Robert Finn

SAN FRANCISCO — Women who are HIV positive are at increased risk of cervical intraepithelial neoplasia and must be followed closely, according to Meg Newman, M.D.

Furthermore, treatment of squamous intraepithelial lesions (SIL) or cervical intraepithelial neoplasia (CIN) is less effective, and there's a very high risk of recurrence, in women with the virus. HIV-positive women should be warned of this possibility, so they'll be prepared for any necessary retreatment, she said at a meeting on HIV management sponsored by the University of California, San Francisco.

Despite the risk of SIL/CIN recurrence in HIV-positive women, it is possible to avoid invasive cervical carcinoma, said Dr. Newman of the University of California, San Francisco, and San Francisco General Hospital. She said her hospital has developed the following treatment guidelines for SIL/CIN in patients with HIV infection:

▸ While treatment of CIN I (mild dysplasia) has a high failure rate in HIV-positive women, it appears to have a relatively low rate of progression. At San Francisco General Hospital, women with CD4 counts more than 200 cells/μL who can commit to follow-up are treated only with close observation.

▸ Cryotherapy is appropriate for a woman with CIN I if her CD4 count is less than 200 cells/μL or if she has a higher CD4 count but is likely to be lost to follow-up.

▸ Appropriate treatment for HIV-infected women with CIN II (moderate to marked dysplasia) or CIN III (severe dysplasia) requires an ablative or excisional procedure.

▸ Cryotherapy is appropriate for CIN II or III if there is a satisfactory colposcopy; there has been no previous cervical treatment; and the lesion is completely visible, less than 2 cm in diameter, and affects only one or two quadrants.

▸ Laser ablation is better when the lesion is greater than 2 cm in diameter or involves three or four quadrants.

▸ The loop electrosurgical excision procedure (LEEP) is helpful when cryotherapy is inappropriate due to lesion size, or if the lesion is located high in the endocervix.

▸ LEEP can't be done when the cervical architecture is disrupted secondary to a prior LEEP or to a cone biopsy.

▸ A cold-knife cone biopsy requires an operating room. This procedure is best used for a high-grade lesion when malignancy is detected on Pap smear and microinvasive disease or a glandular lesion is present.

▸ After excisional or ablative treatment of CIN II or III, topical 5-fluorouracil appears to be useful as an adjunctive treatment.

Finally, Dr. Newman noted that cigarette smoking is one behavior that may play an important role in the acquisition and recurrence of SIL/CIN, and women should be counseled to quit.

SAN FRANCISCO — Women who are HIV positive are at increased risk of cervical intraepithelial neoplasia and must be followed closely, according to Meg Newman, M.D.

Furthermore, treatment of squamous intraepithelial lesions (SIL) or cervical intraepithelial neoplasia (CIN) is less effective, and there's a very high risk of recurrence, in women with the virus. HIV-positive women should be warned of this possibility, so they'll be prepared for any necessary retreatment, she said at a meeting on HIV management sponsored by the University of California, San Francisco.

Despite the risk of SIL/CIN recurrence in HIV-positive women, it is possible to avoid invasive cervical carcinoma, said Dr. Newman of the University of California, San Francisco, and San Francisco General Hospital. She said her hospital has developed the following treatment guidelines for SIL/CIN in patients with HIV infection:

▸ While treatment of CIN I (mild dysplasia) has a high failure rate in HIV-positive women, it appears to have a relatively low rate of progression. At San Francisco General Hospital, women with CD4 counts more than 200 cells/μL who can commit to follow-up are treated only with close observation.

▸ Cryotherapy is appropriate for a woman with CIN I if her CD4 count is less than 200 cells/μL or if she has a higher CD4 count but is likely to be lost to follow-up.

▸ Appropriate treatment for HIV-infected women with CIN II (moderate to marked dysplasia) or CIN III (severe dysplasia) requires an ablative or excisional procedure.

▸ Cryotherapy is appropriate for CIN II or III if there is a satisfactory colposcopy; there has been no previous cervical treatment; and the lesion is completely visible, less than 2 cm in diameter, and affects only one or two quadrants.

▸ Laser ablation is better when the lesion is greater than 2 cm in diameter or involves three or four quadrants.

▸ The loop electrosurgical excision procedure (LEEP) is helpful when cryotherapy is inappropriate due to lesion size, or if the lesion is located high in the endocervix.

▸ LEEP can't be done when the cervical architecture is disrupted secondary to a prior LEEP or to a cone biopsy.

▸ A cold-knife cone biopsy requires an operating room. This procedure is best used for a high-grade lesion when malignancy is detected on Pap smear and microinvasive disease or a glandular lesion is present.

▸ After excisional or ablative treatment of CIN II or III, topical 5-fluorouracil appears to be useful as an adjunctive treatment.

Finally, Dr. Newman noted that cigarette smoking is one behavior that may play an important role in the acquisition and recurrence of SIL/CIN, and women should be counseled to quit.

SAN FRANCISCO — Women who are HIV positive are at increased risk of cervical intraepithelial neoplasia and must be followed closely, according to Meg Newman, M.D.

Furthermore, treatment of squamous intraepithelial lesions (SIL) or cervical intraepithelial neoplasia (CIN) is less effective, and there's a very high risk of recurrence, in women with the virus. HIV-positive women should be warned of this possibility, so they'll be prepared for any necessary retreatment, she said at a meeting on HIV management sponsored by the University of California, San Francisco.

Despite the risk of SIL/CIN recurrence in HIV-positive women, it is possible to avoid invasive cervical carcinoma, said Dr. Newman of the University of California, San Francisco, and San Francisco General Hospital. She said her hospital has developed the following treatment guidelines for SIL/CIN in patients with HIV infection:

▸ While treatment of CIN I (mild dysplasia) has a high failure rate in HIV-positive women, it appears to have a relatively low rate of progression. At San Francisco General Hospital, women with CD4 counts more than 200 cells/μL who can commit to follow-up are treated only with close observation.

▸ Cryotherapy is appropriate for a woman with CIN I if her CD4 count is less than 200 cells/μL or if she has a higher CD4 count but is likely to be lost to follow-up.

▸ Appropriate treatment for HIV-infected women with CIN II (moderate to marked dysplasia) or CIN III (severe dysplasia) requires an ablative or excisional procedure.

▸ Cryotherapy is appropriate for CIN II or III if there is a satisfactory colposcopy; there has been no previous cervical treatment; and the lesion is completely visible, less than 2 cm in diameter, and affects only one or two quadrants.

▸ Laser ablation is better when the lesion is greater than 2 cm in diameter or involves three or four quadrants.

▸ The loop electrosurgical excision procedure (LEEP) is helpful when cryotherapy is inappropriate due to lesion size, or if the lesion is located high in the endocervix.

▸ LEEP can't be done when the cervical architecture is disrupted secondary to a prior LEEP or to a cone biopsy.

▸ A cold-knife cone biopsy requires an operating room. This procedure is best used for a high-grade lesion when malignancy is detected on Pap smear and microinvasive disease or a glandular lesion is present.

▸ After excisional or ablative treatment of CIN II or III, topical 5-fluorouracil appears to be useful as an adjunctive treatment.

Finally, Dr. Newman noted that cigarette smoking is one behavior that may play an important role in the acquisition and recurrence of SIL/CIN, and women should be counseled to quit.

RENO, NEV. — Newborn infants with neurologic injury resulting in death are twice as likely to have had a nighttime delivery as healthy infants, according to a study presented by Adam C. Urato, M.D., at the annual meeting of the Society for Maternal-Fetal Medicine.

The causes of this association are unclear, but may include prolonged labor, differences in staffing at night, and errors by medical personnel due to fatigue, said Dr. Urato of Tufts University, Boston.

The study made use of a Florida state database of perinatal neurologic injuries, created as a result of a law providing for no-fault compensation of families whose children suffer a birth-related neurologic injury.

