Sharon Worcester

NEW ORLEANS – Weight gain between pregnancies decreases the likelihood of a successful vaginal birth after cesarean section, according to findings from a large population-based retrospective cohort study.

The more weight a woman gains between pregnancies, the lower her chances are of a successful vaginal birth after cesarean section (VBAC); conversely, overweight and obese women who lose weight between pregnancies may improve their chances of a successful VBAC, Dr. Lisa S. Callegari reported at the annual meeting of the American College of Obstetricians and Gynecologists.

The overall VBAC success rate among 8,861 women included in the study was 66%, but differences were seen with VBAC success based on prepregnancy body mass index category: The success rate was 70% for normal-weight women, 62% for overweight women, and 56% for obese women, said Dr. Callegari of the University of Washington, Seattle.

After adjustment for a number of factors, including demographics, smoking status, interpregnancy interval, birth year of second pregnancy (to account for temporal changes in VBAC practices), and prenatal care adequacy, weight loss among normal-weight women was not found to be associated with VBAC success, but weight gain of between one and two BMI units (about 6-12 pounds) among normal-weight women was associated with a 7% decrease in the VBAC success rate, compared with weight maintenance.

High weight gain, defined as an increase of more than two BMI units (about 12 pounds) between pregnancies, was associated with a 13% decrease in the VBAC success rate, compared with weight maintenance.

For overweight and obese women, moderate and high weight gain did not affect VBAC success, but weight loss in overweight women was associated with a 12% increase in VBAC success, and weight loss equivalent to 1 or more BMI units in obese women was associated with a 24% increase in VBAC success, Dr. Callegari said.

The findings are based on an analysis of longitudinal birth certificate data linked with hospitalization records between 1992 and 2009. Women who were included underwent primary cesarean delivery for their first birth, and attempted a trial of labor for their second birth.

Although limited by the use of birth certificate data, and also by a large number of cases with missing BMI information, the findings are bolstered by the use of population-based data, an observed dose-response effect, and the biologic plausibility for the findings, Dr. Callegari said.

The findings are important because increasing the rates of VBAC has been proposed as a strategy for decreasing cesarean section rates. However, VBAC rates have been declining in recent years, falling from 23% in 1996 to less than 10% currently. The causes are multifactorial, but these findings suggest that the modifiable risk factors of overweight and obesity are among them, Dr. Callegari said.

"In terms of clinical implications, normal-weight women should return to within one BMI unit of their prepregnancy weight, and overweight and obese women should lose greater than or equal to one BMI unit between pregnancies in order to optimize their chances of VBAC success," she concluded.

Dr. Callegari reported having no disclosures.

NEW ORLEANS – Weight gain between pregnancies decreases the likelihood of a successful vaginal birth after cesarean section, according to findings from a large population-based retrospective cohort study.

The more weight a woman gains between pregnancies, the lower her chances are of a successful vaginal birth after cesarean section (VBAC); conversely, overweight and obese women who lose weight between pregnancies may improve their chances of a successful VBAC, Dr. Lisa S. Callegari reported at the annual meeting of the American College of Obstetricians and Gynecologists.

The overall VBAC success rate among 8,861 women included in the study was 66%, but differences were seen with VBAC success based on prepregnancy body mass index category: The success rate was 70% for normal-weight women, 62% for overweight women, and 56% for obese women, said Dr. Callegari of the University of Washington, Seattle.

After adjustment for a number of factors, including demographics, smoking status, interpregnancy interval, birth year of second pregnancy (to account for temporal changes in VBAC practices), and prenatal care adequacy, weight loss among normal-weight women was not found to be associated with VBAC success, but weight gain of between one and two BMI units (about 6-12 pounds) among normal-weight women was associated with a 7% decrease in the VBAC success rate, compared with weight maintenance.

High weight gain, defined as an increase of more than two BMI units (about 12 pounds) between pregnancies, was associated with a 13% decrease in the VBAC success rate, compared with weight maintenance.

For overweight and obese women, moderate and high weight gain did not affect VBAC success, but weight loss in overweight women was associated with a 12% increase in VBAC success, and weight loss equivalent to 1 or more BMI units in obese women was associated with a 24% increase in VBAC success, Dr. Callegari said.

The findings are based on an analysis of longitudinal birth certificate data linked with hospitalization records between 1992 and 2009. Women who were included underwent primary cesarean delivery for their first birth, and attempted a trial of labor for their second birth.

Although limited by the use of birth certificate data, and also by a large number of cases with missing BMI information, the findings are bolstered by the use of population-based data, an observed dose-response effect, and the biologic plausibility for the findings, Dr. Callegari said.

The findings are important because increasing the rates of VBAC has been proposed as a strategy for decreasing cesarean section rates. However, VBAC rates have been declining in recent years, falling from 23% in 1996 to less than 10% currently. The causes are multifactorial, but these findings suggest that the modifiable risk factors of overweight and obesity are among them, Dr. Callegari said.

"In terms of clinical implications, normal-weight women should return to within one BMI unit of their prepregnancy weight, and overweight and obese women should lose greater than or equal to one BMI unit between pregnancies in order to optimize their chances of VBAC success," she concluded.

Dr. Callegari reported having no disclosures.

NEW ORLEANS – Weight gain between pregnancies decreases the likelihood of a successful vaginal birth after cesarean section, according to findings from a large population-based retrospective cohort study.

The more weight a woman gains between pregnancies, the lower her chances are of a successful vaginal birth after cesarean section (VBAC); conversely, overweight and obese women who lose weight between pregnancies may improve their chances of a successful VBAC, Dr. Lisa S. Callegari reported at the annual meeting of the American College of Obstetricians and Gynecologists.

The overall VBAC success rate among 8,861 women included in the study was 66%, but differences were seen with VBAC success based on prepregnancy body mass index category: The success rate was 70% for normal-weight women, 62% for overweight women, and 56% for obese women, said Dr. Callegari of the University of Washington, Seattle.

After adjustment for a number of factors, including demographics, smoking status, interpregnancy interval, birth year of second pregnancy (to account for temporal changes in VBAC practices), and prenatal care adequacy, weight loss among normal-weight women was not found to be associated with VBAC success, but weight gain of between one and two BMI units (about 6-12 pounds) among normal-weight women was associated with a 7% decrease in the VBAC success rate, compared with weight maintenance.

High weight gain, defined as an increase of more than two BMI units (about 12 pounds) between pregnancies, was associated with a 13% decrease in the VBAC success rate, compared with weight maintenance.

For overweight and obese women, moderate and high weight gain did not affect VBAC success, but weight loss in overweight women was associated with a 12% increase in VBAC success, and weight loss equivalent to 1 or more BMI units in obese women was associated with a 24% increase in VBAC success, Dr. Callegari said.

The findings are based on an analysis of longitudinal birth certificate data linked with hospitalization records between 1992 and 2009. Women who were included underwent primary cesarean delivery for their first birth, and attempted a trial of labor for their second birth.

Although limited by the use of birth certificate data, and also by a large number of cases with missing BMI information, the findings are bolstered by the use of population-based data, an observed dose-response effect, and the biologic plausibility for the findings, Dr. Callegari said.

The findings are important because increasing the rates of VBAC has been proposed as a strategy for decreasing cesarean section rates. However, VBAC rates have been declining in recent years, falling from 23% in 1996 to less than 10% currently. The causes are multifactorial, but these findings suggest that the modifiable risk factors of overweight and obesity are among them, Dr. Callegari said.

"In terms of clinical implications, normal-weight women should return to within one BMI unit of their prepregnancy weight, and overweight and obese women should lose greater than or equal to one BMI unit between pregnancies in order to optimize their chances of VBAC success," she concluded.

Dr. Callegari reported having no disclosures.

NEW ORLEANS – Acceptance is growing for routine bilateral salpingectomy at the time of hysterectomy to reduce the risk of ovarian serous carcinoma, based on findings from a retrospective cohort study.

The bilateral salpingectomy rates at a single institution increased from 3% in 2010 to 73% in the first 6 months of 2012 – a year after the center began offering the procedure to all women undergoing hysterectomy with ovarian preservation, Dr. Susan K. Park reported at the annual meeting of the American College of Obstetricians and Gynecologists.

"Across the board, patient acceptance of undergoing salpingectomy was very high," she said. Patients were counseled at a preoperative appointment that salpingectomy may reduce the risk of posthysterectomy pelvic adnexal masses and serous carcinomas.

Only two women who were offered the procedure declined, said Dr. Park of Olive View–UCLA Medical Center, Los Angeles.

Moreover, there was no difference in operating time or surgical morbidity in a case-control study involving 133 women who underwent hysterectomy with ovarian preservation and salpingectomy and in 433 controls who did not undergo salpingectomy.

Study subjects were women undergoing abdominal, laparoscopic, or vaginal hysterectomy with ovarian preservation. The salpingectomy rate was lowest for vaginal hysterectomy, as visualization of the fallopian tubes is often difficult with that approach. In fact, two of six women who were unable to undergo salpingectomy despite giving consent were unable to have the procedure because of poor visualization of the tubes, Dr. Park said.

The findings are important given that emerging research points to the fallopian tubes as the site of serous carcinogenesis, Dr. Park said.

Though limited by the retrospective, single-center design, this study is the largest known study to date to look at the feasibility and safety of performing salpingectomy at the time of hysterectomy with ovarian preservation, she said.

Long-term follow-up to evaluate the effects of routine bilateral salpingectomy in these subjects is underway, she noted.

Dr. Park reported having no disclosures.

NEW ORLEANS – Acceptance is growing for routine bilateral salpingectomy at the time of hysterectomy to reduce the risk of ovarian serous carcinoma, based on findings from a retrospective cohort study.

The bilateral salpingectomy rates at a single institution increased from 3% in 2010 to 73% in the first 6 months of 2012 – a year after the center began offering the procedure to all women undergoing hysterectomy with ovarian preservation, Dr. Susan K. Park reported at the annual meeting of the American College of Obstetricians and Gynecologists.

"Across the board, patient acceptance of undergoing salpingectomy was very high," she said. Patients were counseled at a preoperative appointment that salpingectomy may reduce the risk of posthysterectomy pelvic adnexal masses and serous carcinomas.

