Timothy F. Kirn

LOS ANGELES — Half of adolescent mothers experience significant depression in the first year after giving birth, according to a study of 417 young mothers followed for 48 months.

The study included roughly equal numbers of Mexican American, African American, and Caucasian mothers who were enrolled within 48 hours of giving birth and then surveyed with a Beck Depression Inventory at 3, 12, 24, and 48 months. Each returned at least three of the four surveys, R. Michelle Schmidt, M.D., said at the annual meeting of the Society for Adolescent Medicine.

The prevalence of depression, defined as moderate to severe symptoms on the inventory, was highest at 3 months (37%), said Dr. Schmidt of Baylor College of Medicine, Houston. After that, the prevalence steadily declined to 21% at 48 months.

Overall, 50% of the subjects had depression in the first year, and 57% had depression at some point during the study.

Depression, when it was present, appeared to persist. Eighty percent of those with depression at 3 months were also depressed at two or more other reporting periods. Moreover, 88% of those depressed at 48 months had been depressed at 12 months, and 15% had depression at every follow-up.

African American subjects had a prevalence of depression only half that of the two other groups at 3 months, and the prevalence among the African American subjects at 48 months was higher than it was at 24 months (20% vs. 16%).

LOS ANGELES — Half of adolescent mothers experience significant depression in the first year after giving birth, according to a study of 417 young mothers followed for 48 months.

The study included roughly equal numbers of Mexican American, African American, and Caucasian mothers who were enrolled within 48 hours of giving birth and then surveyed with a Beck Depression Inventory at 3, 12, 24, and 48 months. Each returned at least three of the four surveys, R. Michelle Schmidt, M.D., said at the annual meeting of the Society for Adolescent Medicine.

The prevalence of depression, defined as moderate to severe symptoms on the inventory, was highest at 3 months (37%), said Dr. Schmidt of Baylor College of Medicine, Houston. After that, the prevalence steadily declined to 21% at 48 months.

Overall, 50% of the subjects had depression in the first year, and 57% had depression at some point during the study.

Depression, when it was present, appeared to persist. Eighty percent of those with depression at 3 months were also depressed at two or more other reporting periods. Moreover, 88% of those depressed at 48 months had been depressed at 12 months, and 15% had depression at every follow-up.

African American subjects had a prevalence of depression only half that of the two other groups at 3 months, and the prevalence among the African American subjects at 48 months was higher than it was at 24 months (20% vs. 16%).

LOS ANGELES — Half of adolescent mothers experience significant depression in the first year after giving birth, according to a study of 417 young mothers followed for 48 months.

The study included roughly equal numbers of Mexican American, African American, and Caucasian mothers who were enrolled within 48 hours of giving birth and then surveyed with a Beck Depression Inventory at 3, 12, 24, and 48 months. Each returned at least three of the four surveys, R. Michelle Schmidt, M.D., said at the annual meeting of the Society for Adolescent Medicine.

The prevalence of depression, defined as moderate to severe symptoms on the inventory, was highest at 3 months (37%), said Dr. Schmidt of Baylor College of Medicine, Houston. After that, the prevalence steadily declined to 21% at 48 months.

Overall, 50% of the subjects had depression in the first year, and 57% had depression at some point during the study.

Depression, when it was present, appeared to persist. Eighty percent of those with depression at 3 months were also depressed at two or more other reporting periods. Moreover, 88% of those depressed at 48 months had been depressed at 12 months, and 15% had depression at every follow-up.

African American subjects had a prevalence of depression only half that of the two other groups at 3 months, and the prevalence among the African American subjects at 48 months was higher than it was at 24 months (20% vs. 16%).

SAN FRANCISCO — A simple clinical rule known as the CURB-65 can be a big help in identifying those patients with community-acquired pneumonia who need to be hospitalized, Michael S. Niederman, M.D., said at the annual meeting of the American College of Physicians.

Unlike the Pneumonia Severity Index, which is designed to predict mortality, CURB-65 is convenient, and was designed specifically to assess need for hospitalization, said Dr. Niederman, chairman of the department of medicine at Winthrop-University Hospital, Mineola, N.Y.

CURB-65—which stands for confusion, urea, respiratory rate, blood pressure, and 65 years of age or older—uses five criteria, to be applied to a patient with a fever less than 37° C and an albumin level less than 3 g/dL. The criteria are confusion, BUN greater than 7 mmol/L, respiratory rate of at least 30 breaths per minute, systolic blood pressure less than 90 mm Hg or diastolic blood pressure less than or equal to 60 mm Hg, and age of 65 years or older.

With this rule, one point is given for each criterion present. A score of 0–1 indicates the patient has a low risk of death and could be sent home, provided there are no complicating factors. A score of 2 indicates that the patient has about a 10% risk of death and should be considered seriously for hospital admission. A score of 3 or higher indicates a 20% or higher risk of death; the patient should be admitted, probably to the intensive care unit.

“I like this rule,” Dr. Niederman said. “It is not 100%, but it is really simple and I can access all these criteria and very quickly know what I want to do with a patient.”

The CURB-65 rule does not replace clinical judgment, he said. But “it is, in my mind, a reality check that I use on every pneumonia patient before I decide where to put them,” Dr. Niederman said. “The one caveat I have is that if you are going to use this [rule], count the respiratory rate yourself.”

SAN FRANCISCO — A simple clinical rule known as the CURB-65 can be a big help in identifying those patients with community-acquired pneumonia who need to be hospitalized, Michael S. Niederman, M.D., said at the annual meeting of the American College of Physicians.

Unlike the Pneumonia Severity Index, which is designed to predict mortality, CURB-65 is convenient, and was designed specifically to assess need for hospitalization, said Dr. Niederman, chairman of the department of medicine at Winthrop-University Hospital, Mineola, N.Y.

CURB-65—which stands for confusion, urea, respiratory rate, blood pressure, and 65 years of age or older—uses five criteria, to be applied to a patient with a fever less than 37° C and an albumin level less than 3 g/dL. The criteria are confusion, BUN greater than 7 mmol/L, respiratory rate of at least 30 breaths per minute, systolic blood pressure less than 90 mm Hg or diastolic blood pressure less than or equal to 60 mm Hg, and age of 65 years or older.

With this rule, one point is given for each criterion present. A score of 0–1 indicates the patient has a low risk of death and could be sent home, provided there are no complicating factors. A score of 2 indicates that the patient has about a 10% risk of death and should be considered seriously for hospital admission. A score of 3 or higher indicates a 20% or higher risk of death; the patient should be admitted, probably to the intensive care unit.

“I like this rule,” Dr. Niederman said. “It is not 100%, but it is really simple and I can access all these criteria and very quickly know what I want to do with a patient.”

The CURB-65 rule does not replace clinical judgment, he said. But “it is, in my mind, a reality check that I use on every pneumonia patient before I decide where to put them,” Dr. Niederman said. “The one caveat I have is that if you are going to use this [rule], count the respiratory rate yourself.”

SAN FRANCISCO — A simple clinical rule known as the CURB-65 can be a big help in identifying those patients with community-acquired pneumonia who need to be hospitalized, Michael S. Niederman, M.D., said at the annual meeting of the American College of Physicians.

Unlike the Pneumonia Severity Index, which is designed to predict mortality, CURB-65 is convenient, and was designed specifically to assess need for hospitalization, said Dr. Niederman, chairman of the department of medicine at Winthrop-University Hospital, Mineola, N.Y.

CURB-65—which stands for confusion, urea, respiratory rate, blood pressure, and 65 years of age or older—uses five criteria, to be applied to a patient with a fever less than 37° C and an albumin level less than 3 g/dL. The criteria are confusion, BUN greater than 7 mmol/L, respiratory rate of at least 30 breaths per minute, systolic blood pressure less than 90 mm Hg or diastolic blood pressure less than or equal to 60 mm Hg, and age of 65 years or older.

With this rule, one point is given for each criterion present. A score of 0–1 indicates the patient has a low risk of death and could be sent home, provided there are no complicating factors. A score of 2 indicates that the patient has about a 10% risk of death and should be considered seriously for hospital admission. A score of 3 or higher indicates a 20% or higher risk of death; the patient should be admitted, probably to the intensive care unit.

“I like this rule,” Dr. Niederman said. “It is not 100%, but it is really simple and I can access all these criteria and very quickly know what I want to do with a patient.”

The CURB-65 rule does not replace clinical judgment, he said. But “it is, in my mind, a reality check that I use on every pneumonia patient before I decide where to put them,” Dr. Niederman said. “The one caveat I have is that if you are going to use this [rule], count the respiratory rate yourself.”

SAN FRANCISCO — Physicians who forgo obtaining cultures from patients who come in with possible community-acquired bacterial pneumonia are probably practicing wisely, John G. Bartlett, M.D., said at the annual meeting of the American College of Physicians.

It has been reported that the etiologic agent in pneumonia is never identified in 50% of cases. But that figure comes from clinical trials, in which patients are tested and cultured exhaustively, said Dr. Bartlett, chief of the division of infectious diseases at Johns Hopkins University, Baltimore.

In the hospital, the etiologic organism is identified in only 15%–20% of pneumonia cases, and the most of those results come from blood culture, not sputum.

“We don't do very well with cultures, and therefore, you can't rely on them,” he said.

