Robert Finn

RENO, NEV. — A less-than-perfect score on a five-item, 10-point cardiovascular profile predicts a poorer outcome for a fetus with heart failure, according to a poster presented by Aleksandra Roczek, M.D., at the annual meeting of the Society for Maternal-Fetal Medicine.

Fetuses in this high-risk group warrant closer follow-up and management from both the obstetric and prenatal cardiology point of view, concluded Dr. Roczek of the University of South Florida, Tampa.

Poor scores on three of the five items—cardiomegaly, hydrops, and venous Doppler measurements—were especially predictive of mortality, Dr. Roczek noted.

She and her colleagues conducted a retrospective examination of 92 pregnancies where fetuses were judged to be at risk for heart failure on the basis of echocardiography and Doppler velocimetry. Of those fetuses, 53 (57%) survived and 39 (43%) did not.

The cardiovascular profile score awards two points each for absence of hydrops, normal venous Doppler, heart function, arterial Doppler, and heart size. The score in each domain is decreased by two points for severe signs and by one point for intermediate signs.

Fetuses with abnormal venous Doppler had a mortality rate of 64%. Mortality was 62.5% in fetuses with hydrops, and 60% in fetuses with cardiomegaly.

The other two factors were less predictive of mortality. Fetuses with abnormal heart function had a 33% mortality, and those with abnormal arterial Doppler had a 17% mortality.

RENO, NEV. — A less-than-perfect score on a five-item, 10-point cardiovascular profile predicts a poorer outcome for a fetus with heart failure, according to a poster presented by Aleksandra Roczek, M.D., at the annual meeting of the Society for Maternal-Fetal Medicine.

Fetuses in this high-risk group warrant closer follow-up and management from both the obstetric and prenatal cardiology point of view, concluded Dr. Roczek of the University of South Florida, Tampa.

Poor scores on three of the five items—cardiomegaly, hydrops, and venous Doppler measurements—were especially predictive of mortality, Dr. Roczek noted.

She and her colleagues conducted a retrospective examination of 92 pregnancies where fetuses were judged to be at risk for heart failure on the basis of echocardiography and Doppler velocimetry. Of those fetuses, 53 (57%) survived and 39 (43%) did not.

The cardiovascular profile score awards two points each for absence of hydrops, normal venous Doppler, heart function, arterial Doppler, and heart size. The score in each domain is decreased by two points for severe signs and by one point for intermediate signs.

Fetuses with abnormal venous Doppler had a mortality rate of 64%. Mortality was 62.5% in fetuses with hydrops, and 60% in fetuses with cardiomegaly.

The other two factors were less predictive of mortality. Fetuses with abnormal heart function had a 33% mortality, and those with abnormal arterial Doppler had a 17% mortality.

RENO, NEV. — A less-than-perfect score on a five-item, 10-point cardiovascular profile predicts a poorer outcome for a fetus with heart failure, according to a poster presented by Aleksandra Roczek, M.D., at the annual meeting of the Society for Maternal-Fetal Medicine.

Fetuses in this high-risk group warrant closer follow-up and management from both the obstetric and prenatal cardiology point of view, concluded Dr. Roczek of the University of South Florida, Tampa.

Poor scores on three of the five items—cardiomegaly, hydrops, and venous Doppler measurements—were especially predictive of mortality, Dr. Roczek noted.

She and her colleagues conducted a retrospective examination of 92 pregnancies where fetuses were judged to be at risk for heart failure on the basis of echocardiography and Doppler velocimetry. Of those fetuses, 53 (57%) survived and 39 (43%) did not.

The cardiovascular profile score awards two points each for absence of hydrops, normal venous Doppler, heart function, arterial Doppler, and heart size. The score in each domain is decreased by two points for severe signs and by one point for intermediate signs.

Fetuses with abnormal venous Doppler had a mortality rate of 64%. Mortality was 62.5% in fetuses with hydrops, and 60% in fetuses with cardiomegaly.

The other two factors were less predictive of mortality. Fetuses with abnormal heart function had a 33% mortality, and those with abnormal arterial Doppler had a 17% mortality.

RENO, NEV. — The inactivated influenza vaccine is safe and effective for women in the second half of pregnancy, results of a large prospective study suggest.

When given at least 2 weeks before exposure, the vaccine reduced the rate of influenza 19-fold, with no evidence of worsening in several obstetric and neonatal outcomes, including premature rupture of membranes, stillbirths, low birth weight, neonatal pneumonia, neonatal death, and major malformations.

The study, which was conducted at the University of Texas Southwestern Medical Center at Dallas, included 2,889 women who received the inactivatd influenza vaccine during the 2003-2004 flu season, which began earlier than usual and was moderately severe. They were compared with 1,988 gestational age-matched pregnant women who did not get vaccinated during the same time period, Jeanne S. Sheffield, M.D., and her associates wrote in a poster presented at the annual meeting of the Society for Maternal-Fetal Medicine.

Six women in the vaccinated group (2.4 per 1,000 women) and 13 in the nonvaccinated group (6.5 per 1,000 women) developed laboratory-confirmed influenza, a statistically significant difference. The overall efficacy of the vaccine was 68%.

But when the analysis was restricted to women who developed influenza more than 2 weeks after vaccination (the time required to develop immunity), there was only one case of influenza (0.4 per 1,000 women), yielding an efficacy of 94%.

The relative risk of developing influenza decreased almost 19-fold when the vaccine was given 2 weeks before exposure.

There were some statistically significant differences between the groups, study co-investigator Scott W. Roberts, M.D., said in an interview with this newspaper.

Women in the vaccination group were seen more frequently than the controls. Those in the vaccination group also had more repeat cesarean deliveries and cases of dystocia, and larger body-mass indexes, the researchers said.

The estimated gestational age (EGA) at delivery was slightly, but significantly, higher in the vaccination group (39.6 weeks), compared with the unvaccinated group (39.4 weeks).

The vaccinated group had significantly fewer births with EGAs of 36 weeks or less, compared with the unvaccinated group. Infants whose mothers were vaccinated were significantly less likely to go to the intensive care nursery.

Women in the vaccinated group were significantly more likely to undergo a cesarean delivery (27% vs. 23%). Dr. Roberts said it is possible that most or all of these differences reflect the fact that the women who were seen in the clinic were more likely to choose getting the vaccination.

Women who were vaccinated had infants that were much less likely to be admitted to the intensive care nursery. Lynda Banzi

RENO, NEV. — The inactivated influenza vaccine is safe and effective for women in the second half of pregnancy, results of a large prospective study suggest.

When given at least 2 weeks before exposure, the vaccine reduced the rate of influenza 19-fold, with no evidence of worsening in several obstetric and neonatal outcomes, including premature rupture of membranes, stillbirths, low birth weight, neonatal pneumonia, neonatal death, and major malformations.

