Robert Finn

ANAHEIM, CALIF. — Long-term daily supplementation with 1,200 mg elemental calcium protects against the development of adenomas and hyperplastic polyps, John A. Baron, M.D., reported at the annual meeting of the American Association for Cancer Research.

For up to 5 years after the end of a randomized, placebo-controlled clinical trial, patients who had received calcium supplementation had a 35% reduction in the risk of adenomas and a 41% reduction in the risk of hyperplastic polyps, said Dr. Baron of Dartmouth Medical School, Lebanon, N.H.

“Personally, I believe that calcium does reduce the risk of adenomas very clearly and probably reduces the risk of cancer itself as well,” he said. “There's one issue that needs to be resolved before calcium can be strongly recommended more generally, and that is that some people believe that calcium supplements may increase the risk of prostate cancer.”

Because of that issue, Dr. Baron said he would shy away from making broad recommendations. “For targeted recommendations for women, I think you could say that calcium is very likely to be effective and very unlikely to have significant toxicity, with the proviso that you'll probably need to take it for a long time before you see an effect on colorectal cancer.”

The original study randomized 930 patients with a history of precancerous adenoma to 1,200 mg of daily elemental calcium for 4 years or to a placebo. That study demonstrated a 19% overall reduction in polyp formation and a 28% reduction in advanced adenomas.

The current study reported on up to 8 years of follow-up data on these same patients after completion of the randomized controlled trial. Of the 865 subjects who survived the original trial, Dr. Barron and his colleagues obtained follow-up information on 822, and 597 had colonoscopies at least 6 months after the end of the trial.

The calculated risk reductions were adjusted for age, sex, study center, the interval between the final study exam and the first follow-up colonoscopy, and participants' reported use of calcium supplementation after the original study.

“We conclude that calcium supplementation is effective in reducing the risk of colorectal adenomas after the cessation of supplementation,” Dr. Baron said. “There's no rebound at all. In fact there appears to be a delayed, more pronounced suppression of colorectal neoplasia during the 5 years after treatment.”

He suggested that calcium may be exerting its effects at an early stage of the cancer process, and those effects only become manifest with a reduction in visible lesions years later.

ANAHEIM, CALIF. — Long-term daily supplementation with 1,200 mg elemental calcium protects against the development of adenomas and hyperplastic polyps, John A. Baron, M.D., reported at the annual meeting of the American Association for Cancer Research.

For up to 5 years after the end of a randomized, placebo-controlled clinical trial, patients who had received calcium supplementation had a 35% reduction in the risk of adenomas and a 41% reduction in the risk of hyperplastic polyps, said Dr. Baron of Dartmouth Medical School, Lebanon, N.H.

“Personally, I believe that calcium does reduce the risk of adenomas very clearly and probably reduces the risk of cancer itself as well,” he said. “There's one issue that needs to be resolved before calcium can be strongly recommended more generally, and that is that some people believe that calcium supplements may increase the risk of prostate cancer.”

Because of that issue, Dr. Baron said he would shy away from making broad recommendations. “For targeted recommendations for women, I think you could say that calcium is very likely to be effective and very unlikely to have significant toxicity, with the proviso that you'll probably need to take it for a long time before you see an effect on colorectal cancer.”

The original study randomized 930 patients with a history of precancerous adenoma to 1,200 mg of daily elemental calcium for 4 years or to a placebo. That study demonstrated a 19% overall reduction in polyp formation and a 28% reduction in advanced adenomas.

The current study reported on up to 8 years of follow-up data on these same patients after completion of the randomized controlled trial. Of the 865 subjects who survived the original trial, Dr. Barron and his colleagues obtained follow-up information on 822, and 597 had colonoscopies at least 6 months after the end of the trial.

The calculated risk reductions were adjusted for age, sex, study center, the interval between the final study exam and the first follow-up colonoscopy, and participants' reported use of calcium supplementation after the original study.

“We conclude that calcium supplementation is effective in reducing the risk of colorectal adenomas after the cessation of supplementation,” Dr. Baron said. “There's no rebound at all. In fact there appears to be a delayed, more pronounced suppression of colorectal neoplasia during the 5 years after treatment.”

He suggested that calcium may be exerting its effects at an early stage of the cancer process, and those effects only become manifest with a reduction in visible lesions years later.

ANAHEIM, CALIF. — Long-term daily supplementation with 1,200 mg elemental calcium protects against the development of adenomas and hyperplastic polyps, John A. Baron, M.D., reported at the annual meeting of the American Association for Cancer Research.

For up to 5 years after the end of a randomized, placebo-controlled clinical trial, patients who had received calcium supplementation had a 35% reduction in the risk of adenomas and a 41% reduction in the risk of hyperplastic polyps, said Dr. Baron of Dartmouth Medical School, Lebanon, N.H.

“Personally, I believe that calcium does reduce the risk of adenomas very clearly and probably reduces the risk of cancer itself as well,” he said. “There's one issue that needs to be resolved before calcium can be strongly recommended more generally, and that is that some people believe that calcium supplements may increase the risk of prostate cancer.”

Because of that issue, Dr. Baron said he would shy away from making broad recommendations. “For targeted recommendations for women, I think you could say that calcium is very likely to be effective and very unlikely to have significant toxicity, with the proviso that you'll probably need to take it for a long time before you see an effect on colorectal cancer.”

The original study randomized 930 patients with a history of precancerous adenoma to 1,200 mg of daily elemental calcium for 4 years or to a placebo. That study demonstrated a 19% overall reduction in polyp formation and a 28% reduction in advanced adenomas.

The current study reported on up to 8 years of follow-up data on these same patients after completion of the randomized controlled trial. Of the 865 subjects who survived the original trial, Dr. Barron and his colleagues obtained follow-up information on 822, and 597 had colonoscopies at least 6 months after the end of the trial.

The calculated risk reductions were adjusted for age, sex, study center, the interval between the final study exam and the first follow-up colonoscopy, and participants' reported use of calcium supplementation after the original study.

“We conclude that calcium supplementation is effective in reducing the risk of colorectal adenomas after the cessation of supplementation,” Dr. Baron said. “There's no rebound at all. In fact there appears to be a delayed, more pronounced suppression of colorectal neoplasia during the 5 years after treatment.”

He suggested that calcium may be exerting its effects at an early stage of the cancer process, and those effects only become manifest with a reduction in visible lesions years later.

RENO, NEV. — The risk of preterm birth is not increased by occupational factors, including hours worked outside the home and jobs requiring physical exertion, Patricia C. Santiago-Munoz, M.D., and colleagues reported in a poster presentation.

These conclusions were based on a large, prospective cohort study involving 1,434 women with prior preterm births who were referred to a specialty clinic, said the researchers from the University of Texas Southwestern Medical Center in Dallas. There, the women participated in a structured interview regarding their obstetric history, their socioeconomic background, and their work outside the home. The findings were presented at the annual meeting of the Society for Maternal-Fetal Medicine.

Other studies have reached conflicting conclusions regarding the risk of outside employment. Some studies have found associations between physically demanding work and preterm birth, while others have found no such associations.

Of the 1,434 women who participated in the study, 25% worked outside the home, and 14% experienced a recurrent preterm birth, defined as a birth at 35 weeks' gestation or less.

