Sharon Worcester

HOLLYWOOD, FLA. — A two-stage procedure may be more appropriate for superobese patients undergoing weight loss surgery, Philip Schauer, M.D., advised at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons.

“These patients [those with a body mass index over 60] can be enormously difficult to operate on,” he said, explaining that challenges such as a thick abdominal wall, enlarged liver, and extensive comorbidities can extend operating time and greatly increase the risk of perioperative complications.

A two-stage procedure using a less technically difficult and less risky operation for the first stage can lead to sufficient short-term weight loss that reduces risk for the higher-risk second-stage procedure such as gastric bypass, said Dr. Schauer, director of advanced laparoscopic and bariatric surgery at the Cleveland Clinic. For the first stage, he recommended vertical sleeve gastrectomy, which is an effective short-term weight loss procedure, or laparoscopic gastric banding. For the second stage, he recommended a Roux-en-Y gastric bypass procedure.

Weight loss after the initial procedure can reduce comorbidities and effectively downstage risk category.

Dr. Schauer reported on a series of 102 patients undergoing a two-stage weight loss procedure at the University of Pittsburgh. The patients' average age at the time of the first procedure was 50, and their BMI ranged up to 91. Each patient had an average of 10 comorbidities, and nearly half had a severe life-threatening disability. All had severe fatty liver disease.

Overall, 23 of the patients had completed the second stage as of February. Most underwent a sleeve gastrectomy followed by Roux-en-Y gastric bypass, Dr. Schauer reported.

After the first stage, average BMI dropped from 65 to the high 30s, and about 45% of excess weight was lost over 12 months. The weight loss had beneficial effects on patients and comorbidities, Dr. Schauer noted.

The rate of major complications in the first stage was 13%, which is “fairly minimal” for this very high-risk population, and the minor complication rate was 16%, he said.

All complications resolved without long-term disability. No deaths occurred.

More than half of the patients in the highest-risk category were downgraded by 1 or 2 categories, which represents a major difference in terms of operative risk at the time of the second procedure. The average number of comorbidities dropped from 10 to 6, and the vast majority of patients experienced major improvements in sleep apnea and diabetes.

Following the second-stage procedure, there were two major complications and three minor complications. None of these resulted in long-term morbidity.

The overall excess weight lost after the second stage was 60%.

The two-stage approach can transform a nonoperative candidate, who would otherwise be denied the most effective weight loss surgery, into a good candidate who has the potential to experience significant weight loss, Dr. Schauer said.

Other surgeons speaking on the topic of weight loss surgery for the superobese argued in favor of other procedures.

Emma Patterson, M.D., for example, said there are very few data on the use of sleeve gastrectomy in the two-stage procedure for the superobese, but several studies support laparoscopic gastric banding in this population.

Patients prefer gastric banding, she said, adding that it is more cost effective, and—according to some studies—it is associated with a lower mortality (0.02% vs. 1%) and complication rate (3% vs. 10%) than gastric bypass.

At least one other study suggested that bypass surgery is less effective than gastric banding in the superobese, said Dr. Patterson, director of bariatric surgery at Oregon Health and Science University, Portland.

And Ninh T. Nguyen, M.D., argued that not all superobese patients are technically difficult to operate on, and a two-stage procedure might subject patients to an unnecessary second surgery. A Roux-en-Y bypass can be performed from the outset in carefully selected lower-risk patients, he said, noting that at least one study shows that this operation is feasible in the superobese.

Furthermore, data suggest that if you can't safely perform a laparoscopic Roux-en-Y bypass operation, then you probably can't safely perform a laparoscopic sleeve gastrectomy either, said Dr. Nguyen, chief of the division of gastrointestinal surgery, University of California Irvine Medical Center. In these patients, he recommends a staged Roux-en-Y procedure.

HOLLYWOOD, FLA. — A two-stage procedure may be more appropriate for superobese patients undergoing weight loss surgery, Philip Schauer, M.D., advised at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons.

“These patients [those with a body mass index over 60] can be enormously difficult to operate on,” he said, explaining that challenges such as a thick abdominal wall, enlarged liver, and extensive comorbidities can extend operating time and greatly increase the risk of perioperative complications.

A two-stage procedure using a less technically difficult and less risky operation for the first stage can lead to sufficient short-term weight loss that reduces risk for the higher-risk second-stage procedure such as gastric bypass, said Dr. Schauer, director of advanced laparoscopic and bariatric surgery at the Cleveland Clinic. For the first stage, he recommended vertical sleeve gastrectomy, which is an effective short-term weight loss procedure, or laparoscopic gastric banding. For the second stage, he recommended a Roux-en-Y gastric bypass procedure.

Weight loss after the initial procedure can reduce comorbidities and effectively downstage risk category.

Dr. Schauer reported on a series of 102 patients undergoing a two-stage weight loss procedure at the University of Pittsburgh. The patients' average age at the time of the first procedure was 50, and their BMI ranged up to 91. Each patient had an average of 10 comorbidities, and nearly half had a severe life-threatening disability. All had severe fatty liver disease.

Overall, 23 of the patients had completed the second stage as of February. Most underwent a sleeve gastrectomy followed by Roux-en-Y gastric bypass, Dr. Schauer reported.

After the first stage, average BMI dropped from 65 to the high 30s, and about 45% of excess weight was lost over 12 months. The weight loss had beneficial effects on patients and comorbidities, Dr. Schauer noted.

The rate of major complications in the first stage was 13%, which is “fairly minimal” for this very high-risk population, and the minor complication rate was 16%, he said.

All complications resolved without long-term disability. No deaths occurred.

More than half of the patients in the highest-risk category were downgraded by 1 or 2 categories, which represents a major difference in terms of operative risk at the time of the second procedure. The average number of comorbidities dropped from 10 to 6, and the vast majority of patients experienced major improvements in sleep apnea and diabetes.

Following the second-stage procedure, there were two major complications and three minor complications. None of these resulted in long-term morbidity.

The overall excess weight lost after the second stage was 60%.

The two-stage approach can transform a nonoperative candidate, who would otherwise be denied the most effective weight loss surgery, into a good candidate who has the potential to experience significant weight loss, Dr. Schauer said.

Other surgeons speaking on the topic of weight loss surgery for the superobese argued in favor of other procedures.

Emma Patterson, M.D., for example, said there are very few data on the use of sleeve gastrectomy in the two-stage procedure for the superobese, but several studies support laparoscopic gastric banding in this population.

Patients prefer gastric banding, she said, adding that it is more cost effective, and—according to some studies—it is associated with a lower mortality (0.02% vs. 1%) and complication rate (3% vs. 10%) than gastric bypass.

At least one other study suggested that bypass surgery is less effective than gastric banding in the superobese, said Dr. Patterson, director of bariatric surgery at Oregon Health and Science University, Portland.

And Ninh T. Nguyen, M.D., argued that not all superobese patients are technically difficult to operate on, and a two-stage procedure might subject patients to an unnecessary second surgery. A Roux-en-Y bypass can be performed from the outset in carefully selected lower-risk patients, he said, noting that at least one study shows that this operation is feasible in the superobese.

Furthermore, data suggest that if you can't safely perform a laparoscopic Roux-en-Y bypass operation, then you probably can't safely perform a laparoscopic sleeve gastrectomy either, said Dr. Nguyen, chief of the division of gastrointestinal surgery, University of California Irvine Medical Center. In these patients, he recommends a staged Roux-en-Y procedure.

HOLLYWOOD, FLA. — A two-stage procedure may be more appropriate for superobese patients undergoing weight loss surgery, Philip Schauer, M.D., advised at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons.