The study, which was conducted at the University of Texas Southwestern Medical Center at Dallas, included 2,889 women who received the inactivatd influenza vaccine during the 2003-2004 flu season, which began earlier than usual and was moderately severe. They were compared with 1,988 gestational age-matched pregnant women who did not get vaccinated during the same time period, Jeanne S. Sheffield, M.D., and her associates wrote in a poster presented at the annual meeting of the Society for Maternal-Fetal Medicine.

Six women in the vaccinated group (2.4 per 1,000 women) and 13 in the nonvaccinated group (6.5 per 1,000 women) developed laboratory-confirmed influenza, a statistically significant difference. The overall efficacy of the vaccine was 68%.

But when the analysis was restricted to women who developed influenza more than 2 weeks after vaccination (the time required to develop immunity), there was only one case of influenza (0.4 per 1,000 women), yielding an efficacy of 94%.

The relative risk of developing influenza decreased almost 19-fold when the vaccine was given 2 weeks before exposure.

There were some statistically significant differences between the groups, study co-investigator Scott W. Roberts, M.D., said in an interview with this newspaper.

Women in the vaccination group were seen more frequently than the controls. Those in the vaccination group also had more repeat cesarean deliveries and cases of dystocia, and larger body-mass indexes, the researchers said.

The estimated gestational age (EGA) at delivery was slightly, but significantly, higher in the vaccination group (39.6 weeks), compared with the unvaccinated group (39.4 weeks).

The vaccinated group had significantly fewer births with EGAs of 36 weeks or less, compared with the unvaccinated group. Infants whose mothers were vaccinated were significantly less likely to go to the intensive care nursery.

Women in the vaccinated group were significantly more likely to undergo a cesarean delivery (27% vs. 23%). Dr. Roberts said it is possible that most or all of these differences reflect the fact that the women who were seen in the clinic were more likely to choose getting the vaccination.

Women who were vaccinated had infants that were much less likely to be admitted to the intensive care nursery. Lynda Banzi

RENO, NEV. — The inactivated influenza vaccine is safe and effective for women in the second half of pregnancy, results of a large prospective study suggest.

When given at least 2 weeks before exposure, the vaccine reduced the rate of influenza 19-fold, with no evidence of worsening in several obstetric and neonatal outcomes, including premature rupture of membranes, stillbirths, low birth weight, neonatal pneumonia, neonatal death, and major malformations.

The study, which was conducted at the University of Texas Southwestern Medical Center at Dallas, included 2,889 women who received the inactivatd influenza vaccine during the 2003-2004 flu season, which began earlier than usual and was moderately severe. They were compared with 1,988 gestational age-matched pregnant women who did not get vaccinated during the same time period, Jeanne S. Sheffield, M.D., and her associates wrote in a poster presented at the annual meeting of the Society for Maternal-Fetal Medicine.

Six women in the vaccinated group (2.4 per 1,000 women) and 13 in the nonvaccinated group (6.5 per 1,000 women) developed laboratory-confirmed influenza, a statistically significant difference. The overall efficacy of the vaccine was 68%.

But when the analysis was restricted to women who developed influenza more than 2 weeks after vaccination (the time required to develop immunity), there was only one case of influenza (0.4 per 1,000 women), yielding an efficacy of 94%.

The relative risk of developing influenza decreased almost 19-fold when the vaccine was given 2 weeks before exposure.

There were some statistically significant differences between the groups, study co-investigator Scott W. Roberts, M.D., said in an interview with this newspaper.

Women in the vaccination group were seen more frequently than the controls. Those in the vaccination group also had more repeat cesarean deliveries and cases of dystocia, and larger body-mass indexes, the researchers said.

The estimated gestational age (EGA) at delivery was slightly, but significantly, higher in the vaccination group (39.6 weeks), compared with the unvaccinated group (39.4 weeks).

The vaccinated group had significantly fewer births with EGAs of 36 weeks or less, compared with the unvaccinated group. Infants whose mothers were vaccinated were significantly less likely to go to the intensive care nursery.

Women in the vaccinated group were significantly more likely to undergo a cesarean delivery (27% vs. 23%). Dr. Roberts said it is possible that most or all of these differences reflect the fact that the women who were seen in the clinic were more likely to choose getting the vaccination.

Women who were vaccinated had infants that were much less likely to be admitted to the intensive care nursery. Lynda Banzi

SANTA FE, N.M. — Men with premature ejaculation appear to have weaker erections and abnormal heart-rate responses in addition to their shortened ejaculatory latency, according to a study presented by Wendi L. Tai at the annual meeting of the Society for Psychophysiological Research.

Clomipramine, which delays ejaculation, also results in more normal penile and heart-rate responses, said Ms. Tai, who worked with David L. Rowland, Ph.D., of Valparaiso (Ind.) University on the study. Ms. Tai is currently at Indiana University, Bloomington.

The double-blind, placebo-controlled study involved 33 men with previously identified premature ejaculation (PE), along with 12 control subjects. The men viewed an erotic film and experienced vibrotactile stimulation 4–6 hours after taking clomipramine or placebo.

When taking placebo, control subjects achieved a full erection in about 4.5 minutes and maintained that erection for the entire 9 minutes of the session. Men with PE, however, reached a significantly smaller penile circumference 2.5 minutes into the session.

Some of the men with PE ejaculated between 2.5 and 4 minutes into the session, but even among the men who maintained their erections for the full 9 minutes, erections were significantly weaker than those of controls. Despite that, the investigators found no evidence that the men with PE had any significant differences in maximal erect penis size, compared with that of the control subjects.

On placebo, control subjects had a heart-rate decrease of about 4 beats/min during the session, whereas men with PE had a heart-rate increase of 2 beats/min.

The erectile and heart-rate responses of men with PE and controls were more alike when they took clomipramine, known to retard ejaculation. Although some men with PE did ejaculate early, those who did not had as strong a penile response as the control subjects—significantly stronger than with placebo. The control subjects had just as strong an erection with clomipramine as with placebo.

Likewise, men with PE and controls did not have significantly different heart-rate responses. Both groups had a heart-rate decrease between 0 and 1 beats/min while taking clomipramine.

Ms. Tai said that her study supported the hypothesis that anxiety plays a role in premature ejaculation and that clomipramine's antianxiety effects may be responsible for its efficacy in retarding ejaculation.

SANTA FE, N.M. — Men with premature ejaculation appear to have weaker erections and abnormal heart-rate responses in addition to their shortened ejaculatory latency, according to a study presented by Wendi L. Tai at the annual meeting of the Society for Psychophysiological Research.

Clomipramine, which delays ejaculation, also results in more normal penile and heart-rate responses, said Ms. Tai, who worked with David L. Rowland, Ph.D., of Valparaiso (Ind.) University on the study. Ms. Tai is currently at Indiana University, Bloomington.

The double-blind, placebo-controlled study involved 33 men with previously identified premature ejaculation (PE), along with 12 control subjects. The men viewed an erotic film and experienced vibrotactile stimulation 4–6 hours after taking clomipramine or placebo.

When taking placebo, control subjects achieved a full erection in about 4.5 minutes and maintained that erection for the entire 9 minutes of the session. Men with PE, however, reached a significantly smaller penile circumference 2.5 minutes into the session.