There was no significant difference in the risk of preterm birth among women who worked outside the home and those who did not. Among those women who worked outside the home, there was no significant difference in the risk of preterm birth among the women who had physically demanding jobs and those who did not. Nor was there a significant relationship between the number of hours worked and the likelihood of preterm birth.

Furthermore, the lack of help inside the home did not increase a patient's risk, and that risk did not vary along with the number of children cared for in the home.

RENO, NEV. — The risk of preterm birth is not increased by occupational factors, including hours worked outside the home and jobs requiring physical exertion, Patricia C. Santiago-Munoz, M.D., and colleagues reported in a poster presentation.

These conclusions were based on a large, prospective cohort study involving 1,434 women with prior preterm births who were referred to a specialty clinic, said the researchers from the University of Texas Southwestern Medical Center in Dallas. There, the women participated in a structured interview regarding their obstetric history, their socioeconomic background, and their work outside the home. The findings were presented at the annual meeting of the Society for Maternal-Fetal Medicine.

Other studies have reached conflicting conclusions regarding the risk of outside employment. Some studies have found associations between physically demanding work and preterm birth, while others have found no such associations.

Of the 1,434 women who participated in the study, 25% worked outside the home, and 14% experienced a recurrent preterm birth, defined as a birth at 35 weeks' gestation or less.

There was no significant difference in the risk of preterm birth among women who worked outside the home and those who did not. Among those women who worked outside the home, there was no significant difference in the risk of preterm birth among the women who had physically demanding jobs and those who did not. Nor was there a significant relationship between the number of hours worked and the likelihood of preterm birth.

Furthermore, the lack of help inside the home did not increase a patient's risk, and that risk did not vary along with the number of children cared for in the home.

RENO, NEV. — The risk of preterm birth is not increased by occupational factors, including hours worked outside the home and jobs requiring physical exertion, Patricia C. Santiago-Munoz, M.D., and colleagues reported in a poster presentation.

These conclusions were based on a large, prospective cohort study involving 1,434 women with prior preterm births who were referred to a specialty clinic, said the researchers from the University of Texas Southwestern Medical Center in Dallas. There, the women participated in a structured interview regarding their obstetric history, their socioeconomic background, and their work outside the home. The findings were presented at the annual meeting of the Society for Maternal-Fetal Medicine.

Other studies have reached conflicting conclusions regarding the risk of outside employment. Some studies have found associations between physically demanding work and preterm birth, while others have found no such associations.

Of the 1,434 women who participated in the study, 25% worked outside the home, and 14% experienced a recurrent preterm birth, defined as a birth at 35 weeks' gestation or less.

There was no significant difference in the risk of preterm birth among women who worked outside the home and those who did not. Among those women who worked outside the home, there was no significant difference in the risk of preterm birth among the women who had physically demanding jobs and those who did not. Nor was there a significant relationship between the number of hours worked and the likelihood of preterm birth.

Furthermore, the lack of help inside the home did not increase a patient's risk, and that risk did not vary along with the number of children cared for in the home.

NEWPORT BEACH, CALIF. — When a new mother reports having infanticidal thoughts, how should one decide whether she poses an imminent danger to the child? The key is to assess several risk factors, Gagan Dhaliwal, M.D., said at the annual meeting of the American College of Forensic Psychiatry.

Dr. Dhaliwal, of the University of South Alabama, Mobile, discussed the hypothetical case of a 19-year-old woman with a 2-week-old son who is seen in an outpatient psychiatric clinic. She reports feeling depressed and lacking energy, and has a loss of appetite and frequent crying spells. She says she's not being a good mother and has thoughts of killing her son.

“First of all, we have to figure out whether these thoughts are in the context of psychosis,” Dr. Dhaliwal said. Upon further questioning, the woman reported that she felt suspicious of others and cannot trust other people. She says that she hears a voice in her head saying, “do it,” a command hallucination related to hurting her son.

The woman says she lives alone, is not sure of the identity of the child's father, and doesn't want to involve her family. She's concerned that her child will be taken away if she's admitted for inpatient treatment, but she agrees to take medication as an outpatient.

At this point there's sufficient cause to break confidentiality and contact the woman's family, Dr. Dhaliwal said. The family reports the woman had been taking medication for bipolar disorder but discontinued it during pregnancy.

Now the physician must answer several questions. Does the woman have a mental illness? Clearly she does, because of her previous history of bipolar disorder.

But is she imminently dangerous to her child? Should inpatient or outpatient treatment be recommended? Should she be committed involuntarily? How does one weigh the issue of mother-child privacy, compared with the governmental intrusion that would be involved in involuntary treatment? What effect would involuntary commitment have on the mother-child relationship? Is that presumably deleterious effect enough to outweigh the mother's potential dangerousness to the child?

Clearly, there's no reason to commit all mothers with aggressive or infanticidal thoughts. Studies have shown that many women post partum have obsessive thoughts about harming their children. The physician must differentiate those common obsessive thoughts from true psychosis, which involves a loss of touch with reality.

The mother with obsessions will attempt to suppress these obsessions and generally recognizes they're products of her own mind. The psychotic mother, believes the thoughts are imposed by an outside force.

In the hypothetical case, the woman's history, her command hallucinations, and her lack of insight argue for psychosis. She also has other risk factors linked with infanticide.

Among the risk factors identified in one study are maternal age less than 17 (relative risk 10.9), second or subsequent-born infants (relative risk 9.3), lack of prenatal care (relative risk 10.3), and low education levels (relative risk about 8 for women who did not complete high school) (N. Engl. J. Med. 1998;339:1211ndash;6).

Other factors that increase the risk are substance abuse; a history of major mental illness, especially major depression or bipolar disorder; a family history of psychiatric illness; childhood abuse; self-doubt as a mother; poverty, a poor support system; and an unavailable partner.

The hypothetical woman doesn't exhibit all of those risk factors. But Dr. Dhaliwal says she exhibits enough to warrant involuntary commitment.

NEWPORT BEACH, CALIF. — When a new mother reports having infanticidal thoughts, how should one decide whether she poses an imminent danger to the child? The key is to assess several risk factors, Gagan Dhaliwal, M.D., said at the annual meeting of the American College of Forensic Psychiatry.

Dr. Dhaliwal, of the University of South Alabama, Mobile, discussed the hypothetical case of a 19-year-old woman with a 2-week-old son who is seen in an outpatient psychiatric clinic. She reports feeling depressed and lacking energy, and has a loss of appetite and frequent crying spells. She says she's not being a good mother and has thoughts of killing her son.

“First of all, we have to figure out whether these thoughts are in the context of psychosis,” Dr. Dhaliwal said. Upon further questioning, the woman reported that she felt suspicious of others and cannot trust other people. She says that she hears a voice in her head saying, “do it,” a command hallucination related to hurting her son.

The woman says she lives alone, is not sure of the identity of the child's father, and doesn't want to involve her family. She's concerned that her child will be taken away if she's admitted for inpatient treatment, but she agrees to take medication as an outpatient.

At this point there's sufficient cause to break confidentiality and contact the woman's family, Dr. Dhaliwal said. The family reports the woman had been taking medication for bipolar disorder but discontinued it during pregnancy.

