Sharon Worcester

Infectious Diseases Clinical Capsules

Avian Flu

Two cases of Avian influenza in a family in Thailand appear to have resulted from person-to-person transmission of the disease. In most of the previous human cases, the individuals had well-documented contact with sick or dying poultry, Kumnuan Ungchusak, M.D., of the Thai Ministry of Public Health, Nonthaburi, Thailand, and colleagues reported.

The index patient became ill following exposure to dying household chickens, and her mother, who came from a distant city to care for her, developed pneumonia and died after providing 16-18 hours of unprotected nursing care. She had no known exposure to poultry. An aunt who helped care for the index patient also developed fever and then pneumonia in the days following the care (N. Engl. J. Med. 2005;352:333-40).

Autopsy tissue from the mother and nasopharyngeal and throat swabs from the aunt were positive for influenza A. Viral gene sequencing showed no change in key features of the virus; the sequences clustered closely with others from recent avian isolates in Thailand, they noted.

Bacterial Meningitis

Ciprofloxacin and ceftriaxone are better than rifampin for prevention of bacterial meningitis in patients at risk of developing the infection, a recent Cochrane Review suggests.

These drugs appear to be as effective as rifampin—the treatment that tends to be used for eradicating Neisseria meningitidis associated with bacterial meningitis—but they are associated with less risk of development of antibiotic resistance, said Abigail Fraser, M.D., of Rabin Medical Centre, Petah-Tikan, Israel, and her colleagues.

Furthermore, ciprofloxacin and ceftriaxone are each given in a single dose, whereas rifampin is given twice daily for 2 days. For this reason, selecting ciprofloxacin or ceftriaxone could improve compliance, the reviewers concluded (Cochrane Database Syst, Rev. 2005 [1]:CD004785.pub2. DOI:10.1002/14651858.CD004785.pub2).

Preventing IPD

A recent outbreak of invasive pneumococcal disease in Alaska led to an investigation that has underscored the preventability of the disease and the importance of vaccination.

Between January 2003 and March 2004, 14 cases of invasive pneumococcal disease were reported in a rural region of the state. The mean number of cases per year in the area is 2.8, according to the Centers for Disease Control and Prevention.

Serotype 12F, which is contained in the 23-valent pneumococcal polysaccharide vaccine, was the cause of disease in 9 of the 14 patients, and 6 of those 9 patients had a medical indication for vaccination (MMWR 2005;54:72-5).

The outbreak highlights the need for providing vaccination in both inpatient and outpatient settings at every opportunity. Because many people without a regular physician might seek care in an emergency department or urgent-care clinic, it is important for these types of facilities to also provide vaccination to those with a medical or age-related indication, the investigators said, noting that doing so could substantially reduce complications and deaths due to pneumococcal disease.

Barriers to vaccination should be identified, and standing orders programs should be implemented, they added.

MRSA Precautions

Single-room or cohort isolation of hospitalized patients with methicillin-resistant Staphylococcus aureus infection does not appear to reduce transmissions, a study suggests.

Admission and weekly screens were performed to determine the incidence of MRSA colonization during the prospective, 1-year study conducted in the intensive care units of two London teaching hospitals. For the middle 6 months of the study period, patients with MRSA were not isolated; during the first 3 months and last 3 months, MRSA-positive patients were isolated in single rooms or nursing cohorts. All 866 patients who needed ICU care for longer than 48 hours were included, Jorge A. Cepeda, M.D., of University College London Hospitals and his colleagues reported.

During the two periods of the study, patients had similar characteristics and MRSA acquisition rates. Use of standard precautions and hand-washing rates did not change between the two study periods. There was no evidence of increased MRSA transmission during the period when infected patients were not isolated, compared with the period when infected patients were moved to isolation rooms (hazard ratio 0.73), the investigators said (Lancet 2005;365:295-304).

Given these findings and the risks inherent in moving and/or isolating critically ill patients, isolation policies in intensive care units with endemic MRSA should be reevaluated, they concluded, adding that efforts to find more effective means of containing MRSA are needed.