Some of the men with PE ejaculated between 2.5 and 4 minutes into the session, but even among the men who maintained their erections for the full 9 minutes, erections were significantly weaker than those of controls. Despite that, the investigators found no evidence that the men with PE had any significant differences in maximal erect penis size, compared with that of the control subjects.

On placebo, control subjects had a heart-rate decrease of about 4 beats/min during the session, whereas men with PE had a heart-rate increase of 2 beats/min.

The erectile and heart-rate responses of men with PE and controls were more alike when they took clomipramine, known to retard ejaculation. Although some men with PE did ejaculate early, those who did not had as strong a penile response as the control subjects—significantly stronger than with placebo. The control subjects had just as strong an erection with clomipramine as with placebo.

Likewise, men with PE and controls did not have significantly different heart-rate responses. Both groups had a heart-rate decrease between 0 and 1 beats/min while taking clomipramine.

Ms. Tai said that her study supported the hypothesis that anxiety plays a role in premature ejaculation and that clomipramine's antianxiety effects may be responsible for its efficacy in retarding ejaculation.

SANTA FE, N.M. — Men with premature ejaculation appear to have weaker erections and abnormal heart-rate responses in addition to their shortened ejaculatory latency, according to a study presented by Wendi L. Tai at the annual meeting of the Society for Psychophysiological Research.

Clomipramine, which delays ejaculation, also results in more normal penile and heart-rate responses, said Ms. Tai, who worked with David L. Rowland, Ph.D., of Valparaiso (Ind.) University on the study. Ms. Tai is currently at Indiana University, Bloomington.

The double-blind, placebo-controlled study involved 33 men with previously identified premature ejaculation (PE), along with 12 control subjects. The men viewed an erotic film and experienced vibrotactile stimulation 4–6 hours after taking clomipramine or placebo.

When taking placebo, control subjects achieved a full erection in about 4.5 minutes and maintained that erection for the entire 9 minutes of the session. Men with PE, however, reached a significantly smaller penile circumference 2.5 minutes into the session.

Some of the men with PE ejaculated between 2.5 and 4 minutes into the session, but even among the men who maintained their erections for the full 9 minutes, erections were significantly weaker than those of controls. Despite that, the investigators found no evidence that the men with PE had any significant differences in maximal erect penis size, compared with that of the control subjects.

On placebo, control subjects had a heart-rate decrease of about 4 beats/min during the session, whereas men with PE had a heart-rate increase of 2 beats/min.

The erectile and heart-rate responses of men with PE and controls were more alike when they took clomipramine, known to retard ejaculation. Although some men with PE did ejaculate early, those who did not had as strong a penile response as the control subjects—significantly stronger than with placebo. The control subjects had just as strong an erection with clomipramine as with placebo.

Likewise, men with PE and controls did not have significantly different heart-rate responses. Both groups had a heart-rate decrease between 0 and 1 beats/min while taking clomipramine.

Ms. Tai said that her study supported the hypothesis that anxiety plays a role in premature ejaculation and that clomipramine's antianxiety effects may be responsible for its efficacy in retarding ejaculation.

SAN FRANCISCO — The epidemic of obesity among children is tightly correlated with the increasing time children spend watching television, but there are a number of effective strategies for reducing television time, William H. Dietz, M.D., said at the annual meeting of the American Academy of Pediatrics.

The strategies derive from 180 interviews with parent/child pairs, said Dr. Dietz, director of the division of nutrition and physical activity at the Centers for Disease Control and Prevention, Atlanta.

Here are some messages to get across to parents, or strategies to use with parents:

▸ Start early. Efforts to reduce television time must start early. It's much easier to avoid placing a television into a child's bedroom than to remove one once it's there.

▸ Pay attention to time as well as content. Most parents are more concerned about what children watch than about how much they watch, but they need to pay more attention to television time, Dr. Dietz said. While parents tend to monitor their children's television habits to make sure they're not exposed to sexuality, violence, or drug use, studies have repeatedly shown that it's total viewing time that predicts overweight most closely. There's a similar relationship between total viewing time and attention-deficit hyperactivity disorder.

▸ Offer children alternatives to TV. According to the CDC interviews, children don't really regard television watching as “fun.” Instead, they regard television watching as a default behavior. “That means that if we ask children what they could do that would be more fun than watching television, we may be able to engage them around behavior change,” Dr. Dietz said. Also, you may have to persuade the parents to work on changing their children's behavior. Parents are likely to control television time if they see it as interfering with important family values such as family time and schoolwork. Parents tend to be amenable to suggestions that mealtimes should be reserved for family discussions and that televisions should be turned off, for example. And they're more amenable to controlling television time during the school week than on weekends.

Television executives themselves have worked to change television watching behavior. Nickelodeon, a popular children's cable channel, voluntarily went dark for 3 hours on Saturday, Oct. 2, 2004, the “Worldwide Day of Play,” and the channel actively encouraged children to become more physically active.

The CDC itself is conducting an expensive advertising campaign called “VERB: It's what you do,” that's aimed at “tweens” (children aged 9–13). In the first year of this campaign, which was launched in October 2002, the CDC spent $125 million to get its message out.

The campaign has been quite successful. In its first year it reached 92% of all tweens, and 74% say they're aware of the campaign. And the CDC is able to document significant increases in weekly free-time physical activity among children reached by the campaign.

Various VERB materials are available at www.cdc.gov

SAN FRANCISCO — The epidemic of obesity among children is tightly correlated with the increasing time children spend watching television, but there are a number of effective strategies for reducing television time, William H. Dietz, M.D., said at the annual meeting of the American Academy of Pediatrics.

The strategies derive from 180 interviews with parent/child pairs, said Dr. Dietz, director of the division of nutrition and physical activity at the Centers for Disease Control and Prevention, Atlanta.

Here are some messages to get across to parents, or strategies to use with parents:

▸ Start early. Efforts to reduce television time must start early. It's much easier to avoid placing a television into a child's bedroom than to remove one once it's there.

▸ Pay attention to time as well as content. Most parents are more concerned about what children watch than about how much they watch, but they need to pay more attention to television time, Dr. Dietz said. While parents tend to monitor their children's television habits to make sure they're not exposed to sexuality, violence, or drug use, studies have repeatedly shown that it's total viewing time that predicts overweight most closely. There's a similar relationship between total viewing time and attention-deficit hyperactivity disorder.

▸ Offer children alternatives to TV. According to the CDC interviews, children don't really regard television watching as “fun.” Instead, they regard television watching as a default behavior. “That means that if we ask children what they could do that would be more fun than watching television, we may be able to engage them around behavior change,” Dr. Dietz said. Also, you may have to persuade the parents to work on changing their children's behavior. Parents are likely to control television time if they see it as interfering with important family values such as family time and schoolwork. Parents tend to be amenable to suggestions that mealtimes should be reserved for family discussions and that televisions should be turned off, for example. And they're more amenable to controlling television time during the school week than on weekends.

