Jane Salodof MacNeil

HOUSTON — Diagnosis of human papillomavirus infection in a genital wart should not trigger a rush to judgment regarding recent sexual transgression or child abuse, Peter J. Lynch, M.D., said at a conference on vulvovaginal diseases.

Only 20% of new human papillomavirus (HPV) infections produce lesions within the first few months. The average incubation period lasts 2 months to 2 years, after which the virus can remain latent for years or even a lifetime in the unsuspecting human host, said Dr. Lynch, a dermatologist in Sacramento.

He attributed 95% of adult infections to sexual transmission but said genital warts in children often result from infections transmitted by parents. Transmission not only can happen during vaginal delivery in a woman who is asymptomatic, but infections can also remain latent for years before a wart is detected, he said at the meeting, sponsored by Baylor College of Medicine.

Theoretically, a parent infected with a finger or hand wart can transmit the virus innocuously when bathing a child. If a genital wart is the only evidence of child abuse, he advised against assuming the child was assaulted. “Vertical transmission occurs and, thus, not all childhood genital HPV infections are child abuse,” he said. “Latency occurs, so that the appearance of active disease does not tell you anything about when the original infection was acquired.”

Clinicians are unable to diagnose latent virus in the absence of discernable lesions, Dr. Lynch said, warning that acetic acid soaks have turned out to be misleading and should not be used. Conventional biopsy also can be misleading, he said; sometimes pathologists will misidentify clear cells as koilocytes.

The best test for identifying HPV type uses polymerase chain reaction, which is expensive and generally reserved for research. Simple inexpensive test kits have become available, but he predicted questions about their accuracy would prevent wide use until they are resolved.

Meanwhile, research in women with sexually transmitted diseases has shown 60% to be infected with HPV. In more typical populations of sexually active women, he estimated prevalence at 20%. Because cervical infections are more common than vulvar infections, he reckoned that 5%-10% of women have active or latent HPV infections of the vulva.

Sexual partners do not need to be examined after a woman is diagnosed with HPV. “The acquisition may not have been sexual. It may have occurred years ago and be latent,” he said.

“How would you examine the partner anyway?” he asked, describing one test used in men as “neither accurate nor specific.” Nonetheless, he added, men diagnosed with HPV should notify female sexual partners because of the risk of cervical and vulvar infection.

When anogenital warts are diagnosed in children, they are often best left alone; nearly 100% will resolve spontaneously within 2 years. If such warts are treated, he recommended home care with imiquimod (Aldara) or podofilox (Condylox) to minimize psychological and physical trauma.

HOUSTON — Diagnosis of human papillomavirus infection in a genital wart should not trigger a rush to judgment regarding recent sexual transgression or child abuse, Peter J. Lynch, M.D., said at a conference on vulvovaginal diseases.

Only 20% of new human papillomavirus (HPV) infections produce lesions within the first few months. The average incubation period lasts 2 months to 2 years, after which the virus can remain latent for years or even a lifetime in the unsuspecting human host, said Dr. Lynch, a dermatologist in Sacramento.

He attributed 95% of adult infections to sexual transmission but said genital warts in children often result from infections transmitted by parents. Transmission not only can happen during vaginal delivery in a woman who is asymptomatic, but infections can also remain latent for years before a wart is detected, he said at the meeting, sponsored by Baylor College of Medicine.

Theoretically, a parent infected with a finger or hand wart can transmit the virus innocuously when bathing a child. If a genital wart is the only evidence of child abuse, he advised against assuming the child was assaulted. “Vertical transmission occurs and, thus, not all childhood genital HPV infections are child abuse,” he said. “Latency occurs, so that the appearance of active disease does not tell you anything about when the original infection was acquired.”

Clinicians are unable to diagnose latent virus in the absence of discernable lesions, Dr. Lynch said, warning that acetic acid soaks have turned out to be misleading and should not be used. Conventional biopsy also can be misleading, he said; sometimes pathologists will misidentify clear cells as koilocytes.

The best test for identifying HPV type uses polymerase chain reaction, which is expensive and generally reserved for research. Simple inexpensive test kits have become available, but he predicted questions about their accuracy would prevent wide use until they are resolved.

Meanwhile, research in women with sexually transmitted diseases has shown 60% to be infected with HPV. In more typical populations of sexually active women, he estimated prevalence at 20%. Because cervical infections are more common than vulvar infections, he reckoned that 5%-10% of women have active or latent HPV infections of the vulva.

Sexual partners do not need to be examined after a woman is diagnosed with HPV. “The acquisition may not have been sexual. It may have occurred years ago and be latent,” he said.

“How would you examine the partner anyway?” he asked, describing one test used in men as “neither accurate nor specific.” Nonetheless, he added, men diagnosed with HPV should notify female sexual partners because of the risk of cervical and vulvar infection.

When anogenital warts are diagnosed in children, they are often best left alone; nearly 100% will resolve spontaneously within 2 years. If such warts are treated, he recommended home care with imiquimod (Aldara) or podofilox (Condylox) to minimize psychological and physical trauma.

HOUSTON — Diagnosis of human papillomavirus infection in a genital wart should not trigger a rush to judgment regarding recent sexual transgression or child abuse, Peter J. Lynch, M.D., said at a conference on vulvovaginal diseases.

Only 20% of new human papillomavirus (HPV) infections produce lesions within the first few months. The average incubation period lasts 2 months to 2 years, after which the virus can remain latent for years or even a lifetime in the unsuspecting human host, said Dr. Lynch, a dermatologist in Sacramento.

He attributed 95% of adult infections to sexual transmission but said genital warts in children often result from infections transmitted by parents. Transmission not only can happen during vaginal delivery in a woman who is asymptomatic, but infections can also remain latent for years before a wart is detected, he said at the meeting, sponsored by Baylor College of Medicine.

Theoretically, a parent infected with a finger or hand wart can transmit the virus innocuously when bathing a child. If a genital wart is the only evidence of child abuse, he advised against assuming the child was assaulted. “Vertical transmission occurs and, thus, not all childhood genital HPV infections are child abuse,” he said. “Latency occurs, so that the appearance of active disease does not tell you anything about when the original infection was acquired.”

Clinicians are unable to diagnose latent virus in the absence of discernable lesions, Dr. Lynch said, warning that acetic acid soaks have turned out to be misleading and should not be used. Conventional biopsy also can be misleading, he said; sometimes pathologists will misidentify clear cells as koilocytes.

The best test for identifying HPV type uses polymerase chain reaction, which is expensive and generally reserved for research. Simple inexpensive test kits have become available, but he predicted questions about their accuracy would prevent wide use until they are resolved.

Meanwhile, research in women with sexually transmitted diseases has shown 60% to be infected with HPV. In more typical populations of sexually active women, he estimated prevalence at 20%. Because cervical infections are more common than vulvar infections, he reckoned that 5%-10% of women have active or latent HPV infections of the vulva.

Sexual partners do not need to be examined after a woman is diagnosed with HPV. “The acquisition may not have been sexual. It may have occurred years ago and be latent,” he said.

“How would you examine the partner anyway?” he asked, describing one test used in men as “neither accurate nor specific.” Nonetheless, he added, men diagnosed with HPV should notify female sexual partners because of the risk of cervical and vulvar infection.

When anogenital warts are diagnosed in children, they are often best left alone; nearly 100% will resolve spontaneously within 2 years. If such warts are treated, he recommended home care with imiquimod (Aldara) or podofilox (Condylox) to minimize psychological and physical trauma.

PHOENIX, ARIZ. — F aster patient cooling and more precise temperature control features in the new generation of hypothermia devices may increase the use of hypothermia therapy in stroke and cardiac arrest, Michael A. DeGeorgia, M.D., said at a meeting sponsored by the Society of Critical Care Medicine.

Dr. DeGeorgia, head of the Neurological Intensive Care Program at the Cleveland Clinic Foundation, noted that the equipment used in the influential studies that found hypothermia therapy reduces mortality was slow to achieve cooling and allowed only imprecise temperature control.

Indeed, he said the air-cooled machine used in one Hypothermia After Cardiac Arrest study group trial (N. Engl. J. Med. 2002;346:549-556) is no longer on the market. Median cooling time was 8 hours, and 70% of patients also required ice packs, Dr. DeGeorgia said.

Another favorable experiment, the Cooling for Acute Ischemic Brain Damage (COOL AID) pilot study (Stroke 2001;32:1847-54), for which Dr. DeGeorgia was an investigator, used a technique he said was developed before he was born. “You could achieve the target temperature, but it was very hard. It took about 4 hours,” Dr. DeGeorgia said. The emerging technology falls into two broad categories: surface cooling and endovascular cooling, according to Dr. DeGeorgia. Around longer and akin to a cold bath, surface cooling typically employs blankets filled with ice water, alcohol, or cold air. It is simple and cheap, he said.

Shivering can become a problem, however, as skin receptors respond to the cold by setting off muscle tensing to produce heat. As a result, he said anesthesia or a neuromuscular blockade must be used.

Among the disadvantages of surface cooling, he also listed slow cooling, imprecise controls, thermal injury, and use of nursing time.

Promising cold-water surface cooling systems described by Dr. DeGeorgia include:

▸ Blanketrol II (Cincinnati Sub-Zero Products, Cincinnati) pumps 2 L/min and has a feedback mechanism, temperature control, and random flow patterns to distribute temperature evenly and effectively.

▸ Meditherm III / MTA 6900 (Gaymar Industries Inc., Orchard Park, N.Y.) pumps 1 L/min, has a feedback mechanism and temperature control, and encircles the patient's legs and torso for maximum surface coverage.

▸ Arctic Sun Temperature Management System (Medivance Inc., Louisville, Colo.) pumps 0.5 to 5 L/min under negative pressure, so that the blanket does not become distended and is less likely to leak. It also has a biodegradable, highly conductive inner liner reducing contact resistance.

Endovascular cooling with a cold saline solution is fast and easy enough for paramedics to use en route to the emergency room, Dr. DeGeorgia said. “It seems to be pretty safe. I think it has a future,” he said, reporting cooling times in minutes instead of hours.

Among the advantages cited by Dr. DeGeorgia are that endovascular cooling offers precise temperature control, does not require general anesthesia or neuromuscular blockade, and demands less attention from nurses. He listed as disadvantages that it is expensive, invasive, and patients may require intubation in response to airway problems that may develop with prolonged cooling.

New devices use counter-current heat exchange, which circulates the coolant in the opposite direction to blood flow to enhance the effectiveness of endovascular cooling. “The blood gets very cold, and the blood returning to the heart is cooled,” he said of one device. “It fakes out the cold receptors on the skin into thinking the body is warm. The body was never designed to be warm on the outside and cold inside.”

Dr. DeGeorgia described the following new endovascular cooling systems as promising:

▸ Reprieve Endovascular Temperature Management System (Radiant Medical Inc., Redwood City, Calif.) places a balloon catheter in the vena cava by way of the femoral vein. A microprocessor-driven controller warms or cools normal saline. The triple-lobed, helically wound balloon creates a large surface area and promotes optimal heat transfer.

▸ The Cool Line, Icy, and Fortius Systems (Alsius Corp., Irvine, Calif.). Cool Line has a two-balloon catheter that enters the superior vena cava by way of the subclavian vein. Icy has a three-balloon catheter and Fortius a serpentine balloon catheter, both of which go to the inferior vena cava via the femoral vein.

▸ Celsius Control System (Innercool Therapies Inc., San Diego) has a thin catheter that also goes through the femoral vein to the inferior vena cava. A metal alloy temperature control element on its tip is more conductive than plastic, and an articulated surface promotes blood mixing.

PHOENIX, ARIZ. — F aster patient cooling and more precise temperature control features in the new generation of hypothermia devices may increase the use of hypothermia therapy in stroke and cardiac arrest, Michael A. DeGeorgia, M.D., said at a meeting sponsored by the Society of Critical Care Medicine.

Dr. DeGeorgia, head of the Neurological Intensive Care Program at the Cleveland Clinic Foundation, noted that the equipment used in the influential studies that found hypothermia therapy reduces mortality was slow to achieve cooling and allowed only imprecise temperature control.

