Jane Salodof MacNeil

LOS ANGELES — Simvastatin lowered testosterone levels by 41%, normalized gonadotropin levels, and reduced cardiovascular risk factors in a small, randomized, controlled trial, suggesting that statins may be a potential treatment for polycystic ovary syndrome.

“Statins would improve the metabolic profile in those patients in terms of lipid levels as well as improve the hormonal problems,” study investigator Antoni J. Duleba, M.D., said at the annual meeting of the Society for Gynecologic Investigation.

The study is the first to demonstrate these benefits in women with polycystic ovary syndrome (PCOS). Dyslipidemia is common with PCOS, but statins are almost never used in PCOS, because the patients are typically young women trying to get pregnant or are at risk of getting pregnant. Statins are contraindicated in pregnancy, said Dr. Duleba of Yale University, New Haven.

The study eliminated pregnancy as a consideration by placing all 48 study participants on oral contraceptive pills (OC) containing 20 mcg of ethinyl estradiol and 150 mcg of desogestrel. One 24-patient cohort was treated with 20 mg of simvastatin daily, along with OC; the other 24 patients received only OC.

Investigators from Yale and Poznan University of Medical Sciences in Poland are conducting the ongoing trial in that country. The women are about 23 years old on average. None received any hormonal treatment or OCs for at least 3 months before enrollment. Organon Inc. supplied the OC Marvelon, and Polfa, a Polish pharmaceutical company, provided simvastatin.

A comparison of hormonal levels at baseline and 12 weeks showed total testosterone fell significantly—an average of 34.6 ng/dL (41%) in the OC-simvastatin group. By contrast, in the OC-alone group, levels fell by only 10.9 ng/dL (14%).

Average dehydroepiandrosterone sulfate (DHEA-S) fell 26% in the OC-simvastatin patients and 28% in the OC-alone group. Luteinizing hormone (LH), however, was reduced 43% in the OC-simvastatin group vs. 9% in the OC-alone cohort.

FSH declined 8%, which was not significant, in the OC-simvastatin patients, but it increased 21% in those taking just OCs.

The LH:FSH ratio declined significantly in the OC-simvastatin group (44%) and fell by 12% in the OC-alone group—not a statistically significant decline.

As expected, the simvastatin group had a significantly improved metabolic profile: Total cholesterol was 10% lower with OC-simvastatin vs. 8% higher with OC alone. Low-density lipoprotein (LDL) cholesterol dropped a significant 24% in the OC-simvastatin patients, but stayed the same in the control group. Conversely, triglyceride levels increased 21% in the OC-only patients but were not much changed in OC-simvastatin patients.

Increases in HDL cholesterol levels were similar: 9% with OC-simvastatin and 13% with OC alone.

Neither group had a significant improvement in insulin sensitivity or change in body mass index.

Dr. Duleba reported that hyperandrogenia declined dramatically in the OC-simvastatin arm, but he said 3 months is too early to determine whether this will lead to improvements in excessive hair growth or other clinical conditions associated with PCOS.

The trial employs a crossover design by which the groups have since switched regimens. The investigators also are looking at biochemical markers of endothelial function and cardiovascular risk.

“We used to only see women who wanted to get pregnant and, on occasion, because of complaints of hirsutism,” he said. “Now, with greater understanding of cardiovascular risk factors, people come to the office and say, 'What can we do to protect ourselves from heart disease, diabetes, high blood pressure—all the cardiovascular problems that our mothers, aunts, and grandmothers had?'”

Although he would not recommend statins to women trying to get pregnant, he concluded that statins could eventually prove to be the answer to their question about cardiovascular risk.

LOS ANGELES — Simvastatin lowered testosterone levels by 41%, normalized gonadotropin levels, and reduced cardiovascular risk factors in a small, randomized, controlled trial, suggesting that statins may be a potential treatment for polycystic ovary syndrome.

“Statins would improve the metabolic profile in those patients in terms of lipid levels as well as improve the hormonal problems,” study investigator Antoni J. Duleba, M.D., said at the annual meeting of the Society for Gynecologic Investigation.

The study is the first to demonstrate these benefits in women with polycystic ovary syndrome (PCOS). Dyslipidemia is common with PCOS, but statins are almost never used in PCOS, because the patients are typically young women trying to get pregnant or are at risk of getting pregnant. Statins are contraindicated in pregnancy, said Dr. Duleba of Yale University, New Haven.

The study eliminated pregnancy as a consideration by placing all 48 study participants on oral contraceptive pills (OC) containing 20 mcg of ethinyl estradiol and 150 mcg of desogestrel. One 24-patient cohort was treated with 20 mg of simvastatin daily, along with OC; the other 24 patients received only OC.

Investigators from Yale and Poznan University of Medical Sciences in Poland are conducting the ongoing trial in that country. The women are about 23 years old on average. None received any hormonal treatment or OCs for at least 3 months before enrollment. Organon Inc. supplied the OC Marvelon, and Polfa, a Polish pharmaceutical company, provided simvastatin.

A comparison of hormonal levels at baseline and 12 weeks showed total testosterone fell significantly—an average of 34.6 ng/dL (41%) in the OC-simvastatin group. By contrast, in the OC-alone group, levels fell by only 10.9 ng/dL (14%).

Average dehydroepiandrosterone sulfate (DHEA-S) fell 26% in the OC-simvastatin patients and 28% in the OC-alone group. Luteinizing hormone (LH), however, was reduced 43% in the OC-simvastatin group vs. 9% in the OC-alone cohort.

FSH declined 8%, which was not significant, in the OC-simvastatin patients, but it increased 21% in those taking just OCs.

The LH:FSH ratio declined significantly in the OC-simvastatin group (44%) and fell by 12% in the OC-alone group—not a statistically significant decline.

As expected, the simvastatin group had a significantly improved metabolic profile: Total cholesterol was 10% lower with OC-simvastatin vs. 8% higher with OC alone. Low-density lipoprotein (LDL) cholesterol dropped a significant 24% in the OC-simvastatin patients, but stayed the same in the control group. Conversely, triglyceride levels increased 21% in the OC-only patients but were not much changed in OC-simvastatin patients.

Increases in HDL cholesterol levels were similar: 9% with OC-simvastatin and 13% with OC alone.

Neither group had a significant improvement in insulin sensitivity or change in body mass index.

Dr. Duleba reported that hyperandrogenia declined dramatically in the OC-simvastatin arm, but he said 3 months is too early to determine whether this will lead to improvements in excessive hair growth or other clinical conditions associated with PCOS.

The trial employs a crossover design by which the groups have since switched regimens. The investigators also are looking at biochemical markers of endothelial function and cardiovascular risk.

“We used to only see women who wanted to get pregnant and, on occasion, because of complaints of hirsutism,” he said. “Now, with greater understanding of cardiovascular risk factors, people come to the office and say, 'What can we do to protect ourselves from heart disease, diabetes, high blood pressure—all the cardiovascular problems that our mothers, aunts, and grandmothers had?'”

Although he would not recommend statins to women trying to get pregnant, he concluded that statins could eventually prove to be the answer to their question about cardiovascular risk.

LOS ANGELES — Simvastatin lowered testosterone levels by 41%, normalized gonadotropin levels, and reduced cardiovascular risk factors in a small, randomized, controlled trial, suggesting that statins may be a potential treatment for polycystic ovary syndrome.

“Statins would improve the metabolic profile in those patients in terms of lipid levels as well as improve the hormonal problems,” study investigator Antoni J. Duleba, M.D., said at the annual meeting of the Society for Gynecologic Investigation.

The study is the first to demonstrate these benefits in women with polycystic ovary syndrome (PCOS). Dyslipidemia is common with PCOS, but statins are almost never used in PCOS, because the patients are typically young women trying to get pregnant or are at risk of getting pregnant. Statins are contraindicated in pregnancy, said Dr. Duleba of Yale University, New Haven.

The study eliminated pregnancy as a consideration by placing all 48 study participants on oral contraceptive pills (OC) containing 20 mcg of ethinyl estradiol and 150 mcg of desogestrel. One 24-patient cohort was treated with 20 mg of simvastatin daily, along with OC; the other 24 patients received only OC.

Investigators from Yale and Poznan University of Medical Sciences in Poland are conducting the ongoing trial in that country. The women are about 23 years old on average. None received any hormonal treatment or OCs for at least 3 months before enrollment. Organon Inc. supplied the OC Marvelon, and Polfa, a Polish pharmaceutical company, provided simvastatin.

A comparison of hormonal levels at baseline and 12 weeks showed total testosterone fell significantly—an average of 34.6 ng/dL (41%) in the OC-simvastatin group. By contrast, in the OC-alone group, levels fell by only 10.9 ng/dL (14%).