Infectious Diseases Clinical Capsules

Avian Flu

Two cases of Avian influenza in a family in Thailand appear to have resulted from person-to-person transmission of the disease. In most of the previous human cases, the individuals had well-documented contact with sick or dying poultry, Kumnuan Ungchusak, M.D., of the Thai Ministry of Public Health, Nonthaburi, Thailand, and colleagues reported.

The index patient became ill following exposure to dying household chickens, and her mother, who came from a distant city to care for her, developed pneumonia and died after providing 16-18 hours of unprotected nursing care. She had no known exposure to poultry. An aunt who helped care for the index patient also developed fever and then pneumonia in the days following the care (N. Engl. J. Med. 2005;352:333-40).

Autopsy tissue from the mother and nasopharyngeal and throat swabs from the aunt were positive for influenza A. Viral gene sequencing showed no change in key features of the virus; the sequences clustered closely with others from recent avian isolates in Thailand, they noted.

Bacterial Meningitis

Ciprofloxacin and ceftriaxone are better than rifampin for prevention of bacterial meningitis in patients at risk of developing the infection, a recent Cochrane Review suggests.

These drugs appear to be as effective as rifampin—the treatment that tends to be used for eradicating Neisseria meningitidis associated with bacterial meningitis—but they are associated with less risk of development of antibiotic resistance, said Abigail Fraser, M.D., of Rabin Medical Centre, Petah-Tikan, Israel, and her colleagues.

Furthermore, ciprofloxacin and ceftriaxone are each given in a single dose, whereas rifampin is given twice daily for 2 days. For this reason, selecting ciprofloxacin or ceftriaxone could improve compliance, the reviewers concluded (Cochrane Database Syst, Rev. 2005 [1]:CD004785.pub2. DOI:10.1002/14651858.CD004785.pub2).

Preventing IPD

A recent outbreak of invasive pneumococcal disease in Alaska led to an investigation that has underscored the preventability of the disease and the importance of vaccination.

Between January 2003 and March 2004, 14 cases of invasive pneumococcal disease were reported in a rural region of the state. The mean number of cases per year in the area is 2.8, according to the Centers for Disease Control and Prevention.

Serotype 12F, which is contained in the 23-valent pneumococcal polysaccharide vaccine, was the cause of disease in 9 of the 14 patients, and 6 of those 9 patients had a medical indication for vaccination (MMWR 2005;54:72-5).

The outbreak highlights the need for providing vaccination in both inpatient and outpatient settings at every opportunity. Because many people without a regular physician might seek care in an emergency department or urgent-care clinic, it is important for these types of facilities to also provide vaccination to those with a medical or age-related indication, the investigators said, noting that doing so could substantially reduce complications and deaths due to pneumococcal disease.

Barriers to vaccination should be identified, and standing orders programs should be implemented, they added.

MRSA Precautions

Single-room or cohort isolation of hospitalized patients with methicillin-resistant Staphylococcus aureus infection does not appear to reduce transmissions, a study suggests.

Admission and weekly screens were performed to determine the incidence of MRSA colonization during the prospective, 1-year study conducted in the intensive care units of two London teaching hospitals. For the middle 6 months of the study period, patients with MRSA were not isolated; during the first 3 months and last 3 months, MRSA-positive patients were isolated in single rooms or nursing cohorts. All 866 patients who needed ICU care for longer than 48 hours were included, Jorge A. Cepeda, M.D., of University College London Hospitals and his colleagues reported.

During the two periods of the study, patients had similar characteristics and MRSA acquisition rates. Use of standard precautions and hand-washing rates did not change between the two study periods. There was no evidence of increased MRSA transmission during the period when infected patients were not isolated, compared with the period when infected patients were moved to isolation rooms (hazard ratio 0.73), the investigators said (Lancet 2005;365:295-304).

Given these findings and the risks inherent in moving and/or isolating critically ill patients, isolation policies in intensive care units with endemic MRSA should be reevaluated, they concluded, adding that efforts to find more effective means of containing MRSA are needed.

