Timothy F. Kirn

SEATTLE — Behavioral training can help men with urinary incontinence after radical prostatectomy, Dr. Patricia S. Goode said at the annual meeting of the American Geriatrics Society.

“There are urology practices themselves that have developed wonderful expertise at behavioral training,” said Dr. Goode, medical director of the continence program at the University of Alabama, Birmingham. “Referral doesn't necessarily have to be to a continence center.”

In a recent published study, she and her group randomly assigned 125 men aged 53–68 years before prostatectomy to a single training session with biofeedback to allow them to learn to contract their pelvic floor muscles at will, or to a usual care control group.

After surgery, it took the men who received training a median of 3.5 months to stop leaking, versus 6 months in the control group. At 6 months, only 32% of the trained men were wearing pads, versus 52% of the control group. And, they calculated that the number of individuals who needed to be treated to stop one man from having to wear a pad was five.

In a study of 20 men aged 55–87 years who had been incontinent after prostatectomy for a mean of 2.5 years, Dr. Goode found that four sessions of training reduced incontinence accidents by 78%, and 3 of the subjects had no accidents after training.

Dr. Goode said that they use biofeedback to teach the men to contract their pelvic floor muscles, but one can also do it during a digital rectal exam, since one can feel when there is proper contraction.

Then the patients are sent home and told to do exercises at home, three times daily, contracting and then relaxing 15 times in a row. At first, she has them contract for 3 seconds and then relax for the same amount of time in each repetition, adding a few seconds a week until they get to hold the contractions for 10–15 seconds.

She tells patients to incorporate the exercises into their daily activities and routine, such as using certain television commercials as a cue. Patients also are told to contract the muscles before they sneeze or cough or are about to lift something or exert themselves. Patients who have urge incontinence also are taught to stop when they feel the urge, instead of rushing to the bathroom. They then are instructed to squeeze their pelvic floor until the urge eases. Then, they can walk calmly to the bathroom, stopping again if necessary.

Dr. Goode also recommends that men avoid caffeine.

ELSEVIER GLOBAL MEDICAL NEWS

SEATTLE — Behavioral training can help men with urinary incontinence after radical prostatectomy, Dr. Patricia S. Goode said at the annual meeting of the American Geriatrics Society.

“There are urology practices themselves that have developed wonderful expertise at behavioral training,” said Dr. Goode, medical director of the continence program at the University of Alabama, Birmingham. “Referral doesn't necessarily have to be to a continence center.”

In a recent published study, she and her group randomly assigned 125 men aged 53–68 years before prostatectomy to a single training session with biofeedback to allow them to learn to contract their pelvic floor muscles at will, or to a usual care control group.

After surgery, it took the men who received training a median of 3.5 months to stop leaking, versus 6 months in the control group. At 6 months, only 32% of the trained men were wearing pads, versus 52% of the control group. And, they calculated that the number of individuals who needed to be treated to stop one man from having to wear a pad was five.

In a study of 20 men aged 55–87 years who had been incontinent after prostatectomy for a mean of 2.5 years, Dr. Goode found that four sessions of training reduced incontinence accidents by 78%, and 3 of the subjects had no accidents after training.

Dr. Goode said that they use biofeedback to teach the men to contract their pelvic floor muscles, but one can also do it during a digital rectal exam, since one can feel when there is proper contraction.

Then the patients are sent home and told to do exercises at home, three times daily, contracting and then relaxing 15 times in a row. At first, she has them contract for 3 seconds and then relax for the same amount of time in each repetition, adding a few seconds a week until they get to hold the contractions for 10–15 seconds.

She tells patients to incorporate the exercises into their daily activities and routine, such as using certain television commercials as a cue. Patients also are told to contract the muscles before they sneeze or cough or are about to lift something or exert themselves. Patients who have urge incontinence also are taught to stop when they feel the urge, instead of rushing to the bathroom. They then are instructed to squeeze their pelvic floor until the urge eases. Then, they can walk calmly to the bathroom, stopping again if necessary.

Dr. Goode also recommends that men avoid caffeine.

ELSEVIER GLOBAL MEDICAL NEWS

SEATTLE — Behavioral training can help men with urinary incontinence after radical prostatectomy, Dr. Patricia S. Goode said at the annual meeting of the American Geriatrics Society.

“There are urology practices themselves that have developed wonderful expertise at behavioral training,” said Dr. Goode, medical director of the continence program at the University of Alabama, Birmingham. “Referral doesn't necessarily have to be to a continence center.”

In a recent published study, she and her group randomly assigned 125 men aged 53–68 years before prostatectomy to a single training session with biofeedback to allow them to learn to contract their pelvic floor muscles at will, or to a usual care control group.

After surgery, it took the men who received training a median of 3.5 months to stop leaking, versus 6 months in the control group. At 6 months, only 32% of the trained men were wearing pads, versus 52% of the control group. And, they calculated that the number of individuals who needed to be treated to stop one man from having to wear a pad was five.

In a study of 20 men aged 55–87 years who had been incontinent after prostatectomy for a mean of 2.5 years, Dr. Goode found that four sessions of training reduced incontinence accidents by 78%, and 3 of the subjects had no accidents after training.

Dr. Goode said that they use biofeedback to teach the men to contract their pelvic floor muscles, but one can also do it during a digital rectal exam, since one can feel when there is proper contraction.

Then the patients are sent home and told to do exercises at home, three times daily, contracting and then relaxing 15 times in a row. At first, she has them contract for 3 seconds and then relax for the same amount of time in each repetition, adding a few seconds a week until they get to hold the contractions for 10–15 seconds.

She tells patients to incorporate the exercises into their daily activities and routine, such as using certain television commercials as a cue. Patients also are told to contract the muscles before they sneeze or cough or are about to lift something or exert themselves. Patients who have urge incontinence also are taught to stop when they feel the urge, instead of rushing to the bathroom. They then are instructed to squeeze their pelvic floor until the urge eases. Then, they can walk calmly to the bathroom, stopping again if necessary.

Dr. Goode also recommends that men avoid caffeine.

ELSEVIER GLOBAL MEDICAL NEWS

SEATTLE — Low-testosterone problems are not as rare as you might think. That's because they are associated with two common problems: erectile dysfunction and metabolic syndrome, Dr. Richard F. Spark said at the annual meeting of the American Association of Clinical Endocrinologists.

“Some new developments indicate that there are a lot more patients with hypogonadism in your practice than we have been aware of,” said Dr. Spark, an endocrinologist at Beth Israel Deaconess Medical Center, Boston.

Dr. Spark said that one of the first reports that erectile dysfunction could be associated with low testosterone was his own, published in 1980. He measured serum testosterone in 105 consecutive patients who were seen for what was then called impotence. They found that 20 of those individuals had low serum testosterone, and when they were treated for that, their erectile dysfunction went away (JAMA 1980;243:750–5).

In 2000, a meta-analysis of studies of testosterone replacement suggested that 57% of patients with erectile dysfunction treated with testosterone had resolution of their problem, including 64% of those with primary hypogonadism (J. Urol. 2000;164:371–5).

Testosterone has gotten a bad rap because of all of the press about athletes who abuse anabolic steroids, and because the controversies regarding hormone therapy for women have made people wary of hormone replacement, Dr. Spark said.

Low testosterone has also been associated with type 2 diabetes and metabolic syndrome, he continued.

In a study of 103 men with type 2 diabetes, 33% were found to have low testosterone levels, and they found low testosterone in all the age groups in the study (J. Clin. Endocrinol. Metab. 2004;89:5462–8).

“The message here is to check testosterone in metabolic syndrome patients and look for metabolic syndrome in low-testosterone patients,” Dr. Spark said.

SEATTLE — Low-testosterone problems are not as rare as you might think. That's because they are associated with two common problems: erectile dysfunction and metabolic syndrome, Dr. Richard F. Spark said at the annual meeting of the American Association of Clinical Endocrinologists.

“Some new developments indicate that there are a lot more patients with hypogonadism in your practice than we have been aware of,” said Dr. Spark, an endocrinologist at Beth Israel Deaconess Medical Center, Boston.

Dr. Spark said that one of the first reports that erectile dysfunction could be associated with low testosterone was his own, published in 1980. He measured serum testosterone in 105 consecutive patients who were seen for what was then called impotence. They found that 20 of those individuals had low serum testosterone, and when they were treated for that, their erectile dysfunction went away (JAMA 1980;243:750–5).

In 2000, a meta-analysis of studies of testosterone replacement suggested that 57% of patients with erectile dysfunction treated with testosterone had resolution of their problem, including 64% of those with primary hypogonadism (J. Urol. 2000;164:371–5).

Testosterone has gotten a bad rap because of all of the press about athletes who abuse anabolic steroids, and because the controversies regarding hormone therapy for women have made people wary of hormone replacement, Dr. Spark said.

Low testosterone has also been associated with type 2 diabetes and metabolic syndrome, he continued.

In a study of 103 men with type 2 diabetes, 33% were found to have low testosterone levels, and they found low testosterone in all the age groups in the study (J. Clin. Endocrinol. Metab. 2004;89:5462–8).

“The message here is to check testosterone in metabolic syndrome patients and look for metabolic syndrome in low-testosterone patients,” Dr. Spark said.

SEATTLE — Low-testosterone problems are not as rare as you might think. That's because they are associated with two common problems: erectile dysfunction and metabolic syndrome, Dr. Richard F. Spark said at the annual meeting of the American Association of Clinical Endocrinologists.

“Some new developments indicate that there are a lot more patients with hypogonadism in your practice than we have been aware of,” said Dr. Spark, an endocrinologist at Beth Israel Deaconess Medical Center, Boston.

Dr. Spark said that one of the first reports that erectile dysfunction could be associated with low testosterone was his own, published in 1980. He measured serum testosterone in 105 consecutive patients who were seen for what was then called impotence. They found that 20 of those individuals had low serum testosterone, and when they were treated for that, their erectile dysfunction went away (JAMA 1980;243:750–5).

In 2000, a meta-analysis of studies of testosterone replacement suggested that 57% of patients with erectile dysfunction treated with testosterone had resolution of their problem, including 64% of those with primary hypogonadism (J. Urol. 2000;164:371–5).

Testosterone has gotten a bad rap because of all of the press about athletes who abuse anabolic steroids, and because the controversies regarding hormone therapy for women have made people wary of hormone replacement, Dr. Spark said.

Low testosterone has also been associated with type 2 diabetes and metabolic syndrome, he continued.

In a study of 103 men with type 2 diabetes, 33% were found to have low testosterone levels, and they found low testosterone in all the age groups in the study (J. Clin. Endocrinol. Metab. 2004;89:5462–8).

“The message here is to check testosterone in metabolic syndrome patients and look for metabolic syndrome in low-testosterone patients,” Dr. Spark said.

