Robert Finn

SANTA FE, N.M. — Although the manufacturer of the Hydro ThermAblator recommends the use of leuprolide acetate to thin the endometrium before performing ablation with the device, this step may be unnecessary, William E. Crowder Jr., M.D., said at the annual meeting of the American Association of Gynecologic Laparoscopists.

In a nonrandomized study, 89 women with menorrhagia were assigned to one of three groups before undergoing treatment with the Hydro ThermAblator (HTA): endometrial thinning with leuprolide (3.75 mg in a single dose), oral contraceptives, or cycle timing. In the cycle timing group, women underwent HTA treatment in the early proliferative phase of the menstrual cycle. On follow-up, there were no differences in menstrual bleeding or patient satisfaction, said Dr. Crowder, a consultant to Boston Scientific, which manufactures the HTA system.

Despite his findings, Dr. Crowder said he is not recommending abandoning endometrial thinning agents. He said he would have to see the results of a randomized trial, currently in process, before he could make that recommendation.

In the current study, women in the three treatment groups rated their posttreatment bleeding on a scale of 1‐4 in which 1 is amenorrhea, 2 is hypomenorrhea, 3 is eumenorrhea, and 4 is menorrhagia. The three treatment groups averaged about 1.5 with no significant differences among them.

In terms of patient satisfaction, on a scale of 1‐3 in which 1 is a good outcome, 2 is fair, and 3 is poor, the average for all three groups was slightly over 1.0. There were no significant differences between groups, said Dr. Crowder, an ob.gyn. in Conroe, Texas.

About half the women in each group underwent ultrasound examination to measure endometrial thickness. Women taking leuprolide had thickness of 7.9 mm, those on oral contraceptives had thickness of 9.1 mm, and those on cycle timing had thickness of 12.0 mm, confirming that leuprolide and oral contraceptives were effective in thinning the endometrium.

SANTA FE, N.M. — Although the manufacturer of the Hydro ThermAblator recommends the use of leuprolide acetate to thin the endometrium before performing ablation with the device, this step may be unnecessary, William E. Crowder Jr., M.D., said at the annual meeting of the American Association of Gynecologic Laparoscopists.

In a nonrandomized study, 89 women with menorrhagia were assigned to one of three groups before undergoing treatment with the Hydro ThermAblator (HTA): endometrial thinning with leuprolide (3.75 mg in a single dose), oral contraceptives, or cycle timing. In the cycle timing group, women underwent HTA treatment in the early proliferative phase of the menstrual cycle. On follow-up, there were no differences in menstrual bleeding or patient satisfaction, said Dr. Crowder, a consultant to Boston Scientific, which manufactures the HTA system.

Despite his findings, Dr. Crowder said he is not recommending abandoning endometrial thinning agents. He said he would have to see the results of a randomized trial, currently in process, before he could make that recommendation.

In the current study, women in the three treatment groups rated their posttreatment bleeding on a scale of 1‐4 in which 1 is amenorrhea, 2 is hypomenorrhea, 3 is eumenorrhea, and 4 is menorrhagia. The three treatment groups averaged about 1.5 with no significant differences among them.

In terms of patient satisfaction, on a scale of 1‐3 in which 1 is a good outcome, 2 is fair, and 3 is poor, the average for all three groups was slightly over 1.0. There were no significant differences between groups, said Dr. Crowder, an ob.gyn. in Conroe, Texas.

About half the women in each group underwent ultrasound examination to measure endometrial thickness. Women taking leuprolide had thickness of 7.9 mm, those on oral contraceptives had thickness of 9.1 mm, and those on cycle timing had thickness of 12.0 mm, confirming that leuprolide and oral contraceptives were effective in thinning the endometrium.

SANTA FE, N.M. — Although the manufacturer of the Hydro ThermAblator recommends the use of leuprolide acetate to thin the endometrium before performing ablation with the device, this step may be unnecessary, William E. Crowder Jr., M.D., said at the annual meeting of the American Association of Gynecologic Laparoscopists.

In a nonrandomized study, 89 women with menorrhagia were assigned to one of three groups before undergoing treatment with the Hydro ThermAblator (HTA): endometrial thinning with leuprolide (3.75 mg in a single dose), oral contraceptives, or cycle timing. In the cycle timing group, women underwent HTA treatment in the early proliferative phase of the menstrual cycle. On follow-up, there were no differences in menstrual bleeding or patient satisfaction, said Dr. Crowder, a consultant to Boston Scientific, which manufactures the HTA system.

Despite his findings, Dr. Crowder said he is not recommending abandoning endometrial thinning agents. He said he would have to see the results of a randomized trial, currently in process, before he could make that recommendation.

In the current study, women in the three treatment groups rated their posttreatment bleeding on a scale of 1‐4 in which 1 is amenorrhea, 2 is hypomenorrhea, 3 is eumenorrhea, and 4 is menorrhagia. The three treatment groups averaged about 1.5 with no significant differences among them.

In terms of patient satisfaction, on a scale of 1‐3 in which 1 is a good outcome, 2 is fair, and 3 is poor, the average for all three groups was slightly over 1.0. There were no significant differences between groups, said Dr. Crowder, an ob.gyn. in Conroe, Texas.

About half the women in each group underwent ultrasound examination to measure endometrial thickness. Women taking leuprolide had thickness of 7.9 mm, those on oral contraceptives had thickness of 9.1 mm, and those on cycle timing had thickness of 12.0 mm, confirming that leuprolide and oral contraceptives were effective in thinning the endometrium.

For the first time, the federal government has issued guidelines on attempting to avoid HIV infection after accidental exposure to the virus outside of the health care workplace.

The Centers for Disease Control and Prevention-issued guidelines call for a 28-day course of a three-drug regimen of highly active antiretroviral therapy, but only if a high-risk exposure occurred within 72 hours of treatment initiation (MMWR 2005;54[RR02]:1–20).

The guidelines define high-risk exposures as those that occur through unprotected sex, condom breakage or slippage, sexual assault, the sharing of injection-drug equipment, or an accident with a source known to be HIV-infected.

If the HIV status of the source is unknown, physicians and patients should make decisions on nonoccupational postexposure prophylaxis (nPEP) on a case-by-case basis, taking into account the specific circumstances of the possible exposure and the risk of infection.

NPEP is not recommended for negligible exposure risks or for exposures that occurred more than 72 hours prior to treatment.

Prophylaxis is also not recommended for people whose behaviors result in frequent, recurrent exposures to HIV, such as those who often have unprotected sex with HIV-infected partners, or injection drug users who often share equipment.

NPEP is intended to be a “safety net,” similar to the prophylaxis that has long been available to health care workers and others who have been exposed to HIV in an occupational setting, Ronald O. Valdiserri, M.D., said during a press teleconference sponsored by the Centers for Disease Control and Prevention.