Infectious Diseases Clinical Capsules

Avian Flu

Two cases of Avian influenza in a family in Thailand appear to have resulted from person-to-person transmission of the disease. In most of the previous human cases, the individuals had well-documented contact with sick or dying poultry, Kumnuan Ungchusak, M.D., of the Thai Ministry of Public Health, Nonthaburi, Thailand, and colleagues reported.

The index patient became ill following exposure to dying household chickens, and her mother, who came from a distant city to care for her, developed pneumonia and died after providing 16-18 hours of unprotected nursing care. She had no known exposure to poultry. An aunt who helped care for the index patient also developed fever and then pneumonia in the days following the care (N. Engl. J. Med. 2005;352:333-40).

Autopsy tissue from the mother and nasopharyngeal and throat swabs from the aunt were positive for influenza A. Viral gene sequencing showed no change in key features of the virus; the sequences clustered closely with others from recent avian isolates in Thailand, they noted.

Bacterial Meningitis

Ciprofloxacin and ceftriaxone are better than rifampin for prevention of bacterial meningitis in patients at risk of developing the infection, a recent Cochrane Review suggests.

These drugs appear to be as effective as rifampin—the treatment that tends to be used for eradicating Neisseria meningitidis associated with bacterial meningitis—but they are associated with less risk of development of antibiotic resistance, said Abigail Fraser, M.D., of Rabin Medical Centre, Petah-Tikan, Israel, and her colleagues.

Furthermore, ciprofloxacin and ceftriaxone are each given in a single dose, whereas rifampin is given twice daily for 2 days. For this reason, selecting ciprofloxacin or ceftriaxone could improve compliance, the reviewers concluded (Cochrane Database Syst, Rev. 2005 [1]:CD004785.pub2. DOI:10.1002/14651858.CD004785.pub2).

Preventing IPD

A recent outbreak of invasive pneumococcal disease in Alaska led to an investigation that has underscored the preventability of the disease and the importance of vaccination.

Between January 2003 and March 2004, 14 cases of invasive pneumococcal disease were reported in a rural region of the state. The mean number of cases per year in the area is 2.8, according to the Centers for Disease Control and Prevention.

Serotype 12F, which is contained in the 23-valent pneumococcal polysaccharide vaccine, was the cause of disease in 9 of the 14 patients, and 6 of those 9 patients had a medical indication for vaccination (MMWR 2005;54:72-5).

The outbreak highlights the need for providing vaccination in both inpatient and outpatient settings at every opportunity. Because many people without a regular physician might seek care in an emergency department or urgent-care clinic, it is important for these types of facilities to also provide vaccination to those with a medical or age-related indication, the investigators said, noting that doing so could substantially reduce complications and deaths due to pneumococcal disease.

Barriers to vaccination should be identified, and standing orders programs should be implemented, they added.

MRSA Precautions

Single-room or cohort isolation of hospitalized patients with methicillin-resistant Staphylococcus aureus infection does not appear to reduce transmissions, a study suggests.

Admission and weekly screens were performed to determine the incidence of MRSA colonization during the prospective, 1-year study conducted in the intensive care units of two London teaching hospitals. For the middle 6 months of the study period, patients with MRSA were not isolated; during the first 3 months and last 3 months, MRSA-positive patients were isolated in single rooms or nursing cohorts. All 866 patients who needed ICU care for longer than 48 hours were included, Jorge A. Cepeda, M.D., of University College London Hospitals and his colleagues reported.

During the two periods of the study, patients had similar characteristics and MRSA acquisition rates. Use of standard precautions and hand-washing rates did not change between the two study periods. There was no evidence of increased MRSA transmission during the period when infected patients were not isolated, compared with the period when infected patients were moved to isolation rooms (hazard ratio 0.73), the investigators said (Lancet 2005;365:295-304).