Average dehydroepiandrosterone sulfate (DHEA-S) fell 26% in the OC-simvastatin patients and 28% in the OC-alone group. Luteinizing hormone (LH), however, was reduced 43% in the OC-simvastatin group vs. 9% in the OC-alone cohort.

FSH declined 8%, which was not significant, in the OC-simvastatin patients, but it increased 21% in those taking just OCs.

The LH:FSH ratio declined significantly in the OC-simvastatin group (44%) and fell by 12% in the OC-alone group—not a statistically significant decline.

As expected, the simvastatin group had a significantly improved metabolic profile: Total cholesterol was 10% lower with OC-simvastatin vs. 8% higher with OC alone. Low-density lipoprotein (LDL) cholesterol dropped a significant 24% in the OC-simvastatin patients, but stayed the same in the control group. Conversely, triglyceride levels increased 21% in the OC-only patients but were not much changed in OC-simvastatin patients.

Increases in HDL cholesterol levels were similar: 9% with OC-simvastatin and 13% with OC alone.

Neither group had a significant improvement in insulin sensitivity or change in body mass index.

Dr. Duleba reported that hyperandrogenia declined dramatically in the OC-simvastatin arm, but he said 3 months is too early to determine whether this will lead to improvements in excessive hair growth or other clinical conditions associated with PCOS.

The trial employs a crossover design by which the groups have since switched regimens. The investigators also are looking at biochemical markers of endothelial function and cardiovascular risk.

“We used to only see women who wanted to get pregnant and, on occasion, because of complaints of hirsutism,” he said. “Now, with greater understanding of cardiovascular risk factors, people come to the office and say, 'What can we do to protect ourselves from heart disease, diabetes, high blood pressure—all the cardiovascular problems that our mothers, aunts, and grandmothers had?'”

Although he would not recommend statins to women trying to get pregnant, he concluded that statins could eventually prove to be the answer to their question about cardiovascular risk.

PHOENIX, ARIZ. — Sensitive skin complaints in the absence of a recognizable skin disease or irritation in female patients should not be dismissed, Albert M. Kligman, M.D., said at a clinical dermatology conference sponsored by Medicis.

Sensitive skin is a real subclinical condition that can be verified with a simple skin test and treated with a daily application of Nivea cream, said Dr. Kligman, professor emeritus of dermatology at the University of Pennsylvania, Philadelphia.

Between 30% and 50% of women in the United States, Europe, and Japan complain of itching, burning, stinging, dryness, tightening, or pain in reaction to topical skin care products, Dr. Kligman said. He blamed the problem on erosion of the stratum corneum by heavy use of skin care products in developed countries.

“Anything able to get through a leaky stratum corneum [is] going to pick up afferent responses,” he said. “There's no question that nerves are involved in this.”

To identify credible complaints in a patient whose skin appears normal, Dr. Kligman recommended a “lactic acid stinging test” he developed with colleagues. He said to apply a 10% solution of lactic acid to the patient's medial cheek and ask about the sensation without offering any cues.

If the patient has sensitive skin, the acid should induce a stinging sensation in 1 or 2 minutes. This will reach a peak in 5 minutes, only to become insignificant in 15 minutes. Some highly sensitive women may find the sensation unbearable and ask to have the acid washed away in 3 minutes, Dr. Kligman said. If, however, a patient has an instant reaction, he would conclude she does not have sensitive skin. Most sensitive skin reactions are moderate, and take time to develop.

Women who react to lactic acid are usually hypersensitive to other substances, he added, listing cause-and-effect relationships between capsaicin and pain, histamine and itching, harsh soaps or cleansers and tightness, and balsam of Peru and burning.

Although sensitive skin may take decades to develop, the remedy can be as quick as 7–8 weeks with daily applications of Nivea cream or a comparable product. “Stingers become nonstingers if you improve their barrier—make their skins less permeable,” he said. “It is possible to convert a sting to a nonstinger just by putting on a bland moisturizer.”

PHOENIX, ARIZ. — Sensitive skin complaints in the absence of a recognizable skin disease or irritation in female patients should not be dismissed, Albert M. Kligman, M.D., said at a clinical dermatology conference sponsored by Medicis.

Sensitive skin is a real subclinical condition that can be verified with a simple skin test and treated with a daily application of Nivea cream, said Dr. Kligman, professor emeritus of dermatology at the University of Pennsylvania, Philadelphia.

Between 30% and 50% of women in the United States, Europe, and Japan complain of itching, burning, stinging, dryness, tightening, or pain in reaction to topical skin care products, Dr. Kligman said. He blamed the problem on erosion of the stratum corneum by heavy use of skin care products in developed countries.

“Anything able to get through a leaky stratum corneum [is] going to pick up afferent responses,” he said. “There's no question that nerves are involved in this.”

To identify credible complaints in a patient whose skin appears normal, Dr. Kligman recommended a “lactic acid stinging test” he developed with colleagues. He said to apply a 10% solution of lactic acid to the patient's medial cheek and ask about the sensation without offering any cues.

If the patient has sensitive skin, the acid should induce a stinging sensation in 1 or 2 minutes. This will reach a peak in 5 minutes, only to become insignificant in 15 minutes. Some highly sensitive women may find the sensation unbearable and ask to have the acid washed away in 3 minutes, Dr. Kligman said. If, however, a patient has an instant reaction, he would conclude she does not have sensitive skin. Most sensitive skin reactions are moderate, and take time to develop.

Women who react to lactic acid are usually hypersensitive to other substances, he added, listing cause-and-effect relationships between capsaicin and pain, histamine and itching, harsh soaps or cleansers and tightness, and balsam of Peru and burning.

Although sensitive skin may take decades to develop, the remedy can be as quick as 7–8 weeks with daily applications of Nivea cream or a comparable product. “Stingers become nonstingers if you improve their barrier—make their skins less permeable,” he said. “It is possible to convert a sting to a nonstinger just by putting on a bland moisturizer.”

PHOENIX, ARIZ. — Sensitive skin complaints in the absence of a recognizable skin disease or irritation in female patients should not be dismissed, Albert M. Kligman, M.D., said at a clinical dermatology conference sponsored by Medicis.

Sensitive skin is a real subclinical condition that can be verified with a simple skin test and treated with a daily application of Nivea cream, said Dr. Kligman, professor emeritus of dermatology at the University of Pennsylvania, Philadelphia.

Between 30% and 50% of women in the United States, Europe, and Japan complain of itching, burning, stinging, dryness, tightening, or pain in reaction to topical skin care products, Dr. Kligman said. He blamed the problem on erosion of the stratum corneum by heavy use of skin care products in developed countries.

“Anything able to get through a leaky stratum corneum [is] going to pick up afferent responses,” he said. “There's no question that nerves are involved in this.”

To identify credible complaints in a patient whose skin appears normal, Dr. Kligman recommended a “lactic acid stinging test” he developed with colleagues. He said to apply a 10% solution of lactic acid to the patient's medial cheek and ask about the sensation without offering any cues.

If the patient has sensitive skin, the acid should induce a stinging sensation in 1 or 2 minutes. This will reach a peak in 5 minutes, only to become insignificant in 15 minutes. Some highly sensitive women may find the sensation unbearable and ask to have the acid washed away in 3 minutes, Dr. Kligman said. If, however, a patient has an instant reaction, he would conclude she does not have sensitive skin. Most sensitive skin reactions are moderate, and take time to develop.

Women who react to lactic acid are usually hypersensitive to other substances, he added, listing cause-and-effect relationships between capsaicin and pain, histamine and itching, harsh soaps or cleansers and tightness, and balsam of Peru and burning.

Although sensitive skin may take decades to develop, the remedy can be as quick as 7–8 weeks with daily applications of Nivea cream or a comparable product. “Stingers become nonstingers if you improve their barrier—make their skins less permeable,” he said. “It is possible to convert a sting to a nonstinger just by putting on a bland moisturizer.”

LAS VEGAS — Sibutramine (Meridia), an adult diet drug, can help control the weight of children with hypothalamic obesity and other syndromes that make behavioral interventions ineffective, results from a small, double-blind, placebo-controlled trial suggest.

Claude Marcus, M.D., reported statistically significant differences in reduction of body mass index (BMI) when the children were on sibutramine, compared with when they were on placebo. Triglyceride levels also declined significantly with sibutramine, Dr. Marcus said at the annual meeting of the North American Association for the Study of Obesity.

“These are very difficult patients to treat,” explained Dr. Marcus of the Karolinska Institute in Stockholm where the trial was conducted.

These patients are extremely resistant to behavioral treatments that help normal children and often have a very low quality of life, he said at the meeting, which was cosponsored by the American Diabetes Association.