SEATTLE — Type 2 diabetes is more than just the loss of insulin sensitivity. It also is clearly related to a loss of β-cells and islet function, probably mediated to some extent by amyloid deposits, Dr. Stephen E. Kahn said at the annual meeting of the American Association of Clinical Endocrinologists.

The disease process of type 2 diabetes “appears to be very similar in many ways to what happens in Alzheimer's disease,” said Dr. Kahn, a professor of internal medicine at the University of Washington, Seattle.

Studies by his group and others have clearly shown that persons with type 2 diabetes have attenuated insulin secretion in response to glucose and that the beginning of this loss of β cells, and β-cell function, precedes the development of diabetes in many cases, he said.

This explains why the trial known as ADOPT (A Diabetes Outcome Progression Trial) showed that rosiglitazone treatment was better than metformin at curtailing progression of type 2 diabetes, and metformin was better than glyburide, said Dr. Kahn, who is also an associate chief of staff at the Veterans Affairs Puget Sound Health Care System in Washington.

The study showed that rosiglitazone treatment resulted in a 62% reduction in risk of progression from monotherapy of type 2 diabetes to add-on therapy relative to glyburide, and a 32% risk reduction relative to metformin (N. Engl. J. Med. 2006;355:2427–43).

The reason was that glyburide increased insulin secretion but did not change insulin sensitivity, so over time, the β cells could not keep up, Dr. Kahn said. Rosiglitazone and metformin, on the other hand, increased insulin sensitivity, lessening the demand on the β cells and preserving their function.

Although there are a number of causes that may be leading to β-cell loss, Dr. Kahn said his recent research has demonstrated that part of it is caused by the deposition of amyloid.

To conduct those experiments, Dr. Kahn and his colleagues had to develop a transgenic mouse that gets amyloid deposits in its islets, something that does not happen normally in the mouse but does happen in humans with type 2 diabetes.

With these mice, Dr. Kahn's group has shown that feeding the animals a high-fat diet resulted in more islets with amyloid deposits, a greater portion of each islet given over to amyloid at the expense of β cells, and a decline insulin secretion (Diabetes 2003;52:372–9).

Next, his group treated the mice with rosiglitazone and metformin while feeding them the high-fat diet, and showed that the treatment prevented amyloid deposition. This occurred presumably because the β cells were not working as hard when the mice were on one of those drugs, and deposition is related to how hard the cells are functioning (Diabetes 2005;54:2235–44).

“It's clearly very provocative and suggests that this may be one mechanism by which these drugs provide better durability than sulfonylureas, which we would predict would increase secretion and result in more amyloid production on a high-fat diet,” he said.

Most recently, his group has looked at why islet transplants fail using this model, because it has been clear for some time that failure is not because of the autoimmune response attacking β cells only. To look at this, they transplanted two groups of mice: one group with transgenic islets that could produce amyloid deposits like a human and one group with nontransgenic islets.

The experiments showed that in the 11 of 12 mice with amyloid potential, the amyloid deposits actually occurred and that there was a clear correlation between the amount of amyloid deposited and the number of β-cell deaths.

They also found that amyloid appeared to prevent new β-cell replication, Dr. Kahn said. “This is the mechanism that might also be going on in type 2 diabetes.”

SEATTLE — Type 2 diabetes is more than just the loss of insulin sensitivity. It also is clearly related to a loss of β-cells and islet function, probably mediated to some extent by amyloid deposits, Dr. Stephen E. Kahn said at the annual meeting of the American Association of Clinical Endocrinologists.

The disease process of type 2 diabetes “appears to be very similar in many ways to what happens in Alzheimer's disease,” said Dr. Kahn, a professor of internal medicine at the University of Washington, Seattle.

Studies by his group and others have clearly shown that persons with type 2 diabetes have attenuated insulin secretion in response to glucose and that the beginning of this loss of β cells, and β-cell function, precedes the development of diabetes in many cases, he said.

This explains why the trial known as ADOPT (A Diabetes Outcome Progression Trial) showed that rosiglitazone treatment was better than metformin at curtailing progression of type 2 diabetes, and metformin was better than glyburide, said Dr. Kahn, who is also an associate chief of staff at the Veterans Affairs Puget Sound Health Care System in Washington.

The study showed that rosiglitazone treatment resulted in a 62% reduction in risk of progression from monotherapy of type 2 diabetes to add-on therapy relative to glyburide, and a 32% risk reduction relative to metformin (N. Engl. J. Med. 2006;355:2427–43).

The reason was that glyburide increased insulin secretion but did not change insulin sensitivity, so over time, the β cells could not keep up, Dr. Kahn said. Rosiglitazone and metformin, on the other hand, increased insulin sensitivity, lessening the demand on the β cells and preserving their function.

Although there are a number of causes that may be leading to β-cell loss, Dr. Kahn said his recent research has demonstrated that part of it is caused by the deposition of amyloid.

To conduct those experiments, Dr. Kahn and his colleagues had to develop a transgenic mouse that gets amyloid deposits in its islets, something that does not happen normally in the mouse but does happen in humans with type 2 diabetes.

With these mice, Dr. Kahn's group has shown that feeding the animals a high-fat diet resulted in more islets with amyloid deposits, a greater portion of each islet given over to amyloid at the expense of β cells, and a decline insulin secretion (Diabetes 2003;52:372–9).

Next, his group treated the mice with rosiglitazone and metformin while feeding them the high-fat diet, and showed that the treatment prevented amyloid deposition. This occurred presumably because the β cells were not working as hard when the mice were on one of those drugs, and deposition is related to how hard the cells are functioning (Diabetes 2005;54:2235–44).

“It's clearly very provocative and suggests that this may be one mechanism by which these drugs provide better durability than sulfonylureas, which we would predict would increase secretion and result in more amyloid production on a high-fat diet,” he said.

Most recently, his group has looked at why islet transplants fail using this model, because it has been clear for some time that failure is not because of the autoimmune response attacking β cells only. To look at this, they transplanted two groups of mice: one group with transgenic islets that could produce amyloid deposits like a human and one group with nontransgenic islets.

The experiments showed that in the 11 of 12 mice with amyloid potential, the amyloid deposits actually occurred and that there was a clear correlation between the amount of amyloid deposited and the number of β-cell deaths.

They also found that amyloid appeared to prevent new β-cell replication, Dr. Kahn said. “This is the mechanism that might also be going on in type 2 diabetes.”

SEATTLE — Type 2 diabetes is more than just the loss of insulin sensitivity. It also is clearly related to a loss of β-cells and islet function, probably mediated to some extent by amyloid deposits, Dr. Stephen E. Kahn said at the annual meeting of the American Association of Clinical Endocrinologists.

The disease process of type 2 diabetes “appears to be very similar in many ways to what happens in Alzheimer's disease,” said Dr. Kahn, a professor of internal medicine at the University of Washington, Seattle.

Studies by his group and others have clearly shown that persons with type 2 diabetes have attenuated insulin secretion in response to glucose and that the beginning of this loss of β cells, and β-cell function, precedes the development of diabetes in many cases, he said.

This explains why the trial known as ADOPT (A Diabetes Outcome Progression Trial) showed that rosiglitazone treatment was better than metformin at curtailing progression of type 2 diabetes, and metformin was better than glyburide, said Dr. Kahn, who is also an associate chief of staff at the Veterans Affairs Puget Sound Health Care System in Washington.

The study showed that rosiglitazone treatment resulted in a 62% reduction in risk of progression from monotherapy of type 2 diabetes to add-on therapy relative to glyburide, and a 32% risk reduction relative to metformin (N. Engl. J. Med. 2006;355:2427–43).

The reason was that glyburide increased insulin secretion but did not change insulin sensitivity, so over time, the β cells could not keep up, Dr. Kahn said. Rosiglitazone and metformin, on the other hand, increased insulin sensitivity, lessening the demand on the β cells and preserving their function.

Although there are a number of causes that may be leading to β-cell loss, Dr. Kahn said his recent research has demonstrated that part of it is caused by the deposition of amyloid.

To conduct those experiments, Dr. Kahn and his colleagues had to develop a transgenic mouse that gets amyloid deposits in its islets, something that does not happen normally in the mouse but does happen in humans with type 2 diabetes.

With these mice, Dr. Kahn's group has shown that feeding the animals a high-fat diet resulted in more islets with amyloid deposits, a greater portion of each islet given over to amyloid at the expense of β cells, and a decline insulin secretion (Diabetes 2003;52:372–9).

Next, his group treated the mice with rosiglitazone and metformin while feeding them the high-fat diet, and showed that the treatment prevented amyloid deposition. This occurred presumably because the β cells were not working as hard when the mice were on one of those drugs, and deposition is related to how hard the cells are functioning (Diabetes 2005;54:2235–44).

“It's clearly very provocative and suggests that this may be one mechanism by which these drugs provide better durability than sulfonylureas, which we would predict would increase secretion and result in more amyloid production on a high-fat diet,” he said.

Most recently, his group has looked at why islet transplants fail using this model, because it has been clear for some time that failure is not because of the autoimmune response attacking β cells only. To look at this, they transplanted two groups of mice: one group with transgenic islets that could produce amyloid deposits like a human and one group with nontransgenic islets.

The experiments showed that in the 11 of 12 mice with amyloid potential, the amyloid deposits actually occurred and that there was a clear correlation between the amount of amyloid deposited and the number of β-cell deaths.

They also found that amyloid appeared to prevent new β-cell replication, Dr. Kahn said. “This is the mechanism that might also be going on in type 2 diabetes.”

SAN FRANCISCO — New HIV and AIDS cases still occur most commonly in the gay male population, and one of the reasons may be because a substantial proportion of infected persons do not know that they are infected.

“We increasingly have been focused on [new infection cases in] women, but the only group in which we have evidence that HIV or AIDS cases are increasing is in the group of men who have sex with men,” Dr. Susan Buchbinder said at a meeting on HIV management sponsored by the University of California, San Francisco.

A high proportion of infected persons are not aware of their serostatus; they engage in risky behavior and come in for testing and treatment way too late, said Dr. Buchbinder, the director of the HIV research section of the San Francisco Department of Public Health.

About 40% of all new HIV/AIDS diagnoses in 2001 were in men who have sex with men (MSM), and by 2004, that figure had risen to 45%, according to Dr. Buchbinder.

Figures from the Centers for Disease Control and Prevention indicate that there were 16,625 new cases in the transmission category of male-to-male sexual contact in 2001. By 2004, there were 18,203.

The annual number of cases in other transmission categories—including intravenous drug use and heterosexual contact—remain flat or are declining.

Another salient feature of the epidemic's evolution is that although roughly 80% of cases still occur in major metropolitan areas, increasing numbers of HIV/AIDS cases are occurring among women in suburban and rural areas, Dr. Buchbinder noted. A disturbing feature of these cases is that almost half of the women are getting infected through heterosexual contact with a man whose risk factor they do not know.