Now the physician must answer several questions. Does the woman have a mental illness? Clearly she does, because of her previous history of bipolar disorder.

But is she imminently dangerous to her child? Should inpatient or outpatient treatment be recommended? Should she be committed involuntarily? How does one weigh the issue of mother-child privacy, compared with the governmental intrusion that would be involved in involuntary treatment? What effect would involuntary commitment have on the mother-child relationship? Is that presumably deleterious effect enough to outweigh the mother's potential dangerousness to the child?

Clearly, there's no reason to commit all mothers with aggressive or infanticidal thoughts. Studies have shown that many women post partum have obsessive thoughts about harming their children. The physician must differentiate those common obsessive thoughts from true psychosis, which involves a loss of touch with reality.

The mother with obsessions will attempt to suppress these obsessions and generally recognizes they're products of her own mind. The psychotic mother, believes the thoughts are imposed by an outside force.

In the hypothetical case, the woman's history, her command hallucinations, and her lack of insight argue for psychosis. She also has other risk factors linked with infanticide.

Among the risk factors identified in one study are maternal age less than 17 (relative risk 10.9), second or subsequent-born infants (relative risk 9.3), lack of prenatal care (relative risk 10.3), and low education levels (relative risk about 8 for women who did not complete high school) (N. Engl. J. Med. 1998;339:1211ndash;6).

Other factors that increase the risk are substance abuse; a history of major mental illness, especially major depression or bipolar disorder; a family history of psychiatric illness; childhood abuse; self-doubt as a mother; poverty, a poor support system; and an unavailable partner.

The hypothetical woman doesn't exhibit all of those risk factors. But Dr. Dhaliwal says she exhibits enough to warrant involuntary commitment.

NEWPORT BEACH, CALIF. — When a new mother reports having infanticidal thoughts, how should one decide whether she poses an imminent danger to the child? The key is to assess several risk factors, Gagan Dhaliwal, M.D., said at the annual meeting of the American College of Forensic Psychiatry.

Dr. Dhaliwal, of the University of South Alabama, Mobile, discussed the hypothetical case of a 19-year-old woman with a 2-week-old son who is seen in an outpatient psychiatric clinic. She reports feeling depressed and lacking energy, and has a loss of appetite and frequent crying spells. She says she's not being a good mother and has thoughts of killing her son.

“First of all, we have to figure out whether these thoughts are in the context of psychosis,” Dr. Dhaliwal said. Upon further questioning, the woman reported that she felt suspicious of others and cannot trust other people. She says that she hears a voice in her head saying, “do it,” a command hallucination related to hurting her son.

The woman says she lives alone, is not sure of the identity of the child's father, and doesn't want to involve her family. She's concerned that her child will be taken away if she's admitted for inpatient treatment, but she agrees to take medication as an outpatient.

At this point there's sufficient cause to break confidentiality and contact the woman's family, Dr. Dhaliwal said. The family reports the woman had been taking medication for bipolar disorder but discontinued it during pregnancy.

Now the physician must answer several questions. Does the woman have a mental illness? Clearly she does, because of her previous history of bipolar disorder.

But is she imminently dangerous to her child? Should inpatient or outpatient treatment be recommended? Should she be committed involuntarily? How does one weigh the issue of mother-child privacy, compared with the governmental intrusion that would be involved in involuntary treatment? What effect would involuntary commitment have on the mother-child relationship? Is that presumably deleterious effect enough to outweigh the mother's potential dangerousness to the child?

Clearly, there's no reason to commit all mothers with aggressive or infanticidal thoughts. Studies have shown that many women post partum have obsessive thoughts about harming their children. The physician must differentiate those common obsessive thoughts from true psychosis, which involves a loss of touch with reality.

The mother with obsessions will attempt to suppress these obsessions and generally recognizes they're products of her own mind. The psychotic mother, believes the thoughts are imposed by an outside force.

In the hypothetical case, the woman's history, her command hallucinations, and her lack of insight argue for psychosis. She also has other risk factors linked with infanticide.

Among the risk factors identified in one study are maternal age less than 17 (relative risk 10.9), second or subsequent-born infants (relative risk 9.3), lack of prenatal care (relative risk 10.3), and low education levels (relative risk about 8 for women who did not complete high school) (N. Engl. J. Med. 1998;339:1211ndash;6).

Other factors that increase the risk are substance abuse; a history of major mental illness, especially major depression or bipolar disorder; a family history of psychiatric illness; childhood abuse; self-doubt as a mother; poverty, a poor support system; and an unavailable partner.

The hypothetical woman doesn't exhibit all of those risk factors. But Dr. Dhaliwal says she exhibits enough to warrant involuntary commitment.

PORTLAND, ORE. — Some cases of apparent imperforate hymen are actually müllerian agenesis, and that possibility should be in the differential diagnosis, David M. Lee, M.D., said at a conference sponsored by the North Pacific Pediatric Society.

He described one case of a 12-year-old girl who had three hymenectomies for what turned out to be müllerian agenesis.

Another case, that of a 15-year-old girl, is perhaps more typical. Her chief complaint was primary amenorrhea and cyclic pain. She had normal breast and pubic hair development. The original ultrasound examination was interpreted as showing a “small uterus,” deviated to the right, and normal ovaries. She had one attempted hymenectomy.

“In defense of the first physician, it does look like an imperforate hymen,” said Dr. Lee of Oregon Health & Science University, Portland. In fact, she had müllerian agenesis and was missing the uterus and the upper vaginal system.

In addition to müllerian agenesis, several other conditions should be in the differential, he said. These include vaginal atresia, longitudinal septi, transverse septum, cervical agenesis, androgen insensitivity syndrome, and intersex conditions.

The work-up should include serum testosterone—which differentiates between müllerian agenesis and androgen insensitivity—and imaging, either ultrasound or MRI.

The incidence of müllerian agenesis is quoted in the published literature as 1 per 5,000 women, but Dr. Lee's clinical impression, based on the number of referrals he receives, is that the actual incidence is higher.

Women with müllerian agenesis have normal 46XX chromosomes, normal external genitalia, normal ovarian function, and normal thelarche and pubarche. The upper vagina is absent, and the lower vagina may be of variable length. They have normal fallopian tubes and uterine horns.

Assisted reproductive technology can help these women have children. This typically involves an egg aspiration, artificial insemination, and a surrogate who carries the embryo to term.

Vaginal dilatation with soft vaginal dilators of progressively larger sizes provides effective treatment for about 90% of women.

The remaining 10% will require surgery to create a neovagina. Dr. Lee uses epidural anesthesia for this surgery. He takes a skin graft from the buttocks or lateral thigh, somewhat thicker than a split-thickness skin graft, but not as thick as a full-thickness graft. He places the graft on an inflatable vaginal stent, and inserts that into the newly dissected neovaginal space, suturing the stent into place.

After about a week of immobilization to allow the graft to take, the patient is brought back to the operating room to have the stent and any necrotic remnants of the graft removed.

“You end up with a neovagina that's usually a normal 10-12 cm length, normally functioning, and it's a very successful procedure,” Dr. Lee said.

Dr. Lee is also developing a laparoscopic procedure. “I mobilize peritoneum from the inside of the abdomen laparoscopically, and then pull that peritoneum down, and use peritoneum rather than a skin graft,” he said. “I think that's going to be eventually the most effective surgical treatment.”