Sputum rarely yields a positive culture, even in a patient with a pneumonia caused by Streptococcus pneumoniae. And blood cultures may give misleading results because they are so often contaminated, Medicare data have suggested. “There have been several reports that have shown that blood cultures really don't affect outcome in any meaningful way,” Dr. Bartlett said.

Instead, current guidelines say when diagnosing suspected pneumonia from bronchitis, an x-ray is key, although not needed in the patient with normal vital signs and no rales. If the x-ray shows an infiltrate, then the patient has pneumonia, and antibiotic treatment can be initiated empirically, with no need for a culture, because experience suggests that most patients get better with empiric treatment. “The x-ray showing an infiltrate is really a pivotal part of the diagnostic evaluation,” he said. “It separates, to a large extent, antibiotics vs. no antibiotics.”

The exception to this empiric-treatment rule is a patient who is ill enough to be hospitalized, he said. In those patients, he would order a urinary antigen test for Legionella species, because of its virulence and because it is a public health problem, and perhaps a urinary antigen test for pneumococcus, to pick up bacteremia.

SAN FRANCISCO — Physicians who forgo obtaining cultures from patients who come in with possible community-acquired bacterial pneumonia are probably practicing wisely, John G. Bartlett, M.D., said at the annual meeting of the American College of Physicians.

It has been reported that the etiologic agent in pneumonia is never identified in 50% of cases. But that figure comes from clinical trials, in which patients are tested and cultured exhaustively, said Dr. Bartlett, chief of the division of infectious diseases at Johns Hopkins University, Baltimore.

In the hospital, the etiologic organism is identified in only 15%–20% of pneumonia cases, and the most of those results come from blood culture, not sputum.

“We don't do very well with cultures, and therefore, you can't rely on them,” he said.

Sputum rarely yields a positive culture, even in a patient with a pneumonia caused by Streptococcus pneumoniae. And blood cultures may give misleading results because they are so often contaminated, Medicare data have suggested. “There have been several reports that have shown that blood cultures really don't affect outcome in any meaningful way,” Dr. Bartlett said.

Instead, current guidelines say when diagnosing suspected pneumonia from bronchitis, an x-ray is key, although not needed in the patient with normal vital signs and no rales. If the x-ray shows an infiltrate, then the patient has pneumonia, and antibiotic treatment can be initiated empirically, with no need for a culture, because experience suggests that most patients get better with empiric treatment. “The x-ray showing an infiltrate is really a pivotal part of the diagnostic evaluation,” he said. “It separates, to a large extent, antibiotics vs. no antibiotics.”

The exception to this empiric-treatment rule is a patient who is ill enough to be hospitalized, he said. In those patients, he would order a urinary antigen test for Legionella species, because of its virulence and because it is a public health problem, and perhaps a urinary antigen test for pneumococcus, to pick up bacteremia.

SAN FRANCISCO — Physicians who forgo obtaining cultures from patients who come in with possible community-acquired bacterial pneumonia are probably practicing wisely, John G. Bartlett, M.D., said at the annual meeting of the American College of Physicians.

It has been reported that the etiologic agent in pneumonia is never identified in 50% of cases. But that figure comes from clinical trials, in which patients are tested and cultured exhaustively, said Dr. Bartlett, chief of the division of infectious diseases at Johns Hopkins University, Baltimore.

In the hospital, the etiologic organism is identified in only 15%–20% of pneumonia cases, and the most of those results come from blood culture, not sputum.

“We don't do very well with cultures, and therefore, you can't rely on them,” he said.

Sputum rarely yields a positive culture, even in a patient with a pneumonia caused by Streptococcus pneumoniae. And blood cultures may give misleading results because they are so often contaminated, Medicare data have suggested. “There have been several reports that have shown that blood cultures really don't affect outcome in any meaningful way,” Dr. Bartlett said.

Instead, current guidelines say when diagnosing suspected pneumonia from bronchitis, an x-ray is key, although not needed in the patient with normal vital signs and no rales. If the x-ray shows an infiltrate, then the patient has pneumonia, and antibiotic treatment can be initiated empirically, with no need for a culture, because experience suggests that most patients get better with empiric treatment. “The x-ray showing an infiltrate is really a pivotal part of the diagnostic evaluation,” he said. “It separates, to a large extent, antibiotics vs. no antibiotics.”

The exception to this empiric-treatment rule is a patient who is ill enough to be hospitalized, he said. In those patients, he would order a urinary antigen test for Legionella species, because of its virulence and because it is a public health problem, and perhaps a urinary antigen test for pneumococcus, to pick up bacteremia.

NAPLES, FLA. — In the last year, Michael B. Morgan, M.D., has seen four cases of angiosarcoma on the breast of women who previously underwent radiation therapy for breast cancer.

Historically, there are only about 100 cases of angiosarcoma a year in the United States, and normally they occur in “sun-battered” areas, said Dr. Morgan, a dermatopathologist who practices in Tampa.

“I think we are at the precipice here of a real interesting and deadly epidemiologic phenomenon,” said Dr. Morgan at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

“I don't want to be Chicken Little, but I honestly think we could be on the cusp of something big, and we need to be vigilant,” he added, in an interview.

Angiosarcoma associated with irradiation of the breast was first noted back in the 1940s, and in that report it was said to be associated with chronic lymphedema. Since then, numerous other reports of angiosarcoma have appeared, but there has been controversy over whether the disease occurs frequently enough to warrant much concern.

It may be, however, that not enough women have been followed out long enough. His four cases were all women who had been treated for breast cancer 20 years previously, which corresponds roughly to the time that breast-conserving treatment with radiation became standard practice, Dr. Morgan said.

Older case series estimated an incidence of angiosarcoma in irradiated, breast-cancer patients of less than 1%; however, more recent series have suggested a prevalence of 1%, and perhaps 3%.

In a recent series of 27 cases seen at Indiana University, it was reported that only 5 of the 27 cases occurred within 3 years of irradiation treatment, and the median interval was 59 months (Am. J. Surg. Pathol. 2004;28:781–8), Dr. Morgan noted.

In that series, lymphedema was largely absent, as has been true also of Dr. Morgan's cases. However, since angiosarcoma can be associated with chronic lymphedema, Dr. Morgan said he is concerned about melanoma patients who have lymph nodes removed.

“I haven't seen this, but I worry about the rash of lymph nodes that we are taking out of people's arms and legs now with melanoma, and whether this indeed is going to end up being a risk,” he said.

The prognosis of angiosarcoma is very poor. In a series of 47 typical angiosarcoma patients reported by Dr. Morgan, the overall survival at 5 years was only 34%, and the local recurrence rate at 5 years was 84% (J. Am. Acad. Dermatol. 2004;50;867–74).

Clinically, a typical angiosarcoma starts out as a bruiselike macule that rapidly evolves into an erythematous patch, and then to a violaceous, ulcerated nodule or plaque. The angiosarcomas on the breast may be somewhat different, because the ones he has seen have mostly been flattened, tan-colored, indurated patches that looked a little like Kaposi's sarcoma, Dr. Morgan said. It can be multifocal at presentation.

Histologically, biopsies usually show a preserved epithelium, with extravasated red cells and lots of nuclei in the deeper dermis, as one would expect of a cancer that arises from endothelial cells of the arteriovenous or lymphatic structures, Dr. Morgan said. In later stages, one can clearly see a complex, vasiform pattern of growth. The most useful stain is CD31, which confirms the endothelial derivation of the neoplastic cells, he added.

In his case series, Dr. Morgan looked at prognostic factors. He found that mitotic rate and recurrence were bad prognostic factors. But the most important factor was the depth of invasion, with a cutoff depth of 3 mm.

“This is about the worst thing I can think of to happen in your skin,” Dr. Morgan said.

NAPLES, FLA. — In the last year, Michael B. Morgan, M.D., has seen four cases of angiosarcoma on the breast of women who previously underwent radiation therapy for breast cancer.

Historically, there are only about 100 cases of angiosarcoma a year in the United States, and normally they occur in “sun-battered” areas, said Dr. Morgan, a dermatopathologist who practices in Tampa.

“I think we are at the precipice here of a real interesting and deadly epidemiologic phenomenon,” said Dr. Morgan at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

“I don't want to be Chicken Little, but I honestly think we could be on the cusp of something big, and we need to be vigilant,” he added, in an interview.

Angiosarcoma associated with irradiation of the breast was first noted back in the 1940s, and in that report it was said to be associated with chronic lymphedema. Since then, numerous other reports of angiosarcoma have appeared, but there has been controversy over whether the disease occurs frequently enough to warrant much concern.

It may be, however, that not enough women have been followed out long enough. His four cases were all women who had been treated for breast cancer 20 years previously, which corresponds roughly to the time that breast-conserving treatment with radiation became standard practice, Dr. Morgan said.

Older case series estimated an incidence of angiosarcoma in irradiated, breast-cancer patients of less than 1%; however, more recent series have suggested a prevalence of 1%, and perhaps 3%.

In a recent series of 27 cases seen at Indiana University, it was reported that only 5 of the 27 cases occurred within 3 years of irradiation treatment, and the median interval was 59 months (Am. J. Surg. Pathol. 2004;28:781–8), Dr. Morgan noted.

In that series, lymphedema was largely absent, as has been true also of Dr. Morgan's cases. However, since angiosarcoma can be associated with chronic lymphedema, Dr. Morgan said he is concerned about melanoma patients who have lymph nodes removed.