“This is that hidden epidemic … that is increasingly moving into less populated areas and heavily impacting women in this country,” she said.

Dr. Buchbinder also discussed the new CDC guidelines for HIV testing adopted in September 2006, which call for “opt-out” testing, meaning that all patients are informed that they will undergo testing unless they choose to forgo it.

The rationale for the new guidelines is based on the estimation that at least 25% of infected persons in the United States are not aware of their serostatus, and that too many people seek treatment when it is too late.

Dr. Buchbinder said that in some populations, the number of people who are not aware that they are HIV positive might be even higher than the estimated one-quarter. In 2004–2005, the CDC randomly interviewed and tested gay men in four cities and found that 48% of those tested were unaware of their infection (MMWR 2005;54:597–601).

Moreover, of those testing positive for the virus the first time, 38% do so within 1 year of developing AIDS. That is too late, said Dr. Buchbinder. People who know that they are HIV positive report that they change their behavior, and the earlier treatment starts, the better, she added.

In a large retrospective review of data from Kaiser Permanente patients going back to the mid-1990s, the investigators found that 43% of patients had a CD4 cell count of fewer than 200 cells/mcL when they first were tested as positive, and another 19% had CD4 cell counts of 200–350 cells/mcL, the point at which it is advised that antiviral treatment should start (J. Acquir. Immune Defic. Syndr. 2003;32:143–52).

Those patients could perhaps have been detected earlier because the group had been in the Kaiser system for a mean of 5 years before testing positive. However, only 26% of the patients had their intravenous drug abuse history or their homosexual activity—possible pointers to infection risk factors—documented in their charts before they tested positive, Dr. Buchbinder noted.

Dr. Buchbinder also discussed the practice of “serosorting.” In serosorting, men who know they are HIV positive modify their behavior depending on their partner's HIV status, such that they have sex only with other men who are positive, or always use a condom when having sex with a negative partner, or ensure that the positive partner is always the receptive partner when having anal sex with a negative partner because of the perceived lower risk of transmission.

She added that data from San Francisco and California suggest that since the late 1990s, the number of MSMs who have unprotected anal sex and the number of cases of rectal gonorrhea and syphilis have increased. However, in San Francisco—where many infected men report that they have sex with uninfected partners less frequently since becoming aware of their serostatus—the HIV infection rates do not seem to be increasing to the same extent.

SAN FRANCISCO — New HIV and AIDS cases still occur most commonly in the gay male population, and one of the reasons may be because a substantial proportion of infected persons do not know that they are infected.

“We increasingly have been focused on [new infection cases in] women, but the only group in which we have evidence that HIV or AIDS cases are increasing is in the group of men who have sex with men,” Dr. Susan Buchbinder said at a meeting on HIV management sponsored by the University of California, San Francisco.

A high proportion of infected persons are not aware of their serostatus; they engage in risky behavior and come in for testing and treatment way too late, said Dr. Buchbinder, the director of the HIV research section of the San Francisco Department of Public Health.

About 40% of all new HIV/AIDS diagnoses in 2001 were in men who have sex with men (MSM), and by 2004, that figure had risen to 45%, according to Dr. Buchbinder.

Figures from the Centers for Disease Control and Prevention indicate that there were 16,625 new cases in the transmission category of male-to-male sexual contact in 2001. By 2004, there were 18,203.

The annual number of cases in other transmission categories—including intravenous drug use and heterosexual contact—remain flat or are declining.

Another salient feature of the epidemic's evolution is that although roughly 80% of cases still occur in major metropolitan areas, increasing numbers of HIV/AIDS cases are occurring among women in suburban and rural areas, Dr. Buchbinder noted. A disturbing feature of these cases is that almost half of the women are getting infected through heterosexual contact with a man whose risk factor they do not know.

“This is that hidden epidemic … that is increasingly moving into less populated areas and heavily impacting women in this country,” she said.

Dr. Buchbinder also discussed the new CDC guidelines for HIV testing adopted in September 2006, which call for “opt-out” testing, meaning that all patients are informed that they will undergo testing unless they choose to forgo it.

The rationale for the new guidelines is based on the estimation that at least 25% of infected persons in the United States are not aware of their serostatus, and that too many people seek treatment when it is too late.

Dr. Buchbinder said that in some populations, the number of people who are not aware that they are HIV positive might be even higher than the estimated one-quarter. In 2004–2005, the CDC randomly interviewed and tested gay men in four cities and found that 48% of those tested were unaware of their infection (MMWR 2005;54:597–601).

Moreover, of those testing positive for the virus the first time, 38% do so within 1 year of developing AIDS. That is too late, said Dr. Buchbinder. People who know that they are HIV positive report that they change their behavior, and the earlier treatment starts, the better, she added.

In a large retrospective review of data from Kaiser Permanente patients going back to the mid-1990s, the investigators found that 43% of patients had a CD4 cell count of fewer than 200 cells/mcL when they first were tested as positive, and another 19% had CD4 cell counts of 200–350 cells/mcL, the point at which it is advised that antiviral treatment should start (J. Acquir. Immune Defic. Syndr. 2003;32:143–52).

Those patients could perhaps have been detected earlier because the group had been in the Kaiser system for a mean of 5 years before testing positive. However, only 26% of the patients had their intravenous drug abuse history or their homosexual activity—possible pointers to infection risk factors—documented in their charts before they tested positive, Dr. Buchbinder noted.

Dr. Buchbinder also discussed the practice of “serosorting.” In serosorting, men who know they are HIV positive modify their behavior depending on their partner's HIV status, such that they have sex only with other men who are positive, or always use a condom when having sex with a negative partner, or ensure that the positive partner is always the receptive partner when having anal sex with a negative partner because of the perceived lower risk of transmission.

She added that data from San Francisco and California suggest that since the late 1990s, the number of MSMs who have unprotected anal sex and the number of cases of rectal gonorrhea and syphilis have increased. However, in San Francisco—where many infected men report that they have sex with uninfected partners less frequently since becoming aware of their serostatus—the HIV infection rates do not seem to be increasing to the same extent.

SAN FRANCISCO — New HIV and AIDS cases still occur most commonly in the gay male population, and one of the reasons may be because a substantial proportion of infected persons do not know that they are infected.

“We increasingly have been focused on [new infection cases in] women, but the only group in which we have evidence that HIV or AIDS cases are increasing is in the group of men who have sex with men,” Dr. Susan Buchbinder said at a meeting on HIV management sponsored by the University of California, San Francisco.

A high proportion of infected persons are not aware of their serostatus; they engage in risky behavior and come in for testing and treatment way too late, said Dr. Buchbinder, the director of the HIV research section of the San Francisco Department of Public Health.

About 40% of all new HIV/AIDS diagnoses in 2001 were in men who have sex with men (MSM), and by 2004, that figure had risen to 45%, according to Dr. Buchbinder.

Figures from the Centers for Disease Control and Prevention indicate that there were 16,625 new cases in the transmission category of male-to-male sexual contact in 2001. By 2004, there were 18,203.

The annual number of cases in other transmission categories—including intravenous drug use and heterosexual contact—remain flat or are declining.

Another salient feature of the epidemic's evolution is that although roughly 80% of cases still occur in major metropolitan areas, increasing numbers of HIV/AIDS cases are occurring among women in suburban and rural areas, Dr. Buchbinder noted. A disturbing feature of these cases is that almost half of the women are getting infected through heterosexual contact with a man whose risk factor they do not know.

“This is that hidden epidemic … that is increasingly moving into less populated areas and heavily impacting women in this country,” she said.

Dr. Buchbinder also discussed the new CDC guidelines for HIV testing adopted in September 2006, which call for “opt-out” testing, meaning that all patients are informed that they will undergo testing unless they choose to forgo it.

The rationale for the new guidelines is based on the estimation that at least 25% of infected persons in the United States are not aware of their serostatus, and that too many people seek treatment when it is too late.

Dr. Buchbinder said that in some populations, the number of people who are not aware that they are HIV positive might be even higher than the estimated one-quarter. In 2004–2005, the CDC randomly interviewed and tested gay men in four cities and found that 48% of those tested were unaware of their infection (MMWR 2005;54:597–601).

Moreover, of those testing positive for the virus the first time, 38% do so within 1 year of developing AIDS. That is too late, said Dr. Buchbinder. People who know that they are HIV positive report that they change their behavior, and the earlier treatment starts, the better, she added.

In a large retrospective review of data from Kaiser Permanente patients going back to the mid-1990s, the investigators found that 43% of patients had a CD4 cell count of fewer than 200 cells/mcL when they first were tested as positive, and another 19% had CD4 cell counts of 200–350 cells/mcL, the point at which it is advised that antiviral treatment should start (J. Acquir. Immune Defic. Syndr. 2003;32:143–52).

Those patients could perhaps have been detected earlier because the group had been in the Kaiser system for a mean of 5 years before testing positive. However, only 26% of the patients had their intravenous drug abuse history or their homosexual activity—possible pointers to infection risk factors—documented in their charts before they tested positive, Dr. Buchbinder noted.

Dr. Buchbinder also discussed the practice of “serosorting.” In serosorting, men who know they are HIV positive modify their behavior depending on their partner's HIV status, such that they have sex only with other men who are positive, or always use a condom when having sex with a negative partner, or ensure that the positive partner is always the receptive partner when having anal sex with a negative partner because of the perceived lower risk of transmission.

She added that data from San Francisco and California suggest that since the late 1990s, the number of MSMs who have unprotected anal sex and the number of cases of rectal gonorrhea and syphilis have increased. However, in San Francisco—where many infected men report that they have sex with uninfected partners less frequently since becoming aware of their serostatus—the HIV infection rates do not seem to be increasing to the same extent.

SAN DIEGO — Antidepressant use could be associated with an increased risk of metabolic syndrome among adult psychiatric inpatients, Stephen B. Woolley, D.Sc., reported at the annual meeting of the American Psychiatric Association.

Dr. Woolley and his colleagues found a 40% increased risk of metabolic syndrome in adult psychiatric inpatients taking an antidepressant. Their study also found that 70% of the inpatients had at least one abnormal marker for metabolic syndrome—putting them at risk for cardiovascular disease, and going on to develop metabolic syndrome and diabetes, said Dr. Woolley of the Institute of Living at the Hartford [Conn.] Hospital.

The investigators reviewed records from 2,075 consecutive inpatients discharged from the Institute of Living in 2005 and 2006, and looked for the presence or absence of each of the five criteria for metabolic syndrome from the Adult Treatment Panel III.

The criteria are central adiposity, measured by waist circumference (greater than 40 inches in men and 35 inches in women); fasting blood triglycerides greater than or equal to 150 mg/dL; an HDL cholesterol level less than 40 mg/dL in men and 50 mg/dL in women; blood pressure greater than or equal to 130/85 mm Hg; and a fasting glucose greater than or equal to 110 mg/dL.