PORTLAND, ORE. — Some cases of apparent imperforate hymen are actually müllerian agenesis, and that possibility should be in the differential diagnosis, David M. Lee, M.D., said at a conference sponsored by the North Pacific Pediatric Society.

He described one case of a 12-year-old girl who had three hymenectomies for what turned out to be müllerian agenesis.

Another case, that of a 15-year-old girl, is perhaps more typical. Her chief complaint was primary amenorrhea and cyclic pain. She had normal breast and pubic hair development. The original ultrasound examination was interpreted as showing a “small uterus,” deviated to the right, and normal ovaries. She had one attempted hymenectomy.

“In defense of the first physician, it does look like an imperforate hymen,” said Dr. Lee of Oregon Health & Science University, Portland. In fact, she had müllerian agenesis and was missing the uterus and the upper vaginal system.

In addition to müllerian agenesis, several other conditions should be in the differential, he said. These include vaginal atresia, longitudinal septi, transverse septum, cervical agenesis, androgen insensitivity syndrome, and intersex conditions.

The work-up should include serum testosterone—which differentiates between müllerian agenesis and androgen insensitivity—and imaging, either ultrasound or MRI.

The incidence of müllerian agenesis is quoted in the published literature as 1 per 5,000 women, but Dr. Lee's clinical impression, based on the number of referrals he receives, is that the actual incidence is higher.

Women with müllerian agenesis have normal 46XX chromosomes, normal external genitalia, normal ovarian function, and normal thelarche and pubarche. The upper vagina is absent, and the lower vagina may be of variable length. They have normal fallopian tubes and uterine horns.

Assisted reproductive technology can help these women have children. This typically involves an egg aspiration, artificial insemination, and a surrogate who carries the embryo to term.

Vaginal dilatation with soft vaginal dilators of progressively larger sizes provides effective treatment for about 90% of women.

The remaining 10% will require surgery to create a neovagina. Dr. Lee uses epidural anesthesia for this surgery. He takes a skin graft from the buttocks or lateral thigh, somewhat thicker than a split-thickness skin graft, but not as thick as a full-thickness graft. He places the graft on an inflatable vaginal stent, and inserts that into the newly dissected neovaginal space, suturing the stent into place.

After about a week of immobilization to allow the graft to take, the patient is brought back to the operating room to have the stent and any necrotic remnants of the graft removed.

“You end up with a neovagina that's usually a normal 10-12 cm length, normally functioning, and it's a very successful procedure,” Dr. Lee said.

Dr. Lee is also developing a laparoscopic procedure. “I mobilize peritoneum from the inside of the abdomen laparoscopically, and then pull that peritoneum down, and use peritoneum rather than a skin graft,” he said. “I think that's going to be eventually the most effective surgical treatment.”

PORTLAND, ORE. — Some cases of apparent imperforate hymen are actually müllerian agenesis, and that possibility should be in the differential diagnosis, David M. Lee, M.D., said at a conference sponsored by the North Pacific Pediatric Society.

He described one case of a 12-year-old girl who had three hymenectomies for what turned out to be müllerian agenesis.

Another case, that of a 15-year-old girl, is perhaps more typical. Her chief complaint was primary amenorrhea and cyclic pain. She had normal breast and pubic hair development. The original ultrasound examination was interpreted as showing a “small uterus,” deviated to the right, and normal ovaries. She had one attempted hymenectomy.

“In defense of the first physician, it does look like an imperforate hymen,” said Dr. Lee of Oregon Health & Science University, Portland. In fact, she had müllerian agenesis and was missing the uterus and the upper vaginal system.

In addition to müllerian agenesis, several other conditions should be in the differential, he said. These include vaginal atresia, longitudinal septi, transverse septum, cervical agenesis, androgen insensitivity syndrome, and intersex conditions.

The work-up should include serum testosterone—which differentiates between müllerian agenesis and androgen insensitivity—and imaging, either ultrasound or MRI.

The incidence of müllerian agenesis is quoted in the published literature as 1 per 5,000 women, but Dr. Lee's clinical impression, based on the number of referrals he receives, is that the actual incidence is higher.

Women with müllerian agenesis have normal 46XX chromosomes, normal external genitalia, normal ovarian function, and normal thelarche and pubarche. The upper vagina is absent, and the lower vagina may be of variable length. They have normal fallopian tubes and uterine horns.

Assisted reproductive technology can help these women have children. This typically involves an egg aspiration, artificial insemination, and a surrogate who carries the embryo to term.

Vaginal dilatation with soft vaginal dilators of progressively larger sizes provides effective treatment for about 90% of women.

The remaining 10% will require surgery to create a neovagina. Dr. Lee uses epidural anesthesia for this surgery. He takes a skin graft from the buttocks or lateral thigh, somewhat thicker than a split-thickness skin graft, but not as thick as a full-thickness graft. He places the graft on an inflatable vaginal stent, and inserts that into the newly dissected neovaginal space, suturing the stent into place.

After about a week of immobilization to allow the graft to take, the patient is brought back to the operating room to have the stent and any necrotic remnants of the graft removed.

“You end up with a neovagina that's usually a normal 10-12 cm length, normally functioning, and it's a very successful procedure,” Dr. Lee said.

Dr. Lee is also developing a laparoscopic procedure. “I mobilize peritoneum from the inside of the abdomen laparoscopically, and then pull that peritoneum down, and use peritoneum rather than a skin graft,” he said. “I think that's going to be eventually the most effective surgical treatment.”

RENO, NEV. — Increased maternal morbidity is significantly associated with magnesium sulfate tocolysis that lasts longer than 48 hours, a retrospective study has demonstrated.

Investigators compared 78 women who received MgSO4 tocolysis for longer than 48 hours with 77 women who received MgSO4 tocolysis for 48 hours or less. Women who received prolonged tocolysis were significantly more likely to have at least one adverse event (56.4% vs. 28.5%).

The most common adverse events were chest tightness, pulmonary edema, and visual disturbances, investigators wrote in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Babies born to the two groups of mothers had similar Apgar scores, hypotonia, and neonatal mortality rates. But babies born to women who underwent prolonged tocolysis had significantly higher magnesium levels, averaging 3.6 mg/dL, compared with 2.8 mg/dL for babies born to control women, reported Anwar Nassar, M.D., and colleagues at the American University of Beirut (Lebanon).

In addition, three infants born to mothers who had received large amounts of MgSO4 showed radiolucent bones and metaphyseal widening, evidence of abnormal bone mineralization.

“Given the scarcity of evidence of its effectiveness as a tocolytic and the potential of significant adverse effects on the mother and neonate, aggressive attempts at prolonging pregnancy with intravenous magnesium sulfate are unjustifiable,” the investigators wrote.

RENO, NEV. — Increased maternal morbidity is significantly associated with magnesium sulfate tocolysis that lasts longer than 48 hours, a retrospective study has demonstrated.

Investigators compared 78 women who received MgSO4 tocolysis for longer than 48 hours with 77 women who received MgSO4 tocolysis for 48 hours or less. Women who received prolonged tocolysis were significantly more likely to have at least one adverse event (56.4% vs. 28.5%).