“I haven't seen this, but I worry about the rash of lymph nodes that we are taking out of people's arms and legs now with melanoma, and whether this indeed is going to end up being a risk,” he said.

The prognosis of angiosarcoma is very poor. In a series of 47 typical angiosarcoma patients reported by Dr. Morgan, the overall survival at 5 years was only 34%, and the local recurrence rate at 5 years was 84% (J. Am. Acad. Dermatol. 2004;50;867–74).

Clinically, a typical angiosarcoma starts out as a bruiselike macule that rapidly evolves into an erythematous patch, and then to a violaceous, ulcerated nodule or plaque. The angiosarcomas on the breast may be somewhat different, because the ones he has seen have mostly been flattened, tan-colored, indurated patches that looked a little like Kaposi's sarcoma, Dr. Morgan said. It can be multifocal at presentation.

Histologically, biopsies usually show a preserved epithelium, with extravasated red cells and lots of nuclei in the deeper dermis, as one would expect of a cancer that arises from endothelial cells of the arteriovenous or lymphatic structures, Dr. Morgan said. In later stages, one can clearly see a complex, vasiform pattern of growth. The most useful stain is CD31, which confirms the endothelial derivation of the neoplastic cells, he added.

In his case series, Dr. Morgan looked at prognostic factors. He found that mitotic rate and recurrence were bad prognostic factors. But the most important factor was the depth of invasion, with a cutoff depth of 3 mm.

“This is about the worst thing I can think of to happen in your skin,” Dr. Morgan said.

NAPLES, FLA. — In the last year, Michael B. Morgan, M.D., has seen four cases of angiosarcoma on the breast of women who previously underwent radiation therapy for breast cancer.

Historically, there are only about 100 cases of angiosarcoma a year in the United States, and normally they occur in “sun-battered” areas, said Dr. Morgan, a dermatopathologist who practices in Tampa.

“I think we are at the precipice here of a real interesting and deadly epidemiologic phenomenon,” said Dr. Morgan at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

“I don't want to be Chicken Little, but I honestly think we could be on the cusp of something big, and we need to be vigilant,” he added, in an interview.

Angiosarcoma associated with irradiation of the breast was first noted back in the 1940s, and in that report it was said to be associated with chronic lymphedema. Since then, numerous other reports of angiosarcoma have appeared, but there has been controversy over whether the disease occurs frequently enough to warrant much concern.

It may be, however, that not enough women have been followed out long enough. His four cases were all women who had been treated for breast cancer 20 years previously, which corresponds roughly to the time that breast-conserving treatment with radiation became standard practice, Dr. Morgan said.

Older case series estimated an incidence of angiosarcoma in irradiated, breast-cancer patients of less than 1%; however, more recent series have suggested a prevalence of 1%, and perhaps 3%.

In a recent series of 27 cases seen at Indiana University, it was reported that only 5 of the 27 cases occurred within 3 years of irradiation treatment, and the median interval was 59 months (Am. J. Surg. Pathol. 2004;28:781–8), Dr. Morgan noted.

In that series, lymphedema was largely absent, as has been true also of Dr. Morgan's cases. However, since angiosarcoma can be associated with chronic lymphedema, Dr. Morgan said he is concerned about melanoma patients who have lymph nodes removed.

“I haven't seen this, but I worry about the rash of lymph nodes that we are taking out of people's arms and legs now with melanoma, and whether this indeed is going to end up being a risk,” he said.

The prognosis of angiosarcoma is very poor. In a series of 47 typical angiosarcoma patients reported by Dr. Morgan, the overall survival at 5 years was only 34%, and the local recurrence rate at 5 years was 84% (J. Am. Acad. Dermatol. 2004;50;867–74).

Clinically, a typical angiosarcoma starts out as a bruiselike macule that rapidly evolves into an erythematous patch, and then to a violaceous, ulcerated nodule or plaque. The angiosarcomas on the breast may be somewhat different, because the ones he has seen have mostly been flattened, tan-colored, indurated patches that looked a little like Kaposi's sarcoma, Dr. Morgan said. It can be multifocal at presentation.

Histologically, biopsies usually show a preserved epithelium, with extravasated red cells and lots of nuclei in the deeper dermis, as one would expect of a cancer that arises from endothelial cells of the arteriovenous or lymphatic structures, Dr. Morgan said. In later stages, one can clearly see a complex, vasiform pattern of growth. The most useful stain is CD31, which confirms the endothelial derivation of the neoplastic cells, he added.

In his case series, Dr. Morgan looked at prognostic factors. He found that mitotic rate and recurrence were bad prognostic factors. But the most important factor was the depth of invasion, with a cutoff depth of 3 mm.

“This is about the worst thing I can think of to happen in your skin,” Dr. Morgan said.

NAPLES, FLA. — Patients with genital herpes often believe they can't transmit the infection while they are asymptomatic, and the majority of transmissions are probably borne of this ignorance, Stephen K. Tyring, M.D., said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

Many patients may be incredulous when you tell them this, because they have been told they must have a lesion or symptoms to transmit the virus.

With such patients, you can point out that 80% of the population is herpes simplex virus type-1 seropositive, but almost nobody ever kisses someone when they have a fever blister on their mouth, said Dr. Tyring, a dermatologist and infectious disease specialist who is medical director of the Center for Clinical Studies at the University of Texas Health Sciences Center, Houston.

The prevalence of herpes simplex type-2 (HSV-2) increased by 30% during the last 2 decades, Dr. Tyring noted.

It is now estimated that 45 million people in the United States, or 15% of the population, are seropositive for HSV-2.

It is estimated that 80% of transmissions occur when the carrier is asymptomatic, Dr. Tyring said.

Women are at greater risk of acquiring the virus, he said. The overall rate of transmission from an infected partner to an uninfected partner is about 10% per year.

The annual rate rises if the infected partner is the male; the female partner has a 20% chance of becoming infected, and a 30% chance if she is seronegative for HSV-1. If the female is the infected partner, the male has a less than 10% chance of infection.

Condoms protect against transmission but are not foolproof, and they probably benefit women more than men.

When men develop herpes lesions or have viral shedding, they tend to do so on the distal genitalia, which the condom covers. Women, however, shed virus into secretions that can get on the base of the penis or even the scrotum.

In a seminal study published last year, in which almost 1,500 infected individuals with seronegative partners were randomly assigned to 500 mg of valacyclovir or placebo once daily, Dr. Tyring and colleagues reported that the rate of transmission was reduced by 50% over an 8-month period (N. Engl. J. Med. 2004;350:11–20).

“The study used valacyclovir, but you can substitute famciclovir or acyclovir and probably get the same result,” Dr. Tyring said.

“The bad news is, we don't have a cure,” he said. “This is just one more tool in the armamentarium.”

The new genital herpes vaccine has been shown to be highly effective, but, unexpectedly, only in women.

A major new trial is underway to better understand why this might be, and, specifically, the mucosal immunity women appear to develop.

Genital herpes increases the risk of HIV transmission two- to fivefold, Dr. Tyring said. This increased risk occurs because there is a reduced epithelial barrier in a person with herpes, but also because the individual with herpes has infiltrates of CD-4-positive cells where the lesions occur.

Studies have shown that one can use acyclovir, valacyclovir, or famciclovir to keep herpes in check in the HIV-infected individual—which not only addresses the herpes but sometimes improves the response to HIV therapy as well, Dr. Tyring said.

For HIV patients with resistant herpes, the Centers for Disease Control and Prevention recommends using a topical formulation of cidofovir.

Condoms can help prevent transmission of herpes simplex virus, but areas not completely covered by the condom remain susceptible to infection. ©W.B. Saunders 2002, Dermatologic Clinics. Volume 20. Number 2

NAPLES, FLA. — Patients with genital herpes often believe they can't transmit the infection while they are asymptomatic, and the majority of transmissions are probably borne of this ignorance, Stephen K. Tyring, M.D., said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

Many patients may be incredulous when you tell them this, because they have been told they must have a lesion or symptoms to transmit the virus.

With such patients, you can point out that 80% of the population is herpes simplex virus type-1 seropositive, but almost nobody ever kisses someone when they have a fever blister on their mouth, said Dr. Tyring, a dermatologist and infectious disease specialist who is medical director of the Center for Clinical Studies at the University of Texas Health Sciences Center, Houston.

The prevalence of herpes simplex type-2 (HSV-2) increased by 30% during the last 2 decades, Dr. Tyring noted.

It is now estimated that 45 million people in the United States, or 15% of the population, are seropositive for HSV-2.

It is estimated that 80% of transmissions occur when the carrier is asymptomatic, Dr. Tyring said.

Women are at greater risk of acquiring the virus, he said. The overall rate of transmission from an infected partner to an uninfected partner is about 10% per year.

The annual rate rises if the infected partner is the male; the female partner has a 20% chance of becoming infected, and a 30% chance if she is seronegative for HSV-1. If the female is the infected partner, the male has a less than 10% chance of infection.

Condoms protect against transmission but are not foolproof, and they probably benefit women more than men.

When men develop herpes lesions or have viral shedding, they tend to do so on the distal genitalia, which the condom covers. Women, however, shed virus into secretions that can get on the base of the penis or even the scrotum.

In a seminal study published last year, in which almost 1,500 infected individuals with seronegative partners were randomly assigned to 500 mg of valacyclovir or placebo once daily, Dr. Tyring and colleagues reported that the rate of transmission was reduced by 50% over an 8-month period (N. Engl. J. Med. 2004;350:11–20).

