Sherry Boschert

SAN FRANCISCO — Pregnant women given a single dose of nevirapine during pregnancy to prevent vertical transmission of HIV were more likely to fail their own HIV treatment if it was started within 6 months of taking the nevirapine, Shahin Lockman, M.D., reported.

The randomized study of 218 women and 30 infants in Botswana found that, for the cohorts as a whole, the peripartum nevirapine dose led to higher rates of virologic failure in women and their infants, compared with women who received a peripartum dose of placebo and their infants, she said at the annual meeting of the Infectious Diseases Society of America.

Most resource-poor nations include nevirapine in their first-line treatment regimens for women and infants. More than 500,000 women each year are believed to receive single-dose nevirapine during pregnancy. This is a simple and affordable measure that halves the risk of vertical transmission, but previous data suggest that it can cause resistance to subsequent nevirapine therapy in 25%–70% of women and 40%–90% of infants, said Dr. Lockman of Brigham and Women's Hospital, Boston.

The current data came from the Mashi study of 12,000 HIV-infected women and 491 infants randomized to receive a single peripartum dose of nevirapine or placebo plus a short course of zidovudine starting at 34 weeks' gestation. Infants received 1 month of zidovudine if formula-fed or 6 months of zidovudine if breast-fed.

Women who developed an AIDS-defining illness or whose CD4 counts fell below 200 cells/mm

Of the 218 women who started antiretroviral therapy and had adequate follow-up, 18% of 112 who previously received single-dose nevirapine and 5% of 106 who previously received single-dose placebo developed virologic failure by 6 months after starting the combination antiretroviral regimen.

At 12 months, 20% of the nevirapine group and 10% of the placebo group had developed virologic failure, defined as an HIV RNA load greater than 400 copies/mL. At 24 months, 28% of the nevirapine group and 11% of the placebo group had failed combination therapy. All differences were statistically significant.

Further analysis showed that the failures occurred in women who started their antiretroviral therapy within 6 months of receiving the single dose of nevirapine but not in women whose therapy began at least 6 months after the single nevirapine dose.

Of the 60 women who started combination antiretroviral therapy within 6 months of the peripartum dose, 42% of the 24 women in the nevirapine group and none of the 36 women in the placebo group developed virologic failure by 6 months. Virologic failure was seen at 12 and 24 months in 46% of the nevirapine group and 3% of the placebo group. All differences were highly significant.

Virologic failure rates did not differ significantly between the nevirapine and placebo groups in the 158 women who started combination therapy at least 6 months after the peripartum dose.

A total of 30 HIV-infected infants were given the same combination antiretroviral therapy. Of 15 infants whose mothers got single-dose nevirapine during pregnancy, 10 developed virologic failure during 2 years of follow-up, compared with 2 of 15 infants in the placebo group. Two infants in the nevirapine group and three in the placebo group died.

Infants in the nevirapine group showed a smaller increase in CD4 counts on combination therapy, compared with those in the placebo group. For mothers, the CD4 counts did not differ significantly between groups.

Only nevirapine exposure predicted the risk of virologic failure in women and infants. Other factors such as maternal age, clinic location, or infant feeding strategy (breast vs. formula) were not predictors.

SAN FRANCISCO — Pregnant women given a single dose of nevirapine during pregnancy to prevent vertical transmission of HIV were more likely to fail their own HIV treatment if it was started within 6 months of taking the nevirapine, Shahin Lockman, M.D., reported.

The randomized study of 218 women and 30 infants in Botswana found that, for the cohorts as a whole, the peripartum nevirapine dose led to higher rates of virologic failure in women and their infants, compared with women who received a peripartum dose of placebo and their infants, she said at the annual meeting of the Infectious Diseases Society of America.

Most resource-poor nations include nevirapine in their first-line treatment regimens for women and infants. More than 500,000 women each year are believed to receive single-dose nevirapine during pregnancy. This is a simple and affordable measure that halves the risk of vertical transmission, but previous data suggest that it can cause resistance to subsequent nevirapine therapy in 25%–70% of women and 40%–90% of infants, said Dr. Lockman of Brigham and Women's Hospital, Boston.

The current data came from the Mashi study of 12,000 HIV-infected women and 491 infants randomized to receive a single peripartum dose of nevirapine or placebo plus a short course of zidovudine starting at 34 weeks' gestation. Infants received 1 month of zidovudine if formula-fed or 6 months of zidovudine if breast-fed.

Women who developed an AIDS-defining illness or whose CD4 counts fell below 200 cells/mm

Of the 218 women who started antiretroviral therapy and had adequate follow-up, 18% of 112 who previously received single-dose nevirapine and 5% of 106 who previously received single-dose placebo developed virologic failure by 6 months after starting the combination antiretroviral regimen.

At 12 months, 20% of the nevirapine group and 10% of the placebo group had developed virologic failure, defined as an HIV RNA load greater than 400 copies/mL. At 24 months, 28% of the nevirapine group and 11% of the placebo group had failed combination therapy. All differences were statistically significant.

Further analysis showed that the failures occurred in women who started their antiretroviral therapy within 6 months of receiving the single dose of nevirapine but not in women whose therapy began at least 6 months after the single nevirapine dose.

Of the 60 women who started combination antiretroviral therapy within 6 months of the peripartum dose, 42% of the 24 women in the nevirapine group and none of the 36 women in the placebo group developed virologic failure by 6 months. Virologic failure was seen at 12 and 24 months in 46% of the nevirapine group and 3% of the placebo group. All differences were highly significant.

Virologic failure rates did not differ significantly between the nevirapine and placebo groups in the 158 women who started combination therapy at least 6 months after the peripartum dose.

A total of 30 HIV-infected infants were given the same combination antiretroviral therapy. Of 15 infants whose mothers got single-dose nevirapine during pregnancy, 10 developed virologic failure during 2 years of follow-up, compared with 2 of 15 infants in the placebo group. Two infants in the nevirapine group and three in the placebo group died.

Infants in the nevirapine group showed a smaller increase in CD4 counts on combination therapy, compared with those in the placebo group. For mothers, the CD4 counts did not differ significantly between groups.

Only nevirapine exposure predicted the risk of virologic failure in women and infants. Other factors such as maternal age, clinic location, or infant feeding strategy (breast vs. formula) were not predictors.

SAN FRANCISCO — Pregnant women given a single dose of nevirapine during pregnancy to prevent vertical transmission of HIV were more likely to fail their own HIV treatment if it was started within 6 months of taking the nevirapine, Shahin Lockman, M.D., reported.

The randomized study of 218 women and 30 infants in Botswana found that, for the cohorts as a whole, the peripartum nevirapine dose led to higher rates of virologic failure in women and their infants, compared with women who received a peripartum dose of placebo and their infants, she said at the annual meeting of the Infectious Diseases Society of America.

Most resource-poor nations include nevirapine in their first-line treatment regimens for women and infants. More than 500,000 women each year are believed to receive single-dose nevirapine during pregnancy. This is a simple and affordable measure that halves the risk of vertical transmission, but previous data suggest that it can cause resistance to subsequent nevirapine therapy in 25%–70% of women and 40%–90% of infants, said Dr. Lockman of Brigham and Women's Hospital, Boston.

The current data came from the Mashi study of 12,000 HIV-infected women and 491 infants randomized to receive a single peripartum dose of nevirapine or placebo plus a short course of zidovudine starting at 34 weeks' gestation. Infants received 1 month of zidovudine if formula-fed or 6 months of zidovudine if breast-fed.

Women who developed an AIDS-defining illness or whose CD4 counts fell below 200 cells/mm

Of the 218 women who started antiretroviral therapy and had adequate follow-up, 18% of 112 who previously received single-dose nevirapine and 5% of 106 who previously received single-dose placebo developed virologic failure by 6 months after starting the combination antiretroviral regimen.

At 12 months, 20% of the nevirapine group and 10% of the placebo group had developed virologic failure, defined as an HIV RNA load greater than 400 copies/mL. At 24 months, 28% of the nevirapine group and 11% of the placebo group had failed combination therapy. All differences were statistically significant.

Further analysis showed that the failures occurred in women who started their antiretroviral therapy within 6 months of receiving the single dose of nevirapine but not in women whose therapy began at least 6 months after the single nevirapine dose.

Of the 60 women who started combination antiretroviral therapy within 6 months of the peripartum dose, 42% of the 24 women in the nevirapine group and none of the 36 women in the placebo group developed virologic failure by 6 months. Virologic failure was seen at 12 and 24 months in 46% of the nevirapine group and 3% of the placebo group. All differences were highly significant.

Virologic failure rates did not differ significantly between the nevirapine and placebo groups in the 158 women who started combination therapy at least 6 months after the peripartum dose.

A total of 30 HIV-infected infants were given the same combination antiretroviral therapy. Of 15 infants whose mothers got single-dose nevirapine during pregnancy, 10 developed virologic failure during 2 years of follow-up, compared with 2 of 15 infants in the placebo group. Two infants in the nevirapine group and three in the placebo group died.

Infants in the nevirapine group showed a smaller increase in CD4 counts on combination therapy, compared with those in the placebo group. For mothers, the CD4 counts did not differ significantly between groups.

Only nevirapine exposure predicted the risk of virologic failure in women and infants. Other factors such as maternal age, clinic location, or infant feeding strategy (breast vs. formula) were not predictors.