Only two women who were offered the procedure declined, said Dr. Park of Olive View–UCLA Medical Center, Los Angeles.

Moreover, there was no difference in operating time or surgical morbidity in a case-control study involving 133 women who underwent hysterectomy with ovarian preservation and salpingectomy and in 433 controls who did not undergo salpingectomy.

Study subjects were women undergoing abdominal, laparoscopic, or vaginal hysterectomy with ovarian preservation. The salpingectomy rate was lowest for vaginal hysterectomy, as visualization of the fallopian tubes is often difficult with that approach. In fact, two of six women who were unable to undergo salpingectomy despite giving consent were unable to have the procedure because of poor visualization of the tubes, Dr. Park said.

The findings are important given that emerging research points to the fallopian tubes as the site of serous carcinogenesis, Dr. Park said.

Though limited by the retrospective, single-center design, this study is the largest known study to date to look at the feasibility and safety of performing salpingectomy at the time of hysterectomy with ovarian preservation, she said.

Long-term follow-up to evaluate the effects of routine bilateral salpingectomy in these subjects is underway, she noted.

Dr. Park reported having no disclosures.

NEW ORLEANS – Acceptance is growing for routine bilateral salpingectomy at the time of hysterectomy to reduce the risk of ovarian serous carcinoma, based on findings from a retrospective cohort study.

The bilateral salpingectomy rates at a single institution increased from 3% in 2010 to 73% in the first 6 months of 2012 – a year after the center began offering the procedure to all women undergoing hysterectomy with ovarian preservation, Dr. Susan K. Park reported at the annual meeting of the American College of Obstetricians and Gynecologists.

"Across the board, patient acceptance of undergoing salpingectomy was very high," she said. Patients were counseled at a preoperative appointment that salpingectomy may reduce the risk of posthysterectomy pelvic adnexal masses and serous carcinomas.

Only two women who were offered the procedure declined, said Dr. Park of Olive View–UCLA Medical Center, Los Angeles.

Moreover, there was no difference in operating time or surgical morbidity in a case-control study involving 133 women who underwent hysterectomy with ovarian preservation and salpingectomy and in 433 controls who did not undergo salpingectomy.

Study subjects were women undergoing abdominal, laparoscopic, or vaginal hysterectomy with ovarian preservation. The salpingectomy rate was lowest for vaginal hysterectomy, as visualization of the fallopian tubes is often difficult with that approach. In fact, two of six women who were unable to undergo salpingectomy despite giving consent were unable to have the procedure because of poor visualization of the tubes, Dr. Park said.

The findings are important given that emerging research points to the fallopian tubes as the site of serous carcinogenesis, Dr. Park said.

Though limited by the retrospective, single-center design, this study is the largest known study to date to look at the feasibility and safety of performing salpingectomy at the time of hysterectomy with ovarian preservation, she said.

Long-term follow-up to evaluate the effects of routine bilateral salpingectomy in these subjects is underway, she noted.

Dr. Park reported having no disclosures.

DESTIN, FLA. – The pediatric-to-adult rheumatologic care transition is a process that should begin early in the course of care, according to Dr. Brian Feldman.

And the process should be presented as a normative event, he said at the Congress of Clinical Rheumatology.

Findings from a 2011 quantitative and qualitative meta-analysis showed that patients prefer an approach that treats transition as a "normal part of life" because that makes the process easier, Dr. Feldman said (J. Adolesc. Health 2011; 48:429-40).

Other basic conclusions from that meta-analysis were that transitioning should involve clarifying and discussing patient expectations about the process, joint planning with the patient regarding the specific steps of transition, and provision of an optimal environment and resources for transitioning, he said.

Another paper on the transition process from the cystic fibrosis literature includes similar advice and provides additional clarification with a list of "transition best practices," said Dr. Feldman, professor of pediatrics and medicine, and senior scientist and head of the division of rheumatology at the Hospital for Sick Children, Toronto.

These best practices include:

• Starting early. "In our clinic, we start transitioning patients when they are 13, when they’re just coming into the adolescent years," he said, noting that patients cannot be seen after the age of 18 years at his center.

• Evaluating the patient without the parent. For Dr. Feldman, this also starts when patients are age 13. Patients are seen without their parents, at least for part of the visit, to help prepare them for the adult care environment where they typically won’t have a parent present during visits.

• Providing transition planning for all patients at a defined age. It’s tempting to delay transition planning until patients are deemed "ready" or "mature enough," but all patients need this, and in the meta-analysis on patient needs, pediatric patients expressed a desire for this type of expectation setting, he noted.

• Arranging for the patient to meet the adult care team prior to the transition to reduce anxiety. In his practice, Dr. Feldman arranges a visit or two with the adult care provider when a patient is 17 and preparing for transition, but still in his care. This provides a chance for the patient to make sure he or she likes the new physician, and provides a sense of familiarity once the transition occurs, he said.

• Keeping the lines of communication open. This pertains to communication between the pediatric and adult care offices to ensure a smooth transition.

• Ensuring that the patient has an ally throughout the process. "In our clinic, that’s either the nurse or the social worker who works with them as they move through this process," he said.

A 2011 systematic review shows that starting the transition early and adhering to best practices really does provide benefits for the patient. In six of the studies included in the review, the programs and practices that were found to be of particular benefit included disease-specific education programs, generic education and skills training, availability of a transition coordinator, joint pediatric and adult clinic services, and separate young adult clinic services that can serve as an intermediate step toward adult care, he said.

Among other factors that Dr. Feldman said he has found useful in his practice are the use of a self-assessment questionnaire at every visit starting at age 13. This encourages patients to know and understand their diagnosis and health status (they are asked about their last eye examination, for example) and to be able to discuss their symptoms and medications. Patients also are asked at the end of each visit to write down what was discussed and what the plan is going forward, and Dr. Feldman completes a transition readiness assessment.

Adolescent patients complete a health screen to identify areas that may need attention in the adolescent medicine clinic or from a social worker, and at age 17, patients are asked to fill out another questionnaire about their transition process to ensure they understand the process, know the name of their new physician, and know what is needed and expected of them during the process.

Considering the transition as a process that begins early will help ensure that patients arrive at the adult care setting armed with the knowledge they need to successfully participate in the management of their care, he said.

Dr. Feldman is a member of the data safety monitoring board for Novartis and Bristol-Myers Squibb. He said he has received research grant support from Baxter and Bayer.

DESTIN, FLA. – The pediatric-to-adult rheumatologic care transition is a process that should begin early in the course of care, according to Dr. Brian Feldman.

And the process should be presented as a normative event, he said at the Congress of Clinical Rheumatology.

Findings from a 2011 quantitative and qualitative meta-analysis showed that patients prefer an approach that treats transition as a "normal part of life" because that makes the process easier, Dr. Feldman said (J. Adolesc. Health 2011; 48:429-40).

Other basic conclusions from that meta-analysis were that transitioning should involve clarifying and discussing patient expectations about the process, joint planning with the patient regarding the specific steps of transition, and provision of an optimal environment and resources for transitioning, he said.

Another paper on the transition process from the cystic fibrosis literature includes similar advice and provides additional clarification with a list of "transition best practices," said Dr. Feldman, professor of pediatrics and medicine, and senior scientist and head of the division of rheumatology at the Hospital for Sick Children, Toronto.

These best practices include:

• Starting early. "In our clinic, we start transitioning patients when they are 13, when they’re just coming into the adolescent years," he said, noting that patients cannot be seen after the age of 18 years at his center.

• Evaluating the patient without the parent. For Dr. Feldman, this also starts when patients are age 13. Patients are seen without their parents, at least for part of the visit, to help prepare them for the adult care environment where they typically won’t have a parent present during visits.

• Providing transition planning for all patients at a defined age. It’s tempting to delay transition planning until patients are deemed "ready" or "mature enough," but all patients need this, and in the meta-analysis on patient needs, pediatric patients expressed a desire for this type of expectation setting, he noted.

• Arranging for the patient to meet the adult care team prior to the transition to reduce anxiety. In his practice, Dr. Feldman arranges a visit or two with the adult care provider when a patient is 17 and preparing for transition, but still in his care. This provides a chance for the patient to make sure he or she likes the new physician, and provides a sense of familiarity once the transition occurs, he said.

• Keeping the lines of communication open. This pertains to communication between the pediatric and adult care offices to ensure a smooth transition.

• Ensuring that the patient has an ally throughout the process. "In our clinic, that’s either the nurse or the social worker who works with them as they move through this process," he said.

A 2011 systematic review shows that starting the transition early and adhering to best practices really does provide benefits for the patient. In six of the studies included in the review, the programs and practices that were found to be of particular benefit included disease-specific education programs, generic education and skills training, availability of a transition coordinator, joint pediatric and adult clinic services, and separate young adult clinic services that can serve as an intermediate step toward adult care, he said.

Among other factors that Dr. Feldman said he has found useful in his practice are the use of a self-assessment questionnaire at every visit starting at age 13. This encourages patients to know and understand their diagnosis and health status (they are asked about their last eye examination, for example) and to be able to discuss their symptoms and medications. Patients also are asked at the end of each visit to write down what was discussed and what the plan is going forward, and Dr. Feldman completes a transition readiness assessment.

Adolescent patients complete a health screen to identify areas that may need attention in the adolescent medicine clinic or from a social worker, and at age 17, patients are asked to fill out another questionnaire about their transition process to ensure they understand the process, know the name of their new physician, and know what is needed and expected of them during the process.

Considering the transition as a process that begins early will help ensure that patients arrive at the adult care setting armed with the knowledge they need to successfully participate in the management of their care, he said.

Dr. Feldman is a member of the data safety monitoring board for Novartis and Bristol-Myers Squibb. He said he has received research grant support from Baxter and Bayer.

DESTIN, FLA. – The pediatric-to-adult rheumatologic care transition is a process that should begin early in the course of care, according to Dr. Brian Feldman.

And the process should be presented as a normative event, he said at the Congress of Clinical Rheumatology.