“These patients [those with a body mass index over 60] can be enormously difficult to operate on,” he said, explaining that challenges such as a thick abdominal wall, enlarged liver, and extensive comorbidities can extend operating time and greatly increase the risk of perioperative complications.

A two-stage procedure using a less technically difficult and less risky operation for the first stage can lead to sufficient short-term weight loss that reduces risk for the higher-risk second-stage procedure such as gastric bypass, said Dr. Schauer, director of advanced laparoscopic and bariatric surgery at the Cleveland Clinic. For the first stage, he recommended vertical sleeve gastrectomy, which is an effective short-term weight loss procedure, or laparoscopic gastric banding. For the second stage, he recommended a Roux-en-Y gastric bypass procedure.

Weight loss after the initial procedure can reduce comorbidities and effectively downstage risk category.

Dr. Schauer reported on a series of 102 patients undergoing a two-stage weight loss procedure at the University of Pittsburgh. The patients' average age at the time of the first procedure was 50, and their BMI ranged up to 91. Each patient had an average of 10 comorbidities, and nearly half had a severe life-threatening disability. All had severe fatty liver disease.

Overall, 23 of the patients had completed the second stage as of February. Most underwent a sleeve gastrectomy followed by Roux-en-Y gastric bypass, Dr. Schauer reported.

After the first stage, average BMI dropped from 65 to the high 30s, and about 45% of excess weight was lost over 12 months. The weight loss had beneficial effects on patients and comorbidities, Dr. Schauer noted.

The rate of major complications in the first stage was 13%, which is “fairly minimal” for this very high-risk population, and the minor complication rate was 16%, he said.

All complications resolved without long-term disability. No deaths occurred.

More than half of the patients in the highest-risk category were downgraded by 1 or 2 categories, which represents a major difference in terms of operative risk at the time of the second procedure. The average number of comorbidities dropped from 10 to 6, and the vast majority of patients experienced major improvements in sleep apnea and diabetes.

Following the second-stage procedure, there were two major complications and three minor complications. None of these resulted in long-term morbidity.

The overall excess weight lost after the second stage was 60%.

The two-stage approach can transform a nonoperative candidate, who would otherwise be denied the most effective weight loss surgery, into a good candidate who has the potential to experience significant weight loss, Dr. Schauer said.

Other surgeons speaking on the topic of weight loss surgery for the superobese argued in favor of other procedures.

Emma Patterson, M.D., for example, said there are very few data on the use of sleeve gastrectomy in the two-stage procedure for the superobese, but several studies support laparoscopic gastric banding in this population.

Patients prefer gastric banding, she said, adding that it is more cost effective, and—according to some studies—it is associated with a lower mortality (0.02% vs. 1%) and complication rate (3% vs. 10%) than gastric bypass.

At least one other study suggested that bypass surgery is less effective than gastric banding in the superobese, said Dr. Patterson, director of bariatric surgery at Oregon Health and Science University, Portland.

And Ninh T. Nguyen, M.D., argued that not all superobese patients are technically difficult to operate on, and a two-stage procedure might subject patients to an unnecessary second surgery. A Roux-en-Y bypass can be performed from the outset in carefully selected lower-risk patients, he said, noting that at least one study shows that this operation is feasible in the superobese.

Furthermore, data suggest that if you can't safely perform a laparoscopic Roux-en-Y bypass operation, then you probably can't safely perform a laparoscopic sleeve gastrectomy either, said Dr. Nguyen, chief of the division of gastrointestinal surgery, University of California Irvine Medical Center. In these patients, he recommends a staged Roux-en-Y procedure.

NEW ORLEANS — Changes in contraceptive methods are frequent among adolescent girls, and tend to reflect pregnancy status and changes in sexual relationships and behaviors, Jennifer L. Woods, M.D., reported at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

A 27-month longitudinal study of 275 sexually active girls ages 14–17 years produced 1,513 pairs of sequential reports on contraceptive use. Of these, 19% consistently used no contraception, 38% consistently used condoms or hormonal contraception, and 43% changed contraceptive methods between quarterly reports during the study period, said Dr. Woods of Indiana University, Indianapolis.

Of those who changed contraception, 82% changed methods at least once during the study, and 44% changed at least three times. About 4% of the changes were from hormonal contraception to no contraception, about 5% of the changes were from no contraception to hormonal contraception, 5% were from condoms to no contraception, and 5% were from no contraception to condoms.

Participants in the study included adolescent patients at primary care clinics. They completed interviews at study entry and exit, and every 3 months during the study period, during which they reported the types of contraceptive method used in the previous 3 months. Method change was defined as any change in the reported contraceptive method at any two sequential quarterly visits.

Significant predictors of change included pregnancy and fewer sexual partners (which predicted both a change from hormonal to no contraception, and from condoms to no contraception), as well as not being pregnant and increased number of sexual partners (which predicted a change from no contraception to the use of condoms only). There were no significant predictors of a change from no contraception to hormonal contraception, Dr. Woods noted.

The findings are of concern, particularly given that consistent use of effective contraceptives by sexually active adolescents, which is among the federal government's Healthy People 2010 national health objectives most relevant to adolescents, has been shown to protect against sexually transmitted diseases and/or pregnancy, Dr. Woods said.

NEW ORLEANS — Changes in contraceptive methods are frequent among adolescent girls, and tend to reflect pregnancy status and changes in sexual relationships and behaviors, Jennifer L. Woods, M.D., reported at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

A 27-month longitudinal study of 275 sexually active girls ages 14–17 years produced 1,513 pairs of sequential reports on contraceptive use. Of these, 19% consistently used no contraception, 38% consistently used condoms or hormonal contraception, and 43% changed contraceptive methods between quarterly reports during the study period, said Dr. Woods of Indiana University, Indianapolis.

Of those who changed contraception, 82% changed methods at least once during the study, and 44% changed at least three times. About 4% of the changes were from hormonal contraception to no contraception, about 5% of the changes were from no contraception to hormonal contraception, 5% were from condoms to no contraception, and 5% were from no contraception to condoms.

Participants in the study included adolescent patients at primary care clinics. They completed interviews at study entry and exit, and every 3 months during the study period, during which they reported the types of contraceptive method used in the previous 3 months. Method change was defined as any change in the reported contraceptive method at any two sequential quarterly visits.

Significant predictors of change included pregnancy and fewer sexual partners (which predicted both a change from hormonal to no contraception, and from condoms to no contraception), as well as not being pregnant and increased number of sexual partners (which predicted a change from no contraception to the use of condoms only). There were no significant predictors of a change from no contraception to hormonal contraception, Dr. Woods noted.

The findings are of concern, particularly given that consistent use of effective contraceptives by sexually active adolescents, which is among the federal government's Healthy People 2010 national health objectives most relevant to adolescents, has been shown to protect against sexually transmitted diseases and/or pregnancy, Dr. Woods said.

NEW ORLEANS — Changes in contraceptive methods are frequent among adolescent girls, and tend to reflect pregnancy status and changes in sexual relationships and behaviors, Jennifer L. Woods, M.D., reported at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

A 27-month longitudinal study of 275 sexually active girls ages 14–17 years produced 1,513 pairs of sequential reports on contraceptive use. Of these, 19% consistently used no contraception, 38% consistently used condoms or hormonal contraception, and 43% changed contraceptive methods between quarterly reports during the study period, said Dr. Woods of Indiana University, Indianapolis.

Of those who changed contraception, 82% changed methods at least once during the study, and 44% changed at least three times. About 4% of the changes were from hormonal contraception to no contraception, about 5% of the changes were from no contraception to hormonal contraception, 5% were from condoms to no contraception, and 5% were from no contraception to condoms.

