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Hotline Helps Providers Navigate Perinatal HIV
The national Perinatal HIV Hotline has fielded hundreds of calls for advice over the past 2 years. Its directors anticipate getting much busier as more labor and delivery services begin offering rapid HIV testing.
There's no nationwide mandate for universal prenatal HIV testing, but it's very strongly recommended by the Centers for Disease Control and Prevention, the American College of Obstetricians and Gynecologists, and the Institutes of Medicine.
“The burden is on the provider to offer it. I can tell you that there are plenty of providers who still do not offer routine HIV testing, even though it's been found to be cost effective,” said Dr. Deborah Cohan, an obstetrician at San Francisco General Hospital and codirector of the hotline. “We know that only offering HIV testing to so-called high-risk patients misses a lot of HIV-infected women.”
In 2000, more than a third of HIV-positive neonates in the United States were born to women who did not know their HIV status until after delivery. “That's totally unacceptable,” she said.
Ideally, every pregnant woman would get prenatal care including HIV testing. At her institution, though, 12% of women in labor have had no prenatal care, making rapid HIV testing the last resort for HIV management before delivery. Dr. Cohan looks forward to more clinicians offering rapid HIV testing and calling the Perinatal HIV Hotline for help in interpreting the result or making management decisions.
Officially called the National Perinatal HIV Consultation and Referral Service, the hotline started taking calls on Labor Day of 2004. Staffers provide free advice and assistance to clinicians every day of the year and around the clock, because labor can happen at any hour.
The requests for help come from a variety of specialties, including the following:
▸ A family physician facing her first HIV-positive pregnant patient needed assurance about her treatment plan.
▸ An urban obstetrician sought help in finding the best program to care for a monolingual Spanish-speaking patient who was pregnant and HIV positive.
▸ A rural midwife and the obstetrician with whom she practices hoped to comanage an HIV-positive pregnant patient with an HIV specialist but didn't know where to find a specialist in their area.
▸ A nurse wanted help in planning a training session for rural pediatricians on the care of newborns exposed to HIV.
The hotline handles around 30 calls per month but is capable of handling four or five times as many, said Dr. Jessica Fogler, a family physician at San Francisco General Hospital and codirector of the hotline.
“I think our numbers will pick up when rapid testing becomes more available,” she added. “A lot of people who are inexperienced are going to be sitting there with a positive test on their hands.”
The U.S. Health Resources and Services Administration's National HIV/AIDS Clinicians' Consultation Center at the hospital runs the Perinatal HIV Hotline and two other telephone help lines for clinicians managing nonpregnant patients with HIV or health care workers who are exposed to HIV or hepatitis B or C.
More than half of calls to the Perinatal HIV Hotline relate to prepartum pregnant women and are fairly evenly divided among the trimesters, records from a 15-month period suggest. Around 5% of calls involve women in labor. Advice includes counseling on HIV treatment of the neonate and postpartum maternal HIV treatment. The hotline also offers advice related to contraception or preconception counseling for HIV-positive women or for HIV-negative women whose sexual partners have HIV.
More than half of callers have MD or DO degrees and are almost evenly represented by obstetricians, family physicians, and infectious disease specialists. Internists, pediatricians, and nurses each make up about 8%–13% of callers.
The hotline's referral service, run by social worker Shannon Weber, maintains a list of clinicians in every state with experience managing HIV who are willing to accept or to comanage infected pregnant patients.
One patient, for example, had started antiretroviral therapy in her third trimester and developed an abacavir hypersensitivity reaction, prompting her health care provider to call for advice. Hotline staffers recommended stopping the medication.
The patient decided at week 34 of pregnancy to move from California to Atlanta. The hotline's referral service helped find her a new doctor there and facilitated communications before the woman got on the bus to move. “She's getting good care,” Ms. Weber said.
More and more calls to the hotline concern women who have been heavily pretreated with antiretroviral medications and now have multidrug-resistant HIV. These patients are “quite complex to manage in pregnancy,” Dr. Cohan said.
Their numbers include women whose mothers had HIV and who were infected at birth. They now are in their late teens and 20s and are pregnant themselves. “They've taken basically every antiretroviral ever produced, and they have very complex virus to help manage,” she added.
Dr. Cohan expects to soon get more calls like a recent one she fielded regarding a woman who was 36 weeks pregnant with severe, worsening preeclampsia. For some reason, she hadn't been tested for HIV until late in pregnancy, even though her partner had HIV.
Her obstetricians had ordered the standard HIV diagnostic tests, an enzyme-linked immunosorbent assay (ELISA), which came back positive, and a Western blot, with results still pending, leaving her diagnosis unconfirmed. Now they needed to deliver her immediately because of the preeclampsia.
“The question was, what to do for this woman who likely had HIV but no confirmatory diagnosis, which is kind of analogous to getting a positive rapid HIV test,” Dr. Cohan said.
Luckily, the hotline was there to help, as it will be when more providers begin using rapid HIV tests.
Operators are standing by.
Family physician Jessica Folger (left) expects to get more hotline calls once rapid testing becomes available. Shannon Weber/Perinatal Hotline
Who to Call
▸ Perinatal HIV Hotline: 888-448-8765. Advice offered 24/7 on treating HIV-infected pregnant women and their infants, HIV testing in pregnancy, and more.
▸ PEPline (National Clinicians' Postexposure Prophylaxis Hotline): 888-448-4911. Advice offered 24/7 for health care workers exposed to HIV, hepatitis B, and hepatitis C.
▸ HIV/AIDS Warmline: 800-933-3413. Advice on managing nonpregnant patients with HIV or AIDS offered weekdays from 8 a.m. to 8 p.m. EST.
Where to Find Information
▸ Public Health Service Task Force Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1 Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV-1 Transmission in the United States, dated July 6, 2006:
▸ A sample script and consent form from the Centers for Disease Control and Prevention for informing women in labor who have unknown HIV status about rapid HIV testing:
www.cdc.gov/hiv/rapid_testing/rt-appendix_b.htm
▸ A 2004 overview of state requirements on HIV testing in pregnancy by the Kaiser Family Foundation:
The national Perinatal HIV Hotline has fielded hundreds of calls for advice over the past 2 years. Its directors anticipate getting much busier as more labor and delivery services begin offering rapid HIV testing.
There's no nationwide mandate for universal prenatal HIV testing, but it's very strongly recommended by the Centers for Disease Control and Prevention, the American College of Obstetricians and Gynecologists, and the Institutes of Medicine.
“The burden is on the provider to offer it. I can tell you that there are plenty of providers who still do not offer routine HIV testing, even though it's been found to be cost effective,” said Dr. Deborah Cohan, an obstetrician at San Francisco General Hospital and codirector of the hotline. “We know that only offering HIV testing to so-called high-risk patients misses a lot of HIV-infected women.”
In 2000, more than a third of HIV-positive neonates in the United States were born to women who did not know their HIV status until after delivery. “That's totally unacceptable,” she said.
Ideally, every pregnant woman would get prenatal care including HIV testing. At her institution, though, 12% of women in labor have had no prenatal care, making rapid HIV testing the last resort for HIV management before delivery. Dr. Cohan looks forward to more clinicians offering rapid HIV testing and calling the Perinatal HIV Hotline for help in interpreting the result or making management decisions.
Officially called the National Perinatal HIV Consultation and Referral Service, the hotline started taking calls on Labor Day of 2004. Staffers provide free advice and assistance to clinicians every day of the year and around the clock, because labor can happen at any hour.
The requests for help come from a variety of specialties, including the following:
▸ A family physician facing her first HIV-positive pregnant patient needed assurance about her treatment plan.
▸ An urban obstetrician sought help in finding the best program to care for a monolingual Spanish-speaking patient who was pregnant and HIV positive.
▸ A rural midwife and the obstetrician with whom she practices hoped to comanage an HIV-positive pregnant patient with an HIV specialist but didn't know where to find a specialist in their area.
▸ A nurse wanted help in planning a training session for rural pediatricians on the care of newborns exposed to HIV.
The hotline handles around 30 calls per month but is capable of handling four or five times as many, said Dr. Jessica Fogler, a family physician at San Francisco General Hospital and codirector of the hotline.
“I think our numbers will pick up when rapid testing becomes more available,” she added. “A lot of people who are inexperienced are going to be sitting there with a positive test on their hands.”
The U.S. Health Resources and Services Administration's National HIV/AIDS Clinicians' Consultation Center at the hospital runs the Perinatal HIV Hotline and two other telephone help lines for clinicians managing nonpregnant patients with HIV or health care workers who are exposed to HIV or hepatitis B or C.
More than half of calls to the Perinatal HIV Hotline relate to prepartum pregnant women and are fairly evenly divided among the trimesters, records from a 15-month period suggest. Around 5% of calls involve women in labor. Advice includes counseling on HIV treatment of the neonate and postpartum maternal HIV treatment. The hotline also offers advice related to contraception or preconception counseling for HIV-positive women or for HIV-negative women whose sexual partners have HIV.
More than half of callers have MD or DO degrees and are almost evenly represented by obstetricians, family physicians, and infectious disease specialists. Internists, pediatricians, and nurses each make up about 8%–13% of callers.
The hotline's referral service, run by social worker Shannon Weber, maintains a list of clinicians in every state with experience managing HIV who are willing to accept or to comanage infected pregnant patients.
One patient, for example, had started antiretroviral therapy in her third trimester and developed an abacavir hypersensitivity reaction, prompting her health care provider to call for advice. Hotline staffers recommended stopping the medication.
The patient decided at week 34 of pregnancy to move from California to Atlanta. The hotline's referral service helped find her a new doctor there and facilitated communications before the woman got on the bus to move. “She's getting good care,” Ms. Weber said.
More and more calls to the hotline concern women who have been heavily pretreated with antiretroviral medications and now have multidrug-resistant HIV. These patients are “quite complex to manage in pregnancy,” Dr. Cohan said.
Their numbers include women whose mothers had HIV and who were infected at birth. They now are in their late teens and 20s and are pregnant themselves. “They've taken basically every antiretroviral ever produced, and they have very complex virus to help manage,” she added.
Dr. Cohan expects to soon get more calls like a recent one she fielded regarding a woman who was 36 weeks pregnant with severe, worsening preeclampsia. For some reason, she hadn't been tested for HIV until late in pregnancy, even though her partner had HIV.
Her obstetricians had ordered the standard HIV diagnostic tests, an enzyme-linked immunosorbent assay (ELISA), which came back positive, and a Western blot, with results still pending, leaving her diagnosis unconfirmed. Now they needed to deliver her immediately because of the preeclampsia.
“The question was, what to do for this woman who likely had HIV but no confirmatory diagnosis, which is kind of analogous to getting a positive rapid HIV test,” Dr. Cohan said.
Luckily, the hotline was there to help, as it will be when more providers begin using rapid HIV tests.
Operators are standing by.
Family physician Jessica Folger (left) expects to get more hotline calls once rapid testing becomes available. Shannon Weber/Perinatal Hotline
Who to Call
▸ Perinatal HIV Hotline: 888-448-8765. Advice offered 24/7 on treating HIV-infected pregnant women and their infants, HIV testing in pregnancy, and more.
▸ PEPline (National Clinicians' Postexposure Prophylaxis Hotline): 888-448-4911. Advice offered 24/7 for health care workers exposed to HIV, hepatitis B, and hepatitis C.
▸ HIV/AIDS Warmline: 800-933-3413. Advice on managing nonpregnant patients with HIV or AIDS offered weekdays from 8 a.m. to 8 p.m. EST.
Where to Find Information
▸ Public Health Service Task Force Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1 Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV-1 Transmission in the United States, dated July 6, 2006:
▸ A sample script and consent form from the Centers for Disease Control and Prevention for informing women in labor who have unknown HIV status about rapid HIV testing:
www.cdc.gov/hiv/rapid_testing/rt-appendix_b.htm
▸ A 2004 overview of state requirements on HIV testing in pregnancy by the Kaiser Family Foundation:
The national Perinatal HIV Hotline has fielded hundreds of calls for advice over the past 2 years. Its directors anticipate getting much busier as more labor and delivery services begin offering rapid HIV testing.
There's no nationwide mandate for universal prenatal HIV testing, but it's very strongly recommended by the Centers for Disease Control and Prevention, the American College of Obstetricians and Gynecologists, and the Institutes of Medicine.
