Michele G. Sullivan

NEW ORLEANS – Suicide attempt is associated with a fourfold increase in the risk of developing a first unprovoked seizure in adults and children older than 3 years, Dale Hesdorffer, Ph.D., said at the annual meeting of the American Epilepsy Society.

Major depression is associated with almost a doubling in the risk of first unprovoked seizure, she said. “There's clearly an underlying susceptibility for all these problems,” said Dr. Hesdorffer of Columbia University, New York City. “This has been shown in several studies, but we don't know what it could be. It's completely undetermined at this point.”

Dr. Hesdorffer presented the results of an Icelandic population-based case-control study that compared depression and suicide attempt rates and the number of depressive symptoms in subjects with and without a first unprovoked seizure.

The study included 387 cases and 773 controls. Major depression prior to the onset of seizure occurred in 11% of cases and 6% of controls. Among the cases, 6% had made a suicide attempt, compared with only 2% of controls. The association remained significant even after controlling for age, gender, number of depressive symptoms, and alcohol intake.

NEW ORLEANS – Suicide attempt is associated with a fourfold increase in the risk of developing a first unprovoked seizure in adults and children older than 3 years, Dale Hesdorffer, Ph.D., said at the annual meeting of the American Epilepsy Society.

Major depression is associated with almost a doubling in the risk of first unprovoked seizure, she said. “There's clearly an underlying susceptibility for all these problems,” said Dr. Hesdorffer of Columbia University, New York City. “This has been shown in several studies, but we don't know what it could be. It's completely undetermined at this point.”

Dr. Hesdorffer presented the results of an Icelandic population-based case-control study that compared depression and suicide attempt rates and the number of depressive symptoms in subjects with and without a first unprovoked seizure.

The study included 387 cases and 773 controls. Major depression prior to the onset of seizure occurred in 11% of cases and 6% of controls. Among the cases, 6% had made a suicide attempt, compared with only 2% of controls. The association remained significant even after controlling for age, gender, number of depressive symptoms, and alcohol intake.

NEW ORLEANS – Suicide attempt is associated with a fourfold increase in the risk of developing a first unprovoked seizure in adults and children older than 3 years, Dale Hesdorffer, Ph.D., said at the annual meeting of the American Epilepsy Society.

Major depression is associated with almost a doubling in the risk of first unprovoked seizure, she said. “There's clearly an underlying susceptibility for all these problems,” said Dr. Hesdorffer of Columbia University, New York City. “This has been shown in several studies, but we don't know what it could be. It's completely undetermined at this point.”

Dr. Hesdorffer presented the results of an Icelandic population-based case-control study that compared depression and suicide attempt rates and the number of depressive symptoms in subjects with and without a first unprovoked seizure.

The study included 387 cases and 773 controls. Major depression prior to the onset of seizure occurred in 11% of cases and 6% of controls. Among the cases, 6% had made a suicide attempt, compared with only 2% of controls. The association remained significant even after controlling for age, gender, number of depressive symptoms, and alcohol intake.

Controlling seizures often lessens behavioral and neuropsychological problems that are ubiquitous in children with refractory epilepsy, said Marc Boel, M.D., of University Hospitals Gasthuisberg, Leuven, Belgium.

Among 573 such children seen in his clinic, 80% showed behavioral problems, and 15% showed significant mental decline related to their epilepsy. About half of the entire group had an IQ of below 50 (Eur. J. Pediatr. Neurol. 2005;8:291-7).

Most of the children had either partial epilepsy (29%) or secondary generalized tonic-clonic epilepsy (25%). About 4% had Lennox-Gastaut syndrome. Other diagnoses included absence epilepsy, photosensitive epilepsies, tuberous sclerosis, West syndrome, severe myoclonic epilepsy of infancy, and continuous spike waves during slow-wave sleep.

The most frequent neurobehavioral disorders were pervasive developmental disorder (8%); attention-deficit hyperactivity disorder (7.5%); loss of self-esteem (9%), and self-induction of seizures (7%). Psychosis, anxiety disorders, intermittent explosive disorder, and cursive seizures were seen at lower rates.

Seizure control helps reduce those symptoms, Dr. Boel said. In 101 of the 220 children who achieved seizure control, behavioral problems disappeared or were minimized. Seizure control had only a limited effect on those patients with psychosis, pervasive developmental disorder, or attention disorders.

Controlling seizures often lessens behavioral and neuropsychological problems that are ubiquitous in children with refractory epilepsy, said Marc Boel, M.D., of University Hospitals Gasthuisberg, Leuven, Belgium.

Among 573 such children seen in his clinic, 80% showed behavioral problems, and 15% showed significant mental decline related to their epilepsy. About half of the entire group had an IQ of below 50 (Eur. J. Pediatr. Neurol. 2005;8:291-7).

Most of the children had either partial epilepsy (29%) or secondary generalized tonic-clonic epilepsy (25%). About 4% had Lennox-Gastaut syndrome. Other diagnoses included absence epilepsy, photosensitive epilepsies, tuberous sclerosis, West syndrome, severe myoclonic epilepsy of infancy, and continuous spike waves during slow-wave sleep.

The most frequent neurobehavioral disorders were pervasive developmental disorder (8%); attention-deficit hyperactivity disorder (7.5%); loss of self-esteem (9%), and self-induction of seizures (7%). Psychosis, anxiety disorders, intermittent explosive disorder, and cursive seizures were seen at lower rates.

Seizure control helps reduce those symptoms, Dr. Boel said. In 101 of the 220 children who achieved seizure control, behavioral problems disappeared or were minimized. Seizure control had only a limited effect on those patients with psychosis, pervasive developmental disorder, or attention disorders.

Controlling seizures often lessens behavioral and neuropsychological problems that are ubiquitous in children with refractory epilepsy, said Marc Boel, M.D., of University Hospitals Gasthuisberg, Leuven, Belgium.

Among 573 such children seen in his clinic, 80% showed behavioral problems, and 15% showed significant mental decline related to their epilepsy. About half of the entire group had an IQ of below 50 (Eur. J. Pediatr. Neurol. 2005;8:291-7).

Most of the children had either partial epilepsy (29%) or secondary generalized tonic-clonic epilepsy (25%). About 4% had Lennox-Gastaut syndrome. Other diagnoses included absence epilepsy, photosensitive epilepsies, tuberous sclerosis, West syndrome, severe myoclonic epilepsy of infancy, and continuous spike waves during slow-wave sleep.

The most frequent neurobehavioral disorders were pervasive developmental disorder (8%); attention-deficit hyperactivity disorder (7.5%); loss of self-esteem (9%), and self-induction of seizures (7%). Psychosis, anxiety disorders, intermittent explosive disorder, and cursive seizures were seen at lower rates.

Seizure control helps reduce those symptoms, Dr. Boel said. In 101 of the 220 children who achieved seizure control, behavioral problems disappeared or were minimized. Seizure control had only a limited effect on those patients with psychosis, pervasive developmental disorder, or attention disorders.

WHITE SULPHUR SPRINGS, W. VA. — Most physicians who prescribe hormone therapy still overestimate both its long-term risks and benefits, R. Stan Williams, M.D., said at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

Compared with internists and family doctors, ob.gyns. were the most likely to display an accurate understanding of these issues. But a large portion still gave incorrect answers to Dr. Williams' physician survey on hormone therapy (HT).

“These people thought they understood the results of the Women's Health Initiative [WHI] and said they were counseling their patients about it, but only 28% of their answers were correct,” said Dr. Williams, professor of ob.gyn. at the University of Florida, Gainesville, and chief of the university's division of reproductive endocrinology and infertility. “Most respondents (67%) dramatically overestimated the risks and benefits,” and 5% of the answers “were actually in the wrong direction—they thought it was a risk when it was a benefit.”

In March 2004, Dr. Williams mailed his survey to all primary care physicians in Florida. The survey asked a specific question about the percentage of annual attributable change of risk of heart disease, stroke, venous thrombosis, breast cancer, colon cancer, hip fracture and death, as reported in the WHI. He sent out more than 6,000 surveys; 600 were returned (203 from ob.gyns., 145 from internists, 219 from family physicians, and 33 from other physicians).

About 35% of ob.gyns., 30% of family physicians, and 17% of internists correctly answered that HT increased the risk of heart disease by less than 1% per year of use. Many thought there was no change in risk (35% of internists, 33% of ob.gyns., and 27% of family physicians). About 20% of internists and 15% of family physicians said the risk rose 10%-30% per year of use.

About 50% of ob.gyns., 35% of internists, and 30% of family physicians correctly answered that HT increased the risk of stroke by less than 1% per year of use. About 20% of family physicians, 17% of internists, and 15% of ob.gyns. said the increased risk was 10%-30% per year of use.

About 50% of ob.gyns., 30% of internists, and 27% of family physicians correctly answered that HT increases the risk of venous thrombosis by less than 1% per year of use. About 30% of ob.gyns., 25% of internists, and 30% of family physicians said the risk was increased by 10%-30% per year of use.

About half of ob.gyns., half of family physicians, and 40% of internists correctly answered that HT increases the risk of breast cancer by less than 1% per year of use. About 17% of internists, 15% of family physicians, and 8% of ob.gyns. said the increased risk was 10%-30% per year of use.

The benefits of HT also were misunderstood. Only about 35% of ob.gyns., 20% of internists, and 17% of family physicians correctly answered that the breast cancer risk fell about 1% per year of use.

Most internists (70%) and family physicians (55%) and 30% of ob.gyns. said HT did not change the risk of colon cancer. Only 20% of ob.gyns., 18% of family physicians, and 20% of internists correctly answered that the risk fell 1% per year of use.

About 17% of ob.gyns., 15% of internists, and 10% of family physicians correctly answered that HT decreases the risk of osteoporotic hip fracture by 1% per year of use. About 60% of internists, 55% of ob.gyns., and 50% of family physicians thought the risk reduction was 10%-30% per year of use.

Most respondents understood that there is no change in overall mortality rates associated with HT use. About 85% of ob.gyns. and 65% of internists and family physicians answered correctly. But a few respondents said the overall mortality risk increased 3%-10% per year of use.

Dr. Williams also asked respondents' views of HT on a scale of 1–5, with 5 being positive. The average rating was 3.89 among ob.gyns., 3.0 among family physicians, and 2.7 among internists.

Last year, he presented results of a similar survey he conducted among 1,000 women aged 45–65, which showed that up to 36% believed their attributable risk of heart disease and stroke was 10%-30% per year of HT use. More than half believed the breast cancer risk was 10%-30% per year of HT, and 60% believed HT could reduce the risk of osteoporotic hip fracture by up to 30% per year.