Indeed, he said the air-cooled machine used in one Hypothermia After Cardiac Arrest study group trial (N. Engl. J. Med. 2002;346:549-556) is no longer on the market. Median cooling time was 8 hours, and 70% of patients also required ice packs, Dr. DeGeorgia said.

Another favorable experiment, the Cooling for Acute Ischemic Brain Damage (COOL AID) pilot study (Stroke 2001;32:1847-54), for which Dr. DeGeorgia was an investigator, used a technique he said was developed before he was born. “You could achieve the target temperature, but it was very hard. It took about 4 hours,” Dr. DeGeorgia said. The emerging technology falls into two broad categories: surface cooling and endovascular cooling, according to Dr. DeGeorgia. Around longer and akin to a cold bath, surface cooling typically employs blankets filled with ice water, alcohol, or cold air. It is simple and cheap, he said.

Shivering can become a problem, however, as skin receptors respond to the cold by setting off muscle tensing to produce heat. As a result, he said anesthesia or a neuromuscular blockade must be used.

Among the disadvantages of surface cooling, he also listed slow cooling, imprecise controls, thermal injury, and use of nursing time.

Promising cold-water surface cooling systems described by Dr. DeGeorgia include:

▸ Blanketrol II (Cincinnati Sub-Zero Products, Cincinnati) pumps 2 L/min and has a feedback mechanism, temperature control, and random flow patterns to distribute temperature evenly and effectively.

▸ Meditherm III / MTA 6900 (Gaymar Industries Inc., Orchard Park, N.Y.) pumps 1 L/min, has a feedback mechanism and temperature control, and encircles the patient's legs and torso for maximum surface coverage.

▸ Arctic Sun Temperature Management System (Medivance Inc., Louisville, Colo.) pumps 0.5 to 5 L/min under negative pressure, so that the blanket does not become distended and is less likely to leak. It also has a biodegradable, highly conductive inner liner reducing contact resistance.

Endovascular cooling with a cold saline solution is fast and easy enough for paramedics to use en route to the emergency room, Dr. DeGeorgia said. “It seems to be pretty safe. I think it has a future,” he said, reporting cooling times in minutes instead of hours.

Among the advantages cited by Dr. DeGeorgia are that endovascular cooling offers precise temperature control, does not require general anesthesia or neuromuscular blockade, and demands less attention from nurses. He listed as disadvantages that it is expensive, invasive, and patients may require intubation in response to airway problems that may develop with prolonged cooling.

New devices use counter-current heat exchange, which circulates the coolant in the opposite direction to blood flow to enhance the effectiveness of endovascular cooling. “The blood gets very cold, and the blood returning to the heart is cooled,” he said of one device. “It fakes out the cold receptors on the skin into thinking the body is warm. The body was never designed to be warm on the outside and cold inside.”

Dr. DeGeorgia described the following new endovascular cooling systems as promising:

▸ Reprieve Endovascular Temperature Management System (Radiant Medical Inc., Redwood City, Calif.) places a balloon catheter in the vena cava by way of the femoral vein. A microprocessor-driven controller warms or cools normal saline. The triple-lobed, helically wound balloon creates a large surface area and promotes optimal heat transfer.

▸ The Cool Line, Icy, and Fortius Systems (Alsius Corp., Irvine, Calif.). Cool Line has a two-balloon catheter that enters the superior vena cava by way of the subclavian vein. Icy has a three-balloon catheter and Fortius a serpentine balloon catheter, both of which go to the inferior vena cava via the femoral vein.

▸ Celsius Control System (Innercool Therapies Inc., San Diego) has a thin catheter that also goes through the femoral vein to the inferior vena cava. A metal alloy temperature control element on its tip is more conductive than plastic, and an articulated surface promotes blood mixing.

PHOENIX, ARIZ. — F aster patient cooling and more precise temperature control features in the new generation of hypothermia devices may increase the use of hypothermia therapy in stroke and cardiac arrest, Michael A. DeGeorgia, M.D., said at a meeting sponsored by the Society of Critical Care Medicine.

Dr. DeGeorgia, head of the Neurological Intensive Care Program at the Cleveland Clinic Foundation, noted that the equipment used in the influential studies that found hypothermia therapy reduces mortality was slow to achieve cooling and allowed only imprecise temperature control.

Indeed, he said the air-cooled machine used in one Hypothermia After Cardiac Arrest study group trial (N. Engl. J. Med. 2002;346:549-556) is no longer on the market. Median cooling time was 8 hours, and 70% of patients also required ice packs, Dr. DeGeorgia said.

Another favorable experiment, the Cooling for Acute Ischemic Brain Damage (COOL AID) pilot study (Stroke 2001;32:1847-54), for which Dr. DeGeorgia was an investigator, used a technique he said was developed before he was born. “You could achieve the target temperature, but it was very hard. It took about 4 hours,” Dr. DeGeorgia said. The emerging technology falls into two broad categories: surface cooling and endovascular cooling, according to Dr. DeGeorgia. Around longer and akin to a cold bath, surface cooling typically employs blankets filled with ice water, alcohol, or cold air. It is simple and cheap, he said.

Shivering can become a problem, however, as skin receptors respond to the cold by setting off muscle tensing to produce heat. As a result, he said anesthesia or a neuromuscular blockade must be used.

Among the disadvantages of surface cooling, he also listed slow cooling, imprecise controls, thermal injury, and use of nursing time.

Promising cold-water surface cooling systems described by Dr. DeGeorgia include:

▸ Blanketrol II (Cincinnati Sub-Zero Products, Cincinnati) pumps 2 L/min and has a feedback mechanism, temperature control, and random flow patterns to distribute temperature evenly and effectively.

▸ Meditherm III / MTA 6900 (Gaymar Industries Inc., Orchard Park, N.Y.) pumps 1 L/min, has a feedback mechanism and temperature control, and encircles the patient's legs and torso for maximum surface coverage.

▸ Arctic Sun Temperature Management System (Medivance Inc., Louisville, Colo.) pumps 0.5 to 5 L/min under negative pressure, so that the blanket does not become distended and is less likely to leak. It also has a biodegradable, highly conductive inner liner reducing contact resistance.

Endovascular cooling with a cold saline solution is fast and easy enough for paramedics to use en route to the emergency room, Dr. DeGeorgia said. “It seems to be pretty safe. I think it has a future,” he said, reporting cooling times in minutes instead of hours.

Among the advantages cited by Dr. DeGeorgia are that endovascular cooling offers precise temperature control, does not require general anesthesia or neuromuscular blockade, and demands less attention from nurses. He listed as disadvantages that it is expensive, invasive, and patients may require intubation in response to airway problems that may develop with prolonged cooling.

New devices use counter-current heat exchange, which circulates the coolant in the opposite direction to blood flow to enhance the effectiveness of endovascular cooling. “The blood gets very cold, and the blood returning to the heart is cooled,” he said of one device. “It fakes out the cold receptors on the skin into thinking the body is warm. The body was never designed to be warm on the outside and cold inside.”

Dr. DeGeorgia described the following new endovascular cooling systems as promising:

▸ Reprieve Endovascular Temperature Management System (Radiant Medical Inc., Redwood City, Calif.) places a balloon catheter in the vena cava by way of the femoral vein. A microprocessor-driven controller warms or cools normal saline. The triple-lobed, helically wound balloon creates a large surface area and promotes optimal heat transfer.

▸ The Cool Line, Icy, and Fortius Systems (Alsius Corp., Irvine, Calif.). Cool Line has a two-balloon catheter that enters the superior vena cava by way of the subclavian vein. Icy has a three-balloon catheter and Fortius a serpentine balloon catheter, both of which go to the inferior vena cava via the femoral vein.

▸ Celsius Control System (Innercool Therapies Inc., San Diego) has a thin catheter that also goes through the femoral vein to the inferior vena cava. A metal alloy temperature control element on its tip is more conductive than plastic, and an articulated surface promotes blood mixing.

HOUSTON — Developmental abnormalities of the vulva and vagina are often easy to correct, but also easy to misdiagnose, Robert K. Zurawin, M.D., warned at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

Many physicians have not been trained to recognize these rare disorders and, as a result, run the risk of doing excessive or inappropriate surgery, according to Dr. Zurawin, chief of the section of pediatric and adolescent gynecology at Baylor and of the gynecology service at Texas Children's Hospital in Houston.

“You need to be familiar with the syndromes before you treat. Many people are confronted with these conditions, and they don't know what they really are,” he said. “With the obstructions, for example, they may just think it is an imperforate hymen and are not even aware that there is even an entity called obstructed hemivagina.”

Clitoral hypertrophy is the only developmental abnormality of the clitoris, according to Dr. Zurawin. It used to be treated by clitoridectomy with “very unsatisfactory results,” he said, describing more conservative procedures in use today. “This is mainly a cosmetic problem for patients, and the surgical management is resection of the enlarged clitoris,” he said.

Abnormalities of the vulva include congenital labial fusion, which he said could be corrected with a simple flap procedure. Surgery is rarely used, however, for acquired labial agglutination. “This is one of most common referrals from pediatricians, because they don't know what to do with it and they are afraid,” Dr. Zurawin said.

He attributed most cases to diaper rash, bubble baths, and detergents that can inflame fair skin. A common treatment is application of estrogen cream daily for several weeks until the labia are separated, he said. After that, parents are told to use oil or cream to keep the labia moist and apart.

Surgery would be used only if the opening were so small that a child was retaining urine, Dr. Zurawin said.

Hypertrophy of the labia minora and majora is primarily a concern of 11- and 12-year-old girls who wear tight jeans, according to Dr. Zurawin. When there is unilateral enlargement of the labia, they complain that the condition is unsightly and uncomfortable. Though labial hypertrophy can be corrected with a simple resection, he said, “Many times I tell them to wait—the other side will catch up.”

Prolapse of the urethral mucosa presents with vaginal bleeding in early childhood and can look frightening, but is fairly common, Dr. Zurawin said. “It responds beautifully to estrogen,” he said, adding that resection is necessary in rare cases and should not be too deep.

For hemangioma of the vulva, he recommended sending the patient to a dermatologist who would use laser therapy.

Among developmental abnormalities of the vagina, imperforate hymen is usually asymptomatic until a child reaches menarche, he said. It can be repaired with a simple incision, but without a digital examination it can easily be mistaken for another vaginal abnormality: transverse vaginal septum. The latter requires surgery and should be resected as much as possible.

Vaginal duplications are often asymptomatic and can be easily resected.

He characterized obstructed hemivagina, however, as “one of the most misdiagnosed anomalies in gynecology.” Children will often have regular periods for a few months until the occlusion interferes. Often surgeons or gynecologists will do a major operation, he said, when all that is necessary is surgery to remove the septum.

Magnetic resonance imaging is not sufficient in these cases, however, as these children might also have undetected renal abnormalities, Dr. Zurawin warned. “I am very adamant about doing simultaneous laparoscopy,” he said. “I want to make sure there are no other associated anomalies.”

Vaginal agenesis is a fairly common anomaly for which there are a variety of approaches to creating a new vagina. With a new combined vaginal and laparoscopic approach, the child could be released from the hospital after an overnight stay and would heal very quickly, he said.

“If you have experience, [developmental abnormalities] are really not that difficult to treat … and we are really developing minimally invasive operations for what used to be large operations,” Dr. Zurawin said.

He recommended most gynecologists not try to correct these conditions, however. “They should really refer them to someone who had been trained. … They shouldn't attempt them by themselves,” he said.

Surgery to Correct Genitalia May Pose Legal Risk

Gynecologists should exercise caution when asked to correct ambiguous genitalia in young children or testify to child abuse, according to Dr. Zurawin.

Sexual assignment operations can produce “a legal medical nightmare,” he warned.

Some children who underwent these procedures have grown up and formed organizations in opposition to them, calling attention to the transgender movement, said Dr. Zurawin.

“The paradox there is the best time to do the surgery is when [children] are 3 years old, before they are old enough to establish their sexual identity and before the surgery is traumatic,” he said. “But on the other hand, psychologically speaking, you have cases of kids coming back later and saying, 'Why did you do this to me? I wanted to be whatever I was.'”

If parents want to go ahead with the surgery, he recommended legal counseling for the parents and the physician, and suggested that they consult transgender societies for their advice as well. “Parents don't have carte blanche in determining the surgical outcomes of their children,” he said.

