S Fine

Women with inflammatory bowel disease do not receive adequate cervical cancer screening or pregnancy counseling.

ammatory bowel disease. Clin Dermatol. 2010;26: 265–273. 3. Bernstein CN, Blanchard JF, Rawsthorne P, et al. The prevalence of extraintestinal diseases in inflammatory bowel disease: a population-based study. Am J Gastroenterol. 2001;96:1116–1122. 4. Yüksel I, Başar O, Ataseven H, et al. Mucocutaneous manifestations in inflammatory bowel disease. Inflamm Bowel Dis. 2009;15:546–550. 5. Farmer RG, Easley KA, Rankin GB. Clinical patterns, natural history, and progression of ulcerative colitis. Dig Dis Sci. 1993;38:1137–1146. 6. Basler RS. Ulcerative colitis and the skin. Med Clin North Am. 1980;64:941–954. 7. White JW. Erythema nodosum. Dermatol Clin. 1985; 3:119–127. 8. Hyrich KL, Lunt M, Watson KD, et al. British Society for Rheumatology Biologics Register. Outcomes after switching from one anti-tumor necrosis factor a agent to a second anti-tumor necrosis factor a agent in patients with rheumatoid arthritis: results from a large UK national cohort study. Arthritis Rheum. 2007;56:13–20.

Appropriate cervical cancer screening remains essential: the case of women with inflammatory bowel disease.

With respect to the NNT to prevent 1 early neonatal death according to risk status, we reanalyzed our data and we found that the NNT to prevent 1 early neonatal death in low-risk pregnancies is 9508, whereas the corresponding NNT for high-risk pregnancies is 251. This observation, coupled with our earlier finding that there was a dose-response relationship between gestational age and NNT (with lower NNT in early gestations), suggests that the association of EFM use and decreased neonatal and infant mortality may indeed be causal. We disagree with the notion that the randomized trials (and therefore their metaanalysis) “compared EFM with properly performed intermittent auscultation (IA).” With he exception of the Athens trial none of the other trials was direct comparison of EFM vs IA as the primary and only ethod of intrapartum fetal surveillance. The remaining rials were comparisons of policies or protocols allowing for ross-over from IA to EFM (when there were fetal heart rate bnormalities by auscultation) and back-up methods, such s scalp pH, which apparently can mask any clinical outome differences that exist between the 2 monitoring echniques. In conclusion, despite Drs Illuzzi and Bracken’s concern, we eiterate our earlier conclusions that “In the United States, the se of EFM was associated with a substantial decrease in early eonatal mortality and morbidity.” We look forward to a large nd adequately powered randomized, controlled trial to disrove our conclusions. f

Missing cohort: Inflammatory bowel disease patients at increased risk for cervical dysplasia may be undervaccinated for HPV.

To the Editor: The human papillomavirus (HPV) is strongly associated with cervical dysplasia. In the United States up to 5% of women have cervical dysplasia on Pap smears. The HPV vaccine is recommended for girls starting at age 11, with ‘‘catch-up vaccination’’ offered for the 13–26 age group. Women with inflammatory bowel disease (IBD) have increased risk for cervical dysplasia and there are no specific guidelines addressing HPV counseling and vaccine administration among these patients. Notably, many young women with IBD in adult gastroenterology practices were no longer receiving care from their pediatricians when the HPV vaccination became available. This study evaluated the rate of HPV vaccine counseling and administration in young adult women with IBD at an urban university medical center. Medical records of consecutive women with IBD age 18–26 years old managed at an IBD center at an urban university during a 2-year period were evaluated. There were no exclusion criteria. Patient age, physician specialty, HPV counseling status, and HPV vaccine administration were obtained. A database was created using Microsoft Excel, with deidentification to ensure anonymity. Medical records of 35 women were evaluated. In addition, all gastroenterologists had an internist and seven had a gynecologist. Documented HPV counseling occurred in six patients (17.1%). Three patients were counseled by gynecologists, with only one receiving HPV vaccine. Two patients were counseled by their internist without HPV vaccine administration. One patient was counseled by a gastroenterologist without documented HPV vaccine administration. There was no documentation of HPV assessment, counseling, or administration in medical records from previous physicians. This study suggests that women with IBD in early adulthood may not have received the HPV vaccine if it was released after they graduated from their pediatrician’s care. This is concerning, as women with IBD have increased risk for development of cervical dysplasia. Assumptions about previous HPV administration by pediatricians may have a role in physician assessment and counseling of HPV vaccine. The known relationship of the HPV vaccine and cervical dysplasia risk must be recognized by all physicians in the care of women with IBD to ensure optimal management.