Participants in the study included adolescent patients at primary care clinics. They completed interviews at study entry and exit, and every 3 months during the study period, during which they reported the types of contraceptive method used in the previous 3 months. Method change was defined as any change in the reported contraceptive method at any two sequential quarterly visits.

Significant predictors of change included pregnancy and fewer sexual partners (which predicted both a change from hormonal to no contraception, and from condoms to no contraception), as well as not being pregnant and increased number of sexual partners (which predicted a change from no contraception to the use of condoms only). There were no significant predictors of a change from no contraception to hormonal contraception, Dr. Woods noted.

The findings are of concern, particularly given that consistent use of effective contraceptives by sexually active adolescents, which is among the federal government's Healthy People 2010 national health objectives most relevant to adolescents, has been shown to protect against sexually transmitted diseases and/or pregnancy, Dr. Woods said.

HOLLYWOOD, FLA. — The goal of chemotherapy for metastatic colorectal cancer is shifting, with greater emphasis now on reducing tumor size to allow for curative resection, Paulo Hoff, M.D., said at the annual meeting of the American College of Surgeons.

The ever-expanding arsenal of chemotherapeutic agents is increasing the likelihood that this goal will be met in a greater number of patients.

“The future is very bright—we have been able to improve dramatically the efficacy of chemotherapy for colorectal cancer,” said Dr. Hoff, deputy chairman of gastrointestinal medical oncology at M.D. Anderson Cancer Center, Houston.

Reducing tumor size would make more patients eligible for surgical resection, which is important, because it has long been known that patients with single or localized metastases who are able to undergo surgery have a 25%–35% chance of cure. However, only 10%–30% of patients are operable at the time of presentation, Dr. Hoff explained.

Data show that chemotherapy can indeed change a patient's status from nonresectable to resectable. In one retrospective study, an oxaliplatin-based regimen used in more than 700 previously nonresectable patients with liver metastases reduced tumor size enough to allow resection in 14% of the patients. Overall 5-year survival rates among 87 patients for whom 5 years of follow-up data were available were similar to those in patients who were resectable at presentation.

In several other studies, oxaliplatin as part of a combination regimen known as FOLFOX, which also includes fluorouracil and leucovorin, was consistently associated with a doubling of the rate of patients whose tumors shrunk by at least 50%, compared with any single drug. Survival also was improved.

Similar outcomes have been shown with irinotecan used in combination with 5FU-LV (a combination known as FOLFIRI).

Even more impressive results were seen when the monoclonal antibody bevacizumab was added to any of these regimens, Dr. Hoff said.

When bevacizumab was added to an irinotecan-based regimen, response rates climbed about 10% to a response rate of 45%, and median survival increased by about 5 months to a median survival of more than 20 months.

Another monoclonal antibody, cetuximab, also showed promise in preliminary trials. In a phase II study that combined the drug with the FOLFOX regimen, the response rate was 81%.

Another benefit of these emerging chemotherapeutic regimens for colorectal cancers is improved treatment of micrometastatic disease. Micrometastases that may remain following resection can lead to recurrence.

Several studies have shown that there is no significant improvement in survival or cure rates following incomplete resection, but tumor reduction may improve the chances of complete resection, Dr. Hoff said.

When tumor reduction isn't possible, the traditional goals of chemotherapy, including promoting survival, delaying tumor progression, and preventing tumor-related complications, still apply.

But with the recent advances—especially if they are combined with advances in surgery and radiation therapy techniques, as well as with systemic chemotherapy agents that target metastases beyond the liver—a major impact will be made on the treatment of colorectal cancer, Dr. Hoff said.

HOLLYWOOD, FLA. — The goal of chemotherapy for metastatic colorectal cancer is shifting, with greater emphasis now on reducing tumor size to allow for curative resection, Paulo Hoff, M.D., said at the annual meeting of the American College of Surgeons.

The ever-expanding arsenal of chemotherapeutic agents is increasing the likelihood that this goal will be met in a greater number of patients.

“The future is very bright—we have been able to improve dramatically the efficacy of chemotherapy for colorectal cancer,” said Dr. Hoff, deputy chairman of gastrointestinal medical oncology at M.D. Anderson Cancer Center, Houston.

Reducing tumor size would make more patients eligible for surgical resection, which is important, because it has long been known that patients with single or localized metastases who are able to undergo surgery have a 25%–35% chance of cure. However, only 10%–30% of patients are operable at the time of presentation, Dr. Hoff explained.

Data show that chemotherapy can indeed change a patient's status from nonresectable to resectable. In one retrospective study, an oxaliplatin-based regimen used in more than 700 previously nonresectable patients with liver metastases reduced tumor size enough to allow resection in 14% of the patients. Overall 5-year survival rates among 87 patients for whom 5 years of follow-up data were available were similar to those in patients who were resectable at presentation.

In several other studies, oxaliplatin as part of a combination regimen known as FOLFOX, which also includes fluorouracil and leucovorin, was consistently associated with a doubling of the rate of patients whose tumors shrunk by at least 50%, compared with any single drug. Survival also was improved.

Similar outcomes have been shown with irinotecan used in combination with 5FU-LV (a combination known as FOLFIRI).

Even more impressive results were seen when the monoclonal antibody bevacizumab was added to any of these regimens, Dr. Hoff said.

When bevacizumab was added to an irinotecan-based regimen, response rates climbed about 10% to a response rate of 45%, and median survival increased by about 5 months to a median survival of more than 20 months.

Another monoclonal antibody, cetuximab, also showed promise in preliminary trials. In a phase II study that combined the drug with the FOLFOX regimen, the response rate was 81%.

Another benefit of these emerging chemotherapeutic regimens for colorectal cancers is improved treatment of micrometastatic disease. Micrometastases that may remain following resection can lead to recurrence.

Several studies have shown that there is no significant improvement in survival or cure rates following incomplete resection, but tumor reduction may improve the chances of complete resection, Dr. Hoff said.

When tumor reduction isn't possible, the traditional goals of chemotherapy, including promoting survival, delaying tumor progression, and preventing tumor-related complications, still apply.

But with the recent advances—especially if they are combined with advances in surgery and radiation therapy techniques, as well as with systemic chemotherapy agents that target metastases beyond the liver—a major impact will be made on the treatment of colorectal cancer, Dr. Hoff said.

HOLLYWOOD, FLA. — The goal of chemotherapy for metastatic colorectal cancer is shifting, with greater emphasis now on reducing tumor size to allow for curative resection, Paulo Hoff, M.D., said at the annual meeting of the American College of Surgeons.

The ever-expanding arsenal of chemotherapeutic agents is increasing the likelihood that this goal will be met in a greater number of patients.

“The future is very bright—we have been able to improve dramatically the efficacy of chemotherapy for colorectal cancer,” said Dr. Hoff, deputy chairman of gastrointestinal medical oncology at M.D. Anderson Cancer Center, Houston.

Reducing tumor size would make more patients eligible for surgical resection, which is important, because it has long been known that patients with single or localized metastases who are able to undergo surgery have a 25%–35% chance of cure. However, only 10%–30% of patients are operable at the time of presentation, Dr. Hoff explained.

Data show that chemotherapy can indeed change a patient's status from nonresectable to resectable. In one retrospective study, an oxaliplatin-based regimen used in more than 700 previously nonresectable patients with liver metastases reduced tumor size enough to allow resection in 14% of the patients. Overall 5-year survival rates among 87 patients for whom 5 years of follow-up data were available were similar to those in patients who were resectable at presentation.

