<?xml version="1.0" encoding="utf-8"?>
<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_3213"
                     title="Cirrhosis Outcomes Better When Tx Guidelines Followed (CME/CE)"
                     score="0.013"
                     href="http://www.medpagetoday.com/Gastroenterology/GeneralHepatology/tb/21964?impressionId=1283457916011"
                     
      &lt;p&gt;Routinely screening liver cirrhosis patients for esophageal varices and treating them according to published guidelines led to lower-than-expected rates of subsequent variceal hemorrhage, researchers found.&lt;/p&gt;
&lt;p&gt;A review of patient charts in a center that showed strong compliance with cirrhosis management guidelines found that the actuarial two-year likelihood of variceal bleeding was 13%  --  compared with a predicted rate of 27% calculated on the basis of liver dysfunction severity, variceal size, and so-called &quot;red wale markings&quot; seen on endoscopy (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.05), according to Jayavani Moodley, MD, of the Cleveland Clinic, and colleagues.&lt;/p&gt;
&lt;p&gt;&quot;In our population, management according to principles endorsed by a recently published practice guideline was associated with a lower bleeding rate than that expected in untreated patients,&quot; Moodley and co-authors wrote in the August issue of &lt;em&gt;Clinical Gastroenterology and Hepatology&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Guidelines issued in 2007 jointly by the American Gastroenterological Association and the American Association for the Study of Liver Disease call for screening cirrhosis patients for esophageal varices and beta-blocker treatment or variceal ligation for patients found to be at risk for bleeding, along with periodic follow-up endoscopy.&lt;/p&gt;
&lt;p&gt;Moodley&apos;s team reviewed charts from 179 patients evaluated for cirrhosis at the Cleveland Clinic from 2003 to 2006 and found that 80% had endoscopic screens for esophageal varices within six months of their initial visit, and a total of 94% had such screens at some point during treatment at the clinic.&lt;/p&gt;
&lt;p&gt;A chart review of endoscopy results revealed that 83 patients had varices  --  including 35 with medium to large lesions.&lt;/p&gt;
&lt;p&gt;The review also indicated that treatments conforming to the AGA/AASLD guidelines were given to 91% of patients with medium or large varices. On the other hand, compliance with the guidelines was lower (60%) among patients with small varices.&lt;/p&gt;
&lt;p&gt;Of those patients without bleeding episodes during follow-up, 82% had their screening endoscopy within six months of their initial visit  --  whereas only 50% of the patients suffering hemorrhages received such prompt screening (&lt;em&gt;P&lt;/em&gt;=0.016).&lt;/p&gt;
&lt;p&gt;Hemorrhage from esophageal varices occurred in nine patients with varices at screening of 12 total bleeding episodes that occurred during the follow-up period.&lt;/p&gt;
&lt;p&gt;Moodley and colleagues had calculated a two-year actuarial probability of 13% that patients with varices would have hemorrhages. In comparison  --  under the standard North Italian Endoscopy Club model for predicting variceal hemorrhage rates  --  27% of the Cleveland Clinic patients with varices would have been expected to develop hemorrhages in two years. This model takes into account the severity of liver dysfunction, the size of varices, and whether red wale markings are present.&lt;/p&gt;
&lt;p&gt;Moodley and colleagues noted that 80% of the clinic&apos;s patients with medium to large varices underwent ligation procedures as opposed to beta-blocker therapy.&lt;/p&gt;
&lt;p&gt;In their report, they wrote that the clinic&apos;s institutional preference was &quot;influenced by two meta-analyses which indicate superiority of esophageal variceal ligation in preventing initial bleeding.&quot; But they also noted that a study published last year found better outcomes for beta-blockers.&lt;/p&gt;
&lt;p&gt;&quot;This finding, if verified, will likely alter our treatment strategy in the future,&quot; Moodley and colleagues commented.&lt;/p&gt;