Given these findings and the risks inherent in moving and/or isolating critically ill patients, isolation policies in intensive care units with endemic MRSA should be reevaluated, they concluded, adding that efforts to find more effective means of containing MRSA are needed.

FAJARDO, P.R. — Epinephrine use in hand and finger surgery doesn't deserve its bad rap, Donald Lalonde, M.D., said at the annual meeting of the American Association for Hand Surgery.

Although epinephrine is commonly thought to be dangerous in the hands and fingers, that belief is based on limited data derived from cases several decades old, said Dr. Lalonde of St. John (N.B.) Regional Hospital. Newer evidence suggests epinephrine is not only safe but beneficial for hand and finger surgery, he added.

"There is a serious disconnect between the experience and the dogma," he said, noting that he has used epinephrine for almost every hand and finger operation in the last 5 years.

A paper published in Plastic Reconstructive Surgery in 2001 suggests the dogma is based on only 21 cases of epinephrine-associated finger infarction. Of 48 reported cases of digital death associated with local anesthesia, 27 occurred in patients who did not receive epinephrine. After reviewing all of these cases, Dr. Lalonde outlined several findings:

▸ More cases of finger infarction occurred without epinephrine than with it, so epinephrine couldn't have been the only factor involved in the poor outcomes.

▸ Almost all the cases took place before 1950, so something occurring prior to that time likely was involved in the poor outcomes.

▸ Until 1948, procaine was the only injected anesthetic available for use with epinephrine. Papers published in 1949 and 1950 in the Journal of the American Medical Association confirmed that there was a recall of toxic lots of procaine with acid pH as low as 1.0, which is extremely toxic, and that the shelf life of procaine was limited, especially in warm temperatures. Expiration dates weren't instituted for procaine, which is no longer used for injections in humans, until 1978.

▸ Lidocaine, which became available after 1948, replaced procaine as the anesthetic of choice because it was associated with less pain and longer duration. As a result, no further investigation was made of procaine toxicity relative to the finger infarction cases.

▸ Despite continued use of lidocaine in finger and hand surgery in various parts of the world, including Canada, no documented cases of finger infarction associated with lidocaine, when used with low-dose epinephrine, have been reported.

▸ There is now an antidote for epinephrine: phentolamine, which became available after the cases in question. No cases of epinephrine-induced digital loss have occurred in which phentolamine was used or considered. The availability of phentolamine further invalidates the meager evidence suggesting epinephrine is unsafe, he said.

Numerous papers on the successful use of epinephrine in hand and finger surgery have been published in recent years, he said.

Dr. Lalonde's own prospective study of more than 3,100 cases over 2 years revealed no incidents of finger infarction. The study, including cases from nine surgeons in six cities, is being revised for publication in the Journal of Hand Surgery, he said.

"With combined clinical experience of well over 100 surgeon-years of [epinephrine] injection in fingers, we have not killed one finger, and not one surgeon had to use phentolamine reversal," he said.

Conversely, he has encountered at least six potentially fatal complications from the use of general anesthesia for hand and finger surgery. Even if finger loss did occur, it would be better to lose a finger than a life, he noted.

FAJARDO, P.R. — Epinephrine use in hand and finger surgery doesn't deserve its bad rap, Donald Lalonde, M.D., said at the annual meeting of the American Association for Hand Surgery.

Although epinephrine is commonly thought to be dangerous in the hands and fingers, that belief is based on limited data derived from cases several decades old, said Dr. Lalonde of St. John (N.B.) Regional Hospital. Newer evidence suggests epinephrine is not only safe but beneficial for hand and finger surgery, he added.

"There is a serious disconnect between the experience and the dogma," he said, noting that he has used epinephrine for almost every hand and finger operation in the last 5 years.

A paper published in Plastic Reconstructive Surgery in 2001 suggests the dogma is based on only 21 cases of epinephrine-associated finger infarction. Of 48 reported cases of digital death associated with local anesthesia, 27 occurred in patients who did not receive epinephrine. After reviewing all of these cases, Dr. Lalonde outlined several findings:

▸ More cases of finger infarction occurred without epinephrine than with it, so epinephrine couldn't have been the only factor involved in the poor outcomes.