In several other studies, oxaliplatin as part of a combination regimen known as FOLFOX, which also includes fluorouracil and leucovorin, was consistently associated with a doubling of the rate of patients whose tumors shrunk by at least 50%, compared with any single drug. Survival also was improved.

Similar outcomes have been shown with irinotecan used in combination with 5FU-LV (a combination known as FOLFIRI).

Even more impressive results were seen when the monoclonal antibody bevacizumab was added to any of these regimens, Dr. Hoff said.

When bevacizumab was added to an irinotecan-based regimen, response rates climbed about 10% to a response rate of 45%, and median survival increased by about 5 months to a median survival of more than 20 months.

Another monoclonal antibody, cetuximab, also showed promise in preliminary trials. In a phase II study that combined the drug with the FOLFOX regimen, the response rate was 81%.

Another benefit of these emerging chemotherapeutic regimens for colorectal cancers is improved treatment of micrometastatic disease. Micrometastases that may remain following resection can lead to recurrence.

Several studies have shown that there is no significant improvement in survival or cure rates following incomplete resection, but tumor reduction may improve the chances of complete resection, Dr. Hoff said.

When tumor reduction isn't possible, the traditional goals of chemotherapy, including promoting survival, delaying tumor progression, and preventing tumor-related complications, still apply.

But with the recent advances—especially if they are combined with advances in surgery and radiation therapy techniques, as well as with systemic chemotherapy agents that target metastases beyond the liver—a major impact will be made on the treatment of colorectal cancer, Dr. Hoff said.

NEW ORLEANS — Apligraf has been used successfully to line a new vagina in a patient with Mayer-Rokitansky-Küster-Hauser syndrome.

The human skin equivalent derived from human infant foreskin has been used widely for wound repair, but this is the first reported successful use for this purpose, Albert Altchek, M.D., reported at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

The 19-year-old patient with congenital absence of the uterus and vagina refused the split-thickness skin graft typically used for treating the condition and instead underwent the Apligraf procedure. Perineal biopsy and dissection were used to create a vaginal space, and 20 Apligraf patches—sewn together and wrapped around a soft, inflatable vaginal stent—were applied to the space, said Dr. Altchek of Mount Sinai School of Medicine, New York.

After the patient remained on bed rest for 1 week, the stent was removed and a second Apligraf application was placed. A week later, the Apligraf lining was found to be degenerating as a result of graft rejection; however, a small patch of vaginal mucosal cells that had been present proliferated to cover the entire neovagina. Soft vaginal stents were used to prevent strictures.

The result was a soft, pliable, moist, normal-looking vaginal mucosal wall, which has maintained patency for 61/2 years without a stent, Dr. Altchek said.

Apligraf was previously thought to stimulate only skin growth, but based on this case, it appears that it “actually preferentially stimulates another tissue—mucosa,” he said.

In the case of the 19-year-old patient, she had an excellent result. At 6-month follow-up she had normal cytology, and at 4 years she reported frequent sexual activity with orgasm. At last contact she was being referred for a surrogate gestational carrier.

This new method for correcting the defects associated with Mayer-Rokitansky-Küster-Hauser syndrome is investigational but shows great promise, he said, noting that it has several advantages over the split-thickness skin graft approach. Aside from scarring at the donor site, the split-thickness graft approach—unlike the Apligraf approach—results in atypical appearance and function; it also tends to cause malodor because the vagina is created using skin.

NEW ORLEANS — Apligraf has been used successfully to line a new vagina in a patient with Mayer-Rokitansky-Küster-Hauser syndrome.

The human skin equivalent derived from human infant foreskin has been used widely for wound repair, but this is the first reported successful use for this purpose, Albert Altchek, M.D., reported at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

The 19-year-old patient with congenital absence of the uterus and vagina refused the split-thickness skin graft typically used for treating the condition and instead underwent the Apligraf procedure. Perineal biopsy and dissection were used to create a vaginal space, and 20 Apligraf patches—sewn together and wrapped around a soft, inflatable vaginal stent—were applied to the space, said Dr. Altchek of Mount Sinai School of Medicine, New York.

After the patient remained on bed rest for 1 week, the stent was removed and a second Apligraf application was placed. A week later, the Apligraf lining was found to be degenerating as a result of graft rejection; however, a small patch of vaginal mucosal cells that had been present proliferated to cover the entire neovagina. Soft vaginal stents were used to prevent strictures.

The result was a soft, pliable, moist, normal-looking vaginal mucosal wall, which has maintained patency for 61/2 years without a stent, Dr. Altchek said.

Apligraf was previously thought to stimulate only skin growth, but based on this case, it appears that it “actually preferentially stimulates another tissue—mucosa,” he said.

In the case of the 19-year-old patient, she had an excellent result. At 6-month follow-up she had normal cytology, and at 4 years she reported frequent sexual activity with orgasm. At last contact she was being referred for a surrogate gestational carrier.

This new method for correcting the defects associated with Mayer-Rokitansky-Küster-Hauser syndrome is investigational but shows great promise, he said, noting that it has several advantages over the split-thickness skin graft approach. Aside from scarring at the donor site, the split-thickness graft approach—unlike the Apligraf approach—results in atypical appearance and function; it also tends to cause malodor because the vagina is created using skin.

NEW ORLEANS — Apligraf has been used successfully to line a new vagina in a patient with Mayer-Rokitansky-Küster-Hauser syndrome.

The human skin equivalent derived from human infant foreskin has been used widely for wound repair, but this is the first reported successful use for this purpose, Albert Altchek, M.D., reported at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

The 19-year-old patient with congenital absence of the uterus and vagina refused the split-thickness skin graft typically used for treating the condition and instead underwent the Apligraf procedure. Perineal biopsy and dissection were used to create a vaginal space, and 20 Apligraf patches—sewn together and wrapped around a soft, inflatable vaginal stent—were applied to the space, said Dr. Altchek of Mount Sinai School of Medicine, New York.

After the patient remained on bed rest for 1 week, the stent was removed and a second Apligraf application was placed. A week later, the Apligraf lining was found to be degenerating as a result of graft rejection; however, a small patch of vaginal mucosal cells that had been present proliferated to cover the entire neovagina. Soft vaginal stents were used to prevent strictures.

The result was a soft, pliable, moist, normal-looking vaginal mucosal wall, which has maintained patency for 61/2 years without a stent, Dr. Altchek said.

Apligraf was previously thought to stimulate only skin growth, but based on this case, it appears that it “actually preferentially stimulates another tissue—mucosa,” he said.

In the case of the 19-year-old patient, she had an excellent result. At 6-month follow-up she had normal cytology, and at 4 years she reported frequent sexual activity with orgasm. At last contact she was being referred for a surrogate gestational carrier.

This new method for correcting the defects associated with Mayer-Rokitansky-Küster-Hauser syndrome is investigational but shows great promise, he said, noting that it has several advantages over the split-thickness skin graft approach. Aside from scarring at the donor site, the split-thickness graft approach—unlike the Apligraf approach—results in atypical appearance and function; it also tends to cause malodor because the vagina is created using skin.

NEW ORLEANS — Decidual cast expulsion may occur in young patients using depot medroxyprogesterone acetate Stephen M. Scott, M.D., said during the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Although decidual casts are typically associated with ectopic pregnancy and can be confused with spontaneous abortion, Dr. Scott described four cases that suggest decidual casts might be a rare but important side effect associated with use of the hormonal contraceptive—particularly among those exposed after a prolonged period of anovulatory endometrial proliferation.

