Sherry Boschert

One in every 640 young adults in the United States survived cancer as a child, and approximately two-thirds of them have at least one chronic health problem.

Better cancer treatments in recent decades increased pediatric cancer survivor rates from below 50% to today's average of 80%, and as a result there is more focus on the long-term medical needs of survivors. Depending on their disease and the treatment they received, these patients are at higher risk for secondary cancers, cardiovascular and lung diseases, learning disabilities and memory difficulties, vision and hearing problems, or infertility.

Long-term follow-up programs for childhood cancer survivors have proliferated in the past 5 years, but too often these patients aren't recognized or adequately cared for, Dr. Anna T. Meadows said in an interview.

“There aren't enough primary care doctors who want to undertake follow-up of pediatric cancer survivors,” said Dr. Meadows, director of the Cancer Survivorship Project and the Living Well After Childhood Cancer program at the Children's Hospital of Philadelphia. “People are not really thinking that the kids grow up, when the average age of our survivors is now in the 40s.”

Dr. Meadows and her associates reviewed reports of subsequent neoplasms in 14,358 participants in the National Cancer Institute's Childhood Cancer Survivor Study. They estimated 30-year cumulative incidences of 9% for second malignant neoplasms and 7% for nonmelanoma skin cancers (J. Clin. Oncol. 2009;27:2356-62).

Although only 13% of the cohort were survivors of Hodgkin's lymphoma, these patients accounted for 34% of the second malignant neoplasms, mainly because of an increased risk for breast cancer; among 157 second breast cancers, 60% were Hodgkin's survivors. The largest proportions of nonmelanoma skin cancers occurred in survivors of Hodgkin's lymphoma (38%), leukemia (32%), and CNS tumors (9%).

A separate systematic review by Dr. Tara Henderson, which is slated to be published in the April issue of the Annals of Internal Medicine, found a 12%-21% risk for breast cancer in female survivors of Hodgkin's lymphoma who were treated with radiation.

“It's the same incidence as in women who have a BRCA mutation, so it's very high risk,” said Dr. Henderson, a pediatric oncologist and director of the Childhood Cancer Survivors Center at the University of Chicago, in an interview.

Like breast cancers in the general population, breast cancer in childhood cancer survivors is curable if diagnosed early, Dr. Henderson noted, so she recommends earlier screening for breast cancer in Hodgkin's lymphoma patients—starting mammography and MRI screening 8 years after treatment or at age 25 years, whichever comes last.

Radiation therapy also commonly increases later risk for skin cancers, sarcomas, and thyroid cancer. “We just have to make clinicians aware that the risk is there,” she said.

Dr. Paul Nathan agreed. If “an adult shows up in your practice for a particular problem who has had cancer as a child, you need to pay close attention,” he said in an interview. “Lumps or bumps that you may otherwise think are fairly innocent in a 20- or 30-year-old may not be” innocuous in cancer survivors, said Dr. Nathan, a hematologist/oncologist at the Hospital for Sick Children, Toronto.

He recommends that physicians consult guidelines for long-term follow-up of childhood cancer survivors, which are updated every 2 years by the Children's Oncology Group and are available at www.survivorshipguidelines.org

It's not uncommon, however, for adult patients to know little about their childhood cancer diagnosis or treatment. A grant from the Agency for Healthcare Research and Quality is helping Dr. Karen J. Wasilewski-Masker and her associates at Children's Healthcare of Atlanta to develop SurvivorLink, a computerized network. In what may be the first project of its kind in the country, SurvivorLink would give primary care physicians, surgeons, and other specialists throughout Georgia access to medical summaries and information on any patient seen in her institution's Childhood Cancer Survivorship Program, she said in an interview.

Not only do survivors need to be educated, so does the medical community. “These patients are out there and have health risks and need to be followed,” Dr. Daniel A. Mulrooney said in a separate interview. Today's physicians learned next to nothing about childhood cancer survivors in their medical training, and it's unlikely that current medical school curricula cover the topic either, he suggested.

“The cumulative incidence curves for secondary cancers [in childhood cancer survivors] have not yet plateaued—we haven't seen any type of downturn,” said Dr. Mulrooney, a pediatric hematologist/oncologist at the University of Minnesota, Minneapolis. “These cancers develop earlier than expected and are likely to increase over time.” It will be challenging, because these patients will grow to the age when cancers are more common.

All of the physicians interviewed for this article declared that they have no conflicts of interest.

'There aren't enough primary care doctors who want to undertake follow-up of pediatric cancer survivors.'

Source DR. MEADOWS

One in every 640 young adults in the United States survived cancer as a child, and approximately two-thirds of them have at least one chronic health problem.

Better cancer treatments in recent decades increased pediatric cancer survivor rates from below 50% to today's average of 80%, and as a result there is more focus on the long-term medical needs of survivors. Depending on their disease and the treatment they received, these patients are at higher risk for secondary cancers, cardiovascular and lung diseases, learning disabilities and memory difficulties, vision and hearing problems, or infertility.

Long-term follow-up programs for childhood cancer survivors have proliferated in the past 5 years, but too often these patients aren't recognized or adequately cared for, Dr. Anna T. Meadows said in an interview.

“There aren't enough primary care doctors who want to undertake follow-up of pediatric cancer survivors,” said Dr. Meadows, director of the Cancer Survivorship Project and the Living Well After Childhood Cancer program at the Children's Hospital of Philadelphia. “People are not really thinking that the kids grow up, when the average age of our survivors is now in the 40s.”

Dr. Meadows and her associates reviewed reports of subsequent neoplasms in 14,358 participants in the National Cancer Institute's Childhood Cancer Survivor Study. They estimated 30-year cumulative incidences of 9% for second malignant neoplasms and 7% for nonmelanoma skin cancers (J. Clin. Oncol. 2009;27:2356-62).

Although only 13% of the cohort were survivors of Hodgkin's lymphoma, these patients accounted for 34% of the second malignant neoplasms, mainly because of an increased risk for breast cancer; among 157 second breast cancers, 60% were Hodgkin's survivors. The largest proportions of nonmelanoma skin cancers occurred in survivors of Hodgkin's lymphoma (38%), leukemia (32%), and CNS tumors (9%).

A separate systematic review by Dr. Tara Henderson, which is slated to be published in the April issue of the Annals of Internal Medicine, found a 12%-21% risk for breast cancer in female survivors of Hodgkin's lymphoma who were treated with radiation.

“It's the same incidence as in women who have a BRCA mutation, so it's very high risk,” said Dr. Henderson, a pediatric oncologist and director of the Childhood Cancer Survivors Center at the University of Chicago, in an interview.

Like breast cancers in the general population, breast cancer in childhood cancer survivors is curable if diagnosed early, Dr. Henderson noted, so she recommends earlier screening for breast cancer in Hodgkin's lymphoma patients—starting mammography and MRI screening 8 years after treatment or at age 25 years, whichever comes last.

Radiation therapy also commonly increases later risk for skin cancers, sarcomas, and thyroid cancer. “We just have to make clinicians aware that the risk is there,” she said.

Dr. Paul Nathan agreed. If “an adult shows up in your practice for a particular problem who has had cancer as a child, you need to pay close attention,” he said in an interview. “Lumps or bumps that you may otherwise think are fairly innocent in a 20- or 30-year-old may not be” innocuous in cancer survivors, said Dr. Nathan, a hematologist/oncologist at the Hospital for Sick Children, Toronto.

He recommends that physicians consult guidelines for long-term follow-up of childhood cancer survivors, which are updated every 2 years by the Children's Oncology Group and are available at www.survivorshipguidelines.org

It's not uncommon, however, for adult patients to know little about their childhood cancer diagnosis or treatment. A grant from the Agency for Healthcare Research and Quality is helping Dr. Karen J. Wasilewski-Masker and her associates at Children's Healthcare of Atlanta to develop SurvivorLink, a computerized network. In what may be the first project of its kind in the country, SurvivorLink would give primary care physicians, surgeons, and other specialists throughout Georgia access to medical summaries and information on any patient seen in her institution's Childhood Cancer Survivorship Program, she said in an interview.

Not only do survivors need to be educated, so does the medical community. “These patients are out there and have health risks and need to be followed,” Dr. Daniel A. Mulrooney said in a separate interview. Today's physicians learned next to nothing about childhood cancer survivors in their medical training, and it's unlikely that current medical school curricula cover the topic either, he suggested.

“The cumulative incidence curves for secondary cancers [in childhood cancer survivors] have not yet plateaued—we haven't seen any type of downturn,” said Dr. Mulrooney, a pediatric hematologist/oncologist at the University of Minnesota, Minneapolis. “These cancers develop earlier than expected and are likely to increase over time.” It will be challenging, because these patients will grow to the age when cancers are more common.

All of the physicians interviewed for this article declared that they have no conflicts of interest.

'There aren't enough primary care doctors who want to undertake follow-up of pediatric cancer survivors.'

Source DR. MEADOWS

One in every 640 young adults in the United States survived cancer as a child, and approximately two-thirds of them have at least one chronic health problem.

Better cancer treatments in recent decades increased pediatric cancer survivor rates from below 50% to today's average of 80%, and as a result there is more focus on the long-term medical needs of survivors. Depending on their disease and the treatment they received, these patients are at higher risk for secondary cancers, cardiovascular and lung diseases, learning disabilities and memory difficulties, vision and hearing problems, or infertility.

Long-term follow-up programs for childhood cancer survivors have proliferated in the past 5 years, but too often these patients aren't recognized or adequately cared for, Dr. Anna T. Meadows said in an interview.

“There aren't enough primary care doctors who want to undertake follow-up of pediatric cancer survivors,” said Dr. Meadows, director of the Cancer Survivorship Project and the Living Well After Childhood Cancer program at the Children's Hospital of Philadelphia. “People are not really thinking that the kids grow up, when the average age of our survivors is now in the 40s.”

Dr. Meadows and her associates reviewed reports of subsequent neoplasms in 14,358 participants in the National Cancer Institute's Childhood Cancer Survivor Study. They estimated 30-year cumulative incidences of 9% for second malignant neoplasms and 7% for nonmelanoma skin cancers (J. Clin. Oncol. 2009;27:2356-62).

Although only 13% of the cohort were survivors of Hodgkin's lymphoma, these patients accounted for 34% of the second malignant neoplasms, mainly because of an increased risk for breast cancer; among 157 second breast cancers, 60% were Hodgkin's survivors. The largest proportions of nonmelanoma skin cancers occurred in survivors of Hodgkin's lymphoma (38%), leukemia (32%), and CNS tumors (9%).

A separate systematic review by Dr. Tara Henderson, which is slated to be published in the April issue of the Annals of Internal Medicine, found a 12%-21% risk for breast cancer in female survivors of Hodgkin's lymphoma who were treated with radiation.

“It's the same incidence as in women who have a BRCA mutation, so it's very high risk,” said Dr. Henderson, a pediatric oncologist and director of the Childhood Cancer Survivors Center at the University of Chicago, in an interview.

Like breast cancers in the general population, breast cancer in childhood cancer survivors is curable if diagnosed early, Dr. Henderson noted, so she recommends earlier screening for breast cancer in Hodgkin's lymphoma patients—starting mammography and MRI screening 8 years after treatment or at age 25 years, whichever comes last.

Radiation therapy also commonly increases later risk for skin cancers, sarcomas, and thyroid cancer. “We just have to make clinicians aware that the risk is there,” she said.

Dr. Paul Nathan agreed. If “an adult shows up in your practice for a particular problem who has had cancer as a child, you need to pay close attention,” he said in an interview. “Lumps or bumps that you may otherwise think are fairly innocent in a 20- or 30-year-old may not be” innocuous in cancer survivors, said Dr. Nathan, a hematologist/oncologist at the Hospital for Sick Children, Toronto.