The most common adverse events were chest tightness, pulmonary edema, and visual disturbances, investigators wrote in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Babies born to the two groups of mothers had similar Apgar scores, hypotonia, and neonatal mortality rates. But babies born to women who underwent prolonged tocolysis had significantly higher magnesium levels, averaging 3.6 mg/dL, compared with 2.8 mg/dL for babies born to control women, reported Anwar Nassar, M.D., and colleagues at the American University of Beirut (Lebanon).

In addition, three infants born to mothers who had received large amounts of MgSO4 showed radiolucent bones and metaphyseal widening, evidence of abnormal bone mineralization.

“Given the scarcity of evidence of its effectiveness as a tocolytic and the potential of significant adverse effects on the mother and neonate, aggressive attempts at prolonging pregnancy with intravenous magnesium sulfate are unjustifiable,” the investigators wrote.

RENO, NEV. — Increased maternal morbidity is significantly associated with magnesium sulfate tocolysis that lasts longer than 48 hours, a retrospective study has demonstrated.

Investigators compared 78 women who received MgSO4 tocolysis for longer than 48 hours with 77 women who received MgSO4 tocolysis for 48 hours or less. Women who received prolonged tocolysis were significantly more likely to have at least one adverse event (56.4% vs. 28.5%).

The most common adverse events were chest tightness, pulmonary edema, and visual disturbances, investigators wrote in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Babies born to the two groups of mothers had similar Apgar scores, hypotonia, and neonatal mortality rates. But babies born to women who underwent prolonged tocolysis had significantly higher magnesium levels, averaging 3.6 mg/dL, compared with 2.8 mg/dL for babies born to control women, reported Anwar Nassar, M.D., and colleagues at the American University of Beirut (Lebanon).

In addition, three infants born to mothers who had received large amounts of MgSO4 showed radiolucent bones and metaphyseal widening, evidence of abnormal bone mineralization.

“Given the scarcity of evidence of its effectiveness as a tocolytic and the potential of significant adverse effects on the mother and neonate, aggressive attempts at prolonging pregnancy with intravenous magnesium sulfate are unjustifiable,” the investigators wrote.

RENO, NEV. — From a societal perspective, the most cost-effective course of action for impending preterm delivery at 24 weeks' gestation is an unwillingness on the part of the physician to perform cesarean section, Gianni Cazan-London, M.D., and colleagues reported in a poster presented at the annual meeting of the Society for Maternal-Fetal Medicine.

The researchers, from the University of Michigan Health System in Ann Arbor, conducted a cost-benefit analysis comparing aggressive management (willingness to perform cesarean section) with nonaggressive management (unwillingness to perform cesarean section).

If the overall goal is simply to produce a surviving infant, the choice of management has only a minimal effect on overall costs, with aggressive management costing $38,434 more than nonaggressive management.

On the other hand, if the goal is to produce a surviving infant who is healthy, aggressive management costs $690,969 more per healthy survivor than does nonaggressive management.

While aggressive management does slightly improve the chances of producing a healthy survivor, it also doubles the probability of producing an infant with major and costly morbidity, according to the analysis.

The investigators based their analysis on a comprehensive literature search, which yielded estimates of the probabilities and costs for various options on a decision-tree model.

Costs included neonatal hospitalization, burial for death, and lifetime interventions and/or special education for infants with major disabilities. The investigators expressed the results in 2004 U.S. dollars.

According to the analysis, unwillingness to perform cesarean section would cost $675,425 per survivor (overall) and $1,688,562 per healthy survivor.

In contrast, willingness to perform cesarean section would cost $713,859 per survivor (overall) and $2,379,531 per healthy survivor.

The investigators noted that emotional and financial costs to parents, health care providers, and society at large are substantial, regardless of the physician's management strategy. They concluded that physicians should strive to provide objective information to the parents whose child is likely to be born with extremely low birth weight. The parents, then, should be allowed to make the ultimate decisions on the aggressiveness of obstetric management.

RENO, NEV. — From a societal perspective, the most cost-effective course of action for impending preterm delivery at 24 weeks' gestation is an unwillingness on the part of the physician to perform cesarean section, Gianni Cazan-London, M.D., and colleagues reported in a poster presented at the annual meeting of the Society for Maternal-Fetal Medicine.

The researchers, from the University of Michigan Health System in Ann Arbor, conducted a cost-benefit analysis comparing aggressive management (willingness to perform cesarean section) with nonaggressive management (unwillingness to perform cesarean section).

If the overall goal is simply to produce a surviving infant, the choice of management has only a minimal effect on overall costs, with aggressive management costing $38,434 more than nonaggressive management.

On the other hand, if the goal is to produce a surviving infant who is healthy, aggressive management costs $690,969 more per healthy survivor than does nonaggressive management.

While aggressive management does slightly improve the chances of producing a healthy survivor, it also doubles the probability of producing an infant with major and costly morbidity, according to the analysis.

The investigators based their analysis on a comprehensive literature search, which yielded estimates of the probabilities and costs for various options on a decision-tree model.

Costs included neonatal hospitalization, burial for death, and lifetime interventions and/or special education for infants with major disabilities. The investigators expressed the results in 2004 U.S. dollars.

According to the analysis, unwillingness to perform cesarean section would cost $675,425 per survivor (overall) and $1,688,562 per healthy survivor.

In contrast, willingness to perform cesarean section would cost $713,859 per survivor (overall) and $2,379,531 per healthy survivor.

The investigators noted that emotional and financial costs to parents, health care providers, and society at large are substantial, regardless of the physician's management strategy. They concluded that physicians should strive to provide objective information to the parents whose child is likely to be born with extremely low birth weight. The parents, then, should be allowed to make the ultimate decisions on the aggressiveness of obstetric management.

RENO, NEV. — From a societal perspective, the most cost-effective course of action for impending preterm delivery at 24 weeks' gestation is an unwillingness on the part of the physician to perform cesarean section, Gianni Cazan-London, M.D., and colleagues reported in a poster presented at the annual meeting of the Society for Maternal-Fetal Medicine.

The researchers, from the University of Michigan Health System in Ann Arbor, conducted a cost-benefit analysis comparing aggressive management (willingness to perform cesarean section) with nonaggressive management (unwillingness to perform cesarean section).

If the overall goal is simply to produce a surviving infant, the choice of management has only a minimal effect on overall costs, with aggressive management costing $38,434 more than nonaggressive management.

On the other hand, if the goal is to produce a surviving infant who is healthy, aggressive management costs $690,969 more per healthy survivor than does nonaggressive management.

While aggressive management does slightly improve the chances of producing a healthy survivor, it also doubles the probability of producing an infant with major and costly morbidity, according to the analysis.

The investigators based their analysis on a comprehensive literature search, which yielded estimates of the probabilities and costs for various options on a decision-tree model.

Costs included neonatal hospitalization, burial for death, and lifetime interventions and/or special education for infants with major disabilities. The investigators expressed the results in 2004 U.S. dollars.

According to the analysis, unwillingness to perform cesarean section would cost $675,425 per survivor (overall) and $1,688,562 per healthy survivor.

In contrast, willingness to perform cesarean section would cost $713,859 per survivor (overall) and $2,379,531 per healthy survivor.