The first case involved a postanorexic 16-year-old girl who was on depot medroxyprogesterone acetate (DMPA) for contraception and presented 1 month after her first injection. She had a large amount of white tissue protruding from the cervical os.

The patient had experienced weight recovery and signs of estrogen stimulation at the time of the injection, but also had persistent amenorrhea at the time of injection.

The second case involved a 20-year-old with cerebral palsy and mental retardation, who was using DMPA for the treatment of dysfunctional uterine bleeding. She presented with tissue passing from the vagina 3 weeks after her first injection.

The third case involved an 11-year-old with factor VIII deficiency, who was treated with DMPA to control hemorrhaging that occurred at her first menarche 8 months earlier. She presented with severe cramps and the sensation of a mass in the vagina.

An examination revealed white tissue protruding from the cervical os.

The fourth case involved a 19-year-old who had a vaginal delivery 5 months earlier and who at 3 months post partum was breast-feeding and amenorrheic. She began using DMPA for contraception at that time, and 2 months later, she presented with bleeding and cramping.

As with the first three cases, examination revealed a large amount of tissue at the cervical os.

The findings in each case were consistent with decidual cast expulsion, and all patients had a negative result on a pregnancy test. The removal of the protruding tissue resulted in symptom resolution, said Dr. Scott of the University of Colorado, Denver.

“We probably all feel comfortable with the fact that decidual cast formation is just an intense reaction and variant of menstruation, but because it is rare and unpredictable, we don't really have a great idea of what elements are needed in order to form a decidual cast and pass it,” Dr. Scott said.

In theory, however, decidual cast formation can be expected when prolonged endometrial proliferation precedes progesterone exposure, leading to a thicker endometrial layer. When the progesterone levels falter, the likelihood of decidual cast formation may be increased, he said.

Although these cases involved varying clinical scenarios, it can be argued that similar hormonal events may have led to the decidual cast formation and passage, he added.

The first three patients had an extended period of amenorrhea with estrogen-only stimulation of the endometrial lining, and thus endometrial proliferation. The fourth patient also may have had prolonged estrogen production with resumption of ovarian estrogen production late in breast-feeding.

DMPA treatment in these patients would then have resulted in a high level of progesterone exposure followed by a gradual decline in progesterone levels that might have led to the decidual casts, he explained.

In most of these cases, the decidual casts were, understandably, very frightening for the patient and/or parent, he said.

For this reason, as well as to fully inform patients about the potential effects of DMPA and to promote treatment compliance, patient counseling should include discussion of decidual cast expulsion as a rare side effect associated with the drug.

Furthermore, because 1% of DMPA failures are ectopic pregnancies (although DMPA is not a known cause of ectopic pregnancies), and because decidual casts and ectopic pregnancies can be easily confused, patients using DMPA who experience tissue passage should be advised to bring the specimen in for evaluation, and should undergo a pregnancy test to avoid delays in diagnosis of ectopic pregnancies, he said.

NEW ORLEANS — Decidual cast expulsion may occur in young patients using depot medroxyprogesterone acetate Stephen M. Scott, M.D., said during the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Although decidual casts are typically associated with ectopic pregnancy and can be confused with spontaneous abortion, Dr. Scott described four cases that suggest decidual casts might be a rare but important side effect associated with use of the hormonal contraceptive—particularly among those exposed after a prolonged period of anovulatory endometrial proliferation.

The first case involved a postanorexic 16-year-old girl who was on depot medroxyprogesterone acetate (DMPA) for contraception and presented 1 month after her first injection. She had a large amount of white tissue protruding from the cervical os.

The patient had experienced weight recovery and signs of estrogen stimulation at the time of the injection, but also had persistent amenorrhea at the time of injection.

The second case involved a 20-year-old with cerebral palsy and mental retardation, who was using DMPA for the treatment of dysfunctional uterine bleeding. She presented with tissue passing from the vagina 3 weeks after her first injection.

The third case involved an 11-year-old with factor VIII deficiency, who was treated with DMPA to control hemorrhaging that occurred at her first menarche 8 months earlier. She presented with severe cramps and the sensation of a mass in the vagina.

An examination revealed white tissue protruding from the cervical os.

The fourth case involved a 19-year-old who had a vaginal delivery 5 months earlier and who at 3 months post partum was breast-feeding and amenorrheic. She began using DMPA for contraception at that time, and 2 months later, she presented with bleeding and cramping.

As with the first three cases, examination revealed a large amount of tissue at the cervical os.

The findings in each case were consistent with decidual cast expulsion, and all patients had a negative result on a pregnancy test. The removal of the protruding tissue resulted in symptom resolution, said Dr. Scott of the University of Colorado, Denver.

“We probably all feel comfortable with the fact that decidual cast formation is just an intense reaction and variant of menstruation, but because it is rare and unpredictable, we don't really have a great idea of what elements are needed in order to form a decidual cast and pass it,” Dr. Scott said.

In theory, however, decidual cast formation can be expected when prolonged endometrial proliferation precedes progesterone exposure, leading to a thicker endometrial layer. When the progesterone levels falter, the likelihood of decidual cast formation may be increased, he said.

Although these cases involved varying clinical scenarios, it can be argued that similar hormonal events may have led to the decidual cast formation and passage, he added.

The first three patients had an extended period of amenorrhea with estrogen-only stimulation of the endometrial lining, and thus endometrial proliferation. The fourth patient also may have had prolonged estrogen production with resumption of ovarian estrogen production late in breast-feeding.

DMPA treatment in these patients would then have resulted in a high level of progesterone exposure followed by a gradual decline in progesterone levels that might have led to the decidual casts, he explained.

In most of these cases, the decidual casts were, understandably, very frightening for the patient and/or parent, he said.

For this reason, as well as to fully inform patients about the potential effects of DMPA and to promote treatment compliance, patient counseling should include discussion of decidual cast expulsion as a rare side effect associated with the drug.

Furthermore, because 1% of DMPA failures are ectopic pregnancies (although DMPA is not a known cause of ectopic pregnancies), and because decidual casts and ectopic pregnancies can be easily confused, patients using DMPA who experience tissue passage should be advised to bring the specimen in for evaluation, and should undergo a pregnancy test to avoid delays in diagnosis of ectopic pregnancies, he said.

NEW ORLEANS — Decidual cast expulsion may occur in young patients using depot medroxyprogesterone acetate Stephen M. Scott, M.D., said during the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Although decidual casts are typically associated with ectopic pregnancy and can be confused with spontaneous abortion, Dr. Scott described four cases that suggest decidual casts might be a rare but important side effect associated with use of the hormonal contraceptive—particularly among those exposed after a prolonged period of anovulatory endometrial proliferation.

The first case involved a postanorexic 16-year-old girl who was on depot medroxyprogesterone acetate (DMPA) for contraception and presented 1 month after her first injection. She had a large amount of white tissue protruding from the cervical os.

The patient had experienced weight recovery and signs of estrogen stimulation at the time of the injection, but also had persistent amenorrhea at the time of injection.

The second case involved a 20-year-old with cerebral palsy and mental retardation, who was using DMPA for the treatment of dysfunctional uterine bleeding. She presented with tissue passing from the vagina 3 weeks after her first injection.

The third case involved an 11-year-old with factor VIII deficiency, who was treated with DMPA to control hemorrhaging that occurred at her first menarche 8 months earlier. She presented with severe cramps and the sensation of a mass in the vagina.

An examination revealed white tissue protruding from the cervical os.

The fourth case involved a 19-year-old who had a vaginal delivery 5 months earlier and who at 3 months post partum was breast-feeding and amenorrheic. She began using DMPA for contraception at that time, and 2 months later, she presented with bleeding and cramping.