Child abuse cases are also risky for gynecologists who are not experienced in developmental anomalies, according to Dr. Zurawin.

“You have to be clinically precise,” he said. “It's especially important to be experienced and competent when being called to evaluate for sexual abuse. You can't just assume a hymen is a hymen.”

HOUSTON — Developmental abnormalities of the vulva and vagina are often easy to correct, but also easy to misdiagnose, Robert K. Zurawin, M.D., warned at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

Many physicians have not been trained to recognize these rare disorders and, as a result, run the risk of doing excessive or inappropriate surgery, according to Dr. Zurawin, chief of the section of pediatric and adolescent gynecology at Baylor and of the gynecology service at Texas Children's Hospital in Houston.

“You need to be familiar with the syndromes before you treat. Many people are confronted with these conditions, and they don't know what they really are,” he said. “With the obstructions, for example, they may just think it is an imperforate hymen and are not even aware that there is even an entity called obstructed hemivagina.”

Clitoral hypertrophy is the only developmental abnormality of the clitoris, according to Dr. Zurawin. It used to be treated by clitoridectomy with “very unsatisfactory results,” he said, describing more conservative procedures in use today. “This is mainly a cosmetic problem for patients, and the surgical management is resection of the enlarged clitoris,” he said.

Abnormalities of the vulva include congenital labial fusion, which he said could be corrected with a simple flap procedure. Surgery is rarely used, however, for acquired labial agglutination. “This is one of most common referrals from pediatricians, because they don't know what to do with it and they are afraid,” Dr. Zurawin said.

He attributed most cases to diaper rash, bubble baths, and detergents that can inflame fair skin. A common treatment is application of estrogen cream daily for several weeks until the labia are separated, he said. After that, parents are told to use oil or cream to keep the labia moist and apart.

Surgery would be used only if the opening were so small that a child was retaining urine, Dr. Zurawin said.

Hypertrophy of the labia minora and majora is primarily a concern of 11- and 12-year-old girls who wear tight jeans, according to Dr. Zurawin. When there is unilateral enlargement of the labia, they complain that the condition is unsightly and uncomfortable. Though labial hypertrophy can be corrected with a simple resection, he said, “Many times I tell them to wait—the other side will catch up.”

Prolapse of the urethral mucosa presents with vaginal bleeding in early childhood and can look frightening, but is fairly common, Dr. Zurawin said. “It responds beautifully to estrogen,” he said, adding that resection is necessary in rare cases and should not be too deep.

For hemangioma of the vulva, he recommended sending the patient to a dermatologist who would use laser therapy.

Among developmental abnormalities of the vagina, imperforate hymen is usually asymptomatic until a child reaches menarche, he said. It can be repaired with a simple incision, but without a digital examination it can easily be mistaken for another vaginal abnormality: transverse vaginal septum. The latter requires surgery and should be resected as much as possible.

Vaginal duplications are often asymptomatic and can be easily resected.

He characterized obstructed hemivagina, however, as “one of the most misdiagnosed anomalies in gynecology.” Children will often have regular periods for a few months until the occlusion interferes. Often surgeons or gynecologists will do a major operation, he said, when all that is necessary is surgery to remove the septum.

Magnetic resonance imaging is not sufficient in these cases, however, as these children might also have undetected renal abnormalities, Dr. Zurawin warned. “I am very adamant about doing simultaneous laparoscopy,” he said. “I want to make sure there are no other associated anomalies.”

Vaginal agenesis is a fairly common anomaly for which there are a variety of approaches to creating a new vagina. With a new combined vaginal and laparoscopic approach, the child could be released from the hospital after an overnight stay and would heal very quickly, he said.

“If you have experience, [developmental abnormalities] are really not that difficult to treat … and we are really developing minimally invasive operations for what used to be large operations,” Dr. Zurawin said.

He recommended most gynecologists not try to correct these conditions, however. “They should really refer them to someone who had been trained. … They shouldn't attempt them by themselves,” he said.

Surgery to Correct Genitalia May Pose Legal Risk

Gynecologists should exercise caution when asked to correct ambiguous genitalia in young children or testify to child abuse, according to Dr. Zurawin.

Sexual assignment operations can produce “a legal medical nightmare,” he warned.

Some children who underwent these procedures have grown up and formed organizations in opposition to them, calling attention to the transgender movement, said Dr. Zurawin.

“The paradox there is the best time to do the surgery is when [children] are 3 years old, before they are old enough to establish their sexual identity and before the surgery is traumatic,” he said. “But on the other hand, psychologically speaking, you have cases of kids coming back later and saying, 'Why did you do this to me? I wanted to be whatever I was.'”

If parents want to go ahead with the surgery, he recommended legal counseling for the parents and the physician, and suggested that they consult transgender societies for their advice as well. “Parents don't have carte blanche in determining the surgical outcomes of their children,” he said.

Child abuse cases are also risky for gynecologists who are not experienced in developmental anomalies, according to Dr. Zurawin.

“You have to be clinically precise,” he said. “It's especially important to be experienced and competent when being called to evaluate for sexual abuse. You can't just assume a hymen is a hymen.”

HOUSTON — Developmental abnormalities of the vulva and vagina are often easy to correct, but also easy to misdiagnose, Robert K. Zurawin, M.D., warned at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

Many physicians have not been trained to recognize these rare disorders and, as a result, run the risk of doing excessive or inappropriate surgery, according to Dr. Zurawin, chief of the section of pediatric and adolescent gynecology at Baylor and of the gynecology service at Texas Children's Hospital in Houston.

“You need to be familiar with the syndromes before you treat. Many people are confronted with these conditions, and they don't know what they really are,” he said. “With the obstructions, for example, they may just think it is an imperforate hymen and are not even aware that there is even an entity called obstructed hemivagina.”

Clitoral hypertrophy is the only developmental abnormality of the clitoris, according to Dr. Zurawin. It used to be treated by clitoridectomy with “very unsatisfactory results,” he said, describing more conservative procedures in use today. “This is mainly a cosmetic problem for patients, and the surgical management is resection of the enlarged clitoris,” he said.

Abnormalities of the vulva include congenital labial fusion, which he said could be corrected with a simple flap procedure. Surgery is rarely used, however, for acquired labial agglutination. “This is one of most common referrals from pediatricians, because they don't know what to do with it and they are afraid,” Dr. Zurawin said.

He attributed most cases to diaper rash, bubble baths, and detergents that can inflame fair skin. A common treatment is application of estrogen cream daily for several weeks until the labia are separated, he said. After that, parents are told to use oil or cream to keep the labia moist and apart.

Surgery would be used only if the opening were so small that a child was retaining urine, Dr. Zurawin said.

Hypertrophy of the labia minora and majora is primarily a concern of 11- and 12-year-old girls who wear tight jeans, according to Dr. Zurawin. When there is unilateral enlargement of the labia, they complain that the condition is unsightly and uncomfortable. Though labial hypertrophy can be corrected with a simple resection, he said, “Many times I tell them to wait—the other side will catch up.”

Prolapse of the urethral mucosa presents with vaginal bleeding in early childhood and can look frightening, but is fairly common, Dr. Zurawin said. “It responds beautifully to estrogen,” he said, adding that resection is necessary in rare cases and should not be too deep.

For hemangioma of the vulva, he recommended sending the patient to a dermatologist who would use laser therapy.

Among developmental abnormalities of the vagina, imperforate hymen is usually asymptomatic until a child reaches menarche, he said. It can be repaired with a simple incision, but without a digital examination it can easily be mistaken for another vaginal abnormality: transverse vaginal septum. The latter requires surgery and should be resected as much as possible.

Vaginal duplications are often asymptomatic and can be easily resected.

He characterized obstructed hemivagina, however, as “one of the most misdiagnosed anomalies in gynecology.” Children will often have regular periods for a few months until the occlusion interferes. Often surgeons or gynecologists will do a major operation, he said, when all that is necessary is surgery to remove the septum.

Magnetic resonance imaging is not sufficient in these cases, however, as these children might also have undetected renal abnormalities, Dr. Zurawin warned. “I am very adamant about doing simultaneous laparoscopy,” he said. “I want to make sure there are no other associated anomalies.”

Vaginal agenesis is a fairly common anomaly for which there are a variety of approaches to creating a new vagina. With a new combined vaginal and laparoscopic approach, the child could be released from the hospital after an overnight stay and would heal very quickly, he said.

“If you have experience, [developmental abnormalities] are really not that difficult to treat … and we are really developing minimally invasive operations for what used to be large operations,” Dr. Zurawin said.

He recommended most gynecologists not try to correct these conditions, however. “They should really refer them to someone who had been trained. … They shouldn't attempt them by themselves,” he said.

Surgery to Correct Genitalia May Pose Legal Risk

Gynecologists should exercise caution when asked to correct ambiguous genitalia in young children or testify to child abuse, according to Dr. Zurawin.

Sexual assignment operations can produce “a legal medical nightmare,” he warned.

Some children who underwent these procedures have grown up and formed organizations in opposition to them, calling attention to the transgender movement, said Dr. Zurawin.

“The paradox there is the best time to do the surgery is when [children] are 3 years old, before they are old enough to establish their sexual identity and before the surgery is traumatic,” he said. “But on the other hand, psychologically speaking, you have cases of kids coming back later and saying, 'Why did you do this to me? I wanted to be whatever I was.'”

If parents want to go ahead with the surgery, he recommended legal counseling for the parents and the physician, and suggested that they consult transgender societies for their advice as well. “Parents don't have carte blanche in determining the surgical outcomes of their children,” he said.

Child abuse cases are also risky for gynecologists who are not experienced in developmental anomalies, according to Dr. Zurawin.

“You have to be clinically precise,” he said. “It's especially important to be experienced and competent when being called to evaluate for sexual abuse. You can't just assume a hymen is a hymen.”

HOUSTON — New retroviral therapies are making human immunodeficiency virus infection a chronic disease that physicians need to monitor when providing obstetric and gynecologic care, according to Hunter A. Hammill, M.D.

“You can't work in a vacuum anymore,” Dr. Hammill told clinicians at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

With 30 different treatment options being used in multiple-drug combinations, zidovudine (AZT) should not be the only HIV drug with which ob.gyns. are familiar. “They need to be aware there are many new agents, and with the new agents, it is becoming a chronic disease,” said Dr. Hammill of the Houston-based college.

Today, half of all HIV-infected patients worldwide are women. As people are living longer with HIV infection, the gynecologic patient population now includes postmenopausal women and young women who were infected congenitally.

“I have had patients who should not have lived and now are pregnant teenagers,” he said.

In the United States, he estimated 950,000 people have HIV, but a quarter of them do not know they are infected. In addition, some patients will claim not to know about their status rather than tell a sexual partner. Dr. Hammill described one such woman who tested positive after giving birth. It turned out she had participated in an HIV trial he had conducted 5 years earlier.

Some states require pregnant women to be tested for the virus. In Texas, where the conference was held, the law allows disclosure to a patient's spouse without consent, but physicians can “pass the buck” when a patient tests positive by simply notifying the health department, he said.

Even patients who are asymptomatic and not pregnant should be monitored regularly for CD4 count and viral load, according to Dr. Hammill. “The CD4 count is your army,” he said. “The viral load is the enemy's army.”

Typically, an asymptomatic patient will have an intermediate CD4 count between 200 and 350 and a viral load around 55,000, Dr. Hammill said. If the count is lower, patients could be vulnerable to pneumonia and opportunistic infections.

Retroviral treatment can bring a patient's viral load down to less than 50, which is not detectable. This is especially important if surgery is planned, he said, as needle sticks are dangerous to physicians and nurses.

He also urged resistance testing for antibodies to antiretroviral drugs and studies to determine which agents will work against a patient's strain of HIV, as the virus can and usually will mutate after treatment. “If you have resistance testing and they are not resistant to the drug they are on, and the viral load doesn't go down—it is going up—what do you think is happening?” he asked. “They are not taking their drugs.”

Gynecologists also should be on the alert for opportunistic infections that can develop rapidly. “With HIV everything gets accelerated,” he said, directing attention to pneumocystis pneumonia, cardiomyopathy, erosive herpes, and giant condyloma.