&lt;p&gt;In an accompanying editorial, two physicians at Boston&apos;s Beth Israel Deaconess Medical Center noted an odd paradox in the study&apos;s findings.&lt;/p&gt;
&lt;p&gt;Although the rate of variceal hemorrhage was low in patients receiving guideline-compliant recommendations (8%), wrote Michelle Lai, MD, MPH, and Nezam Afdhal, MD, it was even lower (6%) among 54 patients who were screened but did not receive the recommended treatment.&lt;/p&gt;
&lt;p&gt;Lai and Afdhal also suggested that findings at a tertiary care center such as the Cleveland Clinic may not apply to community gastroenterology practices. As a result, they indicated, &quot;the findings, therefore, need to be confirmed ... in future studies.&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;No external funding for the analysis was reported.&lt;/p&gt;&lt;p&gt;The authors and editorialists declared they had no potential conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_3167"
                     title="ESC: Mixed Risks for PPIs Plus Clopidogrel (CME/CE)"
                     score="0.011"
                     href="http://www.medpagetoday.com/MeetingCoverage/ESCCongress/tb/21896?impressionId=1283457916011"
                     
      &lt;p&gt;STOCKHOLM  --  Concomitant use of a proton pump inhibitor and clopidogrel (Plavix) significantly increased the risk of myocardial infarction but not death, a meta-analysis involving almost 160,000 patients found.&lt;/p&gt;
&lt;p&gt;The meta-analysis showed a 31% increase in the relative risk of MI (95% CI 1.12 to 1.53) among patients who took the two drugs together compared with those who did not, according to Jolanta Siller-Matula, MD, of the Medical University of Vienna in Austria, and colleagues.&lt;/p&gt;
&lt;p&gt;On the other hand, the analysis of 25 studies found that combined use of the two drugs did not significantly increase the risk of dying (RR=1.04, 95% CI 0.93 to 1.16), Siller-Matula and colleagues reported here at the European Society of Cardiology.&lt;/p&gt;
&lt;p&gt;As well, the meta-analysis showed that treatment with a PPI reduced the risk of gastrointestinal (GI) bleeding by 50% in patients receiving clopidogrel alone or with a placebo, Siller-Matula&apos;s team reported.&lt;/p&gt;
&lt;p&gt;&quot;As meta-analyses have the highest evidence level, this study adds important insights into the discussion on safety of PPIs, especially because randomized trials with PPIs, in particular with omeprazole, are not ethically acceptable as omeprazole decreases the concentration of clopidogrel in the blood,&quot; Siller-Matula told &lt;em&gt;MedPage Today&lt;/em&gt; in an e-mail.&lt;/p&gt;
&lt;p&gt;&quot;This meta-analysis has significant implications for many patients. My advice to clinicians is to only prescribe gastric protection when absolutely necessary. If indicated, pantoprazole should be used, as pantoprazole has no negative effect on platelet inhibition by clopidogrel when assessed ex vivo,&quot; she said.&lt;/p&gt;
&lt;p&gt;Data from large clinical registries have suggested that concomitant treatment with clopidogrel and a PPI worsen clinical outcomes in patients with coronary disease. Other studies have shown no increased risk with use of both drugs.&lt;/p&gt;
&lt;p&gt;The only prospective, randomized trial to evaluate the issue ended prematurely when the sponsor declared bankruptcy. Data collected to discontinuation showed &lt;a href=&quot;http://www.medpagetoday.com/MeetingCoverage/TCT/16133&quot; mce_href=&quot;http://www.medpagetoday.com/MeetingCoverage/TCT/16133&quot; target=&quot;_blank&quot; title=&quot;TCT:&amp;#8200;PPIs&amp;#8200;Safe&amp;#8200;for&amp;#8200;Patients&amp;#8200;Taking&amp;#8200;Antiplatelets&quot;&gt;no difference in risk&lt;/a&gt; among patients treated with clopidogrel or placebo.&lt;/p&gt;
&lt;p&gt;&quot;Given the lack of a definitive trial, we performed a meta-analysis to determine whether concomitant use of PPIs plus clopidogrel increases the incidence of combined major cardiovascular events (MACE), MI, death, or gastrointestinal bleeding in patients with cardiovascular disease,&quot; Siller-Matula explained.&lt;/p&gt;