As with the first three cases, examination revealed a large amount of tissue at the cervical os.

The findings in each case were consistent with decidual cast expulsion, and all patients had a negative result on a pregnancy test. The removal of the protruding tissue resulted in symptom resolution, said Dr. Scott of the University of Colorado, Denver.

“We probably all feel comfortable with the fact that decidual cast formation is just an intense reaction and variant of menstruation, but because it is rare and unpredictable, we don't really have a great idea of what elements are needed in order to form a decidual cast and pass it,” Dr. Scott said.

In theory, however, decidual cast formation can be expected when prolonged endometrial proliferation precedes progesterone exposure, leading to a thicker endometrial layer. When the progesterone levels falter, the likelihood of decidual cast formation may be increased, he said.

Although these cases involved varying clinical scenarios, it can be argued that similar hormonal events may have led to the decidual cast formation and passage, he added.

The first three patients had an extended period of amenorrhea with estrogen-only stimulation of the endometrial lining, and thus endometrial proliferation. The fourth patient also may have had prolonged estrogen production with resumption of ovarian estrogen production late in breast-feeding.

DMPA treatment in these patients would then have resulted in a high level of progesterone exposure followed by a gradual decline in progesterone levels that might have led to the decidual casts, he explained.

In most of these cases, the decidual casts were, understandably, very frightening for the patient and/or parent, he said.

For this reason, as well as to fully inform patients about the potential effects of DMPA and to promote treatment compliance, patient counseling should include discussion of decidual cast expulsion as a rare side effect associated with the drug.

Furthermore, because 1% of DMPA failures are ectopic pregnancies (although DMPA is not a known cause of ectopic pregnancies), and because decidual casts and ectopic pregnancies can be easily confused, patients using DMPA who experience tissue passage should be advised to bring the specimen in for evaluation, and should undergo a pregnancy test to avoid delays in diagnosis of ectopic pregnancies, he said.

Clinicians should perform routine screening of all sexually active women at increased risk for gonorrhea, because of the high risk for pelvic inflammatory disease, ectopic pregnancy, and chronic pelvic pain associated with asymptomatic gonorrhea infection, according to the U.S. Preventive Services Task Force.

Those at risk include sexually active women under age 25 years, those with previous gonorrhea or other sexually transmitted infections, those with new or multiple sex partners, those who don't consistently use condoms, sex workers, and drug users. Pregnant women with these risk factors should be screened at the first prenatal visit, and those with ongoing or new risk factors should also be screened during the third trimester because gonorrhea increases the risk of preterm rupture of membranes, chorioamnionitis, and preterm labor (Ann. Fam. Med. 2005;3:263–7).

The task force recommended against routine screening in women and men at low risk for gonorrhea, and it found insufficient evidence to recommend for or against routine screening in men at high risk.

Clinicians should perform routine screening of all sexually active women at increased risk for gonorrhea, because of the high risk for pelvic inflammatory disease, ectopic pregnancy, and chronic pelvic pain associated with asymptomatic gonorrhea infection, according to the U.S. Preventive Services Task Force.

Those at risk include sexually active women under age 25 years, those with previous gonorrhea or other sexually transmitted infections, those with new or multiple sex partners, those who don't consistently use condoms, sex workers, and drug users. Pregnant women with these risk factors should be screened at the first prenatal visit, and those with ongoing or new risk factors should also be screened during the third trimester because gonorrhea increases the risk of preterm rupture of membranes, chorioamnionitis, and preterm labor (Ann. Fam. Med. 2005;3:263–7).

The task force recommended against routine screening in women and men at low risk for gonorrhea, and it found insufficient evidence to recommend for or against routine screening in men at high risk.

Clinicians should perform routine screening of all sexually active women at increased risk for gonorrhea, because of the high risk for pelvic inflammatory disease, ectopic pregnancy, and chronic pelvic pain associated with asymptomatic gonorrhea infection, according to the U.S. Preventive Services Task Force.

Those at risk include sexually active women under age 25 years, those with previous gonorrhea or other sexually transmitted infections, those with new or multiple sex partners, those who don't consistently use condoms, sex workers, and drug users. Pregnant women with these risk factors should be screened at the first prenatal visit, and those with ongoing or new risk factors should also be screened during the third trimester because gonorrhea increases the risk of preterm rupture of membranes, chorioamnionitis, and preterm labor (Ann. Fam. Med. 2005;3:263–7).

The task force recommended against routine screening in women and men at low risk for gonorrhea, and it found insufficient evidence to recommend for or against routine screening in men at high risk.

NEW ORLEANS — Most young patients with obstructed hemivagina and ipsilateral renal anomalies can be managed conservatively with single stage vaginoplasty, Nicole A. Smith, M.D., reported in a poster at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

This is true even in the setting of infection, wrote Dr. Smith, who also noted that routine laparoscopy is not essential in the management of this condition, which is fairly common but often misdiagnosed.

Misdiagnosis can lead to inappropriate treatment or can delay appropriate treatment (forcing some girls to live unnecessarily with debilitating pain from a condition that could be easily treated), according to Dr. Smith of Children's Hospital Boston.

A series of 27 cases at that hospital over a 12-year period underscores the need for a high level of clinical suspicion for the syndrome in the presence of a suggestive ultrasound.

In the 27 cases, initial ultrasound was 50% sensitive in suggesting a diagnosis; MRI after referral led to correct diagnosis in 85% of patients.

A total of 26 patients underwent vaginal resection, but only 7 underwent laparoscopy. Only seven required a staged vaginoplasty; the reasons for staged vaginoplasty included incomplete previous resection, infection, anatomic distortion, and restenosis, Dr. Smith noted.

NEW ORLEANS — Most young patients with obstructed hemivagina and ipsilateral renal anomalies can be managed conservatively with single stage vaginoplasty, Nicole A. Smith, M.D., reported in a poster at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

This is true even in the setting of infection, wrote Dr. Smith, who also noted that routine laparoscopy is not essential in the management of this condition, which is fairly common but often misdiagnosed.

Misdiagnosis can lead to inappropriate treatment or can delay appropriate treatment (forcing some girls to live unnecessarily with debilitating pain from a condition that could be easily treated), according to Dr. Smith of Children's Hospital Boston.

A series of 27 cases at that hospital over a 12-year period underscores the need for a high level of clinical suspicion for the syndrome in the presence of a suggestive ultrasound.

In the 27 cases, initial ultrasound was 50% sensitive in suggesting a diagnosis; MRI after referral led to correct diagnosis in 85% of patients.

A total of 26 patients underwent vaginal resection, but only 7 underwent laparoscopy. Only seven required a staged vaginoplasty; the reasons for staged vaginoplasty included incomplete previous resection, infection, anatomic distortion, and restenosis, Dr. Smith noted.

NEW ORLEANS — Most young patients with obstructed hemivagina and ipsilateral renal anomalies can be managed conservatively with single stage vaginoplasty, Nicole A. Smith, M.D., reported in a poster at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

This is true even in the setting of infection, wrote Dr. Smith, who also noted that routine laparoscopy is not essential in the management of this condition, which is fairly common but often misdiagnosed.

Misdiagnosis can lead to inappropriate treatment or can delay appropriate treatment (forcing some girls to live unnecessarily with debilitating pain from a condition that could be easily treated), according to Dr. Smith of Children's Hospital Boston.

A series of 27 cases at that hospital over a 12-year period underscores the need for a high level of clinical suspicion for the syndrome in the presence of a suggestive ultrasound.