WHITE SULPHUR SPRINGS, W. VA. — Most physicians who prescribe hormone therapy still overestimate both its long-term risks and benefits, R. Stan Williams, M.D., said at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

Compared with internists and family doctors, ob.gyns. were the most likely to display an accurate understanding of these issues. But a large portion still gave incorrect answers to Dr. Williams' physician survey on hormone therapy (HT).

“These people thought they understood the results of the Women's Health Initiative [WHI] and said they were counseling their patients about it, but only 28% of their answers were correct,” said Dr. Williams, professor of ob.gyn. at the University of Florida, Gainesville, and chief of the university's division of reproductive endocrinology and infertility. “Most respondents (67%) dramatically overestimated the risks and benefits,” and 5% of the answers “were actually in the wrong direction—they thought it was a risk when it was a benefit.”

In March 2004, Dr. Williams mailed his survey to all primary care physicians in Florida. The survey asked a specific question about the percentage of annual attributable change of risk of heart disease, stroke, venous thrombosis, breast cancer, colon cancer, hip fracture and death, as reported in the WHI. He sent out more than 6,000 surveys; 600 were returned (203 from ob.gyns., 145 from internists, 219 from family physicians, and 33 from other physicians).

About 35% of ob.gyns., 30% of family physicians, and 17% of internists correctly answered that HT increased the risk of heart disease by less than 1% per year of use. Many thought there was no change in risk (35% of internists, 33% of ob.gyns., and 27% of family physicians). About 20% of internists and 15% of family physicians said the risk rose 10%-30% per year of use.

About 50% of ob.gyns., 35% of internists, and 30% of family physicians correctly answered that HT increased the risk of stroke by less than 1% per year of use. About 20% of family physicians, 17% of internists, and 15% of ob.gyns. said the increased risk was 10%-30% per year of use.

About 50% of ob.gyns., 30% of internists, and 27% of family physicians correctly answered that HT increases the risk of venous thrombosis by less than 1% per year of use. About 30% of ob.gyns., 25% of internists, and 30% of family physicians said the risk was increased by 10%-30% per year of use.

About half of ob.gyns., half of family physicians, and 40% of internists correctly answered that HT increases the risk of breast cancer by less than 1% per year of use. About 17% of internists, 15% of family physicians, and 8% of ob.gyns. said the increased risk was 10%-30% per year of use.

The benefits of HT also were misunderstood. Only about 35% of ob.gyns., 20% of internists, and 17% of family physicians correctly answered that the breast cancer risk fell about 1% per year of use.

Most internists (70%) and family physicians (55%) and 30% of ob.gyns. said HT did not change the risk of colon cancer. Only 20% of ob.gyns., 18% of family physicians, and 20% of internists correctly answered that the risk fell 1% per year of use.

About 17% of ob.gyns., 15% of internists, and 10% of family physicians correctly answered that HT decreases the risk of osteoporotic hip fracture by 1% per year of use. About 60% of internists, 55% of ob.gyns., and 50% of family physicians thought the risk reduction was 10%-30% per year of use.

Most respondents understood that there is no change in overall mortality rates associated with HT use. About 85% of ob.gyns. and 65% of internists and family physicians answered correctly. But a few respondents said the overall mortality risk increased 3%-10% per year of use.

Dr. Williams also asked respondents' views of HT on a scale of 1–5, with 5 being positive. The average rating was 3.89 among ob.gyns., 3.0 among family physicians, and 2.7 among internists.

Last year, he presented results of a similar survey he conducted among 1,000 women aged 45–65, which showed that up to 36% believed their attributable risk of heart disease and stroke was 10%-30% per year of HT use. More than half believed the breast cancer risk was 10%-30% per year of HT, and 60% believed HT could reduce the risk of osteoporotic hip fracture by up to 30% per year.

WHITE SULPHUR SPRINGS, W. VA. — Most physicians who prescribe hormone therapy still overestimate both its long-term risks and benefits, R. Stan Williams, M.D., said at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

Compared with internists and family doctors, ob.gyns. were the most likely to display an accurate understanding of these issues. But a large portion still gave incorrect answers to Dr. Williams' physician survey on hormone therapy (HT).

“These people thought they understood the results of the Women's Health Initiative [WHI] and said they were counseling their patients about it, but only 28% of their answers were correct,” said Dr. Williams, professor of ob.gyn. at the University of Florida, Gainesville, and chief of the university's division of reproductive endocrinology and infertility. “Most respondents (67%) dramatically overestimated the risks and benefits,” and 5% of the answers “were actually in the wrong direction—they thought it was a risk when it was a benefit.”

In March 2004, Dr. Williams mailed his survey to all primary care physicians in Florida. The survey asked a specific question about the percentage of annual attributable change of risk of heart disease, stroke, venous thrombosis, breast cancer, colon cancer, hip fracture and death, as reported in the WHI. He sent out more than 6,000 surveys; 600 were returned (203 from ob.gyns., 145 from internists, 219 from family physicians, and 33 from other physicians).

About 35% of ob.gyns., 30% of family physicians, and 17% of internists correctly answered that HT increased the risk of heart disease by less than 1% per year of use. Many thought there was no change in risk (35% of internists, 33% of ob.gyns., and 27% of family physicians). About 20% of internists and 15% of family physicians said the risk rose 10%-30% per year of use.

About 50% of ob.gyns., 35% of internists, and 30% of family physicians correctly answered that HT increased the risk of stroke by less than 1% per year of use. About 20% of family physicians, 17% of internists, and 15% of ob.gyns. said the increased risk was 10%-30% per year of use.

About 50% of ob.gyns., 30% of internists, and 27% of family physicians correctly answered that HT increases the risk of venous thrombosis by less than 1% per year of use. About 30% of ob.gyns., 25% of internists, and 30% of family physicians said the risk was increased by 10%-30% per year of use.

About half of ob.gyns., half of family physicians, and 40% of internists correctly answered that HT increases the risk of breast cancer by less than 1% per year of use. About 17% of internists, 15% of family physicians, and 8% of ob.gyns. said the increased risk was 10%-30% per year of use.

The benefits of HT also were misunderstood. Only about 35% of ob.gyns., 20% of internists, and 17% of family physicians correctly answered that the breast cancer risk fell about 1% per year of use.

Most internists (70%) and family physicians (55%) and 30% of ob.gyns. said HT did not change the risk of colon cancer. Only 20% of ob.gyns., 18% of family physicians, and 20% of internists correctly answered that the risk fell 1% per year of use.

About 17% of ob.gyns., 15% of internists, and 10% of family physicians correctly answered that HT decreases the risk of osteoporotic hip fracture by 1% per year of use. About 60% of internists, 55% of ob.gyns., and 50% of family physicians thought the risk reduction was 10%-30% per year of use.

Most respondents understood that there is no change in overall mortality rates associated with HT use. About 85% of ob.gyns. and 65% of internists and family physicians answered correctly. But a few respondents said the overall mortality risk increased 3%-10% per year of use.

Dr. Williams also asked respondents' views of HT on a scale of 1–5, with 5 being positive. The average rating was 3.89 among ob.gyns., 3.0 among family physicians, and 2.7 among internists.

Last year, he presented results of a similar survey he conducted among 1,000 women aged 45–65, which showed that up to 36% believed their attributable risk of heart disease and stroke was 10%-30% per year of HT use. More than half believed the breast cancer risk was 10%-30% per year of HT, and 60% believed HT could reduce the risk of osteoporotic hip fracture by up to 30% per year.

Being almost compliant with antiretroviral therapy was associated with a sharp increase in the risk that HIV-infected patients would develop resistance to one or more of the drugs, P. Richard Harrigan, Ph.D., reported at an American Medical Association press briefing.

In a prospective cohort study of 1,191 HIV-infected patients, those who picked up 80%-90% of their prescription refills, and those who occasionally had low serum drug levels even if they picked up 95% of their medication, had more than a fourfold increase in the risk of developing drug-resistant mutations, said Dr. Harrigan, director of the British Columbia Center for Excellence in HIV Research Labs, Vancouver, B.C.

Inconsistent drug levels allow viral loads to increase and also put pressure on the virus to adapt. Patients who consistently take all their medication suppress viral reproduction so well that mutations are unlikely, and those with poor adherence don't have enough drugs in their system to stimulate mutations.

“Physicians should get this message to patients: Be fully, completely adherent as much as humanly possible,” he said.

In the study of patients in British Columbia, the median age was 37 years, the median CD4 cell count was 280 cells/μL, and the median viral load was 120,000 copies/mL. All patients began antiretroviral therapy during 1996-1999; 26 drug combinations were used. Viral load, drug levels, and resistance genotyping were assessed at baseline, after 1 month of therapy, and then quarterly (J. Infect. Dis. 2005:191;339-47).

After an average follow-up of 2.5 years, 25% of the cohort developed resistance to one or more drugs. Among these, 68.5% were resistant to lamivudine (3TC), 40% to nonnucleoside reverse transcriptase inhibitors, 33% to nucleoside reverse transcriptase inhibitors, and 23% to protease inhibitors.

The highest risk of resistance mutations occurred in those who picked up 80%-90% of their prescription refills. This group was 4.15 times more likely to develop resistance mutations than were those who picked up 0%-20% of their refills.

An 80%-90% refill rate is “pretty reasonable for some diseases, but not for this. It's not like in horseshoes, where close is good enough. Here, close is a bad thing,” Dr. Harrigan said.

Patients with one or two abnormally low drug concentrations in their first two posttherapy plasma samples were 1.45 times more likely to develop mutations than were those with normal drug levels.

But some patients who picked up more than 95% of their medication still weren't taking it consistently, and they, too, were at a high risk of developing resistance mutations. Among this group, those who had two abnormally low drug plasma levels were 4.57 times more likely to develop mutations than were those with normal drug plasma levels.

As long-term survival increases, drug resistance is becoming more of a problem, Dr. Harrigan said. In recent studies, up to 50% of the U.S. population being treated for HIV infection had some degree of resistance.

The 25% resistance rate among the study patients reflects conditions that many American HIV patients don't experience: free access to antiretroviral drugs, provided by Canada's nationalized health system. Still, even with free access to medication, only 30% of the study group was fully adherent, picking up 100% of medication refills and having therapeutic plasma drug levels at every test.

The risk of nonadherence increases as patients move beyond initially prescribed regimens, which usually are the most manageable, said Kathleen Squires, M.D., of the University of Southern California, Los Angeles.

“We're taking patients with adherence problems to begin with, and then putting them on a more complex regimen that can cause even more adherence problems,” she said.

“Nonadherence has punishing effects,” said John Bartlett, M.D., founding director of the Johns Hopkins HIV Care Program. “We've got to figure out better ways to make patients understand they must take their medication as prescribed.”

Being almost compliant with antiretroviral therapy was associated with a sharp increase in the risk that HIV-infected patients would develop resistance to one or more of the drugs, P. Richard Harrigan, Ph.D., reported at an American Medical Association press briefing.