Television executives themselves have worked to change television watching behavior. Nickelodeon, a popular children's cable channel, voluntarily went dark for 3 hours on Saturday, Oct. 2, 2004, the “Worldwide Day of Play,” and the channel actively encouraged children to become more physically active.

The CDC itself is conducting an expensive advertising campaign called “VERB: It's what you do,” that's aimed at “tweens” (children aged 9–13). In the first year of this campaign, which was launched in October 2002, the CDC spent $125 million to get its message out.

The campaign has been quite successful. In its first year it reached 92% of all tweens, and 74% say they're aware of the campaign. And the CDC is able to document significant increases in weekly free-time physical activity among children reached by the campaign.

Various VERB materials are available at www.cdc.gov

SAN FRANCISCO — The epidemic of obesity among children is tightly correlated with the increasing time children spend watching television, but there are a number of effective strategies for reducing television time, William H. Dietz, M.D., said at the annual meeting of the American Academy of Pediatrics.

The strategies derive from 180 interviews with parent/child pairs, said Dr. Dietz, director of the division of nutrition and physical activity at the Centers for Disease Control and Prevention, Atlanta.

Here are some messages to get across to parents, or strategies to use with parents:

▸ Start early. Efforts to reduce television time must start early. It's much easier to avoid placing a television into a child's bedroom than to remove one once it's there.

▸ Pay attention to time as well as content. Most parents are more concerned about what children watch than about how much they watch, but they need to pay more attention to television time, Dr. Dietz said. While parents tend to monitor their children's television habits to make sure they're not exposed to sexuality, violence, or drug use, studies have repeatedly shown that it's total viewing time that predicts overweight most closely. There's a similar relationship between total viewing time and attention-deficit hyperactivity disorder.

▸ Offer children alternatives to TV. According to the CDC interviews, children don't really regard television watching as “fun.” Instead, they regard television watching as a default behavior. “That means that if we ask children what they could do that would be more fun than watching television, we may be able to engage them around behavior change,” Dr. Dietz said. Also, you may have to persuade the parents to work on changing their children's behavior. Parents are likely to control television time if they see it as interfering with important family values such as family time and schoolwork. Parents tend to be amenable to suggestions that mealtimes should be reserved for family discussions and that televisions should be turned off, for example. And they're more amenable to controlling television time during the school week than on weekends.

Television executives themselves have worked to change television watching behavior. Nickelodeon, a popular children's cable channel, voluntarily went dark for 3 hours on Saturday, Oct. 2, 2004, the “Worldwide Day of Play,” and the channel actively encouraged children to become more physically active.

The CDC itself is conducting an expensive advertising campaign called “VERB: It's what you do,” that's aimed at “tweens” (children aged 9–13). In the first year of this campaign, which was launched in October 2002, the CDC spent $125 million to get its message out.

The campaign has been quite successful. In its first year it reached 92% of all tweens, and 74% say they're aware of the campaign. And the CDC is able to document significant increases in weekly free-time physical activity among children reached by the campaign.

Various VERB materials are available at www.cdc.gov

SAN FRANCISCO—All official guidelines on HIV treatment either recommend drug-resistance testing or suggest considering such testing depending on the individual patient, Brad Hare, M.D., said at a meeting on HIV management sponsored by the University of California, San Francisco.

But deciding whether to use genotypic or phenotypic assays can be difficult, said Dr. Hare, a physician in the positive health program at the university.

Genotypic drug-resistance assays identify the presence of specific mutations in the HIV genome. Drug resistance is then inferred through an algorithm or a database analysis that matches these mutations to patterns of drug resistance.

Phenotypic assays use viral isolates or recombinant virus derived directly from the patient's plasma. The analysis derives from a culture-based system, and the concentration of a specific drug needed to inhibit viral replication can be quantified. In general, genotypic testing holds the edge early in a patient's disease, before the virus develops complex patterns of resistance. Phenotypic testing tends to be better late in a patient's infection, when the patient may see more regimen failure due to virus with complex mutations. (See box.)

Both tests may be required in complicated patients.

Results are available in days.

Is less technically complex than phenotypic assay.

Has proven value in predicting short-term virologic outcome.

Mutations may precede phenotypic resistance.

Can detect mixtures of resistant and wild-type virus.

Is less expensive than phenotypic assay.

Is an indirect measure of resistance.

Requires a viral load ≥1,000 copies/mL.

May not detect viral species with <20% prevalence.

Requires interpretation.

Cannot assess interactions between mutations.

Correlates of resistance are less clear for some (especially new) drugs.

Cannot test new drugs immediately.

Is a direct measure of resistance.

Results are similar to assays of bacterial resistance.

Results are easily understood.

Can be used for any drug.

Requires no knowledge of genotypic correlates of resistance.

Assesses effects of interactions between mutations.

Able to test new drugs immediately.

It takes weeks to get results.

Results may oversimplify the situation.

Resistance thresholds are not defined for all drugs or standardized for different assays.

Does not take into account the activity of drugs in combination.

Requires a viral load ≥500-1,000 copies/mL.

May not detect minor species.

Is more expensive than genotypic assay.

SAN FRANCISCO—All official guidelines on HIV treatment either recommend drug-resistance testing or suggest considering such testing depending on the individual patient, Brad Hare, M.D., said at a meeting on HIV management sponsored by the University of California, San Francisco.

But deciding whether to use genotypic or phenotypic assays can be difficult, said Dr. Hare, a physician in the positive health program at the university.

Genotypic drug-resistance assays identify the presence of specific mutations in the HIV genome. Drug resistance is then inferred through an algorithm or a database analysis that matches these mutations to patterns of drug resistance.

Phenotypic assays use viral isolates or recombinant virus derived directly from the patient's plasma. The analysis derives from a culture-based system, and the concentration of a specific drug needed to inhibit viral replication can be quantified. In general, genotypic testing holds the edge early in a patient's disease, before the virus develops complex patterns of resistance. Phenotypic testing tends to be better late in a patient's infection, when the patient may see more regimen failure due to virus with complex mutations. (See box.)

Both tests may be required in complicated patients.

Results are available in days.

Is less technically complex than phenotypic assay.

Has proven value in predicting short-term virologic outcome.

Mutations may precede phenotypic resistance.

Can detect mixtures of resistant and wild-type virus.

Is less expensive than phenotypic assay.

Is an indirect measure of resistance.

Requires a viral load ≥1,000 copies/mL.

May not detect viral species with <20% prevalence.

Requires interpretation.

Cannot assess interactions between mutations.

Correlates of resistance are less clear for some (especially new) drugs.

Cannot test new drugs immediately.

Is a direct measure of resistance.

Results are similar to assays of bacterial resistance.

Results are easily understood.

Can be used for any drug.

Requires no knowledge of genotypic correlates of resistance.

Assesses effects of interactions between mutations.

Able to test new drugs immediately.

It takes weeks to get results.

Results may oversimplify the situation.

Resistance thresholds are not defined for all drugs or standardized for different assays.

Does not take into account the activity of drugs in combination.

Requires a viral load ≥500-1,000 copies/mL.