SAN FRANCISCO — Populationwide rates of bacterial meningitis declined significantly from 1.9 cases per 100,000 people in 1998 to 1.5 per 100,000 in 2003, largely due to a pediatric vaccine that seems to have no herd effect in older people, Michael C. Thigpen, M.D., said.

Dr. Thigpen of the Centers for Disease Control and Prevention, Atlanta, and his associates analyzed surveillance data from nine geographic areas covering a population of 17 million in 1998 and 25 million in 2002. The 2,039 cases of bacterial meningitis in the study killed 16% of patients.

The pneumococcal 7-valent conjugate vaccine (PCV-7) was recommended in 2000 for infants aged 2–23 months; the incidence of pneumococcal meningitis subsequently declined 65% in that age group. No decline in pneumococcal meningitis occurred in older people, as has been seen with other types of invasive pneumococcal disease after the introduction of PCV-7, he said at the annual meeting of the Infectious Diseases Society of America.

Cyclical changes in meningococcal disease also contributed to the reduced incidence of bacterial meningitis. Five pathogens cause 80% of bacterial meningitis: Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae type b, group B streptococcus (GBS), and Listeria monocytogenes.

Recommendations in 2002 for universal GBS screening of pregnant women and the 2005 licensing of meningococcal conjugate vaccine (MCV-4) for youths aged 11–17 years may further affect the incidence of bacterial meningitis. “It remains to be seen how universal GBS screening and MCV-4 will change the epidemiology of bacterial meningitis,” he said.

Among 781 cases of bacterial meningitis reported in 2002–2003, the most common pathogen was S. pneumoniae, accounting for 61% of cases and 76% of deaths. N. meningitidis caused 16% of cases, GBS caused 14%, H. influenzae caused 7%, and Listeria caused 2%.

Because of the success in reducing pneumococcal meningitis in the youngest age group, the median age of patients rose to 39 years. The disease killed 5% of patients younger than 2 months and 28% of patients aged 65 years or older.

“As bacterial meningitis has become even more a disease of adults, with S. pneumoniae causing disease across all ages, further reductions using a targeted approach may be difficult. … Broad strategies, including new vaccines to prevent adult cases of bacterial meningitis, should be considered,” he said.

SAN FRANCISCO — Populationwide rates of bacterial meningitis declined significantly from 1.9 cases per 100,000 people in 1998 to 1.5 per 100,000 in 2003, largely due to a pediatric vaccine that seems to have no herd effect in older people, Michael C. Thigpen, M.D., said.

Dr. Thigpen of the Centers for Disease Control and Prevention, Atlanta, and his associates analyzed surveillance data from nine geographic areas covering a population of 17 million in 1998 and 25 million in 2002. The 2,039 cases of bacterial meningitis in the study killed 16% of patients.

The pneumococcal 7-valent conjugate vaccine (PCV-7) was recommended in 2000 for infants aged 2–23 months; the incidence of pneumococcal meningitis subsequently declined 65% in that age group. No decline in pneumococcal meningitis occurred in older people, as has been seen with other types of invasive pneumococcal disease after the introduction of PCV-7, he said at the annual meeting of the Infectious Diseases Society of America.

Cyclical changes in meningococcal disease also contributed to the reduced incidence of bacterial meningitis. Five pathogens cause 80% of bacterial meningitis: Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae type b, group B streptococcus (GBS), and Listeria monocytogenes.

Recommendations in 2002 for universal GBS screening of pregnant women and the 2005 licensing of meningococcal conjugate vaccine (MCV-4) for youths aged 11–17 years may further affect the incidence of bacterial meningitis. “It remains to be seen how universal GBS screening and MCV-4 will change the epidemiology of bacterial meningitis,” he said.

Among 781 cases of bacterial meningitis reported in 2002–2003, the most common pathogen was S. pneumoniae, accounting for 61% of cases and 76% of deaths. N. meningitidis caused 16% of cases, GBS caused 14%, H. influenzae caused 7%, and Listeria caused 2%.

Because of the success in reducing pneumococcal meningitis in the youngest age group, the median age of patients rose to 39 years. The disease killed 5% of patients younger than 2 months and 28% of patients aged 65 years or older.

“As bacterial meningitis has become even more a disease of adults, with S. pneumoniae causing disease across all ages, further reductions using a targeted approach may be difficult. … Broad strategies, including new vaccines to prevent adult cases of bacterial meningitis, should be considered,” he said.

SAN FRANCISCO — Populationwide rates of bacterial meningitis declined significantly from 1.9 cases per 100,000 people in 1998 to 1.5 per 100,000 in 2003, largely due to a pediatric vaccine that seems to have no herd effect in older people, Michael C. Thigpen, M.D., said.

Dr. Thigpen of the Centers for Disease Control and Prevention, Atlanta, and his associates analyzed surveillance data from nine geographic areas covering a population of 17 million in 1998 and 25 million in 2002. The 2,039 cases of bacterial meningitis in the study killed 16% of patients.

The pneumococcal 7-valent conjugate vaccine (PCV-7) was recommended in 2000 for infants aged 2–23 months; the incidence of pneumococcal meningitis subsequently declined 65% in that age group. No decline in pneumococcal meningitis occurred in older people, as has been seen with other types of invasive pneumococcal disease after the introduction of PCV-7, he said at the annual meeting of the Infectious Diseases Society of America.

Cyclical changes in meningococcal disease also contributed to the reduced incidence of bacterial meningitis. Five pathogens cause 80% of bacterial meningitis: Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae type b, group B streptococcus (GBS), and Listeria monocytogenes.

Recommendations in 2002 for universal GBS screening of pregnant women and the 2005 licensing of meningococcal conjugate vaccine (MCV-4) for youths aged 11–17 years may further affect the incidence of bacterial meningitis. “It remains to be seen how universal GBS screening and MCV-4 will change the epidemiology of bacterial meningitis,” he said.

Among 781 cases of bacterial meningitis reported in 2002–2003, the most common pathogen was S. pneumoniae, accounting for 61% of cases and 76% of deaths. N. meningitidis caused 16% of cases, GBS caused 14%, H. influenzae caused 7%, and Listeria caused 2%.

Because of the success in reducing pneumococcal meningitis in the youngest age group, the median age of patients rose to 39 years. The disease killed 5% of patients younger than 2 months and 28% of patients aged 65 years or older.

“As bacterial meningitis has become even more a disease of adults, with S. pneumoniae causing disease across all ages, further reductions using a targeted approach may be difficult. … Broad strategies, including new vaccines to prevent adult cases of bacterial meningitis, should be considered,” he said.

SAN FRANCISCO — The Centers for Disease Control and Prevention will offer new tools early next year for health care providers who treat patients with HIV to improve prevention of viral transmission.

Of the approximately 40,000 new HIV infections in the United States each year, about a third are transmitted by people who know that they're infected with HIV.

To make a dent in these numbers, physicians must get more comfortable asking detailed questions about sexual practices, drug use, and other sensitive topics and must learn to deliver brief HIV prevention messages at every visit with HIV-positive patients, a panel of experts agreed at the annual meeting of the Infectious Diseases Society of America.

If you're not comfortable questioning and talking in a nonjudgmental fashion with a patient who mentions having a “booty bump” for sex, for example (that's sex with an amphetamine enema), the new Prevention in Care materials might help, said Mark W. Thrun, M.D., medical director of HIV prevention at the Denver Department of Public Health STD/HIV Prevention Training Center.

Physicians who ask HIV-positive patients about aspects of transmission prevention will find that 80% are doing what they need to do to keep themselves and others safe.

The campaign aims to help manage the other 20% by offering free printed materials in English and Spanish available in early 2006 at www.cdcnpin.orginfo@cdcnpin.org

The CDC, in conjunction with other federal agencies, also is planning training sessions at dozens of medical clinics to get physicians to use evidence-based interventions for HIV prevention. A prospective, randomized study of 585 HIV-positive patients found that brief, safer-sex counseling emphasizing the negative consequences of unsafe sex reduced instances of unprotected anal or vaginal intercourse by 38% among patients with two or more sex partners (AIDS 2004;18:1179–86).

Sex isn't the only topic that can get in the way of delivering prevention messages, said panelist Meg D. Newman, M.D., an HIV specialist at San Francisco General Hospital. Racial and ethnic minorities and women make up an increasing proportion of new HIV infections. Cultural issues, gender differences, and socioeconomic factors play roles in patients' decision-making and their openness to prevention messages, she said.

Behavioral change is not always a linear process, she added. “Prevention for positives is about meeting someone where they are and helping them move to a greater knowledge, greater self-acceptance, and self-respect,” Dr. Newman said.

Never assume that your patients have had HIV education, said panelist Jesse Milan Jr., J.D., who has HIV. Giving them one lesson is not enough. Remind them about prevention every time you see them, said Mr. Milan of Silver Spring, Md.

Ask patients probing questions about their behavior and knowledge of HIV transmission, he said. “If you don't ask, they won't tell,” he said.

Dr. Thrun compiled results of separate studies in 1999, 2003, and 2004 showing that far too many physicians don't assess risks for sexually transmitted diseases (STDs). Approximately 55% of 208 primary care providers assessed STD risk in one study, and routine STD assessment was reported by only around 35% of 3 million private physicians, 18% of 315 physicians not trained in infectious diseases, 10% of 315 physicians with infectious diseases training, and 15% of 417 HIV care providers.