&lt;p&gt;A systematic review identified 25 studies that involved a total of 159,138 patients. The studies included observational studies, randomized trials, and post-hoc analyses of randomized trials.&lt;/p&gt;
&lt;p&gt;The primary outcomes were combined MACE, MI, stent thrombosis, death, and GI bleeding.&lt;/p&gt;
&lt;p&gt;The analysis showed that patients treated with clopidogrel and PPIs had a 29% increased relative risk of MACE (95% CI 1.15 to 1.45) as well as a 31% increased risk of MI compared with patients who did not receive the two drugs together.&lt;/p&gt;
&lt;p&gt;The combination of a PPI and clopidogrel was associated with a nonsignificant 4% increase in mortality risk.&lt;/p&gt;
&lt;p&gt;Concomitant use of the two drugs halved the relative risk of GI bleeding (RR=0.50, 95% CI 0.37 to 0.69), compared with patients treated with clopidogrel alone or with placebo.&lt;/p&gt;
&lt;p&gt;Sensitivity analysis showed that the results remained unchanged irrespective of publication type, study quality or size, or risk of clinical events. Despite the consistency of findings, Siller-Matula concluded that concomitant PPI-clopidogrel therapy &quot;might be associated with an increased risk of cardiovascular events.&quot;&lt;/p&gt;
&lt;p&gt;&quot;Prospective randomized trials are required to investigate whether a cause-and-effect relationship truly exists and to explore whether different PPIs worsen clinical outcome in clopidogrel-treated patients, as the PPI-clopidogrel drug-drug interaction seems not to be a class effect,&quot; she added.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;Siller-Matula reported that she and her co-authors had no relevant disclosures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_2878"
                     title="African, European Kids Have Different Gut Bugs (CME/CE)"
                     score="-0.007"
                     href="http://www.medpagetoday.com/Gastroenterology/GeneralGastroenterology/tb/21502?impressionId=1283457916011"
                     
      Children on a Western-style diet appear have different gut bacteria compared with African children, whose eating habits and living environment more closely resemble those of earlier ancestors, researchers have found.&lt;br&gt;
&lt;br&gt;The researchers compared fecal microbiota from 14 healthy young African children living in a rural village in Burkina Faso with that of 15 age-matched Italian children from urban Florence  --  and although the four most common bacterial phyla were found, the amount of each differed between the two groups, according to Paolo Lionetti, MD, of the University of Florence, and colleagues.&lt;br&gt;
&lt;br&gt;For example the African kids had more&lt;em&gt; Actinobacteria&lt;/em&gt; and &lt;em&gt;Bacteroidetes&lt;/em&gt; while the Italians had more &lt;em&gt;Firmicutes &lt;/em&gt;and &lt;em&gt;Proteobacteria  --  &lt;/em&gt;a difference that could play a role in future health problems, Lionetti and co-authors reported in the &lt;em&gt;Proceedings of the National Academy of Sciences&lt;/em&gt;.&lt;p&gt;&lt;/p&gt;
&lt;p&gt;In particular, the increased ratio of &lt;em&gt;Firmicutes&lt;/em&gt; to &lt;em&gt; Bacteroidetes&lt;/em&gt; might predispose children eating typical Western  diets to future obesity, the researchers wrote.&lt;/p&gt;
&lt;p&gt;The African children also had two types of bacteria totally absent in the Italian kids  --  &lt;em&gt;Prevotella&lt;/em&gt; and &lt;em&gt;Xylanibacter  --  &lt;/em&gt;that produce more short-chain fatty acids, known to be protective against inflammation.&lt;/p&gt;
&lt;p&gt;The findings could partially account for an increased prevalence of obesity, allergy, and autoimmune diseases that are largely absent in rural African populations, Lionetti told &lt;em&gt;MedPage Today&lt;/em&gt;, although more research needs to be done.&lt;/p&gt;
&lt;p&gt;&quot;We know that in developed countries there&apos;s a high incidence of obesity, allergy, autoimmune disease, and irritable bowel syndrome, even in children now,&quot; Lionetti said. &quot;Children in the developing world don&apos;t get those diseases, although they do have problems like malnutrition and infection.&quot;&lt;/p&gt;