“The study used valacyclovir, but you can substitute famciclovir or acyclovir and probably get the same result,” Dr. Tyring said.

“The bad news is, we don't have a cure,” he said. “This is just one more tool in the armamentarium.”

The new genital herpes vaccine has been shown to be highly effective, but, unexpectedly, only in women.

A major new trial is underway to better understand why this might be, and, specifically, the mucosal immunity women appear to develop.

Genital herpes increases the risk of HIV transmission two- to fivefold, Dr. Tyring said. This increased risk occurs because there is a reduced epithelial barrier in a person with herpes, but also because the individual with herpes has infiltrates of CD-4-positive cells where the lesions occur.

Studies have shown that one can use acyclovir, valacyclovir, or famciclovir to keep herpes in check in the HIV-infected individual—which not only addresses the herpes but sometimes improves the response to HIV therapy as well, Dr. Tyring said.

For HIV patients with resistant herpes, the Centers for Disease Control and Prevention recommends using a topical formulation of cidofovir.

Condoms can help prevent transmission of herpes simplex virus, but areas not completely covered by the condom remain susceptible to infection. ©W.B. Saunders 2002, Dermatologic Clinics. Volume 20. Number 2

NAPLES, FLA. — Patients with genital herpes often believe they can't transmit the infection while they are asymptomatic, and the majority of transmissions are probably borne of this ignorance, Stephen K. Tyring, M.D., said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

Many patients may be incredulous when you tell them this, because they have been told they must have a lesion or symptoms to transmit the virus.

With such patients, you can point out that 80% of the population is herpes simplex virus type-1 seropositive, but almost nobody ever kisses someone when they have a fever blister on their mouth, said Dr. Tyring, a dermatologist and infectious disease specialist who is medical director of the Center for Clinical Studies at the University of Texas Health Sciences Center, Houston.

The prevalence of herpes simplex type-2 (HSV-2) increased by 30% during the last 2 decades, Dr. Tyring noted.

It is now estimated that 45 million people in the United States, or 15% of the population, are seropositive for HSV-2.

It is estimated that 80% of transmissions occur when the carrier is asymptomatic, Dr. Tyring said.

Women are at greater risk of acquiring the virus, he said. The overall rate of transmission from an infected partner to an uninfected partner is about 10% per year.

The annual rate rises if the infected partner is the male; the female partner has a 20% chance of becoming infected, and a 30% chance if she is seronegative for HSV-1. If the female is the infected partner, the male has a less than 10% chance of infection.

Condoms protect against transmission but are not foolproof, and they probably benefit women more than men.

When men develop herpes lesions or have viral shedding, they tend to do so on the distal genitalia, which the condom covers. Women, however, shed virus into secretions that can get on the base of the penis or even the scrotum.

In a seminal study published last year, in which almost 1,500 infected individuals with seronegative partners were randomly assigned to 500 mg of valacyclovir or placebo once daily, Dr. Tyring and colleagues reported that the rate of transmission was reduced by 50% over an 8-month period (N. Engl. J. Med. 2004;350:11–20).

“The study used valacyclovir, but you can substitute famciclovir or acyclovir and probably get the same result,” Dr. Tyring said.

“The bad news is, we don't have a cure,” he said. “This is just one more tool in the armamentarium.”

The new genital herpes vaccine has been shown to be highly effective, but, unexpectedly, only in women.

A major new trial is underway to better understand why this might be, and, specifically, the mucosal immunity women appear to develop.

Genital herpes increases the risk of HIV transmission two- to fivefold, Dr. Tyring said. This increased risk occurs because there is a reduced epithelial barrier in a person with herpes, but also because the individual with herpes has infiltrates of CD-4-positive cells where the lesions occur.

Studies have shown that one can use acyclovir, valacyclovir, or famciclovir to keep herpes in check in the HIV-infected individual—which not only addresses the herpes but sometimes improves the response to HIV therapy as well, Dr. Tyring said.

For HIV patients with resistant herpes, the Centers for Disease Control and Prevention recommends using a topical formulation of cidofovir.

Condoms can help prevent transmission of herpes simplex virus, but areas not completely covered by the condom remain susceptible to infection. ©W.B. Saunders 2002, Dermatologic Clinics. Volume 20. Number 2

CHICAGO — Only 13% of U.S. patients diagnosed with hepatocellular carcinoma receive potentially curative therapy, Hashem B. El-Serag, M.D., said at the annual Digestive Disease Week.

Moreover, only one-third of those with single lesions get potentially curative therapy, said Dr. El-Serag of Baylor College of Medicine, Houston.

In other countries, potentially curative therapy appears to be used at much higher rates. Such treatment was provided for 40% of all hepatocellular carcinoma patients in a series from Barcelona and 30% of all patients aged over 75 years in Italy.

“There is significant underutilization of potentially curative therapy, even among those with favorable clinical features,” said Dr. El-Serag, who, with his colleagues, examined data for a nationwide cancer registry that is now linked to Medicare data. “The reasons for this observation need to be examined and corrected.”

Dr. El-Serag's study included data from 2,963 patients with hepatocellular carcinoma diagnosed between 1992 and 1999. The patients were entered into any 1 of 11 different regional cancer registries.

In addition to the 13% of patients who received potentially curative therapy, 4% received transarterial chemoablation and 35% received systemic chemotherapy or radiotherapy. The other 48% of the patients received no treatment at all.

The study found that age and ethnicity affected which patients received potentially curative therapy. Among those aged 65–74 years, the rate of the use of potentially curative therapy was 17%, and among racial groups, Asian people had the highest rate of potentially curative therapy—24%—apparently because they had more single and small tumors.

But neither of those characteristics had as strong an influence on rate as did the region where the cancer was diagnosed, Dr. El-Serag said, although he did not identify which regions had the highest or lowest rates.

The rates of attempted therapy did increase over time in the study, but this improvement was not dramatic, he added. For example, between 1992 and 1995, 53% of patients received no treatment. But the rate fell to 43% between 1996 and 1999.

Many physicians have too dismal a view of the prognosis of hepatocellular carcinoma, and that perception does not appear to have changed much between 1999 and the present, Dr. El-Serag said. Specifically, the majority of physicians still do not know that liver transplantation is an option for liver cancer, he added.

CHICAGO — Only 13% of U.S. patients diagnosed with hepatocellular carcinoma receive potentially curative therapy, Hashem B. El-Serag, M.D., said at the annual Digestive Disease Week.

Moreover, only one-third of those with single lesions get potentially curative therapy, said Dr. El-Serag of Baylor College of Medicine, Houston.

In other countries, potentially curative therapy appears to be used at much higher rates. Such treatment was provided for 40% of all hepatocellular carcinoma patients in a series from Barcelona and 30% of all patients aged over 75 years in Italy.

“There is significant underutilization of potentially curative therapy, even among those with favorable clinical features,” said Dr. El-Serag, who, with his colleagues, examined data for a nationwide cancer registry that is now linked to Medicare data. “The reasons for this observation need to be examined and corrected.”

Dr. El-Serag's study included data from 2,963 patients with hepatocellular carcinoma diagnosed between 1992 and 1999. The patients were entered into any 1 of 11 different regional cancer registries.

In addition to the 13% of patients who received potentially curative therapy, 4% received transarterial chemoablation and 35% received systemic chemotherapy or radiotherapy. The other 48% of the patients received no treatment at all.

The study found that age and ethnicity affected which patients received potentially curative therapy. Among those aged 65–74 years, the rate of the use of potentially curative therapy was 17%, and among racial groups, Asian people had the highest rate of potentially curative therapy—24%—apparently because they had more single and small tumors.

But neither of those characteristics had as strong an influence on rate as did the region where the cancer was diagnosed, Dr. El-Serag said, although he did not identify which regions had the highest or lowest rates.

The rates of attempted therapy did increase over time in the study, but this improvement was not dramatic, he added. For example, between 1992 and 1995, 53% of patients received no treatment. But the rate fell to 43% between 1996 and 1999.

Many physicians have too dismal a view of the prognosis of hepatocellular carcinoma, and that perception does not appear to have changed much between 1999 and the present, Dr. El-Serag said. Specifically, the majority of physicians still do not know that liver transplantation is an option for liver cancer, he added.

CHICAGO — Only 13% of U.S. patients diagnosed with hepatocellular carcinoma receive potentially curative therapy, Hashem B. El-Serag, M.D., said at the annual Digestive Disease Week.

Moreover, only one-third of those with single lesions get potentially curative therapy, said Dr. El-Serag of Baylor College of Medicine, Houston.

In other countries, potentially curative therapy appears to be used at much higher rates. Such treatment was provided for 40% of all hepatocellular carcinoma patients in a series from Barcelona and 30% of all patients aged over 75 years in Italy.

“There is significant underutilization of potentially curative therapy, even among those with favorable clinical features,” said Dr. El-Serag, who, with his colleagues, examined data for a nationwide cancer registry that is now linked to Medicare data. “The reasons for this observation need to be examined and corrected.”

Dr. El-Serag's study included data from 2,963 patients with hepatocellular carcinoma diagnosed between 1992 and 1999. The patients were entered into any 1 of 11 different regional cancer registries.

In addition to the 13% of patients who received potentially curative therapy, 4% received transarterial chemoablation and 35% received systemic chemotherapy or radiotherapy. The other 48% of the patients received no treatment at all.