SAN FRANCISCO — The Centers for Disease Control and Prevention will offer new tools early next year for health care providers who treat patients with HIV to improve prevention of viral transmission.

Of the approximately 40,000 new HIV infections in the United States each year, about a third are transmitted by people who know that they're infected with HIV.

To make a dent in these numbers, physicians must get more comfortable asking detailed questions about sexual practices, drug use, and other sensitive topics and must learn to deliver brief HIV prevention messages at every visit with HIV-positive patients, a panel of experts agreed at the annual meeting of the Infectious Diseases Society of America.

If you're not comfortable questioning and talking in a nonjudgmental fashion with a patient who mentions having a “booty bump” for sex, for example (that's sex with an amphetamine enema), the new Prevention in Care materials might help, said Mark W. Thrun, M.D., medical director of HIV prevention at the Denver Department of Public Health STD/HIV Prevention Training Center.

Physicians who ask HIV-positive patients about aspects of transmission prevention will find that 80% are doing what they need to do to keep themselves and others safe.

The campaign aims to help manage the other 20% by offering free printed materials in English and Spanish available in early 2006 at www.cdcnpin.orginfo@cdcnpin.org

The CDC, in conjunction with other federal agencies, also is planning training sessions at dozens of medical clinics to get physicians to use evidence-based interventions for HIV prevention. A prospective, randomized study of 585 HIV-positive patients found that brief, safer-sex counseling emphasizing the negative consequences of unsafe sex reduced instances of unprotected anal or vaginal intercourse by 38% among patients with two or more sex partners (AIDS 2004;18:1179–86).

Sex isn't the only topic that can get in the way of delivering prevention messages, said panelist Meg D. Newman, M.D., an HIV specialist at San Francisco General Hospital. Racial and ethnic minorities and women make up an increasing proportion of new HIV infections. Cultural issues, gender differences, and socioeconomic factors play roles in patients' decision-making and their openness to prevention messages, she said.

Behavioral change is not always a linear process, she added. “Prevention for positives is about meeting someone where they are and helping them move to a greater knowledge, greater self-acceptance, and self-respect,” Dr. Newman said.

Never assume that your patients have had HIV education, said panelist Jesse Milan Jr., J.D., who has HIV. Giving them one lesson is not enough. Remind them about prevention every time you see them, said Mr. Milan of Silver Spring, Md.

Ask patients probing questions about their behavior and knowledge of HIV transmission, he said. “If you don't ask, they won't tell,” he said.

Dr. Thrun compiled results of separate studies in 1999, 2003, and 2004 showing that far too many physicians don't assess risks for sexually transmitted diseases (STDs). Approximately 55% of 208 primary care providers assessed STD risk in one study, and routine STD assessment was reported by only around 35% of 3 million private physicians, 18% of 315 physicians not trained in infectious diseases, 10% of 315 physicians with infectious diseases training, and 15% of 417 HIV care providers.

SAN FRANCISCO — The Centers for Disease Control and Prevention will offer new tools early next year for health care providers who treat patients with HIV to improve prevention of viral transmission.

Of the approximately 40,000 new HIV infections in the United States each year, about a third are transmitted by people who know that they're infected with HIV.

To make a dent in these numbers, physicians must get more comfortable asking detailed questions about sexual practices, drug use, and other sensitive topics and must learn to deliver brief HIV prevention messages at every visit with HIV-positive patients, a panel of experts agreed at the annual meeting of the Infectious Diseases Society of America.

If you're not comfortable questioning and talking in a nonjudgmental fashion with a patient who mentions having a “booty bump” for sex, for example (that's sex with an amphetamine enema), the new Prevention in Care materials might help, said Mark W. Thrun, M.D., medical director of HIV prevention at the Denver Department of Public Health STD/HIV Prevention Training Center.

Physicians who ask HIV-positive patients about aspects of transmission prevention will find that 80% are doing what they need to do to keep themselves and others safe.

The campaign aims to help manage the other 20% by offering free printed materials in English and Spanish available in early 2006 at www.cdcnpin.orginfo@cdcnpin.org

The CDC, in conjunction with other federal agencies, also is planning training sessions at dozens of medical clinics to get physicians to use evidence-based interventions for HIV prevention. A prospective, randomized study of 585 HIV-positive patients found that brief, safer-sex counseling emphasizing the negative consequences of unsafe sex reduced instances of unprotected anal or vaginal intercourse by 38% among patients with two or more sex partners (AIDS 2004;18:1179–86).

Sex isn't the only topic that can get in the way of delivering prevention messages, said panelist Meg D. Newman, M.D., an HIV specialist at San Francisco General Hospital. Racial and ethnic minorities and women make up an increasing proportion of new HIV infections. Cultural issues, gender differences, and socioeconomic factors play roles in patients' decision-making and their openness to prevention messages, she said.

Behavioral change is not always a linear process, she added. “Prevention for positives is about meeting someone where they are and helping them move to a greater knowledge, greater self-acceptance, and self-respect,” Dr. Newman said.

Never assume that your patients have had HIV education, said panelist Jesse Milan Jr., J.D., who has HIV. Giving them one lesson is not enough. Remind them about prevention every time you see them, said Mr. Milan of Silver Spring, Md.

Ask patients probing questions about their behavior and knowledge of HIV transmission, he said. “If you don't ask, they won't tell,” he said.

Dr. Thrun compiled results of separate studies in 1999, 2003, and 2004 showing that far too many physicians don't assess risks for sexually transmitted diseases (STDs). Approximately 55% of 208 primary care providers assessed STD risk in one study, and routine STD assessment was reported by only around 35% of 3 million private physicians, 18% of 315 physicians not trained in infectious diseases, 10% of 315 physicians with infectious diseases training, and 15% of 417 HIV care providers.

SAN FRANCISCO — The incidence of pediatric pneumococcal parapneumonic empyema doubled in Utah and surrounding areas since introduction of the pneumococcal conjugate vaccine, Carrie L. Byington, M.D., said in a poster presentation at the annual meeting of the Infectious Diseases Society of America.

Activity of bacterial serotypes varies by geographical region. In the past decade, Utah has had one of the highest rates of pneumococcal parapneumonic empyema (PPE) in children due to Streptococcus pneumoniae serotype 1, which the vaccine does not cover, said Dr. Byington of the University of Utah, Salt Lake City, and associates.

A search of the Intermountain Health Care data warehouse found 776 cases of pediatric PPE between March 1996 and June 2005, 62% of which were treated at Primary Children's Medical Center, Salt Lake City. In the period 1996–2000, before introduction of 7-valent pneumococcal conjugate vaccine (Prevnar), the center saw 38 cases per year, compared with 72 cases annually between 2001 and 2004, a significant difference.

Among 295 cases of culture-confirmed invasive pneumococcal disease in children at the center, 74 were PPE, representing 18% of invasive pneumococcal disease in the prevaccine years and 32% since the vaccine.

The investigators retrieved and serotyped pleural and fluid isolates of S. pneumoniae from the 74 cases. The proportion of PPE due to serotypes covered in the vaccine decreased from 37% (9 of 24 cases) in the prevaccine era to 14% (7 of 50 cases) in more recent years.

Serotype 1 was the most common cause of PPE due to nonvaccine serotypes in both time periods, but disease due to other nonvaccine serotypes has become more common. Serotype 1 caused 11 (46%) of 24 PPE cases in the earlier period and 17 (34%) of 50 cases since the vaccine. Other nonvaccine serotypes caused only four cases (16%) of PPE in the prevaccine years but 26 cases (52%) of PPE in the postvaccine years.

The pneumococcal vaccine may need to be broadened to cover some of these serotypes, Dr. Byington suggested in an interview.

SAN FRANCISCO — The incidence of pediatric pneumococcal parapneumonic empyema doubled in Utah and surrounding areas since introduction of the pneumococcal conjugate vaccine, Carrie L. Byington, M.D., said in a poster presentation at the annual meeting of the Infectious Diseases Society of America.

Activity of bacterial serotypes varies by geographical region. In the past decade, Utah has had one of the highest rates of pneumococcal parapneumonic empyema (PPE) in children due to Streptococcus pneumoniae serotype 1, which the vaccine does not cover, said Dr. Byington of the University of Utah, Salt Lake City, and associates.

A search of the Intermountain Health Care data warehouse found 776 cases of pediatric PPE between March 1996 and June 2005, 62% of which were treated at Primary Children's Medical Center, Salt Lake City. In the period 1996–2000, before introduction of 7-valent pneumococcal conjugate vaccine (Prevnar), the center saw 38 cases per year, compared with 72 cases annually between 2001 and 2004, a significant difference.

Among 295 cases of culture-confirmed invasive pneumococcal disease in children at the center, 74 were PPE, representing 18% of invasive pneumococcal disease in the prevaccine years and 32% since the vaccine.

The investigators retrieved and serotyped pleural and fluid isolates of S. pneumoniae from the 74 cases. The proportion of PPE due to serotypes covered in the vaccine decreased from 37% (9 of 24 cases) in the prevaccine era to 14% (7 of 50 cases) in more recent years.

Serotype 1 was the most common cause of PPE due to nonvaccine serotypes in both time periods, but disease due to other nonvaccine serotypes has become more common. Serotype 1 caused 11 (46%) of 24 PPE cases in the earlier period and 17 (34%) of 50 cases since the vaccine. Other nonvaccine serotypes caused only four cases (16%) of PPE in the prevaccine years but 26 cases (52%) of PPE in the postvaccine years.