&lt;p&gt;The human gut contains trillions of microbes that contain at least 100 times as many genes as the human genome alone. This vast microbe colony provides enhanced metabolic capabilities and protection against pathogens.&lt;/p&gt;
&lt;p&gt;But researchers don&apos;t know how different living environments and the varied diets around the world have affected the microbial ecology of the human gut.&lt;/p&gt;
&lt;p&gt;So Lionetti and colleagues compared the fecal microbiota of 15 children ages 1 to 6 from urban Florence with that of 14 African children of the same age living in the small rural village of Boulpon  --  a living environment that still resembles that of humans during the agricultural revolution about 10,000 years ago.&lt;/p&gt;
&lt;p&gt;The daily diet in the African village is high in fiber, starch, and plant polysaccharides and low in fat and animal protein  --  consisting mainly of cereals, legumes, and vegetables.&lt;/p&gt;
&lt;p&gt;Microbiota were assessed via high-throughput 165 rDNA sequencing and biochemical analyses, Lionetti said.&lt;/p&gt;
&lt;p&gt;The researchers found significant differences in gut microbiota between the two groups. All of the children were found to have the four most common intestinal bacterial phyla  --  &lt;em&gt;Actinobacteria,&lt;/em&gt; &lt;em&gt;Bacteroidetes, Firmicutes,&lt;/em&gt; and &lt;em&gt;Proteobacteria&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;But the African children had more &lt;em&gt;Actinobacteria&lt;/em&gt; and &lt;em&gt;Bacteroidetes,&lt;/em&gt; while the Italian kids had more &lt;em&gt;Firmicutes&lt;/em&gt; and &lt;em&gt;Proteobacteria&lt;/em&gt;:&lt;ul&gt; &lt;li&gt;Italian children: 10.1%, 6.7%, 63.7%, and 27.3%, respectively &lt;/li&gt; &lt;li&gt;African children: 57.7%, 22.4%, 6.7%, and 0.8%, respectively&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The increased &lt;em&gt;Firmicutes&lt;/em&gt; to &lt;em&gt;Bacteroidetes&lt;/em&gt; ratio was likely the result of higher fiber intake among the Africans, maximizing metabolic energy extraction from ingested plant polysaccharides, the researchers suggested.&lt;/p&gt;
&lt;p&gt;&quot;Reduction in microbial richness is possibly one of the undesirable effects of globalization and of eating generic, nutrient-rich, uncontaminated foods,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;African children also had bacteria from the genus &lt;em&gt;Prevotella&lt;/em&gt; and &lt;em&gt;Xylanibacter &lt;/em&gt; --  known to contain a set of bacterial genes that can ferment cellulose and xylan  --  that were completely lacking in the European children.&lt;/p&gt;
&lt;p&gt;These bacteria produce more short-chain fatty acids, Lionetti said, which have been proven to protect against gut inflammation. As expected, the researchers saw significantly more short-chain fatty acids in African children (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001).&lt;/p&gt;
&lt;p&gt;There were also clear variations in total calorie content between the two groups, ranging from about 670 calories for the youngest group to 1,000 calories for the oldest African groups, while the youngest Italians consumed 1,070 calories and the oldest, about 1,500 calories.&lt;/p&gt;
&lt;p&gt;&quot;The predominant role in changing the microbiome of these children is done by the diet,&quot; Lionetti said. &quot;We change our flora depending on what we eat.&quot;&lt;/p&gt;
&lt;p&gt;He and colleagues concluded that the data indicate the importance of &quot;preserving this treasure of microbial diversity from ancient rural communities worldwide.&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported by Ministero dell&apos;Istruzione, dell&apos;Universita e della Ricerca, Ente Cassa di Risparmio di Firenze Grant, and by Meyer&apos;s Children&apos;s Hospital.&lt;/p&gt;&lt;p&gt;The researchers reported no conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_2841"
                     title="Ablate and Wait in Liver CA, Experts Suggest (CME/CE)"
                     score="-0.008"
                     href="http://www.medpagetoday.com/Transplantation/LiverTransplantation/tb/21452?impressionId=1283457916011"
                     