The study found that age and ethnicity affected which patients received potentially curative therapy. Among those aged 65–74 years, the rate of the use of potentially curative therapy was 17%, and among racial groups, Asian people had the highest rate of potentially curative therapy—24%—apparently because they had more single and small tumors.

But neither of those characteristics had as strong an influence on rate as did the region where the cancer was diagnosed, Dr. El-Serag said, although he did not identify which regions had the highest or lowest rates.

The rates of attempted therapy did increase over time in the study, but this improvement was not dramatic, he added. For example, between 1992 and 1995, 53% of patients received no treatment. But the rate fell to 43% between 1996 and 1999.

Many physicians have too dismal a view of the prognosis of hepatocellular carcinoma, and that perception does not appear to have changed much between 1999 and the present, Dr. El-Serag said. Specifically, the majority of physicians still do not know that liver transplantation is an option for liver cancer, he added.

CHICAGO — Watchful waiting may be the prudent approach now when a patient with hepatitis C does not respond to standard interferon treatment, speakers said at the annual Digestive Disease Week.

That's because a number of promising new approaches and treatments are on the horizon, including longer treatment regimens, a ribavirin prodrug called viramidine, hepatitis C virus protease and polymerase inhibitors, antifibrotic agents, and new interferons.

Currently, about 45% of patients treated with the standard regimen of weekly pegylated interferon-alfa-2a with daily ribavirin given for 48 weeks will not respond adequately, said John B. Gross Jr., M.D., of the Mayo Clinic, Rochester, Minn.

Factors known to be associated with treatment failure include infection with hepatitis C virus genotype 1, a high viral load, advanced hepatic fibrosis or cirrhosis, obesity, underdosing to counter side effects or nonadherence to treatment, and African American race.

With regard to underdosing and lack of adherence, it has been shown that a pronounced response to treatment within the first 12 weeks indicates a high likelihood of a sustained virologic response. When a patient is at least 80% tolerant to initial dosing and adherent to treatment during those first 12 weeks, the percentage of patients achieving a sustained response goes up from about 40% overall to 60%. But when the dose of both drugs needs to be lowered, the percentage drops to 33%, Dr. Gross noted.

Some researchers have been looking at weight-based dosing of ribavirin, which appears to improve the virologic response rate. Others are studying treatment beyond the usual 48 weeks, which appears to cut the relapse rate. The results of those studies are still preliminary, he noted.

Some patients who have not responded to initial interferon therapy probably can be treated again. Patients who would be candidates for a second round of treatment are those who were treated before the pegylated interferon era or combined interferon-ribavirin treatment, or those who were nonadherent the first time.

“It turns out the predictors of a more sustained viral response in this group are just the same as for treatment-naive patients,” Dr. Gross said.

Patients with advanced cirrhosis probably should be enrolled in a clinical trial, he added. But most patients probably should just wait for future developments, with a liver biopsy scheduled for some future date.

Gary L. Davis, M.D., said interferon is likely to remain the basis of treatment even if the new antiviral agents now are in development prove useful.

Interferon will be necessary to combat the drug resistance that will undoubtedly arise with any new antiviral drug, said Dr. Davis of Baylor University, Houston.

At the meeting, early studies were presented on two new types of interferon, pegylated consensus interferon, which is a bioengineered interferon that can be given at a high dose, and an albumin-interferon fusion protein, which has a long half-life and would be given only once every 2–4 weeks. Both had good results in phase I or phase II trials, he said.

The antiviral drugs under study include viramidine, a precursor drug to ribavirin thought to cause less anemia, and several protease and polymerase inhibitors.

In a phase II trial presented at the meeting, viramidine did show a reduced incidence of anemia, Dr. Davis noted. In that trial, 27% of ribavirin-treated controls developed anemia. In comparison, no patients who received the lowest dose of viramidine (400 mg daily) developed anemia and only 2% of those who received the middle dose (600 mg) developed anemia. Of those who received the highest dose, 11% developed anemia, a difference that was not statistically significant.

The 171-patient study was perhaps not large enough to address efficacy with certainty, and many patients dropped out. But the results suggest that the proportion of patients who achieved a virologic response at the end of treatment was similar in all of the groups, and there was less relapse 24 weeks after treatment in those treated with viramidine, reported Robert G. Gish, M.D., of the California Pacific Medical Center, San Francisco.

Some of the protease and polymerase inhibitors being investigated appear powerful, but they are just now entering meaningful clinical trials, Dr. Davis said.

The agents shown in the laboratory to have antifibrosis capability include some that are already available, such as pentoxifylline, sirolimus, and vitamin E, Dr. Davis and Dr. Gross said. But it will be difficult to evaluate them in the clinic because of the lack of good markers of fibrosis.

CHICAGO — Watchful waiting may be the prudent approach now when a patient with hepatitis C does not respond to standard interferon treatment, speakers said at the annual Digestive Disease Week.

That's because a number of promising new approaches and treatments are on the horizon, including longer treatment regimens, a ribavirin prodrug called viramidine, hepatitis C virus protease and polymerase inhibitors, antifibrotic agents, and new interferons.

Currently, about 45% of patients treated with the standard regimen of weekly pegylated interferon-alfa-2a with daily ribavirin given for 48 weeks will not respond adequately, said John B. Gross Jr., M.D., of the Mayo Clinic, Rochester, Minn.

Factors known to be associated with treatment failure include infection with hepatitis C virus genotype 1, a high viral load, advanced hepatic fibrosis or cirrhosis, obesity, underdosing to counter side effects or nonadherence to treatment, and African American race.

With regard to underdosing and lack of adherence, it has been shown that a pronounced response to treatment within the first 12 weeks indicates a high likelihood of a sustained virologic response. When a patient is at least 80% tolerant to initial dosing and adherent to treatment during those first 12 weeks, the percentage of patients achieving a sustained response goes up from about 40% overall to 60%. But when the dose of both drugs needs to be lowered, the percentage drops to 33%, Dr. Gross noted.

Some researchers have been looking at weight-based dosing of ribavirin, which appears to improve the virologic response rate. Others are studying treatment beyond the usual 48 weeks, which appears to cut the relapse rate. The results of those studies are still preliminary, he noted.

Some patients who have not responded to initial interferon therapy probably can be treated again. Patients who would be candidates for a second round of treatment are those who were treated before the pegylated interferon era or combined interferon-ribavirin treatment, or those who were nonadherent the first time.

“It turns out the predictors of a more sustained viral response in this group are just the same as for treatment-naive patients,” Dr. Gross said.

Patients with advanced cirrhosis probably should be enrolled in a clinical trial, he added. But most patients probably should just wait for future developments, with a liver biopsy scheduled for some future date.

Gary L. Davis, M.D., said interferon is likely to remain the basis of treatment even if the new antiviral agents now are in development prove useful.

Interferon will be necessary to combat the drug resistance that will undoubtedly arise with any new antiviral drug, said Dr. Davis of Baylor University, Houston.

At the meeting, early studies were presented on two new types of interferon, pegylated consensus interferon, which is a bioengineered interferon that can be given at a high dose, and an albumin-interferon fusion protein, which has a long half-life and would be given only once every 2–4 weeks. Both had good results in phase I or phase II trials, he said.

The antiviral drugs under study include viramidine, a precursor drug to ribavirin thought to cause less anemia, and several protease and polymerase inhibitors.

In a phase II trial presented at the meeting, viramidine did show a reduced incidence of anemia, Dr. Davis noted. In that trial, 27% of ribavirin-treated controls developed anemia. In comparison, no patients who received the lowest dose of viramidine (400 mg daily) developed anemia and only 2% of those who received the middle dose (600 mg) developed anemia. Of those who received the highest dose, 11% developed anemia, a difference that was not statistically significant.

The 171-patient study was perhaps not large enough to address efficacy with certainty, and many patients dropped out. But the results suggest that the proportion of patients who achieved a virologic response at the end of treatment was similar in all of the groups, and there was less relapse 24 weeks after treatment in those treated with viramidine, reported Robert G. Gish, M.D., of the California Pacific Medical Center, San Francisco.

Some of the protease and polymerase inhibitors being investigated appear powerful, but they are just now entering meaningful clinical trials, Dr. Davis said.

The agents shown in the laboratory to have antifibrosis capability include some that are already available, such as pentoxifylline, sirolimus, and vitamin E, Dr. Davis and Dr. Gross said. But it will be difficult to evaluate them in the clinic because of the lack of good markers of fibrosis.

CHICAGO — Watchful waiting may be the prudent approach now when a patient with hepatitis C does not respond to standard interferon treatment, speakers said at the annual Digestive Disease Week.

That's because a number of promising new approaches and treatments are on the horizon, including longer treatment regimens, a ribavirin prodrug called viramidine, hepatitis C virus protease and polymerase inhibitors, antifibrotic agents, and new interferons.

Currently, about 45% of patients treated with the standard regimen of weekly pegylated interferon-alfa-2a with daily ribavirin given for 48 weeks will not respond adequately, said John B. Gross Jr., M.D., of the Mayo Clinic, Rochester, Minn.

Factors known to be associated with treatment failure include infection with hepatitis C virus genotype 1, a high viral load, advanced hepatic fibrosis or cirrhosis, obesity, underdosing to counter side effects or nonadherence to treatment, and African American race.