May not detect minor species.

Is more expensive than genotypic assay.

SAN FRANCISCO—All official guidelines on HIV treatment either recommend drug-resistance testing or suggest considering such testing depending on the individual patient, Brad Hare, M.D., said at a meeting on HIV management sponsored by the University of California, San Francisco.

But deciding whether to use genotypic or phenotypic assays can be difficult, said Dr. Hare, a physician in the positive health program at the university.

Genotypic drug-resistance assays identify the presence of specific mutations in the HIV genome. Drug resistance is then inferred through an algorithm or a database analysis that matches these mutations to patterns of drug resistance.

Phenotypic assays use viral isolates or recombinant virus derived directly from the patient's plasma. The analysis derives from a culture-based system, and the concentration of a specific drug needed to inhibit viral replication can be quantified. In general, genotypic testing holds the edge early in a patient's disease, before the virus develops complex patterns of resistance. Phenotypic testing tends to be better late in a patient's infection, when the patient may see more regimen failure due to virus with complex mutations. (See box.)

Both tests may be required in complicated patients.

Results are available in days.

Is less technically complex than phenotypic assay.

Has proven value in predicting short-term virologic outcome.

Mutations may precede phenotypic resistance.

Can detect mixtures of resistant and wild-type virus.

Is less expensive than phenotypic assay.

Is an indirect measure of resistance.

Requires a viral load ≥1,000 copies/mL.

May not detect viral species with <20% prevalence.

Requires interpretation.

Cannot assess interactions between mutations.

Correlates of resistance are less clear for some (especially new) drugs.

Cannot test new drugs immediately.

Is a direct measure of resistance.

Results are similar to assays of bacterial resistance.

Results are easily understood.

Can be used for any drug.

Requires no knowledge of genotypic correlates of resistance.

Assesses effects of interactions between mutations.

Able to test new drugs immediately.

It takes weeks to get results.

Results may oversimplify the situation.

Resistance thresholds are not defined for all drugs or standardized for different assays.

Does not take into account the activity of drugs in combination.

Requires a viral load ≥500-1,000 copies/mL.

May not detect minor species.

Is more expensive than genotypic assay.

SAN FRANCISCO—A look at the epidemiology of anal cancer shows the need for thorough anal exams, particularly in patients of either sex with HIV disease, Joel M. Palefsky, M.D., said at a meeting on HIV management sponsored by the University of California, San Francisco.

Before the HIV epidemic, reported rates of anal cancer among men who have sex with men (MSM) were as high as 35/100,000, about the same as the cervical cancer rate in women before universal screening. Data now suggest that MSM with HIV disease have anal cancer rates as high as 100/100,000, or about 10 times the rate of cervical cancer in screened women, which has declined to about 8/100,000, said Dr. Palefsky of the university.

Visual inspection of the anal opening is not enough, although it should not be dispensed with. It can, for example, show the plaques of Bowen's disease. Two centimeters inside the anal canal is a transformation zone where the rectal columnar epithelium meets the anal squamous epithelium. This is where most disease occurs.

After visual inspection, the next step is an anal Pap smear, which must be done without lubricant. Moisten a Dacron (not cotton) swab with tap water or saline and insert it past the anal-rectal junction as far as it will go. As it's pulled out, it will capture a good sample of cells from the transformation zone, which can then be examined cytologically and tested for human papilloma virus (HPV). Virtually everyone with HIV disease—women as well as men—will have an HPV infection, some with as many as 10 virus types.

The next step is a digital rectal exam, which is a good cancer-screening tool, Dr. Palefsky said. Put a lubed finger into the anal canal and feel for masses.

The next step is anoscopy with a standard plastic anoscope. Cancerous and precancerous lesions in the anus appear similar to what one would see in the cervix.

Dr. Palefsky cautioned against dismissing standard-seeming warts, especially in individuals with HIV disease. These patients often have high-grade disease mixed in with the warts. “We recommend sampling, through biopsy, lesions of different appearance when patients have multiple lesions.”

SAN FRANCISCO—A look at the epidemiology of anal cancer shows the need for thorough anal exams, particularly in patients of either sex with HIV disease, Joel M. Palefsky, M.D., said at a meeting on HIV management sponsored by the University of California, San Francisco.

Before the HIV epidemic, reported rates of anal cancer among men who have sex with men (MSM) were as high as 35/100,000, about the same as the cervical cancer rate in women before universal screening. Data now suggest that MSM with HIV disease have anal cancer rates as high as 100/100,000, or about 10 times the rate of cervical cancer in screened women, which has declined to about 8/100,000, said Dr. Palefsky of the university.

Visual inspection of the anal opening is not enough, although it should not be dispensed with. It can, for example, show the plaques of Bowen's disease. Two centimeters inside the anal canal is a transformation zone where the rectal columnar epithelium meets the anal squamous epithelium. This is where most disease occurs.

After visual inspection, the next step is an anal Pap smear, which must be done without lubricant. Moisten a Dacron (not cotton) swab with tap water or saline and insert it past the anal-rectal junction as far as it will go. As it's pulled out, it will capture a good sample of cells from the transformation zone, which can then be examined cytologically and tested for human papilloma virus (HPV). Virtually everyone with HIV disease—women as well as men—will have an HPV infection, some with as many as 10 virus types.

The next step is a digital rectal exam, which is a good cancer-screening tool, Dr. Palefsky said. Put a lubed finger into the anal canal and feel for masses.

The next step is anoscopy with a standard plastic anoscope. Cancerous and precancerous lesions in the anus appear similar to what one would see in the cervix.

Dr. Palefsky cautioned against dismissing standard-seeming warts, especially in individuals with HIV disease. These patients often have high-grade disease mixed in with the warts. “We recommend sampling, through biopsy, lesions of different appearance when patients have multiple lesions.”

SAN FRANCISCO—A look at the epidemiology of anal cancer shows the need for thorough anal exams, particularly in patients of either sex with HIV disease, Joel M. Palefsky, M.D., said at a meeting on HIV management sponsored by the University of California, San Francisco.

Before the HIV epidemic, reported rates of anal cancer among men who have sex with men (MSM) were as high as 35/100,000, about the same as the cervical cancer rate in women before universal screening. Data now suggest that MSM with HIV disease have anal cancer rates as high as 100/100,000, or about 10 times the rate of cervical cancer in screened women, which has declined to about 8/100,000, said Dr. Palefsky of the university.

Visual inspection of the anal opening is not enough, although it should not be dispensed with. It can, for example, show the plaques of Bowen's disease. Two centimeters inside the anal canal is a transformation zone where the rectal columnar epithelium meets the anal squamous epithelium. This is where most disease occurs.

After visual inspection, the next step is an anal Pap smear, which must be done without lubricant. Moisten a Dacron (not cotton) swab with tap water or saline and insert it past the anal-rectal junction as far as it will go. As it's pulled out, it will capture a good sample of cells from the transformation zone, which can then be examined cytologically and tested for human papilloma virus (HPV). Virtually everyone with HIV disease—women as well as men—will have an HPV infection, some with as many as 10 virus types.