In a prospective cohort study of 1,191 HIV-infected patients, those who picked up 80%-90% of their prescription refills, and those who occasionally had low serum drug levels even if they picked up 95% of their medication, had more than a fourfold increase in the risk of developing drug-resistant mutations, said Dr. Harrigan, director of the British Columbia Center for Excellence in HIV Research Labs, Vancouver, B.C.

Inconsistent drug levels allow viral loads to increase and also put pressure on the virus to adapt. Patients who consistently take all their medication suppress viral reproduction so well that mutations are unlikely, and those with poor adherence don't have enough drugs in their system to stimulate mutations.

“Physicians should get this message to patients: Be fully, completely adherent as much as humanly possible,” he said.

In the study of patients in British Columbia, the median age was 37 years, the median CD4 cell count was 280 cells/μL, and the median viral load was 120,000 copies/mL. All patients began antiretroviral therapy during 1996-1999; 26 drug combinations were used. Viral load, drug levels, and resistance genotyping were assessed at baseline, after 1 month of therapy, and then quarterly (J. Infect. Dis. 2005:191;339-47).

After an average follow-up of 2.5 years, 25% of the cohort developed resistance to one or more drugs. Among these, 68.5% were resistant to lamivudine (3TC), 40% to nonnucleoside reverse transcriptase inhibitors, 33% to nucleoside reverse transcriptase inhibitors, and 23% to protease inhibitors.

The highest risk of resistance mutations occurred in those who picked up 80%-90% of their prescription refills. This group was 4.15 times more likely to develop resistance mutations than were those who picked up 0%-20% of their refills.

An 80%-90% refill rate is “pretty reasonable for some diseases, but not for this. It's not like in horseshoes, where close is good enough. Here, close is a bad thing,” Dr. Harrigan said.

Patients with one or two abnormally low drug concentrations in their first two posttherapy plasma samples were 1.45 times more likely to develop mutations than were those with normal drug levels.

But some patients who picked up more than 95% of their medication still weren't taking it consistently, and they, too, were at a high risk of developing resistance mutations. Among this group, those who had two abnormally low drug plasma levels were 4.57 times more likely to develop mutations than were those with normal drug plasma levels.

As long-term survival increases, drug resistance is becoming more of a problem, Dr. Harrigan said. In recent studies, up to 50% of the U.S. population being treated for HIV infection had some degree of resistance.

The 25% resistance rate among the study patients reflects conditions that many American HIV patients don't experience: free access to antiretroviral drugs, provided by Canada's nationalized health system. Still, even with free access to medication, only 30% of the study group was fully adherent, picking up 100% of medication refills and having therapeutic plasma drug levels at every test.

The risk of nonadherence increases as patients move beyond initially prescribed regimens, which usually are the most manageable, said Kathleen Squires, M.D., of the University of Southern California, Los Angeles.

“We're taking patients with adherence problems to begin with, and then putting them on a more complex regimen that can cause even more adherence problems,” she said.

“Nonadherence has punishing effects,” said John Bartlett, M.D., founding director of the Johns Hopkins HIV Care Program. “We've got to figure out better ways to make patients understand they must take their medication as prescribed.”

Being almost compliant with antiretroviral therapy was associated with a sharp increase in the risk that HIV-infected patients would develop resistance to one or more of the drugs, P. Richard Harrigan, Ph.D., reported at an American Medical Association press briefing.

In a prospective cohort study of 1,191 HIV-infected patients, those who picked up 80%-90% of their prescription refills, and those who occasionally had low serum drug levels even if they picked up 95% of their medication, had more than a fourfold increase in the risk of developing drug-resistant mutations, said Dr. Harrigan, director of the British Columbia Center for Excellence in HIV Research Labs, Vancouver, B.C.

Inconsistent drug levels allow viral loads to increase and also put pressure on the virus to adapt. Patients who consistently take all their medication suppress viral reproduction so well that mutations are unlikely, and those with poor adherence don't have enough drugs in their system to stimulate mutations.

“Physicians should get this message to patients: Be fully, completely adherent as much as humanly possible,” he said.

In the study of patients in British Columbia, the median age was 37 years, the median CD4 cell count was 280 cells/μL, and the median viral load was 120,000 copies/mL. All patients began antiretroviral therapy during 1996-1999; 26 drug combinations were used. Viral load, drug levels, and resistance genotyping were assessed at baseline, after 1 month of therapy, and then quarterly (J. Infect. Dis. 2005:191;339-47).

After an average follow-up of 2.5 years, 25% of the cohort developed resistance to one or more drugs. Among these, 68.5% were resistant to lamivudine (3TC), 40% to nonnucleoside reverse transcriptase inhibitors, 33% to nucleoside reverse transcriptase inhibitors, and 23% to protease inhibitors.

The highest risk of resistance mutations occurred in those who picked up 80%-90% of their prescription refills. This group was 4.15 times more likely to develop resistance mutations than were those who picked up 0%-20% of their refills.

An 80%-90% refill rate is “pretty reasonable for some diseases, but not for this. It's not like in horseshoes, where close is good enough. Here, close is a bad thing,” Dr. Harrigan said.

Patients with one or two abnormally low drug concentrations in their first two posttherapy plasma samples were 1.45 times more likely to develop mutations than were those with normal drug levels.

But some patients who picked up more than 95% of their medication still weren't taking it consistently, and they, too, were at a high risk of developing resistance mutations. Among this group, those who had two abnormally low drug plasma levels were 4.57 times more likely to develop mutations than were those with normal drug plasma levels.

As long-term survival increases, drug resistance is becoming more of a problem, Dr. Harrigan said. In recent studies, up to 50% of the U.S. population being treated for HIV infection had some degree of resistance.

The 25% resistance rate among the study patients reflects conditions that many American HIV patients don't experience: free access to antiretroviral drugs, provided by Canada's nationalized health system. Still, even with free access to medication, only 30% of the study group was fully adherent, picking up 100% of medication refills and having therapeutic plasma drug levels at every test.

The risk of nonadherence increases as patients move beyond initially prescribed regimens, which usually are the most manageable, said Kathleen Squires, M.D., of the University of Southern California, Los Angeles.

“We're taking patients with adherence problems to begin with, and then putting them on a more complex regimen that can cause even more adherence problems,” she said.

“Nonadherence has punishing effects,” said John Bartlett, M.D., founding director of the Johns Hopkins HIV Care Program. “We've got to figure out better ways to make patients understand they must take their medication as prescribed.”

Adolescent women who use the injectable contraceptive depot medroxyprogesterone acetate lose bone mineral density each year they are on the drug but appear to rapidly recover that loss when the drug is withdrawn, results of a prospective study suggest.

When counseling young women on birth control methods, physicians should consider DMPA's effect on bone mineral density (BMD).

“The potential loss of bone density is one consideration of the many that go into a women's choice of contraceptive method,” said Delia Scholes, Ph.D., of the Center for Health Studies, Seattle, and her associates.

The researchers prospectively examined BMD in a cohort of 170 females aged 14-18. A total of 80 participants were using DMPA, and 90 were not. The DMPA-exposed teens were significantly more likely to be current smokers, to have been pregnant, have reached earlier menarche, and have a higher body mass index and body fat percentage (Arch. Pediatr. Adolesc. Med. 2005;159:139-44).

During the study, 61 of the DMP users discontinued the contraceptive, affording the opportunity to observe any subsequent changes in BMD.

The DMPA-exposed subjects were receiving the standard dose of 150 mg every 3 months. About 30% of them had received only 1 injection, 31% had received 2 or 3 injections, 21% had received 4-7 injections, and 18% had received at least 18 injections.

In the comparison group, 19% were using oral contraceptives at baseline.

BMD was measured at the hip, spine, and whole body every 6 months for 24-36 months.

After adjusting for baseline and time-dependent variables, the researchers determined that the DMPA users lost significantly more BMD at the hip (-1.81% vs. -0.19%) and spine (-0.97% vs. 1.32%), compared with nonusers. Both groups gained BMD when the whole body was measured, but the DMPA users gained significantly less than the nonusers (0.73% vs. 0.88%).

New users lost bone faster than continuous users. After 24 months, new users showed a -6.09% change at the hip, compared with -2.05% in continuous users and -0.92% in nonusers.

Among the 61 subjects who discontinued DMPA during the study, BMD increased. Their annualized adjusted mean change in BMD was 1.34% for hip, 2.86% for spine, and 3.56% for the whole body.

There was no significance in BMD between nonusers and those who had discontinued DMPA 18 months earlier.

The injection is highly effective in preventing pregnancy, and its quarterly administration helps reduce compliance problems sometime seen in young women using other contraceptives, the researchers said.

In 2004, the Food and Drug Administration issued a black box warning for DMPA stating that prolonged use of the drug could result in significant loss of bone density, that the loss is greater the longer the drug is administered, and that bone density loss may not be completely reversible after discontinuing the drug.

Adolescent women who use the injectable contraceptive depot medroxyprogesterone acetate lose bone mineral density each year they are on the drug but appear to rapidly recover that loss when the drug is withdrawn, results of a prospective study suggest.

When counseling young women on birth control methods, physicians should consider DMPA's effect on bone mineral density (BMD).

“The potential loss of bone density is one consideration of the many that go into a women's choice of contraceptive method,” said Delia Scholes, Ph.D., of the Center for Health Studies, Seattle, and her associates.

The researchers prospectively examined BMD in a cohort of 170 females aged 14-18. A total of 80 participants were using DMPA, and 90 were not. The DMPA-exposed teens were significantly more likely to be current smokers, to have been pregnant, have reached earlier menarche, and have a higher body mass index and body fat percentage (Arch. Pediatr. Adolesc. Med. 2005;159:139-44).

During the study, 61 of the DMP users discontinued the contraceptive, affording the opportunity to observe any subsequent changes in BMD.

The DMPA-exposed subjects were receiving the standard dose of 150 mg every 3 months. About 30% of them had received only 1 injection, 31% had received 2 or 3 injections, 21% had received 4-7 injections, and 18% had received at least 18 injections.

In the comparison group, 19% were using oral contraceptives at baseline.

BMD was measured at the hip, spine, and whole body every 6 months for 24-36 months.

After adjusting for baseline and time-dependent variables, the researchers determined that the DMPA users lost significantly more BMD at the hip (-1.81% vs. -0.19%) and spine (-0.97% vs. 1.32%), compared with nonusers. Both groups gained BMD when the whole body was measured, but the DMPA users gained significantly less than the nonusers (0.73% vs. 0.88%).

New users lost bone faster than continuous users. After 24 months, new users showed a -6.09% change at the hip, compared with -2.05% in continuous users and -0.92% in nonusers.

Among the 61 subjects who discontinued DMPA during the study, BMD increased. Their annualized adjusted mean change in BMD was 1.34% for hip, 2.86% for spine, and 3.56% for the whole body.