The trial enrolled 50 obese young people aged 7–20 years with a range of disorders: mental retardation or attention-deficit hyperactivity disorder (21 children), central nervous system lesions (10), Lawrence-Moon-Bardet-Biedl syndrome (6), Prader-Willi syndrome (4), myelomeningocele (4), Mb Down syndrome (3), and mutation in the MC4R gene (2).

Half of the children started on sibutramine and crossed over to placebo after 20 weeks. The other half started on placebo and switched to sibutramine. In 38 children, doses were escalated from 10 to 15 mg because of unsatisfactory weight loss, but Dr. Marcus said the best dose is still uncertain.

The group that started on sibutramine experienced a 0.72 reduction in BMI while on the drug, followed by a 0.43 rebound when they went on placebo. Conversely, the group that started on placebo lost 0.06 in BMI during the first half of the trial and 0.68 when they went on sibutramine.

Dr. Marcus acknowledged that these amounts are small, compared with other weight-loss studies, but described them as significant for the population. He said sibutramine slowed weight gain in some children who were in a weight-increase phase, while having an extreme effect in others.

“One child lost 40 kilos,” he said, cautioning that the subgroups in the study were too small to make comparisons by disorder.

Sibutramine was generally well tolerated, according to Dr. Marcus. Five children dropped out of the study—three because of recurrence of CNS tumors and two because they did not comply with treatment.

Four youngsters were on concurrent selective serotonin reuptake inhibitors (SSRIs); no side effects were reported with the combination. Three children were diagnosed with severe depression while on placebo.

Dr. Marcus said the children are now off sibutramine because it is only approved for ages 16 and older. He announced plans to start another dose trial that would enable them to resume treatment.

The trial received support from the Swedish Research Council, the Swedish Children's Cancer Foundation, Abbott Scandinavia AB (distributor of sibutramine), and the Freemasons in Stockholm Foundation for Children's Welfare.

LAS VEGAS — Sibutramine (Meridia), an adult diet drug, can help control the weight of children with hypothalamic obesity and other syndromes that make behavioral interventions ineffective, results from a small, double-blind, placebo-controlled trial suggest.

Claude Marcus, M.D., reported statistically significant differences in reduction of body mass index (BMI) when the children were on sibutramine, compared with when they were on placebo. Triglyceride levels also declined significantly with sibutramine, Dr. Marcus said at the annual meeting of the North American Association for the Study of Obesity.

“These are very difficult patients to treat,” explained Dr. Marcus of the Karolinska Institute in Stockholm where the trial was conducted.

These patients are extremely resistant to behavioral treatments that help normal children and often have a very low quality of life, he said at the meeting, which was cosponsored by the American Diabetes Association.

The trial enrolled 50 obese young people aged 7–20 years with a range of disorders: mental retardation or attention-deficit hyperactivity disorder (21 children), central nervous system lesions (10), Lawrence-Moon-Bardet-Biedl syndrome (6), Prader-Willi syndrome (4), myelomeningocele (4), Mb Down syndrome (3), and mutation in the MC4R gene (2).

Half of the children started on sibutramine and crossed over to placebo after 20 weeks. The other half started on placebo and switched to sibutramine. In 38 children, doses were escalated from 10 to 15 mg because of unsatisfactory weight loss, but Dr. Marcus said the best dose is still uncertain.

The group that started on sibutramine experienced a 0.72 reduction in BMI while on the drug, followed by a 0.43 rebound when they went on placebo. Conversely, the group that started on placebo lost 0.06 in BMI during the first half of the trial and 0.68 when they went on sibutramine.

Dr. Marcus acknowledged that these amounts are small, compared with other weight-loss studies, but described them as significant for the population. He said sibutramine slowed weight gain in some children who were in a weight-increase phase, while having an extreme effect in others.

“One child lost 40 kilos,” he said, cautioning that the subgroups in the study were too small to make comparisons by disorder.

Sibutramine was generally well tolerated, according to Dr. Marcus. Five children dropped out of the study—three because of recurrence of CNS tumors and two because they did not comply with treatment.

Four youngsters were on concurrent selective serotonin reuptake inhibitors (SSRIs); no side effects were reported with the combination. Three children were diagnosed with severe depression while on placebo.

Dr. Marcus said the children are now off sibutramine because it is only approved for ages 16 and older. He announced plans to start another dose trial that would enable them to resume treatment.

The trial received support from the Swedish Research Council, the Swedish Children's Cancer Foundation, Abbott Scandinavia AB (distributor of sibutramine), and the Freemasons in Stockholm Foundation for Children's Welfare.

LAS VEGAS — Sibutramine (Meridia), an adult diet drug, can help control the weight of children with hypothalamic obesity and other syndromes that make behavioral interventions ineffective, results from a small, double-blind, placebo-controlled trial suggest.

Claude Marcus, M.D., reported statistically significant differences in reduction of body mass index (BMI) when the children were on sibutramine, compared with when they were on placebo. Triglyceride levels also declined significantly with sibutramine, Dr. Marcus said at the annual meeting of the North American Association for the Study of Obesity.

“These are very difficult patients to treat,” explained Dr. Marcus of the Karolinska Institute in Stockholm where the trial was conducted.

These patients are extremely resistant to behavioral treatments that help normal children and often have a very low quality of life, he said at the meeting, which was cosponsored by the American Diabetes Association.

The trial enrolled 50 obese young people aged 7–20 years with a range of disorders: mental retardation or attention-deficit hyperactivity disorder (21 children), central nervous system lesions (10), Lawrence-Moon-Bardet-Biedl syndrome (6), Prader-Willi syndrome (4), myelomeningocele (4), Mb Down syndrome (3), and mutation in the MC4R gene (2).

Half of the children started on sibutramine and crossed over to placebo after 20 weeks. The other half started on placebo and switched to sibutramine. In 38 children, doses were escalated from 10 to 15 mg because of unsatisfactory weight loss, but Dr. Marcus said the best dose is still uncertain.

The group that started on sibutramine experienced a 0.72 reduction in BMI while on the drug, followed by a 0.43 rebound when they went on placebo. Conversely, the group that started on placebo lost 0.06 in BMI during the first half of the trial and 0.68 when they went on sibutramine.

Dr. Marcus acknowledged that these amounts are small, compared with other weight-loss studies, but described them as significant for the population. He said sibutramine slowed weight gain in some children who were in a weight-increase phase, while having an extreme effect in others.

“One child lost 40 kilos,” he said, cautioning that the subgroups in the study were too small to make comparisons by disorder.

Sibutramine was generally well tolerated, according to Dr. Marcus. Five children dropped out of the study—three because of recurrence of CNS tumors and two because they did not comply with treatment.

Four youngsters were on concurrent selective serotonin reuptake inhibitors (SSRIs); no side effects were reported with the combination. Three children were diagnosed with severe depression while on placebo.

Dr. Marcus said the children are now off sibutramine because it is only approved for ages 16 and older. He announced plans to start another dose trial that would enable them to resume treatment.

The trial received support from the Swedish Research Council, the Swedish Children's Cancer Foundation, Abbott Scandinavia AB (distributor of sibutramine), and the Freemasons in Stockholm Foundation for Children's Welfare.

HOUSTON — Pregnant women should be treated for human immunodeficiency virus infections even if they are asymptomatic and have normal CD4 counts and low viral loads, said Hunter A. Hammill, M.D.

Pregnancy itself does not affect the course of the disease. The woman's condition will not become worse, but the baby is at risk, he said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

“Optimum therapy should be offered to minimize vertical transmission to the infant,” said Dr. Hammill of the college.

Infants of HIV-positive mothers will test positive for 6–8 weeks after birth. Without treatment, about one-third will be infected and remain positive. Breast-feeding can increase the vertical infection rate by 20%.

Studies summarized by Dr. Hammill have reported transmission rates of less than 1%–13% when various therapies were tested in pregnant women. “My series is now down to less than a tenth of a percent vertical transmission with vaginal delivery” when patients are treated with HAART (Highly Active Antiretroviral Therapy), he said.

Dr. Hammill urged practitioners to get up to date on new antiretroviral treatments. About 30 different treatment options are available, he said, and these are typically given in three-drug combinations.

Patients have to be monitored as some agents will have side effects. Among these, he listed unusual dreams, yellow skin, liver and renal toxicities, and nausea lasting several weeks until the patient's body adapts.

Some HAART drugs do pose special risks. He cited rash and hepatic toxicity with nevirapine (Viramune), hyperglycemia with protease inhibitors, and mitochondrial toxicity with nucleoside analogs.

His greatest concern is efavirenz (Sustiva), which is sometimes prescribed because it is considered safe in pregnancy. Because one animal study has linked it to monkey anencephaly, Dr. Hammill said he switches his patients to another drug.