He recommends that physicians consult guidelines for long-term follow-up of childhood cancer survivors, which are updated every 2 years by the Children's Oncology Group and are available at www.survivorshipguidelines.org

It's not uncommon, however, for adult patients to know little about their childhood cancer diagnosis or treatment. A grant from the Agency for Healthcare Research and Quality is helping Dr. Karen J. Wasilewski-Masker and her associates at Children's Healthcare of Atlanta to develop SurvivorLink, a computerized network. In what may be the first project of its kind in the country, SurvivorLink would give primary care physicians, surgeons, and other specialists throughout Georgia access to medical summaries and information on any patient seen in her institution's Childhood Cancer Survivorship Program, she said in an interview.

Not only do survivors need to be educated, so does the medical community. “These patients are out there and have health risks and need to be followed,” Dr. Daniel A. Mulrooney said in a separate interview. Today's physicians learned next to nothing about childhood cancer survivors in their medical training, and it's unlikely that current medical school curricula cover the topic either, he suggested.

“The cumulative incidence curves for secondary cancers [in childhood cancer survivors] have not yet plateaued—we haven't seen any type of downturn,” said Dr. Mulrooney, a pediatric hematologist/oncologist at the University of Minnesota, Minneapolis. “These cancers develop earlier than expected and are likely to increase over time.” It will be challenging, because these patients will grow to the age when cancers are more common.

All of the physicians interviewed for this article declared that they have no conflicts of interest.

'There aren't enough primary care doctors who want to undertake follow-up of pediatric cancer survivors.'

Source DR. MEADOWS

SAN FRANCISCO — Sleep apnea can cause metabolic dysfunction, some of which can be reversed by treating the disorder with continuous positive airway pressure, a small 8-week study of 29 patients suggests.

Nine women with polycystic ovarian syndrome (PCOS) and 20 women without PCOS, all of whom had obstructive sleep apnea, were treated with continuous positive airway pressure (CPAP) at home for 8 weeks. Investigators monitored the use of CPAP to ensure good compliance, and took metabolic measurements at the start and end of the study.

Measures of sleep quality improved for the cohort as a whole after treatment. This was accompanied by both nighttime and daytime reductions in catecholamine levels, Dr. David A. Ehrmann said at the Sixth Annual World Congress on Insulin Resistance Syndrome.

“This has important implications in terms of both the metabolic and cardiovascular effects of obstructive sleep apnea in this population,” said Dr. Ehrmann, professor of medicine at the University of Chicago.

Sophisticated spectral analysis of heart rate variability as a measure of autonomic function showed that lowered catecholamine levels were reflected functionally in a slowing of heart rate, a lower autonomic function, and a lesser degree of epinephrine-induced variability in heart rate after treatment with CPAP, he added.

In lean subjects, greater compliance with CPAP therapy was associated with increased insulin sensitivity. Obese subjects showed a lesser improvement in insulin sensitivity—but an improvement nonetheless—that also was associated with greater use of CPAP, Dr. Ehrmann said. “There's sort of a dose-response relationship between the use of CPAP and changes in metabolic measurements,” he noted.

Among the measures of sleep quality that improved significantly with CPAP therapy, the apnea-hypopnea index score decreased from 24 to 2 per hour of sleep. The oxygen desaturation index score decreased from 12 to 1 per hour of sleep. The arousal index score decreased from 27 to 23 per hour of sleep.

Sleep apnea is recognized as a reversible risk factor for hypertension and for a number of abnormalities associated with insulin resistance syndromes. Women with PCOS are predisposed to develop obstructive sleep apnea at a rate sevenfold higher than women without PCOS, previous studies suggest. Although obesity plays a role, it does not by itself fully account for the higher risk for sleep apnea in women with PCOS.

Nor does androgen excess explain the higher prevalence of sleep apnea with PCOS, he added. In the nine women with PCOS in his study, 24-hour cortisol levels did not change significantly after CPAP treatment, compared with baseline.

In a previous study of 53 women with PCOS and 452 controls, the PCOS group was 30 times more likely to have sleep-disordered breathing and nine times more likely to have daytime sleepiness after researchers controlled for body mass index. Insulin resistance was a stronger predictor of sleep-disordered breathing than was age, BMI, or testosterone levels (J. Clin. Endocrinol. Metab. 2001;86:517-20).

A separate study found that in 29 women with PCOS and 4 controls with obstructive sleep apnea, the risk for apnea was seven times higher in the PCOS group (J. Clin. Endocrinol. Metab. 2006;91:36-42). In that study, the likelihood of impaired glucose correlated with the severity of sleep apnea.

Another study by Dr. Ehrmann and his associates showed that 29 women with PCOS and sleep apnea were significantly more insulin resistant than were 23 women with PCOS but not apnea (J. Clin. Endocrinol. Metab. 2008;93:3878-84).

Disclosures: Dr. Ehrmann reported having no relevant conflicts of interest.

SAN FRANCISCO — Sleep apnea can cause metabolic dysfunction, some of which can be reversed by treating the disorder with continuous positive airway pressure, a small 8-week study of 29 patients suggests.

Nine women with polycystic ovarian syndrome (PCOS) and 20 women without PCOS, all of whom had obstructive sleep apnea, were treated with continuous positive airway pressure (CPAP) at home for 8 weeks. Investigators monitored the use of CPAP to ensure good compliance, and took metabolic measurements at the start and end of the study.

Measures of sleep quality improved for the cohort as a whole after treatment. This was accompanied by both nighttime and daytime reductions in catecholamine levels, Dr. David A. Ehrmann said at the Sixth Annual World Congress on Insulin Resistance Syndrome.

“This has important implications in terms of both the metabolic and cardiovascular effects of obstructive sleep apnea in this population,” said Dr. Ehrmann, professor of medicine at the University of Chicago.

Sophisticated spectral analysis of heart rate variability as a measure of autonomic function showed that lowered catecholamine levels were reflected functionally in a slowing of heart rate, a lower autonomic function, and a lesser degree of epinephrine-induced variability in heart rate after treatment with CPAP, he added.

In lean subjects, greater compliance with CPAP therapy was associated with increased insulin sensitivity. Obese subjects showed a lesser improvement in insulin sensitivity—but an improvement nonetheless—that also was associated with greater use of CPAP, Dr. Ehrmann said. “There's sort of a dose-response relationship between the use of CPAP and changes in metabolic measurements,” he noted.

Among the measures of sleep quality that improved significantly with CPAP therapy, the apnea-hypopnea index score decreased from 24 to 2 per hour of sleep. The oxygen desaturation index score decreased from 12 to 1 per hour of sleep. The arousal index score decreased from 27 to 23 per hour of sleep.

Sleep apnea is recognized as a reversible risk factor for hypertension and for a number of abnormalities associated with insulin resistance syndromes. Women with PCOS are predisposed to develop obstructive sleep apnea at a rate sevenfold higher than women without PCOS, previous studies suggest. Although obesity plays a role, it does not by itself fully account for the higher risk for sleep apnea in women with PCOS.

Nor does androgen excess explain the higher prevalence of sleep apnea with PCOS, he added. In the nine women with PCOS in his study, 24-hour cortisol levels did not change significantly after CPAP treatment, compared with baseline.

In a previous study of 53 women with PCOS and 452 controls, the PCOS group was 30 times more likely to have sleep-disordered breathing and nine times more likely to have daytime sleepiness after researchers controlled for body mass index. Insulin resistance was a stronger predictor of sleep-disordered breathing than was age, BMI, or testosterone levels (J. Clin. Endocrinol. Metab. 2001;86:517-20).

A separate study found that in 29 women with PCOS and 4 controls with obstructive sleep apnea, the risk for apnea was seven times higher in the PCOS group (J. Clin. Endocrinol. Metab. 2006;91:36-42). In that study, the likelihood of impaired glucose correlated with the severity of sleep apnea.

Another study by Dr. Ehrmann and his associates showed that 29 women with PCOS and sleep apnea were significantly more insulin resistant than were 23 women with PCOS but not apnea (J. Clin. Endocrinol. Metab. 2008;93:3878-84).

Disclosures: Dr. Ehrmann reported having no relevant conflicts of interest.

SAN FRANCISCO — Sleep apnea can cause metabolic dysfunction, some of which can be reversed by treating the disorder with continuous positive airway pressure, a small 8-week study of 29 patients suggests.

Nine women with polycystic ovarian syndrome (PCOS) and 20 women without PCOS, all of whom had obstructive sleep apnea, were treated with continuous positive airway pressure (CPAP) at home for 8 weeks. Investigators monitored the use of CPAP to ensure good compliance, and took metabolic measurements at the start and end of the study.

Measures of sleep quality improved for the cohort as a whole after treatment. This was accompanied by both nighttime and daytime reductions in catecholamine levels, Dr. David A. Ehrmann said at the Sixth Annual World Congress on Insulin Resistance Syndrome.

“This has important implications in terms of both the metabolic and cardiovascular effects of obstructive sleep apnea in this population,” said Dr. Ehrmann, professor of medicine at the University of Chicago.

Sophisticated spectral analysis of heart rate variability as a measure of autonomic function showed that lowered catecholamine levels were reflected functionally in a slowing of heart rate, a lower autonomic function, and a lesser degree of epinephrine-induced variability in heart rate after treatment with CPAP, he added.

In lean subjects, greater compliance with CPAP therapy was associated with increased insulin sensitivity. Obese subjects showed a lesser improvement in insulin sensitivity—but an improvement nonetheless—that also was associated with greater use of CPAP, Dr. Ehrmann said. “There's sort of a dose-response relationship between the use of CPAP and changes in metabolic measurements,” he noted.

Among the measures of sleep quality that improved significantly with CPAP therapy, the apnea-hypopnea index score decreased from 24 to 2 per hour of sleep. The oxygen desaturation index score decreased from 12 to 1 per hour of sleep. The arousal index score decreased from 27 to 23 per hour of sleep.

Sleep apnea is recognized as a reversible risk factor for hypertension and for a number of abnormalities associated with insulin resistance syndromes. Women with PCOS are predisposed to develop obstructive sleep apnea at a rate sevenfold higher than women without PCOS, previous studies suggest. Although obesity plays a role, it does not by itself fully account for the higher risk for sleep apnea in women with PCOS.

Nor does androgen excess explain the higher prevalence of sleep apnea with PCOS, he added. In the nine women with PCOS in his study, 24-hour cortisol levels did not change significantly after CPAP treatment, compared with baseline.

In a previous study of 53 women with PCOS and 452 controls, the PCOS group was 30 times more likely to have sleep-disordered breathing and nine times more likely to have daytime sleepiness after researchers controlled for body mass index. Insulin resistance was a stronger predictor of sleep-disordered breathing than was age, BMI, or testosterone levels (J. Clin. Endocrinol. Metab. 2001;86:517-20).

A separate study found that in 29 women with PCOS and 4 controls with obstructive sleep apnea, the risk for apnea was seven times higher in the PCOS group (J. Clin. Endocrinol. Metab. 2006;91:36-42). In that study, the likelihood of impaired glucose correlated with the severity of sleep apnea.

Another study by Dr. Ehrmann and his associates showed that 29 women with PCOS and sleep apnea were significantly more insulin resistant than were 23 women with PCOS but not apnea (J. Clin. Endocrinol. Metab. 2008;93:3878-84).

Disclosures: Dr. Ehrmann reported having no relevant conflicts of interest.

SAN DIEGO — Poor bowel preparation before colonoscopy influenced physicians to recommend follow-up colonoscopies 17 months sooner than they suggested for patients with adequate bowel preparation in a retrospective cohort study of 788 patients.

A 17-month shortening of the follow-up interval also occurred when colonoscopists found an adenoma, suggesting that colonoscopists considered the quality of bowel preparation to be an important factor when determining the follow-up interval, Dr. Veronika Karasek said in a poster presentation at the annual meeting of the American College of Gastroenterology.

The retrospective study included 788 patients with a mean age of 62 years and an average follow-up interval of 60 months. The follow-up interval was shortened by 2.5 months on average for each polyp found, and by 17.2 months on average if an adenoma was found, reported Dr. Karasek of the Veterans Affairs Medical Center, Phoenix and her colleagues. Adenomas were found in 42% of cases, and polyps were found in 60%. Colonoscopy detected a mean of 1.7 polyps per patient.