“It is clearly not a morning-after pill,” he said, pointing out the exacting nature of the 28-day regimen and its potential side effects.

The CDC guidelines are supported by a number of studies, including a recent feasibility study of 700 patients who were evaluated 12 weeks after nPEP was initiated. Of the 700, 7 individuals seroconverted, investigator Michelle Roland, M.D., reported.

Six of the seven seroconverters reported other high-risk encounters in the 6 months before nPEP; three of the seven reported ongoing high-risk behavior even after starting nPEP, suggesting that the failure of nPEP in these patients may not have been entirely due to medication failure.

Adherence to the treatment was fairly good, Dr. Roland said. During week 1, 84% of patients reported no missed doses during the prior 4 days; 78% reported no missed doses during week 2 and week 4.

While stating that no specific multidrug regimen has been shown to be superior to any other in the nPEP population, the guidelines list two preferred regimens and nine alternatives.

The drugs in the preferred nonnucleoside reverse transcriptase inhibitor (NNRTI)-based regimen are efavirenz plus either lamivudine or emtricitabine plus either zidovudine or tenofovir. Efavirenz should be avoided in pregnant women or women of childbearing potential.

The drugs in the preferred protease-inhibitor (PI)-based regimen are lopinavir and ritonavir (coformulated as Kaletra) plus zidovudine plus either lamivudine or emtricitabine.

The 28-day regimen will cost approximately $600–$1,000 depending on the specific drugs prescribed, according to Dr. Valdiserri, deputy director of CDC's National Center for HIV, STD, and TB Prevention.

The federal guidelines come well after some states—including California, Massachusetts, and Rhode Island—instituted their own nPEP guidelines. But Dr. Valdiserri rejected the notion that the federal government has been dragging its feet on issuing guidelines.

He noted that the CDC convened an expert panel in 1998, and the panel concluded that, at that time, there was insufficient evidence on the effectiveness of nPEP.

A second expert panel in 2001 did recommend nPEP based on new data from human and animal studies, but it has taken several more years for the guidelines to make their way through the bureaucracy.

The full set of recommendations, including dosages, side effects, and other prescribing information for 20 antiretroviral drugs and combination formulations, can be found at www.cdc.gov/mmwr/mmwr_rr.html

For the first time, the federal government has issued guidelines on attempting to avoid HIV infection after accidental exposure to the virus outside of the health care workplace.

The Centers for Disease Control and Prevention-issued guidelines call for a 28-day course of a three-drug regimen of highly active antiretroviral therapy, but only if a high-risk exposure occurred within 72 hours of treatment initiation (MMWR 2005;54[RR02]:1–20).

The guidelines define high-risk exposures as those that occur through unprotected sex, condom breakage or slippage, sexual assault, the sharing of injection-drug equipment, or an accident with a source known to be HIV-infected.

If the HIV status of the source is unknown, physicians and patients should make decisions on nonoccupational postexposure prophylaxis (nPEP) on a case-by-case basis, taking into account the specific circumstances of the possible exposure and the risk of infection.

NPEP is not recommended for negligible exposure risks or for exposures that occurred more than 72 hours prior to treatment.

Prophylaxis is also not recommended for people whose behaviors result in frequent, recurrent exposures to HIV, such as those who often have unprotected sex with HIV-infected partners, or injection drug users who often share equipment.

NPEP is intended to be a “safety net,” similar to the prophylaxis that has long been available to health care workers and others who have been exposed to HIV in an occupational setting, Ronald O. Valdiserri, M.D., said during a press teleconference sponsored by the Centers for Disease Control and Prevention.

“It is clearly not a morning-after pill,” he said, pointing out the exacting nature of the 28-day regimen and its potential side effects.

The CDC guidelines are supported by a number of studies, including a recent feasibility study of 700 patients who were evaluated 12 weeks after nPEP was initiated. Of the 700, 7 individuals seroconverted, investigator Michelle Roland, M.D., reported.

Six of the seven seroconverters reported other high-risk encounters in the 6 months before nPEP; three of the seven reported ongoing high-risk behavior even after starting nPEP, suggesting that the failure of nPEP in these patients may not have been entirely due to medication failure.

Adherence to the treatment was fairly good, Dr. Roland said. During week 1, 84% of patients reported no missed doses during the prior 4 days; 78% reported no missed doses during week 2 and week 4.

While stating that no specific multidrug regimen has been shown to be superior to any other in the nPEP population, the guidelines list two preferred regimens and nine alternatives.

The drugs in the preferred nonnucleoside reverse transcriptase inhibitor (NNRTI)-based regimen are efavirenz plus either lamivudine or emtricitabine plus either zidovudine or tenofovir. Efavirenz should be avoided in pregnant women or women of childbearing potential.

The drugs in the preferred protease-inhibitor (PI)-based regimen are lopinavir and ritonavir (coformulated as Kaletra) plus zidovudine plus either lamivudine or emtricitabine.

The 28-day regimen will cost approximately $600–$1,000 depending on the specific drugs prescribed, according to Dr. Valdiserri, deputy director of CDC's National Center for HIV, STD, and TB Prevention.

The federal guidelines come well after some states—including California, Massachusetts, and Rhode Island—instituted their own nPEP guidelines. But Dr. Valdiserri rejected the notion that the federal government has been dragging its feet on issuing guidelines.

He noted that the CDC convened an expert panel in 1998, and the panel concluded that, at that time, there was insufficient evidence on the effectiveness of nPEP.

A second expert panel in 2001 did recommend nPEP based on new data from human and animal studies, but it has taken several more years for the guidelines to make their way through the bureaucracy.

The full set of recommendations, including dosages, side effects, and other prescribing information for 20 antiretroviral drugs and combination formulations, can be found at www.cdc.gov/mmwr/mmwr_rr.html

For the first time, the federal government has issued guidelines on attempting to avoid HIV infection after accidental exposure to the virus outside of the health care workplace.

The Centers for Disease Control and Prevention-issued guidelines call for a 28-day course of a three-drug regimen of highly active antiretroviral therapy, but only if a high-risk exposure occurred within 72 hours of treatment initiation (MMWR 2005;54[RR02]:1–20).

The guidelines define high-risk exposures as those that occur through unprotected sex, condom breakage or slippage, sexual assault, the sharing of injection-drug equipment, or an accident with a source known to be HIV-infected.

If the HIV status of the source is unknown, physicians and patients should make decisions on nonoccupational postexposure prophylaxis (nPEP) on a case-by-case basis, taking into account the specific circumstances of the possible exposure and the risk of infection.

NPEP is not recommended for negligible exposure risks or for exposures that occurred more than 72 hours prior to treatment.

Prophylaxis is also not recommended for people whose behaviors result in frequent, recurrent exposures to HIV, such as those who often have unprotected sex with HIV-infected partners, or injection drug users who often share equipment.