The next step is a digital rectal exam, which is a good cancer-screening tool, Dr. Palefsky said. Put a lubed finger into the anal canal and feel for masses.

The next step is anoscopy with a standard plastic anoscope. Cancerous and precancerous lesions in the anus appear similar to what one would see in the cervix.

Dr. Palefsky cautioned against dismissing standard-seeming warts, especially in individuals with HIV disease. These patients often have high-grade disease mixed in with the warts. “We recommend sampling, through biopsy, lesions of different appearance when patients have multiple lesions.”

SANTA FE, N.M. — While the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders defines only one type of female sexual arousal disorder, there is now physiologic evidence that there are at least two subtypes of the disorder, Lori A. Brotto, Ph.D., reported during the annual meeting of the Society for Psychophysiological Research.

For a diagnosis of female sexual arousal disorder (FSAD), DSM-IV-TR requires “persistent or recurrent inability to attain … an adequate lubrication-swelling response of sexual excitement.”

Although some women with the disorder do complain mostly of genital impairment, others report that while their body becomes aroused, they don't become aroused psychologically.

In a study involving 70 women, Dr. Brotto of the University of Washington in Seattle examined 8 women reporting the genital subtype of FSAD, 26 reporting the subjective subtype, and 36 control subjects reporting no difficulties in becoming aroused.

All of the women watched neutral and erotic films while their vaginal pulse amplitude—a reliable measure of genital arousal—was measured by a vaginal photoplethysmograph. The women in the study also provided a continuous measure of their subjective responses by changing the position of a lever.

The women underwent testing on two occasions, once after laboratory-induced hyperventilation. In previous studies, Dr. Brotto determined that in normal women, hyperventilation, which activates the sympathetic nervous system, increased the change in vaginal pulse amplitude between neutral and erotic films.

In both the control women and the women with FSAD, the erotic film resulted in significant increases in vaginal pulse amplitude.

All of the participants responded to the erotic film with perceived autonomic arousal and perceived physical arousal, but the women with FSAD reported less arousal, the researchers said.

Overall, women in the control group reported greater arousal and more positive affect than did women with FSAD.

The vaginal photoplethysmography supported the reports of women who had complained of problems with genital arousal. Those women showed no significant increase in vaginal pulse amplitude in response to the erotic films.

Women who had complained of a subjective arousal disorder, on the other hand, did show evidence of significant genital arousal, according to the study.

While the women in the control group and the women with the genital arousal subtype of FSAD showed a potentiated physiologic response to the erotic film after hyperventilation, the women with the subjective subtype of FSAD showed a significantly smaller physiologic response after hyperventilation than before.

Hyperventilation resulted in no significant changes in the subjective measures in either the control or the FSAD women. The study finding suggests that the effect of this manipulation occurred exclusively at a physiologic level and was not due to some distraction or other psychological causes.

One implication of the study is that women with the subjective subtype of FSAD may have differences in basal sympathetic tone, compared with women with the genital subtype or women without FSAD, according to Dr. Brotto and the other researchers.

Another implication of the study findings is that vaginal photoplethysmography, now exclusively a laboratory technique, may find a place as a diagnostic tool used to differentiate between FSAD subtypes.

Dr. Brotto pointed out that other data from her lab suggest that photoplethysmographic patterns can serve as an indicator of which women will respond to vasoactive medications with increased arousal.

SANTA FE, N.M. — While the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders defines only one type of female sexual arousal disorder, there is now physiologic evidence that there are at least two subtypes of the disorder, Lori A. Brotto, Ph.D., reported during the annual meeting of the Society for Psychophysiological Research.

For a diagnosis of female sexual arousal disorder (FSAD), DSM-IV-TR requires “persistent or recurrent inability to attain … an adequate lubrication-swelling response of sexual excitement.”

Although some women with the disorder do complain mostly of genital impairment, others report that while their body becomes aroused, they don't become aroused psychologically.

In a study involving 70 women, Dr. Brotto of the University of Washington in Seattle examined 8 women reporting the genital subtype of FSAD, 26 reporting the subjective subtype, and 36 control subjects reporting no difficulties in becoming aroused.

All of the women watched neutral and erotic films while their vaginal pulse amplitude—a reliable measure of genital arousal—was measured by a vaginal photoplethysmograph. The women in the study also provided a continuous measure of their subjective responses by changing the position of a lever.

The women underwent testing on two occasions, once after laboratory-induced hyperventilation. In previous studies, Dr. Brotto determined that in normal women, hyperventilation, which activates the sympathetic nervous system, increased the change in vaginal pulse amplitude between neutral and erotic films.

In both the control women and the women with FSAD, the erotic film resulted in significant increases in vaginal pulse amplitude.

All of the participants responded to the erotic film with perceived autonomic arousal and perceived physical arousal, but the women with FSAD reported less arousal, the researchers said.

Overall, women in the control group reported greater arousal and more positive affect than did women with FSAD.

The vaginal photoplethysmography supported the reports of women who had complained of problems with genital arousal. Those women showed no significant increase in vaginal pulse amplitude in response to the erotic films.

Women who had complained of a subjective arousal disorder, on the other hand, did show evidence of significant genital arousal, according to the study.

While the women in the control group and the women with the genital arousal subtype of FSAD showed a potentiated physiologic response to the erotic film after hyperventilation, the women with the subjective subtype of FSAD showed a significantly smaller physiologic response after hyperventilation than before.

Hyperventilation resulted in no significant changes in the subjective measures in either the control or the FSAD women. The study finding suggests that the effect of this manipulation occurred exclusively at a physiologic level and was not due to some distraction or other psychological causes.

One implication of the study is that women with the subjective subtype of FSAD may have differences in basal sympathetic tone, compared with women with the genital subtype or women without FSAD, according to Dr. Brotto and the other researchers.

Another implication of the study findings is that vaginal photoplethysmography, now exclusively a laboratory technique, may find a place as a diagnostic tool used to differentiate between FSAD subtypes.

Dr. Brotto pointed out that other data from her lab suggest that photoplethysmographic patterns can serve as an indicator of which women will respond to vasoactive medications with increased arousal.

SANTA FE, N.M. — While the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders defines only one type of female sexual arousal disorder, there is now physiologic evidence that there are at least two subtypes of the disorder, Lori A. Brotto, Ph.D., reported during the annual meeting of the Society for Psychophysiological Research.

For a diagnosis of female sexual arousal disorder (FSAD), DSM-IV-TR requires “persistent or recurrent inability to attain … an adequate lubrication-swelling response of sexual excitement.”

Although some women with the disorder do complain mostly of genital impairment, others report that while their body becomes aroused, they don't become aroused psychologically.

In a study involving 70 women, Dr. Brotto of the University of Washington in Seattle examined 8 women reporting the genital subtype of FSAD, 26 reporting the subjective subtype, and 36 control subjects reporting no difficulties in becoming aroused.