“The burden is on the provider to offer it. I can tell you that there are plenty of providers who still do not offer routine HIV testing, even though it's been found to be cost effective,” said Dr. Deborah Cohan, an obstetrician at San Francisco General Hospital and codirector of the hotline. “We know that only offering HIV testing to so-called high-risk patients misses a lot of HIV-infected women.”
In 2000, more than a third of HIV-positive neonates in the United States were born to women who did not know their HIV status until after delivery. “That's totally unacceptable,” she said.
Ideally, every pregnant woman would get prenatal care including HIV testing. At her institution, though, 12% of women in labor have had no prenatal care, making rapid HIV testing the last resort for HIV management before delivery. Dr. Cohan looks forward to more clinicians offering rapid HIV testing and calling the Perinatal HIV Hotline for help in interpreting the result or making management decisions.
Officially called the National Perinatal HIV Consultation and Referral Service, the hotline started taking calls on Labor Day of 2004. Staffers provide free advice and assistance to clinicians every day of the year and around the clock, because labor can happen at any hour.
The requests for help come from a variety of specialties, including the following:
▸ A family physician facing her first HIV-positive pregnant patient needed assurance about her treatment plan.
▸ An urban obstetrician sought help in finding the best program to care for a monolingual Spanish-speaking patient who was pregnant and HIV positive.
▸ A rural midwife and the obstetrician with whom she practices hoped to comanage an HIV-positive pregnant patient with an HIV specialist but didn't know where to find a specialist in their area.
▸ A nurse wanted help in planning a training session for rural pediatricians on the care of newborns exposed to HIV.
The hotline handles around 30 calls per month but is capable of handling four or five times as many, said Dr. Jessica Fogler, a family physician at San Francisco General Hospital and codirector of the hotline.
“I think our numbers will pick up when rapid testing becomes more available,” she added. “A lot of people who are inexperienced are going to be sitting there with a positive test on their hands.”
The U.S. Health Resources and Services Administration's National HIV/AIDS Clinicians' Consultation Center at the hospital runs the Perinatal HIV Hotline and two other telephone help lines for clinicians managing nonpregnant patients with HIV or health care workers who are exposed to HIV or hepatitis B or C.
More than half of calls to the Perinatal HIV Hotline relate to prepartum pregnant women and are fairly evenly divided among the trimesters, records from a 15-month period suggest. Around 5% of calls involve women in labor. Advice includes counseling on HIV treatment of the neonate and postpartum maternal HIV treatment. The hotline also offers advice related to contraception or preconception counseling for HIV-positive women or for HIV-negative women whose sexual partners have HIV.
More than half of callers have MD or DO degrees and are almost evenly represented by obstetricians, family physicians, and infectious disease specialists. Internists, pediatricians, and nurses each make up about 8%–13% of callers.
The hotline's referral service, run by social worker Shannon Weber, maintains a list of clinicians in every state with experience managing HIV who are willing to accept or to comanage infected pregnant patients.
One patient, for example, had started antiretroviral therapy in her third trimester and developed an abacavir hypersensitivity reaction, prompting her health care provider to call for advice. Hotline staffers recommended stopping the medication.
The patient decided at week 34 of pregnancy to move from California to Atlanta. The hotline's referral service helped find her a new doctor there and facilitated communications before the woman got on the bus to move. “She's getting good care,” Ms. Weber said.
More and more calls to the hotline concern women who have been heavily pretreated with antiretroviral medications and now have multidrug-resistant HIV. These patients are “quite complex to manage in pregnancy,” Dr. Cohan said.
Their numbers include women whose mothers had HIV and who were infected at birth. They now are in their late teens and 20s and are pregnant themselves. “They've taken basically every antiretroviral ever produced, and they have very complex virus to help manage,” she added.
Dr. Cohan expects to soon get more calls like a recent one she fielded regarding a woman who was 36 weeks pregnant with severe, worsening preeclampsia. For some reason, she hadn't been tested for HIV until late in pregnancy, even though her partner had HIV.
Her obstetricians had ordered the standard HIV diagnostic tests, an enzyme-linked immunosorbent assay (ELISA), which came back positive, and a Western blot, with results still pending, leaving her diagnosis unconfirmed. Now they needed to deliver her immediately because of the preeclampsia.
“The question was, what to do for this woman who likely had HIV but no confirmatory diagnosis, which is kind of analogous to getting a positive rapid HIV test,” Dr. Cohan said.
Luckily, the hotline was there to help, as it will be when more providers begin using rapid HIV tests.
Operators are standing by.
Family physician Jessica Folger (left) expects to get more hotline calls once rapid testing becomes available. Shannon Weber/Perinatal Hotline
Who to Call
▸ Perinatal HIV Hotline: 888-448-8765. Advice offered 24/7 on treating HIV-infected pregnant women and their infants, HIV testing in pregnancy, and more.
▸ PEPline (National Clinicians' Postexposure Prophylaxis Hotline): 888-448-4911. Advice offered 24/7 for health care workers exposed to HIV, hepatitis B, and hepatitis C.
▸ HIV/AIDS Warmline: 800-933-3413. Advice on managing nonpregnant patients with HIV or AIDS offered weekdays from 8 a.m. to 8 p.m. EST.
Where to Find Information
▸ Public Health Service Task Force Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1 Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV-1 Transmission in the United States, dated July 6, 2006:
▸ A sample script and consent form from the Centers for Disease Control and Prevention for informing women in labor who have unknown HIV status about rapid HIV testing:
www.cdc.gov/hiv/rapid_testing/rt-appendix_b.htm
▸ A 2004 overview of state requirements on HIV testing in pregnancy by the Kaiser Family Foundation:
Lamivudine Is Still Useful Against Some Hepatitis B
SOUTH LAKE TAHOE, CALIF. — Lamivudine and interferon alfa still have independent roles to play in treating some patients with chronic hepatitis B, Dr. Eddie C. Cheung said at an update in gastroenterology and hepatology sponsored by the University of California, Davis.
Lamivudine has shown consistent, rapid antiviral effects, but its role has diminished over time, primarily because of the high rate of drug resistance.
However, even without resistance being present, the drug's antiviral effects have been surpassed by those of entecavir, although lamivudine remains less expensive.
“Resistance is what killed this as a monotherapy,” said Dr. Cheung, chief of hepatology at the Veterans Affairs Northern California Health Care System, Martinez, Calif.
He is a speaker or adviser for GlaxoSmithKline, which makes lamivudine, and for Schering-Plough, which makes interferon alfa.
Lamivudine still is useful in at least three settings, he suggested. First, it can be a good and safe monotherapy if used for less than 6 months. “The resistance is really not an issue” with short-term treatment, he said.
Second, emerging data suggest that lamivudine is useful for treating pregnant women with chronic hepatitis B and a high viral load, to prevent vertical transmission. Treating with lamivudine 6 weeks before delivery can significantly reduce the chance of neonatal infection, Dr. Cheung said.
And third, all chronic hepatitis B carriers who are scheduled to undergo chemotherapy or immunotherapy should be started on prophylactic lamivudine to prevent a flare of their hepatitis B disease. “Please, if [the] oncologist forgets, make sure those patients are on prophylactic lamivudine, which is a good drug for that purpose,” he said.
Another drug that has fallen out of favor for treating hepatitis B—interferon alfa—similarly can be the right treatment for a specific patient. Interferon alfa generally has been replaced by peginterferon alfa.
Interferon alfa may be the treatment of choice for a young, highly motivated patient willing to withstand its significant side effects in order to undergo a relatively short course of therapy with a more durable response and a higher rate of hepatitis B surface antigen loss compared with oral adefovir or entecavir therapy. This treatment strategy carries a higher cost, but its duration is finite.
A young woman who wants to get rid of the virus and start a family, for example, may be a good candidate for interferon alfa monotherapy after counseling about efficacy and side effects.
“This is not an easy therapy to take, so it has to be a really motivated, well-informed patient,” Dr. Cheung said.
The drug is dangerous in patients with cirrhosis and is contraindicated in decompensated patients. For noncirrhotic patients, or those with cirrhosis who are clinically and biochemically compensated, a 16- to 24-week course of interferon alfa may produce hepatitis B e antigen (HBeAg) loss in 33% and HBeAg conversion in 18%. After 5 years, 11%–25% will have HBeAg loss.
No drug-resistant mutants have emerged from this treatment, a unique feature of interferon alfa among hepatitis B therapies.
SOUTH LAKE TAHOE, CALIF. — Lamivudine and interferon alfa still have independent roles to play in treating some patients with chronic hepatitis B, Dr. Eddie C. Cheung said at an update in gastroenterology and hepatology sponsored by the University of California, Davis.
Lamivudine has shown consistent, rapid antiviral effects, but its role has diminished over time, primarily because of the high rate of drug resistance.
However, even without resistance being present, the drug's antiviral effects have been surpassed by those of entecavir, although lamivudine remains less expensive.
“Resistance is what killed this as a monotherapy,” said Dr. Cheung, chief of hepatology at the Veterans Affairs Northern California Health Care System, Martinez, Calif.
He is a speaker or adviser for GlaxoSmithKline, which makes lamivudine, and for Schering-Plough, which makes interferon alfa.
Lamivudine still is useful in at least three settings, he suggested. First, it can be a good and safe monotherapy if used for less than 6 months. “The resistance is really not an issue” with short-term treatment, he said.
Second, emerging data suggest that lamivudine is useful for treating pregnant women with chronic hepatitis B and a high viral load, to prevent vertical transmission. Treating with lamivudine 6 weeks before delivery can significantly reduce the chance of neonatal infection, Dr. Cheung said.
And third, all chronic hepatitis B carriers who are scheduled to undergo chemotherapy or immunotherapy should be started on prophylactic lamivudine to prevent a flare of their hepatitis B disease. “Please, if [the] oncologist forgets, make sure those patients are on prophylactic lamivudine, which is a good drug for that purpose,” he said.
Another drug that has fallen out of favor for treating hepatitis B—interferon alfa—similarly can be the right treatment for a specific patient. Interferon alfa generally has been replaced by peginterferon alfa.
Interferon alfa may be the treatment of choice for a young, highly motivated patient willing to withstand its significant side effects in order to undergo a relatively short course of therapy with a more durable response and a higher rate of hepatitis B surface antigen loss compared with oral adefovir or entecavir therapy. This treatment strategy carries a higher cost, but its duration is finite.
A young woman who wants to get rid of the virus and start a family, for example, may be a good candidate for interferon alfa monotherapy after counseling about efficacy and side effects.
“This is not an easy therapy to take, so it has to be a really motivated, well-informed patient,” Dr. Cheung said.
The drug is dangerous in patients with cirrhosis and is contraindicated in decompensated patients. For noncirrhotic patients, or those with cirrhosis who are clinically and biochemically compensated, a 16- to 24-week course of interferon alfa may produce hepatitis B e antigen (HBeAg) loss in 33% and HBeAg conversion in 18%. After 5 years, 11%–25% will have HBeAg loss.
No drug-resistant mutants have emerged from this treatment, a unique feature of interferon alfa among hepatitis B therapies.
SOUTH LAKE TAHOE, CALIF. — Lamivudine and interferon alfa still have independent roles to play in treating some patients with chronic hepatitis B, Dr. Eddie C. Cheung said at an update in gastroenterology and hepatology sponsored by the University of California, Davis.
Lamivudine has shown consistent, rapid antiviral effects, but its role has diminished over time, primarily because of the high rate of drug resistance.
However, even without resistance being present, the drug's antiviral effects have been surpassed by those of entecavir, although lamivudine remains less expensive.
“Resistance is what killed this as a monotherapy,” said Dr. Cheung, chief of hepatology at the Veterans Affairs Northern California Health Care System, Martinez, Calif.
He is a speaker or adviser for GlaxoSmithKline, which makes lamivudine, and for Schering-Plough, which makes interferon alfa.
Lamivudine still is useful in at least three settings, he suggested. First, it can be a good and safe monotherapy if used for less than 6 months. “The resistance is really not an issue” with short-term treatment, he said.