NPEP is intended to be a “safety net,” similar to the prophylaxis that has long been available to health care workers and others who have been exposed to HIV in an occupational setting, Ronald O. Valdiserri, M.D., said during a press teleconference sponsored by the Centers for Disease Control and Prevention.

“It is clearly not a morning-after pill,” he said, pointing out the exacting nature of the 28-day regimen and its potential side effects.

The CDC guidelines are supported by a number of studies, including a recent feasibility study of 700 patients who were evaluated 12 weeks after nPEP was initiated. Of the 700, 7 individuals seroconverted, investigator Michelle Roland, M.D., reported.

Six of the seven seroconverters reported other high-risk encounters in the 6 months before nPEP; three of the seven reported ongoing high-risk behavior even after starting nPEP, suggesting that the failure of nPEP in these patients may not have been entirely due to medication failure.

Adherence to the treatment was fairly good, Dr. Roland said. During week 1, 84% of patients reported no missed doses during the prior 4 days; 78% reported no missed doses during week 2 and week 4.

While stating that no specific multidrug regimen has been shown to be superior to any other in the nPEP population, the guidelines list two preferred regimens and nine alternatives.

The drugs in the preferred nonnucleoside reverse transcriptase inhibitor (NNRTI)-based regimen are efavirenz plus either lamivudine or emtricitabine plus either zidovudine or tenofovir. Efavirenz should be avoided in pregnant women or women of childbearing potential.

The drugs in the preferred protease-inhibitor (PI)-based regimen are lopinavir and ritonavir (coformulated as Kaletra) plus zidovudine plus either lamivudine or emtricitabine.

The 28-day regimen will cost approximately $600–$1,000 depending on the specific drugs prescribed, according to Dr. Valdiserri, deputy director of CDC's National Center for HIV, STD, and TB Prevention.

The federal guidelines come well after some states—including California, Massachusetts, and Rhode Island—instituted their own nPEP guidelines. But Dr. Valdiserri rejected the notion that the federal government has been dragging its feet on issuing guidelines.

He noted that the CDC convened an expert panel in 1998, and the panel concluded that, at that time, there was insufficient evidence on the effectiveness of nPEP.

A second expert panel in 2001 did recommend nPEP based on new data from human and animal studies, but it has taken several more years for the guidelines to make their way through the bureaucracy.

The full set of recommendations, including dosages, side effects, and other prescribing information for 20 antiretroviral drugs and combination formulations, can be found at www.cdc.gov/mmwr/mmwr_rr.html

SAN FRANCISCO — Women who are HIV positive are at enhanced 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; the patient has had 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 enhanced 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; the patient has had 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 enhanced 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; the patient has had 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 — A 60-second oropharyngeal saline wash coupled with a quantitative polymerase chain reaction assay is 88% sensitive and 85% specific in the diagnosis of Pneumocystis pneumonia, Laurence Huang, M.D., reported at a meeting on HIV management sponsored by the University of California, San Francisco.

In the blinded study, investigators compared quantitative touch-down polymerase chain reaction (QTD PCR) results with bronchoscopy with bronchoalveolar lavage (BAL), which is widely considered to be the standard for the diagnosis of Pneumocystis pneumonia (PCP).

A total of 113 cases of PCP among 108 patients were included in the study (J. Infect. Dis. 2004;189:1679–83).

The use of QTD PCR testing is a way to increase the specificity of the DNA amplification procedure.

In recent years, the sensitivity of bronchoscopy with BAL has proved to be at least 98%, with a specificity of 100%, said Dr. Huang of UCSF and San Francisco General Hospital. The problem is that bronchoscopy with BAL is a relatively lengthy, uncomfortable, and invasive procedure.

Sputum induction takes only 30 minutes, and studies early in the HIV epidemic pegged its sensitivity at somewhere between 74% and 83%. But for unknown reasons, the sensitivity of sputum induction has been decreasing, reaching a low of 57% among 63 cases at San Francisco General in 2003 and 2004. Its specificity remains close to 100%, however.

In the 60-second gargle test, the collection procedure is “as low tech as you can get,” Dr. Huang said, requiring only a sterile specimen cup and 10 mL of sterile saline. It's therefore suitable for use in remote areas or resource-limited settings such as those in developing countries.

The low-tech collection procedure is coupled with a very high-tech detection procedure, namely PCR amplification, that's capable of spotting the DNA from a single organism of Pneumocystis jiroveci.

The test's sensitivity increased to 92% in patients who had received empiric treatment for PCP for 1 day or less, but its specificity declined to 75%.

Compared with the 100% specificity of bronchoscopy with BAL and sputum induction, the 75%–85% specificity of the gargle test is its main drawback. Dr. Huang suggested that people without PCP who nevertheless test positive by the gargle test may be nonsymptomatic carriers who are colonized with P. jiroveci.

He noted that, according to some accounts, as many as 40% of health workers who are exposed to HIV-infected patients may be colonized with the organism.

Dr. Huang declared that he has no financial relationship with a commercial entity.

SAN FRANCISCO — A 60-second oropharyngeal saline wash coupled with a quantitative polymerase chain reaction assay is 88% sensitive and 85% specific in the diagnosis of Pneumocystis pneumonia, Laurence Huang, M.D., reported at a meeting on HIV management sponsored by the University of California, San Francisco.

In the blinded study, investigators compared quantitative touch-down polymerase chain reaction (QTD PCR) results with bronchoscopy with bronchoalveolar lavage (BAL), which is widely considered to be the standard for the diagnosis of Pneumocystis pneumonia (PCP).

A total of 113 cases of PCP among 108 patients were included in the study (J. Infect. Dis. 2004;189:1679–83).

The use of QTD PCR testing is a way to increase the specificity of the DNA amplification procedure.

In recent years, the sensitivity of bronchoscopy with BAL has proved to be at least 98%, with a specificity of 100%, said Dr. Huang of UCSF and San Francisco General Hospital. The problem is that bronchoscopy with BAL is a relatively lengthy, uncomfortable, and invasive procedure.

Sputum induction takes only 30 minutes, and studies early in the HIV epidemic pegged its sensitivity at somewhere between 74% and 83%. But for unknown reasons, the sensitivity of sputum induction has been decreasing, reaching a low of 57% among 63 cases at San Francisco General in 2003 and 2004. Its specificity remains close to 100%, however.

In the 60-second gargle test, the collection procedure is “as low tech as you can get,” Dr. Huang said, requiring only a sterile specimen cup and 10 mL of sterile saline. It's therefore suitable for use in remote areas or resource-limited settings such as those in developing countries.

The low-tech collection procedure is coupled with a very high-tech detection procedure, namely PCR amplification, that's capable of spotting the DNA from a single organism of Pneumocystis jiroveci.

The test's sensitivity increased to 92% in patients who had received empiric treatment for PCP for 1 day or less, but its specificity declined to 75%.