Bowel preparation was reported as adequate in 75% of colonoscopies. If bowel prep was inadequate, “17.1 months were subtracted from average follow-up time,” the authors said.

Good bowel preparation became more challenging in December 2008 when the Food and Drug Administration removed a commonly used, over-the-counter bowel preparation method containing Phospho-soda from the market.

In a separate poster at the meeting, two non–Phospho-soda bowel preparations for colonoscopy—an over-the-counter magnesium citrate solution or 2 L of polyethylene glycol plus ascorbic acid (MoviPrep)—provided good to excellent colon cleansing in a randomized pilot study of 87 patients.

The adequacy of bowel preparation was rated higher in patients who got the split-dose regimen, compared with whole-dose administration, reported Dr. Ron Palmon of Mount Sinai School of Medicine, New York, and his associates

Disclosures: Dr. Karasek reported having no relevant conflicts of interest related to her study. Dr. Palmon's study was funded by Salix Pharmaceuticals Ltd., which markets MoviPrep.

The quality of bowel preparation was seen as important for determining the follow-up interval.

Source DR. KARASEK

SAN DIEGO — Poor bowel preparation before colonoscopy influenced physicians to recommend follow-up colonoscopies 17 months sooner than they suggested for patients with adequate bowel preparation in a retrospective cohort study of 788 patients.

A 17-month shortening of the follow-up interval also occurred when colonoscopists found an adenoma, suggesting that colonoscopists considered the quality of bowel preparation to be an important factor when determining the follow-up interval, Dr. Veronika Karasek said in a poster presentation at the annual meeting of the American College of Gastroenterology.

The retrospective study included 788 patients with a mean age of 62 years and an average follow-up interval of 60 months. The follow-up interval was shortened by 2.5 months on average for each polyp found, and by 17.2 months on average if an adenoma was found, reported Dr. Karasek of the Veterans Affairs Medical Center, Phoenix and her colleagues. Adenomas were found in 42% of cases, and polyps were found in 60%. Colonoscopy detected a mean of 1.7 polyps per patient.

Bowel preparation was reported as adequate in 75% of colonoscopies. If bowel prep was inadequate, “17.1 months were subtracted from average follow-up time,” the authors said.

Good bowel preparation became more challenging in December 2008 when the Food and Drug Administration removed a commonly used, over-the-counter bowel preparation method containing Phospho-soda from the market.

In a separate poster at the meeting, two non–Phospho-soda bowel preparations for colonoscopy—an over-the-counter magnesium citrate solution or 2 L of polyethylene glycol plus ascorbic acid (MoviPrep)—provided good to excellent colon cleansing in a randomized pilot study of 87 patients.

The adequacy of bowel preparation was rated higher in patients who got the split-dose regimen, compared with whole-dose administration, reported Dr. Ron Palmon of Mount Sinai School of Medicine, New York, and his associates

Disclosures: Dr. Karasek reported having no relevant conflicts of interest related to her study. Dr. Palmon's study was funded by Salix Pharmaceuticals Ltd., which markets MoviPrep.

The quality of bowel preparation was seen as important for determining the follow-up interval.

Source DR. KARASEK

SAN DIEGO — Poor bowel preparation before colonoscopy influenced physicians to recommend follow-up colonoscopies 17 months sooner than they suggested for patients with adequate bowel preparation in a retrospective cohort study of 788 patients.

A 17-month shortening of the follow-up interval also occurred when colonoscopists found an adenoma, suggesting that colonoscopists considered the quality of bowel preparation to be an important factor when determining the follow-up interval, Dr. Veronika Karasek said in a poster presentation at the annual meeting of the American College of Gastroenterology.

The retrospective study included 788 patients with a mean age of 62 years and an average follow-up interval of 60 months. The follow-up interval was shortened by 2.5 months on average for each polyp found, and by 17.2 months on average if an adenoma was found, reported Dr. Karasek of the Veterans Affairs Medical Center, Phoenix and her colleagues. Adenomas were found in 42% of cases, and polyps were found in 60%. Colonoscopy detected a mean of 1.7 polyps per patient.

Bowel preparation was reported as adequate in 75% of colonoscopies. If bowel prep was inadequate, “17.1 months were subtracted from average follow-up time,” the authors said.

Good bowel preparation became more challenging in December 2008 when the Food and Drug Administration removed a commonly used, over-the-counter bowel preparation method containing Phospho-soda from the market.

In a separate poster at the meeting, two non–Phospho-soda bowel preparations for colonoscopy—an over-the-counter magnesium citrate solution or 2 L of polyethylene glycol plus ascorbic acid (MoviPrep)—provided good to excellent colon cleansing in a randomized pilot study of 87 patients.

The adequacy of bowel preparation was rated higher in patients who got the split-dose regimen, compared with whole-dose administration, reported Dr. Ron Palmon of Mount Sinai School of Medicine, New York, and his associates

Disclosures: Dr. Karasek reported having no relevant conflicts of interest related to her study. Dr. Palmon's study was funded by Salix Pharmaceuticals Ltd., which markets MoviPrep.

The quality of bowel preparation was seen as important for determining the follow-up interval.

Source DR. KARASEK

SAN FRANCISCO — Because new medications for hepatitis C are expected to be approved within 2 years, some experts are waiting to treat selected patients.

“Over the last year, I've moved increasingly toward deferred treatment, which is a change for me,” Dr. Norah A. Terrault said. “We clearly will have drugs that are going to work better” when used with the current standard regimen of pegylated interferon (peg-IFN) and ribavirin, she said at a meeting on HIV management sponsored by the University of California, San Francisco.

Approval is anticipated in 2011 for two protease inhibitors—telaprevir and boceprevir—that have been in phase III clinical trials for the treatment of hepatitis C virus (HCV), said Dr. Terrault, director of the Viral Hepatitis Center at the university. Using either of these drugs as add-on therapy with peg-IFN plus ribavirin should “push our sustained viral response rates up over 50% consistently,” she said. (See box.)

Clinicians should weigh the pros and cons of immediately treating HCV in patients who are coinfected with HIV, Dr. Terrault suggested. Coinfected patients tend to have accelerated progression of HCV disease with more liver-associated morbidity and mortality, compared with patients who have HCV but not HIV. Treating HCV in coinfected patients may improve the patient's ability to take highly active antiretroviral therapy to combat HIV.

On the other hand, patient characteristics or comorbidities may make it nearly impossible for some patients to tolerate the toxicities associated with peg-IFN and ribavirin. In general, coinfected patients tolerate HCV therapy less well than monoinfected patients. Interactions between HCV drugs and antiretrovirals may necessitate a change in HIV therapy. Clinicians must be comfortable with helping patients get through HCV therapy for it to succeed, Dr. Terrault said.

The main reason to consider deferring HCV therapy, however, is that “better treatments are, I think, just around the corner,” she said.

All of the new HCV treatments in the pipeline are being developed primarily for genotype 1 HCV, so Dr. Terrault does not defer HCV therapy for coinfected patients with genotypes 2 or 3 HCV. Patients with low levels of HCV RNA (less than 600,000 IU/mL) are most likely to achieve a sustained viral response to HCV therapy regardless of genotype, so she still offers HCV therapy to this group. She also offers HCV treatment to patients with advanced fibrosis (bridging fibrosis or cirrhosis) because “they can't wait for new treatments,” she said.

Dr. Terrault also treats acute HCV in coinfected patients who are on stable antiretroviral therapy with no active opportunistic infections and CD4 counts over 200 cells/mm

Disclosures: Dr. Terrault has been a consultant to Schering-Plough Corp., which is developing boceprevir, and to three other companies. She has received grants from Vertex Pharmaceuticals Inc., which is developing telaprevir, and from two other companies.

Therapies in The Pipeline

New treatments for HCV are being developed in several drug classes.

Preliminary data from phase III clinical trials of the two new treatments closest to market entry—the protease inhibitors telaprevir and boceprevir—suggest improved response rates and added toxicities when used with peg-IFN and ribavirin.

Based on early results with telaprevir, she anticipates that 69% of treatment-naive patients will achieve a sustained viral response to treatment with 12 weeks of triple therapy (telaprevir, peg-IFN, and ribavirin) followed by 12-36 weeks of peg-IFN and ribavirin. This regimen could produce response rates of up to 39% in patients who had not responded to previous treatment with peg-IFN and ribavirin, and up to 76% in patients who had relapsed from previous therapy with peg-IFN and ribavirin.

The boceprevir treatment regimen starts with 4 weeks of peg-IFN and ribavirin followed by 24-44 weeks of triple therapy by adding boceprevir. Dr. Terrault anticipates a sustained viral response at 48 weeks in up to 74% of previously untreated patients with genotype 1 HCV and no HIV. No data are available on the use of boceprevir in treatment-experienced patients.

“This is add-on treatment, so you still have peg-interferon and ribavirin side effects, and now you have protease inhibitor side effects,” she noted. Telaprevir most commonly causes anemia, rash, or pruritus. Boceprevir most commonly causes anemia, neutropenia, or dysgeusia.

SAN FRANCISCO — Because new medications for hepatitis C are expected to be approved within 2 years, some experts are waiting to treat selected patients.

“Over the last year, I've moved increasingly toward deferred treatment, which is a change for me,” Dr. Norah A. Terrault said. “We clearly will have drugs that are going to work better” when used with the current standard regimen of pegylated interferon (peg-IFN) and ribavirin, she said at a meeting on HIV management sponsored by the University of California, San Francisco.

Approval is anticipated in 2011 for two protease inhibitors—telaprevir and boceprevir—that have been in phase III clinical trials for the treatment of hepatitis C virus (HCV), said Dr. Terrault, director of the Viral Hepatitis Center at the university. Using either of these drugs as add-on therapy with peg-IFN plus ribavirin should “push our sustained viral response rates up over 50% consistently,” she said. (See box.)

Clinicians should weigh the pros and cons of immediately treating HCV in patients who are coinfected with HIV, Dr. Terrault suggested. Coinfected patients tend to have accelerated progression of HCV disease with more liver-associated morbidity and mortality, compared with patients who have HCV but not HIV. Treating HCV in coinfected patients may improve the patient's ability to take highly active antiretroviral therapy to combat HIV.

On the other hand, patient characteristics or comorbidities may make it nearly impossible for some patients to tolerate the toxicities associated with peg-IFN and ribavirin. In general, coinfected patients tolerate HCV therapy less well than monoinfected patients. Interactions between HCV drugs and antiretrovirals may necessitate a change in HIV therapy. Clinicians must be comfortable with helping patients get through HCV therapy for it to succeed, Dr. Terrault said.

The main reason to consider deferring HCV therapy, however, is that “better treatments are, I think, just around the corner,” she said.

All of the new HCV treatments in the pipeline are being developed primarily for genotype 1 HCV, so Dr. Terrault does not defer HCV therapy for coinfected patients with genotypes 2 or 3 HCV. Patients with low levels of HCV RNA (less than 600,000 IU/mL) are most likely to achieve a sustained viral response to HCV therapy regardless of genotype, so she still offers HCV therapy to this group. She also offers HCV treatment to patients with advanced fibrosis (bridging fibrosis or cirrhosis) because “they can't wait for new treatments,” she said.

Dr. Terrault also treats acute HCV in coinfected patients who are on stable antiretroviral therapy with no active opportunistic infections and CD4 counts over 200 cells/mm

Disclosures: Dr. Terrault has been a consultant to Schering-Plough Corp., which is developing boceprevir, and to three other companies. She has received grants from Vertex Pharmaceuticals Inc., which is developing telaprevir, and from two other companies.

Therapies in The Pipeline

New treatments for HCV are being developed in several drug classes.

Preliminary data from phase III clinical trials of the two new treatments closest to market entry—the protease inhibitors telaprevir and boceprevir—suggest improved response rates and added toxicities when used with peg-IFN and ribavirin.