Of the 447 cases of neurologic injury recorded from 1989 to 2002, there were 80 that resulted in the death of an infant. The database is limited to live-born children with brain or spinal cord injury whose birth weight was greater than 2,500 g. The neurologic problems were caused by oxygen deprivation or mechanical injury occurring in a hospital during labor, birth, delivery, or post delivery.

The 80 deaths were compared with a control group of 999 randomly selected births in Florida from 1996, the midpoint of the time span covered in the neurologic injury database, according to Dr. Urato.

Among the control group, 28% were born during the hours of 11 p.m. to 8 a.m. But 45% of the births with neurologic injury resulting in death occurred during those nighttime hours. Even after correcting the odds ratio for repeat cesarean deliveries, the deaths were 1.95 times more likely to occur at night, a statistically significant increase in risk.

Index cases were significantly less likely than controls to have been born via a normal spontaneous vaginal delivery (12.3% vs. 70.7%), and significantly more likely to have been born via cesarean section (71.7% vs. 21.4%), vacuum delivery (12.3% vs. 6.4%), or forceps delivery (3.7% vs. 1.5%).

Prolonged labor is one possible explanation for the excess of nighttime neurologic injuries resulting in death. Spontaneous labor often leads to an afternoon delivery, but most inductions start during the day. Labors that continue into the night may represent a group at higher risk. But a review of the 80 deaths showed that most did not follow prolonged labor.

Nighttime differences in staffing might be another explanation. All hospital departments, including anesthesia, nursing, pediatrics, and obstetrics, have lower staffing levels at night. But of the 80 deaths, a staffing issue was noted in only a single chart. In that case, the obstetrician was forced to wait for an operating room to perform a cesarean. Other staffing delays might not have been mentioned in the charts, Dr. Urato said.

The third explanation involves fatigue by medical personnel. At some point from 11 p.m. to 8 a.m. most people are at their circadian nadir, with an increased sleep propensity. Many studies of workers have documented an increased risk of accidents and errors at night. No mention of fatigue was made in any of the charts, however.

“Perhaps more than any other field of medicine, obstetrics is associated with nighttime work,” he said. “The image of the obstetrician awakened in the middle of the night to deliver a baby is embedded in our collective consciousness. This finding of increased risk in our field of obstetrics should not surprise us given the preponderance of evidence for other fields that demonstrate that night is indeed a time of increased risk.”

RENO, NEV. — Newborn infants with neurologic injury resulting in death are twice as likely to have had a nighttime delivery as healthy infants, according to a study presented by Adam C. Urato, M.D., at the annual meeting of the Society for Maternal-Fetal Medicine.

The causes of this association are unclear, but may include prolonged labor, differences in staffing at night, and errors by medical personnel due to fatigue, said Dr. Urato of Tufts University, Boston.

The study made use of a Florida state database of perinatal neurologic injuries, created as a result of a law providing for no-fault compensation of families whose children suffer a birth-related neurologic injury.

Of the 447 cases of neurologic injury recorded from 1989 to 2002, there were 80 that resulted in the death of an infant. The database is limited to live-born children with brain or spinal cord injury whose birth weight was greater than 2,500 g. The neurologic problems were caused by oxygen deprivation or mechanical injury occurring in a hospital during labor, birth, delivery, or post delivery.

The 80 deaths were compared with a control group of 999 randomly selected births in Florida from 1996, the midpoint of the time span covered in the neurologic injury database, according to Dr. Urato.

Among the control group, 28% were born during the hours of 11 p.m. to 8 a.m. But 45% of the births with neurologic injury resulting in death occurred during those nighttime hours. Even after correcting the odds ratio for repeat cesarean deliveries, the deaths were 1.95 times more likely to occur at night, a statistically significant increase in risk.

Index cases were significantly less likely than controls to have been born via a normal spontaneous vaginal delivery (12.3% vs. 70.7%), and significantly more likely to have been born via cesarean section (71.7% vs. 21.4%), vacuum delivery (12.3% vs. 6.4%), or forceps delivery (3.7% vs. 1.5%).

Prolonged labor is one possible explanation for the excess of nighttime neurologic injuries resulting in death. Spontaneous labor often leads to an afternoon delivery, but most inductions start during the day. Labors that continue into the night may represent a group at higher risk. But a review of the 80 deaths showed that most did not follow prolonged labor.

Nighttime differences in staffing might be another explanation. All hospital departments, including anesthesia, nursing, pediatrics, and obstetrics, have lower staffing levels at night. But of the 80 deaths, a staffing issue was noted in only a single chart. In that case, the obstetrician was forced to wait for an operating room to perform a cesarean. Other staffing delays might not have been mentioned in the charts, Dr. Urato said.

The third explanation involves fatigue by medical personnel. At some point from 11 p.m. to 8 a.m. most people are at their circadian nadir, with an increased sleep propensity. Many studies of workers have documented an increased risk of accidents and errors at night. No mention of fatigue was made in any of the charts, however.

“Perhaps more than any other field of medicine, obstetrics is associated with nighttime work,” he said. “The image of the obstetrician awakened in the middle of the night to deliver a baby is embedded in our collective consciousness. This finding of increased risk in our field of obstetrics should not surprise us given the preponderance of evidence for other fields that demonstrate that night is indeed a time of increased risk.”

RENO, NEV. — Newborn infants with neurologic injury resulting in death are twice as likely to have had a nighttime delivery as healthy infants, according to a study presented by Adam C. Urato, M.D., at the annual meeting of the Society for Maternal-Fetal Medicine.

The causes of this association are unclear, but may include prolonged labor, differences in staffing at night, and errors by medical personnel due to fatigue, said Dr. Urato of Tufts University, Boston.

The study made use of a Florida state database of perinatal neurologic injuries, created as a result of a law providing for no-fault compensation of families whose children suffer a birth-related neurologic injury.

Of the 447 cases of neurologic injury recorded from 1989 to 2002, there were 80 that resulted in the death of an infant. The database is limited to live-born children with brain or spinal cord injury whose birth weight was greater than 2,500 g. The neurologic problems were caused by oxygen deprivation or mechanical injury occurring in a hospital during labor, birth, delivery, or post delivery.

The 80 deaths were compared with a control group of 999 randomly selected births in Florida from 1996, the midpoint of the time span covered in the neurologic injury database, according to Dr. Urato.

Among the control group, 28% were born during the hours of 11 p.m. to 8 a.m. But 45% of the births with neurologic injury resulting in death occurred during those nighttime hours. Even after correcting the odds ratio for repeat cesarean deliveries, the deaths were 1.95 times more likely to occur at night, a statistically significant increase in risk.

Index cases were significantly less likely than controls to have been born via a normal spontaneous vaginal delivery (12.3% vs. 70.7%), and significantly more likely to have been born via cesarean section (71.7% vs. 21.4%), vacuum delivery (12.3% vs. 6.4%), or forceps delivery (3.7% vs. 1.5%).

Prolonged labor is one possible explanation for the excess of nighttime neurologic injuries resulting in death. Spontaneous labor often leads to an afternoon delivery, but most inductions start during the day. Labors that continue into the night may represent a group at higher risk. But a review of the 80 deaths showed that most did not follow prolonged labor.

Nighttime differences in staffing might be another explanation. All hospital departments, including anesthesia, nursing, pediatrics, and obstetrics, have lower staffing levels at night. But of the 80 deaths, a staffing issue was noted in only a single chart. In that case, the obstetrician was forced to wait for an operating room to perform a cesarean. Other staffing delays might not have been mentioned in the charts, Dr. Urato said.

The third explanation involves fatigue by medical personnel. At some point from 11 p.m. to 8 a.m. most people are at their circadian nadir, with an increased sleep propensity. Many studies of workers have documented an increased risk of accidents and errors at night. No mention of fatigue was made in any of the charts, however.