Compared with the 100% specificity of bronchoscopy with BAL and sputum induction, the 75%–85% specificity of the gargle test is its main drawback. Dr. Huang suggested that people without PCP who nevertheless test positive by the gargle test may be nonsymptomatic carriers who are colonized with P. jiroveci.

He noted that, according to some accounts, as many as 40% of health workers who are exposed to HIV-infected patients may be colonized with the organism.

Dr. Huang declared that he has no financial relationship with a commercial entity.

SAN FRANCISCO — A 60-second oropharyngeal saline wash coupled with a quantitative polymerase chain reaction assay is 88% sensitive and 85% specific in the diagnosis of Pneumocystis pneumonia, Laurence Huang, M.D., reported at a meeting on HIV management sponsored by the University of California, San Francisco.

In the blinded study, investigators compared quantitative touch-down polymerase chain reaction (QTD PCR) results with bronchoscopy with bronchoalveolar lavage (BAL), which is widely considered to be the standard for the diagnosis of Pneumocystis pneumonia (PCP).

A total of 113 cases of PCP among 108 patients were included in the study (J. Infect. Dis. 2004;189:1679–83).

The use of QTD PCR testing is a way to increase the specificity of the DNA amplification procedure.

In recent years, the sensitivity of bronchoscopy with BAL has proved to be at least 98%, with a specificity of 100%, said Dr. Huang of UCSF and San Francisco General Hospital. The problem is that bronchoscopy with BAL is a relatively lengthy, uncomfortable, and invasive procedure.

Sputum induction takes only 30 minutes, and studies early in the HIV epidemic pegged its sensitivity at somewhere between 74% and 83%. But for unknown reasons, the sensitivity of sputum induction has been decreasing, reaching a low of 57% among 63 cases at San Francisco General in 2003 and 2004. Its specificity remains close to 100%, however.

In the 60-second gargle test, the collection procedure is “as low tech as you can get,” Dr. Huang said, requiring only a sterile specimen cup and 10 mL of sterile saline. It's therefore suitable for use in remote areas or resource-limited settings such as those in developing countries.

The low-tech collection procedure is coupled with a very high-tech detection procedure, namely PCR amplification, that's capable of spotting the DNA from a single organism of Pneumocystis jiroveci.

The test's sensitivity increased to 92% in patients who had received empiric treatment for PCP for 1 day or less, but its specificity declined to 75%.

Compared with the 100% specificity of bronchoscopy with BAL and sputum induction, the 75%–85% specificity of the gargle test is its main drawback. Dr. Huang suggested that people without PCP who nevertheless test positive by the gargle test may be nonsymptomatic carriers who are colonized with P. jiroveci.

He noted that, according to some accounts, as many as 40% of health workers who are exposed to HIV-infected patients may be colonized with the organism.

Dr. Huang declared that he has no financial relationship with a commercial entity.

SAN FRANCISCO — The ninth intercostal space in the left upper quadrant provides a safe alternative to umbilicus entry for laparoscopy when the patient has adhesions, Neena Agarwala, M.D., reported in a poster presentation during the annual meeting of the American Association of Gynecologic Laparoscopists.

In a large retrospective study, Dr. Agarwala of the University of Nebraska Medical Center, Omaha, studied all 918 laparoscopies performed over a 6-year period on patients with surgical scars at a university hospital and a community hospital. Of those 918 laparoscopies, 504 (55%) of the patients had umbilical adhesions.

Using the alternate entry position in the left upper quadrant resulted in no trocar-related injuries and only two Veress needle-related injuries.

One was a needle puncture to the left lung margin resulting in transient pneumothorax, and the other was a Veress needle placement in the stomach, which was recognized and repaired immediately.

Extensive adhesion lysis resulted in two bowel injuries that required additional surgery via laparotomy.

The left upper quadrant technique involves the insertion of the Veress needle parallel to the anterior thoracic wall. The needle's course goes along the interior aspect of the ninth rib.

The curvature of the rib together with the rigidity of the peritoneum in this area provides a protected space free of all intraabdominal organs, Dr. Agarwala said.

The umbilical adhesions in these patients resulted from one of three causes. Of the 504 patients with adhesions, 62% had a prior abdominal wall incision, 22% had a prior Pfannenstiel incision, and 16% had a prior laparoscopic incision.

SAN FRANCISCO — The ninth intercostal space in the left upper quadrant provides a safe alternative to umbilicus entry for laparoscopy when the patient has adhesions, Neena Agarwala, M.D., reported in a poster presentation during the annual meeting of the American Association of Gynecologic Laparoscopists.

In a large retrospective study, Dr. Agarwala of the University of Nebraska Medical Center, Omaha, studied all 918 laparoscopies performed over a 6-year period on patients with surgical scars at a university hospital and a community hospital. Of those 918 laparoscopies, 504 (55%) of the patients had umbilical adhesions.

Using the alternate entry position in the left upper quadrant resulted in no trocar-related injuries and only two Veress needle-related injuries.

One was a needle puncture to the left lung margin resulting in transient pneumothorax, and the other was a Veress needle placement in the stomach, which was recognized and repaired immediately.

Extensive adhesion lysis resulted in two bowel injuries that required additional surgery via laparotomy.

The left upper quadrant technique involves the insertion of the Veress needle parallel to the anterior thoracic wall. The needle's course goes along the interior aspect of the ninth rib.

The curvature of the rib together with the rigidity of the peritoneum in this area provides a protected space free of all intraabdominal organs, Dr. Agarwala said.

The umbilical adhesions in these patients resulted from one of three causes. Of the 504 patients with adhesions, 62% had a prior abdominal wall incision, 22% had a prior Pfannenstiel incision, and 16% had a prior laparoscopic incision.

SAN FRANCISCO — The ninth intercostal space in the left upper quadrant provides a safe alternative to umbilicus entry for laparoscopy when the patient has adhesions, Neena Agarwala, M.D., reported in a poster presentation during the annual meeting of the American Association of Gynecologic Laparoscopists.

In a large retrospective study, Dr. Agarwala of the University of Nebraska Medical Center, Omaha, studied all 918 laparoscopies performed over a 6-year period on patients with surgical scars at a university hospital and a community hospital. Of those 918 laparoscopies, 504 (55%) of the patients had umbilical adhesions.

Using the alternate entry position in the left upper quadrant resulted in no trocar-related injuries and only two Veress needle-related injuries.

One was a needle puncture to the left lung margin resulting in transient pneumothorax, and the other was a Veress needle placement in the stomach, which was recognized and repaired immediately.

Extensive adhesion lysis resulted in two bowel injuries that required additional surgery via laparotomy.

The left upper quadrant technique involves the insertion of the Veress needle parallel to the anterior thoracic wall. The needle's course goes along the interior aspect of the ninth rib.