Second, emerging data suggest that lamivudine is useful for treating pregnant women with chronic hepatitis B and a high viral load, to prevent vertical transmission. Treating with lamivudine 6 weeks before delivery can significantly reduce the chance of neonatal infection, Dr. Cheung said.
And third, all chronic hepatitis B carriers who are scheduled to undergo chemotherapy or immunotherapy should be started on prophylactic lamivudine to prevent a flare of their hepatitis B disease. “Please, if [the] oncologist forgets, make sure those patients are on prophylactic lamivudine, which is a good drug for that purpose,” he said.
Another drug that has fallen out of favor for treating hepatitis B—interferon alfa—similarly can be the right treatment for a specific patient. Interferon alfa generally has been replaced by peginterferon alfa.
Interferon alfa may be the treatment of choice for a young, highly motivated patient willing to withstand its significant side effects in order to undergo a relatively short course of therapy with a more durable response and a higher rate of hepatitis B surface antigen loss compared with oral adefovir or entecavir therapy. This treatment strategy carries a higher cost, but its duration is finite.
A young woman who wants to get rid of the virus and start a family, for example, may be a good candidate for interferon alfa monotherapy after counseling about efficacy and side effects.
“This is not an easy therapy to take, so it has to be a really motivated, well-informed patient,” Dr. Cheung said.
The drug is dangerous in patients with cirrhosis and is contraindicated in decompensated patients. For noncirrhotic patients, or those with cirrhosis who are clinically and biochemically compensated, a 16- to 24-week course of interferon alfa may produce hepatitis B e antigen (HBeAg) loss in 33% and HBeAg conversion in 18%. After 5 years, 11%–25% will have HBeAg loss.
No drug-resistant mutants have emerged from this treatment, a unique feature of interferon alfa among hepatitis B therapies.
Rule Out Eight Conditions Before Fatty Liver Disease Dx
SOUTH LAKE TAHOE, CALIF. — Attribute a mild chronic elevation in alanine aminotransferase to fatty liver disease only after considering eight other diagnoses, Dr. Christopher L. Bowlus advised at an update in gastroenterology and hepatology sponsored by the University of California, Davis.
He offered an algorithm for work-up of a patient whose serum alanine aminotransferase (ALT) is 1.5 times higher than the upper limit of normal, as defined by your clinical laboratory. If a physician doesn't do the work-up he described, a treatable condition will be missed in these patients 10% of the time, studies suggest.
The algorithm is based on consensus among physicians, because data on the subject are sparse, he added. “These are very common problems, but no one has really taken the time to look at what is the most effective or cost-effective way of evaluating patients,” said Dr. Bowlus of the university.
After ruling out four common causes of mild, chronic ALT elevation (alcoholic hepatitis, hepatitis B or C infection, and exposure to drugs or toxins that alter ALT), consider four less common diagnoses before fatty liver disease: hemochromatosis, autoimmune hepatitis, alpha-1 antitrypsin deficiency, and Wilson's disease.
When taking the patient's history, ask about alcohol use and parenteral exposures to viral infection through sexual activity, intravenous drug use, or blood transfusion prior to 1990. Inquire about illicit or prescribed drugs or herbal therapies, supplements, and over-the-counter medications that may affect ALT levels. The presence of diabetes is a risk factor for fatty liver disease.
Determine not only if the patient is an immigrant from a region with endemic hepatitis B but also if the patient's parents fit this description. “I've seen lots of positive hepatitis B students born in the United States” whose parents are immigrants, he said.
The physical exam will lead to a specific diagnosis in a minority of patients with ALT elevations. Look for signs of chronic liver disease, such as “spider” lesions on the skin (which can be subtle and usually are on the upper torso), palmar erythema, temporal wasting, hepatomegaly (common in alcoholic liver disease), and splenomegaly (often an early sign of portal hypertension). If the ALT elevation has been present for at least 6 months or the patient is symptomatic or has risk factors for hepatitis B or C infection, it's reasonable to order some lab tests. Get a hepatitis B surface antigen test and a hepatitis C antibody test; negative results rule out these viral infections. An ultrasound of the liver would be appropriate.
A transferrin saturation test is a good screening tool for hemochromatosis. If you need further testing for this condition, a genetic test is the way to go, but be prepared to explain potentially confusing results, Dr. Bowlus suggested.
If none of these leads to a diagnosis, order an antinuclear antibody test to screen for autoimmune hepatitis. A more specific screening tool is the anti-smooth muscle antibody level; a serum protein electrophoresis also can test for this disease.
Get a serum alpha-1 antitrypsin level to screen for alpha-1 antitrypsin deficiency. “We think of this as causing lung disease, but it can cause liver disease alone without lung disease,” he said.
A ceruloplasmin test is helpful to screen for Wilson's disease, an uncommon disease of copper metabolism that usually presents in childhood or early adulthood, although there have been case reports of diagnosis in people in their 50s and 60s.
If none of these potential diagnoses hits the mark, ask the patient to refrain from alcohol and any potentially offending medications or herbs and retest the ALT level in 3–6 months, he said. If ALT remains elevated, repeat all tests.
“If all this is negative, then you should consider that they might have fatty liver disease, particularly if the ultrasound is consistent with fatty liver disease and they have risk factors for fatty liver disease,” he said.
For many patients with elevated ALT who are diabetic or have high cholesterol, all these tests will be negative except that the ultrasound will show a fatty liver.
The appropriateness of a liver biopsy at this point is controversial.
'If all this is negative, then you should consider that they might have fatty liver disease.' DR. BOWLUS
SOUTH LAKE TAHOE, CALIF. — Attribute a mild chronic elevation in alanine aminotransferase to fatty liver disease only after considering eight other diagnoses, Dr. Christopher L. Bowlus advised at an update in gastroenterology and hepatology sponsored by the University of California, Davis.
He offered an algorithm for work-up of a patient whose serum alanine aminotransferase (ALT) is 1.5 times higher than the upper limit of normal, as defined by your clinical laboratory. If a physician doesn't do the work-up he described, a treatable condition will be missed in these patients 10% of the time, studies suggest.
The algorithm is based on consensus among physicians, because data on the subject are sparse, he added. “These are very common problems, but no one has really taken the time to look at what is the most effective or cost-effective way of evaluating patients,” said Dr. Bowlus of the university.
After ruling out four common causes of mild, chronic ALT elevation (alcoholic hepatitis, hepatitis B or C infection, and exposure to drugs or toxins that alter ALT), consider four less common diagnoses before fatty liver disease: hemochromatosis, autoimmune hepatitis, alpha-1 antitrypsin deficiency, and Wilson's disease.
When taking the patient's history, ask about alcohol use and parenteral exposures to viral infection through sexual activity, intravenous drug use, or blood transfusion prior to 1990. Inquire about illicit or prescribed drugs or herbal therapies, supplements, and over-the-counter medications that may affect ALT levels. The presence of diabetes is a risk factor for fatty liver disease.
Determine not only if the patient is an immigrant from a region with endemic hepatitis B but also if the patient's parents fit this description. “I've seen lots of positive hepatitis B students born in the United States” whose parents are immigrants, he said.
The physical exam will lead to a specific diagnosis in a minority of patients with ALT elevations. Look for signs of chronic liver disease, such as “spider” lesions on the skin (which can be subtle and usually are on the upper torso), palmar erythema, temporal wasting, hepatomegaly (common in alcoholic liver disease), and splenomegaly (often an early sign of portal hypertension). If the ALT elevation has been present for at least 6 months or the patient is symptomatic or has risk factors for hepatitis B or C infection, it's reasonable to order some lab tests. Get a hepatitis B surface antigen test and a hepatitis C antibody test; negative results rule out these viral infections. An ultrasound of the liver would be appropriate.
A transferrin saturation test is a good screening tool for hemochromatosis. If you need further testing for this condition, a genetic test is the way to go, but be prepared to explain potentially confusing results, Dr. Bowlus suggested.
If none of these leads to a diagnosis, order an antinuclear antibody test to screen for autoimmune hepatitis. A more specific screening tool is the anti-smooth muscle antibody level; a serum protein electrophoresis also can test for this disease.
Get a serum alpha-1 antitrypsin level to screen for alpha-1 antitrypsin deficiency. “We think of this as causing lung disease, but it can cause liver disease alone without lung disease,” he said.
A ceruloplasmin test is helpful to screen for Wilson's disease, an uncommon disease of copper metabolism that usually presents in childhood or early adulthood, although there have been case reports of diagnosis in people in their 50s and 60s.
If none of these potential diagnoses hits the mark, ask the patient to refrain from alcohol and any potentially offending medications or herbs and retest the ALT level in 3–6 months, he said. If ALT remains elevated, repeat all tests.
“If all this is negative, then you should consider that they might have fatty liver disease, particularly if the ultrasound is consistent with fatty liver disease and they have risk factors for fatty liver disease,” he said.
For many patients with elevated ALT who are diabetic or have high cholesterol, all these tests will be negative except that the ultrasound will show a fatty liver.
The appropriateness of a liver biopsy at this point is controversial.
'If all this is negative, then you should consider that they might have fatty liver disease.' DR. BOWLUS
SOUTH LAKE TAHOE, CALIF. — Attribute a mild chronic elevation in alanine aminotransferase to fatty liver disease only after considering eight other diagnoses, Dr. Christopher L. Bowlus advised at an update in gastroenterology and hepatology sponsored by the University of California, Davis.
He offered an algorithm for work-up of a patient whose serum alanine aminotransferase (ALT) is 1.5 times higher than the upper limit of normal, as defined by your clinical laboratory. If a physician doesn't do the work-up he described, a treatable condition will be missed in these patients 10% of the time, studies suggest.
The algorithm is based on consensus among physicians, because data on the subject are sparse, he added. “These are very common problems, but no one has really taken the time to look at what is the most effective or cost-effective way of evaluating patients,” said Dr. Bowlus of the university.
After ruling out four common causes of mild, chronic ALT elevation (alcoholic hepatitis, hepatitis B or C infection, and exposure to drugs or toxins that alter ALT), consider four less common diagnoses before fatty liver disease: hemochromatosis, autoimmune hepatitis, alpha-1 antitrypsin deficiency, and Wilson's disease.
When taking the patient's history, ask about alcohol use and parenteral exposures to viral infection through sexual activity, intravenous drug use, or blood transfusion prior to 1990. Inquire about illicit or prescribed drugs or herbal therapies, supplements, and over-the-counter medications that may affect ALT levels. The presence of diabetes is a risk factor for fatty liver disease.
Determine not only if the patient is an immigrant from a region with endemic hepatitis B but also if the patient's parents fit this description. “I've seen lots of positive hepatitis B students born in the United States” whose parents are immigrants, he said.
The physical exam will lead to a specific diagnosis in a minority of patients with ALT elevations. Look for signs of chronic liver disease, such as “spider” lesions on the skin (which can be subtle and usually are on the upper torso), palmar erythema, temporal wasting, hepatomegaly (common in alcoholic liver disease), and splenomegaly (often an early sign of portal hypertension). If the ALT elevation has been present for at least 6 months or the patient is symptomatic or has risk factors for hepatitis B or C infection, it's reasonable to order some lab tests. Get a hepatitis B surface antigen test and a hepatitis C antibody test; negative results rule out these viral infections. An ultrasound of the liver would be appropriate.
A transferrin saturation test is a good screening tool for hemochromatosis. If you need further testing for this condition, a genetic test is the way to go, but be prepared to explain potentially confusing results, Dr. Bowlus suggested.
If none of these leads to a diagnosis, order an antinuclear antibody test to screen for autoimmune hepatitis. A more specific screening tool is the anti-smooth muscle antibody level; a serum protein electrophoresis also can test for this disease.
Get a serum alpha-1 antitrypsin level to screen for alpha-1 antitrypsin deficiency. “We think of this as causing lung disease, but it can cause liver disease alone without lung disease,” he said.
A ceruloplasmin test is helpful to screen for Wilson's disease, an uncommon disease of copper metabolism that usually presents in childhood or early adulthood, although there have been case reports of diagnosis in people in their 50s and 60s.
If none of these potential diagnoses hits the mark, ask the patient to refrain from alcohol and any potentially offending medications or herbs and retest the ALT level in 3–6 months, he said. If ALT remains elevated, repeat all tests.