“Perhaps more than any other field of medicine, obstetrics is associated with nighttime work,” he said. “The image of the obstetrician awakened in the middle of the night to deliver a baby is embedded in our collective consciousness. This finding of increased risk in our field of obstetrics should not surprise us given the preponderance of evidence for other fields that demonstrate that night is indeed a time of increased risk.”

RENO, NEV. — Fetal echocardiography before 16 weeks of gestation is feasible and can detect a substantial proportion of cardiac lesions, investigators reported in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

The technique does have limitations regarding accurate visualization of the great artery relationship and the crux of the heart. It may therefore be best to reserve early echocardiography for cases at the greatest risk for cardiac defects, as judged by increased nuchal translucency and the presence of extracardiac lesions. Second-trimester echocardiograms remain the gold standard, concluded Fionnuala McAuliffe, M.D., of University College Dublin (Ireland) and colleagues.

The study involved 160 fetal echocardiograms performed before the 16th week, with an average gestation time of 13.5 weeks. Investigators used the transabdominal approach for 100 cases, and the transvaginal approach in 60 cases in which the transabdominal approach yielded poor visualization.

Of the 160 patients, 100 were referred because of nuchal translucency greater than the 95th percentile, 51 because of a family history of congenital cardiac defects, and 9 because of the presence of extracardiac lesions.

Adequate cardiac examinations were possible in 152 cases, and pregnancy outcome was available in 137 cases. Of those, there were 20 cardiac defects. Fourteen (70%) showed an abnormality on the early echocardiogram, and 6 (30%) were passed as normal.

The early echocardiogram identified two cases of ectopia cordis, two cases of atrioventricular septal defect, two cases of hypoplastic left heart syndrome, two cases of ventricular septal defect, two cases of left atrial isomerism, two cases of hypoplastic right ventricle, and one case each of double outlet right ventricle and cardiac diverticulum.

On the other hand, the early echocardiogram failed to detect three cases of ventricular septal defect, two cases of dextro-looped transposition of the great arteries, and one case of hypertrophic cardiomyopathy.

A four-chamber view of the heart was obtained in all of the cases. The atrioventricular valves could be visualized 96% of the time, the aorta and pulmonary artery 95% of the time, and the inferior and superior vena cava 76% of the time.

Early fetal echocardiography was less effective in visualizing the aortic and ductal arches (45% of the time), branch pulmonary arteries (37% of the time), and pulmonary veins (19% of the time).

RENO, NEV. — Fetal echocardiography before 16 weeks of gestation is feasible and can detect a substantial proportion of cardiac lesions, investigators reported in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

The technique does have limitations regarding accurate visualization of the great artery relationship and the crux of the heart. It may therefore be best to reserve early echocardiography for cases at the greatest risk for cardiac defects, as judged by increased nuchal translucency and the presence of extracardiac lesions. Second-trimester echocardiograms remain the gold standard, concluded Fionnuala McAuliffe, M.D., of University College Dublin (Ireland) and colleagues.

The study involved 160 fetal echocardiograms performed before the 16th week, with an average gestation time of 13.5 weeks. Investigators used the transabdominal approach for 100 cases, and the transvaginal approach in 60 cases in which the transabdominal approach yielded poor visualization.

Of the 160 patients, 100 were referred because of nuchal translucency greater than the 95th percentile, 51 because of a family history of congenital cardiac defects, and 9 because of the presence of extracardiac lesions.

Adequate cardiac examinations were possible in 152 cases, and pregnancy outcome was available in 137 cases. Of those, there were 20 cardiac defects. Fourteen (70%) showed an abnormality on the early echocardiogram, and 6 (30%) were passed as normal.

The early echocardiogram identified two cases of ectopia cordis, two cases of atrioventricular septal defect, two cases of hypoplastic left heart syndrome, two cases of ventricular septal defect, two cases of left atrial isomerism, two cases of hypoplastic right ventricle, and one case each of double outlet right ventricle and cardiac diverticulum.

On the other hand, the early echocardiogram failed to detect three cases of ventricular septal defect, two cases of dextro-looped transposition of the great arteries, and one case of hypertrophic cardiomyopathy.

A four-chamber view of the heart was obtained in all of the cases. The atrioventricular valves could be visualized 96% of the time, the aorta and pulmonary artery 95% of the time, and the inferior and superior vena cava 76% of the time.

Early fetal echocardiography was less effective in visualizing the aortic and ductal arches (45% of the time), branch pulmonary arteries (37% of the time), and pulmonary veins (19% of the time).

RENO, NEV. — Fetal echocardiography before 16 weeks of gestation is feasible and can detect a substantial proportion of cardiac lesions, investigators reported in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

The technique does have limitations regarding accurate visualization of the great artery relationship and the crux of the heart. It may therefore be best to reserve early echocardiography for cases at the greatest risk for cardiac defects, as judged by increased nuchal translucency and the presence of extracardiac lesions. Second-trimester echocardiograms remain the gold standard, concluded Fionnuala McAuliffe, M.D., of University College Dublin (Ireland) and colleagues.

The study involved 160 fetal echocardiograms performed before the 16th week, with an average gestation time of 13.5 weeks. Investigators used the transabdominal approach for 100 cases, and the transvaginal approach in 60 cases in which the transabdominal approach yielded poor visualization.

Of the 160 patients, 100 were referred because of nuchal translucency greater than the 95th percentile, 51 because of a family history of congenital cardiac defects, and 9 because of the presence of extracardiac lesions.

Adequate cardiac examinations were possible in 152 cases, and pregnancy outcome was available in 137 cases. Of those, there were 20 cardiac defects. Fourteen (70%) showed an abnormality on the early echocardiogram, and 6 (30%) were passed as normal.

The early echocardiogram identified two cases of ectopia cordis, two cases of atrioventricular septal defect, two cases of hypoplastic left heart syndrome, two cases of ventricular septal defect, two cases of left atrial isomerism, two cases of hypoplastic right ventricle, and one case each of double outlet right ventricle and cardiac diverticulum.

On the other hand, the early echocardiogram failed to detect three cases of ventricular septal defect, two cases of dextro-looped transposition of the great arteries, and one case of hypertrophic cardiomyopathy.

A four-chamber view of the heart was obtained in all of the cases. The atrioventricular valves could be visualized 96% of the time, the aorta and pulmonary artery 95% of the time, and the inferior and superior vena cava 76% of the time.

Early fetal echocardiography was less effective in visualizing the aortic and ductal arches (45% of the time), branch pulmonary arteries (37% of the time), and pulmonary veins (19% of the time).

RENO, NEV. — Plasma volume expansion, once thought of as a possible treatment for severe preeclampsia, appears to confer no benefit even after a 1-year follow-up, results of a randomized controlled trial suggest.

The trial, which compared plasma volume expansion with temporizing treatment, showed that there were no differences in pregnancy outcomes and no differences in mental or psychomotor scores of the children at 1 year of age, reported Wessel Ganzevoort, M.D., and colleagues of Vrije University Medical Center, Amsterdam.

The study involved 216 women with severe preeclampsia; hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome; or fetal growth restriction related to pregnancy-induced hypertension.

Gestational ages ranged between 24 and 33 weeks at the start of the study, the investigators wrote in a poster that was presented at the annual meeting of the Society for Maternal-Fetal Medicine.

Women randomized to the plasma volume expansion group received 500 mL of 6% hexaethyl starch daily. Patients in both groups received antihypertensive treatment and magnesium sulfate when appropriate, they said.

Of the 111 women in the treatment group, 89 (80%) delivered live infants. Similarly, of the 105 women in the control group, 91 (87%) delivered live infants. The difference between the two groups was not statistically significant.

At 1 year of age, children from both groups showed lower scores than would be expected in the normal population on the Bayley mental developmental index (MDI) and the Bayley psychomotor developmental index (PDI).

But a comparison between the two groups demonstrated no significant differences in the proportion of children with abnormal or suspect MDI or PDI scores.

RENO, NEV. — Plasma volume expansion, once thought of as a possible treatment for severe preeclampsia, appears to confer no benefit even after a 1-year follow-up, results of a randomized controlled trial suggest.