The curvature of the rib together with the rigidity of the peritoneum in this area provides a protected space free of all intraabdominal organs, Dr. Agarwala said.

The umbilical adhesions in these patients resulted from one of three causes. Of the 504 patients with adhesions, 62% had a prior abdominal wall incision, 22% had a prior Pfannenstiel incision, and 16% had a prior laparoscopic incision.

SAN FRANCISCO — A laparoscopic procedure that preserves the hypogastric and pelvic splanchnic nerves appears to reduce urinary retention after treatment of deep pelvic endometriosis, Paulo Ayroza Ribeiro, M.D., reported at the annual meeting of the American Association of Gynecologic Laparoscopists.

In a prospective, nonrandomized study, Dr. Ayroza Ribeiro of Santa Casa Medical School in São Paulo, Brazil, first treated 25 women with laparoscopic radical excision of paracervical deep pelvic endometriosis using standard techniques. Then, after introducing the nerve-sparing technique, he treated an additional 25 women.

Nine of the 25 who underwent the standard procedure experienced urinary retention on day 1 following the operation, 4 still had urinary retention on day 3, and 2 still had urinary retention on day 30.

By comparison, 2 of the 15 women who underwent the nerve-sparing procedure experienced urinary retention on day 1, but all were better by day 3.

The differences in the number of women experiencing urinary retention were statistically significant on day 1, day 3, and day 7 after the procedure.

“Anyone who gets a patient with urinary retention for 30 days, 6 months, 1 year, knows that this is a really great problem,” Dr. Ayroza Ribeiro said at the meeting. “That's why we developed these kind of techniques,” which built upon the work of Marc Possover, M.D., currently of the University of Cologne, Germany.

The new technique starts with a paracervical and pararectal space dissection with identification and preservation of the hypogastric and splanchnic nerves.

It continues with the laparoscopic radical excision of deep pelvic endometriosis using traditional surgical techniques such as blunt dissection and bipolar coagulation.

SAN FRANCISCO — A laparoscopic procedure that preserves the hypogastric and pelvic splanchnic nerves appears to reduce urinary retention after treatment of deep pelvic endometriosis, Paulo Ayroza Ribeiro, M.D., reported at the annual meeting of the American Association of Gynecologic Laparoscopists.

In a prospective, nonrandomized study, Dr. Ayroza Ribeiro of Santa Casa Medical School in São Paulo, Brazil, first treated 25 women with laparoscopic radical excision of paracervical deep pelvic endometriosis using standard techniques. Then, after introducing the nerve-sparing technique, he treated an additional 25 women.

Nine of the 25 who underwent the standard procedure experienced urinary retention on day 1 following the operation, 4 still had urinary retention on day 3, and 2 still had urinary retention on day 30.

By comparison, 2 of the 15 women who underwent the nerve-sparing procedure experienced urinary retention on day 1, but all were better by day 3.

The differences in the number of women experiencing urinary retention were statistically significant on day 1, day 3, and day 7 after the procedure.

“Anyone who gets a patient with urinary retention for 30 days, 6 months, 1 year, knows that this is a really great problem,” Dr. Ayroza Ribeiro said at the meeting. “That's why we developed these kind of techniques,” which built upon the work of Marc Possover, M.D., currently of the University of Cologne, Germany.

The new technique starts with a paracervical and pararectal space dissection with identification and preservation of the hypogastric and splanchnic nerves.

It continues with the laparoscopic radical excision of deep pelvic endometriosis using traditional surgical techniques such as blunt dissection and bipolar coagulation.

SAN FRANCISCO — A laparoscopic procedure that preserves the hypogastric and pelvic splanchnic nerves appears to reduce urinary retention after treatment of deep pelvic endometriosis, Paulo Ayroza Ribeiro, M.D., reported at the annual meeting of the American Association of Gynecologic Laparoscopists.

In a prospective, nonrandomized study, Dr. Ayroza Ribeiro of Santa Casa Medical School in São Paulo, Brazil, first treated 25 women with laparoscopic radical excision of paracervical deep pelvic endometriosis using standard techniques. Then, after introducing the nerve-sparing technique, he treated an additional 25 women.

Nine of the 25 who underwent the standard procedure experienced urinary retention on day 1 following the operation, 4 still had urinary retention on day 3, and 2 still had urinary retention on day 30.

By comparison, 2 of the 15 women who underwent the nerve-sparing procedure experienced urinary retention on day 1, but all were better by day 3.

The differences in the number of women experiencing urinary retention were statistically significant on day 1, day 3, and day 7 after the procedure.

“Anyone who gets a patient with urinary retention for 30 days, 6 months, 1 year, knows that this is a really great problem,” Dr. Ayroza Ribeiro said at the meeting. “That's why we developed these kind of techniques,” which built upon the work of Marc Possover, M.D., currently of the University of Cologne, Germany.

The new technique starts with a paracervical and pararectal space dissection with identification and preservation of the hypogastric and splanchnic nerves.

It continues with the laparoscopic radical excision of deep pelvic endometriosis using traditional surgical techniques such as blunt dissection and bipolar coagulation.

The U.S. Food and Drug Administration has accepted Centocor Inc.'s application to approve infliximab (Remicade) for the treatment of psoriatic arthritis.

Already approved for use in rheumatoid arthritis and Crohn's disease in North America, the European Union, and Japan, infliximab was recently approved for use in psoriatic arthritis by the European Commission.

Centocor, a wholly owned subsidiary of Johnson & Johnson, based its application on two double-blind, placebo-controlled studies involving a total of 304 patients with psoriatic arthritis. In one study, 65% of the patients on infliximab (5 mg/kg) achieved at least a 20% improvement, according to American College of Rheumatology (ACR20) criteria at week 16.

In the second study, some patients taking 5 mg/kg of infliximab began showing improvement as early as week 2. By week 14, 58% of the patients taking infliximab and only 11% of the patients taking placebo achieved ACR20 improvement. The Psoriasis Area and Severity Index score improved by 75% in 63.9% of the infliximab patients and only 2.3% of the placebo patients. Both differences were statistically significant.

Patients with psoriatic arthritis tolerated infliximab well in these studies, with an elevation in liver function tests being the most common abnormality associated with the drug, which inhibits tumor necrosis factor alpha. Investigators noted no deaths, cases of tuberculosis, or other opportunistic infections among the patients taking infliximab in these studies.

The U.S. Food and Drug Administration has accepted Centocor Inc.'s application to approve infliximab (Remicade) for the treatment of psoriatic arthritis.

Already approved for use in rheumatoid arthritis and Crohn's disease in North America, the European Union, and Japan, infliximab was recently approved for use in psoriatic arthritis by the European Commission.

Centocor, a wholly owned subsidiary of Johnson & Johnson, based its application on two double-blind, placebo-controlled studies involving a total of 304 patients with psoriatic arthritis. In one study, 65% of the patients on infliximab (5 mg/kg) achieved at least a 20% improvement, according to American College of Rheumatology (ACR20) criteria at week 16.