With regard to underdosing and lack of adherence, it has been shown that a pronounced response to treatment within the first 12 weeks indicates a high likelihood of a sustained virologic response. When a patient is at least 80% tolerant to initial dosing and adherent to treatment during those first 12 weeks, the percentage of patients achieving a sustained response goes up from about 40% overall to 60%. But when the dose of both drugs needs to be lowered, the percentage drops to 33%, Dr. Gross noted.

Some researchers have been looking at weight-based dosing of ribavirin, which appears to improve the virologic response rate. Others are studying treatment beyond the usual 48 weeks, which appears to cut the relapse rate. The results of those studies are still preliminary, he noted.

Some patients who have not responded to initial interferon therapy probably can be treated again. Patients who would be candidates for a second round of treatment are those who were treated before the pegylated interferon era or combined interferon-ribavirin treatment, or those who were nonadherent the first time.

“It turns out the predictors of a more sustained viral response in this group are just the same as for treatment-naive patients,” Dr. Gross said.

Patients with advanced cirrhosis probably should be enrolled in a clinical trial, he added. But most patients probably should just wait for future developments, with a liver biopsy scheduled for some future date.

Gary L. Davis, M.D., said interferon is likely to remain the basis of treatment even if the new antiviral agents now are in development prove useful.

Interferon will be necessary to combat the drug resistance that will undoubtedly arise with any new antiviral drug, said Dr. Davis of Baylor University, Houston.

At the meeting, early studies were presented on two new types of interferon, pegylated consensus interferon, which is a bioengineered interferon that can be given at a high dose, and an albumin-interferon fusion protein, which has a long half-life and would be given only once every 2–4 weeks. Both had good results in phase I or phase II trials, he said.

The antiviral drugs under study include viramidine, a precursor drug to ribavirin thought to cause less anemia, and several protease and polymerase inhibitors.

In a phase II trial presented at the meeting, viramidine did show a reduced incidence of anemia, Dr. Davis noted. In that trial, 27% of ribavirin-treated controls developed anemia. In comparison, no patients who received the lowest dose of viramidine (400 mg daily) developed anemia and only 2% of those who received the middle dose (600 mg) developed anemia. Of those who received the highest dose, 11% developed anemia, a difference that was not statistically significant.

The 171-patient study was perhaps not large enough to address efficacy with certainty, and many patients dropped out. But the results suggest that the proportion of patients who achieved a virologic response at the end of treatment was similar in all of the groups, and there was less relapse 24 weeks after treatment in those treated with viramidine, reported Robert G. Gish, M.D., of the California Pacific Medical Center, San Francisco.

Some of the protease and polymerase inhibitors being investigated appear powerful, but they are just now entering meaningful clinical trials, Dr. Davis said.

The agents shown in the laboratory to have antifibrosis capability include some that are already available, such as pentoxifylline, sirolimus, and vitamin E, Dr. Davis and Dr. Gross said. But it will be difficult to evaluate them in the clinic because of the lack of good markers of fibrosis.

CHICAGO — Patients do not necessarily prefer virtual colonoscopy to standard colonoscopy, probably because they are not given sedation to ease them through the virtual procedure, Nighat Ullah, M.D., said at the annual Digestive Disease Week.

In a survey of 55 patients who underwent both procedures, 43% preferred virtual colonoscopy, 31% preferred standard colonoscopy, and 26% had no preference, Dr. Ullah said in a poster presentation.

Overall, the survey found no significant differences between the procedures in the patients' experience of pain or embarrassment. The patients' willingness to recommend the two procedures to others and their satisfaction with the experience also did not differ significantly.

However, among those who said they preferred standard colonoscopy, the most common objection to virtual colonoscopy was the discomfort and subsequent bloating that the patients experienced as a result of the procedure, which entails insufflation of the colon, said Dr. Ullah of the division of gastroenterology at Stanford (Calif.) University.

Their survey found that about 50% of the patients reported pain associated with virtual colonoscopy, a figure consistent with other studies, Dr. Ullah said.

Obese patients tend to experience more discomfort, and the elderly, less, she added.

Patients who liked virtual colonoscopy said they preferred it because it was more convenient, mainly because there was no sedation. The exam took less time (15 minutes, compared with 40 minutes), and then the patients were up and out the door with no wait for sedation to wear off and no feeling groggy for the rest of the day, Dr. Ullah said.

In related study, conventional colonoscopy was more sensitive than virtual colonoscopy as a method of examining patients at risk for colon cancer, and was more cost effective as well, in part because if the physician finds a lesion on virtual colonoscopy, the patient still needs a conventional colonoscopy to remove it.

In that study, the sensitivity of conventional colonoscopy for large lesions (10 mm or greater) was 98%, while that of virtual colonoscopy was 59%, said Gillian D. Sanders, Ph.D., of Duke University, Durham, N.C.

CHICAGO — Patients do not necessarily prefer virtual colonoscopy to standard colonoscopy, probably because they are not given sedation to ease them through the virtual procedure, Nighat Ullah, M.D., said at the annual Digestive Disease Week.

In a survey of 55 patients who underwent both procedures, 43% preferred virtual colonoscopy, 31% preferred standard colonoscopy, and 26% had no preference, Dr. Ullah said in a poster presentation.

Overall, the survey found no significant differences between the procedures in the patients' experience of pain or embarrassment. The patients' willingness to recommend the two procedures to others and their satisfaction with the experience also did not differ significantly.

However, among those who said they preferred standard colonoscopy, the most common objection to virtual colonoscopy was the discomfort and subsequent bloating that the patients experienced as a result of the procedure, which entails insufflation of the colon, said Dr. Ullah of the division of gastroenterology at Stanford (Calif.) University.

Their survey found that about 50% of the patients reported pain associated with virtual colonoscopy, a figure consistent with other studies, Dr. Ullah said.

Obese patients tend to experience more discomfort, and the elderly, less, she added.

Patients who liked virtual colonoscopy said they preferred it because it was more convenient, mainly because there was no sedation. The exam took less time (15 minutes, compared with 40 minutes), and then the patients were up and out the door with no wait for sedation to wear off and no feeling groggy for the rest of the day, Dr. Ullah said.

In related study, conventional colonoscopy was more sensitive than virtual colonoscopy as a method of examining patients at risk for colon cancer, and was more cost effective as well, in part because if the physician finds a lesion on virtual colonoscopy, the patient still needs a conventional colonoscopy to remove it.

In that study, the sensitivity of conventional colonoscopy for large lesions (10 mm or greater) was 98%, while that of virtual colonoscopy was 59%, said Gillian D. Sanders, Ph.D., of Duke University, Durham, N.C.

CHICAGO — Patients do not necessarily prefer virtual colonoscopy to standard colonoscopy, probably because they are not given sedation to ease them through the virtual procedure, Nighat Ullah, M.D., said at the annual Digestive Disease Week.

In a survey of 55 patients who underwent both procedures, 43% preferred virtual colonoscopy, 31% preferred standard colonoscopy, and 26% had no preference, Dr. Ullah said in a poster presentation.

Overall, the survey found no significant differences between the procedures in the patients' experience of pain or embarrassment. The patients' willingness to recommend the two procedures to others and their satisfaction with the experience also did not differ significantly.

However, among those who said they preferred standard colonoscopy, the most common objection to virtual colonoscopy was the discomfort and subsequent bloating that the patients experienced as a result of the procedure, which entails insufflation of the colon, said Dr. Ullah of the division of gastroenterology at Stanford (Calif.) University.

Their survey found that about 50% of the patients reported pain associated with virtual colonoscopy, a figure consistent with other studies, Dr. Ullah said.

Obese patients tend to experience more discomfort, and the elderly, less, she added.

Patients who liked virtual colonoscopy said they preferred it because it was more convenient, mainly because there was no sedation. The exam took less time (15 minutes, compared with 40 minutes), and then the patients were up and out the door with no wait for sedation to wear off and no feeling groggy for the rest of the day, Dr. Ullah said.

In related study, conventional colonoscopy was more sensitive than virtual colonoscopy as a method of examining patients at risk for colon cancer, and was more cost effective as well, in part because if the physician finds a lesion on virtual colonoscopy, the patient still needs a conventional colonoscopy to remove it.

In that study, the sensitivity of conventional colonoscopy for large lesions (10 mm or greater) was 98%, while that of virtual colonoscopy was 59%, said Gillian D. Sanders, Ph.D., of Duke University, Durham, N.C.

CHICAGO — Watchful waiting may be the prudent approach now when a patient with hepatitis C does not respond to standard interferon treatment, speakers said at the annual Digestive Disease Week.

That's because a number of promising new approaches and treatments are on the horizon, including longer treatment regimens, a ribavirin prodrug called viramidine, hepatitis C virus protease and polymerase inhibitors, antifibrotic agents, and new interferons.

Currently, about 45% of patients treated with the standard regimen of weekly pegylated interferon-alfa-2a with daily ribavirin given for 48 weeks will not respond adequately, said John B. Gross Jr., M.D., of the Mayo Clinic, Rochester, Minn.

Factors known to be associated with treatment failure include infection with hepatitis C virus genotype 1, a high viral load, advanced hepatic fibrosis or cirrhosis, obesity, underdosing to counter side effects or nonadherence to treatment, and African American race.