“If you see an HIV patient on Sustiva, please think of birth control,” he said.

Dr. Hammill also urged physicians to provide intensive counseling about the importance of complying with treatment. “The big thing in AIDS is adherence,” he said. “If you don't take the drug, it doesn't work.”

HOUSTON — Pregnant women should be treated for human immunodeficiency virus infections even if they are asymptomatic and have normal CD4 counts and low viral loads, said Hunter A. Hammill, M.D.

Pregnancy itself does not affect the course of the disease. The woman's condition will not become worse, but the baby is at risk, he said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

“Optimum therapy should be offered to minimize vertical transmission to the infant,” said Dr. Hammill of the college.

Infants of HIV-positive mothers will test positive for 6–8 weeks after birth. Without treatment, about one-third will be infected and remain positive. Breast-feeding can increase the vertical infection rate by 20%.

Studies summarized by Dr. Hammill have reported transmission rates of less than 1%–13% when various therapies were tested in pregnant women. “My series is now down to less than a tenth of a percent vertical transmission with vaginal delivery” when patients are treated with HAART (Highly Active Antiretroviral Therapy), he said.

Dr. Hammill urged practitioners to get up to date on new antiretroviral treatments. About 30 different treatment options are available, he said, and these are typically given in three-drug combinations.

Patients have to be monitored as some agents will have side effects. Among these, he listed unusual dreams, yellow skin, liver and renal toxicities, and nausea lasting several weeks until the patient's body adapts.

Some HAART drugs do pose special risks. He cited rash and hepatic toxicity with nevirapine (Viramune), hyperglycemia with protease inhibitors, and mitochondrial toxicity with nucleoside analogs.

His greatest concern is efavirenz (Sustiva), which is sometimes prescribed because it is considered safe in pregnancy. Because one animal study has linked it to monkey anencephaly, Dr. Hammill said he switches his patients to another drug.

“If you see an HIV patient on Sustiva, please think of birth control,” he said.

Dr. Hammill also urged physicians to provide intensive counseling about the importance of complying with treatment. “The big thing in AIDS is adherence,” he said. “If you don't take the drug, it doesn't work.”

HOUSTON — Pregnant women should be treated for human immunodeficiency virus infections even if they are asymptomatic and have normal CD4 counts and low viral loads, said Hunter A. Hammill, M.D.

Pregnancy itself does not affect the course of the disease. The woman's condition will not become worse, but the baby is at risk, he said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

“Optimum therapy should be offered to minimize vertical transmission to the infant,” said Dr. Hammill of the college.

Infants of HIV-positive mothers will test positive for 6–8 weeks after birth. Without treatment, about one-third will be infected and remain positive. Breast-feeding can increase the vertical infection rate by 20%.

Studies summarized by Dr. Hammill have reported transmission rates of less than 1%–13% when various therapies were tested in pregnant women. “My series is now down to less than a tenth of a percent vertical transmission with vaginal delivery” when patients are treated with HAART (Highly Active Antiretroviral Therapy), he said.

Dr. Hammill urged practitioners to get up to date on new antiretroviral treatments. About 30 different treatment options are available, he said, and these are typically given in three-drug combinations.

Patients have to be monitored as some agents will have side effects. Among these, he listed unusual dreams, yellow skin, liver and renal toxicities, and nausea lasting several weeks until the patient's body adapts.

Some HAART drugs do pose special risks. He cited rash and hepatic toxicity with nevirapine (Viramune), hyperglycemia with protease inhibitors, and mitochondrial toxicity with nucleoside analogs.

His greatest concern is efavirenz (Sustiva), which is sometimes prescribed because it is considered safe in pregnancy. Because one animal study has linked it to monkey anencephaly, Dr. Hammill said he switches his patients to another drug.

“If you see an HIV patient on Sustiva, please think of birth control,” he said.

Dr. Hammill also urged physicians to provide intensive counseling about the importance of complying with treatment. “The big thing in AIDS is adherence,” he said. “If you don't take the drug, it doesn't work.”

LOS ANGELES — Many women do not go for recommended Pap testing after being diagnosed with the human immunodeficiency virus, despite being at elevated risk for cervical cancer.

Chart reviews of 428 women seen at an urban HIV clinic found 48% had Pap tests within a year of enrollment at the clinic. Yet the clinic's physicians had referred all of the women for testing, many of them repeatedly, Laurie C. Zephyrin, M.D., reported at the annual meeting of the Society for Gynecologic Investigation.

“Those women who had other social factors or who tended to be sicker tended not to have their Pap tests. But they were referred. The primary care physicians were definitely doing their job in referring patients,” said Dr. Zephyrin of the department of obstetrics and gynecology at Johns Hopkins University in Baltimore.

Guidelines call for Pap testing every 6 months in the first year after diagnosis with HIV, and once annually thereafter, according to Dr. Zephyrin. With so many women not being screened in the first year, she called for simplifying the health care delivery system to make tests more accessible at primary care sites.

“I really think there needs to be a reorganization of how we deliver care, particularly to women with conditions such as HIV,” she said.

Dr. Zephyrin and her coinvestigators followed women who enrolled in a large urban HIV clinic affiliated with Johns Hopkins from January 1998 to November 2002. The population was predominantly African American and low income with a median age of 38. More than a third, or 36%, were intravenous drug users.

One in four patients had normal CD4 counts of at least 500. Dr. Zephyrin said that more than 30% had “a diagnosis consistent with AIDS,” as reflected in CD4 counts below 200. About three-fourths of the women, 74%, were on highly active antiretroviral therapy (HAART).

The proportion that had a Pap test increased with time spent in the program. Nearly two-thirds, 63%, were screened within 2 years and 75% were screened within 3 years.

By the end of 6 years, 87% had at least one Pap test.

In the first year, black women were 37% more likely to have a Pap test and women on HAART were 38% more likely, compared with their nonblack and non-HAART counterparts. Dr. Zephyrin speculated that the patients on HAART were in the clinic more often and might have been more compliant.

Compared with women with normal CD4 counts, women with counts of 200–500 were 39% less likely to have a Pap test during the first year. Similarly, intravenous drug users were 32% less likely than were those who were not users.

Dr. Zephyrin reported that although 61% of Pap tests were normal, women who had been diagnosed with AIDS were four times more likely to have an abnormal Pap test result within the first year.

LOS ANGELES — Many women do not go for recommended Pap testing after being diagnosed with the human immunodeficiency virus, despite being at elevated risk for cervical cancer.

Chart reviews of 428 women seen at an urban HIV clinic found 48% had Pap tests within a year of enrollment at the clinic. Yet the clinic's physicians had referred all of the women for testing, many of them repeatedly, Laurie C. Zephyrin, M.D., reported at the annual meeting of the Society for Gynecologic Investigation.

“Those women who had other social factors or who tended to be sicker tended not to have their Pap tests. But they were referred. The primary care physicians were definitely doing their job in referring patients,” said Dr. Zephyrin of the department of obstetrics and gynecology at Johns Hopkins University in Baltimore.

Guidelines call for Pap testing every 6 months in the first year after diagnosis with HIV, and once annually thereafter, according to Dr. Zephyrin. With so many women not being screened in the first year, she called for simplifying the health care delivery system to make tests more accessible at primary care sites.

“I really think there needs to be a reorganization of how we deliver care, particularly to women with conditions such as HIV,” she said.

Dr. Zephyrin and her coinvestigators followed women who enrolled in a large urban HIV clinic affiliated with Johns Hopkins from January 1998 to November 2002. The population was predominantly African American and low income with a median age of 38. More than a third, or 36%, were intravenous drug users.

One in four patients had normal CD4 counts of at least 500. Dr. Zephyrin said that more than 30% had “a diagnosis consistent with AIDS,” as reflected in CD4 counts below 200. About three-fourths of the women, 74%, were on highly active antiretroviral therapy (HAART).

The proportion that had a Pap test increased with time spent in the program. Nearly two-thirds, 63%, were screened within 2 years and 75% were screened within 3 years.

By the end of 6 years, 87% had at least one Pap test.

In the first year, black women were 37% more likely to have a Pap test and women on HAART were 38% more likely, compared with their nonblack and non-HAART counterparts. Dr. Zephyrin speculated that the patients on HAART were in the clinic more often and might have been more compliant.

Compared with women with normal CD4 counts, women with counts of 200–500 were 39% less likely to have a Pap test during the first year. Similarly, intravenous drug users were 32% less likely than were those who were not users.

Dr. Zephyrin reported that although 61% of Pap tests were normal, women who had been diagnosed with AIDS were four times more likely to have an abnormal Pap test result within the first year.