There was no significance in BMD between nonusers and those who had discontinued DMPA 18 months earlier.

The injection is highly effective in preventing pregnancy, and its quarterly administration helps reduce compliance problems sometime seen in young women using other contraceptives, the researchers said.

In 2004, the Food and Drug Administration issued a black box warning for DMPA stating that prolonged use of the drug could result in significant loss of bone density, that the loss is greater the longer the drug is administered, and that bone density loss may not be completely reversible after discontinuing the drug.

Adolescent women who use the injectable contraceptive depot medroxyprogesterone acetate lose bone mineral density each year they are on the drug but appear to rapidly recover that loss when the drug is withdrawn, results of a prospective study suggest.

When counseling young women on birth control methods, physicians should consider DMPA's effect on bone mineral density (BMD).

“The potential loss of bone density is one consideration of the many that go into a women's choice of contraceptive method,” said Delia Scholes, Ph.D., of the Center for Health Studies, Seattle, and her associates.

The researchers prospectively examined BMD in a cohort of 170 females aged 14-18. A total of 80 participants were using DMPA, and 90 were not. The DMPA-exposed teens were significantly more likely to be current smokers, to have been pregnant, have reached earlier menarche, and have a higher body mass index and body fat percentage (Arch. Pediatr. Adolesc. Med. 2005;159:139-44).

During the study, 61 of the DMP users discontinued the contraceptive, affording the opportunity to observe any subsequent changes in BMD.

The DMPA-exposed subjects were receiving the standard dose of 150 mg every 3 months. About 30% of them had received only 1 injection, 31% had received 2 or 3 injections, 21% had received 4-7 injections, and 18% had received at least 18 injections.

In the comparison group, 19% were using oral contraceptives at baseline.

BMD was measured at the hip, spine, and whole body every 6 months for 24-36 months.

After adjusting for baseline and time-dependent variables, the researchers determined that the DMPA users lost significantly more BMD at the hip (-1.81% vs. -0.19%) and spine (-0.97% vs. 1.32%), compared with nonusers. Both groups gained BMD when the whole body was measured, but the DMPA users gained significantly less than the nonusers (0.73% vs. 0.88%).

New users lost bone faster than continuous users. After 24 months, new users showed a -6.09% change at the hip, compared with -2.05% in continuous users and -0.92% in nonusers.

Among the 61 subjects who discontinued DMPA during the study, BMD increased. Their annualized adjusted mean change in BMD was 1.34% for hip, 2.86% for spine, and 3.56% for the whole body.

There was no significance in BMD between nonusers and those who had discontinued DMPA 18 months earlier.

The injection is highly effective in preventing pregnancy, and its quarterly administration helps reduce compliance problems sometime seen in young women using other contraceptives, the researchers said.

In 2004, the Food and Drug Administration issued a black box warning for DMPA stating that prolonged use of the drug could result in significant loss of bone density, that the loss is greater the longer the drug is administered, and that bone density loss may not be completely reversible after discontinuing the drug.

WHITE SULPHUR SPRINGS, W.VA. — A treatment algorithm based on DNA identification of high-risk human papilloma virus subtypes could eliminate much unnecessary surgical intervention for women eventually found to have no cervical abnormality, William Irvin, M.D., reported.

“If the initial HPV DNA screening is negative, the likelihood that the patient harbors a high-grade squamous cervical lesion is very low, and rather than continue with diagnostic loop electrosurgical excision or conization, we would recommend conservative follow-up,” Dr. Irvin of the University of Virginia, Charlottesville, said at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

“It's hoped that by following this algorithm, we can reduce or avoid unnecessary conization and electrosurgical excision procedures in women who are truly at low risk for cervical or endocervical lesions.” (See box.)

Dr. Irvin based his suggestions on the results of two studies. A 1999 Kaiser Permanente study of 137 women with cytologic atypical glandular cells (AGC) found that HPV DNA testing identified 94% of those with high-grade squamous intraepithelial lesions (HSIL) and 100% of those with endocervical adenocarcinoma in situ (Hum. Pathol. 1999;30:816-25).

And his own small study of 28 women with cytologic AGC found that the DNA testing had both a 100% sensitivity for detecting cervical intraepithelial neoplasia and a 100% negative predictive value for ruling out dysplasia.

“The take-home message of our study is that when a patient presents with cytologic AGC, and the HPV testing is negative [for high-risk strains], the likelihood of a high-grade endocervical lesion is exceedingly small, and you could consider that smear to be either reactive in nature or, if pathologic, most likely to be arising from lesions of the endometrium or adnexa,” he said.

Dr. Irvin prospectively analyzed 28 women who presented to a colposcopy clinic from 2002 to 2004. All of the women had a repeat ThinPrep System Pap smear for cytology and HPV testing, a colposcopy, and Fischer electrosurgical conization, followed by Pipelle endometrial biopsy.

A total of 58% of the group had significant pathologic abnormalities. Squamous intraepithelial lesions occurred in 50% of the group; 11 of those were HSIL, and 3 were low-grade squamous intraepithelial lesions. One woman had endocervical adenocarcinoma in situ, and one had endometrial hyperplasia.

Normal cells were found in 42% of the group. No cancers were found in study participants. Four of the HPV DNA samples were contaminated with blood, so results were available for 24 patients. Of those, 17 were positive for high-risk HPV, including all 13 dysplastic patients. Seven of the tests were negative for high-risk HPV, and none of the patients with negative test outcomes had dysplasia.

Management Tips for Women With Cytologic Atypical Glandular Cells

▸For women older than 35 years, women younger than 35 years who have abnormal bleeding, and women with AGC that “favors endometrial cells”: Perform endometrial sampling.

▸If AGC “favors endocervical adenocarcinoma in situ”: Perform cold-knife conization and subsequent cervical curettage.

▸ For AGC not otherwise specified: Perform HPV DNA testing.

If the patient is negative for high-risk HPV, repeat cytology at 6-month intervals until two consecutive normal results are obtained. If abnormal cytology persists, refer the patient to colposcopy.

If the patient is positive for high-risk HPV, the likelihood of a dysplastic cervical lesion—typically high-grade—is high. Perform colposcopy, biopsy as indicated, and obtain endocervical samplings. Base further management on the results of the evaluation.

Source: Dr. Irvin

WHITE SULPHUR SPRINGS, W.VA. — A treatment algorithm based on DNA identification of high-risk human papilloma virus subtypes could eliminate much unnecessary surgical intervention for women eventually found to have no cervical abnormality, William Irvin, M.D., reported.

“If the initial HPV DNA screening is negative, the likelihood that the patient harbors a high-grade squamous cervical lesion is very low, and rather than continue with diagnostic loop electrosurgical excision or conization, we would recommend conservative follow-up,” Dr. Irvin of the University of Virginia, Charlottesville, said at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

“It's hoped that by following this algorithm, we can reduce or avoid unnecessary conization and electrosurgical excision procedures in women who are truly at low risk for cervical or endocervical lesions.” (See box.)

Dr. Irvin based his suggestions on the results of two studies. A 1999 Kaiser Permanente study of 137 women with cytologic atypical glandular cells (AGC) found that HPV DNA testing identified 94% of those with high-grade squamous intraepithelial lesions (HSIL) and 100% of those with endocervical adenocarcinoma in situ (Hum. Pathol. 1999;30:816-25).

And his own small study of 28 women with cytologic AGC found that the DNA testing had both a 100% sensitivity for detecting cervical intraepithelial neoplasia and a 100% negative predictive value for ruling out dysplasia.

“The take-home message of our study is that when a patient presents with cytologic AGC, and the HPV testing is negative [for high-risk strains], the likelihood of a high-grade endocervical lesion is exceedingly small, and you could consider that smear to be either reactive in nature or, if pathologic, most likely to be arising from lesions of the endometrium or adnexa,” he said.

Dr. Irvin prospectively analyzed 28 women who presented to a colposcopy clinic from 2002 to 2004. All of the women had a repeat ThinPrep System Pap smear for cytology and HPV testing, a colposcopy, and Fischer electrosurgical conization, followed by Pipelle endometrial biopsy.

A total of 58% of the group had significant pathologic abnormalities. Squamous intraepithelial lesions occurred in 50% of the group; 11 of those were HSIL, and 3 were low-grade squamous intraepithelial lesions. One woman had endocervical adenocarcinoma in situ, and one had endometrial hyperplasia.

Normal cells were found in 42% of the group. No cancers were found in study participants. Four of the HPV DNA samples were contaminated with blood, so results were available for 24 patients. Of those, 17 were positive for high-risk HPV, including all 13 dysplastic patients. Seven of the tests were negative for high-risk HPV, and none of the patients with negative test outcomes had dysplasia.

Management Tips for Women With Cytologic Atypical Glandular Cells

▸For women older than 35 years, women younger than 35 years who have abnormal bleeding, and women with AGC that “favors endometrial cells”: Perform endometrial sampling.

▸If AGC “favors endocervical adenocarcinoma in situ”: Perform cold-knife conization and subsequent cervical curettage.

▸ For AGC not otherwise specified: Perform HPV DNA testing.

If the patient is negative for high-risk HPV, repeat cytology at 6-month intervals until two consecutive normal results are obtained. If abnormal cytology persists, refer the patient to colposcopy.

If the patient is positive for high-risk HPV, the likelihood of a dysplastic cervical lesion—typically high-grade—is high. Perform colposcopy, biopsy as indicated, and obtain endocervical samplings. Base further management on the results of the evaluation.

Source: Dr. Irvin

WHITE SULPHUR SPRINGS, W.VA. — A treatment algorithm based on DNA identification of high-risk human papilloma virus subtypes could eliminate much unnecessary surgical intervention for women eventually found to have no cervical abnormality, William Irvin, M.D., reported.

“If the initial HPV DNA screening is negative, the likelihood that the patient harbors a high-grade squamous cervical lesion is very low, and rather than continue with diagnostic loop electrosurgical excision or conization, we would recommend conservative follow-up,” Dr. Irvin of the University of Virginia, Charlottesville, said at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

“It's hoped that by following this algorithm, we can reduce or avoid unnecessary conization and electrosurgical excision procedures in women who are truly at low risk for cervical or endocervical lesions.” (See box.)

Dr. Irvin based his suggestions on the results of two studies. A 1999 Kaiser Permanente study of 137 women with cytologic atypical glandular cells (AGC) found that HPV DNA testing identified 94% of those with high-grade squamous intraepithelial lesions (HSIL) and 100% of those with endocervical adenocarcinoma in situ (Hum. Pathol. 1999;30:816-25).

And his own small study of 28 women with cytologic AGC found that the DNA testing had both a 100% sensitivity for detecting cervical intraepithelial neoplasia and a 100% negative predictive value for ruling out dysplasia.