      &lt;p&gt;Outcomes in all patients with hepatocellular carcinoma might improve with an &quot;ablate- and-wait&quot; strategy versus rapid transplantation, according to a group of clinicians who have regularly used the strategy.&lt;/p&gt;
&lt;p&gt;Use of radiofrequency ablation and chemoembolization to downstage large tumors has shown that about 30% of patients do not qualify for transplantation because of disease progression. The strategy warrants consideration for all patients with hepatocellular carcinoma, regardless of whether they fall within the Milan criteria, according to authors of an article in the August issue of &lt;em&gt;Liver Transplantation&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;Those patients who make it to transplantation have an excellent outcome as compared to patients transplanted with tumors beyond the Milan criteria who are not treated,&quot; John Roberts, MD, of the University of California San Francisco, and colleagues wrote in an opinion piece.&lt;/p&gt;
&lt;p&gt;&quot;The median time between the first ablative procedure and transplantation was 8.2 months with a range of 3 to 25 months. This approach suggests that the test of time may be the surest method to select patients with hepatocellular carcinoma who are destined to have good transplant outcomes.&quot;&lt;/p&gt;
&lt;p&gt;The authors argue that their approach of ablating the tumor and then waiting to see whether it recurs or progresses should be expanded to all patients listed for transplantation because of hepatocellular carcinoma. Treating and waiting could help reduce the use of scarce donor organs in patients who will have recurrent disease.&lt;/p&gt;
&lt;p&gt;&quot;Our experience with ablative treatment and then observation suggests that the ultimate outcomes of transplantation are not dependent on the primary tumor but more on time spent waiting for transplantation,&quot; the authors wrote in their conclusion. &quot;It would seem logical that smaller and/or fewer tumors, though more unlikely to have spread, would also benefit from a period of time if the primary tumor can be controlled.&quot;&lt;/p&gt;
&lt;p&gt;&quot;The waiting period may be able to decrease the 10% recurrence rate seen in patients transplanted within Milan,&quot; they added.&lt;/p&gt;
&lt;p&gt;Published more than a decade ago, the Milan criteria for liver transplantation in patients with hepatocellular carcinoma won support because they seemed to identify patients likely to have good transplantation outcomes (&lt;em&gt;N Engl J Med&lt;/em&gt; 1996; 334: 693-699). Based on tumor size and number, the criteria fell victim to the same fallacy as other criteria have, according to the authors.&lt;/p&gt;
&lt;p&gt;&quot;It has not been shown that there is any particular tumor size that represents no risk of recurrence, at least among those tumors that can be detected radiologically,&quot; Roberts and co-authors wrote in their introduction. &quot;Furthermore, the degree of risk is not the same for all patients within the Milan criteria.&quot;&lt;/p&gt;
&lt;p&gt;The San Francisco group&apos;s experience with a strategy of ablate and wait has indicated that patients who fall far outside the Milan criteria do quite well after transplantation, if time is added as a criterion for transplantation. A report covering their experience with 61 patients showed successful downstaging of 43, all but eight of whom had successful orthoptic liver transplants (&lt;em&gt;Hepatol&lt;/em&gt; 2008; 48: 819-827).&lt;/p&gt;
&lt;p&gt;Intention-to-treat analysis showed one- and four-year survival rates of 87.5% and 69.3%, respectively. One- and four-year survival after transplantation was 96.2% and 92.1%, respectively.&lt;/p&gt;
&lt;p&gt;The authors also cited several small clinical studies that have added support to the ablate-and-wait strategy for patients outside the Milan criteria. Cumulatively, the data suggest that a waiting period of about six months after therapy might be appropriate.&lt;/p&gt;
&lt;p&gt;Less evidence has emerged in support of ablate and wait for patients within the Milan criteria. In general, the data suggest that tumor status does not deteriorate between treatment and transplantation.&lt;/p&gt;