The presence of any three of the criteria indicates metabolic syndrome.

The study by Dr. Woolley and his colleagues also found that taking an antidepressant was most strongly associated with an 80% increased risk of dyslipidemia among the inpatients with schizophrenia, a 60% increased risk among those with schizoaffective disorder, and a 120% increased risk among those with major depressive disorder.

Because the study looked only at patients' hospital records, the investigators were unable to determine whether the use of selective serotonin reuptake inhibitors or other antidepressants by themselves might have been the cause of those increased risks, Dr. Woolley said.

Another explanation could be that depressed patients have greater obesity, are more sedentary, and generally live harder lives.

“We found a higher risk in all patients on antidepressants,” Dr. Woolley simply noted.

If the findings are related to something other than the antidepressants specifically, they might be less surprising, said Dr. John W. Goethe, director of the Burlingame Center for Psychiatric Research and Education at the Institute of Living, who presented secondary results from the study.

That is because there is already an observed connection: Metabolic syndrome has been shown to predict a higher risk of later major depressive disorder, Dr. Goethe said.

Overall, the study found that the presence of metabolic syndrome in the patients was 25%, with a range of 24% for patients with bipolar disorder, to 30% for patients with schizophrenia, to 41% for patients with schizoaffective disorder.

Besides the use of antidepressants, another significant predictor of metabolic syndrome in the patients was the use of two antipsychotics, which increased the risk 2.4 times (almost four times for schizophrenia patients). Another predictor was age greater than or equal to 40 years, which increased the risk three times.

The study also found that patients with bipolar disorder were 11 times more likely to have hypertension, compared with patients with other diagnoses, and patients with major depressive disorder were 13 times more likely to have hypertension.

In another part of the study, the investigators took the 317 patients with a depressive disorder, and matched them to figures from the National Health and Nutritional Examination Survey (NHANES) database of the general population, Dr. Goethe said.

Eighty-eight percent of the bipolar and major depressive disorder patients met at least one metabolic syndrome criteria, and 32% met three criteria.

That compared with 71% of the general population reported by the NHANES survey to meet one criterion, and 24% reported to have the metabolic syndrome.

More than 50% of the patients met the waist criteria, and 24% met the dyslipidemia criteria, Dr. Goethe noted.

SAN DIEGO — Antidepressant use could be associated with an increased risk of metabolic syndrome among adult psychiatric inpatients, Stephen B. Woolley, D.Sc., reported at the annual meeting of the American Psychiatric Association.

Dr. Woolley and his colleagues found a 40% increased risk of metabolic syndrome in adult psychiatric inpatients taking an antidepressant. Their study also found that 70% of the inpatients had at least one abnormal marker for metabolic syndrome—putting them at risk for cardiovascular disease, and going on to develop metabolic syndrome and diabetes, said Dr. Woolley of the Institute of Living at the Hartford [Conn.] Hospital.

The investigators reviewed records from 2,075 consecutive inpatients discharged from the Institute of Living in 2005 and 2006, and looked for the presence or absence of each of the five criteria for metabolic syndrome from the Adult Treatment Panel III.

The criteria are central adiposity, measured by waist circumference (greater than 40 inches in men and 35 inches in women); fasting blood triglycerides greater than or equal to 150 mg/dL; an HDL cholesterol level less than 40 mg/dL in men and 50 mg/dL in women; blood pressure greater than or equal to 130/85 mm Hg; and a fasting glucose greater than or equal to 110 mg/dL.

The presence of any three of the criteria indicates metabolic syndrome.

The study by Dr. Woolley and his colleagues also found that taking an antidepressant was most strongly associated with an 80% increased risk of dyslipidemia among the inpatients with schizophrenia, a 60% increased risk among those with schizoaffective disorder, and a 120% increased risk among those with major depressive disorder.

Because the study looked only at patients' hospital records, the investigators were unable to determine whether the use of selective serotonin reuptake inhibitors or other antidepressants by themselves might have been the cause of those increased risks, Dr. Woolley said.

Another explanation could be that depressed patients have greater obesity, are more sedentary, and generally live harder lives.

“We found a higher risk in all patients on antidepressants,” Dr. Woolley simply noted.

If the findings are related to something other than the antidepressants specifically, they might be less surprising, said Dr. John W. Goethe, director of the Burlingame Center for Psychiatric Research and Education at the Institute of Living, who presented secondary results from the study.

That is because there is already an observed connection: Metabolic syndrome has been shown to predict a higher risk of later major depressive disorder, Dr. Goethe said.

Overall, the study found that the presence of metabolic syndrome in the patients was 25%, with a range of 24% for patients with bipolar disorder, to 30% for patients with schizophrenia, to 41% for patients with schizoaffective disorder.

Besides the use of antidepressants, another significant predictor of metabolic syndrome in the patients was the use of two antipsychotics, which increased the risk 2.4 times (almost four times for schizophrenia patients). Another predictor was age greater than or equal to 40 years, which increased the risk three times.

The study also found that patients with bipolar disorder were 11 times more likely to have hypertension, compared with patients with other diagnoses, and patients with major depressive disorder were 13 times more likely to have hypertension.

In another part of the study, the investigators took the 317 patients with a depressive disorder, and matched them to figures from the National Health and Nutritional Examination Survey (NHANES) database of the general population, Dr. Goethe said.

Eighty-eight percent of the bipolar and major depressive disorder patients met at least one metabolic syndrome criteria, and 32% met three criteria.

That compared with 71% of the general population reported by the NHANES survey to meet one criterion, and 24% reported to have the metabolic syndrome.

More than 50% of the patients met the waist criteria, and 24% met the dyslipidemia criteria, Dr. Goethe noted.

SAN DIEGO — Antidepressant use could be associated with an increased risk of metabolic syndrome among adult psychiatric inpatients, Stephen B. Woolley, D.Sc., reported at the annual meeting of the American Psychiatric Association.

Dr. Woolley and his colleagues found a 40% increased risk of metabolic syndrome in adult psychiatric inpatients taking an antidepressant. Their study also found that 70% of the inpatients had at least one abnormal marker for metabolic syndrome—putting them at risk for cardiovascular disease, and going on to develop metabolic syndrome and diabetes, said Dr. Woolley of the Institute of Living at the Hartford [Conn.] Hospital.

The investigators reviewed records from 2,075 consecutive inpatients discharged from the Institute of Living in 2005 and 2006, and looked for the presence or absence of each of the five criteria for metabolic syndrome from the Adult Treatment Panel III.

The criteria are central adiposity, measured by waist circumference (greater than 40 inches in men and 35 inches in women); fasting blood triglycerides greater than or equal to 150 mg/dL; an HDL cholesterol level less than 40 mg/dL in men and 50 mg/dL in women; blood pressure greater than or equal to 130/85 mm Hg; and a fasting glucose greater than or equal to 110 mg/dL.

The presence of any three of the criteria indicates metabolic syndrome.

The study by Dr. Woolley and his colleagues also found that taking an antidepressant was most strongly associated with an 80% increased risk of dyslipidemia among the inpatients with schizophrenia, a 60% increased risk among those with schizoaffective disorder, and a 120% increased risk among those with major depressive disorder.

Because the study looked only at patients' hospital records, the investigators were unable to determine whether the use of selective serotonin reuptake inhibitors or other antidepressants by themselves might have been the cause of those increased risks, Dr. Woolley said.

Another explanation could be that depressed patients have greater obesity, are more sedentary, and generally live harder lives.

“We found a higher risk in all patients on antidepressants,” Dr. Woolley simply noted.

If the findings are related to something other than the antidepressants specifically, they might be less surprising, said Dr. John W. Goethe, director of the Burlingame Center for Psychiatric Research and Education at the Institute of Living, who presented secondary results from the study.

That is because there is already an observed connection: Metabolic syndrome has been shown to predict a higher risk of later major depressive disorder, Dr. Goethe said.

Overall, the study found that the presence of metabolic syndrome in the patients was 25%, with a range of 24% for patients with bipolar disorder, to 30% for patients with schizophrenia, to 41% for patients with schizoaffective disorder.

Besides the use of antidepressants, another significant predictor of metabolic syndrome in the patients was the use of two antipsychotics, which increased the risk 2.4 times (almost four times for schizophrenia patients). Another predictor was age greater than or equal to 40 years, which increased the risk three times.

The study also found that patients with bipolar disorder were 11 times more likely to have hypertension, compared with patients with other diagnoses, and patients with major depressive disorder were 13 times more likely to have hypertension.

In another part of the study, the investigators took the 317 patients with a depressive disorder, and matched them to figures from the National Health and Nutritional Examination Survey (NHANES) database of the general population, Dr. Goethe said.

Eighty-eight percent of the bipolar and major depressive disorder patients met at least one metabolic syndrome criteria, and 32% met three criteria.

That compared with 71% of the general population reported by the NHANES survey to meet one criterion, and 24% reported to have the metabolic syndrome.

More than 50% of the patients met the waist criteria, and 24% met the dyslipidemia criteria, Dr. Goethe noted.

SEATTLE – Pain complaints are so common in older patients with depression, and vice versa, that pain can be used as a signal to pick up depression that would otherwise be missed, Dr. Sumer Verma said at the annual scientific meeting of the American Geriatrics Society.

“Pain is a core symptom of depression, [and] physical symptoms are a major part of the depressive disorder,” said Dr. Verma, director of the Geriatric Psychiatry Education Programs, McLean Hospital in Belmont, Mass. “Not recognizing them, and not taking account of them, is basically not diagnosing depression, and if you don't diagnose it, you are not going to treat it adequately.”

Most patients with depression are not treated aggressively enough, creating the impression treatment is not very effective, Dr. Verma said. Many patients are told they may stop their medication when they first have a response, but that is generally not long enough, he said.

There are several pain and depression studies, Dr. Verma explained at a symposium sponsored by Eli Lilly & Co.

One study of 1,146 patients who met criteria for a major depressive disorder found that 69% came to the doctor with just complaints of physical symptoms. In another study, of 685 patients meeting criteria for depression, 80% reported painful physical symptoms. And, finally, a survey that used data from 118,533 Canadian patients said that the strongest predictor of major depressive disorder was chronic back pain.

There also appears to be a direct correlation between depression and how many physical symptoms a person has. In one study, 1% of those individuals with no physical symptoms or one symptom were depressed. But the rate increased as the number of symptoms increased, until, among those who had nine or more symptoms, the rate was 48%.

In addition, a study in 2003 reported that depression tended to last much longer in those with painful physical symptoms, an average of 19 months, compared with those without pain for an average of 13 months.

This evidence means that older patients who have pain should be queried about mood and/or evaluated for depression, especially since depression is so common in the elderly, Dr. Verma said.