“The take-home message of our study is that when a patient presents with cytologic AGC, and the HPV testing is negative [for high-risk strains], the likelihood of a high-grade endocervical lesion is exceedingly small, and you could consider that smear to be either reactive in nature or, if pathologic, most likely to be arising from lesions of the endometrium or adnexa,” he said.

Dr. Irvin prospectively analyzed 28 women who presented to a colposcopy clinic from 2002 to 2004. All of the women had a repeat ThinPrep System Pap smear for cytology and HPV testing, a colposcopy, and Fischer electrosurgical conization, followed by Pipelle endometrial biopsy.

A total of 58% of the group had significant pathologic abnormalities. Squamous intraepithelial lesions occurred in 50% of the group; 11 of those were HSIL, and 3 were low-grade squamous intraepithelial lesions. One woman had endocervical adenocarcinoma in situ, and one had endometrial hyperplasia.

Normal cells were found in 42% of the group. No cancers were found in study participants. Four of the HPV DNA samples were contaminated with blood, so results were available for 24 patients. Of those, 17 were positive for high-risk HPV, including all 13 dysplastic patients. Seven of the tests were negative for high-risk HPV, and none of the patients with negative test outcomes had dysplasia.

Management Tips for Women With Cytologic Atypical Glandular Cells

▸For women older than 35 years, women younger than 35 years who have abnormal bleeding, and women with AGC that “favors endometrial cells”: Perform endometrial sampling.

▸If AGC “favors endocervical adenocarcinoma in situ”: Perform cold-knife conization and subsequent cervical curettage.

▸ For AGC not otherwise specified: Perform HPV DNA testing.

If the patient is negative for high-risk HPV, repeat cytology at 6-month intervals until two consecutive normal results are obtained. If abnormal cytology persists, refer the patient to colposcopy.

If the patient is positive for high-risk HPV, the likelihood of a dysplastic cervical lesion—typically high-grade—is high. Perform colposcopy, biopsy as indicated, and obtain endocervical samplings. Base further management on the results of the evaluation.

Source: Dr. Irvin

WHITE SULPHUR SPRINGS, W.VA. — Most physicians who prescribe hormone therapy still overestimate both its long-term risks and benefits, R. Stan Williams, M.D., said at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

Compared with internists and family doctors, ob.gyns. were the most likely to display an accurate understanding of these issues. But a large portion still gave incorrect answers to Dr. Williams' statewide physician survey on hormone therapy (HT).

“These people thought they understood the results of the Women's Health Initiative [WHI] and said they were counseling their patients about it, but only 28% of their answers were correct,” said Dr. Williams, professor of ob.gyn of the University of Florida, Gainesville, and chief of the university's division of reproductive endocrinology and infertility.

“Most respondents (67%) dramatically overestimated the risks and benefits,” and 5% of the answers “were actually in the wrong direction; they thought it was a risk when it was actually a benefit,” he said.

In March 2004, Dr. Williams mailed his survey to all primary care physicians in Florida. The survey asked a specific question about the percentage of annual attributable change of risk of heart disease, stroke, venous thrombosis, breast cancer, colon cancer, hip fracture and death, as reported in the WHI.

He sent out more than 6,000 surveys; 600 were returned (203 from ob.gyns., 145 from internists, 219 from family physicians, and 33 from other physicians).

About 35% of ob.gyns., 30% of family physicians, and 17% of internists correctly answered that HT increased the risk of heart disease by less than 1% per year of use. Many thought there was no change in risk (35% of internists, 33% of ob.gyns, and 27% of family physicians). About 20% of internists and 15% of family physicians said the risk was increased 10%-30% per year of use.

About 50% of ob.gyns., 35% of internists, and 30% of family physicians correctly answered that HT increased the risk of stroke by less than 1% per year of use. About 20% of family physicians, 17% of internists, and 15% of ob.gyns. said the increased risk was 10%-30% per year of use.

About 50% of ob.gyns., 30% of internists, and 27% of family physicians correctly answered that HT increases the risk of venous thrombosis by less than 1% per year of use. About 30% of ob.gyns., 25% of internists, and 30% of family physicians said the risk was increased by 10%-30% per year of use.

About half of ob.gyns, half of family physicians, and 40% of internists correctly answered that HT increases the risk of breast cancer by less than 1% per year of use. About 17% of internists, 15% of family physicians, and 8% of ob.gyns said the increased risk was 10%-30% per year of use.

The benefits of HT also were misunderstood. Only about 35% of ob.gyns, 20% of internists, and 17% of family physicians correctly answered that the decrease in risk of breast cancer was about 1% per year of use.

Most internists (70%) and family physicians (55%) and 30% of ob.gyns. said HT did not change the risk of colon cancer. Only 20% of ob.gyns., 18% of family physicians, and 20% of internists correctly answered that the decreased risk was 1% per year of use.

About 17% of ob.gyns., 15% of internists, and 10% of family physicians correctly answered that HT decreases the risk of osteoporotic hip fracture by 1% per year of use.

About 60% of family physicians, 55% of ob.gyns., and 50% of family physicians thought the risk reduction was 10%-30% per year of use.

Most respondents understood that there is no change in overall mortality rates associated with HT use. About 85% of ob.gyns. and 65% of internists and family physicians answered correctly. But a few respondents said the overall mortality risk increased 3%-10% per year of use.

Dr. Williams also asked respondents' views of HT on a scale of 1-5, with 5 being positive. The average rating was 3.89 among ob.gyns., 3.0 among family physicians, and 2.7 among internists.

In 2004, Dr. Williams presented the results of a similar survey he conducted among 1,000 women aged 45-65. This study showed that up to 36% believed that their attributable risk for heart disease and stroke was 10%-30% per year of HT use.

More than half believed the risk for breast cancer was 10%-30% per year of HT, and 60% believed HT could reduce their risk of osteoporotic hip fracture by up to 30% per year.

WHITE SULPHUR SPRINGS, W.VA. — Most physicians who prescribe hormone therapy still overestimate both its long-term risks and benefits, R. Stan Williams, M.D., said at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

Compared with internists and family doctors, ob.gyns. were the most likely to display an accurate understanding of these issues. But a large portion still gave incorrect answers to Dr. Williams' statewide physician survey on hormone therapy (HT).

“These people thought they understood the results of the Women's Health Initiative [WHI] and said they were counseling their patients about it, but only 28% of their answers were correct,” said Dr. Williams, professor of ob.gyn of the University of Florida, Gainesville, and chief of the university's division of reproductive endocrinology and infertility.

“Most respondents (67%) dramatically overestimated the risks and benefits,” and 5% of the answers “were actually in the wrong direction; they thought it was a risk when it was actually a benefit,” he said.

In March 2004, Dr. Williams mailed his survey to all primary care physicians in Florida. The survey asked a specific question about the percentage of annual attributable change of risk of heart disease, stroke, venous thrombosis, breast cancer, colon cancer, hip fracture and death, as reported in the WHI.

He sent out more than 6,000 surveys; 600 were returned (203 from ob.gyns., 145 from internists, 219 from family physicians, and 33 from other physicians).

About 35% of ob.gyns., 30% of family physicians, and 17% of internists correctly answered that HT increased the risk of heart disease by less than 1% per year of use. Many thought there was no change in risk (35% of internists, 33% of ob.gyns, and 27% of family physicians). About 20% of internists and 15% of family physicians said the risk was increased 10%-30% per year of use.

About 50% of ob.gyns., 35% of internists, and 30% of family physicians correctly answered that HT increased the risk of stroke by less than 1% per year of use. About 20% of family physicians, 17% of internists, and 15% of ob.gyns. said the increased risk was 10%-30% per year of use.

About 50% of ob.gyns., 30% of internists, and 27% of family physicians correctly answered that HT increases the risk of venous thrombosis by less than 1% per year of use. About 30% of ob.gyns., 25% of internists, and 30% of family physicians said the risk was increased by 10%-30% per year of use.

About half of ob.gyns, half of family physicians, and 40% of internists correctly answered that HT increases the risk of breast cancer by less than 1% per year of use. About 17% of internists, 15% of family physicians, and 8% of ob.gyns said the increased risk was 10%-30% per year of use.

The benefits of HT also were misunderstood. Only about 35% of ob.gyns, 20% of internists, and 17% of family physicians correctly answered that the decrease in risk of breast cancer was about 1% per year of use.

Most internists (70%) and family physicians (55%) and 30% of ob.gyns. said HT did not change the risk of colon cancer. Only 20% of ob.gyns., 18% of family physicians, and 20% of internists correctly answered that the decreased risk was 1% per year of use.

About 17% of ob.gyns., 15% of internists, and 10% of family physicians correctly answered that HT decreases the risk of osteoporotic hip fracture by 1% per year of use.

About 60% of family physicians, 55% of ob.gyns., and 50% of family physicians thought the risk reduction was 10%-30% per year of use.

Most respondents understood that there is no change in overall mortality rates associated with HT use. About 85% of ob.gyns. and 65% of internists and family physicians answered correctly. But a few respondents said the overall mortality risk increased 3%-10% per year of use.

Dr. Williams also asked respondents' views of HT on a scale of 1-5, with 5 being positive. The average rating was 3.89 among ob.gyns., 3.0 among family physicians, and 2.7 among internists.

In 2004, Dr. Williams presented the results of a similar survey he conducted among 1,000 women aged 45-65. This study showed that up to 36% believed that their attributable risk for heart disease and stroke was 10%-30% per year of HT use.

More than half believed the risk for breast cancer was 10%-30% per year of HT, and 60% believed HT could reduce their risk of osteoporotic hip fracture by up to 30% per year.

WHITE SULPHUR SPRINGS, W.VA. — Most physicians who prescribe hormone therapy still overestimate both its long-term risks and benefits, R. Stan Williams, M.D., said at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

Compared with internists and family doctors, ob.gyns. were the most likely to display an accurate understanding of these issues. But a large portion still gave incorrect answers to Dr. Williams' statewide physician survey on hormone therapy (HT).

“These people thought they understood the results of the Women's Health Initiative [WHI] and said they were counseling their patients about it, but only 28% of their answers were correct,” said Dr. Williams, professor of ob.gyn of the University of Florida, Gainesville, and chief of the university's division of reproductive endocrinology and infertility.

“Most respondents (67%) dramatically overestimated the risks and benefits,” and 5% of the answers “were actually in the wrong direction; they thought it was a risk when it was actually a benefit,” he said.

In March 2004, Dr. Williams mailed his survey to all primary care physicians in Florida. The survey asked a specific question about the percentage of annual attributable change of risk of heart disease, stroke, venous thrombosis, breast cancer, colon cancer, hip fracture and death, as reported in the WHI.

He sent out more than 6,000 surveys; 600 were returned (203 from ob.gyns., 145 from internists, 219 from family physicians, and 33 from other physicians).