LOS ANGELES — Many women do not go for recommended Pap testing after being diagnosed with the human immunodeficiency virus, despite being at elevated risk for cervical cancer.

Chart reviews of 428 women seen at an urban HIV clinic found 48% had Pap tests within a year of enrollment at the clinic. Yet the clinic's physicians had referred all of the women for testing, many of them repeatedly, Laurie C. Zephyrin, M.D., reported at the annual meeting of the Society for Gynecologic Investigation.

“Those women who had other social factors or who tended to be sicker tended not to have their Pap tests. But they were referred. The primary care physicians were definitely doing their job in referring patients,” said Dr. Zephyrin of the department of obstetrics and gynecology at Johns Hopkins University in Baltimore.

Guidelines call for Pap testing every 6 months in the first year after diagnosis with HIV, and once annually thereafter, according to Dr. Zephyrin. With so many women not being screened in the first year, she called for simplifying the health care delivery system to make tests more accessible at primary care sites.

“I really think there needs to be a reorganization of how we deliver care, particularly to women with conditions such as HIV,” she said.

Dr. Zephyrin and her coinvestigators followed women who enrolled in a large urban HIV clinic affiliated with Johns Hopkins from January 1998 to November 2002. The population was predominantly African American and low income with a median age of 38. More than a third, or 36%, were intravenous drug users.

One in four patients had normal CD4 counts of at least 500. Dr. Zephyrin said that more than 30% had “a diagnosis consistent with AIDS,” as reflected in CD4 counts below 200. About three-fourths of the women, 74%, were on highly active antiretroviral therapy (HAART).

The proportion that had a Pap test increased with time spent in the program. Nearly two-thirds, 63%, were screened within 2 years and 75% were screened within 3 years.

By the end of 6 years, 87% had at least one Pap test.

In the first year, black women were 37% more likely to have a Pap test and women on HAART were 38% more likely, compared with their nonblack and non-HAART counterparts. Dr. Zephyrin speculated that the patients on HAART were in the clinic more often and might have been more compliant.

Compared with women with normal CD4 counts, women with counts of 200–500 were 39% less likely to have a Pap test during the first year. Similarly, intravenous drug users were 32% less likely than were those who were not users.

Dr. Zephyrin reported that although 61% of Pap tests were normal, women who had been diagnosed with AIDS were four times more likely to have an abnormal Pap test result within the first year.

PHOENIX, ARIZ. — Intravenous nicardipine can reduce blood pressure by 15%–20% without impairing blood supply to the brain in hypertensive emergencies, preliminary results from an ongoing case-control study suggest.

Results so far suggest nicardipine therapy might even improve cerebral oxygenation (PbrO₂) in ischemic patients, reported study investigator Varun Puri, M.D. “There was no reduction in oxygen delivery to the brain despite significant reduction in [the fraction of inspired oxygen],” he said at a meeting sponsored by the Society of Critical Care Medicine.

Dr. Puri presented data on 17 patients with acute neurological disorders, 11 of whom were women. The patients' average age was 57 years, and the pathologies included seven subarachnoid hemorrhages, four traumatic brain injuries, three intracerebral hemorrhages, two arteriovenous malformations, and one case of anoxia.

The patients had 36 episodes of hypertensive emergency during the study: 11 from acute cardiovascular syndrome, 14 postoperatively, and 11 after trauma. The nicardipine dose, titrated as clinically indicated to lower blood pressure, ranged from 2.5 mg to 15 mg per hour. The duration of treatment ranged from 12 hours to 10 days.

Dr. Puri reported that systolic blood pressure fell from 175 mm Hg pretreatment to 143 mm Hg at 8 hours after treatment, diastolic blood pressure decreased from 84 mm Hg to 69 mm Hg, and mean arterial blood pressure dropped from 114 mm Hg to 95 mm Hg. All the changes were statistically significant.

Brain tissue monitoring over an 8-hour period showed no significant changes in intracranial pressure or partial brain tissue oxygenation (PbtO₂). Fraction of inspired oxygen (FiO₂) fell from 0.72 to 0.62, a statistically significant difference.

In six patients presenting with cerebral hypoxia, average PbtO₂ was 10.4 mm Hg before treatment with nicardipine, a specific arterial dilator. By 4 hours posttreatment, oxygenation had increased to 20.4 mm Hg. At 8 hours, it was 22.2 mm Hg, a statistically significant change.

One severe adverse event was reported: a case of hypotension that responded quickly to a reduction in the nicardipine dose, Dr. Puri said. Five patients eventually required oral antihypertensive agents, and three went on to β-blockers, he said. None had been on β-blockers before the trial, and patients taking two or more agents for hypertension had also been excluded.

The investigators are continuing to enroll patients, said Dr. Puri, of Creighton University Medical Center in Omaha, Neb. Integra LifeSciences Corp., maker of the Licox brain tissue oxygen monitoring system, provided funding for the study.

PHOENIX, ARIZ. — Intravenous nicardipine can reduce blood pressure by 15%–20% without impairing blood supply to the brain in hypertensive emergencies, preliminary results from an ongoing case-control study suggest.

Results so far suggest nicardipine therapy might even improve cerebral oxygenation (PbrO₂) in ischemic patients, reported study investigator Varun Puri, M.D. “There was no reduction in oxygen delivery to the brain despite significant reduction in [the fraction of inspired oxygen],” he said at a meeting sponsored by the Society of Critical Care Medicine.

Dr. Puri presented data on 17 patients with acute neurological disorders, 11 of whom were women. The patients' average age was 57 years, and the pathologies included seven subarachnoid hemorrhages, four traumatic brain injuries, three intracerebral hemorrhages, two arteriovenous malformations, and one case of anoxia.

The patients had 36 episodes of hypertensive emergency during the study: 11 from acute cardiovascular syndrome, 14 postoperatively, and 11 after trauma. The nicardipine dose, titrated as clinically indicated to lower blood pressure, ranged from 2.5 mg to 15 mg per hour. The duration of treatment ranged from 12 hours to 10 days.

Dr. Puri reported that systolic blood pressure fell from 175 mm Hg pretreatment to 143 mm Hg at 8 hours after treatment, diastolic blood pressure decreased from 84 mm Hg to 69 mm Hg, and mean arterial blood pressure dropped from 114 mm Hg to 95 mm Hg. All the changes were statistically significant.

Brain tissue monitoring over an 8-hour period showed no significant changes in intracranial pressure or partial brain tissue oxygenation (PbtO₂). Fraction of inspired oxygen (FiO₂) fell from 0.72 to 0.62, a statistically significant difference.

In six patients presenting with cerebral hypoxia, average PbtO₂ was 10.4 mm Hg before treatment with nicardipine, a specific arterial dilator. By 4 hours posttreatment, oxygenation had increased to 20.4 mm Hg. At 8 hours, it was 22.2 mm Hg, a statistically significant change.

One severe adverse event was reported: a case of hypotension that responded quickly to a reduction in the nicardipine dose, Dr. Puri said. Five patients eventually required oral antihypertensive agents, and three went on to β-blockers, he said. None had been on β-blockers before the trial, and patients taking two or more agents for hypertension had also been excluded.

The investigators are continuing to enroll patients, said Dr. Puri, of Creighton University Medical Center in Omaha, Neb. Integra LifeSciences Corp., maker of the Licox brain tissue oxygen monitoring system, provided funding for the study.

PHOENIX, ARIZ. — Intravenous nicardipine can reduce blood pressure by 15%–20% without impairing blood supply to the brain in hypertensive emergencies, preliminary results from an ongoing case-control study suggest.

Results so far suggest nicardipine therapy might even improve cerebral oxygenation (PbrO₂) in ischemic patients, reported study investigator Varun Puri, M.D. “There was no reduction in oxygen delivery to the brain despite significant reduction in [the fraction of inspired oxygen],” he said at a meeting sponsored by the Society of Critical Care Medicine.

Dr. Puri presented data on 17 patients with acute neurological disorders, 11 of whom were women. The patients' average age was 57 years, and the pathologies included seven subarachnoid hemorrhages, four traumatic brain injuries, three intracerebral hemorrhages, two arteriovenous malformations, and one case of anoxia.

The patients had 36 episodes of hypertensive emergency during the study: 11 from acute cardiovascular syndrome, 14 postoperatively, and 11 after trauma. The nicardipine dose, titrated as clinically indicated to lower blood pressure, ranged from 2.5 mg to 15 mg per hour. The duration of treatment ranged from 12 hours to 10 days.

Dr. Puri reported that systolic blood pressure fell from 175 mm Hg pretreatment to 143 mm Hg at 8 hours after treatment, diastolic blood pressure decreased from 84 mm Hg to 69 mm Hg, and mean arterial blood pressure dropped from 114 mm Hg to 95 mm Hg. All the changes were statistically significant.