The trial, which compared plasma volume expansion with temporizing treatment, showed that there were no differences in pregnancy outcomes and no differences in mental or psychomotor scores of the children at 1 year of age, reported Wessel Ganzevoort, M.D., and colleagues of Vrije University Medical Center, Amsterdam.

The study involved 216 women with severe preeclampsia; hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome; or fetal growth restriction related to pregnancy-induced hypertension.

Gestational ages ranged between 24 and 33 weeks at the start of the study, the investigators wrote in a poster that was presented at the annual meeting of the Society for Maternal-Fetal Medicine.

Women randomized to the plasma volume expansion group received 500 mL of 6% hexaethyl starch daily. Patients in both groups received antihypertensive treatment and magnesium sulfate when appropriate, they said.

Of the 111 women in the treatment group, 89 (80%) delivered live infants. Similarly, of the 105 women in the control group, 91 (87%) delivered live infants. The difference between the two groups was not statistically significant.

At 1 year of age, children from both groups showed lower scores than would be expected in the normal population on the Bayley mental developmental index (MDI) and the Bayley psychomotor developmental index (PDI).

But a comparison between the two groups demonstrated no significant differences in the proportion of children with abnormal or suspect MDI or PDI scores.

RENO, NEV. — Plasma volume expansion, once thought of as a possible treatment for severe preeclampsia, appears to confer no benefit even after a 1-year follow-up, results of a randomized controlled trial suggest.

The trial, which compared plasma volume expansion with temporizing treatment, showed that there were no differences in pregnancy outcomes and no differences in mental or psychomotor scores of the children at 1 year of age, reported Wessel Ganzevoort, M.D., and colleagues of Vrije University Medical Center, Amsterdam.

The study involved 216 women with severe preeclampsia; hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome; or fetal growth restriction related to pregnancy-induced hypertension.

Gestational ages ranged between 24 and 33 weeks at the start of the study, the investigators wrote in a poster that was presented at the annual meeting of the Society for Maternal-Fetal Medicine.

Women randomized to the plasma volume expansion group received 500 mL of 6% hexaethyl starch daily. Patients in both groups received antihypertensive treatment and magnesium sulfate when appropriate, they said.

Of the 111 women in the treatment group, 89 (80%) delivered live infants. Similarly, of the 105 women in the control group, 91 (87%) delivered live infants. The difference between the two groups was not statistically significant.

At 1 year of age, children from both groups showed lower scores than would be expected in the normal population on the Bayley mental developmental index (MDI) and the Bayley psychomotor developmental index (PDI).

But a comparison between the two groups demonstrated no significant differences in the proportion of children with abnormal or suspect MDI or PDI scores.

RENO, NEV. — Fetuses with hypoplastic left heart syndrome and normal chromosomes are unlikely to die in utero, according to a retrospective study of 176 fetuses diagnosed prenatally with the disorder.

Of these fetuses, which were diagnosed over a 12-year period, 133 were live born, 32 underwent therapeutic abortion, and 3 died in utero. The outcome for eight of the fetuses is unknown, Rebecca H. Allen, M.D., and her associates wrote in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Of the 3 fetuses that died in utero, 1 had trisomy 13, 1 had trisomy 18, and 1 was not karyotyped. Both of the fetuses with abnormal karyotypes had other anomalies detected by ultrasound. The third had no anomalies, but was one of triplets. Only 2 of the 133 live-born fetuses had abnormal karyotypes; 29 had other anomalies.

Parents of fetuses with hypoplastic left heart syndrome are sometimes offered interventional procedures, and fetal death occasionally follows. It's unknown whether such procedures contribute to intrauterine death.

“This finding does not argue against prenatal cardiac interventional procedures,” Dr. Allen of Brigham and Women's Hospital, Boston, said in an interview, stating that the study was designed to examine the natural history of the syndrome.

The study emphasizes “the need for karyotype in the evaluation of a fetus with hypoplastic left heart syndrome. A fetus with normal chromosomes and an isolated hypoplastic left heart lesion is a potentially good candidate for in utero cardiac intervention,” she said.

This fetus has hypoplastic left heart syndrome. This sonogram shows a very small left ventricle (LV) and an enlarged right ventricle (RV). The right atrium (RA) and left atrium (LA) also are indicated. Courtesy Dr. Rebecca H. Allen

RENO, NEV. — Fetuses with hypoplastic left heart syndrome and normal chromosomes are unlikely to die in utero, according to a retrospective study of 176 fetuses diagnosed prenatally with the disorder.

Of these fetuses, which were diagnosed over a 12-year period, 133 were live born, 32 underwent therapeutic abortion, and 3 died in utero. The outcome for eight of the fetuses is unknown, Rebecca H. Allen, M.D., and her associates wrote in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Of the 3 fetuses that died in utero, 1 had trisomy 13, 1 had trisomy 18, and 1 was not karyotyped. Both of the fetuses with abnormal karyotypes had other anomalies detected by ultrasound. The third had no anomalies, but was one of triplets. Only 2 of the 133 live-born fetuses had abnormal karyotypes; 29 had other anomalies.

Parents of fetuses with hypoplastic left heart syndrome are sometimes offered interventional procedures, and fetal death occasionally follows. It's unknown whether such procedures contribute to intrauterine death.

“This finding does not argue against prenatal cardiac interventional procedures,” Dr. Allen of Brigham and Women's Hospital, Boston, said in an interview, stating that the study was designed to examine the natural history of the syndrome.

The study emphasizes “the need for karyotype in the evaluation of a fetus with hypoplastic left heart syndrome. A fetus with normal chromosomes and an isolated hypoplastic left heart lesion is a potentially good candidate for in utero cardiac intervention,” she said.

This fetus has hypoplastic left heart syndrome. This sonogram shows a very small left ventricle (LV) and an enlarged right ventricle (RV). The right atrium (RA) and left atrium (LA) also are indicated. Courtesy Dr. Rebecca H. Allen

RENO, NEV. — Fetuses with hypoplastic left heart syndrome and normal chromosomes are unlikely to die in utero, according to a retrospective study of 176 fetuses diagnosed prenatally with the disorder.

Of these fetuses, which were diagnosed over a 12-year period, 133 were live born, 32 underwent therapeutic abortion, and 3 died in utero. The outcome for eight of the fetuses is unknown, Rebecca H. Allen, M.D., and her associates wrote in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Of the 3 fetuses that died in utero, 1 had trisomy 13, 1 had trisomy 18, and 1 was not karyotyped. Both of the fetuses with abnormal karyotypes had other anomalies detected by ultrasound. The third had no anomalies, but was one of triplets. Only 2 of the 133 live-born fetuses had abnormal karyotypes; 29 had other anomalies.

Parents of fetuses with hypoplastic left heart syndrome are sometimes offered interventional procedures, and fetal death occasionally follows. It's unknown whether such procedures contribute to intrauterine death.

“This finding does not argue against prenatal cardiac interventional procedures,” Dr. Allen of Brigham and Women's Hospital, Boston, said in an interview, stating that the study was designed to examine the natural history of the syndrome.

The study emphasizes “the need for karyotype in the evaluation of a fetus with hypoplastic left heart syndrome. A fetus with normal chromosomes and an isolated hypoplastic left heart lesion is a potentially good candidate for in utero cardiac intervention,” she said.

This fetus has hypoplastic left heart syndrome. This sonogram shows a very small left ventricle (LV) and an enlarged right ventricle (RV). The right atrium (RA) and left atrium (LA) also are indicated. Courtesy Dr. Rebecca H. Allen

SAN FRANCISCO — The debate continues to rage on over when to initiate highly active antiretroviral therapy for patients with HIV disease.

At a meeting on HIV management, sponsored by the University of California, San Francisco, Paul A. Volberding, M.D., joked that the answer is obvious: before it's too late, but after it's too early.