“If all this is negative, then you should consider that they might have fatty liver disease, particularly if the ultrasound is consistent with fatty liver disease and they have risk factors for fatty liver disease,” he said.
For many patients with elevated ALT who are diabetic or have high cholesterol, all these tests will be negative except that the ultrasound will show a fatty liver.
The appropriateness of a liver biopsy at this point is controversial.
'If all this is negative, then you should consider that they might have fatty liver disease.' DR. BOWLUS
Revascularization Recommended for Severe Refractory Angina
SAN FRANCISCO — A consensus committee of 10 experts recommended transmyocardial revascularization to provide relief for some patients with severe refractory angina, Dr. Anno Diegeler reported at the annual meeting of the International Society for Minimally Invasive Cardiothoracic Surgery.
“Transmyocardial revascularization is a palliative treatment,” said Dr. Diegeler, of the University of Leipzig, Bad Neustadt, Germany. The treatment provides relief to “a small group of patients with diffuse coronary artery disease with severe, refractory angina,” he said.
The committee reviewed the data on transmyocardial revascularization and formulated recommendations that will be published in the society's journal, Innovations.
They analyzed results from six randomized, controlled trials involving a total of 967 patients that compared transmyocardial revascularization with maximal medical therapy. In addition, they looked at studies that compared coronary artery bypass grafting (CABG) with CABG plus adjunctive transmyocardial revascularization, drawing on three randomized, controlled trials involving 327 patients and an additional three nonrandomized trials.
Dr. Diegeler, chair of the committee, outlined the recommendations at the meeting, dividing them according to two groups of patients.
The first group is stable patients with refractory, severe angina who are not amenable to conventional revascularization and who can be treated solely with transmyocardial revascularization or maximal medical therapy. For such patients, the committee recommended transmyocardial revascularization to provide sustained angina relief, reduce major adverse cardiac events, and improve exercise performance, on the basis of results of randomized, controlled trials (level A evidence); and to reduce readmissions and reinterventions, on the basis of one randomized, controlled trial and nonrandomized data (level B evidence).
The second group is patients with diffuse coronary artery disease and chronic angina who cannot be completely revascularized by CABG alone. For them the committee recommended adding transmyocardial revascularization to improve the likelihood of long-term angina relief (up to 5 years), reduce 30-day mortality and major adverse cardiac events, and improve 1-year exercise performance.
The recommendations for CABG plus transmyocardial revascularization rather than CABG alone were based on levels A and B evidence and were all class II recommendations encompassing conflicting evidence or diverging opinions. The recommendations regarding sole transmyocardial revascularization versus maximal medical therapy were all class I recommendations with solid evidence and general agreement, said Dr. Davy Cheng of the University of Western Ontario, London, who was also a member of the consensus committee.
Compared with maximal medical therapy, transmyocardial infarction reduced angina by at least two New York Heart Association classes and left more patients free of class III or IV angina at 1–5 years. The procedure also improved quality-of-life scores at 1 year.
The improvements in mortality and major adverse cardiac events seen at 30 days and in exercise performance at 1 year after CABG plus transmyocardial revascularization, compared with CABG alone, did not hold up at 5 years after treatment, Dr. Diegeler noted.
The difference between groups in exercise treatment test results at 1 year was a mean of 88 seconds favoring CABG plus transmyocardial revascularization (with a range of 52–123 seconds). The difference was statistically significant and was incorporated into the recommendations, Dr. Diegeler said.
Transmyocardial revascularization provides relief to 'a small group of patients with diffuse coronary artery disease.' DR. DIEGELER
SAN FRANCISCO — A consensus committee of 10 experts recommended transmyocardial revascularization to provide relief for some patients with severe refractory angina, Dr. Anno Diegeler reported at the annual meeting of the International Society for Minimally Invasive Cardiothoracic Surgery.
“Transmyocardial revascularization is a palliative treatment,” said Dr. Diegeler, of the University of Leipzig, Bad Neustadt, Germany. The treatment provides relief to “a small group of patients with diffuse coronary artery disease with severe, refractory angina,” he said.
The committee reviewed the data on transmyocardial revascularization and formulated recommendations that will be published in the society's journal, Innovations.
They analyzed results from six randomized, controlled trials involving a total of 967 patients that compared transmyocardial revascularization with maximal medical therapy. In addition, they looked at studies that compared coronary artery bypass grafting (CABG) with CABG plus adjunctive transmyocardial revascularization, drawing on three randomized, controlled trials involving 327 patients and an additional three nonrandomized trials.
Dr. Diegeler, chair of the committee, outlined the recommendations at the meeting, dividing them according to two groups of patients.
The first group is stable patients with refractory, severe angina who are not amenable to conventional revascularization and who can be treated solely with transmyocardial revascularization or maximal medical therapy. For such patients, the committee recommended transmyocardial revascularization to provide sustained angina relief, reduce major adverse cardiac events, and improve exercise performance, on the basis of results of randomized, controlled trials (level A evidence); and to reduce readmissions and reinterventions, on the basis of one randomized, controlled trial and nonrandomized data (level B evidence).
The second group is patients with diffuse coronary artery disease and chronic angina who cannot be completely revascularized by CABG alone. For them the committee recommended adding transmyocardial revascularization to improve the likelihood of long-term angina relief (up to 5 years), reduce 30-day mortality and major adverse cardiac events, and improve 1-year exercise performance.
The recommendations for CABG plus transmyocardial revascularization rather than CABG alone were based on levels A and B evidence and were all class II recommendations encompassing conflicting evidence or diverging opinions. The recommendations regarding sole transmyocardial revascularization versus maximal medical therapy were all class I recommendations with solid evidence and general agreement, said Dr. Davy Cheng of the University of Western Ontario, London, who was also a member of the consensus committee.
Compared with maximal medical therapy, transmyocardial infarction reduced angina by at least two New York Heart Association classes and left more patients free of class III or IV angina at 1–5 years. The procedure also improved quality-of-life scores at 1 year.
The improvements in mortality and major adverse cardiac events seen at 30 days and in exercise performance at 1 year after CABG plus transmyocardial revascularization, compared with CABG alone, did not hold up at 5 years after treatment, Dr. Diegeler noted.
The difference between groups in exercise treatment test results at 1 year was a mean of 88 seconds favoring CABG plus transmyocardial revascularization (with a range of 52–123 seconds). The difference was statistically significant and was incorporated into the recommendations, Dr. Diegeler said.
Transmyocardial revascularization provides relief to 'a small group of patients with diffuse coronary artery disease.' DR. DIEGELER
SAN FRANCISCO — A consensus committee of 10 experts recommended transmyocardial revascularization to provide relief for some patients with severe refractory angina, Dr. Anno Diegeler reported at the annual meeting of the International Society for Minimally Invasive Cardiothoracic Surgery.
“Transmyocardial revascularization is a palliative treatment,” said Dr. Diegeler, of the University of Leipzig, Bad Neustadt, Germany. The treatment provides relief to “a small group of patients with diffuse coronary artery disease with severe, refractory angina,” he said.
The committee reviewed the data on transmyocardial revascularization and formulated recommendations that will be published in the society's journal, Innovations.
They analyzed results from six randomized, controlled trials involving a total of 967 patients that compared transmyocardial revascularization with maximal medical therapy. In addition, they looked at studies that compared coronary artery bypass grafting (CABG) with CABG plus adjunctive transmyocardial revascularization, drawing on three randomized, controlled trials involving 327 patients and an additional three nonrandomized trials.
Dr. Diegeler, chair of the committee, outlined the recommendations at the meeting, dividing them according to two groups of patients.
The first group is stable patients with refractory, severe angina who are not amenable to conventional revascularization and who can be treated solely with transmyocardial revascularization or maximal medical therapy. For such patients, the committee recommended transmyocardial revascularization to provide sustained angina relief, reduce major adverse cardiac events, and improve exercise performance, on the basis of results of randomized, controlled trials (level A evidence); and to reduce readmissions and reinterventions, on the basis of one randomized, controlled trial and nonrandomized data (level B evidence).
The second group is patients with diffuse coronary artery disease and chronic angina who cannot be completely revascularized by CABG alone. For them the committee recommended adding transmyocardial revascularization to improve the likelihood of long-term angina relief (up to 5 years), reduce 30-day mortality and major adverse cardiac events, and improve 1-year exercise performance.
The recommendations for CABG plus transmyocardial revascularization rather than CABG alone were based on levels A and B evidence and were all class II recommendations encompassing conflicting evidence or diverging opinions. The recommendations regarding sole transmyocardial revascularization versus maximal medical therapy were all class I recommendations with solid evidence and general agreement, said Dr. Davy Cheng of the University of Western Ontario, London, who was also a member of the consensus committee.
Compared with maximal medical therapy, transmyocardial infarction reduced angina by at least two New York Heart Association classes and left more patients free of class III or IV angina at 1–5 years. The procedure also improved quality-of-life scores at 1 year.
The improvements in mortality and major adverse cardiac events seen at 30 days and in exercise performance at 1 year after CABG plus transmyocardial revascularization, compared with CABG alone, did not hold up at 5 years after treatment, Dr. Diegeler noted.
The difference between groups in exercise treatment test results at 1 year was a mean of 88 seconds favoring CABG plus transmyocardial revascularization (with a range of 52–123 seconds). The difference was statistically significant and was incorporated into the recommendations, Dr. Diegeler said.
Transmyocardial revascularization provides relief to 'a small group of patients with diffuse coronary artery disease.' DR. DIEGELER
Summer Viruses May Play Role in Low Birth Weight
MONTEREY, CALIF. — July and August are the peak months for delivering babies weighing less than 1,500 g, but the summer months are not associated with preterm birth, according to a retrospective review from the University of Southern California's Women and Children's Hospital.
The study of 4,108 singleton live births in the 3 years from 2002 through 2004 found no seasonality to preterm deliveries, defined as births before 38 weeks' gestational age. The increase in low-birth-weight babies in summer may correlate with seasonal “summer virus” infections including enteroviruses, adenoviruses, and others, Dr. Ozlem Equils and her associates reported in a poster presentation at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.
In 2002, approximately 13% of babies born in August were low birth weight. About 7% were low birth weight in July 2003, and 6% in July 2004, said Dr. Equils of Cedars-Sinai Medical Center, Los Angeles. Those proportions were higher than in other months of the same years.
Bacterial and viral infections have been associated with preterm birth in other epidemiologic studies, and animal studies have shown an association between infection with enterovirus and preterm birth.
“We know that enterovirus has caused nursing outbreaks—the mother and the baby get sick. We think that it may play a role with these small babies,” Dr. Equils suggested in an interview at the poster.
Obstetricians may want to follow the viral outbreaks in their communities and emphasize infection prevention with patients, she added. If enterovirus is going around, for example, diligent hand washing and perhaps limiting intercourse in the later part of pregnancy may be advisable.
The investigators hope to study placenta samples to see if viruses are present and associated with seasonality and low birth weight. If further research supports these very preliminary associations, it may be possible to identify the presence of viruses from maternal cervical secretions and offer treatment, potentially reducing low-birth-weight deliveries, she speculated.
Previous studies of seasonality and preterm delivery come mainly from developing countries where factors such as droughts and starvation confound the data. It's also difficult to extrapolate observations on seasonality and preterm birth from developed countries in the 1960s through 1980s because of changing environmental conditions and other factors, such as more women entering the labor force, she said.
MONTEREY, CALIF. — July and August are the peak months for delivering babies weighing less than 1,500 g, but the summer months are not associated with preterm birth, according to a retrospective review from the University of Southern California's Women and Children's Hospital.
The study of 4,108 singleton live births in the 3 years from 2002 through 2004 found no seasonality to preterm deliveries, defined as births before 38 weeks' gestational age. The increase in low-birth-weight babies in summer may correlate with seasonal “summer virus” infections including enteroviruses, adenoviruses, and others, Dr. Ozlem Equils and her associates reported in a poster presentation at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.
In 2002, approximately 13% of babies born in August were low birth weight. About 7% were low birth weight in July 2003, and 6% in July 2004, said Dr. Equils of Cedars-Sinai Medical Center, Los Angeles. Those proportions were higher than in other months of the same years.
Bacterial and viral infections have been associated with preterm birth in other epidemiologic studies, and animal studies have shown an association between infection with enterovirus and preterm birth.