Despite the fact that acknowledgement of depression has improved in recent years, it is still vastly underaddressed, he added. In 2003, one report from a household survey of more than 9,000 persons found that only 22% of persons with a major depressive disorder received adequate treatment. In that study, 48% of those with a major depressive disorder received no treatment at all. Of those who received less than optimal treatment, 58% received inadequate treatment, and 42% received minimally adequate treatment.

The reason that so many patients are not adequately treated is because drug treatment often stops after a few months when the patient has a response, but also still has some symptoms. But, persons with some improvement who still have a few symptoms when their treatment ends have a threefold higher risk of relapse than those with no symptoms, Dr. Verma said. That same study also reported that patients with residual symptoms relapsed three times faster.

Patients need to be pushed all the way into remission, he said. That often means 8–9 months of aggressive treatment, and maybe longer.

“Once you've got someone responding, you've got to keep treating them with the same dose of the drug for at least 9 months,” he said.

The drug chosen for a patient should be the one most likely to be effective, not the drug with the most acceptable side-effect profile, as many experts used to advise, he said. The most effective drug may be one the patient previously used that worked.

If one drug does not work, then another can be tried, he noted.

Remission can be judged by scores on standardized tests, but the definition of remission is the easiest metric to use in clinical practice, and the definition of remission is complete functional restoration, Dr. Verma said.

“What should be most important is that there are no symptoms or very few symptoms left, and the person is back to usual function. Anything short of that is inadequate treatment,” he said.

When patients are treated aggressively, 65% will have significant improvement and fully 50% will achieve remission, he said. But the treatment must be aggressive. Moreover, in the patients with pain, the depression is more likely to be significantly improved by depression treatment than is the pain, but that is no reason not to do it, Dr. Verma said. “Treat them to the point they are well, and keep them there,” he said.

SEATTLE – Pain complaints are so common in older patients with depression, and vice versa, that pain can be used as a signal to pick up depression that would otherwise be missed, Dr. Sumer Verma said at the annual scientific meeting of the American Geriatrics Society.

“Pain is a core symptom of depression, [and] physical symptoms are a major part of the depressive disorder,” said Dr. Verma, director of the Geriatric Psychiatry Education Programs, McLean Hospital in Belmont, Mass. “Not recognizing them, and not taking account of them, is basically not diagnosing depression, and if you don't diagnose it, you are not going to treat it adequately.”

Most patients with depression are not treated aggressively enough, creating the impression treatment is not very effective, Dr. Verma said. Many patients are told they may stop their medication when they first have a response, but that is generally not long enough, he said.

There are several pain and depression studies, Dr. Verma explained at a symposium sponsored by Eli Lilly & Co.

One study of 1,146 patients who met criteria for a major depressive disorder found that 69% came to the doctor with just complaints of physical symptoms. In another study, of 685 patients meeting criteria for depression, 80% reported painful physical symptoms. And, finally, a survey that used data from 118,533 Canadian patients said that the strongest predictor of major depressive disorder was chronic back pain.

There also appears to be a direct correlation between depression and how many physical symptoms a person has. In one study, 1% of those individuals with no physical symptoms or one symptom were depressed. But the rate increased as the number of symptoms increased, until, among those who had nine or more symptoms, the rate was 48%.

In addition, a study in 2003 reported that depression tended to last much longer in those with painful physical symptoms, an average of 19 months, compared with those without pain for an average of 13 months.

This evidence means that older patients who have pain should be queried about mood and/or evaluated for depression, especially since depression is so common in the elderly, Dr. Verma said.

Despite the fact that acknowledgement of depression has improved in recent years, it is still vastly underaddressed, he added. In 2003, one report from a household survey of more than 9,000 persons found that only 22% of persons with a major depressive disorder received adequate treatment. In that study, 48% of those with a major depressive disorder received no treatment at all. Of those who received less than optimal treatment, 58% received inadequate treatment, and 42% received minimally adequate treatment.

The reason that so many patients are not adequately treated is because drug treatment often stops after a few months when the patient has a response, but also still has some symptoms. But, persons with some improvement who still have a few symptoms when their treatment ends have a threefold higher risk of relapse than those with no symptoms, Dr. Verma said. That same study also reported that patients with residual symptoms relapsed three times faster.

Patients need to be pushed all the way into remission, he said. That often means 8–9 months of aggressive treatment, and maybe longer.

“Once you've got someone responding, you've got to keep treating them with the same dose of the drug for at least 9 months,” he said.

The drug chosen for a patient should be the one most likely to be effective, not the drug with the most acceptable side-effect profile, as many experts used to advise, he said. The most effective drug may be one the patient previously used that worked.

If one drug does not work, then another can be tried, he noted.

Remission can be judged by scores on standardized tests, but the definition of remission is the easiest metric to use in clinical practice, and the definition of remission is complete functional restoration, Dr. Verma said.

“What should be most important is that there are no symptoms or very few symptoms left, and the person is back to usual function. Anything short of that is inadequate treatment,” he said.

When patients are treated aggressively, 65% will have significant improvement and fully 50% will achieve remission, he said. But the treatment must be aggressive. Moreover, in the patients with pain, the depression is more likely to be significantly improved by depression treatment than is the pain, but that is no reason not to do it, Dr. Verma said. “Treat them to the point they are well, and keep them there,” he said.

SEATTLE – Pain complaints are so common in older patients with depression, and vice versa, that pain can be used as a signal to pick up depression that would otherwise be missed, Dr. Sumer Verma said at the annual scientific meeting of the American Geriatrics Society.

“Pain is a core symptom of depression, [and] physical symptoms are a major part of the depressive disorder,” said Dr. Verma, director of the Geriatric Psychiatry Education Programs, McLean Hospital in Belmont, Mass. “Not recognizing them, and not taking account of them, is basically not diagnosing depression, and if you don't diagnose it, you are not going to treat it adequately.”

Most patients with depression are not treated aggressively enough, creating the impression treatment is not very effective, Dr. Verma said. Many patients are told they may stop their medication when they first have a response, but that is generally not long enough, he said.

There are several pain and depression studies, Dr. Verma explained at a symposium sponsored by Eli Lilly & Co.

One study of 1,146 patients who met criteria for a major depressive disorder found that 69% came to the doctor with just complaints of physical symptoms. In another study, of 685 patients meeting criteria for depression, 80% reported painful physical symptoms. And, finally, a survey that used data from 118,533 Canadian patients said that the strongest predictor of major depressive disorder was chronic back pain.

There also appears to be a direct correlation between depression and how many physical symptoms a person has. In one study, 1% of those individuals with no physical symptoms or one symptom were depressed. But the rate increased as the number of symptoms increased, until, among those who had nine or more symptoms, the rate was 48%.

In addition, a study in 2003 reported that depression tended to last much longer in those with painful physical symptoms, an average of 19 months, compared with those without pain for an average of 13 months.

This evidence means that older patients who have pain should be queried about mood and/or evaluated for depression, especially since depression is so common in the elderly, Dr. Verma said.

Despite the fact that acknowledgement of depression has improved in recent years, it is still vastly underaddressed, he added. In 2003, one report from a household survey of more than 9,000 persons found that only 22% of persons with a major depressive disorder received adequate treatment. In that study, 48% of those with a major depressive disorder received no treatment at all. Of those who received less than optimal treatment, 58% received inadequate treatment, and 42% received minimally adequate treatment.

The reason that so many patients are not adequately treated is because drug treatment often stops after a few months when the patient has a response, but also still has some symptoms. But, persons with some improvement who still have a few symptoms when their treatment ends have a threefold higher risk of relapse than those with no symptoms, Dr. Verma said. That same study also reported that patients with residual symptoms relapsed three times faster.

Patients need to be pushed all the way into remission, he said. That often means 8–9 months of aggressive treatment, and maybe longer.

“Once you've got someone responding, you've got to keep treating them with the same dose of the drug for at least 9 months,” he said.

The drug chosen for a patient should be the one most likely to be effective, not the drug with the most acceptable side-effect profile, as many experts used to advise, he said. The most effective drug may be one the patient previously used that worked.

If one drug does not work, then another can be tried, he noted.

Remission can be judged by scores on standardized tests, but the definition of remission is the easiest metric to use in clinical practice, and the definition of remission is complete functional restoration, Dr. Verma said.

“What should be most important is that there are no symptoms or very few symptoms left, and the person is back to usual function. Anything short of that is inadequate treatment,” he said.

When patients are treated aggressively, 65% will have significant improvement and fully 50% will achieve remission, he said. But the treatment must be aggressive. Moreover, in the patients with pain, the depression is more likely to be significantly improved by depression treatment than is the pain, but that is no reason not to do it, Dr. Verma said. “Treat them to the point they are well, and keep them there,” he said.

SAN FRANCISCO — New HIV and AIDS cases still occur most commonly in the gay male population, and one of the reasons may be because a substantial proportion of infected persons do not know that they are infected.

“We increasingly have been focused on [new infection cases in] women, but the only group in which we have evidence that HIV or AIDS cases are increasing is in the group of men who have sex with men,” Dr. Susan Buchbinder said at a meeting on HIV management sponsored by the University of California, San Francisco.

A high proportion of infected persons are not aware of their serostatus; they engage in risky behavior and come in for testing and treatment way too late, said Dr. Buchbinder, the director of the HIV research section of the San Francisco Department of Public Health.

About 40% of all new HIV/AIDS diagnoses in 2001 were in men who have sex with men (MSM), and by 2004, that figure had risen to 45%, according to Dr. Buchbinder.

Figures from the Centers for Disease Control and Prevention indicate that there were 16,625 new cases in the transmission category of male-to-male sexual contact in 2001. By 2004, there were 18,203.

The annual number of cases in other transmission categories—including intravenous drug use and heterosexual contact—remain flat or are declining.

Another salient feature of the epidemic's evolution is that although roughly 80% of cases still occur in major metropolitan areas, increasing numbers of HIV/AIDS cases are occurring among women in suburban and rural areas, Dr. Buchbinder noted. A disturbing feature of these cases is that almost half of the women are getting infected through heterosexual contact with a man whose risk factor they do not know.

“This is that hidden epidemic … that is increasingly moving into less populated areas and heavily impacting women in this country,” she said.

Dr. Buchbinder also discussed the new CDC guidelines for HIV testing adopted in September 2006, which call for “opt-out” testing, meaning that all patients are informed that they will undergo testing unless they choose to forgo it.

The rationale for the new guidelines is based on the estimation that at least 25% of infected persons in the United States are not aware of their serostatus, and that too many people seek treatment when it is too late.

Dr. Buchbinder said that in some populations, the number of people who are not aware that they are HIV positive might be even higher than the estimated one-quarter. In 2004–2005, the CDC randomly interviewed and tested gay men in four cities and found that 48% of those tested were unaware of their infection (MMWR 2005;54:597–601).