Findings from a 2011 quantitative and qualitative meta-analysis showed that patients prefer an approach that treats transition as a "normal part of life" because that makes the process easier, Dr. Feldman said (J. Adolesc. Health 2011; 48:429-40).

Other basic conclusions from that meta-analysis were that transitioning should involve clarifying and discussing patient expectations about the process, joint planning with the patient regarding the specific steps of transition, and provision of an optimal environment and resources for transitioning, he said.

Another paper on the transition process from the cystic fibrosis literature includes similar advice and provides additional clarification with a list of "transition best practices," said Dr. Feldman, professor of pediatrics and medicine, and senior scientist and head of the division of rheumatology at the Hospital for Sick Children, Toronto.

These best practices include:

• Starting early. "In our clinic, we start transitioning patients when they are 13, when they’re just coming into the adolescent years," he said, noting that patients cannot be seen after the age of 18 years at his center.

• Evaluating the patient without the parent. For Dr. Feldman, this also starts when patients are age 13. Patients are seen without their parents, at least for part of the visit, to help prepare them for the adult care environment where they typically won’t have a parent present during visits.

• Providing transition planning for all patients at a defined age. It’s tempting to delay transition planning until patients are deemed "ready" or "mature enough," but all patients need this, and in the meta-analysis on patient needs, pediatric patients expressed a desire for this type of expectation setting, he noted.

• Arranging for the patient to meet the adult care team prior to the transition to reduce anxiety. In his practice, Dr. Feldman arranges a visit or two with the adult care provider when a patient is 17 and preparing for transition, but still in his care. This provides a chance for the patient to make sure he or she likes the new physician, and provides a sense of familiarity once the transition occurs, he said.

• Keeping the lines of communication open. This pertains to communication between the pediatric and adult care offices to ensure a smooth transition.

• Ensuring that the patient has an ally throughout the process. "In our clinic, that’s either the nurse or the social worker who works with them as they move through this process," he said.

A 2011 systematic review shows that starting the transition early and adhering to best practices really does provide benefits for the patient. In six of the studies included in the review, the programs and practices that were found to be of particular benefit included disease-specific education programs, generic education and skills training, availability of a transition coordinator, joint pediatric and adult clinic services, and separate young adult clinic services that can serve as an intermediate step toward adult care, he said.

Among other factors that Dr. Feldman said he has found useful in his practice are the use of a self-assessment questionnaire at every visit starting at age 13. This encourages patients to know and understand their diagnosis and health status (they are asked about their last eye examination, for example) and to be able to discuss their symptoms and medications. Patients also are asked at the end of each visit to write down what was discussed and what the plan is going forward, and Dr. Feldman completes a transition readiness assessment.

Adolescent patients complete a health screen to identify areas that may need attention in the adolescent medicine clinic or from a social worker, and at age 17, patients are asked to fill out another questionnaire about their transition process to ensure they understand the process, know the name of their new physician, and know what is needed and expected of them during the process.

Considering the transition as a process that begins early will help ensure that patients arrive at the adult care setting armed with the knowledge they need to successfully participate in the management of their care, he said.

Dr. Feldman is a member of the data safety monitoring board for Novartis and Bristol-Myers Squibb. He said he has received research grant support from Baxter and Bayer.

NEW ORLEANS – A postpartum educational script about long-acting reversible contraceptive methods appears to increase interest in those methods, but access may be limited for some women, findings from a randomized controlled trial suggest.

Long-acting reversible contraceptive (LARC) use after the 6-week postpartum visit in 400 women who received the "LARC Script" intervention and 400 controls who did not receive the intervention did not differ significantly (17.6% vs. 13.3%, respectively), but interest in LARC use among those not using a LARC method at follow-up did differ significantly between the groups (31.2% vs. 25.8%), Dr. Jennifer H. Tang reported at the annual meeting of the American College of Obstetricians and Gynecologists.

These findings suggest that the LARC Script is effective, but that barriers – such as financial and provider barriers – may be limiting uptake of LARC use, said Dr. Tang of the University of North Carolina at Chapel Hill.

Study subjects were 800 women aged 14-45 years who were recruited post partum between May 2011 and January 2012 and randomized to the intervention and control groups prior to discharge. A 20-item baseline survey lasting about 10 minutes was administered to all participants; the 1-minute intervention consisting of information about LARC was administered to intervention group subjects, with follow-up surveys conducted at 1-2 weeks (to confirm the 6-week visit) and at 6 weeks to assess outcomes.

About 40% of the subjects were Hispanic, median parity was two, and about a third had no insurance. Only a third of subjects were trying to conceive when they became pregnant, and 20% reported using some form of contraceptive to prevent pregnancy when they became pregnant. Most (80%) were not interested in becoming pregnant again, Dr. Tang said.

Approximately 40% of pregnancy intervals in the United States are less than 18 months, and intervals of 18 months or less are associated with poorer pregnancy outcomes. Thus, the findings of this study suggest a need for additional study to identify barriers to LARC access, she said.

"We need to look into reasons why women who want to receive LARC aren’t actually getting it," she said.

This study was funded by the Fellowship in Family Planning. Dr. Tang reported having no disclosures.

obnews@frontlinemedcom.com

NEW ORLEANS – A postpartum educational script about long-acting reversible contraceptive methods appears to increase interest in those methods, but access may be limited for some women, findings from a randomized controlled trial suggest.

Long-acting reversible contraceptive (LARC) use after the 6-week postpartum visit in 400 women who received the "LARC Script" intervention and 400 controls who did not receive the intervention did not differ significantly (17.6% vs. 13.3%, respectively), but interest in LARC use among those not using a LARC method at follow-up did differ significantly between the groups (31.2% vs. 25.8%), Dr. Jennifer H. Tang reported at the annual meeting of the American College of Obstetricians and Gynecologists.

These findings suggest that the LARC Script is effective, but that barriers – such as financial and provider barriers – may be limiting uptake of LARC use, said Dr. Tang of the University of North Carolina at Chapel Hill.

Study subjects were 800 women aged 14-45 years who were recruited post partum between May 2011 and January 2012 and randomized to the intervention and control groups prior to discharge. A 20-item baseline survey lasting about 10 minutes was administered to all participants; the 1-minute intervention consisting of information about LARC was administered to intervention group subjects, with follow-up surveys conducted at 1-2 weeks (to confirm the 6-week visit) and at 6 weeks to assess outcomes.

About 40% of the subjects were Hispanic, median parity was two, and about a third had no insurance. Only a third of subjects were trying to conceive when they became pregnant, and 20% reported using some form of contraceptive to prevent pregnancy when they became pregnant. Most (80%) were not interested in becoming pregnant again, Dr. Tang said.

Approximately 40% of pregnancy intervals in the United States are less than 18 months, and intervals of 18 months or less are associated with poorer pregnancy outcomes. Thus, the findings of this study suggest a need for additional study to identify barriers to LARC access, she said.

"We need to look into reasons why women who want to receive LARC aren’t actually getting it," she said.

This study was funded by the Fellowship in Family Planning. Dr. Tang reported having no disclosures.

obnews@frontlinemedcom.com

NEW ORLEANS – A postpartum educational script about long-acting reversible contraceptive methods appears to increase interest in those methods, but access may be limited for some women, findings from a randomized controlled trial suggest.

Long-acting reversible contraceptive (LARC) use after the 6-week postpartum visit in 400 women who received the "LARC Script" intervention and 400 controls who did not receive the intervention did not differ significantly (17.6% vs. 13.3%, respectively), but interest in LARC use among those not using a LARC method at follow-up did differ significantly between the groups (31.2% vs. 25.8%), Dr. Jennifer H. Tang reported at the annual meeting of the American College of Obstetricians and Gynecologists.

These findings suggest that the LARC Script is effective, but that barriers – such as financial and provider barriers – may be limiting uptake of LARC use, said Dr. Tang of the University of North Carolina at Chapel Hill.

Study subjects were 800 women aged 14-45 years who were recruited post partum between May 2011 and January 2012 and randomized to the intervention and control groups prior to discharge. A 20-item baseline survey lasting about 10 minutes was administered to all participants; the 1-minute intervention consisting of information about LARC was administered to intervention group subjects, with follow-up surveys conducted at 1-2 weeks (to confirm the 6-week visit) and at 6 weeks to assess outcomes.

About 40% of the subjects were Hispanic, median parity was two, and about a third had no insurance. Only a third of subjects were trying to conceive when they became pregnant, and 20% reported using some form of contraceptive to prevent pregnancy when they became pregnant. Most (80%) were not interested in becoming pregnant again, Dr. Tang said.

Approximately 40% of pregnancy intervals in the United States are less than 18 months, and intervals of 18 months or less are associated with poorer pregnancy outcomes. Thus, the findings of this study suggest a need for additional study to identify barriers to LARC access, she said.

"We need to look into reasons why women who want to receive LARC aren’t actually getting it," she said.

This study was funded by the Fellowship in Family Planning. Dr. Tang reported having no disclosures.

obnews@frontlinemedcom.com

NEW ORLEANS – Use of a novel guided educational pamphlet during the immediate postpartum period is feasible and effective for promoting the use of long-acting reversible contraceptive methods, according to findings from a prospective cohort study.

Of 134 study subjects aged 18 years or older, 78% reported a preference regarding contraceptive method at baseline, and the most popular choices were non–long-acting reversible contraceptive (LARC) methods followed by intrauterine devices (IUDs), implants, and injections. Nearly a quarter (23%) of these women changed their minds after the intervention, with 94% of those ultimately choosing a LARC method, Dr. Ariel Cohen reported at the annual meeting of the American College of Obstetricians and Gynecologists.

Of the 22% of women who had not decided on a contraceptive method at baseline, more than half selected a method after the intervention, and 82% of those selected a LARC method, with IUD being the most popular choice followed by implant and injection methods, said Dr. Cohen of Baystate Medical Center, Springfield, Mass.

The intervention involved a brief interaction between the subject and a research assistant within 4 days of delivery. The research assistant guided the subject through an eight-page educational pamphlet, which included three sections: an interactive section including six questions about contraceptive preferences, a comparative effectiveness section including a World Health Organization contraceptive comparative effectiveness chart, and an information section that provided more details about each contraceptive method.