The investigators noted that emotional and financial costs to parents, health care providers, and society at large are substantial, regardless of the physician's management strategy. They concluded that physicians should strive to provide objective information to the parents whose child is likely to be born with extremely low birth weight. The parents, then, should be allowed to make the ultimate decisions on the aggressiveness of obstetric management.

RENO, NEV. — The rate of very low birth weight in twin pregnancies can be reduced safely with a plan of care that includes cervical length evaluation at 23-25 weeks and long-term indomethacin therapy for women with a short, funneled cervix, Theodore Peck, M.D. reported in a poster session at the annual meeting of the Society for Maternal-Fetal Medicine.

The rate of very low birth-weight twins fell significantly from 11.5% during 1989-1993 to 6.89% during 1999-2003 at Gundersen Lutheran Medical Center in LaCrosse, Wis., where Dr. Peck practices maternal-fetal medicine.

In contrast, the national rate of very low birth-weight infants from twin pregnancies was 10.1% during 1989-1993 and 10.2% during 1999-2003.

The percentage of very low birth-weight twins born at the Wisconsin medical center because of premature rupture of membranes or preterm labor also fell significantly, from 91.2% to 53.2%.

During the more recent time period, women pregnant with twins underwent cervical evaluation by vaginal ultrasound at 23-25 weeks' gestation. Women with cervical lengths less than 3 cm and cervical funneling were instructed to take 25 mg of indomethacin q.i.d. They were not placed routinely on activity restriction, and no cerclages were done.

Fetuses were monitored with amniotic fluid assessment and periodic growth determinations, and indomethacin dosages were adjusted accordingly.

Women were excluded from indomethacin therapy if they had premature rupture of membranes, oligohydramnios, asymmetric intrauterine growth retardation, indication for delivery, or they had attained 33 weeks' gestation.

RENO, NEV. — The rate of very low birth weight in twin pregnancies can be reduced safely with a plan of care that includes cervical length evaluation at 23-25 weeks and long-term indomethacin therapy for women with a short, funneled cervix, Theodore Peck, M.D. reported in a poster session at the annual meeting of the Society for Maternal-Fetal Medicine.

The rate of very low birth-weight twins fell significantly from 11.5% during 1989-1993 to 6.89% during 1999-2003 at Gundersen Lutheran Medical Center in LaCrosse, Wis., where Dr. Peck practices maternal-fetal medicine.

In contrast, the national rate of very low birth-weight infants from twin pregnancies was 10.1% during 1989-1993 and 10.2% during 1999-2003.

The percentage of very low birth-weight twins born at the Wisconsin medical center because of premature rupture of membranes or preterm labor also fell significantly, from 91.2% to 53.2%.

During the more recent time period, women pregnant with twins underwent cervical evaluation by vaginal ultrasound at 23-25 weeks' gestation. Women with cervical lengths less than 3 cm and cervical funneling were instructed to take 25 mg of indomethacin q.i.d. They were not placed routinely on activity restriction, and no cerclages were done.

Fetuses were monitored with amniotic fluid assessment and periodic growth determinations, and indomethacin dosages were adjusted accordingly.

Women were excluded from indomethacin therapy if they had premature rupture of membranes, oligohydramnios, asymmetric intrauterine growth retardation, indication for delivery, or they had attained 33 weeks' gestation.

RENO, NEV. — The rate of very low birth weight in twin pregnancies can be reduced safely with a plan of care that includes cervical length evaluation at 23-25 weeks and long-term indomethacin therapy for women with a short, funneled cervix, Theodore Peck, M.D. reported in a poster session at the annual meeting of the Society for Maternal-Fetal Medicine.

The rate of very low birth-weight twins fell significantly from 11.5% during 1989-1993 to 6.89% during 1999-2003 at Gundersen Lutheran Medical Center in LaCrosse, Wis., where Dr. Peck practices maternal-fetal medicine.

In contrast, the national rate of very low birth-weight infants from twin pregnancies was 10.1% during 1989-1993 and 10.2% during 1999-2003.

The percentage of very low birth-weight twins born at the Wisconsin medical center because of premature rupture of membranes or preterm labor also fell significantly, from 91.2% to 53.2%.

During the more recent time period, women pregnant with twins underwent cervical evaluation by vaginal ultrasound at 23-25 weeks' gestation. Women with cervical lengths less than 3 cm and cervical funneling were instructed to take 25 mg of indomethacin q.i.d. They were not placed routinely on activity restriction, and no cerclages were done.

Fetuses were monitored with amniotic fluid assessment and periodic growth determinations, and indomethacin dosages were adjusted accordingly.

Women were excluded from indomethacin therapy if they had premature rupture of membranes, oligohydramnios, asymmetric intrauterine growth retardation, indication for delivery, or they had attained 33 weeks' gestation.

SAN FRANCISCO — In a large majority of women presenting with chronic pelvic pain, the bladder is the pain-generating organ, Edward J. Stanford, M.D., said at the annual meeting of the American Association of Gynecologic Laparoscopists.

In three studies involving almost 300 women with chronic pelvic pain, the prevalence of interstitial cystitis ranged from 70% to 82%, said Dr. Stanford of St. Mary's Good Samaritan Medical Center, Centralia, Ill.

In the most recent and thorough of these studies, Dr. Stanford followed 64 women with chronic pelvic pain for a year. Each completed the Pelvic Pain and Urgency/Frequency questionnaire and underwent a vulvar touch test, a potassium sensitivity test, cystoscopy with hydrodissection, and laparoscopy. During the laparoscopy, the investigators biopsied suspicious lesions and removed all adhesions.

Although 64% of the women had adhesions, the pain could not be attributed to that, Dr. Stanford said. In 70%, the bladder was the pain-generating organ, 28% had biopsy-proven endometriosis, and 20% had vulvar pain.

Therefore, in the differential diagnosis of chronic pelvic pain, interstitial cystitis must be ranked first, with irritable bowel syndrome, endometriosis, and vulvodynia a distant second, third, and fourth, respectively. Recurrent urinary tract infection was cited in 7% of the cases.

SAN FRANCISCO — In a large majority of women presenting with chronic pelvic pain, the bladder is the pain-generating organ, Edward J. Stanford, M.D., said at the annual meeting of the American Association of Gynecologic Laparoscopists.

In three studies involving almost 300 women with chronic pelvic pain, the prevalence of interstitial cystitis ranged from 70% to 82%, said Dr. Stanford of St. Mary's Good Samaritan Medical Center, Centralia, Ill.

In the most recent and thorough of these studies, Dr. Stanford followed 64 women with chronic pelvic pain for a year. Each completed the Pelvic Pain and Urgency/Frequency questionnaire and underwent a vulvar touch test, a potassium sensitivity test, cystoscopy with hydrodissection, and laparoscopy. During the laparoscopy, the investigators biopsied suspicious lesions and removed all adhesions.

Although 64% of the women had adhesions, the pain could not be attributed to that, Dr. Stanford said. In 70%, the bladder was the pain-generating organ, 28% had biopsy-proven endometriosis, and 20% had vulvar pain.

Therefore, in the differential diagnosis of chronic pelvic pain, interstitial cystitis must be ranked first, with irritable bowel syndrome, endometriosis, and vulvodynia a distant second, third, and fourth, respectively. Recurrent urinary tract infection was cited in 7% of the cases.