Moreover, of those testing positive for the virus the first time, 38% do so within 1 year of developing AIDS. That is too late, said Dr. Buchbinder. People who know that they are HIV positive report that they change their behavior, and the earlier treatment starts, the better, she added.

In a large retrospective review of data from Kaiser Permanente patients going back to the mid-1990s, the investigators found that 43% of patients had a CD4 cell count of fewer than 200 cells/mcL when they first were tested as positive, and another 19% had CD4 cell counts of 200–350 cells/mcL, the point at which it is advised that antiviral treatment should start (J. Acquir. Immune Defic. Syndr. 2003;32:143–52).

Those patients could perhaps have been detected earlier because the group had been in the Kaiser system for a mean of 5 years before testing positive. However, only 26% of the patients had their intravenous drug abuse history or their homosexual activity—possible pointers to infection risk factors—documented in their charts before they tested positive, Dr. Buchbinder noted.

Dr. Buchbinder also discussed the practice of “serosorting.” In serosorting, men who know they are HIV positive modify their behavior depending on their partner's HIV status, such that they have sex only with other men who are positive, or always use a condom when having sex with a negative partner, or ensure that the positive partner is always the receptive partner when having anal sex with a negative partner because of the perceived lower risk of transmission.

She added that data from San Francisco and California suggest that since the late 1990s, the number of MSMs who have unprotected anal sex and the number of cases of rectal gonorrhea and syphilis have increased. However, in San Francisco—where many infected men report that they have sex with uninfected partners less frequently since becoming aware of their serostatus—the HIV infection rates do not seem to be increasing to the same extent.

SAN FRANCISCO — New HIV and AIDS cases still occur most commonly in the gay male population, and one of the reasons may be because a substantial proportion of infected persons do not know that they are infected.

“We increasingly have been focused on [new infection cases in] women, but the only group in which we have evidence that HIV or AIDS cases are increasing is in the group of men who have sex with men,” Dr. Susan Buchbinder said at a meeting on HIV management sponsored by the University of California, San Francisco.

A high proportion of infected persons are not aware of their serostatus; they engage in risky behavior and come in for testing and treatment way too late, said Dr. Buchbinder, the director of the HIV research section of the San Francisco Department of Public Health.

About 40% of all new HIV/AIDS diagnoses in 2001 were in men who have sex with men (MSM), and by 2004, that figure had risen to 45%, according to Dr. Buchbinder.

Figures from the Centers for Disease Control and Prevention indicate that there were 16,625 new cases in the transmission category of male-to-male sexual contact in 2001. By 2004, there were 18,203.

The annual number of cases in other transmission categories—including intravenous drug use and heterosexual contact—remain flat or are declining.

Another salient feature of the epidemic's evolution is that although roughly 80% of cases still occur in major metropolitan areas, increasing numbers of HIV/AIDS cases are occurring among women in suburban and rural areas, Dr. Buchbinder noted. A disturbing feature of these cases is that almost half of the women are getting infected through heterosexual contact with a man whose risk factor they do not know.

“This is that hidden epidemic … that is increasingly moving into less populated areas and heavily impacting women in this country,” she said.

Dr. Buchbinder also discussed the new CDC guidelines for HIV testing adopted in September 2006, which call for “opt-out” testing, meaning that all patients are informed that they will undergo testing unless they choose to forgo it.

The rationale for the new guidelines is based on the estimation that at least 25% of infected persons in the United States are not aware of their serostatus, and that too many people seek treatment when it is too late.

Dr. Buchbinder said that in some populations, the number of people who are not aware that they are HIV positive might be even higher than the estimated one-quarter. In 2004–2005, the CDC randomly interviewed and tested gay men in four cities and found that 48% of those tested were unaware of their infection (MMWR 2005;54:597–601).

Moreover, of those testing positive for the virus the first time, 38% do so within 1 year of developing AIDS. That is too late, said Dr. Buchbinder. People who know that they are HIV positive report that they change their behavior, and the earlier treatment starts, the better, she added.

In a large retrospective review of data from Kaiser Permanente patients going back to the mid-1990s, the investigators found that 43% of patients had a CD4 cell count of fewer than 200 cells/mcL when they first were tested as positive, and another 19% had CD4 cell counts of 200–350 cells/mcL, the point at which it is advised that antiviral treatment should start (J. Acquir. Immune Defic. Syndr. 2003;32:143–52).

Those patients could perhaps have been detected earlier because the group had been in the Kaiser system for a mean of 5 years before testing positive. However, only 26% of the patients had their intravenous drug abuse history or their homosexual activity—possible pointers to infection risk factors—documented in their charts before they tested positive, Dr. Buchbinder noted.

Dr. Buchbinder also discussed the practice of “serosorting.” In serosorting, men who know they are HIV positive modify their behavior depending on their partner's HIV status, such that they have sex only with other men who are positive, or always use a condom when having sex with a negative partner, or ensure that the positive partner is always the receptive partner when having anal sex with a negative partner because of the perceived lower risk of transmission.

She added that data from San Francisco and California suggest that since the late 1990s, the number of MSMs who have unprotected anal sex and the number of cases of rectal gonorrhea and syphilis have increased. However, in San Francisco—where many infected men report that they have sex with uninfected partners less frequently since becoming aware of their serostatus—the HIV infection rates do not seem to be increasing to the same extent.

SAN FRANCISCO — New HIV and AIDS cases still occur most commonly in the gay male population, and one of the reasons may be because a substantial proportion of infected persons do not know that they are infected.

“We increasingly have been focused on [new infection cases in] women, but the only group in which we have evidence that HIV or AIDS cases are increasing is in the group of men who have sex with men,” Dr. Susan Buchbinder said at a meeting on HIV management sponsored by the University of California, San Francisco.

A high proportion of infected persons are not aware of their serostatus; they engage in risky behavior and come in for testing and treatment way too late, said Dr. Buchbinder, the director of the HIV research section of the San Francisco Department of Public Health.

About 40% of all new HIV/AIDS diagnoses in 2001 were in men who have sex with men (MSM), and by 2004, that figure had risen to 45%, according to Dr. Buchbinder.

Figures from the Centers for Disease Control and Prevention indicate that there were 16,625 new cases in the transmission category of male-to-male sexual contact in 2001. By 2004, there were 18,203.

The annual number of cases in other transmission categories—including intravenous drug use and heterosexual contact—remain flat or are declining.

Another salient feature of the epidemic's evolution is that although roughly 80% of cases still occur in major metropolitan areas, increasing numbers of HIV/AIDS cases are occurring among women in suburban and rural areas, Dr. Buchbinder noted. A disturbing feature of these cases is that almost half of the women are getting infected through heterosexual contact with a man whose risk factor they do not know.

“This is that hidden epidemic … that is increasingly moving into less populated areas and heavily impacting women in this country,” she said.

Dr. Buchbinder also discussed the new CDC guidelines for HIV testing adopted in September 2006, which call for “opt-out” testing, meaning that all patients are informed that they will undergo testing unless they choose to forgo it.

The rationale for the new guidelines is based on the estimation that at least 25% of infected persons in the United States are not aware of their serostatus, and that too many people seek treatment when it is too late.

Dr. Buchbinder said that in some populations, the number of people who are not aware that they are HIV positive might be even higher than the estimated one-quarter. In 2004–2005, the CDC randomly interviewed and tested gay men in four cities and found that 48% of those tested were unaware of their infection (MMWR 2005;54:597–601).

Moreover, of those testing positive for the virus the first time, 38% do so within 1 year of developing AIDS. That is too late, said Dr. Buchbinder. People who know that they are HIV positive report that they change their behavior, and the earlier treatment starts, the better, she added.

In a large retrospective review of data from Kaiser Permanente patients going back to the mid-1990s, the investigators found that 43% of patients had a CD4 cell count of fewer than 200 cells/mcL when they first were tested as positive, and another 19% had CD4 cell counts of 200–350 cells/mcL, the point at which it is advised that antiviral treatment should start (J. Acquir. Immune Defic. Syndr. 2003;32:143–52).

Those patients could perhaps have been detected earlier because the group had been in the Kaiser system for a mean of 5 years before testing positive. However, only 26% of the patients had their intravenous drug abuse history or their homosexual activity—possible pointers to infection risk factors—documented in their charts before they tested positive, Dr. Buchbinder noted.

Dr. Buchbinder also discussed the practice of “serosorting.” In serosorting, men who know they are HIV positive modify their behavior depending on their partner's HIV status, such that they have sex only with other men who are positive, or always use a condom when having sex with a negative partner, or ensure that the positive partner is always the receptive partner when having anal sex with a negative partner because of the perceived lower risk of transmission.

She added that data from San Francisco and California suggest that since the late 1990s, the number of MSMs who have unprotected anal sex and the number of cases of rectal gonorrhea and syphilis have increased. However, in San Francisco—where many infected men report that they have sex with uninfected partners less frequently since becoming aware of their serostatus—the HIV infection rates do not seem to be increasing to the same extent.

LOS ANGELES — Hirsutism may be the most reliable way to recognize polycystic ovary syndrome because excess hair is so common with the condition.

But be sure that the patient truly has hirsutism and not just hypertrichosis, Dr. Ricardo Azziz said at a meeting of the Obstetrical and Gynecological Assembly of Southern California.

Hirsutism, which affects 7% of women, is more than a cosmetic problem. It is a sign of the single most common endocrine abnormality today, polycystic ovary syndrome (PCOS), a condition with significant morbidity and mortality, he said.

“There is a myth that perhaps the most common cause of hirsutism is idiopathic hirsutism, and that is incorrect,” said Dr. Azziz of the Center for Androgen-Related Disorders at Cedars-Sinai Medical Center, Los Angeles. “The vast majority of women with hirsutism will have a disorder.”

PCOS is a diagnosis of exclusion, Dr. Azziz said. Ninety-five percent of tumors are detected clinically, not by androgen testing.

For ruling out other conditions, the patient's history (Are the signs and symptoms new or established?) and the physical examination (Is the patient cushingoid?) are key, he said.

Hirsutism needs to be distinguished from hypertrichosis, he said. Many women have fine, downy, villous hairs. But hirsutism requires terminal hairs—hairs more than 5 mm in length, with a hard core, often curly or pigmented—arranged in a male pattern.

If one looks for terminal hairs only on the chin and the belly, one will miss many cases of hirsutism. That's in part because those are the areas many women can see and pluck or shave, Dr. Azziz said.

“The most common mistake examiners make is that they don't do an undressed full-body exam,” he said.

He uses a modified Ferriman-Gallwey scale to rate hairiness in male-pattern areas, which do not include the lower arms and legs, where many nonhirsute women are hairy.

Once a physician gets acquainted with using the scale, it can be quite helpful, particularly because laboratory measurements of androgen levels are quite unreliable in that the normal range is so great, he said. “If you do it in all the patients, over time, your data will be reliable within your practice,” he said.