Subjects were asked about their predelivery method of choice, and were called at 3 months and 6 months post partum for a follow-up evaluation.

The initial intervention took a mean of 8 minutes, and the research assistant had little difficulty obtaining the necessary time and privacy with the subjects, Dr. Cohen noted.

Mean age of the women was 24 years. Most identified as white or Hispanic, most (58%) had at least one other child (median parity, 2), and 84% had a 12th grade education or less.

The findings are important because although ACOG recommends that contraceptive counseling be provided during the intrapartum period, many physicians delay contraception discussion until the postpartum visit, Dr. Cohen said.

"However, research has shown that patients who are at the highest risk for unintended pregnancy have up to a 50% no-show rate at the postpartum visit," she said.

The immediate postpartum period provides a unique opportunity for contraceptive counseling, she added.

"Not only is the patient a captive audience ... she’s also highly motivated to avoid a rapid repeat pregnancy," she said.

Based on these findings, it appears this educational tool would be useful prior to discharge, if administered by either a physician or trained nurse or medical assistant, she said, noting that plans are underway to validate the tool by developing a pre- and posttest and conducting a randomized study, she said.

Dr. Cohen reported having no disclosures.

NEW ORLEANS – Use of a novel guided educational pamphlet during the immediate postpartum period is feasible and effective for promoting the use of long-acting reversible contraceptive methods, according to findings from a prospective cohort study.

Of 134 study subjects aged 18 years or older, 78% reported a preference regarding contraceptive method at baseline, and the most popular choices were non–long-acting reversible contraceptive (LARC) methods followed by intrauterine devices (IUDs), implants, and injections. Nearly a quarter (23%) of these women changed their minds after the intervention, with 94% of those ultimately choosing a LARC method, Dr. Ariel Cohen reported at the annual meeting of the American College of Obstetricians and Gynecologists.

Of the 22% of women who had not decided on a contraceptive method at baseline, more than half selected a method after the intervention, and 82% of those selected a LARC method, with IUD being the most popular choice followed by implant and injection methods, said Dr. Cohen of Baystate Medical Center, Springfield, Mass.

The intervention involved a brief interaction between the subject and a research assistant within 4 days of delivery. The research assistant guided the subject through an eight-page educational pamphlet, which included three sections: an interactive section including six questions about contraceptive preferences, a comparative effectiveness section including a World Health Organization contraceptive comparative effectiveness chart, and an information section that provided more details about each contraceptive method.

Subjects were asked about their predelivery method of choice, and were called at 3 months and 6 months post partum for a follow-up evaluation.

The initial intervention took a mean of 8 minutes, and the research assistant had little difficulty obtaining the necessary time and privacy with the subjects, Dr. Cohen noted.

Mean age of the women was 24 years. Most identified as white or Hispanic, most (58%) had at least one other child (median parity, 2), and 84% had a 12th grade education or less.

The findings are important because although ACOG recommends that contraceptive counseling be provided during the intrapartum period, many physicians delay contraception discussion until the postpartum visit, Dr. Cohen said.

"However, research has shown that patients who are at the highest risk for unintended pregnancy have up to a 50% no-show rate at the postpartum visit," she said.

The immediate postpartum period provides a unique opportunity for contraceptive counseling, she added.

"Not only is the patient a captive audience ... she’s also highly motivated to avoid a rapid repeat pregnancy," she said.

Based on these findings, it appears this educational tool would be useful prior to discharge, if administered by either a physician or trained nurse or medical assistant, she said, noting that plans are underway to validate the tool by developing a pre- and posttest and conducting a randomized study, she said.

Dr. Cohen reported having no disclosures.

NEW ORLEANS – Use of a novel guided educational pamphlet during the immediate postpartum period is feasible and effective for promoting the use of long-acting reversible contraceptive methods, according to findings from a prospective cohort study.

Of 134 study subjects aged 18 years or older, 78% reported a preference regarding contraceptive method at baseline, and the most popular choices were non–long-acting reversible contraceptive (LARC) methods followed by intrauterine devices (IUDs), implants, and injections. Nearly a quarter (23%) of these women changed their minds after the intervention, with 94% of those ultimately choosing a LARC method, Dr. Ariel Cohen reported at the annual meeting of the American College of Obstetricians and Gynecologists.

Of the 22% of women who had not decided on a contraceptive method at baseline, more than half selected a method after the intervention, and 82% of those selected a LARC method, with IUD being the most popular choice followed by implant and injection methods, said Dr. Cohen of Baystate Medical Center, Springfield, Mass.

The intervention involved a brief interaction between the subject and a research assistant within 4 days of delivery. The research assistant guided the subject through an eight-page educational pamphlet, which included three sections: an interactive section including six questions about contraceptive preferences, a comparative effectiveness section including a World Health Organization contraceptive comparative effectiveness chart, and an information section that provided more details about each contraceptive method.

Subjects were asked about their predelivery method of choice, and were called at 3 months and 6 months post partum for a follow-up evaluation.

The initial intervention took a mean of 8 minutes, and the research assistant had little difficulty obtaining the necessary time and privacy with the subjects, Dr. Cohen noted.

Mean age of the women was 24 years. Most identified as white or Hispanic, most (58%) had at least one other child (median parity, 2), and 84% had a 12th grade education or less.

The findings are important because although ACOG recommends that contraceptive counseling be provided during the intrapartum period, many physicians delay contraception discussion until the postpartum visit, Dr. Cohen said.

"However, research has shown that patients who are at the highest risk for unintended pregnancy have up to a 50% no-show rate at the postpartum visit," she said.

The immediate postpartum period provides a unique opportunity for contraceptive counseling, she added.

"Not only is the patient a captive audience ... she’s also highly motivated to avoid a rapid repeat pregnancy," she said.

Based on these findings, it appears this educational tool would be useful prior to discharge, if administered by either a physician or trained nurse or medical assistant, she said, noting that plans are underway to validate the tool by developing a pre- and posttest and conducting a randomized study, she said.

Dr. Cohen reported having no disclosures.

CHARLESTON, S.C. – Cure rates and patient satisfaction following vaginal prolapse repair were high at 3-year follow-up regardless of whether vaginal mesh or native tissue was used for the repair, according to findings from a prospective randomized trial.

The findings raise questions about the long-term value of vaginal mesh repairs because subjects treated with mesh had more complications without experiencing benefit beyond that observed in the native tissue repair patients, Dr. Robert E. Gutman reported at the annual meeting of the Society of Gynecologic Surgeons.

Of 65 women who were enrolled in the trial before enrollment was halted because of a 15.6% mesh exposure rate, 51 – including 25 in the mesh group and 26 in the no mesh group – had quality of life data available for the planned 3-year final analysis, and 41 had 2- or 3-year pelvic organ prolapse quantification (POP-Q) examination information available.

No differences were noted between the groups with respect to POP-Q stage or individual POP-Q points at 3 years, and the majority in both the mesh and no mesh groups (90% and 86%, respectively) improved in stage from baseline, said Dr. Gutman of MedStar Washington Hospital Center and of the department of obstetrics and gynecology and urology at Georgetown University, both in Washington.

Furthermore, no differences were seen between the groups with respect to symptomatic improvement as assessed by the Pelvic Floor Distress Inventory (PFDI), the Pelvic Floor Impact Questionnaire (PFIQ), and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ), including subscale scores. Also, cure rates – using a variety of definitions for cure – did not differ between the groups.

For example, based on a POP-Q stage of 1 or less as a definition of cure, 45% and 43% of those in the mesh and no mesh groups, respectively, were cured. When no prolapse beyond the hymen was used as a definition, 85% and 71% were cured When absence of bulge symptoms (a "no" answer to item 3 on the PFDI) was used as a definition, 92% and 81% were cured. The differences between the groups for these and other definitions – including a rating of very much better or much better on the Patient Global Impression of Improvement Index (PGI-I), having no prolapse reoperation, and composite outcomes using various combinations of these definitions – were not statistically significant, Dr. Gutman said.

Of note, no new mesh exposures occurred between the previously reported 1-year analysis (three cases required surgical excision before 1 year) and the 3-year analysis. The only prolapse reoperation after 1 year was in a woman who also had a reoperation prior to the 1-year analysis, he said at the meeting, which was jointly sponsored by the American College of Surgeons.

Also of note, the anatomic cure rate was lowest for the anterior compartment, and this did not differ between the mesh and no mesh groups.

Patients included in the study were women with stage 2-4 prolapse who were randomized to the mesh or no mesh group at baseline. Three-month and 1-year outcomes were previously reported.

Although the study is underpowered because of the early halting of enrollment, and is limited by the substantial number of patients lost to follow-up, it also has several strengths, including the long-term follow-up, multicenter design, and robust definitions of cure.

Therefore, the findings of a similar cure rate in the mesh and no mesh groups, excellent quality of life improvements in both groups, a mesh exposure rate of 15.6%, and a finding of only one new mesh exposure between 1- and 3-year follow-up, suggest that a "balanced approach is really required for vaginal mesh repairs, including a thorough patient consent," Dr. Gutman concluded.

He reported having no relevant financial disclosures.

obnews@frontlinemedcom.com

CHARLESTON, S.C. – Cure rates and patient satisfaction following vaginal prolapse repair were high at 3-year follow-up regardless of whether vaginal mesh or native tissue was used for the repair, according to findings from a prospective randomized trial.

The findings raise questions about the long-term value of vaginal mesh repairs because subjects treated with mesh had more complications without experiencing benefit beyond that observed in the native tissue repair patients, Dr. Robert E. Gutman reported at the annual meeting of the Society of Gynecologic Surgeons.

Of 65 women who were enrolled in the trial before enrollment was halted because of a 15.6% mesh exposure rate, 51 – including 25 in the mesh group and 26 in the no mesh group – had quality of life data available for the planned 3-year final analysis, and 41 had 2- or 3-year pelvic organ prolapse quantification (POP-Q) examination information available.

No differences were noted between the groups with respect to POP-Q stage or individual POP-Q points at 3 years, and the majority in both the mesh and no mesh groups (90% and 86%, respectively) improved in stage from baseline, said Dr. Gutman of MedStar Washington Hospital Center and of the department of obstetrics and gynecology and urology at Georgetown University, both in Washington.