Brain tissue monitoring over an 8-hour period showed no significant changes in intracranial pressure or partial brain tissue oxygenation (PbtO₂). Fraction of inspired oxygen (FiO₂) fell from 0.72 to 0.62, a statistically significant difference.

In six patients presenting with cerebral hypoxia, average PbtO₂ was 10.4 mm Hg before treatment with nicardipine, a specific arterial dilator. By 4 hours posttreatment, oxygenation had increased to 20.4 mm Hg. At 8 hours, it was 22.2 mm Hg, a statistically significant change.

One severe adverse event was reported: a case of hypotension that responded quickly to a reduction in the nicardipine dose, Dr. Puri said. Five patients eventually required oral antihypertensive agents, and three went on to β-blockers, he said. None had been on β-blockers before the trial, and patients taking two or more agents for hypertension had also been excluded.

The investigators are continuing to enroll patients, said Dr. Puri, of Creighton University Medical Center in Omaha, Neb. Integra LifeSciences Corp., maker of the Licox brain tissue oxygen monitoring system, provided funding for the study.

PHOENIX, ARIZ. — Locally invasive skin cancers with histologies amenable to frozen section are candidates for Mohs surgery, Neil A. Swanson, M.D., said at a clinical dermatology conference sponsored by Medicis.

But the exacting technique is not always appropriate.

Physicians should consider multiple factors in deciding which therapy to use, said Dr. Swanson, chair of dermatology at Oregon Health and Science University in Portland.

"Mohs is not indicated for every cancer but for the ones that are high risk," he said.

Dr. Swanson described a strategy outlining how to decide whether to use the surgical technique for various melanoma and nonmelanoma skin cancers.

Basal cell carcinomas that recur or have been incompletely excised would be treated with Mohs surgery, which Dr. Swanson described as the "penultimate margin control."

For low-risk basal cell carcinoma, he favored excision, curettage and electrodesiccation, cryosurgery, or radiation.

Most basal cell carcinomas will be low-risk, according to Dr. Swanson.

To identify the few cancers that are high risk, he suggested considering the following four factors:

▸ Location. Tumors could be more aggressive in certain facial areas.

▸ Histology. Mohs surgery would be indicated for morpheaform (sclerotic) and for keratotic (metatypical) basal cell tumors.

For noduloulcerative and superficial types, he recommended choosing one of the alternative therapies.

▸ Size. Use Mohs surgery when a basal cell tumor is 2 cm or greater.

Smaller tumors can be treated with another therapy.

▸ Clinical nature. Mohs surgery would be indicated for a tumor that has ill-defined borders, is multicentric, or evidences immunosuppression.

In some large and aggressive cases, he suggested the dermatologist work cooperatively with a specialist.

"One of the most time-consuming things in the operating room is [figuring out] what is this margin going to be," he commented.

"The day before, we do the peripheral margin. We leave the center of the tumor. It is going to be removed anyway by the surgeon."

For melanoma, Dr. Swanson recommended Mohs surgery as an option in head and neck cases; these are often positioned in difficult anatomic sites where tissue preservation is a concern.

He said he always starts with a Wood's light, which he finds especially useful for defining margins.

"I outline the tumor clinically," Dr. Swanson said. "I turn the lights off, and I shine the Wood's light, and I find the margin changes."

After removing the center scar and residual lesions, he will create a standard Mohs rim and repeat frozen sections until the area is "clear." He recommended that the permanent rim always have an additional 2-mm margin.

Nonmelanoma fibrous tumors are also candidates for Mohs surgery. "These are tumors that look fairly small and end up fairly large," he said.

With Merkel cell carcinoma, however, the choice of therapy is difficult to make. "Mohs may or may not be indicated," said Dr. Swanson.

"Leave to the head and neck surgeon to take margins, and hit it with everything you have in the first go-around," he suggested.

Mohs surgery can be effective for leiomyosarcoma and carcinomas in the eyelid, he continued.

Angiosarcoma has very a poor prognosis, however. Although some physicians have attempted to treat it with Mohs surgery, Dr. Swanson said he has not and will not do so.

PHOENIX, ARIZ. — Locally invasive skin cancers with histologies amenable to frozen section are candidates for Mohs surgery, Neil A. Swanson, M.D., said at a clinical dermatology conference sponsored by Medicis.

But the exacting technique is not always appropriate.

Physicians should consider multiple factors in deciding which therapy to use, said Dr. Swanson, chair of dermatology at Oregon Health and Science University in Portland.

"Mohs is not indicated for every cancer but for the ones that are high risk," he said.

Dr. Swanson described a strategy outlining how to decide whether to use the surgical technique for various melanoma and nonmelanoma skin cancers.

Basal cell carcinomas that recur or have been incompletely excised would be treated with Mohs surgery, which Dr. Swanson described as the "penultimate margin control."

For low-risk basal cell carcinoma, he favored excision, curettage and electrodesiccation, cryosurgery, or radiation.

Most basal cell carcinomas will be low-risk, according to Dr. Swanson.

To identify the few cancers that are high risk, he suggested considering the following four factors:

▸ Location. Tumors could be more aggressive in certain facial areas.

▸ Histology. Mohs surgery would be indicated for morpheaform (sclerotic) and for keratotic (metatypical) basal cell tumors.

For noduloulcerative and superficial types, he recommended choosing one of the alternative therapies.

▸ Size. Use Mohs surgery when a basal cell tumor is 2 cm or greater.

Smaller tumors can be treated with another therapy.

▸ Clinical nature. Mohs surgery would be indicated for a tumor that has ill-defined borders, is multicentric, or evidences immunosuppression.

In some large and aggressive cases, he suggested the dermatologist work cooperatively with a specialist.

"One of the most time-consuming things in the operating room is [figuring out] what is this margin going to be," he commented.

"The day before, we do the peripheral margin. We leave the center of the tumor. It is going to be removed anyway by the surgeon."

For melanoma, Dr. Swanson recommended Mohs surgery as an option in head and neck cases; these are often positioned in difficult anatomic sites where tissue preservation is a concern.

He said he always starts with a Wood's light, which he finds especially useful for defining margins.

"I outline the tumor clinically," Dr. Swanson said. "I turn the lights off, and I shine the Wood's light, and I find the margin changes."

After removing the center scar and residual lesions, he will create a standard Mohs rim and repeat frozen sections until the area is "clear." He recommended that the permanent rim always have an additional 2-mm margin.

Nonmelanoma fibrous tumors are also candidates for Mohs surgery. "These are tumors that look fairly small and end up fairly large," he said.

With Merkel cell carcinoma, however, the choice of therapy is difficult to make. "Mohs may or may not be indicated," said Dr. Swanson.

"Leave to the head and neck surgeon to take margins, and hit it with everything you have in the first go-around," he suggested.

Mohs surgery can be effective for leiomyosarcoma and carcinomas in the eyelid, he continued.

Angiosarcoma has very a poor prognosis, however. Although some physicians have attempted to treat it with Mohs surgery, Dr. Swanson said he has not and will not do so.

PHOENIX, ARIZ. — Locally invasive skin cancers with histologies amenable to frozen section are candidates for Mohs surgery, Neil A. Swanson, M.D., said at a clinical dermatology conference sponsored by Medicis.

But the exacting technique is not always appropriate.

Physicians should consider multiple factors in deciding which therapy to use, said Dr. Swanson, chair of dermatology at Oregon Health and Science University in Portland.

"Mohs is not indicated for every cancer but for the ones that are high risk," he said.

Dr. Swanson described a strategy outlining how to decide whether to use the surgical technique for various melanoma and nonmelanoma skin cancers.

Basal cell carcinomas that recur or have been incompletely excised would be treated with Mohs surgery, which Dr. Swanson described as the "penultimate margin control."

For low-risk basal cell carcinoma, he favored excision, curettage and electrodesiccation, cryosurgery, or radiation.

Most basal cell carcinomas will be low-risk, according to Dr. Swanson.

To identify the few cancers that are high risk, he suggested considering the following four factors:

▸ Location. Tumors could be more aggressive in certain facial areas.

▸ Histology. Mohs surgery would be indicated for morpheaform (sclerotic) and for keratotic (metatypical) basal cell tumors.

For noduloulcerative and superficial types, he recommended choosing one of the alternative therapies.

▸ Size. Use Mohs surgery when a basal cell tumor is 2 cm or greater.

Smaller tumors can be treated with another therapy.

▸ Clinical nature. Mohs surgery would be indicated for a tumor that has ill-defined borders, is multicentric, or evidences immunosuppression.

In some large and aggressive cases, he suggested the dermatologist work cooperatively with a specialist.

"One of the most time-consuming things in the operating room is [figuring out] what is this margin going to be," he commented.