In the second study, some patients taking 5 mg/kg of infliximab began showing improvement as early as week 2. By week 14, 58% of the patients taking infliximab and only 11% of the patients taking placebo achieved ACR20 improvement. The Psoriasis Area and Severity Index score improved by 75% in 63.9% of the infliximab patients and only 2.3% of the placebo patients. Both differences were statistically significant.

Patients with psoriatic arthritis tolerated infliximab well in these studies, with an elevation in liver function tests being the most common abnormality associated with the drug, which inhibits tumor necrosis factor alpha. Investigators noted no deaths, cases of tuberculosis, or other opportunistic infections among the patients taking infliximab in these studies.

The U.S. Food and Drug Administration has accepted Centocor Inc.'s application to approve infliximab (Remicade) for the treatment of psoriatic arthritis.

Already approved for use in rheumatoid arthritis and Crohn's disease in North America, the European Union, and Japan, infliximab was recently approved for use in psoriatic arthritis by the European Commission.

Centocor, a wholly owned subsidiary of Johnson & Johnson, based its application on two double-blind, placebo-controlled studies involving a total of 304 patients with psoriatic arthritis. In one study, 65% of the patients on infliximab (5 mg/kg) achieved at least a 20% improvement, according to American College of Rheumatology (ACR20) criteria at week 16.

In the second study, some patients taking 5 mg/kg of infliximab began showing improvement as early as week 2. By week 14, 58% of the patients taking infliximab and only 11% of the patients taking placebo achieved ACR20 improvement. The Psoriasis Area and Severity Index score improved by 75% in 63.9% of the infliximab patients and only 2.3% of the placebo patients. Both differences were statistically significant.

Patients with psoriatic arthritis tolerated infliximab well in these studies, with an elevation in liver function tests being the most common abnormality associated with the drug, which inhibits tumor necrosis factor alpha. Investigators noted no deaths, cases of tuberculosis, or other opportunistic infections among the patients taking infliximab in these studies.

SANTA FE, N.M. — A focus on emotional disclosure is better than a focus on cognitive restructuring when using a written disclosure paradigm for patients with posttraumatic stress disorder, Denise M. Sloan, Ph.D., reported in a poster presentation at the annual meeting of the Society for Psychophysiological Research.

While some previous studies have suggested that patients with posttraumatic stress disorder (PTSD) can be helped by writing about their experiences, the results have been inconsistent, said Dr. Sloan of Temple University, Philadelphia.

To study this systematically, Dr. Sloan and her colleagues asked 82 undergraduate students with PTSD to write about their experiences in three 20-minute sessions.

The students were randomly assigned to one of three groups. The emotional disclosure group was instructed to write about a traumatic experience with as much emotion and feeling as possible. The cognitive restructuring group was instructed to write about a traumatic experience with a focus on what the experience meant to them and how it changed their lives. The control group was instructed to use no emotions or opinions and to write about how they spent their time.

Before the first session, and again 4 weeks after the completion of all three sessions, participants completed the Posttraumatic Stress Disorder Scale (PDS), the Beck Depression Inventory (BDI), and the Pennebaker Inventory of Limbic Languidness (PILL), a measure of physical symptoms.

Participants in the emotional disclosure group had significantly improved scores on the PDS and the PILL at follow-up, while those in the control and cognitive restructuring groups showed no change in those scores. The emotional disclosure group also had a significant improvement in BDI scores, compared with controls. The cognitive restructuring group showed no significant differences from control subjects at follow-up, Dr. Sloan said.

With the Reliable Change Index, the improvements in PTSD symptom severity and depressive symptoms were shown to be clinically meaningful and not only statistically significant.

SANTA FE, N.M. — A focus on emotional disclosure is better than a focus on cognitive restructuring when using a written disclosure paradigm for patients with posttraumatic stress disorder, Denise M. Sloan, Ph.D., reported in a poster presentation at the annual meeting of the Society for Psychophysiological Research.

While some previous studies have suggested that patients with posttraumatic stress disorder (PTSD) can be helped by writing about their experiences, the results have been inconsistent, said Dr. Sloan of Temple University, Philadelphia.

To study this systematically, Dr. Sloan and her colleagues asked 82 undergraduate students with PTSD to write about their experiences in three 20-minute sessions.

The students were randomly assigned to one of three groups. The emotional disclosure group was instructed to write about a traumatic experience with as much emotion and feeling as possible. The cognitive restructuring group was instructed to write about a traumatic experience with a focus on what the experience meant to them and how it changed their lives. The control group was instructed to use no emotions or opinions and to write about how they spent their time.

Before the first session, and again 4 weeks after the completion of all three sessions, participants completed the Posttraumatic Stress Disorder Scale (PDS), the Beck Depression Inventory (BDI), and the Pennebaker Inventory of Limbic Languidness (PILL), a measure of physical symptoms.

Participants in the emotional disclosure group had significantly improved scores on the PDS and the PILL at follow-up, while those in the control and cognitive restructuring groups showed no change in those scores. The emotional disclosure group also had a significant improvement in BDI scores, compared with controls. The cognitive restructuring group showed no significant differences from control subjects at follow-up, Dr. Sloan said.

With the Reliable Change Index, the improvements in PTSD symptom severity and depressive symptoms were shown to be clinically meaningful and not only statistically significant.

SANTA FE, N.M. — A focus on emotional disclosure is better than a focus on cognitive restructuring when using a written disclosure paradigm for patients with posttraumatic stress disorder, Denise M. Sloan, Ph.D., reported in a poster presentation at the annual meeting of the Society for Psychophysiological Research.

While some previous studies have suggested that patients with posttraumatic stress disorder (PTSD) can be helped by writing about their experiences, the results have been inconsistent, said Dr. Sloan of Temple University, Philadelphia.

To study this systematically, Dr. Sloan and her colleagues asked 82 undergraduate students with PTSD to write about their experiences in three 20-minute sessions.

The students were randomly assigned to one of three groups. The emotional disclosure group was instructed to write about a traumatic experience with as much emotion and feeling as possible. The cognitive restructuring group was instructed to write about a traumatic experience with a focus on what the experience meant to them and how it changed their lives. The control group was instructed to use no emotions or opinions and to write about how they spent their time.

Before the first session, and again 4 weeks after the completion of all three sessions, participants completed the Posttraumatic Stress Disorder Scale (PDS), the Beck Depression Inventory (BDI), and the Pennebaker Inventory of Limbic Languidness (PILL), a measure of physical symptoms.

Participants in the emotional disclosure group had significantly improved scores on the PDS and the PILL at follow-up, while those in the control and cognitive restructuring groups showed no change in those scores. The emotional disclosure group also had a significant improvement in BDI scores, compared with controls. The cognitive restructuring group showed no significant differences from control subjects at follow-up, Dr. Sloan said.