Furthermore, no differences were seen between the groups with respect to symptomatic improvement as assessed by the Pelvic Floor Distress Inventory (PFDI), the Pelvic Floor Impact Questionnaire (PFIQ), and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ), including subscale scores. Also, cure rates – using a variety of definitions for cure – did not differ between the groups.

For example, based on a POP-Q stage of 1 or less as a definition of cure, 45% and 43% of those in the mesh and no mesh groups, respectively, were cured. When no prolapse beyond the hymen was used as a definition, 85% and 71% were cured When absence of bulge symptoms (a "no" answer to item 3 on the PFDI) was used as a definition, 92% and 81% were cured. The differences between the groups for these and other definitions – including a rating of very much better or much better on the Patient Global Impression of Improvement Index (PGI-I), having no prolapse reoperation, and composite outcomes using various combinations of these definitions – were not statistically significant, Dr. Gutman said.

Of note, no new mesh exposures occurred between the previously reported 1-year analysis (three cases required surgical excision before 1 year) and the 3-year analysis. The only prolapse reoperation after 1 year was in a woman who also had a reoperation prior to the 1-year analysis, he said at the meeting, which was jointly sponsored by the American College of Surgeons.

Also of note, the anatomic cure rate was lowest for the anterior compartment, and this did not differ between the mesh and no mesh groups.

Patients included in the study were women with stage 2-4 prolapse who were randomized to the mesh or no mesh group at baseline. Three-month and 1-year outcomes were previously reported.

Although the study is underpowered because of the early halting of enrollment, and is limited by the substantial number of patients lost to follow-up, it also has several strengths, including the long-term follow-up, multicenter design, and robust definitions of cure.

Therefore, the findings of a similar cure rate in the mesh and no mesh groups, excellent quality of life improvements in both groups, a mesh exposure rate of 15.6%, and a finding of only one new mesh exposure between 1- and 3-year follow-up, suggest that a "balanced approach is really required for vaginal mesh repairs, including a thorough patient consent," Dr. Gutman concluded.

He reported having no relevant financial disclosures.

obnews@frontlinemedcom.com

CHARLESTON, S.C. – Cure rates and patient satisfaction following vaginal prolapse repair were high at 3-year follow-up regardless of whether vaginal mesh or native tissue was used for the repair, according to findings from a prospective randomized trial.

The findings raise questions about the long-term value of vaginal mesh repairs because subjects treated with mesh had more complications without experiencing benefit beyond that observed in the native tissue repair patients, Dr. Robert E. Gutman reported at the annual meeting of the Society of Gynecologic Surgeons.

Of 65 women who were enrolled in the trial before enrollment was halted because of a 15.6% mesh exposure rate, 51 – including 25 in the mesh group and 26 in the no mesh group – had quality of life data available for the planned 3-year final analysis, and 41 had 2- or 3-year pelvic organ prolapse quantification (POP-Q) examination information available.

No differences were noted between the groups with respect to POP-Q stage or individual POP-Q points at 3 years, and the majority in both the mesh and no mesh groups (90% and 86%, respectively) improved in stage from baseline, said Dr. Gutman of MedStar Washington Hospital Center and of the department of obstetrics and gynecology and urology at Georgetown University, both in Washington.

Furthermore, no differences were seen between the groups with respect to symptomatic improvement as assessed by the Pelvic Floor Distress Inventory (PFDI), the Pelvic Floor Impact Questionnaire (PFIQ), and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ), including subscale scores. Also, cure rates – using a variety of definitions for cure – did not differ between the groups.

For example, based on a POP-Q stage of 1 or less as a definition of cure, 45% and 43% of those in the mesh and no mesh groups, respectively, were cured. When no prolapse beyond the hymen was used as a definition, 85% and 71% were cured When absence of bulge symptoms (a "no" answer to item 3 on the PFDI) was used as a definition, 92% and 81% were cured. The differences between the groups for these and other definitions – including a rating of very much better or much better on the Patient Global Impression of Improvement Index (PGI-I), having no prolapse reoperation, and composite outcomes using various combinations of these definitions – were not statistically significant, Dr. Gutman said.

Of note, no new mesh exposures occurred between the previously reported 1-year analysis (three cases required surgical excision before 1 year) and the 3-year analysis. The only prolapse reoperation after 1 year was in a woman who also had a reoperation prior to the 1-year analysis, he said at the meeting, which was jointly sponsored by the American College of Surgeons.

Also of note, the anatomic cure rate was lowest for the anterior compartment, and this did not differ between the mesh and no mesh groups.

Patients included in the study were women with stage 2-4 prolapse who were randomized to the mesh or no mesh group at baseline. Three-month and 1-year outcomes were previously reported.

Although the study is underpowered because of the early halting of enrollment, and is limited by the substantial number of patients lost to follow-up, it also has several strengths, including the long-term follow-up, multicenter design, and robust definitions of cure.

Therefore, the findings of a similar cure rate in the mesh and no mesh groups, excellent quality of life improvements in both groups, a mesh exposure rate of 15.6%, and a finding of only one new mesh exposure between 1- and 3-year follow-up, suggest that a "balanced approach is really required for vaginal mesh repairs, including a thorough patient consent," Dr. Gutman concluded.

He reported having no relevant financial disclosures.

obnews@frontlinemedcom.com

CHARLESTON, S.C. – Single-incision mini-slings for the treatment of stress urinary incontinence are associated with higher failure and reoperation rates than are retropubic midurethral slings, according to findings from a survey and review of medical records of more than 200 patients.

At a mean follow-up of 21 months, 71 of 93 (76%) women who underwent a single-incision mini-sling procedure reported treatment failure, defined as overall incontinence, compared with 70 of 109 (64%) women who underwent a retropubic midurethral sling procedure, Dr. Annetta M. Madsen reported at the annual meeting of the Society of Gynecologic Surgeons.

After adjustment for body mass index and follow-up time, which differed between the groups, the odds ratio for treatment failure in the mini-sling vs. retropubic midurethral sling group was 1.84, which trended toward statistical significance, said Dr. Madsen of the Mayo Clinic, Rochester, Minn.

The secondary outcomes of postoperative stress-specific incontinence occurred in 47% and 29% of the mini-sling and retropubic midurethral sling groups, respectively. This difference did reach statistical significance (adjusted odds ratio, 2.4). There was no significant difference between the groups with respect to de novo urge.

As for other secondary endpoints, the mini-sling group had significantly reduced odds of reporting global improvement and patient satisfaction, and significantly increased odds of surgery for recurrent or persistent stress urinary incontinence (SUI), compared with the retropubic midurethral sling group, but the retropubic midurethral sling group had a higher reoperation rate for mesh erosion, Dr. Madsen said.

There was no difference in urethrolysis between the groups.

Study participants were women with a mean age of 60 years with SUI or stress-predominant mixed urinary incontinence, who underwent a sling procedure between January, 2008, and December, 2009. Treatment failure was defined by a score of greater than 0 on the International Consultation on Incontinence Questionnaire, an affirmative response to questions about stress incontinence on the questionnaire, or a need for a repeat anti-incontinence procedure.

The mini-sling and retropubic midurethral sling groups were similar with respect to most demographics – with the exception of BMI and duration of follow-up, and also were similar with respect to baseline urodynamics, Dr. Madsen noted.

Although retropubic and transobturator midurethral slings have been shown to have similar efficacy, it has remained unknown how single-incision mini-slings compare with these types of slings, she said.

These findings suggest that the retropubic midurethral sling is associated with higher risk of mesh exposure and reoperation for mesh complications, but with lower rates of stress-specific incontinence, higher global impression of improvement and patient satisfaction, and similar rates of overall urethrolysis and reoperation rates for any indication, Dr. Madsen concluded.

She reported having no disclosures. The meeting was jointly sponsored by the American College of Surgeons.

CHARLESTON, S.C. – Single-incision mini-slings for the treatment of stress urinary incontinence are associated with higher failure and reoperation rates than are retropubic midurethral slings, according to findings from a survey and review of medical records of more than 200 patients.

At a mean follow-up of 21 months, 71 of 93 (76%) women who underwent a single-incision mini-sling procedure reported treatment failure, defined as overall incontinence, compared with 70 of 109 (64%) women who underwent a retropubic midurethral sling procedure, Dr. Annetta M. Madsen reported at the annual meeting of the Society of Gynecologic Surgeons.

After adjustment for body mass index and follow-up time, which differed between the groups, the odds ratio for treatment failure in the mini-sling vs. retropubic midurethral sling group was 1.84, which trended toward statistical significance, said Dr. Madsen of the Mayo Clinic, Rochester, Minn.

The secondary outcomes of postoperative stress-specific incontinence occurred in 47% and 29% of the mini-sling and retropubic midurethral sling groups, respectively. This difference did reach statistical significance (adjusted odds ratio, 2.4). There was no significant difference between the groups with respect to de novo urge.

As for other secondary endpoints, the mini-sling group had significantly reduced odds of reporting global improvement and patient satisfaction, and significantly increased odds of surgery for recurrent or persistent stress urinary incontinence (SUI), compared with the retropubic midurethral sling group, but the retropubic midurethral sling group had a higher reoperation rate for mesh erosion, Dr. Madsen said.

There was no difference in urethrolysis between the groups.

Study participants were women with a mean age of 60 years with SUI or stress-predominant mixed urinary incontinence, who underwent a sling procedure between January, 2008, and December, 2009. Treatment failure was defined by a score of greater than 0 on the International Consultation on Incontinence Questionnaire, an affirmative response to questions about stress incontinence on the questionnaire, or a need for a repeat anti-incontinence procedure.

The mini-sling and retropubic midurethral sling groups were similar with respect to most demographics – with the exception of BMI and duration of follow-up, and also were similar with respect to baseline urodynamics, Dr. Madsen noted.

Although retropubic and transobturator midurethral slings have been shown to have similar efficacy, it has remained unknown how single-incision mini-slings compare with these types of slings, she said.