But whatever the clinician decides, there is a series of steps that must be taken before antiretroviral therapy begins, said Dr. Volberding of the Veterans Affairs Medical Center in San Francisco:

▸ Confirm the HIV results. “We [recently] had in the Bay Area yet another case of a person who had been followed for HIV infection without anyone noticing that his HIV test was negative,” Dr. Volberding said.

▸ Take a detailed health history and conduct a thorough physical exam.

▸ Get a CBC and a chemistry profile.

▸ Order a CD4 cell count and a plasma HIV RNA measurement, Dr. Volberding said.

▸ Consider doing resistance testing. “I think we're at the point where baseline resistance testing should be recommended in all cases,” Dr. Volberding said, noting that this step is not yet part of official practice guidelines.

▸ Assess the patient's readiness for treatment and the likelihood that he or she will be adherent.

▸ Refer the patient for an ophthalmology exam if the CD4 count is below 100 cells/μL.

▸ Make sure female patients get a gynecologic exam with a Pap smear.

▸ Test for syphilis with a rapid plasma reagin test or a Venereal Disease Research Laboratory test.

▸ Test for tuberculin with a purified protein derivative test.

▸ Order a chest x-ray.

▸ Order hepatitis A, B, and C serology.

▸ Order a toxoplasma IgG test.

▸ Order a fasting glucose and a lipid panel.

SAN FRANCISCO — The debate continues to rage on over when to initiate highly active antiretroviral therapy for patients with HIV disease.

At a meeting on HIV management, sponsored by the University of California, San Francisco, Paul A. Volberding, M.D., joked that the answer is obvious: before it's too late, but after it's too early.

But whatever the clinician decides, there is a series of steps that must be taken before antiretroviral therapy begins, said Dr. Volberding of the Veterans Affairs Medical Center in San Francisco:

▸ Confirm the HIV results. “We [recently] had in the Bay Area yet another case of a person who had been followed for HIV infection without anyone noticing that his HIV test was negative,” Dr. Volberding said.

▸ Take a detailed health history and conduct a thorough physical exam.

▸ Get a CBC and a chemistry profile.

▸ Order a CD4 cell count and a plasma HIV RNA measurement, Dr. Volberding said.

▸ Consider doing resistance testing. “I think we're at the point where baseline resistance testing should be recommended in all cases,” Dr. Volberding said, noting that this step is not yet part of official practice guidelines.

▸ Assess the patient's readiness for treatment and the likelihood that he or she will be adherent.

▸ Refer the patient for an ophthalmology exam if the CD4 count is below 100 cells/μL.

▸ Make sure female patients get a gynecologic exam with a Pap smear.

▸ Test for syphilis with a rapid plasma reagin test or a Venereal Disease Research Laboratory test.

▸ Test for tuberculin with a purified protein derivative test.

▸ Order a chest x-ray.

▸ Order hepatitis A, B, and C serology.

▸ Order a toxoplasma IgG test.

▸ Order a fasting glucose and a lipid panel.

SAN FRANCISCO — The debate continues to rage on over when to initiate highly active antiretroviral therapy for patients with HIV disease.

At a meeting on HIV management, sponsored by the University of California, San Francisco, Paul A. Volberding, M.D., joked that the answer is obvious: before it's too late, but after it's too early.

But whatever the clinician decides, there is a series of steps that must be taken before antiretroviral therapy begins, said Dr. Volberding of the Veterans Affairs Medical Center in San Francisco:

▸ Confirm the HIV results. “We [recently] had in the Bay Area yet another case of a person who had been followed for HIV infection without anyone noticing that his HIV test was negative,” Dr. Volberding said.

▸ Take a detailed health history and conduct a thorough physical exam.

▸ Get a CBC and a chemistry profile.

▸ Order a CD4 cell count and a plasma HIV RNA measurement, Dr. Volberding said.

▸ Consider doing resistance testing. “I think we're at the point where baseline resistance testing should be recommended in all cases,” Dr. Volberding said, noting that this step is not yet part of official practice guidelines.

▸ Assess the patient's readiness for treatment and the likelihood that he or she will be adherent.

▸ Refer the patient for an ophthalmology exam if the CD4 count is below 100 cells/μL.

▸ Make sure female patients get a gynecologic exam with a Pap smear.

▸ Test for syphilis with a rapid plasma reagin test or a Venereal Disease Research Laboratory test.

▸ Test for tuberculin with a purified protein derivative test.

▸ Order a chest x-ray.

▸ Order hepatitis A, B, and C serology.

▸ Order a toxoplasma IgG test.

▸ Order a fasting glucose and a lipid panel.

LAS VEGAS – Every cluster headache patient needs to be on a prophylactic drug, Todd D. Rozen, M.D., said at a symposium sponsored by the American Headache Society.

“I tell them, 'I'm not happy, and you shouldn't be happy, until you're cluster free on prevention,'” noted Dr. Rozen, who is with the Michigan Head-Pain and Neurological Institute in Ann Arbor.

There are two types of prophylaxis for cluster headache: transitional treatments, which are intended to prevent cluster headaches from occurring for a short period of time (typically 7-14 days), and maintenance preventive treatments, which are designed to keep a patient cluster free while in a cluster cycle.

Transitional treatments must kick in quickly. They're used for 10-14 days, after which they're tapered down as the maintenance preventives are tapered up to a therapeutic dose. The transitional drug and maintenance preventive drug are typically started at the same time, Dr. Rozen said.

Corticosteroids are the most commonly used transitional treatment. Start prednisone at a dosage of 60-80 mg/day, tapering down over a period of 10-12 days, he said.

Naratriptan can be used at a dosage of 2.5 mg b.i.d., but monitor the patient for rebound headaches. Ergotamine, at a dosage of 2 mg at bedtime or b.i.d., also appears useful.

Dihydroergotamine can be given by daily intramuscular injections over a period of 1-2 weeks, or by an intravenous infusion for 3 days.

For reasons that are unclear, greater occipital nerve blocks seem to work well, giving some patients up to 13 days free of cluster headaches, even when their pain (like that of most cluster patients) is not located in the occipital area. The mechanism of action may involve decreasing afferent impulses to the spinal trigeminal nuclear complex.

For long-term prevention, a number of drugs work well, but many patients will need to be on combination therapy, taking two, three, or even four drugs to fully prevent recurrences.

“Melatonin is really my first-line choice because it is easy to get over the counter and there are no side effects,” Dr. Rozen said. “[For] a small percentage of cluster patients, the night I give them melatonin is the last time they're going to have a cluster.” The typical dosage is 9 mg at bedtime, although some patients have required higher doses.

Verapamil is the best cluster preventive currently available, Dr. Rozen said. He recommended moving the dosage up quickly, since some patients will need up to 1 g/day. ECGs must be performed at every dosage above 480 mg to monitor for heart block. Lithium carbonate, 300 mg t.i.d., appears to be well tolerated in cluster headache.

Valproic acid, when pushed up to a dosage of 3,000 mg at bedtime, is sometimes effective.

Some small, uncontrolled studies suggest that topiramate may be effective for preventing clusters. When trying topiramate, increase the dosage in 25-mg increments every 4-5 days until the patient is taking 75-100 mg/day. When patients do respond to topiramate, it's usually in a short period, 1-2 weeks after starting the agent, he said.

Other preventive treatments that may be effective are transdermal clonidine, tizanidine, indomethacin, nasal capsaicin, gabapentin, baclofen, and histamine desensitization.

For some patients, steroids seem to be the only thing that works, Dr. Rozen noted, and of course patients shouldn't take corticosteroids chronically. He has had success in a single patient with mycophenolate mofetil (CellCept), the steroid-sparing immunosuppressant.

Dr. Rozen acknowledged being a member of the advisory board of Ortho-McNeil Pharmaceuticals Inc., whose products include topiramate (Topamax).

LAS VEGAS – Every cluster headache patient needs to be on a prophylactic drug, Todd D. Rozen, M.D., said at a symposium sponsored by the American Headache Society.