With the Reliable Change Index, the improvements in PTSD symptom severity and depressive symptoms were shown to be clinically meaningful and not only statistically significant.

SAN FRANCISCO — People infected with HIV are diagnosed with acute coronary syndromes an average of 11 years earlier than their HIV-negative counterparts, Priscilla Hsue, M.D., said at a meeting on HIV management sponsored by the University of California, San Francisco.

Moreover, atherosclerosis, as measured by carotid intima-media thickness, progresses much faster in patients who are HIV-positive, and restenosis rates after percutaneous coronary intervention are significantly higher in HIV patients than in controls.

Although protease inhibitors and other components of highly active antiretroviral therapy may contribute to acute coronary syndromes in patients with HIV, this can't account for all of the differences between patients with HIV and noninfected controls. HIV may be an independent coronary risk factor, said Dr. Hsue of the university.

She reported on the results of two studies. One was a retrospective chart review of 68 acute coronary syndrome patients with HIV who were compared with 68 uninfected acute coronary syndrome patients.

Acute coronary syndrome was defined by a diagnosis of acute myocardial infarction or unstable angina. The other was a prospective study of 148 HIV-infected patients and 63 age- and sex-matched controls.

The chart review showed that the average age of HIV-infected acute coronary syndrome patients was 50, compared with 61 for the non-infected patients. HIV patients with acute coronary syndrome were significantly more likely to be male (90% vs. 62%), to be current cigarette smokers (68% vs. 41%), and to have low HDL cholesterol levels (35 mg/dL vs. 41 mg/dL) (Circulation 2004;109:316–9).

HIV patients were significantly less likely to have diabetes (13% vs. 41%), and they had significantly less extensive coronary disease at angiography. An average of 1.3 vessels were involved in patients with HIV compared with 1.9 vessels in controls.

Percutaneous coronary intervention was performed on 29 HIV patients and 21 controls. Restenosis occurred in 15 of the HIV patients (52%) and in 3 controls (14%), a significant difference.

In the prospective study, the HIV-infected patients had significantly higher carotid intima-media thickness (as measured by B-mode ultrasound) than did controls (0.91 mm vs. 0.74 mm).

Investigators detected carotid plaques in 45% of the HIV patients and 24% of the control patients, a significant difference (Circulation 2004;109:1603–8).

In a multivariate analysis combining infected and uninfected patients, HIV infection proved to be an independent predictor of greater intima-media thickness, even after controlling for other classic coronary risk factors, including age, sex, smoking, hypertension, lipid abnormalities, and diabetes.

Other independent predictors were age, LDL cholesterol, cigarette pack-years, and Hispanic race.

Investigators were able to obtain follow-up measurements at 1 year in 121 HIV patients and 27 controls. Among HIV patients, intima-media thickness increased a mean of 0.074 mm, while among control subjects intima-media thickness decreased by 0.006 mm, a significant difference.

Previous studies of noninfected patients suggest that carotid intima-media thickness tends to increase at about 0.01 mm/year, a rate about sevenfold lower than that observed among HIV patients in this study.

These studies suggest that clinicians should engage in aggressive control of risk factors in patients with HIV. Smoking may be of particular importance because of its high prevalence in this population. Hypertension should be treated, LDL cholesterol should be reduced to low levels, and hypertriglyceridemia should be controlled.

SAN FRANCISCO — People infected with HIV are diagnosed with acute coronary syndromes an average of 11 years earlier than their HIV-negative counterparts, Priscilla Hsue, M.D., said at a meeting on HIV management sponsored by the University of California, San Francisco.

Moreover, atherosclerosis, as measured by carotid intima-media thickness, progresses much faster in patients who are HIV-positive, and restenosis rates after percutaneous coronary intervention are significantly higher in HIV patients than in controls.

Although protease inhibitors and other components of highly active antiretroviral therapy may contribute to acute coronary syndromes in patients with HIV, this can't account for all of the differences between patients with HIV and noninfected controls. HIV may be an independent coronary risk factor, said Dr. Hsue of the university.

She reported on the results of two studies. One was a retrospective chart review of 68 acute coronary syndrome patients with HIV who were compared with 68 uninfected acute coronary syndrome patients.

Acute coronary syndrome was defined by a diagnosis of acute myocardial infarction or unstable angina. The other was a prospective study of 148 HIV-infected patients and 63 age- and sex-matched controls.

The chart review showed that the average age of HIV-infected acute coronary syndrome patients was 50, compared with 61 for the non-infected patients. HIV patients with acute coronary syndrome were significantly more likely to be male (90% vs. 62%), to be current cigarette smokers (68% vs. 41%), and to have low HDL cholesterol levels (35 mg/dL vs. 41 mg/dL) (Circulation 2004;109:316–9).

HIV patients were significantly less likely to have diabetes (13% vs. 41%), and they had significantly less extensive coronary disease at angiography. An average of 1.3 vessels were involved in patients with HIV compared with 1.9 vessels in controls.

Percutaneous coronary intervention was performed on 29 HIV patients and 21 controls. Restenosis occurred in 15 of the HIV patients (52%) and in 3 controls (14%), a significant difference.

In the prospective study, the HIV-infected patients had significantly higher carotid intima-media thickness (as measured by B-mode ultrasound) than did controls (0.91 mm vs. 0.74 mm).

Investigators detected carotid plaques in 45% of the HIV patients and 24% of the control patients, a significant difference (Circulation 2004;109:1603–8).

In a multivariate analysis combining infected and uninfected patients, HIV infection proved to be an independent predictor of greater intima-media thickness, even after controlling for other classic coronary risk factors, including age, sex, smoking, hypertension, lipid abnormalities, and diabetes.

Other independent predictors were age, LDL cholesterol, cigarette pack-years, and Hispanic race.

Investigators were able to obtain follow-up measurements at 1 year in 121 HIV patients and 27 controls. Among HIV patients, intima-media thickness increased a mean of 0.074 mm, while among control subjects intima-media thickness decreased by 0.006 mm, a significant difference.

Previous studies of noninfected patients suggest that carotid intima-media thickness tends to increase at about 0.01 mm/year, a rate about sevenfold lower than that observed among HIV patients in this study.

These studies suggest that clinicians should engage in aggressive control of risk factors in patients with HIV. Smoking may be of particular importance because of its high prevalence in this population. Hypertension should be treated, LDL cholesterol should be reduced to low levels, and hypertriglyceridemia should be controlled.

SAN FRANCISCO — People infected with HIV are diagnosed with acute coronary syndromes an average of 11 years earlier than their HIV-negative counterparts, Priscilla Hsue, M.D., said at a meeting on HIV management sponsored by the University of California, San Francisco.