▸ Almost all the cases took place before 1950, so something occurring prior to that time likely was involved in the poor outcomes.

▸ Until 1948, procaine was the only injected anesthetic available for use with epinephrine. Papers published in 1949 and 1950 in the Journal of the American Medical Association confirmed that there was a recall of toxic lots of procaine with acid pH as low as 1.0, which is extremely toxic, and that the shelf life of procaine was limited, especially in warm temperatures. Expiration dates weren't instituted for procaine, which is no longer used for injections in humans, until 1978.

▸ Lidocaine, which became available after 1948, replaced procaine as the anesthetic of choice because it was associated with less pain and longer duration. As a result, no further investigation was made of procaine toxicity relative to the finger infarction cases.

▸ Despite continued use of lidocaine in finger and hand surgery in various parts of the world, including Canada, no documented cases of finger infarction associated with lidocaine, when used with low-dose epinephrine, have been reported.

▸ There is now an antidote for epinephrine: phentolamine, which became available after the cases in question. No cases of epinephrine-induced digital loss have occurred in which phentolamine was used or considered. The availability of phentolamine further invalidates the meager evidence suggesting epinephrine is unsafe, he said.

Numerous papers on the successful use of epinephrine in hand and finger surgery have been published in recent years, he said.

Dr. Lalonde's own prospective study of more than 3,100 cases over 2 years revealed no incidents of finger infarction. The study, including cases from nine surgeons in six cities, is being revised for publication in the Journal of Hand Surgery, he said.

"With combined clinical experience of well over 100 surgeon-years of [epinephrine] injection in fingers, we have not killed one finger, and not one surgeon had to use phentolamine reversal," he said.

Conversely, he has encountered at least six potentially fatal complications from the use of general anesthesia for hand and finger surgery. Even if finger loss did occur, it would be better to lose a finger than a life, he noted.

FAJARDO, P.R. — Epinephrine use in hand and finger surgery doesn't deserve its bad rap, Donald Lalonde, M.D., said at the annual meeting of the American Association for Hand Surgery.

Although epinephrine is commonly thought to be dangerous in the hands and fingers, that belief is based on limited data derived from cases several decades old, said Dr. Lalonde of St. John (N.B.) Regional Hospital. Newer evidence suggests epinephrine is not only safe but beneficial for hand and finger surgery, he added.

"There is a serious disconnect between the experience and the dogma," he said, noting that he has used epinephrine for almost every hand and finger operation in the last 5 years.

A paper published in Plastic Reconstructive Surgery in 2001 suggests the dogma is based on only 21 cases of epinephrine-associated finger infarction. Of 48 reported cases of digital death associated with local anesthesia, 27 occurred in patients who did not receive epinephrine. After reviewing all of these cases, Dr. Lalonde outlined several findings:

▸ More cases of finger infarction occurred without epinephrine than with it, so epinephrine couldn't have been the only factor involved in the poor outcomes.

▸ Almost all the cases took place before 1950, so something occurring prior to that time likely was involved in the poor outcomes.

▸ Until 1948, procaine was the only injected anesthetic available for use with epinephrine. Papers published in 1949 and 1950 in the Journal of the American Medical Association confirmed that there was a recall of toxic lots of procaine with acid pH as low as 1.0, which is extremely toxic, and that the shelf life of procaine was limited, especially in warm temperatures. Expiration dates weren't instituted for procaine, which is no longer used for injections in humans, until 1978.

▸ Lidocaine, which became available after 1948, replaced procaine as the anesthetic of choice because it was associated with less pain and longer duration. As a result, no further investigation was made of procaine toxicity relative to the finger infarction cases.

▸ Despite continued use of lidocaine in finger and hand surgery in various parts of the world, including Canada, no documented cases of finger infarction associated with lidocaine, when used with low-dose epinephrine, have been reported.