These findings suggest that the retropubic midurethral sling is associated with higher risk of mesh exposure and reoperation for mesh complications, but with lower rates of stress-specific incontinence, higher global impression of improvement and patient satisfaction, and similar rates of overall urethrolysis and reoperation rates for any indication, Dr. Madsen concluded.

She reported having no disclosures. The meeting was jointly sponsored by the American College of Surgeons.

CHARLESTON, S.C. – Single-incision mini-slings for the treatment of stress urinary incontinence are associated with higher failure and reoperation rates than are retropubic midurethral slings, according to findings from a survey and review of medical records of more than 200 patients.

At a mean follow-up of 21 months, 71 of 93 (76%) women who underwent a single-incision mini-sling procedure reported treatment failure, defined as overall incontinence, compared with 70 of 109 (64%) women who underwent a retropubic midurethral sling procedure, Dr. Annetta M. Madsen reported at the annual meeting of the Society of Gynecologic Surgeons.

After adjustment for body mass index and follow-up time, which differed between the groups, the odds ratio for treatment failure in the mini-sling vs. retropubic midurethral sling group was 1.84, which trended toward statistical significance, said Dr. Madsen of the Mayo Clinic, Rochester, Minn.

The secondary outcomes of postoperative stress-specific incontinence occurred in 47% and 29% of the mini-sling and retropubic midurethral sling groups, respectively. This difference did reach statistical significance (adjusted odds ratio, 2.4). There was no significant difference between the groups with respect to de novo urge.

As for other secondary endpoints, the mini-sling group had significantly reduced odds of reporting global improvement and patient satisfaction, and significantly increased odds of surgery for recurrent or persistent stress urinary incontinence (SUI), compared with the retropubic midurethral sling group, but the retropubic midurethral sling group had a higher reoperation rate for mesh erosion, Dr. Madsen said.

There was no difference in urethrolysis between the groups.

Study participants were women with a mean age of 60 years with SUI or stress-predominant mixed urinary incontinence, who underwent a sling procedure between January, 2008, and December, 2009. Treatment failure was defined by a score of greater than 0 on the International Consultation on Incontinence Questionnaire, an affirmative response to questions about stress incontinence on the questionnaire, or a need for a repeat anti-incontinence procedure.

The mini-sling and retropubic midurethral sling groups were similar with respect to most demographics – with the exception of BMI and duration of follow-up, and also were similar with respect to baseline urodynamics, Dr. Madsen noted.

Although retropubic and transobturator midurethral slings have been shown to have similar efficacy, it has remained unknown how single-incision mini-slings compare with these types of slings, she said.

These findings suggest that the retropubic midurethral sling is associated with higher risk of mesh exposure and reoperation for mesh complications, but with lower rates of stress-specific incontinence, higher global impression of improvement and patient satisfaction, and similar rates of overall urethrolysis and reoperation rates for any indication, Dr. Madsen concluded.

She reported having no disclosures. The meeting was jointly sponsored by the American College of Surgeons.

NEW ORLEANS – A telephone call made at 4 weeks postpartum to reinforce counseling about contraception did not increase the use of highly effective contraception at 6 months, according to findings from a randomized controlled study involving 258 women.

However, the rates of highly effective contraceptive use at 6 months were fairly high, at 71% and 67% in the intervention and control groups, respectively, and the study identified three factors associated with contraceptive use, Dr. Michelle M. Isley reported at the annual meeting of the American College of Obstetricians and Gynecologists.

On multivariate analysis, an intention to use a highly effective contraceptive method at 1-2 days postpartum was positively associated with use of such a contraceptive method at 6 months. A plan to breast-feed for a longer period of time, and a history of miscarriage were each negatively associated with the use of a highly effective contraceptive method at 6 months, said Dr. Isley of Ohio State University, Columbus.

The finding that an intention to use contraception was associated with actual use at 6 months has possible implications for patient counseling, she said. "This suggests that counseling in the prenatal period is valuable."

Dr. Isley noted, however, that 60% of study participants said their provider had talked to them about contraception prior to delivery. "I think we could do better here."

The finding of a negative association between plans to breast-feed for a longer period and use of contraception at 6 months suggests there may be a perception that birth control is not safe to use during breast-feeding. A simple educational intervention about birth control methods that are safe and effective during breast-feeding could be useful in these cases, Dr. Isley said.

Women planning to breast-feed may also be counting on reduced fertility during lactation.

"If women are relying on lactational amenorrhea for their birth control, then I think we ought to provide better, more thorough information about this method so that women can use it more effectively," she said.

As for the findings of a negative association between prior miscarriage and contraceptive use at 6 months postpartum, it is possible that these women believe their fertility is decreased, but more research is needed to clarify this association, she noted.

Study subjects had a mean age of 29 years and were enrolled and randomized at 1-2 days postpartum. Each woman completed a baseline questionnaire on demographic information and contraceptive use intentions. Those randomized to the intervention group received a phone call at 4 weeks postpartum from a study staff member, who readdressed the importance of postpartum contraception, answered basic questions about contraception, and encouraged the woman to attend her postpartum visit.

Contraceptive methods considered to be highly effective in this study were reversible methods including pills, patch, injection, implants, and intrauterine devices. The intervention and control groups did not differ significantly with respect to baseline characteristics.

The results underscore the importance of finding new and inventive ways of providing postpartum contraception, Dr. Isley said.

"As we all are aware, unintended pregnancy is a prevalent public health problem," she said, noting that improving the postpartum use of highly effective contraceptive methods can decrease unintended pregnancy and provide women with a method for controlling the timing of pregnancy.

"More efforts need to be made to figure out how to talk to women about birth control and how to promote these highly effective methods so that ultimately we can decrease mistimed and unintended pregnancies," she said.

Dr. Isley reported having no disclosures.

NEW ORLEANS – A telephone call made at 4 weeks postpartum to reinforce counseling about contraception did not increase the use of highly effective contraception at 6 months, according to findings from a randomized controlled study involving 258 women.

However, the rates of highly effective contraceptive use at 6 months were fairly high, at 71% and 67% in the intervention and control groups, respectively, and the study identified three factors associated with contraceptive use, Dr. Michelle M. Isley reported at the annual meeting of the American College of Obstetricians and Gynecologists.

On multivariate analysis, an intention to use a highly effective contraceptive method at 1-2 days postpartum was positively associated with use of such a contraceptive method at 6 months. A plan to breast-feed for a longer period of time, and a history of miscarriage were each negatively associated with the use of a highly effective contraceptive method at 6 months, said Dr. Isley of Ohio State University, Columbus.

The finding that an intention to use contraception was associated with actual use at 6 months has possible implications for patient counseling, she said. "This suggests that counseling in the prenatal period is valuable."

Dr. Isley noted, however, that 60% of study participants said their provider had talked to them about contraception prior to delivery. "I think we could do better here."

The finding of a negative association between plans to breast-feed for a longer period and use of contraception at 6 months suggests there may be a perception that birth control is not safe to use during breast-feeding. A simple educational intervention about birth control methods that are safe and effective during breast-feeding could be useful in these cases, Dr. Isley said.

Women planning to breast-feed may also be counting on reduced fertility during lactation.

"If women are relying on lactational amenorrhea for their birth control, then I think we ought to provide better, more thorough information about this method so that women can use it more effectively," she said.

As for the findings of a negative association between prior miscarriage and contraceptive use at 6 months postpartum, it is possible that these women believe their fertility is decreased, but more research is needed to clarify this association, she noted.

Study subjects had a mean age of 29 years and were enrolled and randomized at 1-2 days postpartum. Each woman completed a baseline questionnaire on demographic information and contraceptive use intentions. Those randomized to the intervention group received a phone call at 4 weeks postpartum from a study staff member, who readdressed the importance of postpartum contraception, answered basic questions about contraception, and encouraged the woman to attend her postpartum visit.

Contraceptive methods considered to be highly effective in this study were reversible methods including pills, patch, injection, implants, and intrauterine devices. The intervention and control groups did not differ significantly with respect to baseline characteristics.

The results underscore the importance of finding new and inventive ways of providing postpartum contraception, Dr. Isley said.

"As we all are aware, unintended pregnancy is a prevalent public health problem," she said, noting that improving the postpartum use of highly effective contraceptive methods can decrease unintended pregnancy and provide women with a method for controlling the timing of pregnancy.

"More efforts need to be made to figure out how to talk to women about birth control and how to promote these highly effective methods so that ultimately we can decrease mistimed and unintended pregnancies," she said.

Dr. Isley reported having no disclosures.

NEW ORLEANS – A telephone call made at 4 weeks postpartum to reinforce counseling about contraception did not increase the use of highly effective contraception at 6 months, according to findings from a randomized controlled study involving 258 women.

However, the rates of highly effective contraceptive use at 6 months were fairly high, at 71% and 67% in the intervention and control groups, respectively, and the study identified three factors associated with contraceptive use, Dr. Michelle M. Isley reported at the annual meeting of the American College of Obstetricians and Gynecologists.

On multivariate analysis, an intention to use a highly effective contraceptive method at 1-2 days postpartum was positively associated with use of such a contraceptive method at 6 months. A plan to breast-feed for a longer period of time, and a history of miscarriage were each negatively associated with the use of a highly effective contraceptive method at 6 months, said Dr. Isley of Ohio State University, Columbus.

The finding that an intention to use contraception was associated with actual use at 6 months has possible implications for patient counseling, she said. "This suggests that counseling in the prenatal period is valuable."

Dr. Isley noted, however, that 60% of study participants said their provider had talked to them about contraception prior to delivery. "I think we could do better here."

The finding of a negative association between plans to breast-feed for a longer period and use of contraception at 6 months suggests there may be a perception that birth control is not safe to use during breast-feeding. A simple educational intervention about birth control methods that are safe and effective during breast-feeding could be useful in these cases, Dr. Isley said.

Women planning to breast-feed may also be counting on reduced fertility during lactation.

"If women are relying on lactational amenorrhea for their birth control, then I think we ought to provide better, more thorough information about this method so that women can use it more effectively," she said.

As for the findings of a negative association between prior miscarriage and contraceptive use at 6 months postpartum, it is possible that these women believe their fertility is decreased, but more research is needed to clarify this association, she noted.