Based on early results with telaprevir, she anticipates that 69% of treatment-naive patients will achieve a sustained viral response to treatment with 12 weeks of triple therapy (telaprevir, peg-IFN, and ribavirin) followed by 12-36 weeks of peg-IFN and ribavirin. This regimen could produce response rates of up to 39% in patients who had not responded to previous treatment with peg-IFN and ribavirin, and up to 76% in patients who had relapsed from previous therapy with peg-IFN and ribavirin.

The boceprevir treatment regimen starts with 4 weeks of peg-IFN and ribavirin followed by 24-44 weeks of triple therapy by adding boceprevir. Dr. Terrault anticipates a sustained viral response at 48 weeks in up to 74% of previously untreated patients with genotype 1 HCV and no HIV. No data are available on the use of boceprevir in treatment-experienced patients.

“This is add-on treatment, so you still have peg-interferon and ribavirin side effects, and now you have protease inhibitor side effects,” she noted. Telaprevir most commonly causes anemia, rash, or pruritus. Boceprevir most commonly causes anemia, neutropenia, or dysgeusia.

SAN FRANCISCO — Because new medications for hepatitis C are expected to be approved within 2 years, some experts are waiting to treat selected patients.

“Over the last year, I've moved increasingly toward deferred treatment, which is a change for me,” Dr. Norah A. Terrault said. “We clearly will have drugs that are going to work better” when used with the current standard regimen of pegylated interferon (peg-IFN) and ribavirin, she said at a meeting on HIV management sponsored by the University of California, San Francisco.

Approval is anticipated in 2011 for two protease inhibitors—telaprevir and boceprevir—that have been in phase III clinical trials for the treatment of hepatitis C virus (HCV), said Dr. Terrault, director of the Viral Hepatitis Center at the university. Using either of these drugs as add-on therapy with peg-IFN plus ribavirin should “push our sustained viral response rates up over 50% consistently,” she said. (See box.)

Clinicians should weigh the pros and cons of immediately treating HCV in patients who are coinfected with HIV, Dr. Terrault suggested. Coinfected patients tend to have accelerated progression of HCV disease with more liver-associated morbidity and mortality, compared with patients who have HCV but not HIV. Treating HCV in coinfected patients may improve the patient's ability to take highly active antiretroviral therapy to combat HIV.

On the other hand, patient characteristics or comorbidities may make it nearly impossible for some patients to tolerate the toxicities associated with peg-IFN and ribavirin. In general, coinfected patients tolerate HCV therapy less well than monoinfected patients. Interactions between HCV drugs and antiretrovirals may necessitate a change in HIV therapy. Clinicians must be comfortable with helping patients get through HCV therapy for it to succeed, Dr. Terrault said.

The main reason to consider deferring HCV therapy, however, is that “better treatments are, I think, just around the corner,” she said.

All of the new HCV treatments in the pipeline are being developed primarily for genotype 1 HCV, so Dr. Terrault does not defer HCV therapy for coinfected patients with genotypes 2 or 3 HCV. Patients with low levels of HCV RNA (less than 600,000 IU/mL) are most likely to achieve a sustained viral response to HCV therapy regardless of genotype, so she still offers HCV therapy to this group. She also offers HCV treatment to patients with advanced fibrosis (bridging fibrosis or cirrhosis) because “they can't wait for new treatments,” she said.

Dr. Terrault also treats acute HCV in coinfected patients who are on stable antiretroviral therapy with no active opportunistic infections and CD4 counts over 200 cells/mm

Disclosures: Dr. Terrault has been a consultant to Schering-Plough Corp., which is developing boceprevir, and to three other companies. She has received grants from Vertex Pharmaceuticals Inc., which is developing telaprevir, and from two other companies.

Therapies in The Pipeline

New treatments for HCV are being developed in several drug classes.

Preliminary data from phase III clinical trials of the two new treatments closest to market entry—the protease inhibitors telaprevir and boceprevir—suggest improved response rates and added toxicities when used with peg-IFN and ribavirin.

Based on early results with telaprevir, she anticipates that 69% of treatment-naive patients will achieve a sustained viral response to treatment with 12 weeks of triple therapy (telaprevir, peg-IFN, and ribavirin) followed by 12-36 weeks of peg-IFN and ribavirin. This regimen could produce response rates of up to 39% in patients who had not responded to previous treatment with peg-IFN and ribavirin, and up to 76% in patients who had relapsed from previous therapy with peg-IFN and ribavirin.

The boceprevir treatment regimen starts with 4 weeks of peg-IFN and ribavirin followed by 24-44 weeks of triple therapy by adding boceprevir. Dr. Terrault anticipates a sustained viral response at 48 weeks in up to 74% of previously untreated patients with genotype 1 HCV and no HIV. No data are available on the use of boceprevir in treatment-experienced patients.

“This is add-on treatment, so you still have peg-interferon and ribavirin side effects, and now you have protease inhibitor side effects,” she noted. Telaprevir most commonly causes anemia, rash, or pruritus. Boceprevir most commonly causes anemia, neutropenia, or dysgeusia.

SAN DIEGO — Microvesicular steatosis may be more common in patients with nonalcoholic fatty liver disease than previously thought and is associated with markers of severe disease, a study of 1,022 biopsies suggests.

Of the liver biopsies from adult patients with nonalcoholic fatty liver disease (NAFLD), 10% showed microvesicular steatosis when reviewed by a pathology committee for the study, Dr. Sweta R. Tandra and her associates reported at the annual meeting of the American College of Gastroenterology.

Previously, microvesicular steatosis was thought to be rare in patients with NAFLD, which is more typically associated with macrovesicular steatosis, said Dr. Tandra of Indiana University, Indianapolis. The significance of the presence of microvesicular steatosis has been unclear.

The investigators identified microvesicular steatosis in 102 (10%) of the biopsies, which came from patients who had an average age of 50 years and a mean body mass index of 35 kg/m

The presence of microvesicular steatosis was significantly associated with histologic indexes denoting severe disease, including higher grades of macrovesicular steatosis, advanced fibrosis, ballooned hepatocytes, megamitochondria, higher NAFLD activity scores, and a diagnosis of nonalcoholic steatohepatitis, she said.

The findings were based on a multivariate analysis that adjusted for the influence of age, sex, race, body mass index, and the presence of diabetes.

The presence of macrovesicular steatosis increased the likelihood of finding microvesicular steatosis two- to sixfold.

Also, patients with fibrosis were two to six times more likely to have microvesicular steatosis than were patients without fibrosis.

Microvesicular steatosis was three to four times more likely in the presence of ballooning and five times more likely in the presence of megamitochondria, two markers of cell injury.

No associations were seen between microvesicular steatosis and lobular inflammation or levels of aspartate aminotransferase (AST) or alanine aminotransferase (ALT).

Biopsies for the study were obtained from a consortium of eight clinical research centers and one data coordinating center sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases.

On histology, macrovesicular steatosis is defined by a single, large vacuole of fat that fills up the hepatocyte and displaces the nucleus to the periphery of the cell.

In comparison, the presence of multiple small intracellular lipid droplets with an undisplaced nucleus generally defines microvesicular steatosis, which has been thought to result from impaired mitochondrial beta-oxidation of fatty acids, Dr. Tandra said.

The investigators defined microvesicular steatosis as the presence of “nonzonal contiguous patches of foamy hepatocytes with centrally placed nucleus” on hematoxylin and eosin staining under light microscopy, she added.

“As microvesicular steatosis generally indicates mitochondrial dysfunction, our data support a role for mitochondrial dysfunction in the pathogenesis of nonalcoholic steatohepatitis,” Dr. Tandra said.

More research is needed to clarify the significance of microvesicular steatosis in patients with NAFLD, she added.

Disclosures: Dr. Tandra reported having no conflicts of interest related to the study.

Microvesicular steatosis was significantly associated with histologic indexes denoting severe disease.

Source DR. TANDRA

SAN DIEGO — Microvesicular steatosis may be more common in patients with nonalcoholic fatty liver disease than previously thought and is associated with markers of severe disease, a study of 1,022 biopsies suggests.

Of the liver biopsies from adult patients with nonalcoholic fatty liver disease (NAFLD), 10% showed microvesicular steatosis when reviewed by a pathology committee for the study, Dr. Sweta R. Tandra and her associates reported at the annual meeting of the American College of Gastroenterology.

Previously, microvesicular steatosis was thought to be rare in patients with NAFLD, which is more typically associated with macrovesicular steatosis, said Dr. Tandra of Indiana University, Indianapolis. The significance of the presence of microvesicular steatosis has been unclear.

The investigators identified microvesicular steatosis in 102 (10%) of the biopsies, which came from patients who had an average age of 50 years and a mean body mass index of 35 kg/m

The presence of microvesicular steatosis was significantly associated with histologic indexes denoting severe disease, including higher grades of macrovesicular steatosis, advanced fibrosis, ballooned hepatocytes, megamitochondria, higher NAFLD activity scores, and a diagnosis of nonalcoholic steatohepatitis, she said.

The findings were based on a multivariate analysis that adjusted for the influence of age, sex, race, body mass index, and the presence of diabetes.

The presence of macrovesicular steatosis increased the likelihood of finding microvesicular steatosis two- to sixfold.

Also, patients with fibrosis were two to six times more likely to have microvesicular steatosis than were patients without fibrosis.

Microvesicular steatosis was three to four times more likely in the presence of ballooning and five times more likely in the presence of megamitochondria, two markers of cell injury.

No associations were seen between microvesicular steatosis and lobular inflammation or levels of aspartate aminotransferase (AST) or alanine aminotransferase (ALT).

Biopsies for the study were obtained from a consortium of eight clinical research centers and one data coordinating center sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases.

On histology, macrovesicular steatosis is defined by a single, large vacuole of fat that fills up the hepatocyte and displaces the nucleus to the periphery of the cell.

In comparison, the presence of multiple small intracellular lipid droplets with an undisplaced nucleus generally defines microvesicular steatosis, which has been thought to result from impaired mitochondrial beta-oxidation of fatty acids, Dr. Tandra said.

The investigators defined microvesicular steatosis as the presence of “nonzonal contiguous patches of foamy hepatocytes with centrally placed nucleus” on hematoxylin and eosin staining under light microscopy, she added.

“As microvesicular steatosis generally indicates mitochondrial dysfunction, our data support a role for mitochondrial dysfunction in the pathogenesis of nonalcoholic steatohepatitis,” Dr. Tandra said.

More research is needed to clarify the significance of microvesicular steatosis in patients with NAFLD, she added.

Disclosures: Dr. Tandra reported having no conflicts of interest related to the study.

Microvesicular steatosis was significantly associated with histologic indexes denoting severe disease.

Source DR. TANDRA

SAN DIEGO — Microvesicular steatosis may be more common in patients with nonalcoholic fatty liver disease than previously thought and is associated with markers of severe disease, a study of 1,022 biopsies suggests.

Of the liver biopsies from adult patients with nonalcoholic fatty liver disease (NAFLD), 10% showed microvesicular steatosis when reviewed by a pathology committee for the study, Dr. Sweta R. Tandra and her associates reported at the annual meeting of the American College of Gastroenterology.

Previously, microvesicular steatosis was thought to be rare in patients with NAFLD, which is more typically associated with macrovesicular steatosis, said Dr. Tandra of Indiana University, Indianapolis. The significance of the presence of microvesicular steatosis has been unclear.

The investigators identified microvesicular steatosis in 102 (10%) of the biopsies, which came from patients who had an average age of 50 years and a mean body mass index of 35 kg/m

The presence of microvesicular steatosis was significantly associated with histologic indexes denoting severe disease, including higher grades of macrovesicular steatosis, advanced fibrosis, ballooned hepatocytes, megamitochondria, higher NAFLD activity scores, and a diagnosis of nonalcoholic steatohepatitis, she said.

The findings were based on a multivariate analysis that adjusted for the influence of age, sex, race, body mass index, and the presence of diabetes.

The presence of macrovesicular steatosis increased the likelihood of finding microvesicular steatosis two- to sixfold.

Also, patients with fibrosis were two to six times more likely to have microvesicular steatosis than were patients without fibrosis.