“I tell them, 'I'm not happy, and you shouldn't be happy, until you're cluster free on prevention,'” noted Dr. Rozen, who is with the Michigan Head-Pain and Neurological Institute in Ann Arbor.

There are two types of prophylaxis for cluster headache: transitional treatments, which are intended to prevent cluster headaches from occurring for a short period of time (typically 7-14 days), and maintenance preventive treatments, which are designed to keep a patient cluster free while in a cluster cycle.

Transitional treatments must kick in quickly. They're used for 10-14 days, after which they're tapered down as the maintenance preventives are tapered up to a therapeutic dose. The transitional drug and maintenance preventive drug are typically started at the same time, Dr. Rozen said.

Corticosteroids are the most commonly used transitional treatment. Start prednisone at a dosage of 60-80 mg/day, tapering down over a period of 10-12 days, he said.

Naratriptan can be used at a dosage of 2.5 mg b.i.d., but monitor the patient for rebound headaches. Ergotamine, at a dosage of 2 mg at bedtime or b.i.d., also appears useful.

Dihydroergotamine can be given by daily intramuscular injections over a period of 1-2 weeks, or by an intravenous infusion for 3 days.

For reasons that are unclear, greater occipital nerve blocks seem to work well, giving some patients up to 13 days free of cluster headaches, even when their pain (like that of most cluster patients) is not located in the occipital area. The mechanism of action may involve decreasing afferent impulses to the spinal trigeminal nuclear complex.

For long-term prevention, a number of drugs work well, but many patients will need to be on combination therapy, taking two, three, or even four drugs to fully prevent recurrences.

“Melatonin is really my first-line choice because it is easy to get over the counter and there are no side effects,” Dr. Rozen said. “[For] a small percentage of cluster patients, the night I give them melatonin is the last time they're going to have a cluster.” The typical dosage is 9 mg at bedtime, although some patients have required higher doses.

Verapamil is the best cluster preventive currently available, Dr. Rozen said. He recommended moving the dosage up quickly, since some patients will need up to 1 g/day. ECGs must be performed at every dosage above 480 mg to monitor for heart block. Lithium carbonate, 300 mg t.i.d., appears to be well tolerated in cluster headache.

Valproic acid, when pushed up to a dosage of 3,000 mg at bedtime, is sometimes effective.

Some small, uncontrolled studies suggest that topiramate may be effective for preventing clusters. When trying topiramate, increase the dosage in 25-mg increments every 4-5 days until the patient is taking 75-100 mg/day. When patients do respond to topiramate, it's usually in a short period, 1-2 weeks after starting the agent, he said.

Other preventive treatments that may be effective are transdermal clonidine, tizanidine, indomethacin, nasal capsaicin, gabapentin, baclofen, and histamine desensitization.

For some patients, steroids seem to be the only thing that works, Dr. Rozen noted, and of course patients shouldn't take corticosteroids chronically. He has had success in a single patient with mycophenolate mofetil (CellCept), the steroid-sparing immunosuppressant.

Dr. Rozen acknowledged being a member of the advisory board of Ortho-McNeil Pharmaceuticals Inc., whose products include topiramate (Topamax).

LAS VEGAS – Every cluster headache patient needs to be on a prophylactic drug, Todd D. Rozen, M.D., said at a symposium sponsored by the American Headache Society.

“I tell them, 'I'm not happy, and you shouldn't be happy, until you're cluster free on prevention,'” noted Dr. Rozen, who is with the Michigan Head-Pain and Neurological Institute in Ann Arbor.

There are two types of prophylaxis for cluster headache: transitional treatments, which are intended to prevent cluster headaches from occurring for a short period of time (typically 7-14 days), and maintenance preventive treatments, which are designed to keep a patient cluster free while in a cluster cycle.

Transitional treatments must kick in quickly. They're used for 10-14 days, after which they're tapered down as the maintenance preventives are tapered up to a therapeutic dose. The transitional drug and maintenance preventive drug are typically started at the same time, Dr. Rozen said.

Corticosteroids are the most commonly used transitional treatment. Start prednisone at a dosage of 60-80 mg/day, tapering down over a period of 10-12 days, he said.

Naratriptan can be used at a dosage of 2.5 mg b.i.d., but monitor the patient for rebound headaches. Ergotamine, at a dosage of 2 mg at bedtime or b.i.d., also appears useful.

Dihydroergotamine can be given by daily intramuscular injections over a period of 1-2 weeks, or by an intravenous infusion for 3 days.

For reasons that are unclear, greater occipital nerve blocks seem to work well, giving some patients up to 13 days free of cluster headaches, even when their pain (like that of most cluster patients) is not located in the occipital area. The mechanism of action may involve decreasing afferent impulses to the spinal trigeminal nuclear complex.

For long-term prevention, a number of drugs work well, but many patients will need to be on combination therapy, taking two, three, or even four drugs to fully prevent recurrences.

“Melatonin is really my first-line choice because it is easy to get over the counter and there are no side effects,” Dr. Rozen said. “[For] a small percentage of cluster patients, the night I give them melatonin is the last time they're going to have a cluster.” The typical dosage is 9 mg at bedtime, although some patients have required higher doses.

Verapamil is the best cluster preventive currently available, Dr. Rozen said. He recommended moving the dosage up quickly, since some patients will need up to 1 g/day. ECGs must be performed at every dosage above 480 mg to monitor for heart block. Lithium carbonate, 300 mg t.i.d., appears to be well tolerated in cluster headache.

Valproic acid, when pushed up to a dosage of 3,000 mg at bedtime, is sometimes effective.

Some small, uncontrolled studies suggest that topiramate may be effective for preventing clusters. When trying topiramate, increase the dosage in 25-mg increments every 4-5 days until the patient is taking 75-100 mg/day. When patients do respond to topiramate, it's usually in a short period, 1-2 weeks after starting the agent, he said.

Other preventive treatments that may be effective are transdermal clonidine, tizanidine, indomethacin, nasal capsaicin, gabapentin, baclofen, and histamine desensitization.

For some patients, steroids seem to be the only thing that works, Dr. Rozen noted, and of course patients shouldn't take corticosteroids chronically. He has had success in a single patient with mycophenolate mofetil (CellCept), the steroid-sparing immunosuppressant.

Dr. Rozen acknowledged being a member of the advisory board of Ortho-McNeil Pharmaceuticals Inc., whose products include topiramate (Topamax).

SAN FRANCISCO — In patients coinfected with HIV and hepatitis C, the presence of HIV disease complicates the treatment of hepatitis C, and, likewise, the presence of hepatitis C complicates the treatment of HIV, Teresa L. Wright, M.D., said at a meeting on HIV management sponsored by the University of California, San Francisco.

Based on recently published studies and current U.S. and Canadian guidelines, Dr. Wright of UCSF listed some key principles in the management of patients coinfected with HIV and hepatitis C virus (HCV):

▸ If the patient is in an early stage of HIV disease, consider HCV therapy prior to HIV treatment.

▸ If the patient's HIV disease is progressing, optimize HIV control first. Then, once the patient is on a stable HIV regimen, consider HCV therapy.

▸ Treat psychiatric disease and substance abuse, which can lead to reinfection.

▸ When treating HCV, peginterferon alfa-2a should be administered subcutaneously at a fixed dosage of 180 mcg once a week. Peginterferon alfa-2b should be administered subcutaneously at a dosage of 1.5 mcg/kg once per week. Two recently published studies indicate that total HCV viral suppression is more likely with either of the pegylated interferons plus ribavirin than with standard interferon plus ribavirin. Neither of the studies compared pegylated interferon alfa-2a (Pegasys) directly with pegylated interferon alfa-2b (Peg-Intron).