&lt;p&gt;Geographic variation in the time to transplantation complicates the ablate-and-wait strategy. Roberts and co-authors cited 2007 data showing that 62% of patients underwent liver transplantation within three months after receiving exception points for hepatocellular carcinoma. A shorter waiting time might increase risk of cancer recurrence, but data on recurrence of hepatocellular carcinoma are incomplete.&lt;/p&gt;
&lt;p&gt;&quot;The more rapid transplantation rate in some geographic areas is going to create some issues if transplantation is delayed under an ablate-and-wait strategy,&quot; the authors acknowledged. &quot;Fortunately, if the wait is six months long, major effects on center transplant numbers are likely to be small.&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The authors reported that they had no relevant disclosures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_2711"
                     title="IAC: HAART Brings Down Liver Enzymes (CME/CE)"
                     score="-0.01"
                     href="http://www.medpagetoday.com/MeetingCoverage/IAC/tb/21298?impressionId=1283457916011"
                     
      &lt;p&gt;VIENNA  --  Levels of elevated liver enzymes start to decline as patients with HIV undergo treatment with highly active antiretroviral therapy (HAART), Ugandan researchers reported.&lt;/p&gt;
&lt;p&gt;At the start of the study, 40% of treatment-naive patients had elevated liver enzymes but after 30 months on a combination regimen anchored by the non-nucleoside reverse transcriptase inhibitors, that number dropped to about 12%, Ponsiano Ocama, MD, of Makerere University in Kampala, Uganda, reported at the International AIDS Conference here.&lt;/p&gt;
&lt;p&gt;Ocama noted at his poster presentation that the decline was attenuated in men after 24 months of therapy but continued among women. He suggested that the treatment effect may have waned in men because of alcohol consumption.&lt;/p&gt;
&lt;p&gt;&quot;We are the highest per capita consumers of beer in Africa,&quot; Ocama told &lt;em&gt;MedPage Today&lt;/em&gt;. &quot;And men in Uganda tend to drink more beer than women.&quot;&lt;/p&gt;
&lt;p&gt;Among men, the percentage with elevated enzymes declined to about 22% after 24 months and rose slightly to 24% at 30 months.&lt;/p&gt;
&lt;p&gt;Among women the drop was sharper and continued to be steeper at every six-month time point. By 30 months, only about 6% of women had elevated enzyme levels, Ocama said.&lt;/p&gt;
&lt;p&gt;The difference between men and women in reduction of enzyme levels achieved statistical significance (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.0001).&lt;/p&gt;
&lt;p&gt;&quot;It would have been interesting to have seen what the alcohol intake was of these men at baseline, because we know that alcohol can impact liver enzymes,&quot; Jeffrey Samet, MD, of Boston University School of Medicine, commented to &lt;em&gt;MedPage Today.&lt;/em&gt;&lt;/p&gt;
&lt;p&gt;Ocama said baseline alcohol levels were not collected among the 546 patients whose charts were scrutinized for the study.&lt;/p&gt;
&lt;p&gt;At baseline, 217 of these patients had elevated enzyme levels, but just 1% (eight patients) had Grade 3-4 aspartate aminotransferase elevations and only two of those were diagnosed with jaundice.&lt;/p&gt;
&lt;p&gt;The median age of the patients in the study was 38 and 69% were women.&lt;/p&gt;
&lt;p&gt;The median level of CD4-positive cells at the beginning of therapy was 98 cells/mcg/ml. All of the patients were started on therapy with a lamivudine (3TC) regimen containing a second nucleoside reverse transcriptase inhibitor  --  either stavudine (d4T) or zidovudine (AZT).&lt;/p&gt;
&lt;p&gt;For 74% of the patients, the non-nucleoside reverse transcriptase inhibitor anchor was nevirapine (Viramune). The rest were on efavirenz (Sustiva).&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;Ocama had no disclosures.&lt;/p&gt;&lt;p&gt;Samet disclosed a financial relationship with Gilead.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
</recommendedContent>