Microvesicular steatosis was three to four times more likely in the presence of ballooning and five times more likely in the presence of megamitochondria, two markers of cell injury.

No associations were seen between microvesicular steatosis and lobular inflammation or levels of aspartate aminotransferase (AST) or alanine aminotransferase (ALT).

Biopsies for the study were obtained from a consortium of eight clinical research centers and one data coordinating center sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases.

On histology, macrovesicular steatosis is defined by a single, large vacuole of fat that fills up the hepatocyte and displaces the nucleus to the periphery of the cell.

In comparison, the presence of multiple small intracellular lipid droplets with an undisplaced nucleus generally defines microvesicular steatosis, which has been thought to result from impaired mitochondrial beta-oxidation of fatty acids, Dr. Tandra said.

The investigators defined microvesicular steatosis as the presence of “nonzonal contiguous patches of foamy hepatocytes with centrally placed nucleus” on hematoxylin and eosin staining under light microscopy, she added.

“As microvesicular steatosis generally indicates mitochondrial dysfunction, our data support a role for mitochondrial dysfunction in the pathogenesis of nonalcoholic steatohepatitis,” Dr. Tandra said.

More research is needed to clarify the significance of microvesicular steatosis in patients with NAFLD, she added.

Disclosures: Dr. Tandra reported having no conflicts of interest related to the study.

Microvesicular steatosis was significantly associated with histologic indexes denoting severe disease.

Source DR. TANDRA

SAN FRANCISCO — Substance abuse is such a common cause of anxiety or depression in HIV-infected patients that Dr. Robert B. Daroff Jr. advises getting a toxicology screen in every patient with HIV and a mood disorder.

“It's the only objective measure I have in psychiatry. I might as well use it,” said Dr. Daroff, director of the HIV Psychiatry Program at the San Francisco Veterans Affairs Medical Center.

Social factors also may cause or contribute to mood disorders. Feelings of helplessness and dependency, social isolation, or difficulty communicating with significant others can lead to anxiety or depression, he said at a meeting on the medical management of HIV and AIDS sponsored by the University of California, San Francisco.

Biologic factors such as metabolic or endocrine abnormalities and side effects from antiretroviral therapy can also cause psychiatric disorders in patients with HIV. When anti-HIV drugs may be causing the mood disorder, consider possibly subtracting a drug from the patient's regimen, Dr. Daroff suggested. (See box.)

Approximately 36% of patients with HIV had major depression and 16% of them had generalized anxiety disorder, one study found (Arch. Gen. Psychiatry 2001;58:721-8).

Mood disorders may impair compliance with antiretroviral therapy in patients with HIV.

In a survey of psychiatrists with AIDS expertise, the top choices for first-line treatment of depression in patients with HIV who had not yet started antiretrovirals were desipramine, amitriptyline, fluvoxamine, or a monoamine oxidase inhibitor, Dr. Daroff said.

For patients already on highly active antiretroviral therapy with a ritonavir-boosted protease inhibitor, the top choices for an antidepressant were citalopram or escitalopram, and Dr. Daroff said that he would put sertraline among these top choices if efficacy, acceptability, and cost are all considered.

Few psychiatric drugs are contraindicated in patients on antiretrovirals. Patients taking protease inhibitors should avoid pimozide, midazolam, triazolam, and St. John's wort.

Patients who are taking non-nucleoside reductase inhibitors should avoid alprazolam, midazolam, triazolam, and St. John's wort.

If a patient may have bipolar depression, avoid tricyclic antidepressants and dual-acting medications such as venlafaxine or duloxetine to decrease the risk of switching to mania.

Quetiapine or lamotrigine may be better than an antidepressant in these patients, he said.

Treatment for anxiety disorders most often involves SSRIs, venlafaxine, benzodiazepines, or buspirone.

Start at a quarter to half of normal dosing and increase the dose slowly because patients with HIV are “exquisitely sensitive to side effects,” Dr. Daroff advised.

Psychotherapy should be part of the therapeutic approach, he said. “I think we're underprescribing psychotherapy in HIV.”

Psychotherapy was associated with decreased HIV levels and improved CD4 counts in 7 of 14 randomized, controlled trials in patients with HIV, a review found.

Findings from the review (Psychosom. Med. 2008;70:575-84) and from other studies suggest that psychotherapy reduces mental distress associated with HIV, and that different forms of psychotherapy may be equally effective in helping these patients, Dr. Daroff said.

The kind of psychotherapy the patient receives seems to be less important than the quality of the relationship between the therapist and the patient, “which suggests that there is great power in the relationship you build with your patients,” he added.

Disclosures: Dr. Daroff said that he had no relevant conflicts of interest.

When anti-HIV drugs may be causing a patient's mood disorder, consider subtracting a drug from the regimen, Dr. Robert B. Daroff Jr. advised.

Source Courtesy Patricia Reed

Psychiatric Side Effects of ARVs

Didanosine: Nervousness, anxiety, confusion, insomnia.

Lamivudine: Insomnia, mania.

Stavudine: Confusion, depression, anxiety, mania, insomnia.

Zidovudine (AZT): Mania, depression, anxiety, insomnia, confusion.

Raltegravir: May worsen preexisting depression.

Efavirenz: Stepped-up dosing reduces neuropsychiatric side effects seen in clinical trials.

Source: Dr. Daroff

SAN FRANCISCO — Substance abuse is such a common cause of anxiety or depression in HIV-infected patients that Dr. Robert B. Daroff Jr. advises getting a toxicology screen in every patient with HIV and a mood disorder.

“It's the only objective measure I have in psychiatry. I might as well use it,” said Dr. Daroff, director of the HIV Psychiatry Program at the San Francisco Veterans Affairs Medical Center.

Social factors also may cause or contribute to mood disorders. Feelings of helplessness and dependency, social isolation, or difficulty communicating with significant others can lead to anxiety or depression, he said at a meeting on the medical management of HIV and AIDS sponsored by the University of California, San Francisco.

Biologic factors such as metabolic or endocrine abnormalities and side effects from antiretroviral therapy can also cause psychiatric disorders in patients with HIV. When anti-HIV drugs may be causing the mood disorder, consider possibly subtracting a drug from the patient's regimen, Dr. Daroff suggested. (See box.)

Approximately 36% of patients with HIV had major depression and 16% of them had generalized anxiety disorder, one study found (Arch. Gen. Psychiatry 2001;58:721-8).

Mood disorders may impair compliance with antiretroviral therapy in patients with HIV.

In a survey of psychiatrists with AIDS expertise, the top choices for first-line treatment of depression in patients with HIV who had not yet started antiretrovirals were desipramine, amitriptyline, fluvoxamine, or a monoamine oxidase inhibitor, Dr. Daroff said.

For patients already on highly active antiretroviral therapy with a ritonavir-boosted protease inhibitor, the top choices for an antidepressant were citalopram or escitalopram, and Dr. Daroff said that he would put sertraline among these top choices if efficacy, acceptability, and cost are all considered.

Few psychiatric drugs are contraindicated in patients on antiretrovirals. Patients taking protease inhibitors should avoid pimozide, midazolam, triazolam, and St. John's wort.

Patients who are taking non-nucleoside reductase inhibitors should avoid alprazolam, midazolam, triazolam, and St. John's wort.

If a patient may have bipolar depression, avoid tricyclic antidepressants and dual-acting medications such as venlafaxine or duloxetine to decrease the risk of switching to mania.

Quetiapine or lamotrigine may be better than an antidepressant in these patients, he said.

Treatment for anxiety disorders most often involves SSRIs, venlafaxine, benzodiazepines, or buspirone.

Start at a quarter to half of normal dosing and increase the dose slowly because patients with HIV are “exquisitely sensitive to side effects,” Dr. Daroff advised.

Psychotherapy should be part of the therapeutic approach, he said. “I think we're underprescribing psychotherapy in HIV.”

Psychotherapy was associated with decreased HIV levels and improved CD4 counts in 7 of 14 randomized, controlled trials in patients with HIV, a review found.

Findings from the review (Psychosom. Med. 2008;70:575-84) and from other studies suggest that psychotherapy reduces mental distress associated with HIV, and that different forms of psychotherapy may be equally effective in helping these patients, Dr. Daroff said.

The kind of psychotherapy the patient receives seems to be less important than the quality of the relationship between the therapist and the patient, “which suggests that there is great power in the relationship you build with your patients,” he added.

Disclosures: Dr. Daroff said that he had no relevant conflicts of interest.

When anti-HIV drugs may be causing a patient's mood disorder, consider subtracting a drug from the regimen, Dr. Robert B. Daroff Jr. advised.

Source Courtesy Patricia Reed

Psychiatric Side Effects of ARVs

Didanosine: Nervousness, anxiety, confusion, insomnia.

Lamivudine: Insomnia, mania.

Stavudine: Confusion, depression, anxiety, mania, insomnia.

Zidovudine (AZT): Mania, depression, anxiety, insomnia, confusion.

Raltegravir: May worsen preexisting depression.

Efavirenz: Stepped-up dosing reduces neuropsychiatric side effects seen in clinical trials.

Source: Dr. Daroff

SAN FRANCISCO — Substance abuse is such a common cause of anxiety or depression in HIV-infected patients that Dr. Robert B. Daroff Jr. advises getting a toxicology screen in every patient with HIV and a mood disorder.

“It's the only objective measure I have in psychiatry. I might as well use it,” said Dr. Daroff, director of the HIV Psychiatry Program at the San Francisco Veterans Affairs Medical Center.

Social factors also may cause or contribute to mood disorders. Feelings of helplessness and dependency, social isolation, or difficulty communicating with significant others can lead to anxiety or depression, he said at a meeting on the medical management of HIV and AIDS sponsored by the University of California, San Francisco.

Biologic factors such as metabolic or endocrine abnormalities and side effects from antiretroviral therapy can also cause psychiatric disorders in patients with HIV. When anti-HIV drugs may be causing the mood disorder, consider possibly subtracting a drug from the patient's regimen, Dr. Daroff suggested. (See box.)

Approximately 36% of patients with HIV had major depression and 16% of them had generalized anxiety disorder, one study found (Arch. Gen. Psychiatry 2001;58:721-8).

Mood disorders may impair compliance with antiretroviral therapy in patients with HIV.

In a survey of psychiatrists with AIDS expertise, the top choices for first-line treatment of depression in patients with HIV who had not yet started antiretrovirals were desipramine, amitriptyline, fluvoxamine, or a monoamine oxidase inhibitor, Dr. Daroff said.

For patients already on highly active antiretroviral therapy with a ritonavir-boosted protease inhibitor, the top choices for an antidepressant were citalopram or escitalopram, and Dr. Daroff said that he would put sertraline among these top choices if efficacy, acceptability, and cost are all considered.

Few psychiatric drugs are contraindicated in patients on antiretrovirals. Patients taking protease inhibitors should avoid pimozide, midazolam, triazolam, and St. John's wort.

Patients who are taking non-nucleoside reductase inhibitors should avoid alprazolam, midazolam, triazolam, and St. John's wort.

If a patient may have bipolar depression, avoid tricyclic antidepressants and dual-acting medications such as venlafaxine or duloxetine to decrease the risk of switching to mania.

Quetiapine or lamotrigine may be better than an antidepressant in these patients, he said.

Treatment for anxiety disorders most often involves SSRIs, venlafaxine, benzodiazepines, or buspirone.

Start at a quarter to half of normal dosing and increase the dose slowly because patients with HIV are “exquisitely sensitive to side effects,” Dr. Daroff advised.

Psychotherapy should be part of the therapeutic approach, he said. “I think we're underprescribing psychotherapy in HIV.”

Psychotherapy was associated with decreased HIV levels and improved CD4 counts in 7 of 14 randomized, controlled trials in patients with HIV, a review found.

Findings from the review (Psychosom. Med. 2008;70:575-84) and from other studies suggest that psychotherapy reduces mental distress associated with HIV, and that different forms of psychotherapy may be equally effective in helping these patients, Dr. Daroff said.