In the 27 cases, initial ultrasound was 50% sensitive in suggesting a diagnosis; MRI after referral led to correct diagnosis in 85% of patients.

A total of 26 patients underwent vaginal resection, but only 7 underwent laparoscopy. Only seven required a staged vaginoplasty; the reasons for staged vaginoplasty included incomplete previous resection, infection, anatomic distortion, and restenosis, Dr. Smith noted.

NEW ORLEANS — A recent series of “curious” cases of large vulvar or labial abscesses in previously healthy children were associated with methicillin-resistant Staphylococcus aureus and represent the first reported cases of such abscesses in the pediatric and adolescent population, S. Paige Hertweck, M.D., reported at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Six patients, aged 2, 16, and 17 months and 3, 12, and 16 years, presented during 2004 with vulvar or labial abscesses requiring debridement and drainage. All had confirmed S. aureus infection, and five of the patients had MRSA.

The MRSA cases presented initially with a red papule that progressed rapidly, and by day 2 a fulminant abscess extended significantly beyond the labia. The abscesses had an area greater than 5 cm.

After debridement and 48–72 hours of continuous drainage, all patients were treated with antibiotics. The use of small incisions at each end of the abscess cavities allowed digital manipulation, and the use of a small Penrose drain threaded through each incision and tied to itself allowed continuous drainage that negated the need for extensive packing, which can be difficult in children.

None of the children had typical risk factors for MRSA, although three did have household contacts with lesions that might have been associated with MRSA. All the infections were sensitive to clindamycin, Bactrim (trimethoprim-sulfamethoxazole), and vancomycin, Dr. Hertweck noted.

MRSA should be considered in all patients presenting with rapidly progressing vulvar or labial erythema. Aggressive treatment with incision and drainage in such cases is warranted, she said, noting that a limited incision site and the use of a Penrose drain are recommended in children.

Appropriate antibiotic therapy should also be initiated.

“While our sensitivities may not translate to your community, it might be appropriate to start with something like clindamycin,” she said.

NEW ORLEANS — A recent series of “curious” cases of large vulvar or labial abscesses in previously healthy children were associated with methicillin-resistant Staphylococcus aureus and represent the first reported cases of such abscesses in the pediatric and adolescent population, S. Paige Hertweck, M.D., reported at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Six patients, aged 2, 16, and 17 months and 3, 12, and 16 years, presented during 2004 with vulvar or labial abscesses requiring debridement and drainage. All had confirmed S. aureus infection, and five of the patients had MRSA.

The MRSA cases presented initially with a red papule that progressed rapidly, and by day 2 a fulminant abscess extended significantly beyond the labia. The abscesses had an area greater than 5 cm.

After debridement and 48–72 hours of continuous drainage, all patients were treated with antibiotics. The use of small incisions at each end of the abscess cavities allowed digital manipulation, and the use of a small Penrose drain threaded through each incision and tied to itself allowed continuous drainage that negated the need for extensive packing, which can be difficult in children.

None of the children had typical risk factors for MRSA, although three did have household contacts with lesions that might have been associated with MRSA. All the infections were sensitive to clindamycin, Bactrim (trimethoprim-sulfamethoxazole), and vancomycin, Dr. Hertweck noted.

MRSA should be considered in all patients presenting with rapidly progressing vulvar or labial erythema. Aggressive treatment with incision and drainage in such cases is warranted, she said, noting that a limited incision site and the use of a Penrose drain are recommended in children.

Appropriate antibiotic therapy should also be initiated.

“While our sensitivities may not translate to your community, it might be appropriate to start with something like clindamycin,” she said.

NEW ORLEANS — A recent series of “curious” cases of large vulvar or labial abscesses in previously healthy children were associated with methicillin-resistant Staphylococcus aureus and represent the first reported cases of such abscesses in the pediatric and adolescent population, S. Paige Hertweck, M.D., reported at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Six patients, aged 2, 16, and 17 months and 3, 12, and 16 years, presented during 2004 with vulvar or labial abscesses requiring debridement and drainage. All had confirmed S. aureus infection, and five of the patients had MRSA.

The MRSA cases presented initially with a red papule that progressed rapidly, and by day 2 a fulminant abscess extended significantly beyond the labia. The abscesses had an area greater than 5 cm.

After debridement and 48–72 hours of continuous drainage, all patients were treated with antibiotics. The use of small incisions at each end of the abscess cavities allowed digital manipulation, and the use of a small Penrose drain threaded through each incision and tied to itself allowed continuous drainage that negated the need for extensive packing, which can be difficult in children.

None of the children had typical risk factors for MRSA, although three did have household contacts with lesions that might have been associated with MRSA. All the infections were sensitive to clindamycin, Bactrim (trimethoprim-sulfamethoxazole), and vancomycin, Dr. Hertweck noted.

MRSA should be considered in all patients presenting with rapidly progressing vulvar or labial erythema. Aggressive treatment with incision and drainage in such cases is warranted, she said, noting that a limited incision site and the use of a Penrose drain are recommended in children.

Appropriate antibiotic therapy should also be initiated.

“While our sensitivities may not translate to your community, it might be appropriate to start with something like clindamycin,” she said.

The HIV/AIDS epidemic can be controlled but only with intensified global attention in the form of funding and leadership, United Nations officials and AIDS experts said in response to a status report by U.N. Secretary-General Kofi Annan.

The threat of HIV/aids requires the same kind of attention that is being paid to other pressing concerns, such as global security, Peter Piot, M.D., executive director of the Joint United Nations Programme on HIV/AIDS (UNAIDS) said at a press briefing following release of the report, which was prepared for a high-level U.N. ministerial gathering to assess progress toward meeting goals set out in a Declaration of Commitment on HIV/AIDS. The declaration was adopted in 2001 by the U.N. General Assembly special session on HIV/AIDS.

The report states that “despite encouraging signs that the epidemic is beginning to be contained in a small but growing number of countries, the overall epidemic continues to expand, with much of the world at risk of falling short of the targets set forth in the declaration.”

In 2004 there were more new infections (4.9 million) and more AIDS deaths (3.1 million) than in previous years, and as of December, an estimated 39.4 million people were living with HIV, Secretary-General Annan wrote.

Furthermore, the toll of HIV/AIDS on women and girls has intensified, and many of the countries most affected are falling short of the 2005 target of reducing the level of infection in young people.

The expansion of the epidemic is outpacing the global response. About $6 billion were available in 2004 to implement comprehensive programs in 135 low- and middle-income countries, up 23% from 2003. But by 2007, if current trends in spending continue, funding will be insufficient to finance a response that is “comprehensive in both scope and coverage,” according to the report.

Achieving the targets specified in the declaration, including rapid expansion of HIV prevention, care, treatment and impact alleviation programs, will require immediate government action and substantial increases in funding.

“We are seeing real signs of progress in tackling AIDS at the community level, but it is still not enough,” Secretary-General Annan said at the press briefing. “It is time for governments to translate commitment into concrete action.”

Dr. Piot agreed, adding that access to prevention and treatment must be expanded.

As of December, only 12% of those requiring antiretroviral therapy were receiving it.

The HIV/AIDS epidemic can be controlled but only with intensified global attention in the form of funding and leadership, United Nations officials and AIDS experts said in response to a status report by U.N. Secretary-General Kofi Annan.

The threat of HIV/aids requires the same kind of attention that is being paid to other pressing concerns, such as global security, Peter Piot, M.D., executive director of the Joint United Nations Programme on HIV/AIDS (UNAIDS) said at a press briefing following release of the report, which was prepared for a high-level U.N. ministerial gathering to assess progress toward meeting goals set out in a Declaration of Commitment on HIV/AIDS. The declaration was adopted in 2001 by the U.N. General Assembly special session on HIV/AIDS.