Addressing concerns that HIV medications can interfere with the efficacy of oral contraceptives, Dr. Hammill said he prescribes the OCs at higher doses. He also warned of a high incidence of cervical dysplasia and recommended that women with abnormal Pap smears be screened every 3 months, although many insurance companies will not pay for the added tests.

“You would hate to have a woman die of cervical cancer that could have been prevented and her HIV is in remission,” he said.

Finally, he urged physicians to touch women with HIV as they would other patients. “These patients feel very ostracized. All the normal things we do with patients can be done,” he said.

HOUSTON — New retroviral therapies are making human immunodeficiency virus infection a chronic disease that physicians need to monitor when providing obstetric and gynecologic care, according to Hunter A. Hammill, M.D.

“You can't work in a vacuum anymore,” Dr. Hammill told clinicians at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

With 30 different treatment options being used in multiple-drug combinations, zidovudine (AZT) should not be the only HIV drug with which ob.gyns. are familiar. “They need to be aware there are many new agents, and with the new agents, it is becoming a chronic disease,” said Dr. Hammill of the Houston-based college.

Today, half of all HIV-infected patients worldwide are women. As people are living longer with HIV infection, the gynecologic patient population now includes postmenopausal women and young women who were infected congenitally.

“I have had patients who should not have lived and now are pregnant teenagers,” he said.

In the United States, he estimated 950,000 people have HIV, but a quarter of them do not know they are infected. In addition, some patients will claim not to know about their status rather than tell a sexual partner. Dr. Hammill described one such woman who tested positive after giving birth. It turned out she had participated in an HIV trial he had conducted 5 years earlier.

Some states require pregnant women to be tested for the virus. In Texas, where the conference was held, the law allows disclosure to a patient's spouse without consent, but physicians can “pass the buck” when a patient tests positive by simply notifying the health department, he said.

Even patients who are asymptomatic and not pregnant should be monitored regularly for CD4 count and viral load, according to Dr. Hammill. “The CD4 count is your army,” he said. “The viral load is the enemy's army.”

Typically, an asymptomatic patient will have an intermediate CD4 count between 200 and 350 and a viral load around 55,000, Dr. Hammill said. If the count is lower, patients could be vulnerable to pneumonia and opportunistic infections.

Retroviral treatment can bring a patient's viral load down to less than 50, which is not detectable. This is especially important if surgery is planned, he said, as needle sticks are dangerous to physicians and nurses.

He also urged resistance testing for antibodies to antiretroviral drugs and studies to determine which agents will work against a patient's strain of HIV, as the virus can and usually will mutate after treatment. “If you have resistance testing and they are not resistant to the drug they are on, and the viral load doesn't go down—it is going up—what do you think is happening?” he asked. “They are not taking their drugs.”

Gynecologists also should be on the alert for opportunistic infections that can develop rapidly. “With HIV everything gets accelerated,” he said, directing attention to pneumocystis pneumonia, cardiomyopathy, erosive herpes, and giant condyloma.

Addressing concerns that HIV medications can interfere with the efficacy of oral contraceptives, Dr. Hammill said he prescribes the OCs at higher doses. He also warned of a high incidence of cervical dysplasia and recommended that women with abnormal Pap smears be screened every 3 months, although many insurance companies will not pay for the added tests.

“You would hate to have a woman die of cervical cancer that could have been prevented and her HIV is in remission,” he said.

Finally, he urged physicians to touch women with HIV as they would other patients. “These patients feel very ostracized. All the normal things we do with patients can be done,” he said.

HOUSTON — New retroviral therapies are making human immunodeficiency virus infection a chronic disease that physicians need to monitor when providing obstetric and gynecologic care, according to Hunter A. Hammill, M.D.

“You can't work in a vacuum anymore,” Dr. Hammill told clinicians at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

With 30 different treatment options being used in multiple-drug combinations, zidovudine (AZT) should not be the only HIV drug with which ob.gyns. are familiar. “They need to be aware there are many new agents, and with the new agents, it is becoming a chronic disease,” said Dr. Hammill of the Houston-based college.

Today, half of all HIV-infected patients worldwide are women. As people are living longer with HIV infection, the gynecologic patient population now includes postmenopausal women and young women who were infected congenitally.

“I have had patients who should not have lived and now are pregnant teenagers,” he said.

In the United States, he estimated 950,000 people have HIV, but a quarter of them do not know they are infected. In addition, some patients will claim not to know about their status rather than tell a sexual partner. Dr. Hammill described one such woman who tested positive after giving birth. It turned out she had participated in an HIV trial he had conducted 5 years earlier.

Some states require pregnant women to be tested for the virus. In Texas, where the conference was held, the law allows disclosure to a patient's spouse without consent, but physicians can “pass the buck” when a patient tests positive by simply notifying the health department, he said.

Even patients who are asymptomatic and not pregnant should be monitored regularly for CD4 count and viral load, according to Dr. Hammill. “The CD4 count is your army,” he said. “The viral load is the enemy's army.”

Typically, an asymptomatic patient will have an intermediate CD4 count between 200 and 350 and a viral load around 55,000, Dr. Hammill said. If the count is lower, patients could be vulnerable to pneumonia and opportunistic infections.

Retroviral treatment can bring a patient's viral load down to less than 50, which is not detectable. This is especially important if surgery is planned, he said, as needle sticks are dangerous to physicians and nurses.

He also urged resistance testing for antibodies to antiretroviral drugs and studies to determine which agents will work against a patient's strain of HIV, as the virus can and usually will mutate after treatment. “If you have resistance testing and they are not resistant to the drug they are on, and the viral load doesn't go down—it is going up—what do you think is happening?” he asked. “They are not taking their drugs.”

Gynecologists also should be on the alert for opportunistic infections that can develop rapidly. “With HIV everything gets accelerated,” he said, directing attention to pneumocystis pneumonia, cardiomyopathy, erosive herpes, and giant condyloma.

Addressing concerns that HIV medications can interfere with the efficacy of oral contraceptives, Dr. Hammill said he prescribes the OCs at higher doses. He also warned of a high incidence of cervical dysplasia and recommended that women with abnormal Pap smears be screened every 3 months, although many insurance companies will not pay for the added tests.

“You would hate to have a woman die of cervical cancer that could have been prevented and her HIV is in remission,” he said.

Finally, he urged physicians to touch women with HIV as they would other patients. “These patients feel very ostracized. All the normal things we do with patients can be done,” he said.

HOUSTON — Whether to treat genital warts would seem like a no-brainer, but Peter J. Lynch, M.D., has a list of reasons for not trying to eradicate some vulvar lesions.

Many genital warts resolve spontaneously. The underlying cause, human papillomavirus (HPV), is so widespread that it's “nearly universal.” Moreover, destroying the lesion will not eradicate latent virus in the host, he said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

“There's a high rate of recurrence with all forms of treatment and a high cost for treatment, both economically and psychologically, with very little benefit,” concluded Dr. Lynch, a dermatologist in Sacramento.

Having said all that, he included himself among the majority of clinicians who treat genital warts. The patient's wishes, concerns about cancer risks, and legal vulnerability make genital warts difficult to ignore, he said.

Vulvar warts must be characterized and the source of infection confirmed before they are treated. Vulvar lesions from HPV infection are highly variable, he said, listing the most common forms:

▸ Filiform warts (condyloma acuminata) are taller than they are wide. They are about a quarter-inch to a half an inch long and skin colored or slightly pink. The tip is a little thicker than the stalk and often consists of brush-like bristles.

▸ Papules or nodules are as wide as they are tall—usually about the size of a pencil eraser (but sometimes as large as a plum), and skin colored or light brown. These are usually smooth but can feel rough if they occur in dry anogenital tissue.

▸ Flat warts are small, bare-topped, barely elevated papules that are wider than they are tall. They are about a quarter-inch in diameter and skin colored, pink, tan, or dark brown. The most common type of wart in the vulva, flat warts can coalesce into flat-topped plaques.

Dr. Lynch recommended biopsy to make certain the cause is HPV infection and to rule out malignancy, especially in flat warts, which are the most likely to show dysplasia. More than 90% of vulvar HPV infections are caused by low-risk forms of the virus.

High-risk types such as HPV 16 and HPV 18 occur in 5%-8% of vulvar HPV infections. Although these can lead to malignancy, he characterized the transition as very slow, with ample time for curative therapy.

Once vulvar HPV infection is established, other anogenital areas should be examined to rule out possible HPV infection there, as well. The next step to take, is to choose among the following three therapeutic options:

▸ Home-based medical therapy in which the patient applies a 5% cream of imiquimod (Aldara) or podofilox (Condylox). The weekly frequency might be every other day for imiquimod or 3 days in a row for podofilox. Dr. Lynch estimated about a third of patients will have complete clearance after 2 months of such treatment.

▸ Office-based medical therapy allows the clinician to monitor compliance. Dr. Lynch characterized this choice as inconvenient for patient and clinician, and the response rate is similar to home-based treatment.

▸ Office-based destructive treatment can be quite effective. Treatments requiring anesthesia (electrosurgery, excision, laser therapy) can have a 100% response rate. Treatments that can be done without anesthesia (cryotherapy, podophyllin, tri- or bichloracetic acid, and 5-fluorouracil) will lead to complete clearance in two-thirds of patients, Dr. Lynch estimated at the meeting.

“Unfortunately, there are no criteria to choose one [treatment] over the other. It is disturbing how little we have, except for anecdotal data,” Dr. Lynch said of the three options.

His recommendation: “Either use home therapy, where the patient treats herself … or go to destructive therapy. Expect at least a 35% recurrence rate with either approach. Medical therapy in the office has all the disadvantages of home therapy without any improvement in results.”

One caveat:Dr. Lynch said vulvar warts should be treated in pregnant women, but he warned that podophyllin and its derivatives should not be used.

HOUSTON — Whether to treat genital warts would seem like a no-brainer, but Peter J. Lynch, M.D., has a list of reasons for not trying to eradicate some vulvar lesions.

Many genital warts resolve spontaneously. The underlying cause, human papillomavirus (HPV), is so widespread that it's “nearly universal.” Moreover, destroying the lesion will not eradicate latent virus in the host, he said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

“There's a high rate of recurrence with all forms of treatment and a high cost for treatment, both economically and psychologically, with very little benefit,” concluded Dr. Lynch, a dermatologist in Sacramento.

Having said all that, he included himself among the majority of clinicians who treat genital warts. The patient's wishes, concerns about cancer risks, and legal vulnerability make genital warts difficult to ignore, he said.

Vulvar warts must be characterized and the source of infection confirmed before they are treated. Vulvar lesions from HPV infection are highly variable, he said, listing the most common forms:

▸ Filiform warts (condyloma acuminata) are taller than they are wide. They are about a quarter-inch to a half an inch long and skin colored or slightly pink. The tip is a little thicker than the stalk and often consists of brush-like bristles.

▸ Papules or nodules are as wide as they are tall—usually about the size of a pencil eraser (but sometimes as large as a plum), and skin colored or light brown. These are usually smooth but can feel rough if they occur in dry anogenital tissue.

▸ Flat warts are small, bare-topped, barely elevated papules that are wider than they are tall. They are about a quarter-inch in diameter and skin colored, pink, tan, or dark brown. The most common type of wart in the vulva, flat warts can coalesce into flat-topped plaques.

Dr. Lynch recommended biopsy to make certain the cause is HPV infection and to rule out malignancy, especially in flat warts, which are the most likely to show dysplasia. More than 90% of vulvar HPV infections are caused by low-risk forms of the virus.

High-risk types such as HPV 16 and HPV 18 occur in 5%-8% of vulvar HPV infections. Although these can lead to malignancy, he characterized the transition as very slow, with ample time for curative therapy.

Once vulvar HPV infection is established, other anogenital areas should be examined to rule out possible HPV infection there, as well. The next step to take, is to choose among the following three therapeutic options:

▸ Home-based medical therapy in which the patient applies a 5% cream of imiquimod (Aldara) or podofilox (Condylox). The weekly frequency might be every other day for imiquimod or 3 days in a row for podofilox. Dr. Lynch estimated about a third of patients will have complete clearance after 2 months of such treatment.

▸ Office-based medical therapy allows the clinician to monitor compliance. Dr. Lynch characterized this choice as inconvenient for patient and clinician, and the response rate is similar to home-based treatment.