About 35% of ob.gyns., 30% of family physicians, and 17% of internists correctly answered that HT increased the risk of heart disease by less than 1% per year of use. Many thought there was no change in risk (35% of internists, 33% of ob.gyns, and 27% of family physicians). About 20% of internists and 15% of family physicians said the risk was increased 10%-30% per year of use.

About 50% of ob.gyns., 35% of internists, and 30% of family physicians correctly answered that HT increased the risk of stroke by less than 1% per year of use. About 20% of family physicians, 17% of internists, and 15% of ob.gyns. said the increased risk was 10%-30% per year of use.

About 50% of ob.gyns., 30% of internists, and 27% of family physicians correctly answered that HT increases the risk of venous thrombosis by less than 1% per year of use. About 30% of ob.gyns., 25% of internists, and 30% of family physicians said the risk was increased by 10%-30% per year of use.

About half of ob.gyns, half of family physicians, and 40% of internists correctly answered that HT increases the risk of breast cancer by less than 1% per year of use. About 17% of internists, 15% of family physicians, and 8% of ob.gyns said the increased risk was 10%-30% per year of use.

The benefits of HT also were misunderstood. Only about 35% of ob.gyns, 20% of internists, and 17% of family physicians correctly answered that the decrease in risk of breast cancer was about 1% per year of use.

Most internists (70%) and family physicians (55%) and 30% of ob.gyns. said HT did not change the risk of colon cancer. Only 20% of ob.gyns., 18% of family physicians, and 20% of internists correctly answered that the decreased risk was 1% per year of use.

About 17% of ob.gyns., 15% of internists, and 10% of family physicians correctly answered that HT decreases the risk of osteoporotic hip fracture by 1% per year of use.

About 60% of family physicians, 55% of ob.gyns., and 50% of family physicians thought the risk reduction was 10%-30% per year of use.

Most respondents understood that there is no change in overall mortality rates associated with HT use. About 85% of ob.gyns. and 65% of internists and family physicians answered correctly. But a few respondents said the overall mortality risk increased 3%-10% per year of use.

Dr. Williams also asked respondents' views of HT on a scale of 1-5, with 5 being positive. The average rating was 3.89 among ob.gyns., 3.0 among family physicians, and 2.7 among internists.

In 2004, Dr. Williams presented the results of a similar survey he conducted among 1,000 women aged 45-65. This study showed that up to 36% believed that their attributable risk for heart disease and stroke was 10%-30% per year of HT use.

More than half believed the risk for breast cancer was 10%-30% per year of HT, and 60% believed HT could reduce their risk of osteoporotic hip fracture by up to 30% per year.

WHITE SULPHUR SPRINGS, W.VA. — Within just 6-12 months of discontinuing hormone therapy, more than 96% of postmenopausal women will show altered vaginal pH, a marker for tissue change and its associated genital atrophy, Murray Freedman, M.D., reported.

Only 10 of 300 women maintained a normal vaginal pH of 4.5 or less after discontinuing HT use, and seven of those women had elevated serum estradiol levels related to obesity-driven estrogen production, said Dr. Freedman, of the Medical College of Georgia, Augusta.

The rest of the women had both elevated vaginal pH and decreased serum estradiol. The most common clinical finding in the study was involution of the vulvar structures and a rapidly occurring introital stenosis, which correlated with frequent complaints of dyspareunia, he noted at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

Because the onset of genital atrophy is insidious and its measurement subjective, the number who experienced it was “hard to quantify,” Dr. Freedman said in an interview. “There is no real measurement for it. But for many of these women, the stenosis became noticeable within 6-12 months.”

Dr. Freedman's observations have led him to conclude that the dyspareunia many postmenopausal women experience has more to do with introital stenosis than with vaginal dryness. “The dryness was secondary to the stenosis and the involution of the distal vagina. Once you got past the introitus, the upper vagina was uncompromised.”

His prospective observational study evaluated a total of 300 women who had discontinued hormone therapy after publication of the initial Women's Health Initiative results in July 2002. All women underwent a pelvic exam and had their vaginal pH tested within 12 months of therapy discontinuation (most within 6 months). Those women with a normal vaginal pH level (4.5 or below) had their serum estradiol level evaluated.

The vast majority of the women (290) had a pH level of more than 4.5. Only 10 maintained a normal vaginal pH. Three of those women had serum estradiol of less than 20 pcg/mL, consistent with postmenopausal status.

The other seven had normal circulating estradiol levels. One of these was a 50-year-old woman with her uterus, fallopian tubes, and ovaries intact, who had been placed on HT for menopausal symptoms. The other six women were older (57-76 years) and either overweight or obese. “Their normal estrogen levels and the resulting normal vaginal pH were due to a high production of endogenous estrogen secondary to obesity,” Dr. Freedman said.

In addition to observing introital stenosis, he noted that the urethral meatus became more prominent in many women, assuming almost a tubular form and expanding to constitute up to two-thirds of the introitus. This is not surprising, he said, because the urethra and trigone are just as heavily endowed with estrogen receptors as are the lower vagina and vulva and just as susceptible to involutional change with estrogen deficiency.

“Embryologically, the vulva, distal vagina, trigone, and urethra are all derived from the urogenital sinus and contain the highest concentration of estrogen receptors. The upper vagina is actually a downgrowth of the müllerian system” and so less susceptible to change associated with estrogen depletion.

Because genital atrophy is so widespread and rapid after menopause in the absence of HT, women should be proactively counseled about how to maintain good genital health. If the decision is made to discontinue HT, topical estrogen can prevent genital atrophy and, if administered within the first year of estrogen cessation, can even reverse some changes.

Coitus at least once a week helps maintain tissue integrity by dilation and increased genital blood flow. “In the absence of both estrogen and sexual activity, the rapidity of involution is compounded,” he said.

Women who do not have a male partner can be counseled to use topical estrogen and a vibrator or vaginal dilator, and to become orgasmic, periodically. “This will maintain a normal, healthy vagina,” Dr. Freedman said.

However, he continued, most physicians — especially males — never really broach the subject of sexuality with their postmenopausal patients.

“To those men, I would put this question: 'At what age would you like your genitalia to begin shrinking?'” Dr. Freedman said. “I bet it wouldn't be 51, which is the average age of menopause in this country.”

This 55-year-old who quit HT a year ago exhibits almost total involution of the genitalia. Courtesy Dr. Murray Freedman

WHITE SULPHUR SPRINGS, W.VA. — Within just 6-12 months of discontinuing hormone therapy, more than 96% of postmenopausal women will show altered vaginal pH, a marker for tissue change and its associated genital atrophy, Murray Freedman, M.D., reported.

Only 10 of 300 women maintained a normal vaginal pH of 4.5 or less after discontinuing HT use, and seven of those women had elevated serum estradiol levels related to obesity-driven estrogen production, said Dr. Freedman, of the Medical College of Georgia, Augusta.

The rest of the women had both elevated vaginal pH and decreased serum estradiol. The most common clinical finding in the study was involution of the vulvar structures and a rapidly occurring introital stenosis, which correlated with frequent complaints of dyspareunia, he noted at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

Because the onset of genital atrophy is insidious and its measurement subjective, the number who experienced it was “hard to quantify,” Dr. Freedman said in an interview. “There is no real measurement for it. But for many of these women, the stenosis became noticeable within 6-12 months.”

Dr. Freedman's observations have led him to conclude that the dyspareunia many postmenopausal women experience has more to do with introital stenosis than with vaginal dryness. “The dryness was secondary to the stenosis and the involution of the distal vagina. Once you got past the introitus, the upper vagina was uncompromised.”

His prospective observational study evaluated a total of 300 women who had discontinued hormone therapy after publication of the initial Women's Health Initiative results in July 2002. All women underwent a pelvic exam and had their vaginal pH tested within 12 months of therapy discontinuation (most within 6 months). Those women with a normal vaginal pH level (4.5 or below) had their serum estradiol level evaluated.

The vast majority of the women (290) had a pH level of more than 4.5. Only 10 maintained a normal vaginal pH. Three of those women had serum estradiol of less than 20 pcg/mL, consistent with postmenopausal status.

The other seven had normal circulating estradiol levels. One of these was a 50-year-old woman with her uterus, fallopian tubes, and ovaries intact, who had been placed on HT for menopausal symptoms. The other six women were older (57-76 years) and either overweight or obese. “Their normal estrogen levels and the resulting normal vaginal pH were due to a high production of endogenous estrogen secondary to obesity,” Dr. Freedman said.

In addition to observing introital stenosis, he noted that the urethral meatus became more prominent in many women, assuming almost a tubular form and expanding to constitute up to two-thirds of the introitus. This is not surprising, he said, because the urethra and trigone are just as heavily endowed with estrogen receptors as are the lower vagina and vulva and just as susceptible to involutional change with estrogen deficiency.

“Embryologically, the vulva, distal vagina, trigone, and urethra are all derived from the urogenital sinus and contain the highest concentration of estrogen receptors. The upper vagina is actually a downgrowth of the müllerian system” and so less susceptible to change associated with estrogen depletion.

Because genital atrophy is so widespread and rapid after menopause in the absence of HT, women should be proactively counseled about how to maintain good genital health. If the decision is made to discontinue HT, topical estrogen can prevent genital atrophy and, if administered within the first year of estrogen cessation, can even reverse some changes.

Coitus at least once a week helps maintain tissue integrity by dilation and increased genital blood flow. “In the absence of both estrogen and sexual activity, the rapidity of involution is compounded,” he said.

Women who do not have a male partner can be counseled to use topical estrogen and a vibrator or vaginal dilator, and to become orgasmic, periodically. “This will maintain a normal, healthy vagina,” Dr. Freedman said.

However, he continued, most physicians — especially males — never really broach the subject of sexuality with their postmenopausal patients.

“To those men, I would put this question: 'At what age would you like your genitalia to begin shrinking?'” Dr. Freedman said. “I bet it wouldn't be 51, which is the average age of menopause in this country.”

This 55-year-old who quit HT a year ago exhibits almost total involution of the genitalia. Courtesy Dr. Murray Freedman

WHITE SULPHUR SPRINGS, W.VA. — Within just 6-12 months of discontinuing hormone therapy, more than 96% of postmenopausal women will show altered vaginal pH, a marker for tissue change and its associated genital atrophy, Murray Freedman, M.D., reported.

Only 10 of 300 women maintained a normal vaginal pH of 4.5 or less after discontinuing HT use, and seven of those women had elevated serum estradiol levels related to obesity-driven estrogen production, said Dr. Freedman, of the Medical College of Georgia, Augusta.