SAN FRANCISCO — In a large majority of women presenting with chronic pelvic pain, the bladder is the pain-generating organ, Edward J. Stanford, M.D., said at the annual meeting of the American Association of Gynecologic Laparoscopists.

In three studies involving almost 300 women with chronic pelvic pain, the prevalence of interstitial cystitis ranged from 70% to 82%, said Dr. Stanford of St. Mary's Good Samaritan Medical Center, Centralia, Ill.

In the most recent and thorough of these studies, Dr. Stanford followed 64 women with chronic pelvic pain for a year. Each completed the Pelvic Pain and Urgency/Frequency questionnaire and underwent a vulvar touch test, a potassium sensitivity test, cystoscopy with hydrodissection, and laparoscopy. During the laparoscopy, the investigators biopsied suspicious lesions and removed all adhesions.

Although 64% of the women had adhesions, the pain could not be attributed to that, Dr. Stanford said. In 70%, the bladder was the pain-generating organ, 28% had biopsy-proven endometriosis, and 20% had vulvar pain.

Therefore, in the differential diagnosis of chronic pelvic pain, interstitial cystitis must be ranked first, with irritable bowel syndrome, endometriosis, and vulvodynia a distant second, third, and fourth, respectively. Recurrent urinary tract infection was cited in 7% of the cases.

SAN FRANCISCO — Lymphogranuloma venereum, once common among gay men but rare in the United States for the last decade, may be poised to make a comeback, Gail Bolan, M.D., said at a meeting on HIV management sponsored by the University of California, San Francisco.

The Centers for Disease Control and Prevention recently reported on an outbreak of lymphogranuloma venereum (LGV) among men who have sex with men in the Netherlands (MMWR 2004;53:985-8).

There has been one confirmed U.S. case of the opportunistic infection out of Emory University (Atlanta), and the New York City Department of Health and Mental Hygiene announced the discovery of two others in New York in February. Another possible case from San Francisco has not yet been confirmed, said Dr. Bolan, chief of the sexually transmitted disease control branch of the California Department of Health Services, in Berkeley.

LGV is common in Africa, Southeast Asia, Central and South America, and the Caribbean but has been rare in developed countries in recent years.

The outbreak in the Netherlands included 92 confirmed cases during an 18-month period in 2003 and 2004, compared with an average of 5 cases annually during previous years.

Chlamydia trachomatis is the causative organism in LGV, but only certain serotypes are involved, not the ones responsible for garden-variety chlamydia infections. The classic presentation includes inguinal adenopathy (buboes). These start as painless papules, nodules, or ulcers that resolve spontaneously.

In the outbreak in the Netherlands, however, only one of the patients had a genital bubo. Most patients presented with GI symptoms, including bloody proctitis and mucopurulent anal discharge.

Other symptoms in this presentation, which is sometimes mistaken for Crohn's disease, include bleeding, tenesmus, fever, and constitutional symptoms. Anoscopy shows diffuse friability and discrete ulcerations.

The destructive granulomatous process can cause complications such as scarring, genital elephantiasis, fistulas, rectal strictures, and perianal abscesses.

The CDC's study of the Netherlands outbreak identified several risk factors, including unprotected receptive anal intercourse or fisting; casual-sex gatherings; and other concurrent STDs. Of the patients whose HIV status was known, 77% were HIV-positive.

A positive chlamydia test from the mucosal site or a bubo aspirate is necessary to confirm the diagnosis. For rectal lesions, it's better to get a swab under control by anoscopy than by taking a blind rectal swab, Dr. Bolan said.

But the available serologic tests are poorly standardized, she added. It's better, when possible, to confirm the presence of the specific LGV serotype by polymerase chain reaction sequencing or tissue culture and monoclonal antibodies.

The CDC's treatment guidelines recommend oral doxycycline, 100 mg b.i.d., for 21 days. Oral erythromycin, 500 mg four times daily for 21 days, is an alternative. Some experts also recommend oral azithromycin, 1 g weekly for 3 weeks, but this has never been formally evaluated.

Partners of affected patients (within the 30 days prior to the onset of symptoms) need evaluation. If these individuals are asymptomatic, they should be treated with doxycycline, 100 mg b.i.d., for 7 days, or with a single dose of 1 g of azithromycin.

Dr. Bolan stated that she has no financial relationships relevant to her presentation.

SAN FRANCISCO — Lymphogranuloma venereum, once common among gay men but rare in the United States for the last decade, may be poised to make a comeback, Gail Bolan, M.D., said at a meeting on HIV management sponsored by the University of California, San Francisco.

The Centers for Disease Control and Prevention recently reported on an outbreak of lymphogranuloma venereum (LGV) among men who have sex with men in the Netherlands (MMWR 2004;53:985-8).

There has been one confirmed U.S. case of the opportunistic infection out of Emory University (Atlanta), and the New York City Department of Health and Mental Hygiene announced the discovery of two others in New York in February. Another possible case from San Francisco has not yet been confirmed, said Dr. Bolan, chief of the sexually transmitted disease control branch of the California Department of Health Services, in Berkeley.

LGV is common in Africa, Southeast Asia, Central and South America, and the Caribbean but has been rare in developed countries in recent years.

The outbreak in the Netherlands included 92 confirmed cases during an 18-month period in 2003 and 2004, compared with an average of 5 cases annually during previous years.

Chlamydia trachomatis is the causative organism in LGV, but only certain serotypes are involved, not the ones responsible for garden-variety chlamydia infections. The classic presentation includes inguinal adenopathy (buboes). These start as painless papules, nodules, or ulcers that resolve spontaneously.

In the outbreak in the Netherlands, however, only one of the patients had a genital bubo. Most patients presented with GI symptoms, including bloody proctitis and mucopurulent anal discharge.

Other symptoms in this presentation, which is sometimes mistaken for Crohn's disease, include bleeding, tenesmus, fever, and constitutional symptoms. Anoscopy shows diffuse friability and discrete ulcerations.

The destructive granulomatous process can cause complications such as scarring, genital elephantiasis, fistulas, rectal strictures, and perianal abscesses.

The CDC's study of the Netherlands outbreak identified several risk factors, including unprotected receptive anal intercourse or fisting; casual-sex gatherings; and other concurrent STDs. Of the patients whose HIV status was known, 77% were HIV-positive.

A positive chlamydia test from the mucosal site or a bubo aspirate is necessary to confirm the diagnosis. For rectal lesions, it's better to get a swab under control by anoscopy than by taking a blind rectal swab, Dr. Bolan said.

But the available serologic tests are poorly standardized, she added. It's better, when possible, to confirm the presence of the specific LGV serotype by polymerase chain reaction sequencing or tissue culture and monoclonal antibodies.

The CDC's treatment guidelines recommend oral doxycycline, 100 mg b.i.d., for 21 days. Oral erythromycin, 500 mg four times daily for 21 days, is an alternative. Some experts also recommend oral azithromycin, 1 g weekly for 3 weeks, but this has never been formally evaluated.

Partners of affected patients (within the 30 days prior to the onset of symptoms) need evaluation. If these individuals are asymptomatic, they should be treated with doxycycline, 100 mg b.i.d., for 7 days, or with a single dose of 1 g of azithromycin.