The kind of psychotherapy the patient receives seems to be less important than the quality of the relationship between the therapist and the patient, “which suggests that there is great power in the relationship you build with your patients,” he added.

Disclosures: Dr. Daroff said that he had no relevant conflicts of interest.

When anti-HIV drugs may be causing a patient's mood disorder, consider subtracting a drug from the regimen, Dr. Robert B. Daroff Jr. advised.

Source Courtesy Patricia Reed

Psychiatric Side Effects of ARVs

Didanosine: Nervousness, anxiety, confusion, insomnia.

Lamivudine: Insomnia, mania.

Stavudine: Confusion, depression, anxiety, mania, insomnia.

Zidovudine (AZT): Mania, depression, anxiety, insomnia, confusion.

Raltegravir: May worsen preexisting depression.

Efavirenz: Stepped-up dosing reduces neuropsychiatric side effects seen in clinical trials.

Source: Dr. Daroff

Not all patients are equal when it comes to melanoma risk.

Knowing which patients may be more likely to develop melanoma can serve as a prompt to increase suspicion during examination, said Dr. James M. Grichnik. Be on the lookout for patients with the following features and characteristics, he suggested at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation.

Nevi
The presence of even one atypical (dysplastic) nevus independently predicts up to a 60% greater risk for melanoma, said Dr. Grichnik, director of the melanoma program and professor of dermatology at the University of Miami.

Higher numbers of common nevi also increase risk. Nevi counts are associated with UV exposure, and can be used as a surrogate marker for UV-induced cutaneous damage. Melanoma risk increases 47% with 16-40 common nevi on the whole body, he noted. Risk increases as mole count climbs, with nearly a seven-fold increased risk associated with nevi counts of 101 and higher (Euro. J. Ca. 2005;41:28-44).

Phenotype
Light-colored skin, hair, and eyes are associated with an increased melanoma risk. In 60 studies published before Sept. 2002, melanoma risk was twice as high with skin type I, compared with skin type IV; with fair skin color, compared with dark skin color; and with a high density rather than a low density of freckles. Compared with dark eyes, blue eyes were associated with a 47% higher risk. And melanoma risk was more than three times higher with red hair, compared with dark hair (Euro. J. Ca. 2005;41:28-44).

UV Exposure
Use of tanning beds increases melanoma risk 75% if the first exposure occurs before age 35 years, according to Dr. Grichnik. Multiple studies report that melanoma risk is higher in people who have experienced short, intense episodes of burning sun exposure (especially during childhood). The effects of chronic sun exposure are more difficult to determine, but may be associated with lentigo maligna-type melanoma.

Occupation
Airline crews, especially pilots, have a higher-than expected incidence of melanoma (BMJ 2002;325:567). This may be due to greater sun-exposed activities between flights in areas of the world with high sun exposure levels, he speculated.

Socioeconomics
Wealthier people are more likely to develop melanoma, compared with age-matched populations - the opposite of trends for squamous cell carcinoma, according to studies. Again, the higher risk for melanoma may be associated with sunny holidays in winter, and sun-exposed recreational activities enabled by affluence, Dr. Grichnik suggested.

History
Taking a good personal history can identify some of the risk factors listed above. Family history is important too - a significant proportion of patients with melanoma will have genetic risk factors for the disease, he said.

Thirteen percent of melanoma patients have at least one first-degree relative with melanoma (Hum. Genet. 2009;126:499-510). The disease appears to be twice as common in people who have a parent with a history of melanoma, three times as common if a sibling has had melanoma, and nine times as common if both a parent and a sibling have had melanoma, compared with people who have no family history of melanoma.

Once a melanoma is identifed, a variety of tools can help discern whether it is deadly, Dr. Grichnik added. These include the American Joint Committee on Cancer criteria for staging and classification of melanomas, the mitotic rate, nodal status, circulating tumor cell status, molecular marker status, and a history of prior nonmelanoma skin cancer or other cancers.

Dr. Grichnik is a founder and shareholder in DigitalDerm Inc. and has been a consultant and researcher for Electro-Optical Systems Inc. and Spectral Image Inc. SDEF and this news organization are owned by Elsevier.

^{Young girl having sun cream administered to her shoulder by her mother.
©Mark Swallow/iStockphoto.com}

Not all patients are equal when it comes to melanoma risk.

Knowing which patients may be more likely to develop melanoma can serve as a prompt to increase suspicion during examination, said Dr. James M. Grichnik. Be on the lookout for patients with the following features and characteristics, he suggested at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation.

Nevi
The presence of even one atypical (dysplastic) nevus independently predicts up to a 60% greater risk for melanoma, said Dr. Grichnik, director of the melanoma program and professor of dermatology at the University of Miami.

Higher numbers of common nevi also increase risk. Nevi counts are associated with UV exposure, and can be used as a surrogate marker for UV-induced cutaneous damage. Melanoma risk increases 47% with 16-40 common nevi on the whole body, he noted. Risk increases as mole count climbs, with nearly a seven-fold increased risk associated with nevi counts of 101 and higher (Euro. J. Ca. 2005;41:28-44).

Phenotype
Light-colored skin, hair, and eyes are associated with an increased melanoma risk. In 60 studies published before Sept. 2002, melanoma risk was twice as high with skin type I, compared with skin type IV; with fair skin color, compared with dark skin color; and with a high density rather than a low density of freckles. Compared with dark eyes, blue eyes were associated with a 47% higher risk. And melanoma risk was more than three times higher with red hair, compared with dark hair (Euro. J. Ca. 2005;41:28-44).

UV Exposure
Use of tanning beds increases melanoma risk 75% if the first exposure occurs before age 35 years, according to Dr. Grichnik. Multiple studies report that melanoma risk is higher in people who have experienced short, intense episodes of burning sun exposure (especially during childhood). The effects of chronic sun exposure are more difficult to determine, but may be associated with lentigo maligna-type melanoma.

Occupation
Airline crews, especially pilots, have a higher-than expected incidence of melanoma (BMJ 2002;325:567). This may be due to greater sun-exposed activities between flights in areas of the world with high sun exposure levels, he speculated.

Socioeconomics
Wealthier people are more likely to develop melanoma, compared with age-matched populations - the opposite of trends for squamous cell carcinoma, according to studies. Again, the higher risk for melanoma may be associated with sunny holidays in winter, and sun-exposed recreational activities enabled by affluence, Dr. Grichnik suggested.

History
Taking a good personal history can identify some of the risk factors listed above. Family history is important too - a significant proportion of patients with melanoma will have genetic risk factors for the disease, he said.

Thirteen percent of melanoma patients have at least one first-degree relative with melanoma (Hum. Genet. 2009;126:499-510). The disease appears to be twice as common in people who have a parent with a history of melanoma, three times as common if a sibling has had melanoma, and nine times as common if both a parent and a sibling have had melanoma, compared with people who have no family history of melanoma.

Once a melanoma is identifed, a variety of tools can help discern whether it is deadly, Dr. Grichnik added. These include the American Joint Committee on Cancer criteria for staging and classification of melanomas, the mitotic rate, nodal status, circulating tumor cell status, molecular marker status, and a history of prior nonmelanoma skin cancer or other cancers.

Dr. Grichnik is a founder and shareholder in DigitalDerm Inc. and has been a consultant and researcher for Electro-Optical Systems Inc. and Spectral Image Inc. SDEF and this news organization are owned by Elsevier.

^{Young girl having sun cream administered to her shoulder by her mother.
©Mark Swallow/iStockphoto.com}

Not all patients are equal when it comes to melanoma risk.

Knowing which patients may be more likely to develop melanoma can serve as a prompt to increase suspicion during examination, said Dr. James M. Grichnik. Be on the lookout for patients with the following features and characteristics, he suggested at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation.

Nevi
The presence of even one atypical (dysplastic) nevus independently predicts up to a 60% greater risk for melanoma, said Dr. Grichnik, director of the melanoma program and professor of dermatology at the University of Miami.

Higher numbers of common nevi also increase risk. Nevi counts are associated with UV exposure, and can be used as a surrogate marker for UV-induced cutaneous damage. Melanoma risk increases 47% with 16-40 common nevi on the whole body, he noted. Risk increases as mole count climbs, with nearly a seven-fold increased risk associated with nevi counts of 101 and higher (Euro. J. Ca. 2005;41:28-44).

Phenotype
Light-colored skin, hair, and eyes are associated with an increased melanoma risk. In 60 studies published before Sept. 2002, melanoma risk was twice as high with skin type I, compared with skin type IV; with fair skin color, compared with dark skin color; and with a high density rather than a low density of freckles. Compared with dark eyes, blue eyes were associated with a 47% higher risk. And melanoma risk was more than three times higher with red hair, compared with dark hair (Euro. J. Ca. 2005;41:28-44).

UV Exposure
Use of tanning beds increases melanoma risk 75% if the first exposure occurs before age 35 years, according to Dr. Grichnik. Multiple studies report that melanoma risk is higher in people who have experienced short, intense episodes of burning sun exposure (especially during childhood). The effects of chronic sun exposure are more difficult to determine, but may be associated with lentigo maligna-type melanoma.

Occupation
Airline crews, especially pilots, have a higher-than expected incidence of melanoma (BMJ 2002;325:567). This may be due to greater sun-exposed activities between flights in areas of the world with high sun exposure levels, he speculated.

Socioeconomics
Wealthier people are more likely to develop melanoma, compared with age-matched populations - the opposite of trends for squamous cell carcinoma, according to studies. Again, the higher risk for melanoma may be associated with sunny holidays in winter, and sun-exposed recreational activities enabled by affluence, Dr. Grichnik suggested.

History
Taking a good personal history can identify some of the risk factors listed above. Family history is important too - a significant proportion of patients with melanoma will have genetic risk factors for the disease, he said.

Thirteen percent of melanoma patients have at least one first-degree relative with melanoma (Hum. Genet. 2009;126:499-510). The disease appears to be twice as common in people who have a parent with a history of melanoma, three times as common if a sibling has had melanoma, and nine times as common if both a parent and a sibling have had melanoma, compared with people who have no family history of melanoma.

Once a melanoma is identifed, a variety of tools can help discern whether it is deadly, Dr. Grichnik added. These include the American Joint Committee on Cancer criteria for staging and classification of melanomas, the mitotic rate, nodal status, circulating tumor cell status, molecular marker status, and a history of prior nonmelanoma skin cancer or other cancers.

Dr. Grichnik is a founder and shareholder in DigitalDerm Inc. and has been a consultant and researcher for Electro-Optical Systems Inc. and Spectral Image Inc. SDEF and this news organization are owned by Elsevier.

^{Young girl having sun cream administered to her shoulder by her mother.
©Mark Swallow/iStockphoto.com}

Women who used hormone therapy were more likely to need cataract surgery, a risk potentiated by drinking alcohol, a large Swedish prospective study found.

In a 98-month study of 30,861 postmenopausal women, those who had ever used hormone therapy (HT) had a 14% higher risk for cataract extraction and current HT users had an 18% higher risk, compared with women who never used HT in a multivariate adjusted analysis, Dr. Birgitta Ejdervik Lindblad and her associates reported (Ophthalmology doi:10.1016/j.ophtha.2009.07.046

Cataract extraction was even more likely in women who were using HT and drank alcohol. Among current HT users, any alcohol consumption was associated with a 29% higher risk for cataract extraction, and those who drank more than one alcoholic drink per day had a 42% higher risk, compared with women who were neither using HT nor drinking alcohol. (One drink was defined as about 13 g of alcohol, roughly equal to one glass of wine, bottle of beer, or drink of liquor.) Drinking alcohol has been associated with increased levels of plasma estrogen in postmenopausal women in prior studies.

Investigators collected data from women in the Swedish Mammography Cohort who completed questionnaires in September 1997 about hormone status, use of hormone therapy, and lifestyle factors. The researchers followed them through October 2005 and compared their names with those on Swedish registers of cataract surgeries, which identified 4,324 women who underwent cataract surgery during the study period.