The rest of the women had both elevated vaginal pH and decreased serum estradiol. The most common clinical finding in the study was involution of the vulvar structures and a rapidly occurring introital stenosis, which correlated with frequent complaints of dyspareunia, he noted at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

Because the onset of genital atrophy is insidious and its measurement subjective, the number who experienced it was “hard to quantify,” Dr. Freedman said in an interview. “There is no real measurement for it. But for many of these women, the stenosis became noticeable within 6-12 months.”

Dr. Freedman's observations have led him to conclude that the dyspareunia many postmenopausal women experience has more to do with introital stenosis than with vaginal dryness. “The dryness was secondary to the stenosis and the involution of the distal vagina. Once you got past the introitus, the upper vagina was uncompromised.”

His prospective observational study evaluated a total of 300 women who had discontinued hormone therapy after publication of the initial Women's Health Initiative results in July 2002. All women underwent a pelvic exam and had their vaginal pH tested within 12 months of therapy discontinuation (most within 6 months). Those women with a normal vaginal pH level (4.5 or below) had their serum estradiol level evaluated.

The vast majority of the women (290) had a pH level of more than 4.5. Only 10 maintained a normal vaginal pH. Three of those women had serum estradiol of less than 20 pcg/mL, consistent with postmenopausal status.

The other seven had normal circulating estradiol levels. One of these was a 50-year-old woman with her uterus, fallopian tubes, and ovaries intact, who had been placed on HT for menopausal symptoms. The other six women were older (57-76 years) and either overweight or obese. “Their normal estrogen levels and the resulting normal vaginal pH were due to a high production of endogenous estrogen secondary to obesity,” Dr. Freedman said.

In addition to observing introital stenosis, he noted that the urethral meatus became more prominent in many women, assuming almost a tubular form and expanding to constitute up to two-thirds of the introitus. This is not surprising, he said, because the urethra and trigone are just as heavily endowed with estrogen receptors as are the lower vagina and vulva and just as susceptible to involutional change with estrogen deficiency.

“Embryologically, the vulva, distal vagina, trigone, and urethra are all derived from the urogenital sinus and contain the highest concentration of estrogen receptors. The upper vagina is actually a downgrowth of the müllerian system” and so less susceptible to change associated with estrogen depletion.

Because genital atrophy is so widespread and rapid after menopause in the absence of HT, women should be proactively counseled about how to maintain good genital health. If the decision is made to discontinue HT, topical estrogen can prevent genital atrophy and, if administered within the first year of estrogen cessation, can even reverse some changes.

Coitus at least once a week helps maintain tissue integrity by dilation and increased genital blood flow. “In the absence of both estrogen and sexual activity, the rapidity of involution is compounded,” he said.

Women who do not have a male partner can be counseled to use topical estrogen and a vibrator or vaginal dilator, and to become orgasmic, periodically. “This will maintain a normal, healthy vagina,” Dr. Freedman said.

However, he continued, most physicians — especially males — never really broach the subject of sexuality with their postmenopausal patients.

“To those men, I would put this question: 'At what age would you like your genitalia to begin shrinking?'” Dr. Freedman said. “I bet it wouldn't be 51, which is the average age of menopause in this country.”

This 55-year-old who quit HT a year ago exhibits almost total involution of the genitalia. Courtesy Dr. Murray Freedman

Parents of adolescents appear to accept the idea of vaccinating their teens against sexually transmitted infections, expressing the most concern about the efficacy of the vaccine and the severity of the infection it could prevent, rather than the mode of transmission, Gregory D. Zimet, Ph.D., and his colleagues have reported.

Some surveys have suggested that pediatricians and other adolescent health providers might be reluctant to recommend STI vaccines, perhaps because of concerns about how parents might react.

“The high acceptability ratings reported by most parents in this study suggest that most parents would not react negatively to the suggestion,” said Dr. Zimet of Indiana University, Indianapolis (Arch. Pediatr. Adolesc. Med. 2005;159:132-7).

The researchers surveyed 278 parents of adolescents aged 12-17 years. The mean age of parents was 41 years.

The mean age of children was 14 years, and 69% were female.

The survey presented nine different vaccine scenarios, each of which uniquely defined four variables: mode of transmission (STI or non-STI), severity of infection (curable, chronic and incurable, usually fatal); vaccine efficacy (50%, 70%, or 90%); and availability of behavioral methods of prevention (such as condoms or hand washing).

For each scenario, parents were asked, “If this vaccine were available today and you had the time, would you let your child get vaccinated?” Parents rated vaccine acceptability on a scale of 0-100, with 100 being “I would definitely let my child get this vaccine.”

The parents were recruited from urban, Midwestern adolescent medicine clinics and private practices. More than half (56%) were white, and about 40% were African American. Less than 2% were Hispanic.

The least acceptable scenario, with a mean score of about 75, was a vaccine with 50% efficacy against a non-STI that could be prevented by hand washing.

The most acceptable scenario, with a mean score of 88.6, was a vaccine with 90% efficacy that protected against a usually fatal non-STI that could not be prevented by hand washing.

The mean score for the six STI scenarios was slightly, but not significantly, higher than the mean score for the three non-STI scenarios. The lowest-scoring STI vaccine scenario was a vaccine that was 50% effective against a curable STI that could not be prevented with condoms (75.7). The highest-scoring STI scenario was a vaccine that was 70% effective in preventing a usually fatal STI that could be prevented by the use of condoms (84.4).

For the majority of parents, sexual transmissibility had the least influence on acceptability ratings. Vaccine efficacy was the most influential factor in the ratings, followed by severity of infection and availability of behavioral protection. However, 31 parents (11%) indicated a relatively strong preference for an STI vaccine, and 16 parents (6%) indicated a relatively strong opposition to it.

About a quarter (27%) of the parents gave ratings of 100 to every vaccine. High accepters were more likely to be in the urban clinics and to have only a high school diploma. Acceptability was not related to the child's age, suggesting that parents might not make these decisions based on the proximity of their child's sexual activity.

Parents of adolescents appear to accept the idea of vaccinating their teens against sexually transmitted infections, expressing the most concern about the efficacy of the vaccine and the severity of the infection it could prevent, rather than the mode of transmission, Gregory D. Zimet, Ph.D., and his colleagues have reported.

Some surveys have suggested that pediatricians and other adolescent health providers might be reluctant to recommend STI vaccines, perhaps because of concerns about how parents might react.

“The high acceptability ratings reported by most parents in this study suggest that most parents would not react negatively to the suggestion,” said Dr. Zimet of Indiana University, Indianapolis (Arch. Pediatr. Adolesc. Med. 2005;159:132-7).

The researchers surveyed 278 parents of adolescents aged 12-17 years. The mean age of parents was 41 years.

The mean age of children was 14 years, and 69% were female.

The survey presented nine different vaccine scenarios, each of which uniquely defined four variables: mode of transmission (STI or non-STI), severity of infection (curable, chronic and incurable, usually fatal); vaccine efficacy (50%, 70%, or 90%); and availability of behavioral methods of prevention (such as condoms or hand washing).

For each scenario, parents were asked, “If this vaccine were available today and you had the time, would you let your child get vaccinated?” Parents rated vaccine acceptability on a scale of 0-100, with 100 being “I would definitely let my child get this vaccine.”

The parents were recruited from urban, Midwestern adolescent medicine clinics and private practices. More than half (56%) were white, and about 40% were African American. Less than 2% were Hispanic.

The least acceptable scenario, with a mean score of about 75, was a vaccine with 50% efficacy against a non-STI that could be prevented by hand washing.

The most acceptable scenario, with a mean score of 88.6, was a vaccine with 90% efficacy that protected against a usually fatal non-STI that could not be prevented by hand washing.

The mean score for the six STI scenarios was slightly, but not significantly, higher than the mean score for the three non-STI scenarios. The lowest-scoring STI vaccine scenario was a vaccine that was 50% effective against a curable STI that could not be prevented with condoms (75.7). The highest-scoring STI scenario was a vaccine that was 70% effective in preventing a usually fatal STI that could be prevented by the use of condoms (84.4).

For the majority of parents, sexual transmissibility had the least influence on acceptability ratings. Vaccine efficacy was the most influential factor in the ratings, followed by severity of infection and availability of behavioral protection. However, 31 parents (11%) indicated a relatively strong preference for an STI vaccine, and 16 parents (6%) indicated a relatively strong opposition to it.

About a quarter (27%) of the parents gave ratings of 100 to every vaccine. High accepters were more likely to be in the urban clinics and to have only a high school diploma. Acceptability was not related to the child's age, suggesting that parents might not make these decisions based on the proximity of their child's sexual activity.

Parents of adolescents appear to accept the idea of vaccinating their teens against sexually transmitted infections, expressing the most concern about the efficacy of the vaccine and the severity of the infection it could prevent, rather than the mode of transmission, Gregory D. Zimet, Ph.D., and his colleagues have reported.

Some surveys have suggested that pediatricians and other adolescent health providers might be reluctant to recommend STI vaccines, perhaps because of concerns about how parents might react.

“The high acceptability ratings reported by most parents in this study suggest that most parents would not react negatively to the suggestion,” said Dr. Zimet of Indiana University, Indianapolis (Arch. Pediatr. Adolesc. Med. 2005;159:132-7).

The researchers surveyed 278 parents of adolescents aged 12-17 years. The mean age of parents was 41 years.

The mean age of children was 14 years, and 69% were female.

The survey presented nine different vaccine scenarios, each of which uniquely defined four variables: mode of transmission (STI or non-STI), severity of infection (curable, chronic and incurable, usually fatal); vaccine efficacy (50%, 70%, or 90%); and availability of behavioral methods of prevention (such as condoms or hand washing).

For each scenario, parents were asked, “If this vaccine were available today and you had the time, would you let your child get vaccinated?” Parents rated vaccine acceptability on a scale of 0-100, with 100 being “I would definitely let my child get this vaccine.”

The parents were recruited from urban, Midwestern adolescent medicine clinics and private practices. More than half (56%) were white, and about 40% were African American. Less than 2% were Hispanic.

The least acceptable scenario, with a mean score of about 75, was a vaccine with 50% efficacy against a non-STI that could be prevented by hand washing.

The most acceptable scenario, with a mean score of 88.6, was a vaccine with 90% efficacy that protected against a usually fatal non-STI that could not be prevented by hand washing.

The mean score for the six STI scenarios was slightly, but not significantly, higher than the mean score for the three non-STI scenarios. The lowest-scoring STI vaccine scenario was a vaccine that was 50% effective against a curable STI that could not be prevented with condoms (75.7). The highest-scoring STI scenario was a vaccine that was 70% effective in preventing a usually fatal STI that could be prevented by the use of condoms (84.4).

For the majority of parents, sexual transmissibility had the least influence on acceptability ratings. Vaccine efficacy was the most influential factor in the ratings, followed by severity of infection and availability of behavioral protection. However, 31 parents (11%) indicated a relatively strong preference for an STI vaccine, and 16 parents (6%) indicated a relatively strong opposition to it.

