICD-9 codes, and gestational age at delivery was determined from a research registry.

The rates of pyelonephritis were the same in the women with polymicrobial growth and those with a negative urine culture (0.22% and 0%). Similarly, preterm delivery at less than 37 weeks' gestation occurred in 18% of women with polymicrobial growth and 16% of those with negative urine cultures, and delivery at less than 34 weeks occurred in 6% and 5%, respectively, Dr. Naresh reported.

There were no differences between the groups in maternal age, race, socioeconomic status, and tobacco use, but women with polymicrobial growth had higher rates of group B streptococcal (GBS) infection (41% vs. 32%). “Put another way, women with GBS were more likely to have polymicrobial growth than women who were GBS negative,” she said, adding that those with vaginal GBS may “have a higher bacterial load in the vagina and are therefore more prone to having contamination of their urine specimen.”

Women with polymicrobial growth also were more likely to have had a previous preterm birth (8.7%), compared with women with negative urine cultures (1.3%). “Unfortunately, I don't have an explanation for this, especially since there is no association between polymicrobial growth and preterm delivery in the current pregnancy,” she said.

The mean date of collection of urine was 12.3 weeks of gestation in the polymicrobial group and 11.6 weeks in those with negative cultures. “It's questionable whether this has any clinical significance, although it clearly has statistical significance.”

Practices vary among obstetric providers regarding the management of polymicrobial growth in urine cultures. “Some practitioners routinely repeat the culture—at least that's a very common practice at my institution. They feel that that the polymicrobes may themselves be pathogenic, or may be covering up a monomicrobial infection. Others regard it essentially as a negative result, and still others might treat with antibiotics,” Dr. Naresh said.

“I believe these cultures likely represent contamination, and I feel I can safely recommend that they do not have to be repeated,” she said.