▸ Office-based destructive treatment can be quite effective. Treatments requiring anesthesia (electrosurgery, excision, laser therapy) can have a 100% response rate. Treatments that can be done without anesthesia (cryotherapy, podophyllin, tri- or bichloracetic acid, and 5-fluorouracil) will lead to complete clearance in two-thirds of patients, Dr. Lynch estimated at the meeting.

“Unfortunately, there are no criteria to choose one [treatment] over the other. It is disturbing how little we have, except for anecdotal data,” Dr. Lynch said of the three options.

His recommendation: “Either use home therapy, where the patient treats herself … or go to destructive therapy. Expect at least a 35% recurrence rate with either approach. Medical therapy in the office has all the disadvantages of home therapy without any improvement in results.”

One caveat:Dr. Lynch said vulvar warts should be treated in pregnant women, but he warned that podophyllin and its derivatives should not be used.

HOUSTON — Whether to treat genital warts would seem like a no-brainer, but Peter J. Lynch, M.D., has a list of reasons for not trying to eradicate some vulvar lesions.

Many genital warts resolve spontaneously. The underlying cause, human papillomavirus (HPV), is so widespread that it's “nearly universal.” Moreover, destroying the lesion will not eradicate latent virus in the host, he said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

“There's a high rate of recurrence with all forms of treatment and a high cost for treatment, both economically and psychologically, with very little benefit,” concluded Dr. Lynch, a dermatologist in Sacramento.

Having said all that, he included himself among the majority of clinicians who treat genital warts. The patient's wishes, concerns about cancer risks, and legal vulnerability make genital warts difficult to ignore, he said.

Vulvar warts must be characterized and the source of infection confirmed before they are treated. Vulvar lesions from HPV infection are highly variable, he said, listing the most common forms:

▸ Filiform warts (condyloma acuminata) are taller than they are wide. They are about a quarter-inch to a half an inch long and skin colored or slightly pink. The tip is a little thicker than the stalk and often consists of brush-like bristles.

▸ Papules or nodules are as wide as they are tall—usually about the size of a pencil eraser (but sometimes as large as a plum), and skin colored or light brown. These are usually smooth but can feel rough if they occur in dry anogenital tissue.

▸ Flat warts are small, bare-topped, barely elevated papules that are wider than they are tall. They are about a quarter-inch in diameter and skin colored, pink, tan, or dark brown. The most common type of wart in the vulva, flat warts can coalesce into flat-topped plaques.

Dr. Lynch recommended biopsy to make certain the cause is HPV infection and to rule out malignancy, especially in flat warts, which are the most likely to show dysplasia. More than 90% of vulvar HPV infections are caused by low-risk forms of the virus.

High-risk types such as HPV 16 and HPV 18 occur in 5%-8% of vulvar HPV infections. Although these can lead to malignancy, he characterized the transition as very slow, with ample time for curative therapy.

Once vulvar HPV infection is established, other anogenital areas should be examined to rule out possible HPV infection there, as well. The next step to take, is to choose among the following three therapeutic options:

▸ Home-based medical therapy in which the patient applies a 5% cream of imiquimod (Aldara) or podofilox (Condylox). The weekly frequency might be every other day for imiquimod or 3 days in a row for podofilox. Dr. Lynch estimated about a third of patients will have complete clearance after 2 months of such treatment.

▸ Office-based medical therapy allows the clinician to monitor compliance. Dr. Lynch characterized this choice as inconvenient for patient and clinician, and the response rate is similar to home-based treatment.

▸ Office-based destructive treatment can be quite effective. Treatments requiring anesthesia (electrosurgery, excision, laser therapy) can have a 100% response rate. Treatments that can be done without anesthesia (cryotherapy, podophyllin, tri- or bichloracetic acid, and 5-fluorouracil) will lead to complete clearance in two-thirds of patients, Dr. Lynch estimated at the meeting.

“Unfortunately, there are no criteria to choose one [treatment] over the other. It is disturbing how little we have, except for anecdotal data,” Dr. Lynch said of the three options.

His recommendation: “Either use home therapy, where the patient treats herself … or go to destructive therapy. Expect at least a 35% recurrence rate with either approach. Medical therapy in the office has all the disadvantages of home therapy without any improvement in results.”

One caveat:Dr. Lynch said vulvar warts should be treated in pregnant women, but he warned that podophyllin and its derivatives should not be used.

HOUSTON — Diagnosis of human papillomavirus infection in a genital wart should not trigger a rush to judgment regarding recent sexual transgression or child abuse, Peter J. Lynch, M.D., said at a conference on vulvovaginal diseases.

Only 20% of new human papillomavirus (HPV) infections produce lesions within the first few months. The average incubation period lasts 2 months to 2 years, after which the virus can remain latent for years or even a lifetime in the unsuspecting human host, said Dr. Lynch, a dermatologist in Sacramento.

He attributed 95% of adult infections to sexual transmission but said genital warts in children often result from infections transmitted by parents. Transmission not only can happen during vaginal delivery in a woman who is asymptomatic, but infections can also remain latent for years before a wart is detected, he said at the meeting, sponsored by Baylor College of Medicine.

Theoretically, a parent infected with a finger or hand wart can transmit the virus innocuously when bathing a child. If a genital wart is the only evidence of child abuse, he advised practitioners not to assume the child was assaulted.

“Vertical transmission occurs and, thus, not all childhood genital HPV infections are child abuse,” he said. “Latency occurs, so that the appearance of active disease does not tell you anything about when the original infection was acquired.”

HPV is widespread in the general population, but it is difficult to diagnose, and its prevalence has been hard to establish, according to Dr. Lynch. It grows only in epithelial cells, and researchers have been unable to grow the virus in culture.

Clinicians are unable to diagnose latent virus in the absence of discernable lesions, Dr. Lynch said, warning that acetic acid soaks have turned out to be misleading and should not be used. Conventional biopsy also can be misleading, he said; sometimes pathologists will misidentify clear cells as koilocytes.

The best test for identifying HPV type uses polymerase chain reaction, which is expensive and generally reserved for research, said Dr. Lynch. Though simple inexpensive test kits have become available, he predicted questions about their accuracy would prevent wide use until they are resolved.

Meanwhile, research in women with sexually transmitted diseases has shown 60% to be infected with HPV. In more typical populations of sexually active women, he estimated prevalence at 20%. Because cervical infections are more common than vulvar infections, he reckoned that 5%-10% of women have active or latent HPV infections of the vulva.

Sexual partners do not need to be examined after a woman is diagnosed with HPV. “The acquisition may not have been sexual; it may have occurred years ago and be latent,” he said.

“How would you examine the partner anyway?” he asked, describing one test used in men as “neither accurate nor specific.” Nonetheless, he added, men diagnosed with HPV should notify female sexual partners because of the risk of cervical and vulvar infection.

When anogenital warts are diagnosed in children, they are often best left alone; nearly 100% will resolve spontaneously within 2 years. If such warts are treated, he recommended home care with imiquimod (Aldara) or podofilox (Condylox) to minimize psychological and physical trauma.

HOUSTON — Diagnosis of human papillomavirus infection in a genital wart should not trigger a rush to judgment regarding recent sexual transgression or child abuse, Peter J. Lynch, M.D., said at a conference on vulvovaginal diseases.

Only 20% of new human papillomavirus (HPV) infections produce lesions within the first few months. The average incubation period lasts 2 months to 2 years, after which the virus can remain latent for years or even a lifetime in the unsuspecting human host, said Dr. Lynch, a dermatologist in Sacramento.

He attributed 95% of adult infections to sexual transmission but said genital warts in children often result from infections transmitted by parents. Transmission not only can happen during vaginal delivery in a woman who is asymptomatic, but infections can also remain latent for years before a wart is detected, he said at the meeting, sponsored by Baylor College of Medicine.

Theoretically, a parent infected with a finger or hand wart can transmit the virus innocuously when bathing a child. If a genital wart is the only evidence of child abuse, he advised practitioners not to assume the child was assaulted.

“Vertical transmission occurs and, thus, not all childhood genital HPV infections are child abuse,” he said. “Latency occurs, so that the appearance of active disease does not tell you anything about when the original infection was acquired.”

HPV is widespread in the general population, but it is difficult to diagnose, and its prevalence has been hard to establish, according to Dr. Lynch. It grows only in epithelial cells, and researchers have been unable to grow the virus in culture.

Clinicians are unable to diagnose latent virus in the absence of discernable lesions, Dr. Lynch said, warning that acetic acid soaks have turned out to be misleading and should not be used. Conventional biopsy also can be misleading, he said; sometimes pathologists will misidentify clear cells as koilocytes.

The best test for identifying HPV type uses polymerase chain reaction, which is expensive and generally reserved for research, said Dr. Lynch. Though simple inexpensive test kits have become available, he predicted questions about their accuracy would prevent wide use until they are resolved.

Meanwhile, research in women with sexually transmitted diseases has shown 60% to be infected with HPV. In more typical populations of sexually active women, he estimated prevalence at 20%. Because cervical infections are more common than vulvar infections, he reckoned that 5%-10% of women have active or latent HPV infections of the vulva.

Sexual partners do not need to be examined after a woman is diagnosed with HPV. “The acquisition may not have been sexual; it may have occurred years ago and be latent,” he said.

“How would you examine the partner anyway?” he asked, describing one test used in men as “neither accurate nor specific.” Nonetheless, he added, men diagnosed with HPV should notify female sexual partners because of the risk of cervical and vulvar infection.

When anogenital warts are diagnosed in children, they are often best left alone; nearly 100% will resolve spontaneously within 2 years. If such warts are treated, he recommended home care with imiquimod (Aldara) or podofilox (Condylox) to minimize psychological and physical trauma.

HOUSTON — Diagnosis of human papillomavirus infection in a genital wart should not trigger a rush to judgment regarding recent sexual transgression or child abuse, Peter J. Lynch, M.D., said at a conference on vulvovaginal diseases.

Only 20% of new human papillomavirus (HPV) infections produce lesions within the first few months. The average incubation period lasts 2 months to 2 years, after which the virus can remain latent for years or even a lifetime in the unsuspecting human host, said Dr. Lynch, a dermatologist in Sacramento.

He attributed 95% of adult infections to sexual transmission but said genital warts in children often result from infections transmitted by parents. Transmission not only can happen during vaginal delivery in a woman who is asymptomatic, but infections can also remain latent for years before a wart is detected, he said at the meeting, sponsored by Baylor College of Medicine.

Theoretically, a parent infected with a finger or hand wart can transmit the virus innocuously when bathing a child. If a genital wart is the only evidence of child abuse, he advised practitioners not to assume the child was assaulted.

“Vertical transmission occurs and, thus, not all childhood genital HPV infections are child abuse,” he said. “Latency occurs, so that the appearance of active disease does not tell you anything about when the original infection was acquired.”

HPV is widespread in the general population, but it is difficult to diagnose, and its prevalence has been hard to establish, according to Dr. Lynch. It grows only in epithelial cells, and researchers have been unable to grow the virus in culture.

Clinicians are unable to diagnose latent virus in the absence of discernable lesions, Dr. Lynch said, warning that acetic acid soaks have turned out to be misleading and should not be used. Conventional biopsy also can be misleading, he said; sometimes pathologists will misidentify clear cells as koilocytes.

The best test for identifying HPV type uses polymerase chain reaction, which is expensive and generally reserved for research, said Dr. Lynch. Though simple inexpensive test kits have become available, he predicted questions about their accuracy would prevent wide use until they are resolved.

Meanwhile, research in women with sexually transmitted diseases has shown 60% to be infected with HPV. In more typical populations of sexually active women, he estimated prevalence at 20%. Because cervical infections are more common than vulvar infections, he reckoned that 5%-10% of women have active or latent HPV infections of the vulva.

Sexual partners do not need to be examined after a woman is diagnosed with HPV. “The acquisition may not have been sexual; it may have occurred years ago and be latent,” he said.

“How would you examine the partner anyway?” he asked, describing one test used in men as “neither accurate nor specific.” Nonetheless, he added, men diagnosed with HPV should notify female sexual partners because of the risk of cervical and vulvar infection.