Study subjects had a mean age of 29 years and were enrolled and randomized at 1-2 days postpartum. Each woman completed a baseline questionnaire on demographic information and contraceptive use intentions. Those randomized to the intervention group received a phone call at 4 weeks postpartum from a study staff member, who readdressed the importance of postpartum contraception, answered basic questions about contraception, and encouraged the woman to attend her postpartum visit.

Contraceptive methods considered to be highly effective in this study were reversible methods including pills, patch, injection, implants, and intrauterine devices. The intervention and control groups did not differ significantly with respect to baseline characteristics.

The results underscore the importance of finding new and inventive ways of providing postpartum contraception, Dr. Isley said.

"As we all are aware, unintended pregnancy is a prevalent public health problem," she said, noting that improving the postpartum use of highly effective contraceptive methods can decrease unintended pregnancy and provide women with a method for controlling the timing of pregnancy.

"More efforts need to be made to figure out how to talk to women about birth control and how to promote these highly effective methods so that ultimately we can decrease mistimed and unintended pregnancies," she said.

Dr. Isley reported having no disclosures.

NEW ORLEANS – Maternal body mass index does not affect the efficacy of low-dose aspirin for preventing preeclampsia or preterm birth, according to a secondary analysis of data from the National Institute of Child Health and Human Development’s Maternal-Fetal Medicine Units Network trial.

In the large randomized controlled trial, aspirin was not found to be of benefit for preventing preeclampsia; however, some meta-analyses have suggested a modest benefit, Dr. Jessica Cantu noted at the annual meeting of the American College of Obstetricians and Gynecologists. In one meta-analysis of individual patient data from 31 studies that included more than 32,000 women, aspirin-treated patients had a 10% relative risk reduction, compared with controls, she said.

In fact, aspirin is the only intervention that has shown any potential benefit for preventing preeclampsia, which occurs in 5%-8% of pregnancies and causes 18% of maternal deaths, said Dr. Cantu of the University of Alabama at Birmingham.

"So why is it that the randomized controlled trials have not shown benefit? Potential reasons are that the aspirin dose used was small in these trials, ranging from 50 to 150 mg/day. Second, the contradictory results may lie in the timing of initiation, with more recent data suggesting benefit when aspirin is initiated at less than 16 weeks’ gestation. Finally, maternal obesity is a potential reason for the lack of significant benefit in clinical trials," she said.

Since obese women are at increased risk for preeclampsia, and since obesity and preeclampsia share certain pathophysiological features, including endothelial dysfunction, oxidative stress, and an increased state of inflammation, it seems plausible that obese pregnant women might benefit the most from low-dose aspirin therapy.

"On the other hand, study dose of low-dose aspirin may be too small to have an effect on these women," she said.

To take a closer look at the impact of body mass index on outcomes in the Maternal-Fetal Medicine Units Network trial, which included women at high risk for preeclampsia, a secondary analysis of data from 2,479 women in that trial was performed to determine if outcomes varied by BMI class.

No significant differences were seen in the relative risk of preeclampsia between those with a BMI of 30 or less and those with a BMI of greater than 30 when aspirin was initiated at 13-26 weeks’ gestation. There also was no difference between the groups with respect to the rate of delivery prior to 37 weeks’ gestation.

Even after additional analyses were performed to compare outcomes in obese and nonobese patients from each of four high-risk subgroups of patients in the study, and when patients were further stratified into four BMI subgroups (normal, overweight, obese, and morbidly obese) the effects of aspirin therapy did not differ based on BMI class.

This study is limited by the fact that it involves a secondary analysis of data. Also, the timing of initiation of aspirin therapy may have contributed to the overall lack of an effect, Dr. Cantu said.

"These limitations notwithstanding, we conclude that there is no effect of maternal BMI on aspirin efficacy for the prevention of preeclampsia or preterm birth," she said.

Dr. Cantu reported having no disclosures.

obnews@frontlinemedcom.com

NEW ORLEANS – Maternal body mass index does not affect the efficacy of low-dose aspirin for preventing preeclampsia or preterm birth, according to a secondary analysis of data from the National Institute of Child Health and Human Development’s Maternal-Fetal Medicine Units Network trial.

In the large randomized controlled trial, aspirin was not found to be of benefit for preventing preeclampsia; however, some meta-analyses have suggested a modest benefit, Dr. Jessica Cantu noted at the annual meeting of the American College of Obstetricians and Gynecologists. In one meta-analysis of individual patient data from 31 studies that included more than 32,000 women, aspirin-treated patients had a 10% relative risk reduction, compared with controls, she said.

In fact, aspirin is the only intervention that has shown any potential benefit for preventing preeclampsia, which occurs in 5%-8% of pregnancies and causes 18% of maternal deaths, said Dr. Cantu of the University of Alabama at Birmingham.

"So why is it that the randomized controlled trials have not shown benefit? Potential reasons are that the aspirin dose used was small in these trials, ranging from 50 to 150 mg/day. Second, the contradictory results may lie in the timing of initiation, with more recent data suggesting benefit when aspirin is initiated at less than 16 weeks’ gestation. Finally, maternal obesity is a potential reason for the lack of significant benefit in clinical trials," she said.

Since obese women are at increased risk for preeclampsia, and since obesity and preeclampsia share certain pathophysiological features, including endothelial dysfunction, oxidative stress, and an increased state of inflammation, it seems plausible that obese pregnant women might benefit the most from low-dose aspirin therapy.

"On the other hand, study dose of low-dose aspirin may be too small to have an effect on these women," she said.

To take a closer look at the impact of body mass index on outcomes in the Maternal-Fetal Medicine Units Network trial, which included women at high risk for preeclampsia, a secondary analysis of data from 2,479 women in that trial was performed to determine if outcomes varied by BMI class.

No significant differences were seen in the relative risk of preeclampsia between those with a BMI of 30 or less and those with a BMI of greater than 30 when aspirin was initiated at 13-26 weeks’ gestation. There also was no difference between the groups with respect to the rate of delivery prior to 37 weeks’ gestation.

Even after additional analyses were performed to compare outcomes in obese and nonobese patients from each of four high-risk subgroups of patients in the study, and when patients were further stratified into four BMI subgroups (normal, overweight, obese, and morbidly obese) the effects of aspirin therapy did not differ based on BMI class.

This study is limited by the fact that it involves a secondary analysis of data. Also, the timing of initiation of aspirin therapy may have contributed to the overall lack of an effect, Dr. Cantu said.

"These limitations notwithstanding, we conclude that there is no effect of maternal BMI on aspirin efficacy for the prevention of preeclampsia or preterm birth," she said.

Dr. Cantu reported having no disclosures.

obnews@frontlinemedcom.com

NEW ORLEANS – Maternal body mass index does not affect the efficacy of low-dose aspirin for preventing preeclampsia or preterm birth, according to a secondary analysis of data from the National Institute of Child Health and Human Development’s Maternal-Fetal Medicine Units Network trial.

In the large randomized controlled trial, aspirin was not found to be of benefit for preventing preeclampsia; however, some meta-analyses have suggested a modest benefit, Dr. Jessica Cantu noted at the annual meeting of the American College of Obstetricians and Gynecologists. In one meta-analysis of individual patient data from 31 studies that included more than 32,000 women, aspirin-treated patients had a 10% relative risk reduction, compared with controls, she said.

In fact, aspirin is the only intervention that has shown any potential benefit for preventing preeclampsia, which occurs in 5%-8% of pregnancies and causes 18% of maternal deaths, said Dr. Cantu of the University of Alabama at Birmingham.

"So why is it that the randomized controlled trials have not shown benefit? Potential reasons are that the aspirin dose used was small in these trials, ranging from 50 to 150 mg/day. Second, the contradictory results may lie in the timing of initiation, with more recent data suggesting benefit when aspirin is initiated at less than 16 weeks’ gestation. Finally, maternal obesity is a potential reason for the lack of significant benefit in clinical trials," she said.

Since obese women are at increased risk for preeclampsia, and since obesity and preeclampsia share certain pathophysiological features, including endothelial dysfunction, oxidative stress, and an increased state of inflammation, it seems plausible that obese pregnant women might benefit the most from low-dose aspirin therapy.

"On the other hand, study dose of low-dose aspirin may be too small to have an effect on these women," she said.

To take a closer look at the impact of body mass index on outcomes in the Maternal-Fetal Medicine Units Network trial, which included women at high risk for preeclampsia, a secondary analysis of data from 2,479 women in that trial was performed to determine if outcomes varied by BMI class.

No significant differences were seen in the relative risk of preeclampsia between those with a BMI of 30 or less and those with a BMI of greater than 30 when aspirin was initiated at 13-26 weeks’ gestation. There also was no difference between the groups with respect to the rate of delivery prior to 37 weeks’ gestation.

Even after additional analyses were performed to compare outcomes in obese and nonobese patients from each of four high-risk subgroups of patients in the study, and when patients were further stratified into four BMI subgroups (normal, overweight, obese, and morbidly obese) the effects of aspirin therapy did not differ based on BMI class.

This study is limited by the fact that it involves a secondary analysis of data. Also, the timing of initiation of aspirin therapy may have contributed to the overall lack of an effect, Dr. Cantu said.

"These limitations notwithstanding, we conclude that there is no effect of maternal BMI on aspirin efficacy for the prevention of preeclampsia or preterm birth," she said.

Dr. Cantu reported having no disclosures.

obnews@frontlinemedcom.com

MIAMI BEACH – The extent of vascular disease, not the presence of diabetes or the cause of the ulceration, should drive the decision to intervene in a patient with a "diabetic foot," according to Dr. Joshua Beckman.

"When do I intervene on a diabetic foot? When I intervene on all feet: when there’s inadequate blood flow to heal the lesion," he said at the International Symposium on Endovascular Therapy 2013.

When lesions are detected in diabetic patients with PAD, assess for ankle pressures and determine ankle brachial index regardless of whether the lesion is neuropathic, he advised, explaining that, "even if you have a neuropathic initiation for your ulcer, if you have a low perfusion pressure, particularly under 50 mmHg, you’re not going to heal that lesion no matter how it was started."