Moreover, atherosclerosis, as measured by carotid intima-media thickness, progresses much faster in patients who are HIV-positive, and restenosis rates after percutaneous coronary intervention are significantly higher in HIV patients than in controls.

Although protease inhibitors and other components of highly active antiretroviral therapy may contribute to acute coronary syndromes in patients with HIV, this can't account for all of the differences between patients with HIV and noninfected controls. HIV may be an independent coronary risk factor, said Dr. Hsue of the university.

She reported on the results of two studies. One was a retrospective chart review of 68 acute coronary syndrome patients with HIV who were compared with 68 uninfected acute coronary syndrome patients.

Acute coronary syndrome was defined by a diagnosis of acute myocardial infarction or unstable angina. The other was a prospective study of 148 HIV-infected patients and 63 age- and sex-matched controls.

The chart review showed that the average age of HIV-infected acute coronary syndrome patients was 50, compared with 61 for the non-infected patients. HIV patients with acute coronary syndrome were significantly more likely to be male (90% vs. 62%), to be current cigarette smokers (68% vs. 41%), and to have low HDL cholesterol levels (35 mg/dL vs. 41 mg/dL) (Circulation 2004;109:316–9).

HIV patients were significantly less likely to have diabetes (13% vs. 41%), and they had significantly less extensive coronary disease at angiography. An average of 1.3 vessels were involved in patients with HIV compared with 1.9 vessels in controls.

Percutaneous coronary intervention was performed on 29 HIV patients and 21 controls. Restenosis occurred in 15 of the HIV patients (52%) and in 3 controls (14%), a significant difference.

In the prospective study, the HIV-infected patients had significantly higher carotid intima-media thickness (as measured by B-mode ultrasound) than did controls (0.91 mm vs. 0.74 mm).

Investigators detected carotid plaques in 45% of the HIV patients and 24% of the control patients, a significant difference (Circulation 2004;109:1603–8).

In a multivariate analysis combining infected and uninfected patients, HIV infection proved to be an independent predictor of greater intima-media thickness, even after controlling for other classic coronary risk factors, including age, sex, smoking, hypertension, lipid abnormalities, and diabetes.

Other independent predictors were age, LDL cholesterol, cigarette pack-years, and Hispanic race.

Investigators were able to obtain follow-up measurements at 1 year in 121 HIV patients and 27 controls. Among HIV patients, intima-media thickness increased a mean of 0.074 mm, while among control subjects intima-media thickness decreased by 0.006 mm, a significant difference.

Previous studies of noninfected patients suggest that carotid intima-media thickness tends to increase at about 0.01 mm/year, a rate about sevenfold lower than that observed among HIV patients in this study.

These studies suggest that clinicians should engage in aggressive control of risk factors in patients with HIV. Smoking may be of particular importance because of its high prevalence in this population. Hypertension should be treated, LDL cholesterol should be reduced to low levels, and hypertriglyceridemia should be controlled.

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

Prior to 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 rate of cervical cancer among women before universal screening.

Now, data 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 among screened women, which has declined to about 8/100,000, said Dr. Palefsky of the university.

Visual inspection of the anal opening is not sufficient, he said, although this step should certainly not be dispensed with. Visual inspection can, for example, turn up the diffuse, hyperpigmented, flat plaques of Bowen's disease. “Most of the action is occurring intraanally, where you need special techniques to see what's going on.”

Two centimeters inside the anal canal is a transformation zone where the rectal columnar epithelium meets the anal squamous epithelium. This transformation zone is quite similar to the cervical transformation zone, and similarly, that's where most disease occurs.

Anal and cervical disease have many other similarities as well, especially in their association with human papilloma virus (HPV) infection.

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 HPV. Virtually everyone with HIV disease—regardless of gender—will have HPV infection, some with as many as 10 virus types.

A Pap smear tests for dysplasia, not cancer, so the next step is a digital rectal exam, which is a good cancer-screening tool, Dr. Palefsky said. Put a lubricated finger in the anal canal and feel for subcutaneous masses that would not otherwise be visible.

Next, perform an anoscopy with a standard plastic anoscope. Cancerous and precancerous lesions in the anus appear quite 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 these warts. “We recommend sampling, through biopsy, lesions of different appearance when patients have multiple lesions, which is often the case.”

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

Prior to 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 rate of cervical cancer among women before universal screening.

Now, data 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 among screened women, which has declined to about 8/100,000, said Dr. Palefsky of the university.

Visual inspection of the anal opening is not sufficient, he said, although this step should certainly not be dispensed with. Visual inspection can, for example, turn up the diffuse, hyperpigmented, flat plaques of Bowen's disease. “Most of the action is occurring intraanally, where you need special techniques to see what's going on.”

Two centimeters inside the anal canal is a transformation zone where the rectal columnar epithelium meets the anal squamous epithelium. This transformation zone is quite similar to the cervical transformation zone, and similarly, that's where most disease occurs.

Anal and cervical disease have many other similarities as well, especially in their association with human papilloma virus (HPV) infection.

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 HPV. Virtually everyone with HIV disease—regardless of gender—will have HPV infection, some with as many as 10 virus types.

A Pap smear tests for dysplasia, not cancer, so the next step is a digital rectal exam, which is a good cancer-screening tool, Dr. Palefsky said. Put a lubricated finger in the anal canal and feel for subcutaneous masses that would not otherwise be visible.

Next, perform an anoscopy with a standard plastic anoscope. Cancerous and precancerous lesions in the anus appear quite 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 these warts. “We recommend sampling, through biopsy, lesions of different appearance when patients have multiple lesions, which is often the case.”

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

Prior to 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 rate of cervical cancer among women before universal screening.

Now, data 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 among screened women, which has declined to about 8/100,000, said Dr. Palefsky of the university.

Visual inspection of the anal opening is not sufficient, he said, although this step should certainly not be dispensed with. Visual inspection can, for example, turn up the diffuse, hyperpigmented, flat plaques of Bowen's disease. “Most of the action is occurring intraanally, where you need special techniques to see what's going on.”

Two centimeters inside the anal canal is a transformation zone where the rectal columnar epithelium meets the anal squamous epithelium. This transformation zone is quite similar to the cervical transformation zone, and similarly, that's where most disease occurs.

Anal and cervical disease have many other similarities as well, especially in their association with human papilloma virus (HPV) infection.

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 HPV. Virtually everyone with HIV disease—regardless of gender—will have HPV infection, some with as many as 10 virus types.

A Pap smear tests for dysplasia, not cancer, so the next step is a digital rectal exam, which is a good cancer-screening tool, Dr. Palefsky said. Put a lubricated finger in the anal canal and feel for subcutaneous masses that would not otherwise be visible.

Next, perform an anoscopy with a standard plastic anoscope. Cancerous and precancerous lesions in the anus appear quite 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 these warts. “We recommend sampling, through biopsy, lesions of different appearance when patients have multiple lesions, which is often the case.”