Among women aged 65 years or older, the risk for cataract surgery was 73% higher in those using hormone therapy, compared with women who never used HT, after the researchers adjusted for the effects of alcohol consumption, smoking, diabetes, hypertension, steroid or vitamin use, body mass index, and education level.

Longer use of HT was associated with higher risk for cataract extraction in a linear fashion, added Dr. Lindblad of the Karolinska Institute, Stockholm. Current users of hormone therapy reported longer duration of HT (a mean of 6 years) compared with past users (4 years). Women who used HT for more than 10 years had a 20% higher risk of cataract extraction, compared with women who never used HT.

If the findings can be confirmed, the increased risk for cataract extraction should be added to the list of increased risks for breast cancer and cardiovascular disease that are associated with HT use, the investigators said.

Dr. Lindblad and associates advised caution in comparing their study with those conducted outside of Sweden because HT preparations vary between countries. Hormone therapy with estrogen alone is more common in the United States.

And U.S. versions of HT for postmenopausal symptoms like hot flushes most commonly use conjugated estrogens alone or in combination with progesterone-like progestins, while in Sweden the predominant hormone therapy is a combination of estradiol with testosterone-like progestins.

At the start of the study, 39% of women were using hormone therapy, 11% had used HT in the past, and 50% had never used HT. Half of current users took HT to relieve hot flushes, 33% used it for urogenital symptoms, and 17% took HT for both.

The risk for cataract extraction in women using HT did not differ significantly based on current or past smoking.

The investigators reported having no conflicts of interest related to the study, which was funded by Swedish government agencies and research foundations.

Women who used hormone therapy were more likely to need cataract surgery, a risk potentiated by drinking alcohol, a large Swedish prospective study found.

In a 98-month study of 30,861 postmenopausal women, those who had ever used hormone therapy (HT) had a 14% higher risk for cataract extraction and current HT users had an 18% higher risk, compared with women who never used HT in a multivariate adjusted analysis, Dr. Birgitta Ejdervik Lindblad and her associates reported (Ophthalmology doi:10.1016/j.ophtha.2009.07.046

Cataract extraction was even more likely in women who were using HT and drank alcohol. Among current HT users, any alcohol consumption was associated with a 29% higher risk for cataract extraction, and those who drank more than one alcoholic drink per day had a 42% higher risk, compared with women who were neither using HT nor drinking alcohol. (One drink was defined as about 13 g of alcohol, roughly equal to one glass of wine, bottle of beer, or drink of liquor.) Drinking alcohol has been associated with increased levels of plasma estrogen in postmenopausal women in prior studies.

Investigators collected data from women in the Swedish Mammography Cohort who completed questionnaires in September 1997 about hormone status, use of hormone therapy, and lifestyle factors. The researchers followed them through October 2005 and compared their names with those on Swedish registers of cataract surgeries, which identified 4,324 women who underwent cataract surgery during the study period.

Among women aged 65 years or older, the risk for cataract surgery was 73% higher in those using hormone therapy, compared with women who never used HT, after the researchers adjusted for the effects of alcohol consumption, smoking, diabetes, hypertension, steroid or vitamin use, body mass index, and education level.

Longer use of HT was associated with higher risk for cataract extraction in a linear fashion, added Dr. Lindblad of the Karolinska Institute, Stockholm. Current users of hormone therapy reported longer duration of HT (a mean of 6 years) compared with past users (4 years). Women who used HT for more than 10 years had a 20% higher risk of cataract extraction, compared with women who never used HT.

If the findings can be confirmed, the increased risk for cataract extraction should be added to the list of increased risks for breast cancer and cardiovascular disease that are associated with HT use, the investigators said.

Dr. Lindblad and associates advised caution in comparing their study with those conducted outside of Sweden because HT preparations vary between countries. Hormone therapy with estrogen alone is more common in the United States.

And U.S. versions of HT for postmenopausal symptoms like hot flushes most commonly use conjugated estrogens alone or in combination with progesterone-like progestins, while in Sweden the predominant hormone therapy is a combination of estradiol with testosterone-like progestins.

At the start of the study, 39% of women were using hormone therapy, 11% had used HT in the past, and 50% had never used HT. Half of current users took HT to relieve hot flushes, 33% used it for urogenital symptoms, and 17% took HT for both.

The risk for cataract extraction in women using HT did not differ significantly based on current or past smoking.

The investigators reported having no conflicts of interest related to the study, which was funded by Swedish government agencies and research foundations.

Women who used hormone therapy were more likely to need cataract surgery, a risk potentiated by drinking alcohol, a large Swedish prospective study found.

In a 98-month study of 30,861 postmenopausal women, those who had ever used hormone therapy (HT) had a 14% higher risk for cataract extraction and current HT users had an 18% higher risk, compared with women who never used HT in a multivariate adjusted analysis, Dr. Birgitta Ejdervik Lindblad and her associates reported (Ophthalmology doi:10.1016/j.ophtha.2009.07.046

Cataract extraction was even more likely in women who were using HT and drank alcohol. Among current HT users, any alcohol consumption was associated with a 29% higher risk for cataract extraction, and those who drank more than one alcoholic drink per day had a 42% higher risk, compared with women who were neither using HT nor drinking alcohol. (One drink was defined as about 13 g of alcohol, roughly equal to one glass of wine, bottle of beer, or drink of liquor.) Drinking alcohol has been associated with increased levels of plasma estrogen in postmenopausal women in prior studies.

Investigators collected data from women in the Swedish Mammography Cohort who completed questionnaires in September 1997 about hormone status, use of hormone therapy, and lifestyle factors. The researchers followed them through October 2005 and compared their names with those on Swedish registers of cataract surgeries, which identified 4,324 women who underwent cataract surgery during the study period.

Among women aged 65 years or older, the risk for cataract surgery was 73% higher in those using hormone therapy, compared with women who never used HT, after the researchers adjusted for the effects of alcohol consumption, smoking, diabetes, hypertension, steroid or vitamin use, body mass index, and education level.

Longer use of HT was associated with higher risk for cataract extraction in a linear fashion, added Dr. Lindblad of the Karolinska Institute, Stockholm. Current users of hormone therapy reported longer duration of HT (a mean of 6 years) compared with past users (4 years). Women who used HT for more than 10 years had a 20% higher risk of cataract extraction, compared with women who never used HT.

If the findings can be confirmed, the increased risk for cataract extraction should be added to the list of increased risks for breast cancer and cardiovascular disease that are associated with HT use, the investigators said.

Dr. Lindblad and associates advised caution in comparing their study with those conducted outside of Sweden because HT preparations vary between countries. Hormone therapy with estrogen alone is more common in the United States.

And U.S. versions of HT for postmenopausal symptoms like hot flushes most commonly use conjugated estrogens alone or in combination with progesterone-like progestins, while in Sweden the predominant hormone therapy is a combination of estradiol with testosterone-like progestins.

At the start of the study, 39% of women were using hormone therapy, 11% had used HT in the past, and 50% had never used HT. Half of current users took HT to relieve hot flushes, 33% used it for urogenital symptoms, and 17% took HT for both.

The risk for cataract extraction in women using HT did not differ significantly based on current or past smoking.

The investigators reported having no conflicts of interest related to the study, which was funded by Swedish government agencies and research foundations.

Major Finding: Six months of 70-minute aerobic exercise sessions three days per week significantly reduced the severity of menopausal symptoms while improving physical fitness.

Data Source: An uncontrolled study in 65 postmenopausal women.

Disclosures: The investigators reported having no conflicts of interest.

Postmenopausal women improved their physical fitness and reported reductions in the severity of menopausal symptoms after 12-24 weeks of aerobic exercise in three 70-minute sessions per week.

The 65 women (mean age 50.1 years) rated the severity of menopausal symptoms on the self-administered Menopause Rating Scale questionnaire at baseline, 12 weeks, and 24 weeks in the uncontrolled study. The program of aerobic and calisthenic exercise aimed for 75%–80% of maximal heart rate according to the Karvonen method and consisted of 10 minutes of warm-up exercises; 40 minutes of aerobics; 15 minutes of exercise targeting the abdomen, hip, and leg muscles; and 5 minutes for cool-down and stretching.

Participants reported significant decreases in the severity of hot flushes, night sweats, cardiac symptoms, muscle and joint pain, sleeping disorder symptoms, depressive mood, irritability, anxiety, exhaustion, sexual problems, and urinary symptoms between the start and the end of the study, Dr. Selma Karacan of Selcuk University in Konya, Turkey reported.

Some of the symptoms showed improvement by 12 weeks and further significant improvements by 24 weeks, including vasomotor symptoms, muscle and joint pain, psychological symptoms, and sexual problems. The women reported no significant change in vaginal dryness (Sci. Sports 2009 [doi:10.1016/j.scispo.2009.07.004

Significant improvements also were seen in resting heart rate, systolic and diastolic blood pressures, flexibility, aerobic power, and the ability to perform sit-ups, push-ups, and right or left hand grips. Body weight, body mass index, body fat percentage, and fat weight decreased significantly, with no change in lean body mass values.

The findings support results from previous observational studies of physically active postmenopausal women compared with age-matched, sedentary control women. No randomized controlled trials have looked at the efficacy of exercise in managing hot flushes.

A decrease due to safety concerns in recent years in the use of hormone replacement therapy to manage the vasomotor symptoms of menopause adds to the importance of finding that evidence-based lifestyle modifications can help menopausal symptoms, Dr. Karacan said.

Major Finding: Six months of 70-minute aerobic exercise sessions three days per week significantly reduced the severity of menopausal symptoms while improving physical fitness.

Data Source: An uncontrolled study in 65 postmenopausal women.

Disclosures: The investigators reported having no conflicts of interest.

Postmenopausal women improved their physical fitness and reported reductions in the severity of menopausal symptoms after 12-24 weeks of aerobic exercise in three 70-minute sessions per week.

The 65 women (mean age 50.1 years) rated the severity of menopausal symptoms on the self-administered Menopause Rating Scale questionnaire at baseline, 12 weeks, and 24 weeks in the uncontrolled study. The program of aerobic and calisthenic exercise aimed for 75%–80% of maximal heart rate according to the Karvonen method and consisted of 10 minutes of warm-up exercises; 40 minutes of aerobics; 15 minutes of exercise targeting the abdomen, hip, and leg muscles; and 5 minutes for cool-down and stretching.

Participants reported significant decreases in the severity of hot flushes, night sweats, cardiac symptoms, muscle and joint pain, sleeping disorder symptoms, depressive mood, irritability, anxiety, exhaustion, sexual problems, and urinary symptoms between the start and the end of the study, Dr. Selma Karacan of Selcuk University in Konya, Turkey reported.

Some of the symptoms showed improvement by 12 weeks and further significant improvements by 24 weeks, including vasomotor symptoms, muscle and joint pain, psychological symptoms, and sexual problems. The women reported no significant change in vaginal dryness (Sci. Sports 2009 [doi:10.1016/j.scispo.2009.07.004

Significant improvements also were seen in resting heart rate, systolic and diastolic blood pressures, flexibility, aerobic power, and the ability to perform sit-ups, push-ups, and right or left hand grips. Body weight, body mass index, body fat percentage, and fat weight decreased significantly, with no change in lean body mass values.

The findings support results from previous observational studies of physically active postmenopausal women compared with age-matched, sedentary control women. No randomized controlled trials have looked at the efficacy of exercise in managing hot flushes.

A decrease due to safety concerns in recent years in the use of hormone replacement therapy to manage the vasomotor symptoms of menopause adds to the importance of finding that evidence-based lifestyle modifications can help menopausal symptoms, Dr. Karacan said.

Major Finding: Six months of 70-minute aerobic exercise sessions three days per week significantly reduced the severity of menopausal symptoms while improving physical fitness.

Data Source: An uncontrolled study in 65 postmenopausal women.

Disclosures: The investigators reported having no conflicts of interest.

Postmenopausal women improved their physical fitness and reported reductions in the severity of menopausal symptoms after 12-24 weeks of aerobic exercise in three 70-minute sessions per week.