The pneumococcal vaccine may need to be broadened to cover some of these serotypes, Dr. Byington suggested in an interview.

SAN FRANCISCO — The incidence of pediatric pneumococcal parapneumonic empyema doubled in Utah and surrounding areas since introduction of the pneumococcal conjugate vaccine, Carrie L. Byington, M.D., said in a poster presentation at the annual meeting of the Infectious Diseases Society of America.

Activity of bacterial serotypes varies by geographical region. In the past decade, Utah has had one of the highest rates of pneumococcal parapneumonic empyema (PPE) in children due to Streptococcus pneumoniae serotype 1, which the vaccine does not cover, said Dr. Byington of the University of Utah, Salt Lake City, and associates.

A search of the Intermountain Health Care data warehouse found 776 cases of pediatric PPE between March 1996 and June 2005, 62% of which were treated at Primary Children's Medical Center, Salt Lake City. In the period 1996–2000, before introduction of 7-valent pneumococcal conjugate vaccine (Prevnar), the center saw 38 cases per year, compared with 72 cases annually between 2001 and 2004, a significant difference.

Among 295 cases of culture-confirmed invasive pneumococcal disease in children at the center, 74 were PPE, representing 18% of invasive pneumococcal disease in the prevaccine years and 32% since the vaccine.

The investigators retrieved and serotyped pleural and fluid isolates of S. pneumoniae from the 74 cases. The proportion of PPE due to serotypes covered in the vaccine decreased from 37% (9 of 24 cases) in the prevaccine era to 14% (7 of 50 cases) in more recent years.

Serotype 1 was the most common cause of PPE due to nonvaccine serotypes in both time periods, but disease due to other nonvaccine serotypes has become more common. Serotype 1 caused 11 (46%) of 24 PPE cases in the earlier period and 17 (34%) of 50 cases since the vaccine. Other nonvaccine serotypes caused only four cases (16%) of PPE in the prevaccine years but 26 cases (52%) of PPE in the postvaccine years.

The pneumococcal vaccine may need to be broadened to cover some of these serotypes, Dr. Byington suggested in an interview.

OAKLAND, CALIF. – Gay men seeking treatment for methamphetamine use significantly reduced both drug use and risky sexual behaviors during a 16-week program, Steven Shoptaw, Ph.D., said at a conference sponsored by the American Foundation for AIDS Research.

A study that randomized 162 gay and bisexual men to one of four treatment groups found strategies that employed “contingency management,” in which participants were rewarded for drug-free urine samples, worked best to reduce methamphetamine use. A version of cognitive-behavioral therapy (CBT) geared specifically toward gay and bisexual men worked best to quickly reduce the riskiest sexual behavior–unprotected receptive anal intercourse, he said.

Drug abuse treatment deserves a primary role in HIV prevention strategies for gay men, said Dr. Shoptaw of the University of California, Los Angeles.

The four treatment groups used conventional cognitive-behavioral therapy, contingency management, a combination of the two, or gay-specific CBT. All participants underwent urine screening thrice weekly, and those in the contingency management groups whose urine samples were drug free received monetary vouchers that could be redeemed for goods or services. Participants called contingency management “peeing for dollars.”

The gay-specific CBT addressed both drug abuse and HIV-related sexual risk behaviors and incorporated references to gay culture. For instance, the group might discuss how revealing one's drug problem is similar to the coming-out process. A session on identifying triggers for drug abuse relapse might discuss circuit parties or sex clubs frequented by methamphetamine-using gay or bisexual men.

Monthly monitoring of sexual behaviors showed that all groups had reduced risky sexual behavior at 4 weeks of therapy, with significantly greater improvement seen in the gay-specific CBT group throughout the 16-week program, compared with the other groups.

After the program ended, the differences among groups evened out, but all maintained improvements compared with baseline. At 6-month and 1-year follow-ups, participants reported approximately one or fewer occasions of unprotected receptive anal intercourse in the previous 6 months, compared with two or three occasions reported at baseline.

Among the entire cohort, 83% of urine samples at the end of 16 weeks were drug free, compared with 52% at baseline.

Participants in the groups that employed “peeing for dollars” were significantly more likely to complete the 16-week program, provide more drug-free urine samples, and to have longer periods of consecutive drug-free urine samples during treatment, compared with the group using conventional CBT alone, Dr. Shoptaw said at the conference, which was cosponsored by the Pacific AIDS Education and Training Center.

The gay-specific CBT group also produced more drug-free urine samples during treatment than did the conventional cognitive-behavioral therapy group.

The study will appear in the journal Drug and Alcohol Dependence.

As with the changes in risky sexual behavior, the differences in drug use between groups disappeared after the program ended, but all groups maintained improvements. At 1 year, urine samples were drug free in 82% of the cognitive-behavioral therapy group, 73% of the contingency management group, 73% of the combination-therapy group, and 67% of the gay-specific therapy group. The differences were not significant.

Previous data showed methamphetamine use clearly is associated with sexual behaviors that increase the risk of HIV transmission. “When gay and bisexual men avoid methamphetamine use, they generally engage in sexual behaviors at considerably lower risk,” Dr. Shoptaw said.

OAKLAND, CALIF. – Gay men seeking treatment for methamphetamine use significantly reduced both drug use and risky sexual behaviors during a 16-week program, Steven Shoptaw, Ph.D., said at a conference sponsored by the American Foundation for AIDS Research.

A study that randomized 162 gay and bisexual men to one of four treatment groups found strategies that employed “contingency management,” in which participants were rewarded for drug-free urine samples, worked best to reduce methamphetamine use. A version of cognitive-behavioral therapy (CBT) geared specifically toward gay and bisexual men worked best to quickly reduce the riskiest sexual behavior–unprotected receptive anal intercourse, he said.

Drug abuse treatment deserves a primary role in HIV prevention strategies for gay men, said Dr. Shoptaw of the University of California, Los Angeles.

The four treatment groups used conventional cognitive-behavioral therapy, contingency management, a combination of the two, or gay-specific CBT. All participants underwent urine screening thrice weekly, and those in the contingency management groups whose urine samples were drug free received monetary vouchers that could be redeemed for goods or services. Participants called contingency management “peeing for dollars.”

The gay-specific CBT addressed both drug abuse and HIV-related sexual risk behaviors and incorporated references to gay culture. For instance, the group might discuss how revealing one's drug problem is similar to the coming-out process. A session on identifying triggers for drug abuse relapse might discuss circuit parties or sex clubs frequented by methamphetamine-using gay or bisexual men.

Monthly monitoring of sexual behaviors showed that all groups had reduced risky sexual behavior at 4 weeks of therapy, with significantly greater improvement seen in the gay-specific CBT group throughout the 16-week program, compared with the other groups.

After the program ended, the differences among groups evened out, but all maintained improvements compared with baseline. At 6-month and 1-year follow-ups, participants reported approximately one or fewer occasions of unprotected receptive anal intercourse in the previous 6 months, compared with two or three occasions reported at baseline.

Among the entire cohort, 83% of urine samples at the end of 16 weeks were drug free, compared with 52% at baseline.

Participants in the groups that employed “peeing for dollars” were significantly more likely to complete the 16-week program, provide more drug-free urine samples, and to have longer periods of consecutive drug-free urine samples during treatment, compared with the group using conventional CBT alone, Dr. Shoptaw said at the conference, which was cosponsored by the Pacific AIDS Education and Training Center.

The gay-specific CBT group also produced more drug-free urine samples during treatment than did the conventional cognitive-behavioral therapy group.

The study will appear in the journal Drug and Alcohol Dependence.

As with the changes in risky sexual behavior, the differences in drug use between groups disappeared after the program ended, but all groups maintained improvements. At 1 year, urine samples were drug free in 82% of the cognitive-behavioral therapy group, 73% of the contingency management group, 73% of the combination-therapy group, and 67% of the gay-specific therapy group. The differences were not significant.

Previous data showed methamphetamine use clearly is associated with sexual behaviors that increase the risk of HIV transmission. “When gay and bisexual men avoid methamphetamine use, they generally engage in sexual behaviors at considerably lower risk,” Dr. Shoptaw said.

OAKLAND, CALIF. – Gay men seeking treatment for methamphetamine use significantly reduced both drug use and risky sexual behaviors during a 16-week program, Steven Shoptaw, Ph.D., said at a conference sponsored by the American Foundation for AIDS Research.

A study that randomized 162 gay and bisexual men to one of four treatment groups found strategies that employed “contingency management,” in which participants were rewarded for drug-free urine samples, worked best to reduce methamphetamine use. A version of cognitive-behavioral therapy (CBT) geared specifically toward gay and bisexual men worked best to quickly reduce the riskiest sexual behavior–unprotected receptive anal intercourse, he said.

Drug abuse treatment deserves a primary role in HIV prevention strategies for gay men, said Dr. Shoptaw of the University of California, Los Angeles.

The four treatment groups used conventional cognitive-behavioral therapy, contingency management, a combination of the two, or gay-specific CBT. All participants underwent urine screening thrice weekly, and those in the contingency management groups whose urine samples were drug free received monetary vouchers that could be redeemed for goods or services. Participants called contingency management “peeing for dollars.”