▸ Start patients on a reduced dosage of ribavirin. The guidelines recommend that the dosage of combination ribavirin should reach 400 mg b.i.d. But Dr. Wright said, “we know from a lot of experience with hepatitis C monoinfected patients that this dose of ribavirin is going to be inadequate and suboptimal, particularly in patients with genotype 1 infections. So I think most of us now are increasingly trying to get patients up at higher doses of ribavirin if tolerated.” She mentioned a daily dosage of 1,000-1,200 mg.

▸ Especially with the higher dosages of ribavirin, patients are likely to require growth hormone support with epoetin alfa and/or granulocyte colony-stimulating factor.

▸ When treating HCV, avoid HIV regimens containing didanosine (Videx) because of ribavirin-associated increases in drug levels and mitochondrial toxicity.

▸ Monitor patients closely for side effects and drug-drug interactions.

Dr. Wright said she had no financial relationships relevant to her presentation.

SAN FRANCISCO — In patients coinfected with HIV and hepatitis C, the presence of HIV disease complicates the treatment of hepatitis C, and, likewise, the presence of hepatitis C complicates the treatment of HIV, Teresa L. Wright, M.D., said at a meeting on HIV management sponsored by the University of California, San Francisco.

Based on recently published studies and current U.S. and Canadian guidelines, Dr. Wright of UCSF listed some key principles in the management of patients coinfected with HIV and hepatitis C virus (HCV):

▸ If the patient is in an early stage of HIV disease, consider HCV therapy prior to HIV treatment.

▸ If the patient's HIV disease is progressing, optimize HIV control first. Then, once the patient is on a stable HIV regimen, consider HCV therapy.

▸ Treat psychiatric disease and substance abuse, which can lead to reinfection.

▸ When treating HCV, peginterferon alfa-2a should be administered subcutaneously at a fixed dosage of 180 mcg once a week. Peginterferon alfa-2b should be administered subcutaneously at a dosage of 1.5 mcg/kg once per week. Two recently published studies indicate that total HCV viral suppression is more likely with either of the pegylated interferons plus ribavirin than with standard interferon plus ribavirin. Neither of the studies compared pegylated interferon alfa-2a (Pegasys) directly with pegylated interferon alfa-2b (Peg-Intron).

▸ Start patients on a reduced dosage of ribavirin. The guidelines recommend that the dosage of combination ribavirin should reach 400 mg b.i.d. But Dr. Wright said, “we know from a lot of experience with hepatitis C monoinfected patients that this dose of ribavirin is going to be inadequate and suboptimal, particularly in patients with genotype 1 infections. So I think most of us now are increasingly trying to get patients up at higher doses of ribavirin if tolerated.” She mentioned a daily dosage of 1,000-1,200 mg.

▸ Especially with the higher dosages of ribavirin, patients are likely to require growth hormone support with epoetin alfa and/or granulocyte colony-stimulating factor.

▸ When treating HCV, avoid HIV regimens containing didanosine (Videx) because of ribavirin-associated increases in drug levels and mitochondrial toxicity.

▸ Monitor patients closely for side effects and drug-drug interactions.

Dr. Wright said she had no financial relationships relevant to her presentation.

SAN FRANCISCO — In patients coinfected with HIV and hepatitis C, the presence of HIV disease complicates the treatment of hepatitis C, and, likewise, the presence of hepatitis C complicates the treatment of HIV, Teresa L. Wright, M.D., said at a meeting on HIV management sponsored by the University of California, San Francisco.

Based on recently published studies and current U.S. and Canadian guidelines, Dr. Wright of UCSF listed some key principles in the management of patients coinfected with HIV and hepatitis C virus (HCV):

▸ If the patient is in an early stage of HIV disease, consider HCV therapy prior to HIV treatment.

▸ If the patient's HIV disease is progressing, optimize HIV control first. Then, once the patient is on a stable HIV regimen, consider HCV therapy.

▸ Treat psychiatric disease and substance abuse, which can lead to reinfection.

▸ When treating HCV, peginterferon alfa-2a should be administered subcutaneously at a fixed dosage of 180 mcg once a week. Peginterferon alfa-2b should be administered subcutaneously at a dosage of 1.5 mcg/kg once per week. Two recently published studies indicate that total HCV viral suppression is more likely with either of the pegylated interferons plus ribavirin than with standard interferon plus ribavirin. Neither of the studies compared pegylated interferon alfa-2a (Pegasys) directly with pegylated interferon alfa-2b (Peg-Intron).

▸ Start patients on a reduced dosage of ribavirin. The guidelines recommend that the dosage of combination ribavirin should reach 400 mg b.i.d. But Dr. Wright said, “we know from a lot of experience with hepatitis C monoinfected patients that this dose of ribavirin is going to be inadequate and suboptimal, particularly in patients with genotype 1 infections. So I think most of us now are increasingly trying to get patients up at higher doses of ribavirin if tolerated.” She mentioned a daily dosage of 1,000-1,200 mg.

▸ Especially with the higher dosages of ribavirin, patients are likely to require growth hormone support with epoetin alfa and/or granulocyte colony-stimulating factor.

▸ When treating HCV, avoid HIV regimens containing didanosine (Videx) because of ribavirin-associated increases in drug levels and mitochondrial toxicity.

▸ Monitor patients closely for side effects and drug-drug interactions.

Dr. Wright said she had no financial relationships relevant to her presentation.

SAN DIEGO — Hair restoration surgery can be a lucrative addition to a cosmetic surgery practice, but efficiency and speed are crucial, E. Antonio Mangubat, M.D., said at the annual meeting of the American Academy of Cosmetic Surgery.

Hair restoration surgery can be time consuming, with each procedure taking 2-6 hours depending on the amount of hair transplanted. But unlike most surgical procedures, the physician can work on up to four patients in parallel, if he or she has highly trained staff, said Dr. Mangubat, who practices in Tukwila, Wash.

"You're part of a team, and you've got to give up a little bit of that ego that says you have to do it all," Dr. Mangubat said. He estimates that his staff conducts 60%-80% of each operation. "I'm only in the operating room for my part of the operation, and I can go off and do other things."

Dr. Mangubat harvests the donor hair, designs and prepares the recipient sites, and supervises the other activities. Technicians place all the grafts and take care of all patient preparation and cleanup.

Competition in the hair restoration field is driving down prices at the same time that costs are increasing, in part because of the more refined approach required by follicular unit grafting. This gives much better cosmetic results, especially along the hair line, than do the old-style hair plugs.

So speed is important, but not only for increased production. Studies show that speed has a large effect on graft survival, with 95% of grafts surviving for 2 hours outside of the body, but only 86% surviving for 4 hours. Speed is also important for patient comfort. "Can you imagine being in there 12 hours versus 6 hours?" he asked.

Technology can also help. Dr. Mangubat uses a multibladed knife that can harvest up to eight strips of donor skin and associated hair follicles simultaneously. He closes the donor site with staples—which takes 3 minutes and gives a good cosmetic result at the expense of some patient discomfort—instead of sutures, which can take up to 15-20 minutes to do correctly.

And he's a proponent of using a graft cutter, a device in which thin slivers of donor tissue are placed on a series of blades and smacked with a hammer into smaller pieces. In the pre-graft cutter era, a 1,000-graft session lasted 5 hours and required four staff members (three cutters and one placer) for a total of 20 person-hours, not counting the physician's time.

But using a graft cutter, a 1,000-graft session takes 4 hours and requires a single assistant to place the grafts, for a total of 4 person-hours. This greatly increases surgical productivity with no decrease in patient satisfaction, Dr. Mangubat said.

SAN DIEGO — Hair restoration surgery can be a lucrative addition to a cosmetic surgery practice, but efficiency and speed are crucial, E. Antonio Mangubat, M.D., said at the annual meeting of the American Academy of Cosmetic Surgery.

Hair restoration surgery can be time consuming, with each procedure taking 2-6 hours depending on the amount of hair transplanted. But unlike most surgical procedures, the physician can work on up to four patients in parallel, if he or she has highly trained staff, said Dr. Mangubat, who practices in Tukwila, Wash.