“We know that enterovirus has caused nursing outbreaks—the mother and the baby get sick. We think that it may play a role with these small babies,” Dr. Equils suggested in an interview at the poster.
Obstetricians may want to follow the viral outbreaks in their communities and emphasize infection prevention with patients, she added. If enterovirus is going around, for example, diligent hand washing and perhaps limiting intercourse in the later part of pregnancy may be advisable.
The investigators hope to study placenta samples to see if viruses are present and associated with seasonality and low birth weight. If further research supports these very preliminary associations, it may be possible to identify the presence of viruses from maternal cervical secretions and offer treatment, potentially reducing low-birth-weight deliveries, she speculated.
Previous studies of seasonality and preterm delivery come mainly from developing countries where factors such as droughts and starvation confound the data. It's also difficult to extrapolate observations on seasonality and preterm birth from developed countries in the 1960s through 1980s because of changing environmental conditions and other factors, such as more women entering the labor force, she said.
MONTEREY, CALIF. — July and August are the peak months for delivering babies weighing less than 1,500 g, but the summer months are not associated with preterm birth, according to a retrospective review from the University of Southern California's Women and Children's Hospital.
The study of 4,108 singleton live births in the 3 years from 2002 through 2004 found no seasonality to preterm deliveries, defined as births before 38 weeks' gestational age. The increase in low-birth-weight babies in summer may correlate with seasonal “summer virus” infections including enteroviruses, adenoviruses, and others, Dr. Ozlem Equils and her associates reported in a poster presentation at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.
In 2002, approximately 13% of babies born in August were low birth weight. About 7% were low birth weight in July 2003, and 6% in July 2004, said Dr. Equils of Cedars-Sinai Medical Center, Los Angeles. Those proportions were higher than in other months of the same years.
Bacterial and viral infections have been associated with preterm birth in other epidemiologic studies, and animal studies have shown an association between infection with enterovirus and preterm birth.
“We know that enterovirus has caused nursing outbreaks—the mother and the baby get sick. We think that it may play a role with these small babies,” Dr. Equils suggested in an interview at the poster.
Obstetricians may want to follow the viral outbreaks in their communities and emphasize infection prevention with patients, she added. If enterovirus is going around, for example, diligent hand washing and perhaps limiting intercourse in the later part of pregnancy may be advisable.
The investigators hope to study placenta samples to see if viruses are present and associated with seasonality and low birth weight. If further research supports these very preliminary associations, it may be possible to identify the presence of viruses from maternal cervical secretions and offer treatment, potentially reducing low-birth-weight deliveries, she speculated.
Previous studies of seasonality and preterm delivery come mainly from developing countries where factors such as droughts and starvation confound the data. It's also difficult to extrapolate observations on seasonality and preterm birth from developed countries in the 1960s through 1980s because of changing environmental conditions and other factors, such as more women entering the labor force, she said.
More Uninsured May Visit EDs After Medicaid Cuts
SAN FRANCISCO — More uninsured patients will be seen in emergency departments if states cut back Medicaid programs, Dr. Robert A. Lowe said at the annual meeting of the Society for Academic Emergency Medicine.
A study in Oregon confirmed the assumption that Medicaid cutbacks increase the proportion of patients without insurance among those seeking emergency care, said Dr. Lowe, director of the Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland.
The state's Medicaid program—the Oregon Health Plan—was “the crown jewel of Oregon health policy” in the early 1990s, but a state fiscal crisis led to cutbacks in 2003, he said. Enrollees who missed a premium payment for 1 month were locked out of the plan for 6 months. A new copayment of $50 for emergency department (ED) visits was added, and the scope of benefits shrank. Within 6 months of the policy changes, 50,000 people lost coverage by the plan.
An analysis of data from before and after the changes showed that the cutbacks produced an abrupt and sustained increase in the number of uninsured patients seeking emergency care, Dr. Lowe and his associates reported.
In 10 urban EDs, the total number of visits remained relatively flat: 31,492 per month in 2002 and 31,910 per month in 2004. The number of patients covered by the Oregon Health Plan seen in the 10 EDs declined by 5,076 per year (from 7,964 per month in 2002 to 7,541 per month in 2004). The number of commercially insured patients seen fell by 12,144 per year (from 11,020 per month in 2002 to 10,008 per month in 2004). The number of uninsured patients seen in the 10 EDs rose by 18,348 per year (from 4,018 per month in 2002 to 5,547 per month in 2004).
Data from 25 of Oregon's 59 EDs, including 16 urban and nine rural hospitals, showed increased numbers of uninsured patient visits in 2004 over those in 2003—differences that were statistically significant in 24 hospitals. The proportion of patients covered under the Oregon Health Plan or by commercial insurance fell significantly in 20 of the 25 EDs.
“The policy implications of this are of concern because almost all states are now undergoing cutbacks in Medicaid, which would lead us to expect substantial increases in ED use by the uninsured nationwide,” Dr. Lowe said.
The decline in commercial insurance coverage probably was a result of the recession and loss of jobs during this time period, he added.
The increase in the number of uninsured patients exceeded the combined drops in patients covered by the Medicaid plan or commercial insurance, which also may be related to the recession, Dr. Lowe said.
SAN FRANCISCO — More uninsured patients will be seen in emergency departments if states cut back Medicaid programs, Dr. Robert A. Lowe said at the annual meeting of the Society for Academic Emergency Medicine.
A study in Oregon confirmed the assumption that Medicaid cutbacks increase the proportion of patients without insurance among those seeking emergency care, said Dr. Lowe, director of the Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland.
The state's Medicaid program—the Oregon Health Plan—was “the crown jewel of Oregon health policy” in the early 1990s, but a state fiscal crisis led to cutbacks in 2003, he said. Enrollees who missed a premium payment for 1 month were locked out of the plan for 6 months. A new copayment of $50 for emergency department (ED) visits was added, and the scope of benefits shrank. Within 6 months of the policy changes, 50,000 people lost coverage by the plan.
An analysis of data from before and after the changes showed that the cutbacks produced an abrupt and sustained increase in the number of uninsured patients seeking emergency care, Dr. Lowe and his associates reported.
In 10 urban EDs, the total number of visits remained relatively flat: 31,492 per month in 2002 and 31,910 per month in 2004. The number of patients covered by the Oregon Health Plan seen in the 10 EDs declined by 5,076 per year (from 7,964 per month in 2002 to 7,541 per month in 2004). The number of commercially insured patients seen fell by 12,144 per year (from 11,020 per month in 2002 to 10,008 per month in 2004). The number of uninsured patients seen in the 10 EDs rose by 18,348 per year (from 4,018 per month in 2002 to 5,547 per month in 2004).
Data from 25 of Oregon's 59 EDs, including 16 urban and nine rural hospitals, showed increased numbers of uninsured patient visits in 2004 over those in 2003—differences that were statistically significant in 24 hospitals. The proportion of patients covered under the Oregon Health Plan or by commercial insurance fell significantly in 20 of the 25 EDs.
“The policy implications of this are of concern because almost all states are now undergoing cutbacks in Medicaid, which would lead us to expect substantial increases in ED use by the uninsured nationwide,” Dr. Lowe said.
The decline in commercial insurance coverage probably was a result of the recession and loss of jobs during this time period, he added.
The increase in the number of uninsured patients exceeded the combined drops in patients covered by the Medicaid plan or commercial insurance, which also may be related to the recession, Dr. Lowe said.
SAN FRANCISCO — More uninsured patients will be seen in emergency departments if states cut back Medicaid programs, Dr. Robert A. Lowe said at the annual meeting of the Society for Academic Emergency Medicine.
A study in Oregon confirmed the assumption that Medicaid cutbacks increase the proportion of patients without insurance among those seeking emergency care, said Dr. Lowe, director of the Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland.
The state's Medicaid program—the Oregon Health Plan—was “the crown jewel of Oregon health policy” in the early 1990s, but a state fiscal crisis led to cutbacks in 2003, he said. Enrollees who missed a premium payment for 1 month were locked out of the plan for 6 months. A new copayment of $50 for emergency department (ED) visits was added, and the scope of benefits shrank. Within 6 months of the policy changes, 50,000 people lost coverage by the plan.
An analysis of data from before and after the changes showed that the cutbacks produced an abrupt and sustained increase in the number of uninsured patients seeking emergency care, Dr. Lowe and his associates reported.
In 10 urban EDs, the total number of visits remained relatively flat: 31,492 per month in 2002 and 31,910 per month in 2004. The number of patients covered by the Oregon Health Plan seen in the 10 EDs declined by 5,076 per year (from 7,964 per month in 2002 to 7,541 per month in 2004). The number of commercially insured patients seen fell by 12,144 per year (from 11,020 per month in 2002 to 10,008 per month in 2004). The number of uninsured patients seen in the 10 EDs rose by 18,348 per year (from 4,018 per month in 2002 to 5,547 per month in 2004).
Data from 25 of Oregon's 59 EDs, including 16 urban and nine rural hospitals, showed increased numbers of uninsured patient visits in 2004 over those in 2003—differences that were statistically significant in 24 hospitals. The proportion of patients covered under the Oregon Health Plan or by commercial insurance fell significantly in 20 of the 25 EDs.
“The policy implications of this are of concern because almost all states are now undergoing cutbacks in Medicaid, which would lead us to expect substantial increases in ED use by the uninsured nationwide,” Dr. Lowe said.
The decline in commercial insurance coverage probably was a result of the recession and loss of jobs during this time period, he added.
The increase in the number of uninsured patients exceeded the combined drops in patients covered by the Medicaid plan or commercial insurance, which also may be related to the recession, Dr. Lowe said.
Point-of-Care Group B Strep Test Gets Approved
MONTEREY, CALIF. — A newly approved rapid test for group B streptococcus colonization in pregnancy can be performed by labor and delivery nurses and generates results in about an hour and a half, Dr. Rodney K. Edwards reported.
The Xpert GBS assay is the first rapid test approved for group B streptococcal (GBS) screening at the point of care and may improve GBS detection and prophylactic treatment at the time of labor, potentially reducing the incidence of early-onset neonatal GBS infection, he said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.
The test was approved by the Food and Drug Administration on July 25 and is commercially available now.
Conventional GBS screening by culture at 35–37 weeks' gestation misses subsequent colonization. Results aren't available for 14–48 hours, so culture isn't helpful in assessing GBS colonization in previously unscreened women in labor. Because GBS colonization can be intermittent, culture results from 35–37 weeks' gestation have a positive predictive value of 67%–85% for GBS colonization at the time of labor.
A previously approved rapid GBS test, the IDI-Strep B test, must be analyzed in laboratories, which may not be available around the clock, added Dr. Edwards of the University of Florida, Gainesville. He has been a speaker for Cepheid, the company that makes both rapid GBS assays and that funded the study.
The Xpert GBS assay compared favorably with culture and had greater sensitivity and a better negative predictive value than the IDI-Strep B test in a prospective study of 784 pregnant women seen at six medical centers. Vaginal/rectal swabs from each patient were analyzed by Xpert GBS assay, culture, and IDI-Strep B test. Labor and delivery nurses performed the Xpert GBS assay on 548 women in labor. Laboratory workers analyzed swabs from these patients by culture and IDI-Strep B test, and used all three screening tests on samples from the 418 intrapartum patients.
The prevalence of GBS colonization was 24%. Compared with culture, the Xpert GBS assay was 91% sensitive, which is above the Centers for Disease Control (CDC) and Prevention's recommendation that a rapid intrapartum screening test for GBS be at least 85% sensitive, he noted. The 95% confidence interval for the Xpert GBS assay's sensitivity did not cross 85%.
The assay had a specificity of 96%, a positive predictive value of 88%, a negative predictive value of 97%, and an accuracy rate of 95% compared with culture.
The IDI-Strep B test's 79% sensitivity and 94% negative predictive value compared with culture were significantly less accurate than the results obtained by the Xpert GBS assay. The IDI-Strep B test's 95% specificity, 84% positive predictive value, and 92% accuracy rate were comparable to results in those categories from the Xpert GBS assay.
The Xpert GBS assay will cost $45 per test. “Whether or not that is something worth doing at that price, that's up to interpretation,” Dr. Edwards said. Although the cost is higher than for culture, “I think it compares favorably to other rapid tests that we perform on labor and delivery units such as fetal fibronectin.”