The gay-specific CBT addressed both drug abuse and HIV-related sexual risk behaviors and incorporated references to gay culture. For instance, the group might discuss how revealing one's drug problem is similar to the coming-out process. A session on identifying triggers for drug abuse relapse might discuss circuit parties or sex clubs frequented by methamphetamine-using gay or bisexual men.

Monthly monitoring of sexual behaviors showed that all groups had reduced risky sexual behavior at 4 weeks of therapy, with significantly greater improvement seen in the gay-specific CBT group throughout the 16-week program, compared with the other groups.

After the program ended, the differences among groups evened out, but all maintained improvements compared with baseline. At 6-month and 1-year follow-ups, participants reported approximately one or fewer occasions of unprotected receptive anal intercourse in the previous 6 months, compared with two or three occasions reported at baseline.

Among the entire cohort, 83% of urine samples at the end of 16 weeks were drug free, compared with 52% at baseline.

Participants in the groups that employed “peeing for dollars” were significantly more likely to complete the 16-week program, provide more drug-free urine samples, and to have longer periods of consecutive drug-free urine samples during treatment, compared with the group using conventional CBT alone, Dr. Shoptaw said at the conference, which was cosponsored by the Pacific AIDS Education and Training Center.

The gay-specific CBT group also produced more drug-free urine samples during treatment than did the conventional cognitive-behavioral therapy group.

The study will appear in the journal Drug and Alcohol Dependence.

As with the changes in risky sexual behavior, the differences in drug use between groups disappeared after the program ended, but all groups maintained improvements. At 1 year, urine samples were drug free in 82% of the cognitive-behavioral therapy group, 73% of the contingency management group, 73% of the combination-therapy group, and 67% of the gay-specific therapy group. The differences were not significant.

Previous data showed methamphetamine use clearly is associated with sexual behaviors that increase the risk of HIV transmission. “When gay and bisexual men avoid methamphetamine use, they generally engage in sexual behaviors at considerably lower risk,” Dr. Shoptaw said.

SAN FRANCISCO — Using telemedicine to manage approximately one patient per week with acute infection at home instead of in the hospital netted $128,000 in savings in 1 year, Lawrence J. Eron, M.D., said at the annual meeting of the Infectious Diseases Society of America.

Telemedicine more commonly is used to help manage rural patients with chronic health problems.

In this study, Dr. Eron of the Kaiser Moanalua Medical Center, Honolulu, and his associates used telemedicine in a more urban/suburban setting for home-based monitoring of 34 patients with pneumonia, 8 with cellulitis, 3 with urinary tract infection, 2 with bacterial endocarditis, and 1 with cholecystitis.

Most patients were treated for 2–3 days in the hospital before being discharged home with telemedicine, but 15 required no hospitalization. The telemedical care lasted a median of 5 days per patient.

Figuring that each day avoided hospitalization costs of $1,000, telemedicine reduced costs by $240,000 for the 48 patients. Subtracting the costs of telemedicine—for equipment, personnel, and technical consultations—netted a savings of $128,000, he calculated.

The medical center plans to grow its telemedicine program to handle four patients with infections per week. “That's not a great number of patients, but that would save us $747,000 per year, we calculate. That's real money,” Dr. Eron said.

All but six patients were cured. Three of the six required rehospitalization. A subanalysis of 25 telemedicine patients matched to patients treated only in the hospital found much shorter convalescent periods with telemedicine. The telemedicine group returned to normal activities of daily living in 8 days, compared with 21 days for the hospitalized patients.

“Convalescence is more rapid at home,” but it can be hard to get anxious patients to leave what they consider the safety of the hospital to go home, he said.

Patients in the study were skeptical of the telemedicine arrangements initially. At the end of their time with the telemedicine unit, however, many were reluctant to give up the technology, Dr. Eron added.

The telemedicine unit connected the patient with health care providers over regular telephone lines that allowed them to see and speak with each other via video cameras and screens. The equipment included a stethoscope, blood pressure cuff, and pulse oximeter.

“The transmission of the heart sounds is as good, if not better, than if you're standing by the patient with your own stethoscope,” he said.

Dr. Eron has no relationship with the company that makes the telemedicine unit, American Telecare Inc., Eden Prairie, Minn.

Many issues still must be addressed before this becomes the standard of care, he added. During the study, there were problems with “freeze-ups” of the technology and disconnections of the phone lines.

Reimbursement will be a challenge for many physicians who already face difficulties being reimbursed for telephone consultations, he predicted.

SAN FRANCISCO — Using telemedicine to manage approximately one patient per week with acute infection at home instead of in the hospital netted $128,000 in savings in 1 year, Lawrence J. Eron, M.D., said at the annual meeting of the Infectious Diseases Society of America.

Telemedicine more commonly is used to help manage rural patients with chronic health problems.

In this study, Dr. Eron of the Kaiser Moanalua Medical Center, Honolulu, and his associates used telemedicine in a more urban/suburban setting for home-based monitoring of 34 patients with pneumonia, 8 with cellulitis, 3 with urinary tract infection, 2 with bacterial endocarditis, and 1 with cholecystitis.

Most patients were treated for 2–3 days in the hospital before being discharged home with telemedicine, but 15 required no hospitalization. The telemedical care lasted a median of 5 days per patient.

Figuring that each day avoided hospitalization costs of $1,000, telemedicine reduced costs by $240,000 for the 48 patients. Subtracting the costs of telemedicine—for equipment, personnel, and technical consultations—netted a savings of $128,000, he calculated.

The medical center plans to grow its telemedicine program to handle four patients with infections per week. “That's not a great number of patients, but that would save us $747,000 per year, we calculate. That's real money,” Dr. Eron said.

All but six patients were cured. Three of the six required rehospitalization. A subanalysis of 25 telemedicine patients matched to patients treated only in the hospital found much shorter convalescent periods with telemedicine. The telemedicine group returned to normal activities of daily living in 8 days, compared with 21 days for the hospitalized patients.

“Convalescence is more rapid at home,” but it can be hard to get anxious patients to leave what they consider the safety of the hospital to go home, he said.

Patients in the study were skeptical of the telemedicine arrangements initially. At the end of their time with the telemedicine unit, however, many were reluctant to give up the technology, Dr. Eron added.

The telemedicine unit connected the patient with health care providers over regular telephone lines that allowed them to see and speak with each other via video cameras and screens. The equipment included a stethoscope, blood pressure cuff, and pulse oximeter.

“The transmission of the heart sounds is as good, if not better, than if you're standing by the patient with your own stethoscope,” he said.

Dr. Eron has no relationship with the company that makes the telemedicine unit, American Telecare Inc., Eden Prairie, Minn.

Many issues still must be addressed before this becomes the standard of care, he added. During the study, there were problems with “freeze-ups” of the technology and disconnections of the phone lines.

Reimbursement will be a challenge for many physicians who already face difficulties being reimbursed for telephone consultations, he predicted.

SAN FRANCISCO — Using telemedicine to manage approximately one patient per week with acute infection at home instead of in the hospital netted $128,000 in savings in 1 year, Lawrence J. Eron, M.D., said at the annual meeting of the Infectious Diseases Society of America.

Telemedicine more commonly is used to help manage rural patients with chronic health problems.

In this study, Dr. Eron of the Kaiser Moanalua Medical Center, Honolulu, and his associates used telemedicine in a more urban/suburban setting for home-based monitoring of 34 patients with pneumonia, 8 with cellulitis, 3 with urinary tract infection, 2 with bacterial endocarditis, and 1 with cholecystitis.

Most patients were treated for 2–3 days in the hospital before being discharged home with telemedicine, but 15 required no hospitalization. The telemedical care lasted a median of 5 days per patient.

Figuring that each day avoided hospitalization costs of $1,000, telemedicine reduced costs by $240,000 for the 48 patients. Subtracting the costs of telemedicine—for equipment, personnel, and technical consultations—netted a savings of $128,000, he calculated.

The medical center plans to grow its telemedicine program to handle four patients with infections per week. “That's not a great number of patients, but that would save us $747,000 per year, we calculate. That's real money,” Dr. Eron said.

All but six patients were cured. Three of the six required rehospitalization. A subanalysis of 25 telemedicine patients matched to patients treated only in the hospital found much shorter convalescent periods with telemedicine. The telemedicine group returned to normal activities of daily living in 8 days, compared with 21 days for the hospitalized patients.

“Convalescence is more rapid at home,” but it can be hard to get anxious patients to leave what they consider the safety of the hospital to go home, he said.

Patients in the study were skeptical of the telemedicine arrangements initially. At the end of their time with the telemedicine unit, however, many were reluctant to give up the technology, Dr. Eron added.

The telemedicine unit connected the patient with health care providers over regular telephone lines that allowed them to see and speak with each other via video cameras and screens. The equipment included a stethoscope, blood pressure cuff, and pulse oximeter.

“The transmission of the heart sounds is as good, if not better, than if you're standing by the patient with your own stethoscope,” he said.

Dr. Eron has no relationship with the company that makes the telemedicine unit, American Telecare Inc., Eden Prairie, Minn.

Many issues still must be addressed before this becomes the standard of care, he added. During the study, there were problems with “freeze-ups” of the technology and disconnections of the phone lines.

Reimbursement will be a challenge for many physicians who already face difficulties being reimbursed for telephone consultations, he predicted.

SAN DIEGO — The risk of pouch dilatation may be lowered if weight is lost before surgery, according to a study of morbidly obese patients in the Netherlands, Karlijn J.P. van Wessem, M.D., said at an international congress of the Society of Laparoendoscopic Surgeons.