"You're part of a team, and you've got to give up a little bit of that ego that says you have to do it all," Dr. Mangubat said. He estimates that his staff conducts 60%-80% of each operation. "I'm only in the operating room for my part of the operation, and I can go off and do other things."

Dr. Mangubat harvests the donor hair, designs and prepares the recipient sites, and supervises the other activities. Technicians place all the grafts and take care of all patient preparation and cleanup.

Competition in the hair restoration field is driving down prices at the same time that costs are increasing, in part because of the more refined approach required by follicular unit grafting. This gives much better cosmetic results, especially along the hair line, than do the old-style hair plugs.

So speed is important, but not only for increased production. Studies show that speed has a large effect on graft survival, with 95% of grafts surviving for 2 hours outside of the body, but only 86% surviving for 4 hours. Speed is also important for patient comfort. "Can you imagine being in there 12 hours versus 6 hours?" he asked.

Technology can also help. Dr. Mangubat uses a multibladed knife that can harvest up to eight strips of donor skin and associated hair follicles simultaneously. He closes the donor site with staples—which takes 3 minutes and gives a good cosmetic result at the expense of some patient discomfort—instead of sutures, which can take up to 15-20 minutes to do correctly.

And he's a proponent of using a graft cutter, a device in which thin slivers of donor tissue are placed on a series of blades and smacked with a hammer into smaller pieces. In the pre-graft cutter era, a 1,000-graft session lasted 5 hours and required four staff members (three cutters and one placer) for a total of 20 person-hours, not counting the physician's time.

But using a graft cutter, a 1,000-graft session takes 4 hours and requires a single assistant to place the grafts, for a total of 4 person-hours. This greatly increases surgical productivity with no decrease in patient satisfaction, Dr. Mangubat said.

SAN DIEGO — Hair restoration surgery can be a lucrative addition to a cosmetic surgery practice, but efficiency and speed are crucial, E. Antonio Mangubat, M.D., said at the annual meeting of the American Academy of Cosmetic Surgery.

Hair restoration surgery can be time consuming, with each procedure taking 2-6 hours depending on the amount of hair transplanted. But unlike most surgical procedures, the physician can work on up to four patients in parallel, if he or she has highly trained staff, said Dr. Mangubat, who practices in Tukwila, Wash.

"You're part of a team, and you've got to give up a little bit of that ego that says you have to do it all," Dr. Mangubat said. He estimates that his staff conducts 60%-80% of each operation. "I'm only in the operating room for my part of the operation, and I can go off and do other things."

Dr. Mangubat harvests the donor hair, designs and prepares the recipient sites, and supervises the other activities. Technicians place all the grafts and take care of all patient preparation and cleanup.

Competition in the hair restoration field is driving down prices at the same time that costs are increasing, in part because of the more refined approach required by follicular unit grafting. This gives much better cosmetic results, especially along the hair line, than do the old-style hair plugs.

So speed is important, but not only for increased production. Studies show that speed has a large effect on graft survival, with 95% of grafts surviving for 2 hours outside of the body, but only 86% surviving for 4 hours. Speed is also important for patient comfort. "Can you imagine being in there 12 hours versus 6 hours?" he asked.

Technology can also help. Dr. Mangubat uses a multibladed knife that can harvest up to eight strips of donor skin and associated hair follicles simultaneously. He closes the donor site with staples—which takes 3 minutes and gives a good cosmetic result at the expense of some patient discomfort—instead of sutures, which can take up to 15-20 minutes to do correctly.

And he's a proponent of using a graft cutter, a device in which thin slivers of donor tissue are placed on a series of blades and smacked with a hammer into smaller pieces. In the pre-graft cutter era, a 1,000-graft session lasted 5 hours and required four staff members (three cutters and one placer) for a total of 20 person-hours, not counting the physician's time.

But using a graft cutter, a 1,000-graft session takes 4 hours and requires a single assistant to place the grafts, for a total of 4 person-hours. This greatly increases surgical productivity with no decrease in patient satisfaction, Dr. Mangubat said.

RENO, NEV. — A retrospective study examining 473 pregnancies complicated by preeclampsia has uncovered a number of significant racial and ethnic differences in the expression of the disorder.

African American women with preeclampsia tend to have more severe hypertension and more often require antihypertensive medication than the population at large, according to a poster presentation by Amy Goodwin, M.D., of Case Western Reserve University, Cleveland, and associates at the annual meeting of the Society for Maternal-Fetal Medicine.

While 37% of the full sample had severe hypertension at diagnosis, 45% of African American women had severe hypertension. African American women were also significantly more likely to require antihypertensive medication intrapartum (12% vs. 8.8%), post partum (18% vs. 13%), and at discharge (35% vs. 27%).

Non-Hispanic Caucasian women more frequently manifest severe hypertension with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. While 24% of the full sample exhibited HELLP, the rate among Caucasian women was 30%.

Hispanic women tend to present with preeclampsia later in gestation and with less severe disease than the rest of the population. They presented at a mean of 36 weeks of gestation vs. 34.4 weeks for the rest of the population, and a smaller proportion of them exhibited severe hypertension at diagnosis (27% vs. 37%).

The study found no significant differences by race or ethnicity in a number of other factors including proteinuria, eclampsia, intrauterine fetal distress, intrauterine growth retardation, abruption, and recurrent preeclampsia.

RENO, NEV. — A retrospective study examining 473 pregnancies complicated by preeclampsia has uncovered a number of significant racial and ethnic differences in the expression of the disorder.

African American women with preeclampsia tend to have more severe hypertension and more often require antihypertensive medication than the population at large, according to a poster presentation by Amy Goodwin, M.D., of Case Western Reserve University, Cleveland, and associates at the annual meeting of the Society for Maternal-Fetal Medicine.

While 37% of the full sample had severe hypertension at diagnosis, 45% of African American women had severe hypertension. African American women were also significantly more likely to require antihypertensive medication intrapartum (12% vs. 8.8%), post partum (18% vs. 13%), and at discharge (35% vs. 27%).

Non-Hispanic Caucasian women more frequently manifest severe hypertension with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. While 24% of the full sample exhibited HELLP, the rate among Caucasian women was 30%.

Hispanic women tend to present with preeclampsia later in gestation and with less severe disease than the rest of the population. They presented at a mean of 36 weeks of gestation vs. 34.4 weeks for the rest of the population, and a smaller proportion of them exhibited severe hypertension at diagnosis (27% vs. 37%).

The study found no significant differences by race or ethnicity in a number of other factors including proteinuria, eclampsia, intrauterine fetal distress, intrauterine growth retardation, abruption, and recurrent preeclampsia.

RENO, NEV. — A retrospective study examining 473 pregnancies complicated by preeclampsia has uncovered a number of significant racial and ethnic differences in the expression of the disorder.

African American women with preeclampsia tend to have more severe hypertension and more often require antihypertensive medication than the population at large, according to a poster presentation by Amy Goodwin, M.D., of Case Western Reserve University, Cleveland, and associates at the annual meeting of the Society for Maternal-Fetal Medicine.

While 37% of the full sample had severe hypertension at diagnosis, 45% of African American women had severe hypertension. African American women were also significantly more likely to require antihypertensive medication intrapartum (12% vs. 8.8%), post partum (18% vs. 13%), and at discharge (35% vs. 27%).

Non-Hispanic Caucasian women more frequently manifest severe hypertension with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. While 24% of the full sample exhibited HELLP, the rate among Caucasian women was 30%.

Hispanic women tend to present with preeclampsia later in gestation and with less severe disease than the rest of the population. They presented at a mean of 36 weeks of gestation vs. 34.4 weeks for the rest of the population, and a smaller proportion of them exhibited severe hypertension at diagnosis (27% vs. 37%).

The study found no significant differences by race or ethnicity in a number of other factors including proteinuria, eclampsia, intrauterine fetal distress, intrauterine growth retardation, abruption, and recurrent preeclampsia.