When anogenital warts are diagnosed in children, they are often best left alone; nearly 100% will resolve spontaneously within 2 years. If such warts are treated, he recommended home care with imiquimod (Aldara) or podofilox (Condylox) to minimize psychological and physical trauma.

PHOENIX, ARIZ.—Risk of death from sepsis increases by 6%-10% with every hour that passes from the onset of septic shock until the start of effective antimicrobial therapy, according to a review of more than 2,600 consecutive cases at 15 intensive care units in five U.S. and Canadian cities.

“You already have a substantially increased risk of death if you get antibiotics by the second hour after onset of hypotension compared with the first hour—and that odds ratio continues to climb out to 36 hours,” principal investigator Anand Kumar, M.D., said at a meeting sponsored by the Society of Critical Care Medicine.

Relatively few patients received appropriate antibiotics within 2 hours, however.

Dr. Kumar, head of the emergency department at the University of Manitoba in Winnipeg, reported that at every hospital studied, “Only half of septic shock patients received an antibiotic within 6 hours of onset of recurrent or persistent hypotension.”

Early administration of appropriate antibiotics is crucial because it eliminates the source of sepsis, according to Dr. Kumar. “You can keep the patients alive for days, but if you don't eliminate the source in the first couple of hours, they are not going to make it,” he said.

All told, 43.8% of 2,731 septic shock patients reviewed by Dr. Kumar and his colleagues survived to hospital discharge. Removing patients who were moribund at presentation (those who required intubation or cardiopulmonary resuscitation in the field) reduced the population to 2,675 patients, but barely nudged the survival rate up to 44.7%.

The population had slightly more men than women and an average age of 62.5 years. Nearly half the patients, 43%, came from emergency departments. Another 28% had been in medical wards, and 18% on surgical floors.

Nosocomial infections accounted for 42% of cases. Malignancy was the most common comorbidity (20%), followed by chemotherapy and elective surgery, each about 15%. The average Acute Physiology and Chronic Health Evaluation II score was 25.9.

Dr. Kumar said emergency departments were about an hour faster than other areas of the hospital in delivering antibiotics, but still too slow. The median emergency department time to treat was 4.5-5 hours.

The investigation started with animal studies. Mortality was held to 10% if the animals were given an antibiotic within a 12-hour window before the onset of hypotension, according to Dr. Kumar. The mortality was 80% if the antibiotic was started 15 hours afterward, and 100% at 24 hours.

In the human retrospective study reported at the meeting, 89% of patients who received an appropriate antibiotic within the first half-hour survived, he said. By the second hour, the survival rate dropped to 84%, and it continued to drop at a rate of 7.5% every hour thereafter.

Subset analyses by numerous factors mostly produced P values of .0001 without changing the risk, according to Dr. Kumar. Patients who were obviously sicker at presentation received antibiotics faster, improving their odds of surviving, he said.

Only about 50 patients, all in the United States, had methicillin-resistant Staphylococcus aureus, which was not seen in Winnipeg, according to Dr. Kumar.

He noted that the investigators focused on time to effective antibiotics. If the first choice is not effective, the effects of any initial delay can be all the more overwhelming, he said.

Dr. Kumar called for hospitals to use medical response teams with algorithm protocols for patients in septic shock. He reported his hospital instituted the following changes in response to the study:

▸ Staff can start intravenous antibiotics in hypotensive sepsis patients without waiting for approval.

▸ Nurses have been told that the first dose of any new antibiotic is an automatic stat order.

▸ No sepsis patient is transferred to an ICU without receiving an antibiotic before leaving the emergency department.

Many emergency physicians do not realize that an antibiotic order may wait for hours if it is not marked “stat,” according to Dr. Kumar. If the patient is transferred to an ICU, more hours might pass before the antibiotic is delivered with scheduled medications, he warned.

“These simple administrative changes can reduce time to antibiotics by 2 hours,” he said. “And, if these data hold, that's a translation to a 15% absolute improvement in mortality.”

PHOENIX, ARIZ.—Risk of death from sepsis increases by 6%-10% with every hour that passes from the onset of septic shock until the start of effective antimicrobial therapy, according to a review of more than 2,600 consecutive cases at 15 intensive care units in five U.S. and Canadian cities.

“You already have a substantially increased risk of death if you get antibiotics by the second hour after onset of hypotension compared with the first hour—and that odds ratio continues to climb out to 36 hours,” principal investigator Anand Kumar, M.D., said at a meeting sponsored by the Society of Critical Care Medicine.

Relatively few patients received appropriate antibiotics within 2 hours, however.

Dr. Kumar, head of the emergency department at the University of Manitoba in Winnipeg, reported that at every hospital studied, “Only half of septic shock patients received an antibiotic within 6 hours of onset of recurrent or persistent hypotension.”

Early administration of appropriate antibiotics is crucial because it eliminates the source of sepsis, according to Dr. Kumar. “You can keep the patients alive for days, but if you don't eliminate the source in the first couple of hours, they are not going to make it,” he said.

All told, 43.8% of 2,731 septic shock patients reviewed by Dr. Kumar and his colleagues survived to hospital discharge. Removing patients who were moribund at presentation (those who required intubation or cardiopulmonary resuscitation in the field) reduced the population to 2,675 patients, but barely nudged the survival rate up to 44.7%.

The population had slightly more men than women and an average age of 62.5 years. Nearly half the patients, 43%, came from emergency departments. Another 28% had been in medical wards, and 18% on surgical floors.

Nosocomial infections accounted for 42% of cases. Malignancy was the most common comorbidity (20%), followed by chemotherapy and elective surgery, each about 15%. The average Acute Physiology and Chronic Health Evaluation II score was 25.9.

Dr. Kumar said emergency departments were about an hour faster than other areas of the hospital in delivering antibiotics, but still too slow. The median emergency department time to treat was 4.5-5 hours.

The investigation started with animal studies. Mortality was held to 10% if the animals were given an antibiotic within a 12-hour window before the onset of hypotension, according to Dr. Kumar. The mortality was 80% if the antibiotic was started 15 hours afterward, and 100% at 24 hours.

In the human retrospective study reported at the meeting, 89% of patients who received an appropriate antibiotic within the first half-hour survived, he said. By the second hour, the survival rate dropped to 84%, and it continued to drop at a rate of 7.5% every hour thereafter.

Subset analyses by numerous factors mostly produced P values of .0001 without changing the risk, according to Dr. Kumar. Patients who were obviously sicker at presentation received antibiotics faster, improving their odds of surviving, he said.

Only about 50 patients, all in the United States, had methicillin-resistant Staphylococcus aureus, which was not seen in Winnipeg, according to Dr. Kumar.

He noted that the investigators focused on time to effective antibiotics. If the first choice is not effective, the effects of any initial delay can be all the more overwhelming, he said.

Dr. Kumar called for hospitals to use medical response teams with algorithm protocols for patients in septic shock. He reported his hospital instituted the following changes in response to the study:

▸ Staff can start intravenous antibiotics in hypotensive sepsis patients without waiting for approval.

▸ Nurses have been told that the first dose of any new antibiotic is an automatic stat order.

▸ No sepsis patient is transferred to an ICU without receiving an antibiotic before leaving the emergency department.

Many emergency physicians do not realize that an antibiotic order may wait for hours if it is not marked “stat,” according to Dr. Kumar. If the patient is transferred to an ICU, more hours might pass before the antibiotic is delivered with scheduled medications, he warned.

“These simple administrative changes can reduce time to antibiotics by 2 hours,” he said. “And, if these data hold, that's a translation to a 15% absolute improvement in mortality.”

PHOENIX, ARIZ.—Risk of death from sepsis increases by 6%-10% with every hour that passes from the onset of septic shock until the start of effective antimicrobial therapy, according to a review of more than 2,600 consecutive cases at 15 intensive care units in five U.S. and Canadian cities.

“You already have a substantially increased risk of death if you get antibiotics by the second hour after onset of hypotension compared with the first hour—and that odds ratio continues to climb out to 36 hours,” principal investigator Anand Kumar, M.D., said at a meeting sponsored by the Society of Critical Care Medicine.

Relatively few patients received appropriate antibiotics within 2 hours, however.

Dr. Kumar, head of the emergency department at the University of Manitoba in Winnipeg, reported that at every hospital studied, “Only half of septic shock patients received an antibiotic within 6 hours of onset of recurrent or persistent hypotension.”

Early administration of appropriate antibiotics is crucial because it eliminates the source of sepsis, according to Dr. Kumar. “You can keep the patients alive for days, but if you don't eliminate the source in the first couple of hours, they are not going to make it,” he said.

All told, 43.8% of 2,731 septic shock patients reviewed by Dr. Kumar and his colleagues survived to hospital discharge. Removing patients who were moribund at presentation (those who required intubation or cardiopulmonary resuscitation in the field) reduced the population to 2,675 patients, but barely nudged the survival rate up to 44.7%.

The population had slightly more men than women and an average age of 62.5 years. Nearly half the patients, 43%, came from emergency departments. Another 28% had been in medical wards, and 18% on surgical floors.

Nosocomial infections accounted for 42% of cases. Malignancy was the most common comorbidity (20%), followed by chemotherapy and elective surgery, each about 15%. The average Acute Physiology and Chronic Health Evaluation II score was 25.9.

Dr. Kumar said emergency departments were about an hour faster than other areas of the hospital in delivering antibiotics, but still too slow. The median emergency department time to treat was 4.5-5 hours.

The investigation started with animal studies. Mortality was held to 10% if the animals were given an antibiotic within a 12-hour window before the onset of hypotension, according to Dr. Kumar. The mortality was 80% if the antibiotic was started 15 hours afterward, and 100% at 24 hours.

In the human retrospective study reported at the meeting, 89% of patients who received an appropriate antibiotic within the first half-hour survived, he said. By the second hour, the survival rate dropped to 84%, and it continued to drop at a rate of 7.5% every hour thereafter.

Subset analyses by numerous factors mostly produced P values of .0001 without changing the risk, according to Dr. Kumar. Patients who were obviously sicker at presentation received antibiotics faster, improving their odds of surviving, he said.

Only about 50 patients, all in the United States, had methicillin-resistant Staphylococcus aureus, which was not seen in Winnipeg, according to Dr. Kumar.

He noted that the investigators focused on time to effective antibiotics. If the first choice is not effective, the effects of any initial delay can be all the more overwhelming, he said.

Dr. Kumar called for hospitals to use medical response teams with algorithm protocols for patients in septic shock. He reported his hospital instituted the following changes in response to the study:

▸ Staff can start intravenous antibiotics in hypotensive sepsis patients without waiting for approval.

▸ Nurses have been told that the first dose of any new antibiotic is an automatic stat order.

▸ No sepsis patient is transferred to an ICU without receiving an antibiotic before leaving the emergency department.

Many emergency physicians do not realize that an antibiotic order may wait for hours if it is not marked “stat,” according to Dr. Kumar. If the patient is transferred to an ICU, more hours might pass before the antibiotic is delivered with scheduled medications, he warned.

“These simple administrative changes can reduce time to antibiotics by 2 hours,” he said. “And, if these data hold, that's a translation to a 15% absolute improvement in mortality.”

PHOENIX, ARIZ.—Despite an American Heart Association recommendation that cardiopulmonary resuscitation stop if patients do not respond within 30 minutes, a review of one emergency department's experience found the average effort lasted significantly longer.

Mean total resuscitation time was 66 minutes when cardiopulmonary resuscitation (CPR) began before the patient arrived at the hospital, and 36 minutes if CPR was started in the emergency department, emergency physicians Lara Wagner, M.D., and Jared Strote, M.D., reported at a meeting sponsored by the Society of Critical Care Medicine.

The duration of CPR was also significantly longer in medical cases than in trauma cases, a difference that was statistically significant. A chart review of failed attempts showed average times of 73 minutes and 51 minutes, respectively. The average for all attempts was 55 minutes.

“It appears a lot was due to the clock being restarted when paramedics arrived at the emergency department,” said Dr. Strote of the University of Washington Medical Center in Seattle. One possibility, he suggested, was that “the doctors were not taking into account all the resuscitation that was happening in the field.”