All of the women watched neutral and erotic films while their vaginal pulse amplitude—a reliable measure of genital arousal—was measured by a vaginal photoplethysmograph. The women in the study also provided a continuous measure of their subjective responses by changing the position of a lever.

The women underwent testing on two occasions, once after laboratory-induced hyperventilation. In previous studies, Dr. Brotto determined that in normal women, hyperventilation, which activates the sympathetic nervous system, increased the change in vaginal pulse amplitude between neutral and erotic films.

In both the control women and the women with FSAD, the erotic film resulted in significant increases in vaginal pulse amplitude.

All of the participants responded to the erotic film with perceived autonomic arousal and perceived physical arousal, but the women with FSAD reported less arousal, the researchers said.

Overall, women in the control group reported greater arousal and more positive affect than did women with FSAD.

The vaginal photoplethysmography supported the reports of women who had complained of problems with genital arousal. Those women showed no significant increase in vaginal pulse amplitude in response to the erotic films.

Women who had complained of a subjective arousal disorder, on the other hand, did show evidence of significant genital arousal, according to the study.

While the women in the control group and the women with the genital arousal subtype of FSAD showed a potentiated physiologic response to the erotic film after hyperventilation, the women with the subjective subtype of FSAD showed a significantly smaller physiologic response after hyperventilation than before.

Hyperventilation resulted in no significant changes in the subjective measures in either the control or the FSAD women. The study finding suggests that the effect of this manipulation occurred exclusively at a physiologic level and was not due to some distraction or other psychological causes.

One implication of the study is that women with the subjective subtype of FSAD may have differences in basal sympathetic tone, compared with women with the genital subtype or women without FSAD, according to Dr. Brotto and the other researchers.

Another implication of the study findings is that vaginal photoplethysmography, now exclusively a laboratory technique, may find a place as a diagnostic tool used to differentiate between FSAD subtypes.

Dr. Brotto pointed out that other data from her lab suggest that photoplethysmographic patterns can serve as an indicator of which women will respond to vasoactive medications with increased arousal.

SAN FRANCISCO — In an overwhelming 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 of 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 patient 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 laparoscopic period, suspicious lesions were biopsied and adhesions removed.

Although 64% did have adhesions, the pain could not be attributed to this cause, 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 ranked second, third, and fourth, respectively.

SAN FRANCISCO — In an overwhelming 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 of 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 patient 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 laparoscopic period, suspicious lesions were biopsied and adhesions removed.

Although 64% did have adhesions, the pain could not be attributed to this cause, 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 ranked second, third, and fourth, respectively.

SAN FRANCISCO — In an overwhelming 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 of 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 patient 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 laparoscopic period, suspicious lesions were biopsied and adhesions removed.

Although 64% did have adhesions, the pain could not be attributed to this cause, 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 ranked second, third, and fourth, respectively.

LAS VEGAS — The flow rate of oxygen routinely prescribed to abort cluster migraine is too low to be effective in many patients, Todd D. Rozen, M.D., said at a symposium sponsored by the American Headache Society.

Clinicians typically prescribe flow rates of 7–10 L/min, said Dr. Rozen of the Michigan Head-Pain and Neurological Institute in Ann Arbor. About 30% of patients fail to respond to flow rates in this range.

Dr. Rozen described three patients whose headaches were apparently refractory to oxygen but who all responded well when the flow rate was pushed to 15 L/min—about the maximum flow rate delivered by most medical-grade oxygen regulators (Neurology 2004;63:593).

“I'm now telling my patients that you're not resistant to oxygen until you try 15 L/min,” Dr. Rozen said.

There are a number of caveats regarding oxygen therapy for cluster headache. The gas must be delivered through a nonrebreather face mask, and patients must be cautioned strongly about the highly flammable nature of pure oxygen. In addition, the higher flow rates may be dangerous in patients with chronic obstructive pulmonary disease.

Oxygen is thought to exert its effect on cluster headaches through cerebral arterio- and vasoconstriction. Many people whose headaches appear refractory to oxygen therapy are smokers; according to the pulmonary literature, smokers exhibit less vasoconstriction in response to 100% oxygen than do nonsmokers.

Dr. Rozen hypothesized that in some individuals, a higher oxygen flow rate is needed to obtain a clinically meaningful degree of vasoconstriction.

The goal of abortive treatment is to stop the pain within 10–15 minutes.

Oxygen therapy is a good choice for patients whose cardiovascular risk factors render them unsuitable candidates for injected sumatriptan. “I don't know how many times I've seen cluster patients who have never tried oxygen,” Dr. Rozen said.

LAS VEGAS — The flow rate of oxygen routinely prescribed to abort cluster migraine is too low to be effective in many patients, Todd D. Rozen, M.D., said at a symposium sponsored by the American Headache Society.

Clinicians typically prescribe flow rates of 7–10 L/min, said Dr. Rozen of the Michigan Head-Pain and Neurological Institute in Ann Arbor. About 30% of patients fail to respond to flow rates in this range.

Dr. Rozen described three patients whose headaches were apparently refractory to oxygen but who all responded well when the flow rate was pushed to 15 L/min—about the maximum flow rate delivered by most medical-grade oxygen regulators (Neurology 2004;63:593).

“I'm now telling my patients that you're not resistant to oxygen until you try 15 L/min,” Dr. Rozen said.

There are a number of caveats regarding oxygen therapy for cluster headache. The gas must be delivered through a nonrebreather face mask, and patients must be cautioned strongly about the highly flammable nature of pure oxygen. In addition, the higher flow rates may be dangerous in patients with chronic obstructive pulmonary disease.

Oxygen is thought to exert its effect on cluster headaches through cerebral arterio- and vasoconstriction. Many people whose headaches appear refractory to oxygen therapy are smokers; according to the pulmonary literature, smokers exhibit less vasoconstriction in response to 100% oxygen than do nonsmokers.

Dr. Rozen hypothesized that in some individuals, a higher oxygen flow rate is needed to obtain a clinically meaningful degree of vasoconstriction.

The goal of abortive treatment is to stop the pain within 10–15 minutes.

Oxygen therapy is a good choice for patients whose cardiovascular risk factors render them unsuitable candidates for injected sumatriptan. “I don't know how many times I've seen cluster patients who have never tried oxygen,” Dr. Rozen said.

LAS VEGAS — The flow rate of oxygen routinely prescribed to abort cluster migraine is too low to be effective in many patients, Todd D. Rozen, M.D., said at a symposium sponsored by the American Headache Society.

Clinicians typically prescribe flow rates of 7–10 L/min, said Dr. Rozen of the Michigan Head-Pain and Neurological Institute in Ann Arbor. About 30% of patients fail to respond to flow rates in this range.

Dr. Rozen described three patients whose headaches were apparently refractory to oxygen but who all responded well when the flow rate was pushed to 15 L/min—about the maximum flow rate delivered by most medical-grade oxygen regulators (Neurology 2004;63:593).

“I'm now telling my patients that you're not resistant to oxygen until you try 15 L/min,” Dr. Rozen said.