An intensive preoperative weight loss program reduced mean body mass index (BMI) in 47 patients before laparoscopic banding, and only 1 patient (2%) developed pouch dilatation 10 months after surgery, said Dr. van Wessem of Reinier de Graff Hospital, Delft, the Netherlands. Complication rates of 6%–21% have been reported in the literature, she added.

A physician supervised patients with a mean BMI greater than 40 kg/m

Mean BMI was reduced from an initial 45 kg/m

Beyond 6 weeks after surgery, there were no significant changes in BMI during a relatively short mean follow-up of 18 months, out to 28 months in some patients. Because the mean BMI stayed relatively high, especially in men, the study's results raise questions about whether gastric banding is appropriate for all patients or whether tighter selection should exclude some, such as men, she said.

Complications developed in seven patients (15%), a rate comparable with those reported in the literature. Three developed gastric obstructions due to misplacement of the band. The cases were among the first 15 patients, so the problems might be attributed to the learning curve, she said. The bands were repositioned laparoscopically.

A port-site leakage was repaired in one patient. Two did not lose weight despite maximum filling of the band. Their bands were removed, and they'll undergo gastric bypass surgery later, Dr. van Wessem said.

SAN DIEGO — The risk of pouch dilatation may be lowered if weight is lost before surgery, according to a study of morbidly obese patients in the Netherlands, Karlijn J.P. van Wessem, M.D., said at an international congress of the Society of Laparoendoscopic Surgeons.

An intensive preoperative weight loss program reduced mean body mass index (BMI) in 47 patients before laparoscopic banding, and only 1 patient (2%) developed pouch dilatation 10 months after surgery, said Dr. van Wessem of Reinier de Graff Hospital, Delft, the Netherlands. Complication rates of 6%–21% have been reported in the literature, she added.

A physician supervised patients with a mean BMI greater than 40 kg/m

Mean BMI was reduced from an initial 45 kg/m

Beyond 6 weeks after surgery, there were no significant changes in BMI during a relatively short mean follow-up of 18 months, out to 28 months in some patients. Because the mean BMI stayed relatively high, especially in men, the study's results raise questions about whether gastric banding is appropriate for all patients or whether tighter selection should exclude some, such as men, she said.

Complications developed in seven patients (15%), a rate comparable with those reported in the literature. Three developed gastric obstructions due to misplacement of the band. The cases were among the first 15 patients, so the problems might be attributed to the learning curve, she said. The bands were repositioned laparoscopically.

A port-site leakage was repaired in one patient. Two did not lose weight despite maximum filling of the band. Their bands were removed, and they'll undergo gastric bypass surgery later, Dr. van Wessem said.

SAN DIEGO — The risk of pouch dilatation may be lowered if weight is lost before surgery, according to a study of morbidly obese patients in the Netherlands, Karlijn J.P. van Wessem, M.D., said at an international congress of the Society of Laparoendoscopic Surgeons.

An intensive preoperative weight loss program reduced mean body mass index (BMI) in 47 patients before laparoscopic banding, and only 1 patient (2%) developed pouch dilatation 10 months after surgery, said Dr. van Wessem of Reinier de Graff Hospital, Delft, the Netherlands. Complication rates of 6%–21% have been reported in the literature, she added.

A physician supervised patients with a mean BMI greater than 40 kg/m

Mean BMI was reduced from an initial 45 kg/m

Beyond 6 weeks after surgery, there were no significant changes in BMI during a relatively short mean follow-up of 18 months, out to 28 months in some patients. Because the mean BMI stayed relatively high, especially in men, the study's results raise questions about whether gastric banding is appropriate for all patients or whether tighter selection should exclude some, such as men, she said.

Complications developed in seven patients (15%), a rate comparable with those reported in the literature. Three developed gastric obstructions due to misplacement of the band. The cases were among the first 15 patients, so the problems might be attributed to the learning curve, she said. The bands were repositioned laparoscopically.

A port-site leakage was repaired in one patient. Two did not lose weight despite maximum filling of the band. Their bands were removed, and they'll undergo gastric bypass surgery later, Dr. van Wessem said.

SAN FRANCISCO — Don't reach for the vancomycin when you see uncomplicated cellulitis, because in most cases, empiric therapy is still needed to fight the β-hemolytic streptococci, Ramesh V. Nathan, M.D., said at the annual meeting of the Infectious Diseases Society of America.

Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) might be on the tips of everyone's tongues these days, but group A streptococci remain the cause of most cases of cellulitis that can't be cultured because the patients lack abscesses or wounds, Dr. Nathan explained in a poster presentation.

Serology results for 54 adult patients with uncomplicated cellulitis showed streptococcal antibodies in 45 (83%). In general, most soft tissue infections are caused by β-hemolytic streptococci or S. aureus, so the 9 cases (17%) with negative streptococcal serologies were presumed to be caused by S. aureus, said Dr. Nathan of the University of California, Los Angeles.

Traditionally, β-lactam antibiotics have been the mainstay of treatment for uncomplicated cellulitis because of their excellent activity against both organisms.

Older literature suggested β-hemolytic streptococci caused most cases of uncomplicated cellulitis even after the emergence of MRSA, but it was unclear whether this had remained true, given the current epidemic of MRSA, Dr. Nathan said.

“Even in the era of community-acquired MRSA, β-hemolytic strep is still a very, very common cause of cellulitis. That means that for therapy, β-lactam antibiotics such as oxacillin or cefazolin are still going to be the most useful,” he said in an interview at the poster session.

Although serologies in most patients were positive for both antistreptolysin O and deoxyribonuclease B antibodies, indicating β-hemolytic streptococci infection, some were positive for just one or the other antibody. Both tests should be done for accurate diagnosis, he said.

The most common site of infection was the legs, followed by arms or hands, trunk, and face. Several comorbidities were highly associated with β-hemolytic streptococci infection: chronic lymphedema, cirrhosis, obesity, and recurrent cellulitis. No comorbidities were seen, however, in 16 patients—a significant proportion (30%) of the whole cohort.

Two patients with negative serologies were found to have group B streptococci by fortuitous blood cultures, Dr. Nathan added. Both patients had diabetes.

The proportion of β-hemolytic streptococci infections in diabetic patients may be underestimated because the usual antibody tests do not detect group B streptococci, he said. Even in the diabetic patients in the study, most infections were caused by β-hemolytic streptococci.

All those with recurrent cellulitis who reported a previous cellulitis in the same limb had β-hemolytic streptococcal infection.

The study excluded patients with abscesses and significant ulcers or wounds that could be cultured. It also excluded patients with infections that are more typically caused by a variety of etiologic agents and by polymicrobial infections including periorbital, perineal, and groin infections; diabetic foot ulcers; and infections originating from bite wounds or foreign bodies.

This severe cellulitis infection on the leg of a 31-year-old woman, presumed to be due to MRSA, did not respond to doxycycline. After group A streptococcus was identified as the etiologic pathogen, the patient responded well to penicillin. Courtesy Dr. Arthur Jeng

SAN FRANCISCO — Don't reach for the vancomycin when you see uncomplicated cellulitis, because in most cases, empiric therapy is still needed to fight the β-hemolytic streptococci, Ramesh V. Nathan, M.D., said at the annual meeting of the Infectious Diseases Society of America.

Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) might be on the tips of everyone's tongues these days, but group A streptococci remain the cause of most cases of cellulitis that can't be cultured because the patients lack abscesses or wounds, Dr. Nathan explained in a poster presentation.

Serology results for 54 adult patients with uncomplicated cellulitis showed streptococcal antibodies in 45 (83%). In general, most soft tissue infections are caused by β-hemolytic streptococci or S. aureus, so the 9 cases (17%) with negative streptococcal serologies were presumed to be caused by S. aureus, said Dr. Nathan of the University of California, Los Angeles.

Traditionally, β-lactam antibiotics have been the mainstay of treatment for uncomplicated cellulitis because of their excellent activity against both organisms.

Older literature suggested β-hemolytic streptococci caused most cases of uncomplicated cellulitis even after the emergence of MRSA, but it was unclear whether this had remained true, given the current epidemic of MRSA, Dr. Nathan said.

“Even in the era of community-acquired MRSA, β-hemolytic strep is still a very, very common cause of cellulitis. That means that for therapy, β-lactam antibiotics such as oxacillin or cefazolin are still going to be the most useful,” he said in an interview at the poster session.

Although serologies in most patients were positive for both antistreptolysin O and deoxyribonuclease B antibodies, indicating β-hemolytic streptococci infection, some were positive for just one or the other antibody. Both tests should be done for accurate diagnosis, he said.

The most common site of infection was the legs, followed by arms or hands, trunk, and face. Several comorbidities were highly associated with β-hemolytic streptococci infection: chronic lymphedema, cirrhosis, obesity, and recurrent cellulitis. No comorbidities were seen, however, in 16 patients—a significant proportion (30%) of the whole cohort.

Two patients with negative serologies were found to have group B streptococci by fortuitous blood cultures, Dr. Nathan added. Both patients had diabetes.

The proportion of β-hemolytic streptococci infections in diabetic patients may be underestimated because the usual antibody tests do not detect group B streptococci, he said. Even in the diabetic patients in the study, most infections were caused by β-hemolytic streptococci.