Regarding underdosing and lack of adherence, it has been shown that a pronounced response to treatment within the first 12 weeks indicates a high likelihood of a sustained response. When a patient is at least 80% tolerant to initial dosing and adherent to treatment during those first 12 weeks, the percentage of patients achieving a sustained response goes from about 40% to 60%. But when the dose of both drugs needs to be lowered, the percentage drops to 33%, Dr. Gross noted.

Some researchers have been looking at weight-based dosing of ribavirin, which appears to improve virologic response. Others have been studying treatment beyond the usual 48 weeks, which appears to cut the relapse rate. The results of those studies are still preliminary, he noted.

Some patients who have not responded to initial interferon therapy probably can be treated again. Patients who would be candidates for a second round of treatment are those who were treated before the pegylated interferon era or combined interferon-ribavirin treatment, or those who were nonadherent the first time.

“It turns out the predictors of a more sustained viral response in this group are just the same as for treatment-naive patients,” Dr. Gross said.

Patients with advanced cirrhosis probably should be enrolled in a clinical trial, he added. But most patients probably should just wait for future developments, with a liver biopsy scheduled for some future date.

Gary L. Davis, M.D., said interferon is likely to remain the basis of treatment even if the new antiviral agents in development prove useful.

Interferon will be necessary to combat the drug resistance that will undoubtedly arise with any new antiviral drug, said Dr. Davis of Baylor University, Houston.

At the meeting, early studies were presented on two new types of interferon, pegylated consensus interferon, which is a bioengineered interferon that can be given at a high dose, and an albumin-interferon fusion protein, which has a long half-life and would be given only once every 2–4 weeks. Both had good results in phase I or phase II trials, he said.

The antiviral drugs under study include viramidine, a precursor drug to ribavirin thought to cause less anemia, and several protease and polymerase inhibitors.

In a phase II trial presented at the meeting, viramidine showed a reduced incidence of anemia, Dr. Davis noted. In that trial, 27% of ribavirin-treated controls developed anemia. In comparison, no patients who received the lowest dose of viramidine (400 mg daily) developed anemia, and only 2% of those who received the middle dose (600 mg) developed anemia. Of those who received the highest dose, 11% developed anemia, a difference that was not statistically significant.

The 171-patient study was perhaps not large enough to address efficacy with certainty, and many patients dropped out. But the results suggest that the proportion of patients who achieved a virologic response at the end of treatment was similar in all of the groups, and there was less relapse 24 weeks after treatment in those treated with viramidine, reported Robert G. Gish, M.D., of the California Pacific Medical Center, San Francisco.

Some of the protease and polymerase inhibitors being investigated appear powerful, but they are just now entering meaningful clinical trials, Dr. Davis said.

CHICAGO — Watchful waiting may be the prudent approach now when a patient with hepatitis C does not respond to standard interferon treatment, speakers said at the annual Digestive Disease Week.

That's because a number of promising new approaches and treatments are on the horizon, including longer treatment regimens, a ribavirin prodrug called viramidine, hepatitis C virus protease and polymerase inhibitors, antifibrotic agents, and new interferons.

Currently, about 45% of patients treated with the standard regimen of weekly pegylated interferon-alfa-2a with daily ribavirin given for 48 weeks will not respond adequately, said John B. Gross Jr., M.D., of the Mayo Clinic, Rochester, Minn.

Factors known to be associated with treatment failure include infection with hepatitis C virus genotype 1, a high viral load, advanced hepatic fibrosis or cirrhosis, obesity, underdosing to counter side effects or nonadherence to treatment, and African American race.

Regarding underdosing and lack of adherence, it has been shown that a pronounced response to treatment within the first 12 weeks indicates a high likelihood of a sustained response. When a patient is at least 80% tolerant to initial dosing and adherent to treatment during those first 12 weeks, the percentage of patients achieving a sustained response goes from about 40% to 60%. But when the dose of both drugs needs to be lowered, the percentage drops to 33%, Dr. Gross noted.

Some researchers have been looking at weight-based dosing of ribavirin, which appears to improve virologic response. Others have been studying treatment beyond the usual 48 weeks, which appears to cut the relapse rate. The results of those studies are still preliminary, he noted.

Some patients who have not responded to initial interferon therapy probably can be treated again. Patients who would be candidates for a second round of treatment are those who were treated before the pegylated interferon era or combined interferon-ribavirin treatment, or those who were nonadherent the first time.

“It turns out the predictors of a more sustained viral response in this group are just the same as for treatment-naive patients,” Dr. Gross said.

Patients with advanced cirrhosis probably should be enrolled in a clinical trial, he added. But most patients probably should just wait for future developments, with a liver biopsy scheduled for some future date.

Gary L. Davis, M.D., said interferon is likely to remain the basis of treatment even if the new antiviral agents in development prove useful.

Interferon will be necessary to combat the drug resistance that will undoubtedly arise with any new antiviral drug, said Dr. Davis of Baylor University, Houston.

At the meeting, early studies were presented on two new types of interferon, pegylated consensus interferon, which is a bioengineered interferon that can be given at a high dose, and an albumin-interferon fusion protein, which has a long half-life and would be given only once every 2–4 weeks. Both had good results in phase I or phase II trials, he said.

The antiviral drugs under study include viramidine, a precursor drug to ribavirin thought to cause less anemia, and several protease and polymerase inhibitors.

In a phase II trial presented at the meeting, viramidine showed a reduced incidence of anemia, Dr. Davis noted. In that trial, 27% of ribavirin-treated controls developed anemia. In comparison, no patients who received the lowest dose of viramidine (400 mg daily) developed anemia, and only 2% of those who received the middle dose (600 mg) developed anemia. Of those who received the highest dose, 11% developed anemia, a difference that was not statistically significant.

The 171-patient study was perhaps not large enough to address efficacy with certainty, and many patients dropped out. But the results suggest that the proportion of patients who achieved a virologic response at the end of treatment was similar in all of the groups, and there was less relapse 24 weeks after treatment in those treated with viramidine, reported Robert G. Gish, M.D., of the California Pacific Medical Center, San Francisco.

Some of the protease and polymerase inhibitors being investigated appear powerful, but they are just now entering meaningful clinical trials, Dr. Davis said.

CHICAGO — Watchful waiting may be the prudent approach now when a patient with hepatitis C does not respond to standard interferon treatment, speakers said at the annual Digestive Disease Week.

That's because a number of promising new approaches and treatments are on the horizon, including longer treatment regimens, a ribavirin prodrug called viramidine, hepatitis C virus protease and polymerase inhibitors, antifibrotic agents, and new interferons.

Currently, about 45% of patients treated with the standard regimen of weekly pegylated interferon-alfa-2a with daily ribavirin given for 48 weeks will not respond adequately, said John B. Gross Jr., M.D., of the Mayo Clinic, Rochester, Minn.

Factors known to be associated with treatment failure include infection with hepatitis C virus genotype 1, a high viral load, advanced hepatic fibrosis or cirrhosis, obesity, underdosing to counter side effects or nonadherence to treatment, and African American race.

Regarding underdosing and lack of adherence, it has been shown that a pronounced response to treatment within the first 12 weeks indicates a high likelihood of a sustained response. When a patient is at least 80% tolerant to initial dosing and adherent to treatment during those first 12 weeks, the percentage of patients achieving a sustained response goes from about 40% to 60%. But when the dose of both drugs needs to be lowered, the percentage drops to 33%, Dr. Gross noted.

Some researchers have been looking at weight-based dosing of ribavirin, which appears to improve virologic response. Others have been studying treatment beyond the usual 48 weeks, which appears to cut the relapse rate. The results of those studies are still preliminary, he noted.

Some patients who have not responded to initial interferon therapy probably can be treated again. Patients who would be candidates for a second round of treatment are those who were treated before the pegylated interferon era or combined interferon-ribavirin treatment, or those who were nonadherent the first time.

“It turns out the predictors of a more sustained viral response in this group are just the same as for treatment-naive patients,” Dr. Gross said.

Patients with advanced cirrhosis probably should be enrolled in a clinical trial, he added. But most patients probably should just wait for future developments, with a liver biopsy scheduled for some future date.

Gary L. Davis, M.D., said interferon is likely to remain the basis of treatment even if the new antiviral agents in development prove useful.

Interferon will be necessary to combat the drug resistance that will undoubtedly arise with any new antiviral drug, said Dr. Davis of Baylor University, Houston.

At the meeting, early studies were presented on two new types of interferon, pegylated consensus interferon, which is a bioengineered interferon that can be given at a high dose, and an albumin-interferon fusion protein, which has a long half-life and would be given only once every 2–4 weeks. Both had good results in phase I or phase II trials, he said.

The antiviral drugs under study include viramidine, a precursor drug to ribavirin thought to cause less anemia, and several protease and polymerase inhibitors.

In a phase II trial presented at the meeting, viramidine showed a reduced incidence of anemia, Dr. Davis noted. In that trial, 27% of ribavirin-treated controls developed anemia. In comparison, no patients who received the lowest dose of viramidine (400 mg daily) developed anemia, and only 2% of those who received the middle dose (600 mg) developed anemia. Of those who received the highest dose, 11% developed anemia, a difference that was not statistically significant.

The 171-patient study was perhaps not large enough to address efficacy with certainty, and many patients dropped out. But the results suggest that the proportion of patients who achieved a virologic response at the end of treatment was similar in all of the groups, and there was less relapse 24 weeks after treatment in those treated with viramidine, reported Robert G. Gish, M.D., of the California Pacific Medical Center, San Francisco.