"I always assess patients, whether I think the lesion is a neuropathic one or not, for the ankle pressures and do ankle brachial index and, assuming it’s low, I refer for revascularization based on the same criteria I would everybody else," said Dr. Beckman of Harvard Medical School, Boston.

That said, up to one-third of patients with diabetes have peripheral artery disease, and its presence is an independent predictor of adverse outcomes. "In fact, the combination of PAD and diabetes represents the group of people in the United States that has the most amputations, and their risk may be 20-fold that of people without both PAD and diabetes," he noted.

Indeed, the risk of amputation is much greater in diabetic patients, regardless of the care they receive, Dr. Beckman said, citing a study of 136 lower-extremity angiograms in patients with PAD. The odds ratios for amputation and death at 4.5 years’ follow-up were 5.4 for those with diabetes and 3.1 for those without diabetes (Diabetes Care 2001;24:1433-7).

Additionally, in a study of 1,244 men with claudication, the risk of ischemic ulceration was 4-fold higher in diabetic patients than in nondiabetic patients. Ankle brachial indices ranged from 0.9 to 0.1, and there was no point at which a diabetic patient was not worse off than a nondiabetic patient, he said. The risk in a diabetic patient with an ankle brachial index of 0.9 was equal to the risk in a nondiabetic patient with an ankle brachial index of 0.1 (J. Vasc. Surg. 2001;34:962-70).

Diabetic patients also can have a number of other initiators of diabetic foot ulceration, including neuropathy, bone deformity, callus, penetrating injury, and ill-fitting shoes. In combination, these factors can be especially problematic, he said.

Also, the extensor muscle abnormality that can result from motor neuropathy can change foot morphology, thereby increasing pressure on areas such as the ball of the foot, where ulcers are common.

Furthermore, a patient with neuropathy can walk around for a long time without recognizing a problem that an individual with normal nerve function wouldn’t tolerate. "A diabetic patient can have a bad shoe that rubs all day and not appreciate it," Dr. Beckman said.

With PAD, there are a "whole host of issues we never deal with in the nondiabetic patient that really accelerate the pathway toward ischemic ulceration and critical limb ischemia," he said. "Diabetes is a risk multiplier. It makes things worse, and it’s far more involved in the initiation [of ulceration] than in the decision whether to fix somebody."

Further underscoring the importance of such follow-up is a study of 533 diabetic patients hospitalized for critical limb ischemia. Nearly 50% of them developed critical limb ischemia in the contralateral limb at 6-year follow-up (Diabetes Res. Clin. Prac. 2007;77:445-50).

"So this is a group of people who need not only exquisite care, but exquisite surveillance, because it is very likely that, over time, they will come back to your office with the same problem in the other foot. I’m not recommending intervention or surgery in the asymptomatic foot, but I am suggesting you should probably never let them go, and have routine follow-ups where you look at their feet every time," he said.

Dr. Beckman reported having no disclosures relevant to his talk.

sboschert@frontlinemedcom.com

MIAMI BEACH – The extent of vascular disease, not the presence of diabetes or the cause of the ulceration, should drive the decision to intervene in a patient with a "diabetic foot," according to Dr. Joshua Beckman.

"When do I intervene on a diabetic foot? When I intervene on all feet: when there’s inadequate blood flow to heal the lesion," he said at the International Symposium on Endovascular Therapy 2013.

When lesions are detected in diabetic patients with PAD, assess for ankle pressures and determine ankle brachial index regardless of whether the lesion is neuropathic, he advised, explaining that, "even if you have a neuropathic initiation for your ulcer, if you have a low perfusion pressure, particularly under 50 mmHg, you’re not going to heal that lesion no matter how it was started."

"I always assess patients, whether I think the lesion is a neuropathic one or not, for the ankle pressures and do ankle brachial index and, assuming it’s low, I refer for revascularization based on the same criteria I would everybody else," said Dr. Beckman of Harvard Medical School, Boston.

That said, up to one-third of patients with diabetes have peripheral artery disease, and its presence is an independent predictor of adverse outcomes. "In fact, the combination of PAD and diabetes represents the group of people in the United States that has the most amputations, and their risk may be 20-fold that of people without both PAD and diabetes," he noted.

Indeed, the risk of amputation is much greater in diabetic patients, regardless of the care they receive, Dr. Beckman said, citing a study of 136 lower-extremity angiograms in patients with PAD. The odds ratios for amputation and death at 4.5 years’ follow-up were 5.4 for those with diabetes and 3.1 for those without diabetes (Diabetes Care 2001;24:1433-7).

Additionally, in a study of 1,244 men with claudication, the risk of ischemic ulceration was 4-fold higher in diabetic patients than in nondiabetic patients. Ankle brachial indices ranged from 0.9 to 0.1, and there was no point at which a diabetic patient was not worse off than a nondiabetic patient, he said. The risk in a diabetic patient with an ankle brachial index of 0.9 was equal to the risk in a nondiabetic patient with an ankle brachial index of 0.1 (J. Vasc. Surg. 2001;34:962-70).

Diabetic patients also can have a number of other initiators of diabetic foot ulceration, including neuropathy, bone deformity, callus, penetrating injury, and ill-fitting shoes. In combination, these factors can be especially problematic, he said.

Also, the extensor muscle abnormality that can result from motor neuropathy can change foot morphology, thereby increasing pressure on areas such as the ball of the foot, where ulcers are common.

Furthermore, a patient with neuropathy can walk around for a long time without recognizing a problem that an individual with normal nerve function wouldn’t tolerate. "A diabetic patient can have a bad shoe that rubs all day and not appreciate it," Dr. Beckman said.

With PAD, there are a "whole host of issues we never deal with in the nondiabetic patient that really accelerate the pathway toward ischemic ulceration and critical limb ischemia," he said. "Diabetes is a risk multiplier. It makes things worse, and it’s far more involved in the initiation [of ulceration] than in the decision whether to fix somebody."

Further underscoring the importance of such follow-up is a study of 533 diabetic patients hospitalized for critical limb ischemia. Nearly 50% of them developed critical limb ischemia in the contralateral limb at 6-year follow-up (Diabetes Res. Clin. Prac. 2007;77:445-50).

"So this is a group of people who need not only exquisite care, but exquisite surveillance, because it is very likely that, over time, they will come back to your office with the same problem in the other foot. I’m not recommending intervention or surgery in the asymptomatic foot, but I am suggesting you should probably never let them go, and have routine follow-ups where you look at their feet every time," he said.

Dr. Beckman reported having no disclosures relevant to his talk.

sboschert@frontlinemedcom.com

MIAMI BEACH – The extent of vascular disease, not the presence of diabetes or the cause of the ulceration, should drive the decision to intervene in a patient with a "diabetic foot," according to Dr. Joshua Beckman.

"When do I intervene on a diabetic foot? When I intervene on all feet: when there’s inadequate blood flow to heal the lesion," he said at the International Symposium on Endovascular Therapy 2013.

When lesions are detected in diabetic patients with PAD, assess for ankle pressures and determine ankle brachial index regardless of whether the lesion is neuropathic, he advised, explaining that, "even if you have a neuropathic initiation for your ulcer, if you have a low perfusion pressure, particularly under 50 mmHg, you’re not going to heal that lesion no matter how it was started."

"I always assess patients, whether I think the lesion is a neuropathic one or not, for the ankle pressures and do ankle brachial index and, assuming it’s low, I refer for revascularization based on the same criteria I would everybody else," said Dr. Beckman of Harvard Medical School, Boston.

That said, up to one-third of patients with diabetes have peripheral artery disease, and its presence is an independent predictor of adverse outcomes. "In fact, the combination of PAD and diabetes represents the group of people in the United States that has the most amputations, and their risk may be 20-fold that of people without both PAD and diabetes," he noted.

Indeed, the risk of amputation is much greater in diabetic patients, regardless of the care they receive, Dr. Beckman said, citing a study of 136 lower-extremity angiograms in patients with PAD. The odds ratios for amputation and death at 4.5 years’ follow-up were 5.4 for those with diabetes and 3.1 for those without diabetes (Diabetes Care 2001;24:1433-7).

Additionally, in a study of 1,244 men with claudication, the risk of ischemic ulceration was 4-fold higher in diabetic patients than in nondiabetic patients. Ankle brachial indices ranged from 0.9 to 0.1, and there was no point at which a diabetic patient was not worse off than a nondiabetic patient, he said. The risk in a diabetic patient with an ankle brachial index of 0.9 was equal to the risk in a nondiabetic patient with an ankle brachial index of 0.1 (J. Vasc. Surg. 2001;34:962-70).

Diabetic patients also can have a number of other initiators of diabetic foot ulceration, including neuropathy, bone deformity, callus, penetrating injury, and ill-fitting shoes. In combination, these factors can be especially problematic, he said.

Also, the extensor muscle abnormality that can result from motor neuropathy can change foot morphology, thereby increasing pressure on areas such as the ball of the foot, where ulcers are common.

Furthermore, a patient with neuropathy can walk around for a long time without recognizing a problem that an individual with normal nerve function wouldn’t tolerate. "A diabetic patient can have a bad shoe that rubs all day and not appreciate it," Dr. Beckman said.

With PAD, there are a "whole host of issues we never deal with in the nondiabetic patient that really accelerate the pathway toward ischemic ulceration and critical limb ischemia," he said. "Diabetes is a risk multiplier. It makes things worse, and it’s far more involved in the initiation [of ulceration] than in the decision whether to fix somebody."

Further underscoring the importance of such follow-up is a study of 533 diabetic patients hospitalized for critical limb ischemia. Nearly 50% of them developed critical limb ischemia in the contralateral limb at 6-year follow-up (Diabetes Res. Clin. Prac. 2007;77:445-50).

"So this is a group of people who need not only exquisite care, but exquisite surveillance, because it is very likely that, over time, they will come back to your office with the same problem in the other foot. I’m not recommending intervention or surgery in the asymptomatic foot, but I am suggesting you should probably never let them go, and have routine follow-ups where you look at their feet every time," he said.

Dr. Beckman reported having no disclosures relevant to his talk.

sboschert@frontlinemedcom.com