All those with recurrent cellulitis who reported a previous cellulitis in the same limb had β-hemolytic streptococcal infection.

The study excluded patients with abscesses and significant ulcers or wounds that could be cultured. It also excluded patients with infections that are more typically caused by a variety of etiologic agents and by polymicrobial infections including periorbital, perineal, and groin infections; diabetic foot ulcers; and infections originating from bite wounds or foreign bodies.

This severe cellulitis infection on the leg of a 31-year-old woman, presumed to be due to MRSA, did not respond to doxycycline. After group A streptococcus was identified as the etiologic pathogen, the patient responded well to penicillin. Courtesy Dr. Arthur Jeng

SAN FRANCISCO — Don't reach for the vancomycin when you see uncomplicated cellulitis, because in most cases, empiric therapy is still needed to fight the β-hemolytic streptococci, Ramesh V. Nathan, M.D., said at the annual meeting of the Infectious Diseases Society of America.

Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) might be on the tips of everyone's tongues these days, but group A streptococci remain the cause of most cases of cellulitis that can't be cultured because the patients lack abscesses or wounds, Dr. Nathan explained in a poster presentation.

Serology results for 54 adult patients with uncomplicated cellulitis showed streptococcal antibodies in 45 (83%). In general, most soft tissue infections are caused by β-hemolytic streptococci or S. aureus, so the 9 cases (17%) with negative streptococcal serologies were presumed to be caused by S. aureus, said Dr. Nathan of the University of California, Los Angeles.

Traditionally, β-lactam antibiotics have been the mainstay of treatment for uncomplicated cellulitis because of their excellent activity against both organisms.

Older literature suggested β-hemolytic streptococci caused most cases of uncomplicated cellulitis even after the emergence of MRSA, but it was unclear whether this had remained true, given the current epidemic of MRSA, Dr. Nathan said.

“Even in the era of community-acquired MRSA, β-hemolytic strep is still a very, very common cause of cellulitis. That means that for therapy, β-lactam antibiotics such as oxacillin or cefazolin are still going to be the most useful,” he said in an interview at the poster session.

Although serologies in most patients were positive for both antistreptolysin O and deoxyribonuclease B antibodies, indicating β-hemolytic streptococci infection, some were positive for just one or the other antibody. Both tests should be done for accurate diagnosis, he said.

The most common site of infection was the legs, followed by arms or hands, trunk, and face. Several comorbidities were highly associated with β-hemolytic streptococci infection: chronic lymphedema, cirrhosis, obesity, and recurrent cellulitis. No comorbidities were seen, however, in 16 patients—a significant proportion (30%) of the whole cohort.

Two patients with negative serologies were found to have group B streptococci by fortuitous blood cultures, Dr. Nathan added. Both patients had diabetes.

The proportion of β-hemolytic streptococci infections in diabetic patients may be underestimated because the usual antibody tests do not detect group B streptococci, he said. Even in the diabetic patients in the study, most infections were caused by β-hemolytic streptococci.

All those with recurrent cellulitis who reported a previous cellulitis in the same limb had β-hemolytic streptococcal infection.

The study excluded patients with abscesses and significant ulcers or wounds that could be cultured. It also excluded patients with infections that are more typically caused by a variety of etiologic agents and by polymicrobial infections including periorbital, perineal, and groin infections; diabetic foot ulcers; and infections originating from bite wounds or foreign bodies.

This severe cellulitis infection on the leg of a 31-year-old woman, presumed to be due to MRSA, did not respond to doxycycline. After group A streptococcus was identified as the etiologic pathogen, the patient responded well to penicillin. Courtesy Dr. Arthur Jeng

SAN FRANCISCO — Low levels of immunity to pertussis in adolescent Hispanic mothers and their newborns may help explain their overrepresentation in pertussis cases and in deaths from the disease, C. Mary Healy, M.D., said in a poster presentation at the annual meeting of the Infectious Diseases Society of America.

A study of pertussis toxin-specific IgG concentrations found low concentrations in umbilical cord blood from 220 consecutive term singletons born to Hispanic women, with the lowest geometric mean concentrations in infants born to adolescent mothers. The low antibody levels likely reflect waning of vaccine-induced or natural immunity, she said.

Dr. Healy of Baylor College of Medicine, Houston, and her associates also compared pertussis toxin-specific IgG concentrations in blood samples from 55 mothers and their infants and found a ratio indicating efficient transfer of antibodies across the placenta. That suggests that one reason infants may be so susceptible to acquiring life-threatening pertussis in the first 4 months of life is because their mothers supply them with few antibodies.

“If you have high levels in the mothers, for example through vaccination, then the likelihood is that the antibodies will transmit very efficiently to infants and, hopefully, protect them at that most vulnerable period in the first few months of life before they begin their primary series of immunizations,” she said in an interview at the meeting.

Currently there are no recommendations to vaccinate pregnant women against pertussis. Discussions are underway about whether to give pregnant women one of two relatively new acellular pertussis vaccines licensed for use in adolescents, Dr. Healy said.

“Hispanic women, especially adolescents, should be immunized with newly licensed acellular pertussis vaccine to prevent pertussis in themselves and life-threatening disease in their infants,” she concluded in her poster.

Pertussis incidence is increasing among infants younger than 4 months of age, too young to have completed the DTaP primary vaccination series at ages 2, 4, and 6 months. The annual incidence of pertussis in the United States increased fivefold since 1980 despite childhood immunization rates above 80%, mainly due to disease in the youngest infants, according to federal statistics.

Pertussis incidence was 74% higher in Hispanic infants than in infants of other ethnicities throughout the 1990s despite comparable childhood immunization rates. Pertussis was reported in 68/100,000 Hispanic infants, compared with 39/100,000 non-Hispanic infants. Among infant deaths from pertussis between 1990 and 2000, 36%–41% who died were Hispanic infants. In addition, Hispanics made up 19% of children in 2003, according to U.S. Census data. The reasons for this ethnic difference in pertussis are unclear and require further study, she said.

Mothers of the 220 infants in the study had a mean age of 26 years (ranging from 14 to 42 years), and they reported a mean of 8 years of education.

Thirty percent did not begin prenatal care until the second trimester and 28% had fewer than nine prenatal care visits, which the investigators considered to be delayed prenatal care and inadequate prenatal care, respectively.

For the 55 matched mother-infant pairs, investigators stratified them by age groups of Hispanic mothers in Texas: 10% aged 10–19 years, 30% aged 20–24 years, 30% aged 25–29 years, and 30% aged 30 years or older.

The investigators quantified pertussis antibody levels using enzyme-linked immunosorbent assay (ELISA). The geometric mean concentration of pertussis toxin-specific IgG was 8.45 ELISA U/mL for all infants and 4.63 ELISA U/mL for infants of adolescent mothers, which was a significant difference, Dr. Healy said.

SAN FRANCISCO — Low levels of immunity to pertussis in adolescent Hispanic mothers and their newborns may help explain their overrepresentation in pertussis cases and in deaths from the disease, C. Mary Healy, M.D., said in a poster presentation at the annual meeting of the Infectious Diseases Society of America.

A study of pertussis toxin-specific IgG concentrations found low concentrations in umbilical cord blood from 220 consecutive term singletons born to Hispanic women, with the lowest geometric mean concentrations in infants born to adolescent mothers. The low antibody levels likely reflect waning of vaccine-induced or natural immunity, she said.

Dr. Healy of Baylor College of Medicine, Houston, and her associates also compared pertussis toxin-specific IgG concentrations in blood samples from 55 mothers and their infants and found a ratio indicating efficient transfer of antibodies across the placenta. That suggests that one reason infants may be so susceptible to acquiring life-threatening pertussis in the first 4 months of life is because their mothers supply them with few antibodies.

“If you have high levels in the mothers, for example through vaccination, then the likelihood is that the antibodies will transmit very efficiently to infants and, hopefully, protect them at that most vulnerable period in the first few months of life before they begin their primary series of immunizations,” she said in an interview at the meeting.

Currently there are no recommendations to vaccinate pregnant women against pertussis. Discussions are underway about whether to give pregnant women one of two relatively new acellular pertussis vaccines licensed for use in adolescents, Dr. Healy said.

“Hispanic women, especially adolescents, should be immunized with newly licensed acellular pertussis vaccine to prevent pertussis in themselves and life-threatening disease in their infants,” she concluded in her poster.

Pertussis incidence is increasing among infants younger than 4 months of age, too young to have completed the DTaP primary vaccination series at ages 2, 4, and 6 months. The annual incidence of pertussis in the United States increased fivefold since 1980 despite childhood immunization rates above 80%, mainly due to disease in the youngest infants, according to federal statistics.

Pertussis incidence was 74% higher in Hispanic infants than in infants of other ethnicities throughout the 1990s despite comparable childhood immunization rates. Pertussis was reported in 68/100,000 Hispanic infants, compared with 39/100,000 non-Hispanic infants. Among infant deaths from pertussis between 1990 and 2000, 36%–41% who died were Hispanic infants. In addition, Hispanics made up 19% of children in 2003, according to U.S. Census data. The reasons for this ethnic difference in pertussis are unclear and require further study, she said.

Mothers of the 220 infants in the study had a mean age of 26 years (ranging from 14 to 42 years), and they reported a mean of 8 years of education.

Thirty percent did not begin prenatal care until the second trimester and 28% had fewer than nine prenatal care visits, which the investigators considered to be delayed prenatal care and inadequate prenatal care, respectively.