Some of the protease and polymerase inhibitors being investigated appear powerful, but they are just now entering meaningful clinical trials, Dr. Davis said.

NAPLES, FLA. — In the last year, Michael B. Morgan, M.D., has seen four cases of angiosarcoma on the breast of women who previously underwent radiation therapy for breast cancer.

Historically, there are only about 100 cases of angiosarcoma a year in the United States, and normally they occur in “sun-battered” areas, said Dr. Morgan, a dermatopathologist who practices in Tampa.

“I think we are at the precipice here of a real interesting and deadly epidemiologic phenomenon,” he said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

“I don't want to be Chicken Little, but I honestly think we could be on the cusp of something big, and we need to be vigilant,” he added.

Angiosarcoma associated with irradiation of the breast was first noted back in the 1940s, and in that report it was said to be associated with chronic lymphedema. Since then, numerous other reports of angiosarcoma have appeared, but there has been controversy over whether the disease occurs frequently enough to warrant concern.

It may be, however, that not enough women have been followed long enough. His four cases were all women who had been treated for breast cancer 20 years previously, which corresponds roughly to the time that breast-conserving treatment with radiation became standard practice, Dr. Morgan said.

Older case series estimated an incidence of angiosarcoma in irradiated, breast-cancer patients of less than 1%; however, more recent series have suggested a prevalence of 1%, and perhaps 3%.

In a recent series of 27 cases seen at Indiana University, it was reported that only 5 of the 27 cases occurred within 3 years of irradiation treatment, and the median interval was 59 months (Am. J. Surg. Pathol. 2004;28:781–8), Dr. Morgan noted.

In that series, lymphedema was largely absent; this has also been true in Dr. Morgan's cases. However, since angiosarcoma can be associated with chronic lymphedema, Dr. Morgan said he is concerned about melanoma patients who have lymph nodes removed.

“I haven't seen this, but I worry about the rash of lymph nodes that we are taking out of people's arms and legs now with melanoma, and whether this indeed is going to end up being a risk,” he said.

The prognosis of angiosarcoma is very poor. In a series of 47 typical angiosarcoma patients reported by Dr. Morgan, the overall survival at 5 years was only 34%, and the local recurrence rate at 5 years was 84% (J. Am. Acad. Dermatol. 2004;50;867–74).

Clinically, a typical angiosarcoma starts out as a bruiselike macule that rapidly evolves into an erythematous patch, and then to a violaceous, ulcerated nodule or plaque. The angiosarcomas on the breast may be somewhat different, because the ones he has seen have mostly been flattened, tan-colored, indurated patches that looked a little like Kaposi's sarcoma, Dr. Morgan said. It can be multifocal at presentation.

Histologically, biopsies usually show a preserved epithelium, with extravasated red cells and lots of nuclei in the deeper dermis, as one would expect of a cancer that arises from endothelial cells of the arteriovenous or lymphatic structures, Dr. Morgan said. In later stages, one can clearly see a complex, vasiform pattern of growth. The most useful stain is CD31, which confirms the endothelial derivation of the neoplastic cells, he added.

In his case series, Dr. Morgan looked at prognostic factors. He found that mitotic rate and recurrence were bad prognostic factors. But, the most important factor was the depth of invasion, with a cutoff depth of 3 mm.

NAPLES, FLA. — In the last year, Michael B. Morgan, M.D., has seen four cases of angiosarcoma on the breast of women who previously underwent radiation therapy for breast cancer.

Historically, there are only about 100 cases of angiosarcoma a year in the United States, and normally they occur in “sun-battered” areas, said Dr. Morgan, a dermatopathologist who practices in Tampa.

“I think we are at the precipice here of a real interesting and deadly epidemiologic phenomenon,” he said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

“I don't want to be Chicken Little, but I honestly think we could be on the cusp of something big, and we need to be vigilant,” he added.

Angiosarcoma associated with irradiation of the breast was first noted back in the 1940s, and in that report it was said to be associated with chronic lymphedema. Since then, numerous other reports of angiosarcoma have appeared, but there has been controversy over whether the disease occurs frequently enough to warrant concern.

It may be, however, that not enough women have been followed long enough. His four cases were all women who had been treated for breast cancer 20 years previously, which corresponds roughly to the time that breast-conserving treatment with radiation became standard practice, Dr. Morgan said.

Older case series estimated an incidence of angiosarcoma in irradiated, breast-cancer patients of less than 1%; however, more recent series have suggested a prevalence of 1%, and perhaps 3%.

In a recent series of 27 cases seen at Indiana University, it was reported that only 5 of the 27 cases occurred within 3 years of irradiation treatment, and the median interval was 59 months (Am. J. Surg. Pathol. 2004;28:781–8), Dr. Morgan noted.

In that series, lymphedema was largely absent; this has also been true in Dr. Morgan's cases. However, since angiosarcoma can be associated with chronic lymphedema, Dr. Morgan said he is concerned about melanoma patients who have lymph nodes removed.

“I haven't seen this, but I worry about the rash of lymph nodes that we are taking out of people's arms and legs now with melanoma, and whether this indeed is going to end up being a risk,” he said.

The prognosis of angiosarcoma is very poor. In a series of 47 typical angiosarcoma patients reported by Dr. Morgan, the overall survival at 5 years was only 34%, and the local recurrence rate at 5 years was 84% (J. Am. Acad. Dermatol. 2004;50;867–74).

Clinically, a typical angiosarcoma starts out as a bruiselike macule that rapidly evolves into an erythematous patch, and then to a violaceous, ulcerated nodule or plaque. The angiosarcomas on the breast may be somewhat different, because the ones he has seen have mostly been flattened, tan-colored, indurated patches that looked a little like Kaposi's sarcoma, Dr. Morgan said. It can be multifocal at presentation.

Histologically, biopsies usually show a preserved epithelium, with extravasated red cells and lots of nuclei in the deeper dermis, as one would expect of a cancer that arises from endothelial cells of the arteriovenous or lymphatic structures, Dr. Morgan said. In later stages, one can clearly see a complex, vasiform pattern of growth. The most useful stain is CD31, which confirms the endothelial derivation of the neoplastic cells, he added.

In his case series, Dr. Morgan looked at prognostic factors. He found that mitotic rate and recurrence were bad prognostic factors. But, the most important factor was the depth of invasion, with a cutoff depth of 3 mm.

NAPLES, FLA. — In the last year, Michael B. Morgan, M.D., has seen four cases of angiosarcoma on the breast of women who previously underwent radiation therapy for breast cancer.

Historically, there are only about 100 cases of angiosarcoma a year in the United States, and normally they occur in “sun-battered” areas, said Dr. Morgan, a dermatopathologist who practices in Tampa.

“I think we are at the precipice here of a real interesting and deadly epidemiologic phenomenon,” he said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

“I don't want to be Chicken Little, but I honestly think we could be on the cusp of something big, and we need to be vigilant,” he added.

Angiosarcoma associated with irradiation of the breast was first noted back in the 1940s, and in that report it was said to be associated with chronic lymphedema. Since then, numerous other reports of angiosarcoma have appeared, but there has been controversy over whether the disease occurs frequently enough to warrant concern.

It may be, however, that not enough women have been followed long enough. His four cases were all women who had been treated for breast cancer 20 years previously, which corresponds roughly to the time that breast-conserving treatment with radiation became standard practice, Dr. Morgan said.

Older case series estimated an incidence of angiosarcoma in irradiated, breast-cancer patients of less than 1%; however, more recent series have suggested a prevalence of 1%, and perhaps 3%.

In a recent series of 27 cases seen at Indiana University, it was reported that only 5 of the 27 cases occurred within 3 years of irradiation treatment, and the median interval was 59 months (Am. J. Surg. Pathol. 2004;28:781–8), Dr. Morgan noted.

In that series, lymphedema was largely absent; this has also been true in Dr. Morgan's cases. However, since angiosarcoma can be associated with chronic lymphedema, Dr. Morgan said he is concerned about melanoma patients who have lymph nodes removed.

“I haven't seen this, but I worry about the rash of lymph nodes that we are taking out of people's arms and legs now with melanoma, and whether this indeed is going to end up being a risk,” he said.

The prognosis of angiosarcoma is very poor. In a series of 47 typical angiosarcoma patients reported by Dr. Morgan, the overall survival at 5 years was only 34%, and the local recurrence rate at 5 years was 84% (J. Am. Acad. Dermatol. 2004;50;867–74).

Clinically, a typical angiosarcoma starts out as a bruiselike macule that rapidly evolves into an erythematous patch, and then to a violaceous, ulcerated nodule or plaque. The angiosarcomas on the breast may be somewhat different, because the ones he has seen have mostly been flattened, tan-colored, indurated patches that looked a little like Kaposi's sarcoma, Dr. Morgan said. It can be multifocal at presentation.

Histologically, biopsies usually show a preserved epithelium, with extravasated red cells and lots of nuclei in the deeper dermis, as one would expect of a cancer that arises from endothelial cells of the arteriovenous or lymphatic structures, Dr. Morgan said. In later stages, one can clearly see a complex, vasiform pattern of growth. The most useful stain is CD31, which confirms the endothelial derivation of the neoplastic cells, he added.

In his case series, Dr. Morgan looked at prognostic factors. He found that mitotic rate and recurrence were bad prognostic factors. But, the most important factor was the depth of invasion, with a cutoff depth of 3 mm.