The 65 women (mean age 50.1 years) rated the severity of menopausal symptoms on the self-administered Menopause Rating Scale questionnaire at baseline, 12 weeks, and 24 weeks in the uncontrolled study. The program of aerobic and calisthenic exercise aimed for 75%–80% of maximal heart rate according to the Karvonen method and consisted of 10 minutes of warm-up exercises; 40 minutes of aerobics; 15 minutes of exercise targeting the abdomen, hip, and leg muscles; and 5 minutes for cool-down and stretching.

Participants reported significant decreases in the severity of hot flushes, night sweats, cardiac symptoms, muscle and joint pain, sleeping disorder symptoms, depressive mood, irritability, anxiety, exhaustion, sexual problems, and urinary symptoms between the start and the end of the study, Dr. Selma Karacan of Selcuk University in Konya, Turkey reported.

Some of the symptoms showed improvement by 12 weeks and further significant improvements by 24 weeks, including vasomotor symptoms, muscle and joint pain, psychological symptoms, and sexual problems. The women reported no significant change in vaginal dryness (Sci. Sports 2009 [doi:10.1016/j.scispo.2009.07.004

Significant improvements also were seen in resting heart rate, systolic and diastolic blood pressures, flexibility, aerobic power, and the ability to perform sit-ups, push-ups, and right or left hand grips. Body weight, body mass index, body fat percentage, and fat weight decreased significantly, with no change in lean body mass values.

The findings support results from previous observational studies of physically active postmenopausal women compared with age-matched, sedentary control women. No randomized controlled trials have looked at the efficacy of exercise in managing hot flushes.

A decrease due to safety concerns in recent years in the use of hormone replacement therapy to manage the vasomotor symptoms of menopause adds to the importance of finding that evidence-based lifestyle modifications can help menopausal symptoms, Dr. Karacan said.

SAN FRANCISCO — People with HIV infection tend to have more risk factors for bone loss than do those without, and antiretroviral medications may be adding to that risk.

The specific role of antiretroviral therapy in bone loss has been controversial: Some studies say there is no association, but others suggest that the drugs do contribute to bone loss.

The results of two small but well-conducted studies recently tipped the emphasis toward concern about the differential effects of antiretrovirals on bone mineral density, Dr. Dolores Shoback said.

“I think it's very provocative. We certainly need more data, and this needs to be confirmed,” she said at a meeting on HIV management sponsored by the University of California, San Francisco.

One randomized, controlled trial of 71 HIV-infected patients suggested that antiretroviral regimens that contain a protease inhibitor booster have a greater negative impact on spinal bone density than do regimens without a boosted protease inhibitor, said Dr. Shoback, who is professor of medicine at the university.

At baseline, 31% of the patients were osteopenic and 3% were osteoporotic.

Bone densities were retested after 48 weeks of combination HIV therapy with a nonnucleoside reverse transcriptase inhibitor (NNRTI) and nucleoside reverse transcriptase inhibitors (NRTIs), or an NNRTI and a boosted protease inhibitor, or two NRTIs and a boosted protease inhibitor.

On average, the cohort as a whole lost 4% of lumbar spine bone mineral density and 3% of hip bone density over the course of 48 weeks (AIDS 2009;23:817-24).

“To put that in perspective, in early menopause, 1%–5% per year is about the rate of change we see at the spine, so this is a significant change in bone mineral density,” she said.

The groups that were treated with boosted protease inhibitors lost significantly more spinal density—4.4% when combined with an NNRTI and 5.8% when combined with NRTIs—compared with the NNRTI-plus-NRTI arm (1.5%).

The changes in hip bone density did not differ significantly by treatment group, Dr. Shoback reported.

The second study randomized 50 HIV-infected patients to treatment with lopinavir/ritonavir plus zidovudine/lamivudine or lopinavir/ritonavir plus nevirapine, with bone densities compared at baseline and 2 years.

The zidovudine/lamivudine group lost 6.3% of bone mineral density in the hip and 5.1% in the spine, compared with smaller losses of 2.3% in the hip and 2.6% in the spine in the nevirapine group.

Spinal density decreased mainly in the first year and then stabilized, but hip density continued to fall in the second year (AIDS 2009;23:1367-76).

The investigators speculated that zidovudine/lamivudine increased osteoclastic activity. “I think there probably is, in fact, a signal here,” Dr. Shoback said.

There are not enough data yet to support changing antiretroviral regimens if bone mineral density is low, she added, but physicians should pay attention to nutrition (especially calcium and vitamin D), lifestyle factors, and weight-bearing exercise in patients with HIV.

Ongoing immune activation in HIV infection leads to high levels of cytokines.

“There pretty much isn't a cytokine that doesn't have a negative effect on bone,” she said.

Many other risk factors for bone loss and fractures are more common in the setting of HIV. Five of six cross-sectional studies found low levels of hydroxyvitamin D in patients with HIV.

Compared with the HIV-negative population, people with HIV have higher rates of smoking and alcohol use, are more likely to be treated with steroids, and are more likely to have periods of immobilization and illness, bouts of weight loss, hypogonadism (in men), and amenorrhea (in women).

Disclosures: Dr. Shoback has been a speaker for Novartis.

In one study, patients on combination HIV therapy lost 4% of lumbar spine bone mineral density.

Source DR. SHOBACK

SAN FRANCISCO — People with HIV infection tend to have more risk factors for bone loss than do those without, and antiretroviral medications may be adding to that risk.

The specific role of antiretroviral therapy in bone loss has been controversial: Some studies say there is no association, but others suggest that the drugs do contribute to bone loss.

The results of two small but well-conducted studies recently tipped the emphasis toward concern about the differential effects of antiretrovirals on bone mineral density, Dr. Dolores Shoback said.

“I think it's very provocative. We certainly need more data, and this needs to be confirmed,” she said at a meeting on HIV management sponsored by the University of California, San Francisco.

One randomized, controlled trial of 71 HIV-infected patients suggested that antiretroviral regimens that contain a protease inhibitor booster have a greater negative impact on spinal bone density than do regimens without a boosted protease inhibitor, said Dr. Shoback, who is professor of medicine at the university.

At baseline, 31% of the patients were osteopenic and 3% were osteoporotic.

Bone densities were retested after 48 weeks of combination HIV therapy with a nonnucleoside reverse transcriptase inhibitor (NNRTI) and nucleoside reverse transcriptase inhibitors (NRTIs), or an NNRTI and a boosted protease inhibitor, or two NRTIs and a boosted protease inhibitor.

On average, the cohort as a whole lost 4% of lumbar spine bone mineral density and 3% of hip bone density over the course of 48 weeks (AIDS 2009;23:817-24).

“To put that in perspective, in early menopause, 1%–5% per year is about the rate of change we see at the spine, so this is a significant change in bone mineral density,” she said.

The groups that were treated with boosted protease inhibitors lost significantly more spinal density—4.4% when combined with an NNRTI and 5.8% when combined with NRTIs—compared with the NNRTI-plus-NRTI arm (1.5%).

The changes in hip bone density did not differ significantly by treatment group, Dr. Shoback reported.

The second study randomized 50 HIV-infected patients to treatment with lopinavir/ritonavir plus zidovudine/lamivudine or lopinavir/ritonavir plus nevirapine, with bone densities compared at baseline and 2 years.

The zidovudine/lamivudine group lost 6.3% of bone mineral density in the hip and 5.1% in the spine, compared with smaller losses of 2.3% in the hip and 2.6% in the spine in the nevirapine group.

Spinal density decreased mainly in the first year and then stabilized, but hip density continued to fall in the second year (AIDS 2009;23:1367-76).

The investigators speculated that zidovudine/lamivudine increased osteoclastic activity. “I think there probably is, in fact, a signal here,” Dr. Shoback said.

There are not enough data yet to support changing antiretroviral regimens if bone mineral density is low, she added, but physicians should pay attention to nutrition (especially calcium and vitamin D), lifestyle factors, and weight-bearing exercise in patients with HIV.

Ongoing immune activation in HIV infection leads to high levels of cytokines.

“There pretty much isn't a cytokine that doesn't have a negative effect on bone,” she said.

Many other risk factors for bone loss and fractures are more common in the setting of HIV. Five of six cross-sectional studies found low levels of hydroxyvitamin D in patients with HIV.

Compared with the HIV-negative population, people with HIV have higher rates of smoking and alcohol use, are more likely to be treated with steroids, and are more likely to have periods of immobilization and illness, bouts of weight loss, hypogonadism (in men), and amenorrhea (in women).

Disclosures: Dr. Shoback has been a speaker for Novartis.

In one study, patients on combination HIV therapy lost 4% of lumbar spine bone mineral density.

Source DR. SHOBACK

SAN FRANCISCO — People with HIV infection tend to have more risk factors for bone loss than do those without, and antiretroviral medications may be adding to that risk.

The specific role of antiretroviral therapy in bone loss has been controversial: Some studies say there is no association, but others suggest that the drugs do contribute to bone loss.

The results of two small but well-conducted studies recently tipped the emphasis toward concern about the differential effects of antiretrovirals on bone mineral density, Dr. Dolores Shoback said.

“I think it's very provocative. We certainly need more data, and this needs to be confirmed,” she said at a meeting on HIV management sponsored by the University of California, San Francisco.

One randomized, controlled trial of 71 HIV-infected patients suggested that antiretroviral regimens that contain a protease inhibitor booster have a greater negative impact on spinal bone density than do regimens without a boosted protease inhibitor, said Dr. Shoback, who is professor of medicine at the university.

At baseline, 31% of the patients were osteopenic and 3% were osteoporotic.

Bone densities were retested after 48 weeks of combination HIV therapy with a nonnucleoside reverse transcriptase inhibitor (NNRTI) and nucleoside reverse transcriptase inhibitors (NRTIs), or an NNRTI and a boosted protease inhibitor, or two NRTIs and a boosted protease inhibitor.

On average, the cohort as a whole lost 4% of lumbar spine bone mineral density and 3% of hip bone density over the course of 48 weeks (AIDS 2009;23:817-24).

“To put that in perspective, in early menopause, 1%–5% per year is about the rate of change we see at the spine, so this is a significant change in bone mineral density,” she said.

The groups that were treated with boosted protease inhibitors lost significantly more spinal density—4.4% when combined with an NNRTI and 5.8% when combined with NRTIs—compared with the NNRTI-plus-NRTI arm (1.5%).

The changes in hip bone density did not differ significantly by treatment group, Dr. Shoback reported.

The second study randomized 50 HIV-infected patients to treatment with lopinavir/ritonavir plus zidovudine/lamivudine or lopinavir/ritonavir plus nevirapine, with bone densities compared at baseline and 2 years.

The zidovudine/lamivudine group lost 6.3% of bone mineral density in the hip and 5.1% in the spine, compared with smaller losses of 2.3% in the hip and 2.6% in the spine in the nevirapine group.

Spinal density decreased mainly in the first year and then stabilized, but hip density continued to fall in the second year (AIDS 2009;23:1367-76).

The investigators speculated that zidovudine/lamivudine increased osteoclastic activity. “I think there probably is, in fact, a signal here,” Dr. Shoback said.

There are not enough data yet to support changing antiretroviral regimens if bone mineral density is low, she added, but physicians should pay attention to nutrition (especially calcium and vitamin D), lifestyle factors, and weight-bearing exercise in patients with HIV.

Ongoing immune activation in HIV infection leads to high levels of cytokines.

“There pretty much isn't a cytokine that doesn't have a negative effect on bone,” she said.

Many other risk factors for bone loss and fractures are more common in the setting of HIV. Five of six cross-sectional studies found low levels of hydroxyvitamin D in patients with HIV.

Compared with the HIV-negative population, people with HIV have higher rates of smoking and alcohol use, are more likely to be treated with steroids, and are more likely to have periods of immobilization and illness, bouts of weight loss, hypogonadism (in men), and amenorrhea (in women).

Disclosures: Dr. Shoback has been a speaker for Novartis.

In one study, patients on combination HIV therapy lost 4% of lumbar spine bone mineral density.

Source DR. SHOBACK