There are a number of caveats regarding oxygen therapy for cluster headache. The gas must be delivered through a nonrebreather face mask, and patients must be cautioned strongly about the highly flammable nature of pure oxygen. In addition, the higher flow rates may be dangerous in patients with chronic obstructive pulmonary disease.

Oxygen is thought to exert its effect on cluster headaches through cerebral arterio- and vasoconstriction. Many people whose headaches appear refractory to oxygen therapy are smokers; according to the pulmonary literature, smokers exhibit less vasoconstriction in response to 100% oxygen than do nonsmokers.

Dr. Rozen hypothesized that in some individuals, a higher oxygen flow rate is needed to obtain a clinically meaningful degree of vasoconstriction.

The goal of abortive treatment is to stop the pain within 10–15 minutes.

Oxygen therapy is a good choice for patients whose cardiovascular risk factors render them unsuitable candidates for injected sumatriptan. “I don't know how many times I've seen cluster patients who have never tried oxygen,” Dr. Rozen said.

LAS VEGAS — Even in a neurologist's office, every headache patient merits a general history and a physical examination, which may be the best tools with which to differentiate secondary from primary headaches, John G. Edmeads, M.D., said at a symposium sponsored by the American Headache Society.

“The headache never walks alone” when it is secondary to a general medical condition, said Dr. Edmeads of Sunnybrook Medical Centre, Toronto.

“There's always something on history or physical to give you a clue that there's a general medical disease going on. And once you have this clue you can diagnose them through a focused work-up that won't cost an arm and a leg,” he said.

Dr. Edmeads offered the following suggestions:

▸ Neurologists can't assume that patients have had a thorough evaluation before reaching their offices. Dr. Edmeads said that he has had patients ask about the blood pressure cuff as if they had never seen one before.

▸ Be suspicious if the patient's signs and symptoms don't clearly meet International Headache Society criteria for primary headache. Any patient whose headache doesn't meet the society's criteria deserves additional investigation.

▸ If it's not clearly migraine or tension-type headache, look for evidence of central nervous system involvement, either in the brain or its coverings. If there's any indication of CNS involvement, the next step includes neuroimaging and possibly examination of the patient's cerebrospinal fluid.

▸ If there are no signs or symptoms of CNS involvement, then conduct a general medical screen. This should include a CBC; an erythrocyte sedimentation rate; electrolytes, including calcium and phosphate; BUN and creatinine; liver enzymes and bilirubin; thyroid function studies, including TSH, T3, and T4; and a chest x-ray. Answers will come back within a day or two and will cost less than a couple of hundred dollars, Dr. Edmeads said.

▸ If those studies are negative, consider serum protein electrophoresis and arterial blood gases. In winter, consider carbon monoxide poisoning and test for carboxyhemoglobin. Carbon monoxide poisoning often results from poorly maintained heaters and will often present as daily, diffuse, nocturnal headaches that clear up in the morning when patients get out into the fresh air.

▸ If all results are still negative, but you still have a strong suspicion that the headache is the result of a general medical condition, consider a consultation with a general internist.

LAS VEGAS — Even in a neurologist's office, every headache patient merits a general history and a physical examination, which may be the best tools with which to differentiate secondary from primary headaches, John G. Edmeads, M.D., said at a symposium sponsored by the American Headache Society.

“The headache never walks alone” when it is secondary to a general medical condition, said Dr. Edmeads of Sunnybrook Medical Centre, Toronto.

“There's always something on history or physical to give you a clue that there's a general medical disease going on. And once you have this clue you can diagnose them through a focused work-up that won't cost an arm and a leg,” he said.

Dr. Edmeads offered the following suggestions:

▸ Neurologists can't assume that patients have had a thorough evaluation before reaching their offices. Dr. Edmeads said that he has had patients ask about the blood pressure cuff as if they had never seen one before.

▸ Be suspicious if the patient's signs and symptoms don't clearly meet International Headache Society criteria for primary headache. Any patient whose headache doesn't meet the society's criteria deserves additional investigation.

▸ If it's not clearly migraine or tension-type headache, look for evidence of central nervous system involvement, either in the brain or its coverings. If there's any indication of CNS involvement, the next step includes neuroimaging and possibly examination of the patient's cerebrospinal fluid.

▸ If there are no signs or symptoms of CNS involvement, then conduct a general medical screen. This should include a CBC; an erythrocyte sedimentation rate; electrolytes, including calcium and phosphate; BUN and creatinine; liver enzymes and bilirubin; thyroid function studies, including TSH, T3, and T4; and a chest x-ray. Answers will come back within a day or two and will cost less than a couple of hundred dollars, Dr. Edmeads said.

▸ If those studies are negative, consider serum protein electrophoresis and arterial blood gases. In winter, consider carbon monoxide poisoning and test for carboxyhemoglobin. Carbon monoxide poisoning often results from poorly maintained heaters and will often present as daily, diffuse, nocturnal headaches that clear up in the morning when patients get out into the fresh air.

▸ If all results are still negative, but you still have a strong suspicion that the headache is the result of a general medical condition, consider a consultation with a general internist.

LAS VEGAS — Even in a neurologist's office, every headache patient merits a general history and a physical examination, which may be the best tools with which to differentiate secondary from primary headaches, John G. Edmeads, M.D., said at a symposium sponsored by the American Headache Society.

“The headache never walks alone” when it is secondary to a general medical condition, said Dr. Edmeads of Sunnybrook Medical Centre, Toronto.

“There's always something on history or physical to give you a clue that there's a general medical disease going on. And once you have this clue you can diagnose them through a focused work-up that won't cost an arm and a leg,” he said.

Dr. Edmeads offered the following suggestions:

▸ Neurologists can't assume that patients have had a thorough evaluation before reaching their offices. Dr. Edmeads said that he has had patients ask about the blood pressure cuff as if they had never seen one before.

▸ Be suspicious if the patient's signs and symptoms don't clearly meet International Headache Society criteria for primary headache. Any patient whose headache doesn't meet the society's criteria deserves additional investigation.

▸ If it's not clearly migraine or tension-type headache, look for evidence of central nervous system involvement, either in the brain or its coverings. If there's any indication of CNS involvement, the next step includes neuroimaging and possibly examination of the patient's cerebrospinal fluid.

▸ If there are no signs or symptoms of CNS involvement, then conduct a general medical screen. This should include a CBC; an erythrocyte sedimentation rate; electrolytes, including calcium and phosphate; BUN and creatinine; liver enzymes and bilirubin; thyroid function studies, including TSH, T3, and T4; and a chest x-ray. Answers will come back within a day or two and will cost less than a couple of hundred dollars, Dr. Edmeads said.

▸ If those studies are negative, consider serum protein electrophoresis and arterial blood gases. In winter, consider carbon monoxide poisoning and test for carboxyhemoglobin. Carbon monoxide poisoning often results from poorly maintained heaters and will often present as daily, diffuse, nocturnal headaches that clear up in the morning when patients get out into the fresh air.

▸ If all results are still negative, but you still have a strong suspicion that the headache is the result of a general medical condition, consider a consultation with a general internist.