Medical therapy generally requires two arms, blocking androgen production and blocking its activity, according to Dr. Azziz.

The best approach to blocking androgen production is an oral contraceptive. Many endocrinologists recommend metformin for hirsutism.

But metformin has a less direct effect on androgen production than an oral contraceptive, and its efficacy for hirsutism is “modest” at best, Dr. Azziz said. Glucocorticoids should not be used because they induce insulin insensitivity and therefore can worsen the metabolic profile of patients with hirsutism.

In addition to inhibiting androgen production, treatment should block androgen activity also, because the hair follicles are already sensitized. Available medications include spironolactone, flutamide, and finasteride.

Of those, Dr. Azziz said he most often uses spironolactone, starting at a dose of 25 mg/day and escalating, if necessary, up to a maximum of 200 mg/day. Most patients will adjust and become tolerant to the diuretic effect of the medication.

Treated individuals need to have patience, he noted. When patients are treated with combination therapy for androgen excess, acne will resolve first, in about 2 months. Anovulation, when that is part of the goal of treatment, will resolve in 2–3 months. But hirsutism takes between 2 and 8 months to begin improving.

About 80% of patients will have a good response with combination therapy.

In the meantime, good options for the patient include shaving and eflornithine HCL (Vaniqa), although eflornithine is approved only for use on the face, and it is not known what effect greater application might have.

Plucking is probably not a good idea because it can cause folliculitis.

Waxing removes hair, but it is essentially like plucking and does not destroy the hair follicle, except when it is used long term.

LOS ANGELES — Hirsutism may be the most reliable way to recognize polycystic ovary syndrome because excess hair is so common with the condition.

But be sure that the patient truly has hirsutism and not just hypertrichosis, Dr. Ricardo Azziz said at a meeting of the Obstetrical and Gynecological Assembly of Southern California.

Hirsutism, which affects 7% of women, is more than a cosmetic problem. It is a sign of the single most common endocrine abnormality today, polycystic ovary syndrome (PCOS), a condition with significant morbidity and mortality, he said.

“There is a myth that perhaps the most common cause of hirsutism is idiopathic hirsutism, and that is incorrect,” said Dr. Azziz of the Center for Androgen-Related Disorders at Cedars-Sinai Medical Center, Los Angeles. “The vast majority of women with hirsutism will have a disorder.”

PCOS is a diagnosis of exclusion, Dr. Azziz said. Ninety-five percent of tumors are detected clinically, not by androgen testing.

For ruling out other conditions, the patient's history (Are the signs and symptoms new or established?) and the physical examination (Is the patient cushingoid?) are key, he said.

Hirsutism needs to be distinguished from hypertrichosis, he said. Many women have fine, downy, villous hairs. But hirsutism requires terminal hairs—hairs more than 5 mm in length, with a hard core, often curly or pigmented—arranged in a male pattern.

If one looks for terminal hairs only on the chin and the belly, one will miss many cases of hirsutism. That's in part because those are the areas many women can see and pluck or shave, Dr. Azziz said.

“The most common mistake examiners make is that they don't do an undressed full-body exam,” he said.

He uses a modified Ferriman-Gallwey scale to rate hairiness in male-pattern areas, which do not include the lower arms and legs, where many nonhirsute women are hairy.

Once a physician gets acquainted with using the scale, it can be quite helpful, particularly because laboratory measurements of androgen levels are quite unreliable in that the normal range is so great, he said. “If you do it in all the patients, over time, your data will be reliable within your practice,” he said.

Medical therapy generally requires two arms, blocking androgen production and blocking its activity, according to Dr. Azziz.

The best approach to blocking androgen production is an oral contraceptive. Many endocrinologists recommend metformin for hirsutism.

But metformin has a less direct effect on androgen production than an oral contraceptive, and its efficacy for hirsutism is “modest” at best, Dr. Azziz said. Glucocorticoids should not be used because they induce insulin insensitivity and therefore can worsen the metabolic profile of patients with hirsutism.

In addition to inhibiting androgen production, treatment should block androgen activity also, because the hair follicles are already sensitized. Available medications include spironolactone, flutamide, and finasteride.

Of those, Dr. Azziz said he most often uses spironolactone, starting at a dose of 25 mg/day and escalating, if necessary, up to a maximum of 200 mg/day. Most patients will adjust and become tolerant to the diuretic effect of the medication.

Treated individuals need to have patience, he noted. When patients are treated with combination therapy for androgen excess, acne will resolve first, in about 2 months. Anovulation, when that is part of the goal of treatment, will resolve in 2–3 months. But hirsutism takes between 2 and 8 months to begin improving.

About 80% of patients will have a good response with combination therapy.

In the meantime, good options for the patient include shaving and eflornithine HCL (Vaniqa), although eflornithine is approved only for use on the face, and it is not known what effect greater application might have.

Plucking is probably not a good idea because it can cause folliculitis.

Waxing removes hair, but it is essentially like plucking and does not destroy the hair follicle, except when it is used long term.

LOS ANGELES — Hirsutism may be the most reliable way to recognize polycystic ovary syndrome because excess hair is so common with the condition.

But be sure that the patient truly has hirsutism and not just hypertrichosis, Dr. Ricardo Azziz said at a meeting of the Obstetrical and Gynecological Assembly of Southern California.

Hirsutism, which affects 7% of women, is more than a cosmetic problem. It is a sign of the single most common endocrine abnormality today, polycystic ovary syndrome (PCOS), a condition with significant morbidity and mortality, he said.

“There is a myth that perhaps the most common cause of hirsutism is idiopathic hirsutism, and that is incorrect,” said Dr. Azziz of the Center for Androgen-Related Disorders at Cedars-Sinai Medical Center, Los Angeles. “The vast majority of women with hirsutism will have a disorder.”

PCOS is a diagnosis of exclusion, Dr. Azziz said. Ninety-five percent of tumors are detected clinically, not by androgen testing.

For ruling out other conditions, the patient's history (Are the signs and symptoms new or established?) and the physical examination (Is the patient cushingoid?) are key, he said.

Hirsutism needs to be distinguished from hypertrichosis, he said. Many women have fine, downy, villous hairs. But hirsutism requires terminal hairs—hairs more than 5 mm in length, with a hard core, often curly or pigmented—arranged in a male pattern.

If one looks for terminal hairs only on the chin and the belly, one will miss many cases of hirsutism. That's in part because those are the areas many women can see and pluck or shave, Dr. Azziz said.

“The most common mistake examiners make is that they don't do an undressed full-body exam,” he said.

He uses a modified Ferriman-Gallwey scale to rate hairiness in male-pattern areas, which do not include the lower arms and legs, where many nonhirsute women are hairy.

Once a physician gets acquainted with using the scale, it can be quite helpful, particularly because laboratory measurements of androgen levels are quite unreliable in that the normal range is so great, he said. “If you do it in all the patients, over time, your data will be reliable within your practice,” he said.

Medical therapy generally requires two arms, blocking androgen production and blocking its activity, according to Dr. Azziz.

The best approach to blocking androgen production is an oral contraceptive. Many endocrinologists recommend metformin for hirsutism.

But metformin has a less direct effect on androgen production than an oral contraceptive, and its efficacy for hirsutism is “modest” at best, Dr. Azziz said. Glucocorticoids should not be used because they induce insulin insensitivity and therefore can worsen the metabolic profile of patients with hirsutism.

In addition to inhibiting androgen production, treatment should block androgen activity also, because the hair follicles are already sensitized. Available medications include spironolactone, flutamide, and finasteride.

Of those, Dr. Azziz said he most often uses spironolactone, starting at a dose of 25 mg/day and escalating, if necessary, up to a maximum of 200 mg/day. Most patients will adjust and become tolerant to the diuretic effect of the medication.

Treated individuals need to have patience, he noted. When patients are treated with combination therapy for androgen excess, acne will resolve first, in about 2 months. Anovulation, when that is part of the goal of treatment, will resolve in 2–3 months. But hirsutism takes between 2 and 8 months to begin improving.

About 80% of patients will have a good response with combination therapy.

In the meantime, good options for the patient include shaving and eflornithine HCL (Vaniqa), although eflornithine is approved only for use on the face, and it is not known what effect greater application might have.

Plucking is probably not a good idea because it can cause folliculitis.

Waxing removes hair, but it is essentially like plucking and does not destroy the hair follicle, except when it is used long term.

LOS ANGELES — HIV-positive patients on antiretroviral therapy who are prescribed lipid-lowering agents do not respond to those drugs as well as other patients do, according to a large retrospective study by Kaiser Permanente.

The HIV patients were only 57% as likely to reach the National Cholesterol Education Program's Adult Treatment Panel III (ATP-III) lipid goals with treatment, compared with patients not HIV infected, Michael Silverberg, Ph.D., and his colleagues said in a poster presentation at the 14th Conference on Retroviruses and Opportunistic Infections.

The HIV patients also had a mean drop in total cholesterol that was lower than the change in controls (18% vs. 22%), as well as lower drops in LDL cholesterol (22% vs. 24%) and in triglycerides (36% vs. 53%).

Few previous studies have investigated the response of HIV patients on antiretroviral therapy to lipid-lowering treatment, said Dr. Silverberg of the division of research, Kaiser Permanente Northern California, Oakland. Their investigation analyzed data from all the HIV patients in their health system seen between 1996 and 2005 who met the ATP-III definition of dyslipidemia, and compared them each with 10 controls, matched for age, sex, and first year of lipidemia, who also received lipid-lowering therapy.

The study also found that HIV patients on a regimen of a protease inhibitor plus a nonnucleoside reverse transcriptase inhibitor had the lowest reductions in total cholesterol and triglycerides of any of the HIV patients. Their mean reduction in total cholesterol was 17%, and their mean reduction in triglycerides was 16%.

The most common lipid-lowering therapy used in the patients and the controls was a statin, and pravastatin was used more commonly in the HIV patients than in the controls, Dr. Silverberg said.

LOS ANGELES — HIV-positive patients on antiretroviral therapy who are prescribed lipid-lowering agents do not respond to those drugs as well as other patients do, according to a large retrospective study by Kaiser Permanente.

The HIV patients were only 57% as likely to reach the National Cholesterol Education Program's Adult Treatment Panel III (ATP-III) lipid goals with treatment, compared with patients not HIV infected, Michael Silverberg, Ph.D., and his colleagues said in a poster presentation at the 14th Conference on Retroviruses and Opportunistic Infections.

The HIV patients also had a mean drop in total cholesterol that was lower than the change in controls (18% vs. 22%), as well as lower drops in LDL cholesterol (22% vs. 24%) and in triglycerides (36% vs. 53%).