About a quarter (27%) of the parents gave ratings of 100 to every vaccine. High accepters were more likely to be in the urban clinics and to have only a high school diploma. Acceptability was not related to the child's age, suggesting that parents might not make these decisions based on the proximity of their child's sexual activity.

All pregnant women should undergo screening for Toxoplasma gondii infection once each trimester, and all newborns should be screened for congenital toxoplasmosis, Kenneth M. Boyer, M.D., and colleagues have recommended.

Even a thorough history fails to identify about half of pregnant women who have an acute infection, according to Dr. Boyer of Rush University Medical Center, Chicago. Only a serologic screening process would identify all infected women and newborns in time to administer the medical treatment necessary to prevent neurologic sequelae of the illness in these infants (Am. J. Obstet. Gynecol. 2005;192:564-71).

“It is difficult to imagine that any informed mother or father would choose not to include this screening in their prenatal care, considering that almost all untreated infants who are infected … in utero experience ophthalmologic and/or neurologic disease, and that treatment of the fetus and infant clearly reduces these risks,” they said.

The researchers retrospectively analyzed the medical records of 131 infants and children with congenital toxoplasmosis who were referred to the Chicago Collaborative Treatment Trial. The study focused on demographic data and the mothers' understanding of factors surrounding their exposure to the parasite.

The women were questioned about their exposure during pregnancy to cats, cat litter, gardening, and sandboxes. They also were questioned about their consumption of raw or undercooked meat, eggs, or unpasteurized milk, as well as the nature and timing of their exposure; and any illness during pregnancy that was compatible with infection, especially prolonged fever, night sweats, myalgia, headache, and lymphadenopathy.

Most of the women (75%) could recall a conceivable exposure, but only 39% specifically recalled exposure to cat litter or raw meat dishes. One-quarter of the women could not identify any possible exposure to either cats or raw or undercooked foods.

More than half (52%) could not recall an infectious illness of any kind during pregnancy. Almost half (48%) noted an illness that might have been caused by the parasite; 27% recalled fever or night sweats and 23% recalled lymphadenopathy.

Ten of the women had serologic testing for toxoplasmosis before delivery. Three of those were living in France at the time, where such testing is part of routine obstetric care. Each of the remaining seven women had compatible illness or identified risk factors. One woman was tested because an ultrasound noted ascites in her twin fetuses. Three were tested because their physicians were looking for the cause of the illness, and three were tested as part of routine obstetric care.

Since only three women were tested as part of an investigation of an infectious illness, it is apparent that many physicians do not consider toxoplasmosis as a possible cause of these nonspecific symptoms during pregnancy, the authors noted. “This observation points out the importance of greater recognition by obstetricians of the pediatric implications of maternal infection and infectious symptoms during pregnancy.”

The only way to prevent or detect a higher proportion of infants with congenital infection is by systematic serologic screening, they concluded, adding that cost analyses should be performed before any decision making occurs.

However, the potentially devastating lifelong effects of congenital toxoplasmosis, and the recognized benefits of early identification and treatment, make a compelling case for systematic screening, the researchers said.

Additionally, they noted, congenital toxoplasmosis is more common than many genetic and metabolic diseases, such as phenylketonuria, congenital hypothyroidism, and congenital adrenal hyperplasia, for which mandatory neonatal screening already exists.

The American College of Obstetricians and Gynecologists recommends routine toxoplasmosis screening only in HIV-positive pregnant women. Routine screening also may be justifiable in women who are cat owners, the college says.

ACOG does not recommend routine screening for every pregnant woman, because there is a low incidence of seropositivity in the United States. Countries such as France and Austria, which have mandated screening, have high rates of seropositivity among their populations.

Serologic screening in pregnant women may yield equivocal results because IgM antibodies to the parasite can persist for long periods, according to the American College of Obstetrics and Gynecologists.

All pregnant women should undergo screening for Toxoplasma gondii infection once each trimester, and all newborns should be screened for congenital toxoplasmosis, Kenneth M. Boyer, M.D., and colleagues have recommended.

Even a thorough history fails to identify about half of pregnant women who have an acute infection, according to Dr. Boyer of Rush University Medical Center, Chicago. Only a serologic screening process would identify all infected women and newborns in time to administer the medical treatment necessary to prevent neurologic sequelae of the illness in these infants (Am. J. Obstet. Gynecol. 2005;192:564-71).

“It is difficult to imagine that any informed mother or father would choose not to include this screening in their prenatal care, considering that almost all untreated infants who are infected … in utero experience ophthalmologic and/or neurologic disease, and that treatment of the fetus and infant clearly reduces these risks,” they said.

The researchers retrospectively analyzed the medical records of 131 infants and children with congenital toxoplasmosis who were referred to the Chicago Collaborative Treatment Trial. The study focused on demographic data and the mothers' understanding of factors surrounding their exposure to the parasite.

The women were questioned about their exposure during pregnancy to cats, cat litter, gardening, and sandboxes. They also were questioned about their consumption of raw or undercooked meat, eggs, or unpasteurized milk, as well as the nature and timing of their exposure; and any illness during pregnancy that was compatible with infection, especially prolonged fever, night sweats, myalgia, headache, and lymphadenopathy.

Most of the women (75%) could recall a conceivable exposure, but only 39% specifically recalled exposure to cat litter or raw meat dishes. One-quarter of the women could not identify any possible exposure to either cats or raw or undercooked foods.

More than half (52%) could not recall an infectious illness of any kind during pregnancy. Almost half (48%) noted an illness that might have been caused by the parasite; 27% recalled fever or night sweats and 23% recalled lymphadenopathy.

Ten of the women had serologic testing for toxoplasmosis before delivery. Three of those were living in France at the time, where such testing is part of routine obstetric care. Each of the remaining seven women had compatible illness or identified risk factors. One woman was tested because an ultrasound noted ascites in her twin fetuses. Three were tested because their physicians were looking for the cause of the illness, and three were tested as part of routine obstetric care.

Since only three women were tested as part of an investigation of an infectious illness, it is apparent that many physicians do not consider toxoplasmosis as a possible cause of these nonspecific symptoms during pregnancy, the authors noted. “This observation points out the importance of greater recognition by obstetricians of the pediatric implications of maternal infection and infectious symptoms during pregnancy.”

The only way to prevent or detect a higher proportion of infants with congenital infection is by systematic serologic screening, they concluded, adding that cost analyses should be performed before any decision making occurs.

However, the potentially devastating lifelong effects of congenital toxoplasmosis, and the recognized benefits of early identification and treatment, make a compelling case for systematic screening, the researchers said.

Additionally, they noted, congenital toxoplasmosis is more common than many genetic and metabolic diseases, such as phenylketonuria, congenital hypothyroidism, and congenital adrenal hyperplasia, for which mandatory neonatal screening already exists.

The American College of Obstetricians and Gynecologists recommends routine toxoplasmosis screening only in HIV-positive pregnant women. Routine screening also may be justifiable in women who are cat owners, the college says.

ACOG does not recommend routine screening for every pregnant woman, because there is a low incidence of seropositivity in the United States. Countries such as France and Austria, which have mandated screening, have high rates of seropositivity among their populations.

Serologic screening in pregnant women may yield equivocal results because IgM antibodies to the parasite can persist for long periods, according to the American College of Obstetrics and Gynecologists.

All pregnant women should undergo screening for Toxoplasma gondii infection once each trimester, and all newborns should be screened for congenital toxoplasmosis, Kenneth M. Boyer, M.D., and colleagues have recommended.

Even a thorough history fails to identify about half of pregnant women who have an acute infection, according to Dr. Boyer of Rush University Medical Center, Chicago. Only a serologic screening process would identify all infected women and newborns in time to administer the medical treatment necessary to prevent neurologic sequelae of the illness in these infants (Am. J. Obstet. Gynecol. 2005;192:564-71).

“It is difficult to imagine that any informed mother or father would choose not to include this screening in their prenatal care, considering that almost all untreated infants who are infected … in utero experience ophthalmologic and/or neurologic disease, and that treatment of the fetus and infant clearly reduces these risks,” they said.

The researchers retrospectively analyzed the medical records of 131 infants and children with congenital toxoplasmosis who were referred to the Chicago Collaborative Treatment Trial. The study focused on demographic data and the mothers' understanding of factors surrounding their exposure to the parasite.

The women were questioned about their exposure during pregnancy to cats, cat litter, gardening, and sandboxes. They also were questioned about their consumption of raw or undercooked meat, eggs, or unpasteurized milk, as well as the nature and timing of their exposure; and any illness during pregnancy that was compatible with infection, especially prolonged fever, night sweats, myalgia, headache, and lymphadenopathy.

Most of the women (75%) could recall a conceivable exposure, but only 39% specifically recalled exposure to cat litter or raw meat dishes. One-quarter of the women could not identify any possible exposure to either cats or raw or undercooked foods.

More than half (52%) could not recall an infectious illness of any kind during pregnancy. Almost half (48%) noted an illness that might have been caused by the parasite; 27% recalled fever or night sweats and 23% recalled lymphadenopathy.

Ten of the women had serologic testing for toxoplasmosis before delivery. Three of those were living in France at the time, where such testing is part of routine obstetric care. Each of the remaining seven women had compatible illness or identified risk factors. One woman was tested because an ultrasound noted ascites in her twin fetuses. Three were tested because their physicians were looking for the cause of the illness, and three were tested as part of routine obstetric care.

Since only three women were tested as part of an investigation of an infectious illness, it is apparent that many physicians do not consider toxoplasmosis as a possible cause of these nonspecific symptoms during pregnancy, the authors noted. “This observation points out the importance of greater recognition by obstetricians of the pediatric implications of maternal infection and infectious symptoms during pregnancy.”

The only way to prevent or detect a higher proportion of infants with congenital infection is by systematic serologic screening, they concluded, adding that cost analyses should be performed before any decision making occurs.

However, the potentially devastating lifelong effects of congenital toxoplasmosis, and the recognized benefits of early identification and treatment, make a compelling case for systematic screening, the researchers said.

Additionally, they noted, congenital toxoplasmosis is more common than many genetic and metabolic diseases, such as phenylketonuria, congenital hypothyroidism, and congenital adrenal hyperplasia, for which mandatory neonatal screening already exists.

The American College of Obstetricians and Gynecologists recommends routine toxoplasmosis screening only in HIV-positive pregnant women. Routine screening also may be justifiable in women who are cat owners, the college says.

ACOG does not recommend routine screening for every pregnant woman, because there is a low incidence of seropositivity in the United States. Countries such as France and Austria, which have mandated screening, have high rates of seropositivity among their populations.

Serologic screening in pregnant women may yield equivocal results because IgM antibodies to the parasite can persist for long periods, according to the American College of Obstetrics and Gynecologists.