Another explanation could be that the paramedics or the emergency physicians thought they saw a response in the patients who arrived by ambulance, said Dr. Wagner, a resident at the university. “At any point during resuscitation efforts, did they … regain a rhythm and start again?” she asked.

The study reviewed charts of 126 patients who died after resuscitation attempts from September 2001 to August 2003. These included 76 trauma cases and 50 medical arrests. In 83 cases, CPR was started before the patients arrived in the emergency department; the other 43 patients went into arrest in the ED. Thirteen patients had “Do not resuscitate” orders.

Analysis by age, gender, and race did not turn up significant differences, the authors reported. They speculated that the longer time spent in medical cases “may be due in part to longer medical arrest field resuscitation time versus a 'scoop and run' trauma arrest strategy.”

The phenomenon needs to be addressed, according to Dr. Strote, because longer-than-appropriate resuscitation times can be harmful. “It's hurting other patients in terms of resources that are being used,” he said. “And after 30 minutes, [the resuscitated patients'] chance of reasonable recovery is near zero, but there does remain a chance they will recover with brain damage or significant organ damage.”

The ongoing study has been expanded to review more patients and more years, Dr. Wagner added. “We're looking to see what is going on in the 30 minutes or so before they arrive at the ED,” she said.

PHOENIX, ARIZ.—Despite an American Heart Association recommendation that cardiopulmonary resuscitation stop if patients do not respond within 30 minutes, a review of one emergency department's experience found the average effort lasted significantly longer.

Mean total resuscitation time was 66 minutes when cardiopulmonary resuscitation (CPR) began before the patient arrived at the hospital, and 36 minutes if CPR was started in the emergency department, emergency physicians Lara Wagner, M.D., and Jared Strote, M.D., reported at a meeting sponsored by the Society of Critical Care Medicine.

The duration of CPR was also significantly longer in medical cases than in trauma cases, a difference that was statistically significant. A chart review of failed attempts showed average times of 73 minutes and 51 minutes, respectively. The average for all attempts was 55 minutes.

“It appears a lot was due to the clock being restarted when paramedics arrived at the emergency department,” said Dr. Strote of the University of Washington Medical Center in Seattle. One possibility, he suggested, was that “the doctors were not taking into account all the resuscitation that was happening in the field.”

Another explanation could be that the paramedics or the emergency physicians thought they saw a response in the patients who arrived by ambulance, said Dr. Wagner, a resident at the university. “At any point during resuscitation efforts, did they … regain a rhythm and start again?” she asked.

The study reviewed charts of 126 patients who died after resuscitation attempts from September 2001 to August 2003. These included 76 trauma cases and 50 medical arrests. In 83 cases, CPR was started before the patients arrived in the emergency department; the other 43 patients went into arrest in the ED. Thirteen patients had “Do not resuscitate” orders.

Analysis by age, gender, and race did not turn up significant differences, the authors reported. They speculated that the longer time spent in medical cases “may be due in part to longer medical arrest field resuscitation time versus a 'scoop and run' trauma arrest strategy.”

The phenomenon needs to be addressed, according to Dr. Strote, because longer-than-appropriate resuscitation times can be harmful. “It's hurting other patients in terms of resources that are being used,” he said. “And after 30 minutes, [the resuscitated patients'] chance of reasonable recovery is near zero, but there does remain a chance they will recover with brain damage or significant organ damage.”

The ongoing study has been expanded to review more patients and more years, Dr. Wagner added. “We're looking to see what is going on in the 30 minutes or so before they arrive at the ED,” she said.

PHOENIX, ARIZ.—Despite an American Heart Association recommendation that cardiopulmonary resuscitation stop if patients do not respond within 30 minutes, a review of one emergency department's experience found the average effort lasted significantly longer.

Mean total resuscitation time was 66 minutes when cardiopulmonary resuscitation (CPR) began before the patient arrived at the hospital, and 36 minutes if CPR was started in the emergency department, emergency physicians Lara Wagner, M.D., and Jared Strote, M.D., reported at a meeting sponsored by the Society of Critical Care Medicine.

The duration of CPR was also significantly longer in medical cases than in trauma cases, a difference that was statistically significant. A chart review of failed attempts showed average times of 73 minutes and 51 minutes, respectively. The average for all attempts was 55 minutes.

“It appears a lot was due to the clock being restarted when paramedics arrived at the emergency department,” said Dr. Strote of the University of Washington Medical Center in Seattle. One possibility, he suggested, was that “the doctors were not taking into account all the resuscitation that was happening in the field.”

Another explanation could be that the paramedics or the emergency physicians thought they saw a response in the patients who arrived by ambulance, said Dr. Wagner, a resident at the university. “At any point during resuscitation efforts, did they … regain a rhythm and start again?” she asked.

The study reviewed charts of 126 patients who died after resuscitation attempts from September 2001 to August 2003. These included 76 trauma cases and 50 medical arrests. In 83 cases, CPR was started before the patients arrived in the emergency department; the other 43 patients went into arrest in the ED. Thirteen patients had “Do not resuscitate” orders.

Analysis by age, gender, and race did not turn up significant differences, the authors reported. They speculated that the longer time spent in medical cases “may be due in part to longer medical arrest field resuscitation time versus a 'scoop and run' trauma arrest strategy.”

The phenomenon needs to be addressed, according to Dr. Strote, because longer-than-appropriate resuscitation times can be harmful. “It's hurting other patients in terms of resources that are being used,” he said. “And after 30 minutes, [the resuscitated patients'] chance of reasonable recovery is near zero, but there does remain a chance they will recover with brain damage or significant organ damage.”

The ongoing study has been expanded to review more patients and more years, Dr. Wagner added. “We're looking to see what is going on in the 30 minutes or so before they arrive at the ED,” she said.

PHOENIX, ARIZ.—Therapeutic hypothermia after cardiac arrest offers proven neurological benefits to patients and should be implemented in hospitals worldwide, Simon R. Dixon, M.B., said at a congress of the Society of Critical Care Medicine.

Only about 20 hospitals in the United States are doing therapeutic hypothermia, said Dr. Dixon, codirector of cardiovascular research at William Beaumont Hospital in Royal Oak, Mich.

Medical staffs have been slow to adopt hypothermia, despite an International Liaison Committee on Resuscitation (ILCOR) task force advisory statement (Circulation 2003;108:118-21) endorsing its use after cardiac arrest, he said.

“This statement should really serve as a call to action to physicians around the world that hypothermia is here, and we should be doing it to improve care to our patients,” he said. “And it's discouraging that even though this statement was issued 2 years ago, adoption of this therapy is so slow throughout the world.”

Although much effort goes to improving resuscitation of cardiac patients, little has been done to improve neurologic dysfunction. “It is important to remember that neurological aspects determine the longevity or most of the disability in these patients when they go home,” he said.

The ILCOR statement followed two trials that found patients had better outcomes if given therapeutic hypothermia after cardiac arrest. The percentages of hypothermia patients with favorable neurologic recovery were 49%—versus 26% for a control group—in an Australian study (N. Engl. J. Med. 2002;346:557-63) and 55%—versus 39% for controls—in a European study (N. Engl. J. Med. 2002;346:549-56).

Other studies, published (Am. J. Physiol. Heart Circ. Physiol. 2002;282:H1584-91) and ongoing, have also indicated that therapeutic hypothermia can reduce the size of an infarction, Dr. Dixon noted.

“These two trials suggest if the heart can be cooled adequately by the time angioplasty is done, probably there will be benefit from hypothermia,” he said, citing the Cooling for Myocardial Infarction (COOL MI) and Intravascular Cooling Adjunctive to Primary Coronary Intervention (ICE-IT) studies.

Dr. Dixon concluded that evidence clearly shows hypothermia to be safe and effective. Nonetheless, training requirements and fear of side effects have so far inhibited wider use, he said.

Session moderator Stefan A. Mayer, M.D., a consultant to and shareholder in several hypothermia device companies, also urged greater use of the therapy in cardiac cases. Dr. Mayer, director of critical care neurology at Columbia University, New York, warned that uncontrolled fever can be damaging and ongoing in ischemia and in stroke.

“In cardiac arrest you've got to make them hypothermic,” he said. “Why wait for a patient to get febrile and try to get it [temperature] down? That's like waiting for the toothpaste to get out of the tube and try to get it back.”

One Hospital's Experience With Therapeutic Hypothermia

Therapeutic hypothermia is not risk free, but its side effects are predictable and can be managed, according to a physician who has 8 years' experience cooling critically ill patients at the Free University Medical Center in Amsterdam.

“Our treatments can have severe side effects, but the good news is most side effects of hypothermia can be prevented or controlled. So fear of side effects should not prevent you from using this,” internist/intensivist Kees H. Polderman, M.D., said at a congress of the Society of Critical Care Medicine.

The optimal duration and depth of cooling and time to rewarming have yet to be determined, Dr. Polderman said. Nonetheless, he maintained that therapeutic hypothermia could be used safely for cardiac protection as well as neural protection.

“Start cooling as early and as quickly as possible, both to produce the effects we are looking for and to reduce the severity of some side effects,” he advised. “Do not rewarm too fast.”

Dr. Polderman encouraged physicians to educate themselves on the physiologic changes and side effects that can be expected before starting hypothermia. They need to know “which are harmful, which we can treat, and which we can ignore,” he said.

Among high-risk side effects, Dr. Polderman cited coagulopathy, impaired coagulation cascade, electrolyte disorders, and hypovolemia. He warned that insulin sensitivity and insulin secretion both decrease, so physicians need to monitor glucose and to be prepared to avert hyperglycemia. Amylase, platelets, and white blood cells also need to be monitored, he said.

The hospital laboratory must be told that the patient is being cooled because temperature can alter laboratory test results. In addition, pharmacokinetics of some medications can change, but for many drugs these effects are not yet known, he warned.

Dr. Polderman listed manifest bleeding, severe coagulation disorders, airway and wound infections, and myocardial ischemia as low-risk events. Manifest pancreatic and intracerebral bleeding are rare, he said. Patients undergoing long-term cooling need antibiotic prophylaxis and protection against bedsores, he advised.

PHOENIX, ARIZ.—Therapeutic hypothermia after cardiac arrest offers proven neurological benefits to patients and should be implemented in hospitals worldwide, Simon R. Dixon, M.B., said at a congress of the Society of Critical Care Medicine.

Only about 20 hospitals in the United States are doing therapeutic hypothermia, said Dr. Dixon, codirector of cardiovascular research at William Beaumont Hospital in Royal Oak, Mich.

Medical staffs have been slow to adopt hypothermia, despite an International Liaison Committee on Resuscitation (ILCOR) task force advisory statement (Circulation 2003;108:118-21) endorsing its use after cardiac arrest, he said.

“This statement should really serve as a call to action to physicians around the world that hypothermia is here, and we should be doing it to improve care to our patients,” he said. “And it's discouraging that even though this statement was issued 2 years ago, adoption of this therapy is so slow throughout the world.”

Although much effort goes to improving resuscitation of cardiac patients, little has been done to improve neurologic dysfunction. “It is important to remember that neurological aspects determine the longevity or most of the disability in these patients when they go home,” he said.

The ILCOR statement followed two trials that found patients had better outcomes if given therapeutic hypothermia after cardiac arrest. The percentages of hypothermia patients with favorable neurologic recovery were 49%—versus 26% for a control group—in an Australian study (N. Engl. J. Med. 2002;346:557-63) and 55%—versus 39% for controls—in a European study (N. Engl. J. Med. 2002;346:549-56).

Other studies, published (Am. J. Physiol. Heart Circ. Physiol. 2002;282:H1584-91) and ongoing, have also indicated that therapeutic hypothermia can reduce the size of an infarction, Dr. Dixon noted.

“These two trials suggest if the heart can be cooled adequately by the time angioplasty is done, probably there will be benefit from hypothermia,” he said, citing the Cooling for Myocardial Infarction (COOL MI) and Intravascular Cooling Adjunctive to Primary Coronary Intervention (ICE-IT) studies.

Dr. Dixon concluded that evidence clearly shows hypothermia to be safe and effective. Nonetheless, training requirements and fear of side effects have so far inhibited wider use, he said.

Session moderator Stefan A. Mayer, M.D., a consultant to and shareholder in several hypothermia device companies, also urged greater use of the therapy in cardiac cases. Dr. Mayer, director of critical care neurology at Columbia University, New York, warned that uncontrolled fever can be damaging and ongoing in ischemia and in stroke.