The report states that “despite encouraging signs that the epidemic is beginning to be contained in a small but growing number of countries, the overall epidemic continues to expand, with much of the world at risk of falling short of the targets set forth in the declaration.”

In 2004 there were more new infections (4.9 million) and more AIDS deaths (3.1 million) than in previous years, and as of December, an estimated 39.4 million people were living with HIV, Secretary-General Annan wrote.

Furthermore, the toll of HIV/AIDS on women and girls has intensified, and many of the countries most affected are falling short of the 2005 target of reducing the level of infection in young people.

The expansion of the epidemic is outpacing the global response. About $6 billion were available in 2004 to implement comprehensive programs in 135 low- and middle-income countries, up 23% from 2003. But by 2007, if current trends in spending continue, funding will be insufficient to finance a response that is “comprehensive in both scope and coverage,” according to the report.

Achieving the targets specified in the declaration, including rapid expansion of HIV prevention, care, treatment and impact alleviation programs, will require immediate government action and substantial increases in funding.

“We are seeing real signs of progress in tackling AIDS at the community level, but it is still not enough,” Secretary-General Annan said at the press briefing. “It is time for governments to translate commitment into concrete action.”

Dr. Piot agreed, adding that access to prevention and treatment must be expanded.

As of December, only 12% of those requiring antiretroviral therapy were receiving it.

The HIV/AIDS epidemic can be controlled but only with intensified global attention in the form of funding and leadership, United Nations officials and AIDS experts said in response to a status report by U.N. Secretary-General Kofi Annan.

The threat of HIV/aids requires the same kind of attention that is being paid to other pressing concerns, such as global security, Peter Piot, M.D., executive director of the Joint United Nations Programme on HIV/AIDS (UNAIDS) said at a press briefing following release of the report, which was prepared for a high-level U.N. ministerial gathering to assess progress toward meeting goals set out in a Declaration of Commitment on HIV/AIDS. The declaration was adopted in 2001 by the U.N. General Assembly special session on HIV/AIDS.

The report states that “despite encouraging signs that the epidemic is beginning to be contained in a small but growing number of countries, the overall epidemic continues to expand, with much of the world at risk of falling short of the targets set forth in the declaration.”

In 2004 there were more new infections (4.9 million) and more AIDS deaths (3.1 million) than in previous years, and as of December, an estimated 39.4 million people were living with HIV, Secretary-General Annan wrote.

Furthermore, the toll of HIV/AIDS on women and girls has intensified, and many of the countries most affected are falling short of the 2005 target of reducing the level of infection in young people.

The expansion of the epidemic is outpacing the global response. About $6 billion were available in 2004 to implement comprehensive programs in 135 low- and middle-income countries, up 23% from 2003. But by 2007, if current trends in spending continue, funding will be insufficient to finance a response that is “comprehensive in both scope and coverage,” according to the report.

Achieving the targets specified in the declaration, including rapid expansion of HIV prevention, care, treatment and impact alleviation programs, will require immediate government action and substantial increases in funding.

“We are seeing real signs of progress in tackling AIDS at the community level, but it is still not enough,” Secretary-General Annan said at the press briefing. “It is time for governments to translate commitment into concrete action.”

Dr. Piot agreed, adding that access to prevention and treatment must be expanded.

As of December, only 12% of those requiring antiretroviral therapy were receiving it.

NEW ORLEANS – Higher educational and career goals among adolescent girls are widely considered to be protective against pregnancy, but a recent study suggests that this is true only among those who specifically view pregnancy as an impediment to achieving these goals.

Of 351 racially and ethnically diverse nulliparous teens who completed a questionnaire asking about such factors as educational and career goals, anticipated effects of childbearing on these goals, personal desire to avoid pregnancy, and sexual behavior and contraceptive use, 64% had college aspirations and 58% planned to pursue a career as well as eventual motherhood, Sara Jumping Eagle, M.D., reported in a poster at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Most (74%) said their goals were achievable, but only 42% said that pregnancy would interfere with their achievement of those goals. Only those young women who considered pregnancy an obstacle to their goals were significantly more likely to want to remain nonpregnant (77% vs. 27%), had plans to abort if they became pregnant (27% vs. 4%), and had plans to use contraception consistently in the future (90% vs. 79%), said Dr. Jumping Eagle of the University of Colorado, Denver.

The findings challenge the conventional approach to risk assessment, which assumes “that there are sets of risk and protective factors that differ in quantity between teenagers who do and do not become mothers but [that] exert similar effects on them.” Dr. Jumping Eagle noted.

She concluded that more time within pregnancy prevention intervention programs should be spent teaching that pregnancy is likely to make the achievement of career goals so difficult that the girls would be “willing to overlook the inconveniences associated with using contraception.”

NEW ORLEANS – Higher educational and career goals among adolescent girls are widely considered to be protective against pregnancy, but a recent study suggests that this is true only among those who specifically view pregnancy as an impediment to achieving these goals.

Of 351 racially and ethnically diverse nulliparous teens who completed a questionnaire asking about such factors as educational and career goals, anticipated effects of childbearing on these goals, personal desire to avoid pregnancy, and sexual behavior and contraceptive use, 64% had college aspirations and 58% planned to pursue a career as well as eventual motherhood, Sara Jumping Eagle, M.D., reported in a poster at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Most (74%) said their goals were achievable, but only 42% said that pregnancy would interfere with their achievement of those goals. Only those young women who considered pregnancy an obstacle to their goals were significantly more likely to want to remain nonpregnant (77% vs. 27%), had plans to abort if they became pregnant (27% vs. 4%), and had plans to use contraception consistently in the future (90% vs. 79%), said Dr. Jumping Eagle of the University of Colorado, Denver.

The findings challenge the conventional approach to risk assessment, which assumes “that there are sets of risk and protective factors that differ in quantity between teenagers who do and do not become mothers but [that] exert similar effects on them.” Dr. Jumping Eagle noted.

She concluded that more time within pregnancy prevention intervention programs should be spent teaching that pregnancy is likely to make the achievement of career goals so difficult that the girls would be “willing to overlook the inconveniences associated with using contraception.”

NEW ORLEANS – Higher educational and career goals among adolescent girls are widely considered to be protective against pregnancy, but a recent study suggests that this is true only among those who specifically view pregnancy as an impediment to achieving these goals.

Of 351 racially and ethnically diverse nulliparous teens who completed a questionnaire asking about such factors as educational and career goals, anticipated effects of childbearing on these goals, personal desire to avoid pregnancy, and sexual behavior and contraceptive use, 64% had college aspirations and 58% planned to pursue a career as well as eventual motherhood, Sara Jumping Eagle, M.D., reported in a poster at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Most (74%) said their goals were achievable, but only 42% said that pregnancy would interfere with their achievement of those goals. Only those young women who considered pregnancy an obstacle to their goals were significantly more likely to want to remain nonpregnant (77% vs. 27%), had plans to abort if they became pregnant (27% vs. 4%), and had plans to use contraception consistently in the future (90% vs. 79%), said Dr. Jumping Eagle of the University of Colorado, Denver.

The findings challenge the conventional approach to risk assessment, which assumes “that there are sets of risk and protective factors that differ in quantity between teenagers who do and do not become mothers but [that] exert similar effects on them.” Dr. Jumping Eagle noted.

She concluded that more time within pregnancy prevention intervention programs should be spent teaching that pregnancy is likely to make the achievement of career goals so difficult that the girls would be “willing to overlook the inconveniences associated with using contraception.”