"The day before, we do the peripheral margin. We leave the center of the tumor. It is going to be removed anyway by the surgeon."

For melanoma, Dr. Swanson recommended Mohs surgery as an option in head and neck cases; these are often positioned in difficult anatomic sites where tissue preservation is a concern.

He said he always starts with a Wood's light, which he finds especially useful for defining margins.

"I outline the tumor clinically," Dr. Swanson said. "I turn the lights off, and I shine the Wood's light, and I find the margin changes."

After removing the center scar and residual lesions, he will create a standard Mohs rim and repeat frozen sections until the area is "clear." He recommended that the permanent rim always have an additional 2-mm margin.

Nonmelanoma fibrous tumors are also candidates for Mohs surgery. "These are tumors that look fairly small and end up fairly large," he said.

With Merkel cell carcinoma, however, the choice of therapy is difficult to make. "Mohs may or may not be indicated," said Dr. Swanson.

"Leave to the head and neck surgeon to take margins, and hit it with everything you have in the first go-around," he suggested.

Mohs surgery can be effective for leiomyosarcoma and carcinomas in the eyelid, he continued.

Angiosarcoma has very a poor prognosis, however. Although some physicians have attempted to treat it with Mohs surgery, Dr. Swanson said he has not and will not do so.

LOS ANGELES — A pregnant smoker who cuts back just one cigarette a day in her third trimester can hope to increase her newborn's birth weight by24 g, according to a prospective study reported at the annual meeting of the Society for Gynecologic Investigation.

“The message is, Keep at 'em. Don't stop trying to get women to reduce their smoking volume,” said Ira M. Bernstein, M.D., who presented data on 160 women and their offspring.

The mothers were enrolled in a randomized, prospective trial of a voucher system designed to help pregnant women stop smoking or stay cigarette free. Dr. Bernstein of the University of Vermont, Burlington, said investigators determined a woman's smoking volume by a combination of self-reports, and measurement of urinary cotinine and exhaled carbon monoxide.

Before pregnancy, the group averaged 18.2 cigarettes a day. They had already cut down to 6.7 cigarettes per day by the time they enrolled in the study, which was at 12 weeks' gestation on average. By 28 weeks, they were down to 4.8 cigarettes daily.

All had singleton pregnancies with a mean birth weight of 3,266 g. The mean gestational age at delivery was 38.6 weeks, with 17 babies born preterm. Stepwise multivariate regression analysis found smoking in the third trimester accounted for 10% of variance in birth weight. Dr. Bernstein reported a linear relationship in which babies weighed 24 g less at birth for every cigarette their mothers smoked per day in the third trimester.

“The literature is mixed. Some data say the first trimester is critical. These data support that the third trimester is more important,” he said.

The National Institutes of Health and a General Clinical Research Center grant supported the study.

LOS ANGELES — A pregnant smoker who cuts back just one cigarette a day in her third trimester can hope to increase her newborn's birth weight by24 g, according to a prospective study reported at the annual meeting of the Society for Gynecologic Investigation.

“The message is, Keep at 'em. Don't stop trying to get women to reduce their smoking volume,” said Ira M. Bernstein, M.D., who presented data on 160 women and their offspring.

The mothers were enrolled in a randomized, prospective trial of a voucher system designed to help pregnant women stop smoking or stay cigarette free. Dr. Bernstein of the University of Vermont, Burlington, said investigators determined a woman's smoking volume by a combination of self-reports, and measurement of urinary cotinine and exhaled carbon monoxide.

Before pregnancy, the group averaged 18.2 cigarettes a day. They had already cut down to 6.7 cigarettes per day by the time they enrolled in the study, which was at 12 weeks' gestation on average. By 28 weeks, they were down to 4.8 cigarettes daily.

All had singleton pregnancies with a mean birth weight of 3,266 g. The mean gestational age at delivery was 38.6 weeks, with 17 babies born preterm. Stepwise multivariate regression analysis found smoking in the third trimester accounted for 10% of variance in birth weight. Dr. Bernstein reported a linear relationship in which babies weighed 24 g less at birth for every cigarette their mothers smoked per day in the third trimester.

“The literature is mixed. Some data say the first trimester is critical. These data support that the third trimester is more important,” he said.

The National Institutes of Health and a General Clinical Research Center grant supported the study.

LOS ANGELES — A pregnant smoker who cuts back just one cigarette a day in her third trimester can hope to increase her newborn's birth weight by24 g, according to a prospective study reported at the annual meeting of the Society for Gynecologic Investigation.

“The message is, Keep at 'em. Don't stop trying to get women to reduce their smoking volume,” said Ira M. Bernstein, M.D., who presented data on 160 women and their offspring.

The mothers were enrolled in a randomized, prospective trial of a voucher system designed to help pregnant women stop smoking or stay cigarette free. Dr. Bernstein of the University of Vermont, Burlington, said investigators determined a woman's smoking volume by a combination of self-reports, and measurement of urinary cotinine and exhaled carbon monoxide.

Before pregnancy, the group averaged 18.2 cigarettes a day. They had already cut down to 6.7 cigarettes per day by the time they enrolled in the study, which was at 12 weeks' gestation on average. By 28 weeks, they were down to 4.8 cigarettes daily.

All had singleton pregnancies with a mean birth weight of 3,266 g. The mean gestational age at delivery was 38.6 weeks, with 17 babies born preterm. Stepwise multivariate regression analysis found smoking in the third trimester accounted for 10% of variance in birth weight. Dr. Bernstein reported a linear relationship in which babies weighed 24 g less at birth for every cigarette their mothers smoked per day in the third trimester.

“The literature is mixed. Some data say the first trimester is critical. These data support that the third trimester is more important,” he said.

The National Institutes of Health and a General Clinical Research Center grant supported the study.

LOS ANGELES — Many women do not go for recommended Pap testing after being diagnosed with the human immunodeficiency virus, despite being at elevated risk for cervical cancer.

Chart reviews of 428 women at an urban HIV clinic found 48% had Pap tests within a year of enrollment at the clinic. Yet the clinic's physicians had referred all the women for testing, many of them repeatedly, Laurie C. Zephyrin, M.D., reported at the annual meeting of the Society for Gynecologic Investigation.

“Those women who had other social factors or who tended to be sicker tended not to have their Pap tests. But they were referred. The primary care physicians were definitely doing their job in referring patients,” said Dr. Zephyrin of the department of obstetrics and gynecology at Johns Hopkins University in Baltimore.

Guidelines call for Pap testing every 6 months in the first year after diagnosis with HIV, and once annually thereafter, according to Dr. Zephyrin. With so many women not being screened in the first year, she called for simplifying the health care delivery system to make tests more accessible at primary care sites. “I really think there needs to be a reorganization of how we deliver care, particularly to women with conditions such as HIV,” she said.

Dr. Zephyrin and her coinvestigators followed women who enrolled in a large urban HIV clinic affiliated with Johns Hopkins from January 1998 to November 2002. The population was predominantly African American and low income with a median age of 38. More than a third, or 36%, were intravenous drug users.

One in four patients had normal CD4 counts of at least 500. Dr. Zephyrin said more than 30% had “a diagnosis consistent with AIDS,” as reflected in CD4 counts below 200. About three-fourths of the women, 74%, were on highly active antiretroviral therapy (HAART).

The proportion that had a Pap test increased with time spent in the program. Nearly two-thirds, 63%, were screened within 2 years and 75% were screened within 3 years. By the end of 6 years, 87% had at least one Pap test.

In the first year, black women were 37% more likely to have a Pap test and women on HAART were 38% more likely, compared with their nonblack and non-HAART counterparts. Dr. Zephyrin speculated that the patients on HAART were in the clinic more often and might have been more compliant.

Compared with women with normal CD4 counts, women with counts of 200ndash;500 were 39% less likely to have a Pap test during the first year. Similarly, intravenous drug users were 32% less likely than were those who were not users.

Dr. Zephyrin said while 61% of Pap tests were normal, women diagnosed with AIDS were four times more likely to have an abnormal test result in the first year.

LOS ANGELES — Many women do not go for recommended Pap testing after being diagnosed with the human immunodeficiency virus, despite being at elevated risk for cervical cancer.

Chart reviews of 428 women at an urban HIV clinic found 48% had Pap tests within a year of enrollment at the clinic. Yet the clinic's physicians had referred all the women for testing, many of them repeatedly, Laurie C. Zephyrin, M.D., reported at the annual meeting of the Society for Gynecologic Investigation.

“Those women who had other social factors or who tended to be sicker tended not to have their Pap tests. But they were referred. The primary care physicians were definitely doing their job in referring patients,” said Dr. Zephyrin of the department of obstetrics and gynecology at Johns Hopkins University in Baltimore.