“In cardiac arrest you've got to make them hypothermic,” he said. “Why wait for a patient to get febrile and try to get it [temperature] down? That's like waiting for the toothpaste to get out of the tube and try to get it back.”

One Hospital's Experience With Therapeutic Hypothermia

Therapeutic hypothermia is not risk free, but its side effects are predictable and can be managed, according to a physician who has 8 years' experience cooling critically ill patients at the Free University Medical Center in Amsterdam.

“Our treatments can have severe side effects, but the good news is most side effects of hypothermia can be prevented or controlled. So fear of side effects should not prevent you from using this,” internist/intensivist Kees H. Polderman, M.D., said at a congress of the Society of Critical Care Medicine.

The optimal duration and depth of cooling and time to rewarming have yet to be determined, Dr. Polderman said. Nonetheless, he maintained that therapeutic hypothermia could be used safely for cardiac protection as well as neural protection.

“Start cooling as early and as quickly as possible, both to produce the effects we are looking for and to reduce the severity of some side effects,” he advised. “Do not rewarm too fast.”

Dr. Polderman encouraged physicians to educate themselves on the physiologic changes and side effects that can be expected before starting hypothermia. They need to know “which are harmful, which we can treat, and which we can ignore,” he said.

Among high-risk side effects, Dr. Polderman cited coagulopathy, impaired coagulation cascade, electrolyte disorders, and hypovolemia. He warned that insulin sensitivity and insulin secretion both decrease, so physicians need to monitor glucose and to be prepared to avert hyperglycemia. Amylase, platelets, and white blood cells also need to be monitored, he said.

The hospital laboratory must be told that the patient is being cooled because temperature can alter laboratory test results. In addition, pharmacokinetics of some medications can change, but for many drugs these effects are not yet known, he warned.

Dr. Polderman listed manifest bleeding, severe coagulation disorders, airway and wound infections, and myocardial ischemia as low-risk events. Manifest pancreatic and intracerebral bleeding are rare, he said. Patients undergoing long-term cooling need antibiotic prophylaxis and protection against bedsores, he advised.

PHOENIX, ARIZ.—Therapeutic hypothermia after cardiac arrest offers proven neurological benefits to patients and should be implemented in hospitals worldwide, Simon R. Dixon, M.B., said at a congress of the Society of Critical Care Medicine.

Only about 20 hospitals in the United States are doing therapeutic hypothermia, said Dr. Dixon, codirector of cardiovascular research at William Beaumont Hospital in Royal Oak, Mich.

Medical staffs have been slow to adopt hypothermia, despite an International Liaison Committee on Resuscitation (ILCOR) task force advisory statement (Circulation 2003;108:118-21) endorsing its use after cardiac arrest, he said.

“This statement should really serve as a call to action to physicians around the world that hypothermia is here, and we should be doing it to improve care to our patients,” he said. “And it's discouraging that even though this statement was issued 2 years ago, adoption of this therapy is so slow throughout the world.”

Although much effort goes to improving resuscitation of cardiac patients, little has been done to improve neurologic dysfunction. “It is important to remember that neurological aspects determine the longevity or most of the disability in these patients when they go home,” he said.

The ILCOR statement followed two trials that found patients had better outcomes if given therapeutic hypothermia after cardiac arrest. The percentages of hypothermia patients with favorable neurologic recovery were 49%—versus 26% for a control group—in an Australian study (N. Engl. J. Med. 2002;346:557-63) and 55%—versus 39% for controls—in a European study (N. Engl. J. Med. 2002;346:549-56).

Other studies, published (Am. J. Physiol. Heart Circ. Physiol. 2002;282:H1584-91) and ongoing, have also indicated that therapeutic hypothermia can reduce the size of an infarction, Dr. Dixon noted.

“These two trials suggest if the heart can be cooled adequately by the time angioplasty is done, probably there will be benefit from hypothermia,” he said, citing the Cooling for Myocardial Infarction (COOL MI) and Intravascular Cooling Adjunctive to Primary Coronary Intervention (ICE-IT) studies.

Dr. Dixon concluded that evidence clearly shows hypothermia to be safe and effective. Nonetheless, training requirements and fear of side effects have so far inhibited wider use, he said.

Session moderator Stefan A. Mayer, M.D., a consultant to and shareholder in several hypothermia device companies, also urged greater use of the therapy in cardiac cases. Dr. Mayer, director of critical care neurology at Columbia University, New York, warned that uncontrolled fever can be damaging and ongoing in ischemia and in stroke.

“In cardiac arrest you've got to make them hypothermic,” he said. “Why wait for a patient to get febrile and try to get it [temperature] down? That's like waiting for the toothpaste to get out of the tube and try to get it back.”

One Hospital's Experience With Therapeutic Hypothermia

Therapeutic hypothermia is not risk free, but its side effects are predictable and can be managed, according to a physician who has 8 years' experience cooling critically ill patients at the Free University Medical Center in Amsterdam.

“Our treatments can have severe side effects, but the good news is most side effects of hypothermia can be prevented or controlled. So fear of side effects should not prevent you from using this,” internist/intensivist Kees H. Polderman, M.D., said at a congress of the Society of Critical Care Medicine.

The optimal duration and depth of cooling and time to rewarming have yet to be determined, Dr. Polderman said. Nonetheless, he maintained that therapeutic hypothermia could be used safely for cardiac protection as well as neural protection.

“Start cooling as early and as quickly as possible, both to produce the effects we are looking for and to reduce the severity of some side effects,” he advised. “Do not rewarm too fast.”

Dr. Polderman encouraged physicians to educate themselves on the physiologic changes and side effects that can be expected before starting hypothermia. They need to know “which are harmful, which we can treat, and which we can ignore,” he said.

Among high-risk side effects, Dr. Polderman cited coagulopathy, impaired coagulation cascade, electrolyte disorders, and hypovolemia. He warned that insulin sensitivity and insulin secretion both decrease, so physicians need to monitor glucose and to be prepared to avert hyperglycemia. Amylase, platelets, and white blood cells also need to be monitored, he said.

The hospital laboratory must be told that the patient is being cooled because temperature can alter laboratory test results. In addition, pharmacokinetics of some medications can change, but for many drugs these effects are not yet known, he warned.

Dr. Polderman listed manifest bleeding, severe coagulation disorders, airway and wound infections, and myocardial ischemia as low-risk events. Manifest pancreatic and intracerebral bleeding are rare, he said. Patients undergoing long-term cooling need antibiotic prophylaxis and protection against bedsores, he advised.

PHOENIX — Measurement of N-acetylaspartate with magnetic resonance spectroscopy shows regional differences in brain metabolism after traumatic injury, according to a report at a congress of the Society of Critical Care Medicine.

Paul M. Vespa, M.D., director of neurocritical care at the University of California, Los Angeles, described the ongoing observational study being done by neurosurgeons in the university's brain injury research center.

He reported that N-acetylaspartate (NAA) levels were most reduced in the area of the brain with the most damage (P = .0001), but he noted that other areas also showed effects.

“Even normal-appearing brain regions have low NAA,” he said, showing a skull-like image he called a “phantom replacement model.”

Circles that looked like ping-pong balls represented different concentrations of NAA and filled the model, which was matched with microdialysis.

“You can determine a map of NAA and get actual NAA values throughout the brain,” he said.

NAA is a metabolic marker for mitochondrial dysfunction and corresponded to elevated lactate/pyruvate levels, another sign of distress, in 20 patients studied so far, according to Dr. Vespa. The lowest levels were seen in patients with the longest duration of high lactate/pyruvate levels, he said.

As described by Dr. Vespa, measuring NAA with magnetic resonance spectroscopy (MRS) holds promise as a noninvasive way of assessing damage to areas of the brain missed by microdialysis monitoring.

Microdialysis has the advantage of being continuous, he said, but it only allows a small section to be monitored. MRS can take a picture of the whole brain, he continued, but it can only be used once daily at most and usually only once per hospitalization.

“It [MRS] will be done as a snapshot,” he said. “It won't be a monitor, but it will be an image of the whole brain. And you will be able to know whether certain segments of the brain are at risk.”

The technology is currently available and in clinical use with brain tumors, according to Dr. Vespa. Before MRS measurements of NAA can be used in assessing traumatic brain injury, these findings need to be confirmed by studies comparing findings to the cerebral metabolic rate of oxygen, he said, adding that those studies are in progress.

PHOENIX — Measurement of N-acetylaspartate with magnetic resonance spectroscopy shows regional differences in brain metabolism after traumatic injury, according to a report at a congress of the Society of Critical Care Medicine.

Paul M. Vespa, M.D., director of neurocritical care at the University of California, Los Angeles, described the ongoing observational study being done by neurosurgeons in the university's brain injury research center.

He reported that N-acetylaspartate (NAA) levels were most reduced in the area of the brain with the most damage (P = .0001), but he noted that other areas also showed effects.

“Even normal-appearing brain regions have low NAA,” he said, showing a skull-like image he called a “phantom replacement model.”

Circles that looked like ping-pong balls represented different concentrations of NAA and filled the model, which was matched with microdialysis.

“You can determine a map of NAA and get actual NAA values throughout the brain,” he said.

NAA is a metabolic marker for mitochondrial dysfunction and corresponded to elevated lactate/pyruvate levels, another sign of distress, in 20 patients studied so far, according to Dr. Vespa. The lowest levels were seen in patients with the longest duration of high lactate/pyruvate levels, he said.

As described by Dr. Vespa, measuring NAA with magnetic resonance spectroscopy (MRS) holds promise as a noninvasive way of assessing damage to areas of the brain missed by microdialysis monitoring.

Microdialysis has the advantage of being continuous, he said, but it only allows a small section to be monitored. MRS can take a picture of the whole brain, he continued, but it can only be used once daily at most and usually only once per hospitalization.

“It [MRS] will be done as a snapshot,” he said. “It won't be a monitor, but it will be an image of the whole brain. And you will be able to know whether certain segments of the brain are at risk.”

The technology is currently available and in clinical use with brain tumors, according to Dr. Vespa. Before MRS measurements of NAA can be used in assessing traumatic brain injury, these findings need to be confirmed by studies comparing findings to the cerebral metabolic rate of oxygen, he said, adding that those studies are in progress.

PHOENIX — Measurement of N-acetylaspartate with magnetic resonance spectroscopy shows regional differences in brain metabolism after traumatic injury, according to a report at a congress of the Society of Critical Care Medicine.

Paul M. Vespa, M.D., director of neurocritical care at the University of California, Los Angeles, described the ongoing observational study being done by neurosurgeons in the university's brain injury research center.

He reported that N-acetylaspartate (NAA) levels were most reduced in the area of the brain with the most damage (P = .0001), but he noted that other areas also showed effects.

“Even normal-appearing brain regions have low NAA,” he said, showing a skull-like image he called a “phantom replacement model.”

Circles that looked like ping-pong balls represented different concentrations of NAA and filled the model, which was matched with microdialysis.

“You can determine a map of NAA and get actual NAA values throughout the brain,” he said.

NAA is a metabolic marker for mitochondrial dysfunction and corresponded to elevated lactate/pyruvate levels, another sign of distress, in 20 patients studied so far, according to Dr. Vespa. The lowest levels were seen in patients with the longest duration of high lactate/pyruvate levels, he said.

As described by Dr. Vespa, measuring NAA with magnetic resonance spectroscopy (MRS) holds promise as a noninvasive way of assessing damage to areas of the brain missed by microdialysis monitoring.

Microdialysis has the advantage of being continuous, he said, but it only allows a small section to be monitored. MRS can take a picture of the whole brain, he continued, but it can only be used once daily at most and usually only once per hospitalization.

“It [MRS] will be done as a snapshot,” he said. “It won't be a monitor, but it will be an image of the whole brain. And you will be able to know whether certain segments of the brain are at risk.”

The technology is currently available and in clinical use with brain tumors, according to Dr. Vespa. Before MRS measurements of NAA can be used in assessing traumatic brain injury, these findings need to be confirmed by studies comparing findings to the cerebral metabolic rate of oxygen, he said, adding that those studies are in progress.