Dr. Bolan stated that she has no financial relationships relevant to her presentation.

SAN FRANCISCO — Lymphogranuloma venereum, once common among gay men but rare in the United States for the last decade, may be poised to make a comeback, Gail Bolan, M.D., said at a meeting on HIV management sponsored by the University of California, San Francisco.

The Centers for Disease Control and Prevention recently reported on an outbreak of lymphogranuloma venereum (LGV) among men who have sex with men in the Netherlands (MMWR 2004;53:985-8).

There has been one confirmed U.S. case of the opportunistic infection out of Emory University (Atlanta), and the New York City Department of Health and Mental Hygiene announced the discovery of two others in New York in February. Another possible case from San Francisco has not yet been confirmed, said Dr. Bolan, chief of the sexually transmitted disease control branch of the California Department of Health Services, in Berkeley.

LGV is common in Africa, Southeast Asia, Central and South America, and the Caribbean but has been rare in developed countries in recent years.

The outbreak in the Netherlands included 92 confirmed cases during an 18-month period in 2003 and 2004, compared with an average of 5 cases annually during previous years.

Chlamydia trachomatis is the causative organism in LGV, but only certain serotypes are involved, not the ones responsible for garden-variety chlamydia infections. The classic presentation includes inguinal adenopathy (buboes). These start as painless papules, nodules, or ulcers that resolve spontaneously.

In the outbreak in the Netherlands, however, only one of the patients had a genital bubo. Most patients presented with GI symptoms, including bloody proctitis and mucopurulent anal discharge.

Other symptoms in this presentation, which is sometimes mistaken for Crohn's disease, include bleeding, tenesmus, fever, and constitutional symptoms. Anoscopy shows diffuse friability and discrete ulcerations.

The destructive granulomatous process can cause complications such as scarring, genital elephantiasis, fistulas, rectal strictures, and perianal abscesses.

The CDC's study of the Netherlands outbreak identified several risk factors, including unprotected receptive anal intercourse or fisting; casual-sex gatherings; and other concurrent STDs. Of the patients whose HIV status was known, 77% were HIV-positive.

A positive chlamydia test from the mucosal site or a bubo aspirate is necessary to confirm the diagnosis. For rectal lesions, it's better to get a swab under control by anoscopy than by taking a blind rectal swab, Dr. Bolan said.

But the available serologic tests are poorly standardized, she added. It's better, when possible, to confirm the presence of the specific LGV serotype by polymerase chain reaction sequencing or tissue culture and monoclonal antibodies.

The CDC's treatment guidelines recommend oral doxycycline, 100 mg b.i.d., for 21 days. Oral erythromycin, 500 mg four times daily for 21 days, is an alternative. Some experts also recommend oral azithromycin, 1 g weekly for 3 weeks, but this has never been formally evaluated.

Partners of affected patients (within the 30 days prior to the onset of symptoms) need evaluation. If these individuals are asymptomatic, they should be treated with doxycycline, 100 mg b.i.d., for 7 days, or with a single dose of 1 g of azithromycin.

Dr. Bolan stated that she has no financial relationships relevant to her presentation.

SAN DIEGO — Electrocautery using the Colorado needle appears to be at least as effective as the UltraPulse CO2 laser for blepharoplasty, Cameron K. Rokhsar, M.D., reported at the annual meeting of the American Academy of Cosmetic Surgery.

The techniques resulted in equivalent amounts of ecchymosis, edema, and erythema, as assessed by both physician and patient during the 30-day postoperative period. In addition, there were no significant differences in the width of the scar left by each method, said Dr. Rokhsar, a dermatologist in private practice in San Diego.

The study involved 12 patients, 11 of whom had an upper-eyelid blepharoplasty and 2 of whom had a lower-eyelid conjunctival blepharoplasty. After an initial incision with a 15C blade, they were randomly assigned to have the skin, orbicularis, and fat of one eye excised by the CO2 laser and those of the other eye excised using the Colorado needle and electrocautery.

The CO2 laser was operated with a coherent 0.2-mm beam at 150 mJ, 3.5 W, and 25 Hz. The Colorado needle has an ultrasharp, 5-μm tungsten tip; it was operated in this study at a cutting setting of 2 and a coagulation setting of 2.

Patients were assessed at days 1, 3, 7, 14, and 30 following surgery. At day 30, eyes treated with the CO2 laser had scars 1.03 mm in width, and eyes treated with the Colorado needle had scars 1.08 mm in width. These did not differ significantly.

SAN DIEGO — Electrocautery using the Colorado needle appears to be at least as effective as the UltraPulse CO2 laser for blepharoplasty, Cameron K. Rokhsar, M.D., reported at the annual meeting of the American Academy of Cosmetic Surgery.

The techniques resulted in equivalent amounts of ecchymosis, edema, and erythema, as assessed by both physician and patient during the 30-day postoperative period. In addition, there were no significant differences in the width of the scar left by each method, said Dr. Rokhsar, a dermatologist in private practice in San Diego.

The study involved 12 patients, 11 of whom had an upper-eyelid blepharoplasty and 2 of whom had a lower-eyelid conjunctival blepharoplasty. After an initial incision with a 15C blade, they were randomly assigned to have the skin, orbicularis, and fat of one eye excised by the CO2 laser and those of the other eye excised using the Colorado needle and electrocautery.

The CO2 laser was operated with a coherent 0.2-mm beam at 150 mJ, 3.5 W, and 25 Hz. The Colorado needle has an ultrasharp, 5-μm tungsten tip; it was operated in this study at a cutting setting of 2 and a coagulation setting of 2.

Patients were assessed at days 1, 3, 7, 14, and 30 following surgery. At day 30, eyes treated with the CO2 laser had scars 1.03 mm in width, and eyes treated with the Colorado needle had scars 1.08 mm in width. These did not differ significantly.

SAN DIEGO — Electrocautery using the Colorado needle appears to be at least as effective as the UltraPulse CO2 laser for blepharoplasty, Cameron K. Rokhsar, M.D., reported at the annual meeting of the American Academy of Cosmetic Surgery.

The techniques resulted in equivalent amounts of ecchymosis, edema, and erythema, as assessed by both physician and patient during the 30-day postoperative period. In addition, there were no significant differences in the width of the scar left by each method, said Dr. Rokhsar, a dermatologist in private practice in San Diego.

The study involved 12 patients, 11 of whom had an upper-eyelid blepharoplasty and 2 of whom had a lower-eyelid conjunctival blepharoplasty. After an initial incision with a 15C blade, they were randomly assigned to have the skin, orbicularis, and fat of one eye excised by the CO2 laser and those of the other eye excised using the Colorado needle and electrocautery.

The CO2 laser was operated with a coherent 0.2-mm beam at 150 mJ, 3.5 W, and 25 Hz. The Colorado needle has an ultrasharp, 5-μm tungsten tip; it was operated in this study at a cutting setting of 2 and a coagulation setting of 2.

Patients were assessed at days 1, 3, 7, 14, and 30 following surgery. At day 30, eyes treated with the CO2 laser had scars 1.03 mm in width, and eyes treated with the Colorado needle had scars 1.08 mm in width. These did not differ significantly.