The test is made to be processed using a GeneXpert Dx system, which costs about $20,000.
One physician in the audience suggested that replacing culture screening with Xpert GBS screening would require doing an intrapartum assay on every woman. “It's a paradigm shift on labor and delivery” units, he said.
Dr. Edwards said that initially the assay would be used for women in labor without a prior screening culture—“people who come in for premature rupture of membranes or preterm labor, or unregistered patients,” he suggested. An eventual replacement of the assay for the current screening strategies could significantly increase the work of labor and delivery nurses. The nurses at his institutions liked doing the assay in the study, however, because they felt that it improved clinical care. “Our nurses now miss it and continue to ask me, 'When is that machine coming back?'”
The assay is a qualitative, automated real-time polymerase chain reaction (PCR) test with fluorogenic detection of the amplified DNA. Unlike other PCR tests, it doesn't require that the sample be separately prepared and is designed to purify, concentrate, detect, and identify targeted nucleic acid sequences from unprocessed samples.
The study's analysis excluded results from another 244 swabs—12 from patients who were enrolled more than once, 10 from patients with “unresolved” results after two attempts at Xpert GBS assay, and 222 that were vaginal/perianal swabs instead of vaginal/rectal swabs recommended by the CDC.
The investigators did analyze results from the excluded swabs, however, and found that the Xpert GBS assay was significantly less sensitive using vaginal/perianal swabs, compared with vaginal/rectal swabs. “I have no idea why this is the case. It doesn't make sense to me,” and an additional study is planned comparing screening of vaginal/rectal and vaginal/perianal samples, he said. The sensitivity of culture did not differ significantly between types of swabs.
Conventional GBS screening by culture at 35–37 weeks' gestation misses subsequent colonization. DR. EDWARDS
MONTEREY, CALIF. — A newly approved rapid test for group B streptococcus colonization in pregnancy can be performed by labor and delivery nurses and generates results in about an hour and a half, Dr. Rodney K. Edwards reported.
The Xpert GBS assay is the first rapid test approved for group B streptococcal (GBS) screening at the point of care and may improve GBS detection and prophylactic treatment at the time of labor, potentially reducing the incidence of early-onset neonatal GBS infection, he said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.
The test was approved by the Food and Drug Administration on July 25 and is commercially available now.
Conventional GBS screening by culture at 35–37 weeks' gestation misses subsequent colonization. Results aren't available for 14–48 hours, so culture isn't helpful in assessing GBS colonization in previously unscreened women in labor. Because GBS colonization can be intermittent, culture results from 35–37 weeks' gestation have a positive predictive value of 67%–85% for GBS colonization at the time of labor.
A previously approved rapid GBS test, the IDI-Strep B test, must be analyzed in laboratories, which may not be available around the clock, added Dr. Edwards of the University of Florida, Gainesville. He has been a speaker for Cepheid, the company that makes both rapid GBS assays and that funded the study.
The Xpert GBS assay compared favorably with culture and had greater sensitivity and a better negative predictive value than the IDI-Strep B test in a prospective study of 784 pregnant women seen at six medical centers. Vaginal/rectal swabs from each patient were analyzed by Xpert GBS assay, culture, and IDI-Strep B test. Labor and delivery nurses performed the Xpert GBS assay on 548 women in labor. Laboratory workers analyzed swabs from these patients by culture and IDI-Strep B test, and used all three screening tests on samples from the 418 intrapartum patients.
The prevalence of GBS colonization was 24%. Compared with culture, the Xpert GBS assay was 91% sensitive, which is above the Centers for Disease Control (CDC) and Prevention's recommendation that a rapid intrapartum screening test for GBS be at least 85% sensitive, he noted. The 95% confidence interval for the Xpert GBS assay's sensitivity did not cross 85%.
The assay had a specificity of 96%, a positive predictive value of 88%, a negative predictive value of 97%, and an accuracy rate of 95% compared with culture.
The IDI-Strep B test's 79% sensitivity and 94% negative predictive value compared with culture were significantly less accurate than the results obtained by the Xpert GBS assay. The IDI-Strep B test's 95% specificity, 84% positive predictive value, and 92% accuracy rate were comparable to results in those categories from the Xpert GBS assay.
The Xpert GBS assay will cost $45 per test. “Whether or not that is something worth doing at that price, that's up to interpretation,” Dr. Edwards said. Although the cost is higher than for culture, “I think it compares favorably to other rapid tests that we perform on labor and delivery units such as fetal fibronectin.”
The test is made to be processed using a GeneXpert Dx system, which costs about $20,000.
One physician in the audience suggested that replacing culture screening with Xpert GBS screening would require doing an intrapartum assay on every woman. “It's a paradigm shift on labor and delivery” units, he said.
Dr. Edwards said that initially the assay would be used for women in labor without a prior screening culture—“people who come in for premature rupture of membranes or preterm labor, or unregistered patients,” he suggested. An eventual replacement of the assay for the current screening strategies could significantly increase the work of labor and delivery nurses. The nurses at his institutions liked doing the assay in the study, however, because they felt that it improved clinical care. “Our nurses now miss it and continue to ask me, 'When is that machine coming back?'”
The assay is a qualitative, automated real-time polymerase chain reaction (PCR) test with fluorogenic detection of the amplified DNA. Unlike other PCR tests, it doesn't require that the sample be separately prepared and is designed to purify, concentrate, detect, and identify targeted nucleic acid sequences from unprocessed samples.
The study's analysis excluded results from another 244 swabs—12 from patients who were enrolled more than once, 10 from patients with “unresolved” results after two attempts at Xpert GBS assay, and 222 that were vaginal/perianal swabs instead of vaginal/rectal swabs recommended by the CDC.
The investigators did analyze results from the excluded swabs, however, and found that the Xpert GBS assay was significantly less sensitive using vaginal/perianal swabs, compared with vaginal/rectal swabs. “I have no idea why this is the case. It doesn't make sense to me,” and an additional study is planned comparing screening of vaginal/rectal and vaginal/perianal samples, he said. The sensitivity of culture did not differ significantly between types of swabs.
Conventional GBS screening by culture at 35–37 weeks' gestation misses subsequent colonization. DR. EDWARDS
MONTEREY, CALIF. — A newly approved rapid test for group B streptococcus colonization in pregnancy can be performed by labor and delivery nurses and generates results in about an hour and a half, Dr. Rodney K. Edwards reported.
The Xpert GBS assay is the first rapid test approved for group B streptococcal (GBS) screening at the point of care and may improve GBS detection and prophylactic treatment at the time of labor, potentially reducing the incidence of early-onset neonatal GBS infection, he said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.
The test was approved by the Food and Drug Administration on July 25 and is commercially available now.
Conventional GBS screening by culture at 35–37 weeks' gestation misses subsequent colonization. Results aren't available for 14–48 hours, so culture isn't helpful in assessing GBS colonization in previously unscreened women in labor. Because GBS colonization can be intermittent, culture results from 35–37 weeks' gestation have a positive predictive value of 67%–85% for GBS colonization at the time of labor.
A previously approved rapid GBS test, the IDI-Strep B test, must be analyzed in laboratories, which may not be available around the clock, added Dr. Edwards of the University of Florida, Gainesville. He has been a speaker for Cepheid, the company that makes both rapid GBS assays and that funded the study.
The Xpert GBS assay compared favorably with culture and had greater sensitivity and a better negative predictive value than the IDI-Strep B test in a prospective study of 784 pregnant women seen at six medical centers. Vaginal/rectal swabs from each patient were analyzed by Xpert GBS assay, culture, and IDI-Strep B test. Labor and delivery nurses performed the Xpert GBS assay on 548 women in labor. Laboratory workers analyzed swabs from these patients by culture and IDI-Strep B test, and used all three screening tests on samples from the 418 intrapartum patients.
The prevalence of GBS colonization was 24%. Compared with culture, the Xpert GBS assay was 91% sensitive, which is above the Centers for Disease Control (CDC) and Prevention's recommendation that a rapid intrapartum screening test for GBS be at least 85% sensitive, he noted. The 95% confidence interval for the Xpert GBS assay's sensitivity did not cross 85%.
The assay had a specificity of 96%, a positive predictive value of 88%, a negative predictive value of 97%, and an accuracy rate of 95% compared with culture.
The IDI-Strep B test's 79% sensitivity and 94% negative predictive value compared with culture were significantly less accurate than the results obtained by the Xpert GBS assay. The IDI-Strep B test's 95% specificity, 84% positive predictive value, and 92% accuracy rate were comparable to results in those categories from the Xpert GBS assay.
The Xpert GBS assay will cost $45 per test. “Whether or not that is something worth doing at that price, that's up to interpretation,” Dr. Edwards said. Although the cost is higher than for culture, “I think it compares favorably to other rapid tests that we perform on labor and delivery units such as fetal fibronectin.”
The test is made to be processed using a GeneXpert Dx system, which costs about $20,000.
One physician in the audience suggested that replacing culture screening with Xpert GBS screening would require doing an intrapartum assay on every woman. “It's a paradigm shift on labor and delivery” units, he said.
Dr. Edwards said that initially the assay would be used for women in labor without a prior screening culture—“people who come in for premature rupture of membranes or preterm labor, or unregistered patients,” he suggested. An eventual replacement of the assay for the current screening strategies could significantly increase the work of labor and delivery nurses. The nurses at his institutions liked doing the assay in the study, however, because they felt that it improved clinical care. “Our nurses now miss it and continue to ask me, 'When is that machine coming back?'”
The assay is a qualitative, automated real-time polymerase chain reaction (PCR) test with fluorogenic detection of the amplified DNA. Unlike other PCR tests, it doesn't require that the sample be separately prepared and is designed to purify, concentrate, detect, and identify targeted nucleic acid sequences from unprocessed samples.
The study's analysis excluded results from another 244 swabs—12 from patients who were enrolled more than once, 10 from patients with “unresolved” results after two attempts at Xpert GBS assay, and 222 that were vaginal/perianal swabs instead of vaginal/rectal swabs recommended by the CDC.
The investigators did analyze results from the excluded swabs, however, and found that the Xpert GBS assay was significantly less sensitive using vaginal/perianal swabs, compared with vaginal/rectal swabs. “I have no idea why this is the case. It doesn't make sense to me,” and an additional study is planned comparing screening of vaginal/rectal and vaginal/perianal samples, he said. The sensitivity of culture did not differ significantly between types of swabs.
Conventional GBS screening by culture at 35–37 weeks' gestation misses subsequent colonization. DR. EDWARDS
Suspect Chronic Varicella Zoster in Immunocompromised Children
SAN FRANCISCO — Suspect chronic varicella zoster in all immunocompromised children, not just those with HIV, Dr. Christopher Bohyer said at the annual meeting of the American Academy of Dermatology.
Test zosterlike lesions in immunocompromised children for drug resistance, because chronic varicella typically implies antibiotic resistance, said Dr. Bohyer of Indiana University, Bloomington.
He presented what may be the first case of chronic varicella zoster in a child after bone marrow transplant. Other cases have been reported in children who have undergone chemotherapy or who have HIV. Dr. Bohyer's patient was an 11-year-old boy who was diagnosed in 2003 with acute myelogenous leukemia and was treated with chemotherapy. He relapsed in April 2004, who underwent donor stem cell transplant as treatment for acute myelogenous leukemia, and developed acute graft-versus-host disease. After the boy left the hospital, in September 2004 he developed abdominal pain. An eruption on his head and neck was identified as varicella zoster infection, and he was treated with high-dose IV acyclovir.
The patient went home but was readmitted with another unusual cutaneous eruption on his whole body. The vesicles and papules housed varicella zoster, culture showed. Another round of high-dose acyclovir stemmed the eruption of any new lesions, but the chronic lesions did not resolve. At this time the patient's condition deteriorated so much that support was withdrawn, and he died.
SAN FRANCISCO — Suspect chronic varicella zoster in all immunocompromised children, not just those with HIV, Dr. Christopher Bohyer said at the annual meeting of the American Academy of Dermatology.
Test zosterlike lesions in immunocompromised children for drug resistance, because chronic varicella typically implies antibiotic resistance, said Dr. Bohyer of Indiana University, Bloomington.