▸ There is now an antidote for epinephrine: phentolamine, which became available after the cases in question. No cases of epinephrine-induced digital loss have occurred in which phentolamine was used or considered. The availability of phentolamine further invalidates the meager evidence suggesting epinephrine is unsafe, he said.

Numerous papers on the successful use of epinephrine in hand and finger surgery have been published in recent years, he said.

Dr. Lalonde's own prospective study of more than 3,100 cases over 2 years revealed no incidents of finger infarction. The study, including cases from nine surgeons in six cities, is being revised for publication in the Journal of Hand Surgery, he said.

"With combined clinical experience of well over 100 surgeon-years of [epinephrine] injection in fingers, we have not killed one finger, and not one surgeon had to use phentolamine reversal," he said.

Conversely, he has encountered at least six potentially fatal complications from the use of general anesthesia for hand and finger surgery. Even if finger loss did occur, it would be better to lose a finger than a life, he noted.

FAJARDO, P.R. — Surgery is the best option for treatment in children with global brachial plexus birth palsies, a study suggests.

Final shoulder function in 36 infants with such injuries who underwent surgery was fair in 22% of patients, satisfactory in 50%, good in 22%, and excellent in 6%. Final shoulder function was poor in 100% of 12 control patients who did not undergo surgery, Patricia DiTaranto, M.D., said at the annual meeting of the American Association for Hand Surgery.

Hand function in the surgery patients was fair in 19%, satisfactory in 58%, good in 17%, and excellent in 6%. Hand function in those who did not undergo surgery was poor in 25% and fair in 75%, said Dr. DiTaranto of Miami Children's Hospital.

Functional outcomes were determined using the Gilbert-Raimondi system, she noted. The children studied were born at a single institution over a 4-year period and were followed for at least 2.5 years. All had global brachial plexus injuries at birth, and the clinical findings persisted at 6-month follow-up. Those in the surgery group underwent surgical reconstruction of the brachial plexus; the surgical strategy of nerve repair and transfer focused on recovery of shoulder stability and hand function, Dr. DiTaranto noted.

FAJARDO, P.R. — Surgery is the best option for treatment in children with global brachial plexus birth palsies, a study suggests.

Final shoulder function in 36 infants with such injuries who underwent surgery was fair in 22% of patients, satisfactory in 50%, good in 22%, and excellent in 6%. Final shoulder function was poor in 100% of 12 control patients who did not undergo surgery, Patricia DiTaranto, M.D., said at the annual meeting of the American Association for Hand Surgery.

Hand function in the surgery patients was fair in 19%, satisfactory in 58%, good in 17%, and excellent in 6%. Hand function in those who did not undergo surgery was poor in 25% and fair in 75%, said Dr. DiTaranto of Miami Children's Hospital.

Functional outcomes were determined using the Gilbert-Raimondi system, she noted. The children studied were born at a single institution over a 4-year period and were followed for at least 2.5 years. All had global brachial plexus injuries at birth, and the clinical findings persisted at 6-month follow-up. Those in the surgery group underwent surgical reconstruction of the brachial plexus; the surgical strategy of nerve repair and transfer focused on recovery of shoulder stability and hand function, Dr. DiTaranto noted.

FAJARDO, P.R. — Surgery is the best option for treatment in children with global brachial plexus birth palsies, a study suggests.

Final shoulder function in 36 infants with such injuries who underwent surgery was fair in 22% of patients, satisfactory in 50%, good in 22%, and excellent in 6%. Final shoulder function was poor in 100% of 12 control patients who did not undergo surgery, Patricia DiTaranto, M.D., said at the annual meeting of the American Association for Hand Surgery.

Hand function in the surgery patients was fair in 19%, satisfactory in 58%, good in 17%, and excellent in 6%. Hand function in those who did not undergo surgery was poor in 25% and fair in 75%, said Dr. DiTaranto of Miami Children's Hospital.