Guidelines call for Pap testing every 6 months in the first year after diagnosis with HIV, and once annually thereafter, according to Dr. Zephyrin. With so many women not being screened in the first year, she called for simplifying the health care delivery system to make tests more accessible at primary care sites. “I really think there needs to be a reorganization of how we deliver care, particularly to women with conditions such as HIV,” she said.

Dr. Zephyrin and her coinvestigators followed women who enrolled in a large urban HIV clinic affiliated with Johns Hopkins from January 1998 to November 2002. The population was predominantly African American and low income with a median age of 38. More than a third, or 36%, were intravenous drug users.

One in four patients had normal CD4 counts of at least 500. Dr. Zephyrin said more than 30% had “a diagnosis consistent with AIDS,” as reflected in CD4 counts below 200. About three-fourths of the women, 74%, were on highly active antiretroviral therapy (HAART).

The proportion that had a Pap test increased with time spent in the program. Nearly two-thirds, 63%, were screened within 2 years and 75% were screened within 3 years. By the end of 6 years, 87% had at least one Pap test.

In the first year, black women were 37% more likely to have a Pap test and women on HAART were 38% more likely, compared with their nonblack and non-HAART counterparts. Dr. Zephyrin speculated that the patients on HAART were in the clinic more often and might have been more compliant.

Compared with women with normal CD4 counts, women with counts of 200ndash;500 were 39% less likely to have a Pap test during the first year. Similarly, intravenous drug users were 32% less likely than were those who were not users.

Dr. Zephyrin said while 61% of Pap tests were normal, women diagnosed with AIDS were four times more likely to have an abnormal test result in the first year.

LOS ANGELES — Many women do not go for recommended Pap testing after being diagnosed with the human immunodeficiency virus, despite being at elevated risk for cervical cancer.

Chart reviews of 428 women at an urban HIV clinic found 48% had Pap tests within a year of enrollment at the clinic. Yet the clinic's physicians had referred all the women for testing, many of them repeatedly, Laurie C. Zephyrin, M.D., reported at the annual meeting of the Society for Gynecologic Investigation.

“Those women who had other social factors or who tended to be sicker tended not to have their Pap tests. But they were referred. The primary care physicians were definitely doing their job in referring patients,” said Dr. Zephyrin of the department of obstetrics and gynecology at Johns Hopkins University in Baltimore.

Guidelines call for Pap testing every 6 months in the first year after diagnosis with HIV, and once annually thereafter, according to Dr. Zephyrin. With so many women not being screened in the first year, she called for simplifying the health care delivery system to make tests more accessible at primary care sites. “I really think there needs to be a reorganization of how we deliver care, particularly to women with conditions such as HIV,” she said.

Dr. Zephyrin and her coinvestigators followed women who enrolled in a large urban HIV clinic affiliated with Johns Hopkins from January 1998 to November 2002. The population was predominantly African American and low income with a median age of 38. More than a third, or 36%, were intravenous drug users.

One in four patients had normal CD4 counts of at least 500. Dr. Zephyrin said more than 30% had “a diagnosis consistent with AIDS,” as reflected in CD4 counts below 200. About three-fourths of the women, 74%, were on highly active antiretroviral therapy (HAART).

The proportion that had a Pap test increased with time spent in the program. Nearly two-thirds, 63%, were screened within 2 years and 75% were screened within 3 years. By the end of 6 years, 87% had at least one Pap test.

In the first year, black women were 37% more likely to have a Pap test and women on HAART were 38% more likely, compared with their nonblack and non-HAART counterparts. Dr. Zephyrin speculated that the patients on HAART were in the clinic more often and might have been more compliant.

Compared with women with normal CD4 counts, women with counts of 200ndash;500 were 39% less likely to have a Pap test during the first year. Similarly, intravenous drug users were 32% less likely than were those who were not users.

Dr. Zephyrin said while 61% of Pap tests were normal, women diagnosed with AIDS were four times more likely to have an abnormal test result in the first year.

LOS ANGELES — St. John's wort does not appear to interfere with the antiandrogenic effects of oral contraceptive pills, Robin Fogle, M.D., said at the annual meeting of the Society for Gynecologic Investigation.

She said testosterone levels decreased, while a marker of androgen metabolism increased, in 15 healthy women treated with St. John's wort and Loestrin 1/20 (norethindrone/estradiol) in a 4-month study.

Although the changes did not reach statistical significance, the outcomes strongly suggest St. John's wort will not interfere with the pill's effects when used as a primary treatment for hirsutism, said Dr. Fogle, of the University of Southern California, Los Angeles, in an interview.

The study was undertaken because reports have shown the over-the-counter herbal remedy, commonly used for depression and inflammation, induces cytochrome P450 activity. This can interfere with the efficacy of some drugs, including oral contraceptives, Dr. Fogle and her coinvestigators wrote in a poster presented at the meeting.

None of the women in the study had hirsutism. They took Loestrin 1/20 for four consecutive 28-day cycles. During the last two cycles, the protocol added 300 mg of St. John's wort taken three times daily.

Mean testosterone fell 10.7% (from 44.8 ng/dL to 40.0 ng/dL), and free testosterone fell 15.8% (from 0.38 ng/dL to 0.32 ng/dL) after the addition of St. John's wort. Conversely, 3α-androstanediol glucuronide, the marker of androgen metabolism, rose 6.5% from 2 ng/mL to 2.13 ng/mL.

“It appears that St. John's wort enhances androgen metabolism and does not interfere with the antiandrogenic properties of oral contraceptive pills,” they said.

LOS ANGELES — St. John's wort does not appear to interfere with the antiandrogenic effects of oral contraceptive pills, Robin Fogle, M.D., said at the annual meeting of the Society for Gynecologic Investigation.

She said testosterone levels decreased, while a marker of androgen metabolism increased, in 15 healthy women treated with St. John's wort and Loestrin 1/20 (norethindrone/estradiol) in a 4-month study.

Although the changes did not reach statistical significance, the outcomes strongly suggest St. John's wort will not interfere with the pill's effects when used as a primary treatment for hirsutism, said Dr. Fogle, of the University of Southern California, Los Angeles, in an interview.

The study was undertaken because reports have shown the over-the-counter herbal remedy, commonly used for depression and inflammation, induces cytochrome P450 activity. This can interfere with the efficacy of some drugs, including oral contraceptives, Dr. Fogle and her coinvestigators wrote in a poster presented at the meeting.

None of the women in the study had hirsutism. They took Loestrin 1/20 for four consecutive 28-day cycles. During the last two cycles, the protocol added 300 mg of St. John's wort taken three times daily.

Mean testosterone fell 10.7% (from 44.8 ng/dL to 40.0 ng/dL), and free testosterone fell 15.8% (from 0.38 ng/dL to 0.32 ng/dL) after the addition of St. John's wort. Conversely, 3α-androstanediol glucuronide, the marker of androgen metabolism, rose 6.5% from 2 ng/mL to 2.13 ng/mL.

“It appears that St. John's wort enhances androgen metabolism and does not interfere with the antiandrogenic properties of oral contraceptive pills,” they said.

LOS ANGELES — St. John's wort does not appear to interfere with the antiandrogenic effects of oral contraceptive pills, Robin Fogle, M.D., said at the annual meeting of the Society for Gynecologic Investigation.

She said testosterone levels decreased, while a marker of androgen metabolism increased, in 15 healthy women treated with St. John's wort and Loestrin 1/20 (norethindrone/estradiol) in a 4-month study.

Although the changes did not reach statistical significance, the outcomes strongly suggest St. John's wort will not interfere with the pill's effects when used as a primary treatment for hirsutism, said Dr. Fogle, of the University of Southern California, Los Angeles, in an interview.

The study was undertaken because reports have shown the over-the-counter herbal remedy, commonly used for depression and inflammation, induces cytochrome P450 activity. This can interfere with the efficacy of some drugs, including oral contraceptives, Dr. Fogle and her coinvestigators wrote in a poster presented at the meeting.

None of the women in the study had hirsutism. They took Loestrin 1/20 for four consecutive 28-day cycles. During the last two cycles, the protocol added 300 mg of St. John's wort taken three times daily.

Mean testosterone fell 10.7% (from 44.8 ng/dL to 40.0 ng/dL), and free testosterone fell 15.8% (from 0.38 ng/dL to 0.32 ng/dL) after the addition of St. John's wort. Conversely, 3α-androstanediol glucuronide, the marker of androgen metabolism, rose 6.5% from 2 ng/mL to 2.13 ng/mL.

“It appears that St. John's wort enhances androgen metabolism and does not interfere with the antiandrogenic properties of oral contraceptive pills,” they said.