Few previous studies have investigated the response of HIV patients on antiretroviral therapy to lipid-lowering treatment, said Dr. Silverberg of the division of research, Kaiser Permanente Northern California, Oakland. Their investigation analyzed data from all the HIV patients in their health system seen between 1996 and 2005 who met the ATP-III definition of dyslipidemia, and compared them each with 10 controls, matched for age, sex, and first year of lipidemia, who also received lipid-lowering therapy.

The study also found that HIV patients on a regimen of a protease inhibitor plus a nonnucleoside reverse transcriptase inhibitor had the lowest reductions in total cholesterol and triglycerides of any of the HIV patients. Their mean reduction in total cholesterol was 17%, and their mean reduction in triglycerides was 16%.

The most common lipid-lowering therapy used in the patients and the controls was a statin, and pravastatin was used more commonly in the HIV patients than in the controls, Dr. Silverberg said.

LOS ANGELES — HIV-positive patients on antiretroviral therapy who are prescribed lipid-lowering agents do not respond to those drugs as well as other patients do, according to a large retrospective study by Kaiser Permanente.

The HIV patients were only 57% as likely to reach the National Cholesterol Education Program's Adult Treatment Panel III (ATP-III) lipid goals with treatment, compared with patients not HIV infected, Michael Silverberg, Ph.D., and his colleagues said in a poster presentation at the 14th Conference on Retroviruses and Opportunistic Infections.

The HIV patients also had a mean drop in total cholesterol that was lower than the change in controls (18% vs. 22%), as well as lower drops in LDL cholesterol (22% vs. 24%) and in triglycerides (36% vs. 53%).

Few previous studies have investigated the response of HIV patients on antiretroviral therapy to lipid-lowering treatment, said Dr. Silverberg of the division of research, Kaiser Permanente Northern California, Oakland. Their investigation analyzed data from all the HIV patients in their health system seen between 1996 and 2005 who met the ATP-III definition of dyslipidemia, and compared them each with 10 controls, matched for age, sex, and first year of lipidemia, who also received lipid-lowering therapy.

The study also found that HIV patients on a regimen of a protease inhibitor plus a nonnucleoside reverse transcriptase inhibitor had the lowest reductions in total cholesterol and triglycerides of any of the HIV patients. Their mean reduction in total cholesterol was 17%, and their mean reduction in triglycerides was 16%.

The most common lipid-lowering therapy used in the patients and the controls was a statin, and pravastatin was used more commonly in the HIV patients than in the controls, Dr. Silverberg said.

LOS ANGELES — Obesity, like cardiovascular disease risk, can originate in the womb, a phenomenon that could have important implications in managing the current obesity epidemic, Dr. Thomas R. Moore said at a meeting of the Obstetrical and Gynecological Assembly of Southern California.

Much evidence now indicates that infants born to mothers with diabetes are likely to become overweight children and adults. They are also more likely to develop gestational diabetes and possibly diabetes as adults.

However, the evidence also seems to suggest that infants born underweight may face a similar risk of obesity and are more likely to experience cardiovascular disease, said Dr. Moore, the chairman of the department of reproductive medicine at the University of California, San Diego.

With regard to the association between a diabetic mother and later obesity in the child, Dr. Moore cited a study of the Pima Indians of Arizona, who have been followed closely in a study since 1965 and among whom there is a high rate of obesity and diabetes.

In that study, the investigators looked at siblings in families with a mother who was diabetic. They compared siblings born before the mother was diagnosed as diabetic with siblings born after her diagnosis. In 19 families in which one sibling had diabetes and the other did not, 15 of the diabetic children were born after their mother's diagnosis, and only 4 were born before (Diabetes 2000;49:2208–11).

There was no difference in the number of siblings with diabetes in those families born before or after a father's diabetes diagnosis.

The siblings who were exposed to intrauterine diabetes also were a mean 2.6 kg/m

In another study linking heaviness and diabetes in the child to that in the mother, Norwegian investigators looked at almost 140,000 women who had given birth. They found that the rate of gestational diabetes among the women was 31/1,000 in those whose own mothers had diabetes when they were born, compared with a rate of 4/1,000 in those whose own mothers did not have diabetes (BMJ 2000;321:546–7).

Dr. Moore said that in his own practice, he is careful to measure and record body mass index, not just weight, and to help patients who want to lose weight before conception.

Moreover, whenever he manages maternal diabetes in pregnancy, Dr. Moore said he is mindful that the disease can have critical implications for the life of the infant.

“I actually believe I'm making a difference in the adult health of the fetus, who I am helping to treat through the mother by optimizing glucose control,” Dr. Moore said.

In reference to the risks facing underweight newborns, Dr. Moore said that most of the data come from epidemiologic studies that show those infants are more likely to develop high insulin levels, hypertension, diabetes, stroke, and heart disease.

He said that the theory explaining this phenomenon, the “thrifty phenotype,” asserts that when a fetus is growth- or nutrient restricted, it shunts nutrients to the most essential organs. One of the mechanisms the fetus body uses to prevent nutrients from going to less essential systems, such as the musculature, is by making those systems insulin resistant. This insulin resistance persists after birth and predisposes the individual to the conditions associated with metabolic syndrome.

The theory calls into question the common practice in neonatal nurseries of trying to get as many calories as possible into underweight infants in an effort to get them to gain weight quickly, said Dr. Moore.

LOS ANGELES — Obesity, like cardiovascular disease risk, can originate in the womb, a phenomenon that could have important implications in managing the current obesity epidemic, Dr. Thomas R. Moore said at a meeting of the Obstetrical and Gynecological Assembly of Southern California.

Much evidence now indicates that infants born to mothers with diabetes are likely to become overweight children and adults. They are also more likely to develop gestational diabetes and possibly diabetes as adults.

However, the evidence also seems to suggest that infants born underweight may face a similar risk of obesity and are more likely to experience cardiovascular disease, said Dr. Moore, the chairman of the department of reproductive medicine at the University of California, San Diego.

With regard to the association between a diabetic mother and later obesity in the child, Dr. Moore cited a study of the Pima Indians of Arizona, who have been followed closely in a study since 1965 and among whom there is a high rate of obesity and diabetes.

In that study, the investigators looked at siblings in families with a mother who was diabetic. They compared siblings born before the mother was diagnosed as diabetic with siblings born after her diagnosis. In 19 families in which one sibling had diabetes and the other did not, 15 of the diabetic children were born after their mother's diagnosis, and only 4 were born before (Diabetes 2000;49:2208–11).

There was no difference in the number of siblings with diabetes in those families born before or after a father's diabetes diagnosis.

The siblings who were exposed to intrauterine diabetes also were a mean 2.6 kg/m

In another study linking heaviness and diabetes in the child to that in the mother, Norwegian investigators looked at almost 140,000 women who had given birth. They found that the rate of gestational diabetes among the women was 31/1,000 in those whose own mothers had diabetes when they were born, compared with a rate of 4/1,000 in those whose own mothers did not have diabetes (BMJ 2000;321:546–7).

Dr. Moore said that in his own practice, he is careful to measure and record body mass index, not just weight, and to help patients who want to lose weight before conception.

Moreover, whenever he manages maternal diabetes in pregnancy, Dr. Moore said he is mindful that the disease can have critical implications for the life of the infant.

“I actually believe I'm making a difference in the adult health of the fetus, who I am helping to treat through the mother by optimizing glucose control,” Dr. Moore said.

In reference to the risks facing underweight newborns, Dr. Moore said that most of the data come from epidemiologic studies that show those infants are more likely to develop high insulin levels, hypertension, diabetes, stroke, and heart disease.

He said that the theory explaining this phenomenon, the “thrifty phenotype,” asserts that when a fetus is growth- or nutrient restricted, it shunts nutrients to the most essential organs. One of the mechanisms the fetus body uses to prevent nutrients from going to less essential systems, such as the musculature, is by making those systems insulin resistant. This insulin resistance persists after birth and predisposes the individual to the conditions associated with metabolic syndrome.

The theory calls into question the common practice in neonatal nurseries of trying to get as many calories as possible into underweight infants in an effort to get them to gain weight quickly, said Dr. Moore.

LOS ANGELES — Obesity, like cardiovascular disease risk, can originate in the womb, a phenomenon that could have important implications in managing the current obesity epidemic, Dr. Thomas R. Moore said at a meeting of the Obstetrical and Gynecological Assembly of Southern California.

Much evidence now indicates that infants born to mothers with diabetes are likely to become overweight children and adults. They are also more likely to develop gestational diabetes and possibly diabetes as adults.

However, the evidence also seems to suggest that infants born underweight may face a similar risk of obesity and are more likely to experience cardiovascular disease, said Dr. Moore, the chairman of the department of reproductive medicine at the University of California, San Diego.

With regard to the association between a diabetic mother and later obesity in the child, Dr. Moore cited a study of the Pima Indians of Arizona, who have been followed closely in a study since 1965 and among whom there is a high rate of obesity and diabetes.

In that study, the investigators looked at siblings in families with a mother who was diabetic. They compared siblings born before the mother was diagnosed as diabetic with siblings born after her diagnosis. In 19 families in which one sibling had diabetes and the other did not, 15 of the diabetic children were born after their mother's diagnosis, and only 4 were born before (Diabetes 2000;49:2208–11).

There was no difference in the number of siblings with diabetes in those families born before or after a father's diabetes diagnosis.

The siblings who were exposed to intrauterine diabetes also were a mean 2.6 kg/m

In another study linking heaviness and diabetes in the child to that in the mother, Norwegian investigators looked at almost 140,000 women who had given birth. They found that the rate of gestational diabetes among the women was 31/1,000 in those whose own mothers had diabetes when they were born, compared with a rate of 4/1,000 in those whose own mothers did not have diabetes (BMJ 2000;321:546–7).

Dr. Moore said that in his own practice, he is careful to measure and record body mass index, not just weight, and to help patients who want to lose weight before conception.

Moreover, whenever he manages maternal diabetes in pregnancy, Dr. Moore said he is mindful that the disease can have critical implications for the life of the infant.

“I actually believe I'm making a difference in the adult health of the fetus, who I am helping to treat through the mother by optimizing glucose control,” Dr. Moore said.

In reference to the risks facing underweight newborns, Dr. Moore said that most of the data come from epidemiologic studies that show those infants are more likely to develop high insulin levels, hypertension, diabetes, stroke, and heart disease.

He said that the theory explaining this phenomenon, the “thrifty phenotype,” asserts that when a fetus is growth- or nutrient restricted, it shunts nutrients to the most essential organs. One of the mechanisms the fetus body uses to prevent nutrients from going to less essential systems, such as the musculature, is by making those systems insulin resistant. This insulin resistance persists after birth and predisposes the individual to the conditions associated with metabolic syndrome.

The theory calls into question the common practice in neonatal nurseries of trying to get as many calories as possible into underweight infants in an effort to get them to gain weight quickly, said Dr. Moore.