He presented what may be the first case of chronic varicella zoster in a child after bone marrow transplant. Other cases have been reported in children who have undergone chemotherapy or who have HIV. Dr. Bohyer's patient was an 11-year-old boy who was diagnosed in 2003 with acute myelogenous leukemia and was treated with chemotherapy. He relapsed in April 2004, who underwent donor stem cell transplant as treatment for acute myelogenous leukemia, and developed acute graft-versus-host disease. After the boy left the hospital, in September 2004 he developed abdominal pain. An eruption on his head and neck was identified as varicella zoster infection, and he was treated with high-dose IV acyclovir.
The patient went home but was readmitted with another unusual cutaneous eruption on his whole body. The vesicles and papules housed varicella zoster, culture showed. Another round of high-dose acyclovir stemmed the eruption of any new lesions, but the chronic lesions did not resolve. At this time the patient's condition deteriorated so much that support was withdrawn, and he died.
SAN FRANCISCO — Suspect chronic varicella zoster in all immunocompromised children, not just those with HIV, Dr. Christopher Bohyer said at the annual meeting of the American Academy of Dermatology.
Test zosterlike lesions in immunocompromised children for drug resistance, because chronic varicella typically implies antibiotic resistance, said Dr. Bohyer of Indiana University, Bloomington.
He presented what may be the first case of chronic varicella zoster in a child after bone marrow transplant. Other cases have been reported in children who have undergone chemotherapy or who have HIV. Dr. Bohyer's patient was an 11-year-old boy who was diagnosed in 2003 with acute myelogenous leukemia and was treated with chemotherapy. He relapsed in April 2004, who underwent donor stem cell transplant as treatment for acute myelogenous leukemia, and developed acute graft-versus-host disease. After the boy left the hospital, in September 2004 he developed abdominal pain. An eruption on his head and neck was identified as varicella zoster infection, and he was treated with high-dose IV acyclovir.
The patient went home but was readmitted with another unusual cutaneous eruption on his whole body. The vesicles and papules housed varicella zoster, culture showed. Another round of high-dose acyclovir stemmed the eruption of any new lesions, but the chronic lesions did not resolve. At this time the patient's condition deteriorated so much that support was withdrawn, and he died.
Experts Compare Soft Tissue Augmentation Tips
LAS VEGAS There's no one right way to do facial soft tissue augmentation, so success depends on both scientific and artful practice, a panel of experts agreed at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.
The members shared tips and compared their preferences for soft tissue augmentation, beginning with the various fillers they use in their practices.
Dr. Kimberly J. Butterwick does a lot of fat transfers. Most of her patients understand the need to come back for maintenance, so she hasn't used the permanent fillers. "When they come back every 46 months for Botox you can put in your Restylane or your filler. They may also want a light peel at the same time. So I use a lot of the Restylane and Hylaform products because patients like to get all their maintenance at one visit, and do that two or three times a year," said Dr. Butterwick, who practices in San Diego.
"I think patients are looking for bulk implants, not fillers, but the problem with permanent fillers in this country is that we don't have enough experience looking at the adverse eventshypersensitivity, granulomas, and long-term effects. It's not something that I recommend for my patients," said Dr. Neil S. Sadick of Cornell University in New York.
Most patients in his practice are moving on to three-dimensional volumetric filling, with Sculptra probably accounting for the largest increase in share. "Even Radiesse is gaining increasing usage. Patients are looking for something that will last 12 years, which I think is the optimal duration for a given filler," he said.
Dr. Suzan Obagi also avoids permanent fillers. "Patients might say they want something permanent, but I explain to them that, from a safety standpoint, something we can adapt over time" may be better, said Dr. Obagi of the University of Pittsburgh.
For patients who do want something permanent, she does fat transfers. "About 80% of my transfers use fat, and 20% use the other fillers," she said.
When it comes to harvesting fat, she goes to areas where the fat is not likely to fluctuate. "If the patient loses or gains 10 pounds, fat from there is less likely to hypertrophy. For some patients it's abdominal fat; for some patients it's the hips," she said.
After reviewing the literature, Dr. Butterwick says she believes that there is no evidence that fat from one area survives better than from any other, so she also harvests from areas that are least resistant to dietary changes. "I do like the outer thigh; it comes out quickly and is avascular," she said.
In a radioisotope study, "we found no difference in terms of fat aging and longevity from different anatomic sites," Dr. Sadick remarked. People who were thinner had greater fat longevity. For thin patients, he usually harvests from the abdomen and hips.
With thin patients, "there's very little margin for error to avoid indentation," Dr. Obagi pointed out. "I do augmentation in a lot of yoga instructors and marathon runners. Usually you have to go to the buttock, and you have to be very good at your technique." For these patients, she uses a standard cannula because it has more of a blunted tip.
Dr. Butterwick said that "sometimes you have to hunt around and harvest from the arms or from multiple areas. It takes longer, so you might just choose to use Sculptra in that patient."
When the discussion turned to fat contouring in the midface and periorbital area, she suggested that the facial autografting muscle injection system's anatomic approach gives a result similar to the Coleman technique and that "the fat may survive longer because of the proximity to the muscle."
Dr. Obagi uses a modified Coleman technique, as does Dr. Sadick. He said that "the key to success and greater longevity is in layering the fat or filler in different anatomic areas."
With thin patients, such as marathoners, 'there's very little margin for error to avoid indentation.' DR. OBAGI
LAS VEGAS There's no one right way to do facial soft tissue augmentation, so success depends on both scientific and artful practice, a panel of experts agreed at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.
The members shared tips and compared their preferences for soft tissue augmentation, beginning with the various fillers they use in their practices.
Dr. Kimberly J. Butterwick does a lot of fat transfers. Most of her patients understand the need to come back for maintenance, so she hasn't used the permanent fillers. "When they come back every 46 months for Botox you can put in your Restylane or your filler. They may also want a light peel at the same time. So I use a lot of the Restylane and Hylaform products because patients like to get all their maintenance at one visit, and do that two or three times a year," said Dr. Butterwick, who practices in San Diego.
"I think patients are looking for bulk implants, not fillers, but the problem with permanent fillers in this country is that we don't have enough experience looking at the adverse eventshypersensitivity, granulomas, and long-term effects. It's not something that I recommend for my patients," said Dr. Neil S. Sadick of Cornell University in New York.
Most patients in his practice are moving on to three-dimensional volumetric filling, with Sculptra probably accounting for the largest increase in share. "Even Radiesse is gaining increasing usage. Patients are looking for something that will last 12 years, which I think is the optimal duration for a given filler," he said.
Dr. Suzan Obagi also avoids permanent fillers. "Patients might say they want something permanent, but I explain to them that, from a safety standpoint, something we can adapt over time" may be better, said Dr. Obagi of the University of Pittsburgh.
For patients who do want something permanent, she does fat transfers. "About 80% of my transfers use fat, and 20% use the other fillers," she said.
When it comes to harvesting fat, she goes to areas where the fat is not likely to fluctuate. "If the patient loses or gains 10 pounds, fat from there is less likely to hypertrophy. For some patients it's abdominal fat; for some patients it's the hips," she said.
After reviewing the literature, Dr. Butterwick says she believes that there is no evidence that fat from one area survives better than from any other, so she also harvests from areas that are least resistant to dietary changes. "I do like the outer thigh; it comes out quickly and is avascular," she said.
In a radioisotope study, "we found no difference in terms of fat aging and longevity from different anatomic sites," Dr. Sadick remarked. People who were thinner had greater fat longevity. For thin patients, he usually harvests from the abdomen and hips.
With thin patients, "there's very little margin for error to avoid indentation," Dr. Obagi pointed out. "I do augmentation in a lot of yoga instructors and marathon runners. Usually you have to go to the buttock, and you have to be very good at your technique." For these patients, she uses a standard cannula because it has more of a blunted tip.
Dr. Butterwick said that "sometimes you have to hunt around and harvest from the arms or from multiple areas. It takes longer, so you might just choose to use Sculptra in that patient."
When the discussion turned to fat contouring in the midface and periorbital area, she suggested that the facial autografting muscle injection system's anatomic approach gives a result similar to the Coleman technique and that "the fat may survive longer because of the proximity to the muscle."
Dr. Obagi uses a modified Coleman technique, as does Dr. Sadick. He said that "the key to success and greater longevity is in layering the fat or filler in different anatomic areas."
With thin patients, such as marathoners, 'there's very little margin for error to avoid indentation.' DR. OBAGI
LAS VEGAS There's no one right way to do facial soft tissue augmentation, so success depends on both scientific and artful practice, a panel of experts agreed at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.
The members shared tips and compared their preferences for soft tissue augmentation, beginning with the various fillers they use in their practices.
Dr. Kimberly J. Butterwick does a lot of fat transfers. Most of her patients understand the need to come back for maintenance, so she hasn't used the permanent fillers. "When they come back every 46 months for Botox you can put in your Restylane or your filler. They may also want a light peel at the same time. So I use a lot of the Restylane and Hylaform products because patients like to get all their maintenance at one visit, and do that two or three times a year," said Dr. Butterwick, who practices in San Diego.
"I think patients are looking for bulk implants, not fillers, but the problem with permanent fillers in this country is that we don't have enough experience looking at the adverse eventshypersensitivity, granulomas, and long-term effects. It's not something that I recommend for my patients," said Dr. Neil S. Sadick of Cornell University in New York.
Most patients in his practice are moving on to three-dimensional volumetric filling, with Sculptra probably accounting for the largest increase in share. "Even Radiesse is gaining increasing usage. Patients are looking for something that will last 12 years, which I think is the optimal duration for a given filler," he said.
Dr. Suzan Obagi also avoids permanent fillers. "Patients might say they want something permanent, but I explain to them that, from a safety standpoint, something we can adapt over time" may be better, said Dr. Obagi of the University of Pittsburgh.
For patients who do want something permanent, she does fat transfers. "About 80% of my transfers use fat, and 20% use the other fillers," she said.
When it comes to harvesting fat, she goes to areas where the fat is not likely to fluctuate. "If the patient loses or gains 10 pounds, fat from there is less likely to hypertrophy. For some patients it's abdominal fat; for some patients it's the hips," she said.
After reviewing the literature, Dr. Butterwick says she believes that there is no evidence that fat from one area survives better than from any other, so she also harvests from areas that are least resistant to dietary changes. "I do like the outer thigh; it comes out quickly and is avascular," she said.
In a radioisotope study, "we found no difference in terms of fat aging and longevity from different anatomic sites," Dr. Sadick remarked. People who were thinner had greater fat longevity. For thin patients, he usually harvests from the abdomen and hips.
With thin patients, "there's very little margin for error to avoid indentation," Dr. Obagi pointed out. "I do augmentation in a lot of yoga instructors and marathon runners. Usually you have to go to the buttock, and you have to be very good at your technique." For these patients, she uses a standard cannula because it has more of a blunted tip.
Dr. Butterwick said that "sometimes you have to hunt around and harvest from the arms or from multiple areas. It takes longer, so you might just choose to use Sculptra in that patient."
When the discussion turned to fat contouring in the midface and periorbital area, she suggested that the facial autografting muscle injection system's anatomic approach gives a result similar to the Coleman technique and that "the fat may survive longer because of the proximity to the muscle."
Dr. Obagi uses a modified Coleman technique, as does Dr. Sadick. He said that "the key to success and greater longevity is in layering the fat or filler in different anatomic areas."
With thin patients, such as marathoners, 'there's very little margin for error to avoid indentation.' DR. OBAGI
Follow Hemangiomas; Outcome Not Guaranteed
LAS VEGAS Telling parents that an infant's facial hemangioma will go away and doesn't need follow-up is no longer acceptable, Dr. Edward D. Buckingham said at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.
Older studies that support the leave-it-alone approach defined "acceptable" cosmetic outcomes in ways that don't meet today's higher standards, said Dr. Buckingham of Austin, Tex.
Hemangiomas are benign tumors that evolve from an initial proliferative phase to a second phase of involution, in which the tumor gradually disappears. Complications can include scars from ulcerations, epidermal atrophy from thinning of the skin as the tumor grows, cosmetic distortion of facial features, residual telangiectasias, redundant skin after involution, or cartilage destruction by some hemangiomas around the ear or nose.