For the 55 matched mother-infant pairs, investigators stratified them by age groups of Hispanic mothers in Texas: 10% aged 10–19 years, 30% aged 20–24 years, 30% aged 25–29 years, and 30% aged 30 years or older.

The investigators quantified pertussis antibody levels using enzyme-linked immunosorbent assay (ELISA). The geometric mean concentration of pertussis toxin-specific IgG was 8.45 ELISA U/mL for all infants and 4.63 ELISA U/mL for infants of adolescent mothers, which was a significant difference, Dr. Healy said.

SAN FRANCISCO — Low levels of immunity to pertussis in adolescent Hispanic mothers and their newborns may help explain their overrepresentation in pertussis cases and in deaths from the disease, C. Mary Healy, M.D., said in a poster presentation at the annual meeting of the Infectious Diseases Society of America.

A study of pertussis toxin-specific IgG concentrations found low concentrations in umbilical cord blood from 220 consecutive term singletons born to Hispanic women, with the lowest geometric mean concentrations in infants born to adolescent mothers. The low antibody levels likely reflect waning of vaccine-induced or natural immunity, she said.

Dr. Healy of Baylor College of Medicine, Houston, and her associates also compared pertussis toxin-specific IgG concentrations in blood samples from 55 mothers and their infants and found a ratio indicating efficient transfer of antibodies across the placenta. That suggests that one reason infants may be so susceptible to acquiring life-threatening pertussis in the first 4 months of life is because their mothers supply them with few antibodies.

“If you have high levels in the mothers, for example through vaccination, then the likelihood is that the antibodies will transmit very efficiently to infants and, hopefully, protect them at that most vulnerable period in the first few months of life before they begin their primary series of immunizations,” she said in an interview at the meeting.

Currently there are no recommendations to vaccinate pregnant women against pertussis. Discussions are underway about whether to give pregnant women one of two relatively new acellular pertussis vaccines licensed for use in adolescents, Dr. Healy said.

“Hispanic women, especially adolescents, should be immunized with newly licensed acellular pertussis vaccine to prevent pertussis in themselves and life-threatening disease in their infants,” she concluded in her poster.

Pertussis incidence is increasing among infants younger than 4 months of age, too young to have completed the DTaP primary vaccination series at ages 2, 4, and 6 months. The annual incidence of pertussis in the United States increased fivefold since 1980 despite childhood immunization rates above 80%, mainly due to disease in the youngest infants, according to federal statistics.

Pertussis incidence was 74% higher in Hispanic infants than in infants of other ethnicities throughout the 1990s despite comparable childhood immunization rates. Pertussis was reported in 68/100,000 Hispanic infants, compared with 39/100,000 non-Hispanic infants. Among infant deaths from pertussis between 1990 and 2000, 36%–41% who died were Hispanic infants. In addition, Hispanics made up 19% of children in 2003, according to U.S. Census data. The reasons for this ethnic difference in pertussis are unclear and require further study, she said.

Mothers of the 220 infants in the study had a mean age of 26 years (ranging from 14 to 42 years), and they reported a mean of 8 years of education.

Thirty percent did not begin prenatal care until the second trimester and 28% had fewer than nine prenatal care visits, which the investigators considered to be delayed prenatal care and inadequate prenatal care, respectively.

For the 55 matched mother-infant pairs, investigators stratified them by age groups of Hispanic mothers in Texas: 10% aged 10–19 years, 30% aged 20–24 years, 30% aged 25–29 years, and 30% aged 30 years or older.

The investigators quantified pertussis antibody levels using enzyme-linked immunosorbent assay (ELISA). The geometric mean concentration of pertussis toxin-specific IgG was 8.45 ELISA U/mL for all infants and 4.63 ELISA U/mL for infants of adolescent mothers, which was a significant difference, Dr. Healy said.

RANCHO MIRAGE, CALIF. — Supracervical hysterectomy did not leave women with better sexual function or quality of life, compared with total abdominal hysterectomy in the first randomized study to evaluate these outcomes in women who have had an abdominal hysterectomy.

Renewed interest in supracervical hysterectomies in recent decades grew out of speculation that women undergoing hysterectomies might enjoy better postoperative sexual function if the cervix were left intact.

The study's findings confirm previous nonrandomized results from British, Danish, and Finnish studies that found no difference in function or quality of life with supracervical rather than total abdominal hysterectomy.

“I hope we can separate myth from reality in counseling patients” who are considering hysterectomy, Lee Learman, M.D., said at the annual meeting of the Society of Gynecologic Surgeons.

The study included 135 women scheduled for hysterectomies at four U.S. clinical centers to treat symptomatic uterine fibroids and/or abnormal uterine bleeding refractory to hormonal management.

At randomization, women in the supracervical hysterectomy group had higher scores on the 100-point Medical Outcomes Study sexual problems scale, with 100 representing no problems. The mean score of 69 suggested better baseline sexual function, compared with the abdominal hysterectomy group (mean score of 55).

Phone interviews 4 weeks after surgery and then every 3 months for 2 years found significant improvements in sexual problems scores in both groups within 6 months. Scores plateaued by 1 year. At 2 years, scores were similar between groups—82 in the supracervical hysterectomy group, and 80 in the abdominal hysterectomy group, said Dr. Learman of San Francisco General Hospital, and his associates.

The principal investigator for the study was Miriam Kupperman, Ph.D., also of the hospital.

The supracervical hysterectomy group reported higher orgasm frequency and quality scores at 6 months, but no differences between groups were seen at 2 years.

Both groups reported psychological benefits even before they had physically recovered from the surgery, quality of life assessments found. Health-related quality of life after hysterectomy was similar between groups.

RANCHO MIRAGE, CALIF. — Supracervical hysterectomy did not leave women with better sexual function or quality of life, compared with total abdominal hysterectomy in the first randomized study to evaluate these outcomes in women who have had an abdominal hysterectomy.

Renewed interest in supracervical hysterectomies in recent decades grew out of speculation that women undergoing hysterectomies might enjoy better postoperative sexual function if the cervix were left intact.

The study's findings confirm previous nonrandomized results from British, Danish, and Finnish studies that found no difference in function or quality of life with supracervical rather than total abdominal hysterectomy.

“I hope we can separate myth from reality in counseling patients” who are considering hysterectomy, Lee Learman, M.D., said at the annual meeting of the Society of Gynecologic Surgeons.

The study included 135 women scheduled for hysterectomies at four U.S. clinical centers to treat symptomatic uterine fibroids and/or abnormal uterine bleeding refractory to hormonal management.

At randomization, women in the supracervical hysterectomy group had higher scores on the 100-point Medical Outcomes Study sexual problems scale, with 100 representing no problems. The mean score of 69 suggested better baseline sexual function, compared with the abdominal hysterectomy group (mean score of 55).

Phone interviews 4 weeks after surgery and then every 3 months for 2 years found significant improvements in sexual problems scores in both groups within 6 months. Scores plateaued by 1 year. At 2 years, scores were similar between groups—82 in the supracervical hysterectomy group, and 80 in the abdominal hysterectomy group, said Dr. Learman of San Francisco General Hospital, and his associates.

The principal investigator for the study was Miriam Kupperman, Ph.D., also of the hospital.

The supracervical hysterectomy group reported higher orgasm frequency and quality scores at 6 months, but no differences between groups were seen at 2 years.

Both groups reported psychological benefits even before they had physically recovered from the surgery, quality of life assessments found. Health-related quality of life after hysterectomy was similar between groups.

RANCHO MIRAGE, CALIF. — Supracervical hysterectomy did not leave women with better sexual function or quality of life, compared with total abdominal hysterectomy in the first randomized study to evaluate these outcomes in women who have had an abdominal hysterectomy.

Renewed interest in supracervical hysterectomies in recent decades grew out of speculation that women undergoing hysterectomies might enjoy better postoperative sexual function if the cervix were left intact.

The study's findings confirm previous nonrandomized results from British, Danish, and Finnish studies that found no difference in function or quality of life with supracervical rather than total abdominal hysterectomy.

“I hope we can separate myth from reality in counseling patients” who are considering hysterectomy, Lee Learman, M.D., said at the annual meeting of the Society of Gynecologic Surgeons.

The study included 135 women scheduled for hysterectomies at four U.S. clinical centers to treat symptomatic uterine fibroids and/or abnormal uterine bleeding refractory to hormonal management.

At randomization, women in the supracervical hysterectomy group had higher scores on the 100-point Medical Outcomes Study sexual problems scale, with 100 representing no problems. The mean score of 69 suggested better baseline sexual function, compared with the abdominal hysterectomy group (mean score of 55).

Phone interviews 4 weeks after surgery and then every 3 months for 2 years found significant improvements in sexual problems scores in both groups within 6 months. Scores plateaued by 1 year. At 2 years, scores were similar between groups—82 in the supracervical hysterectomy group, and 80 in the abdominal hysterectomy group, said Dr. Learman of San Francisco General Hospital, and his associates.

The principal investigator for the study was Miriam Kupperman, Ph.D., also of the hospital.

The supracervical hysterectomy group reported higher orgasm frequency and quality scores at 6 months, but no differences between groups were seen at 2 years.

Both groups reported psychological benefits even before they had physically recovered from the surgery, quality of life assessments found. Health-related quality of life after hysterectomy was similar between groups.