In the half of children with hemangiomas who show significant ("early") involution before age 5, 38% had "imperfect" cosmetic outcomes, one 1983 study found. In the other half of children whose hemangiomas did not show significant ("late") involution by 5 years of age, 80% had imperfect cosmetic outcomes.
Once the hemangioma stops proliferating, the rate of involution can give a sense of the likelihood of an acceptable cosmetic outcome without medical or surgical treatment.
Observation alone may be adequate management for small hemangiomas in clinically insignificant cosmetic areas, but this does not mean forgetting about the lesion. All birthmarks that develop during the first month of life should be evaluated by a specialist and followed through serial evaluations, Dr. Buckingham said.
There are reasons to treat many hemangiomas during the proliferative or involution phases with the goals of preventing the lesion from getting larger than it needs to be and achieving the best cosmetic results by age 2 or 3 years, when children begin to form a self-image, he said.
Evaluation by a specialist also is key to proper diagnosis of hemangiomas, which commonly are confused with port wine stains, said Dr. Marcelo Hochman. Port wine stains are venous malformations, not tumors, and require different and more difficult treatment.
Hemangiomas occur in 4%10% of white newborns, with girls four times more likely than boys to develop the lesions. Most hemangiomas develop on the head or neck. Diagnosis is made by history and physical exam; ultrasound imaging should be performed if more than three hemangiomas are present to check for involvement of the liver or spleen, said Dr. Hochman of Charleston, S.C.
Dr. Buckingham warned that hemangiomas on the upper or lower eyelid can endanger vision permanently and deserve referral to a pediatric ophthalmologist.
There is no consensus on treating hemangiomas. Photodynamic therapy (PDT), steroids, and surgery are the main treatment options. Treat superficial or rapidly proliferating hemangiomas every 48 weeks with PDT, a safe option with very little risk of scarring, he said.
PDT on the area around an ulcerated hemangioma can help heal the ulcer, data show. Retreat every 46 weeks if needed, Dr. Buckingham suggested. PDT also cleans up residual telangiectasias.
For deep hemangiomas, inject steroids into the lesion or try a 10-week course of oral steroids during proliferation; expect a 30%90% response. Combine steroids and photodynamic therapy for compound lesions. Refer children on oral steroids to an endocrinologist for weekly evaluation.
Reserve surgical debulking for cleanup during involution, or during the proliferative phase for hemangiomas that don't respond to steroids or that threaten vision.
"You don't have to get every bit of tissue out. These are benign tumors in young children, and we have plenty of opportunity in ensuing years to clean things up," Dr. Hochman said.
Hemangiomas: Fact vs. Fiction
Confusion about the differences between vascular malformations and hemangiomas abound. Many physicians entertain the following common misconceptions about hemangiomas, Dr. Hochman said:
Myth: Hemangiomas are big bags of blood, so surgical resection carries a big risk of bleeding.
Reality: Hemangiomas are solid tumors. Surgical removal is relatively simple.
Myth: There are numerous and tortuous feeder vessels in hemangiomas that require embolization.
Reality: Hemangiomas typically have one feeder vessel that's easily isolated. "This is very low-tech surgery," Dr. Hochman said.
Myth: Hemangiomas infiltrate surrounding tissues and are difficult to remove.
Reality: Hemangiomas can push tissue out of the way, giving the impression of infiltration, but there is always a plane between the tumor and surrounding normal tissues. Dissection is relatively easy in discrete planes that occur naturally and can be created between the superficial and deep components of the hemangioma, or in the deep component, or within the fibrofatty residuum of skin and scar tissue.
Dr. Hochman cautioned that while these myths don't apply to apply to hemangiomas, they may apply to malformations like port wine stains.
LAS VEGAS Telling parents that an infant's facial hemangioma will go away and doesn't need follow-up is no longer acceptable, Dr. Edward D. Buckingham said at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.
Older studies that support the leave-it-alone approach defined "acceptable" cosmetic outcomes in ways that don't meet today's higher standards, said Dr. Buckingham of Austin, Tex.
Hemangiomas are benign tumors that evolve from an initial proliferative phase to a second phase of involution, in which the tumor gradually disappears. Complications can include scars from ulcerations, epidermal atrophy from thinning of the skin as the tumor grows, cosmetic distortion of facial features, residual telangiectasias, redundant skin after involution, or cartilage destruction by some hemangiomas around the ear or nose.
In the half of children with hemangiomas who show significant ("early") involution before age 5, 38% had "imperfect" cosmetic outcomes, one 1983 study found. In the other half of children whose hemangiomas did not show significant ("late") involution by 5 years of age, 80% had imperfect cosmetic outcomes.
Once the hemangioma stops proliferating, the rate of involution can give a sense of the likelihood of an acceptable cosmetic outcome without medical or surgical treatment.
Observation alone may be adequate management for small hemangiomas in clinically insignificant cosmetic areas, but this does not mean forgetting about the lesion. All birthmarks that develop during the first month of life should be evaluated by a specialist and followed through serial evaluations, Dr. Buckingham said.
There are reasons to treat many hemangiomas during the proliferative or involution phases with the goals of preventing the lesion from getting larger than it needs to be and achieving the best cosmetic results by age 2 or 3 years, when children begin to form a self-image, he said.
Evaluation by a specialist also is key to proper diagnosis of hemangiomas, which commonly are confused with port wine stains, said Dr. Marcelo Hochman. Port wine stains are venous malformations, not tumors, and require different and more difficult treatment.
Hemangiomas occur in 4%10% of white newborns, with girls four times more likely than boys to develop the lesions. Most hemangiomas develop on the head or neck. Diagnosis is made by history and physical exam; ultrasound imaging should be performed if more than three hemangiomas are present to check for involvement of the liver or spleen, said Dr. Hochman of Charleston, S.C.
Dr. Buckingham warned that hemangiomas on the upper or lower eyelid can endanger vision permanently and deserve referral to a pediatric ophthalmologist.
There is no consensus on treating hemangiomas. Photodynamic therapy (PDT), steroids, and surgery are the main treatment options. Treat superficial or rapidly proliferating hemangiomas every 48 weeks with PDT, a safe option with very little risk of scarring, he said.
PDT on the area around an ulcerated hemangioma can help heal the ulcer, data show. Retreat every 46 weeks if needed, Dr. Buckingham suggested. PDT also cleans up residual telangiectasias.
For deep hemangiomas, inject steroids into the lesion or try a 10-week course of oral steroids during proliferation; expect a 30%90% response. Combine steroids and photodynamic therapy for compound lesions. Refer children on oral steroids to an endocrinologist for weekly evaluation.
Reserve surgical debulking for cleanup during involution, or during the proliferative phase for hemangiomas that don't respond to steroids or that threaten vision.
"You don't have to get every bit of tissue out. These are benign tumors in young children, and we have plenty of opportunity in ensuing years to clean things up," Dr. Hochman said.
Hemangiomas: Fact vs. Fiction
Confusion about the differences between vascular malformations and hemangiomas abound. Many physicians entertain the following common misconceptions about hemangiomas, Dr. Hochman said:
Myth: Hemangiomas are big bags of blood, so surgical resection carries a big risk of bleeding.
Reality: Hemangiomas are solid tumors. Surgical removal is relatively simple.
Myth: There are numerous and tortuous feeder vessels in hemangiomas that require embolization.
Reality: Hemangiomas typically have one feeder vessel that's easily isolated. "This is very low-tech surgery," Dr. Hochman said.
Myth: Hemangiomas infiltrate surrounding tissues and are difficult to remove.
Reality: Hemangiomas can push tissue out of the way, giving the impression of infiltration, but there is always a plane between the tumor and surrounding normal tissues. Dissection is relatively easy in discrete planes that occur naturally and can be created between the superficial and deep components of the hemangioma, or in the deep component, or within the fibrofatty residuum of skin and scar tissue.
Dr. Hochman cautioned that while these myths don't apply to apply to hemangiomas, they may apply to malformations like port wine stains.
LAS VEGAS Telling parents that an infant's facial hemangioma will go away and doesn't need follow-up is no longer acceptable, Dr. Edward D. Buckingham said at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.
Older studies that support the leave-it-alone approach defined "acceptable" cosmetic outcomes in ways that don't meet today's higher standards, said Dr. Buckingham of Austin, Tex.
Hemangiomas are benign tumors that evolve from an initial proliferative phase to a second phase of involution, in which the tumor gradually disappears. Complications can include scars from ulcerations, epidermal atrophy from thinning of the skin as the tumor grows, cosmetic distortion of facial features, residual telangiectasias, redundant skin after involution, or cartilage destruction by some hemangiomas around the ear or nose.
In the half of children with hemangiomas who show significant ("early") involution before age 5, 38% had "imperfect" cosmetic outcomes, one 1983 study found. In the other half of children whose hemangiomas did not show significant ("late") involution by 5 years of age, 80% had imperfect cosmetic outcomes.
Once the hemangioma stops proliferating, the rate of involution can give a sense of the likelihood of an acceptable cosmetic outcome without medical or surgical treatment.
Observation alone may be adequate management for small hemangiomas in clinically insignificant cosmetic areas, but this does not mean forgetting about the lesion. All birthmarks that develop during the first month of life should be evaluated by a specialist and followed through serial evaluations, Dr. Buckingham said.
There are reasons to treat many hemangiomas during the proliferative or involution phases with the goals of preventing the lesion from getting larger than it needs to be and achieving the best cosmetic results by age 2 or 3 years, when children begin to form a self-image, he said.
Evaluation by a specialist also is key to proper diagnosis of hemangiomas, which commonly are confused with port wine stains, said Dr. Marcelo Hochman. Port wine stains are venous malformations, not tumors, and require different and more difficult treatment.
Hemangiomas occur in 4%10% of white newborns, with girls four times more likely than boys to develop the lesions. Most hemangiomas develop on the head or neck. Diagnosis is made by history and physical exam; ultrasound imaging should be performed if more than three hemangiomas are present to check for involvement of the liver or spleen, said Dr. Hochman of Charleston, S.C.
Dr. Buckingham warned that hemangiomas on the upper or lower eyelid can endanger vision permanently and deserve referral to a pediatric ophthalmologist.
There is no consensus on treating hemangiomas. Photodynamic therapy (PDT), steroids, and surgery are the main treatment options. Treat superficial or rapidly proliferating hemangiomas every 48 weeks with PDT, a safe option with very little risk of scarring, he said.
PDT on the area around an ulcerated hemangioma can help heal the ulcer, data show. Retreat every 46 weeks if needed, Dr. Buckingham suggested. PDT also cleans up residual telangiectasias.
For deep hemangiomas, inject steroids into the lesion or try a 10-week course of oral steroids during proliferation; expect a 30%90% response. Combine steroids and photodynamic therapy for compound lesions. Refer children on oral steroids to an endocrinologist for weekly evaluation.
Reserve surgical debulking for cleanup during involution, or during the proliferative phase for hemangiomas that don't respond to steroids or that threaten vision.
"You don't have to get every bit of tissue out. These are benign tumors in young children, and we have plenty of opportunity in ensuing years to clean things up," Dr. Hochman said.
Hemangiomas: Fact vs. Fiction
Confusion about the differences between vascular malformations and hemangiomas abound. Many physicians entertain the following common misconceptions about hemangiomas, Dr. Hochman said:
Myth: Hemangiomas are big bags of blood, so surgical resection carries a big risk of bleeding.
Reality: Hemangiomas are solid tumors. Surgical removal is relatively simple.
Myth: There are numerous and tortuous feeder vessels in hemangiomas that require embolization.
Reality: Hemangiomas typically have one feeder vessel that's easily isolated. "This is very low-tech surgery," Dr. Hochman said.
Myth: Hemangiomas infiltrate surrounding tissues and are difficult to remove.
Reality: Hemangiomas can push tissue out of the way, giving the impression of infiltration, but there is always a plane between the tumor and surrounding normal tissues. Dissection is relatively easy in discrete planes that occur naturally and can be created between the superficial and deep components of the hemangioma, or in the deep component, or within the fibrofatty residuum of skin and scar tissue.
Dr. Hochman cautioned that while these myths don't apply to apply to hemangiomas, they may apply to malformations like port wine stains.