Functional outcomes were determined using the Gilbert-Raimondi system, she noted. The children studied were born at a single institution over a 4-year period and were followed for at least 2.5 years. All had global brachial plexus injuries at birth, and the clinical findings persisted at 6-month follow-up. Those in the surgery group underwent surgical reconstruction of the brachial plexus; the surgical strategy of nerve repair and transfer focused on recovery of shoulder stability and hand function, Dr. DiTaranto noted.

Urinary tract infections caused by drug-resistant Escherichia coli may have an animal origin, Meena Ramchandani, M.D., of the University of California, Berkeley, and colleagues reported.

A number of cases across the United States caused by a trimethoprim-sulfamethoxazole (TMP-SMZ)-resistant E. coli strain belonging to a single clonal group sparked concerns about a possible association with contaminated food products. An investigation of 495 animal isolates showed that 128 had an electrophoretic pattern indistinguishable from that of the resistant strain in humans, and 14 of those were TMP-SMZ resistant. One, from a cow, was 94% similar to the pattern of a uropathogenic E. coli strain recovered from a human patient (Clin. Infect. Dis. 2005;40:251–7).

The possibility that contaminated food products are the source of drug-resistant UTIs has serious public health implications, the investigators concluded, noting that the introduction of the clonal group E. coli strain in this study doubled the prevalence of TMP-SMZ-resistant UTIs in one community.

However, in an editorial, Thomas Hooten, M.D., and Mansour Samadpour, M.D., of the University of Washington, Seattle, said that although they agree with the basic premise of the article, the findings do not convince them of a link between the animal- and human-associated resistant E. coli strains. The study fails to provide clear epidemiologic linkage between the strains, they noted (Clin. Infect. Dis. 2005;40:258–9).

Urinary tract infections caused by drug-resistant Escherichia coli may have an animal origin, Meena Ramchandani, M.D., of the University of California, Berkeley, and colleagues reported.

A number of cases across the United States caused by a trimethoprim-sulfamethoxazole (TMP-SMZ)-resistant E. coli strain belonging to a single clonal group sparked concerns about a possible association with contaminated food products. An investigation of 495 animal isolates showed that 128 had an electrophoretic pattern indistinguishable from that of the resistant strain in humans, and 14 of those were TMP-SMZ resistant. One, from a cow, was 94% similar to the pattern of a uropathogenic E. coli strain recovered from a human patient (Clin. Infect. Dis. 2005;40:251–7).

The possibility that contaminated food products are the source of drug-resistant UTIs has serious public health implications, the investigators concluded, noting that the introduction of the clonal group E. coli strain in this study doubled the prevalence of TMP-SMZ-resistant UTIs in one community.

However, in an editorial, Thomas Hooten, M.D., and Mansour Samadpour, M.D., of the University of Washington, Seattle, said that although they agree with the basic premise of the article, the findings do not convince them of a link between the animal- and human-associated resistant E. coli strains. The study fails to provide clear epidemiologic linkage between the strains, they noted (Clin. Infect. Dis. 2005;40:258–9).

Urinary tract infections caused by drug-resistant Escherichia coli may have an animal origin, Meena Ramchandani, M.D., of the University of California, Berkeley, and colleagues reported.

A number of cases across the United States caused by a trimethoprim-sulfamethoxazole (TMP-SMZ)-resistant E. coli strain belonging to a single clonal group sparked concerns about a possible association with contaminated food products. An investigation of 495 animal isolates showed that 128 had an electrophoretic pattern indistinguishable from that of the resistant strain in humans, and 14 of those were TMP-SMZ resistant. One, from a cow, was 94% similar to the pattern of a uropathogenic E. coli strain recovered from a human patient (Clin. Infect. Dis. 2005;40:251–7).

The possibility that contaminated food products are the source of drug-resistant UTIs has serious public health implications, the investigators concluded, noting that the introduction of the clonal group E. coli strain in this study doubled the prevalence of TMP-SMZ-resistant UTIs in one community.

However, in an editorial, Thomas Hooten, M.D., and Mansour Samadpour, M.D., of the University of Washington, Seattle, said that although they agree with the basic premise of the article, the findings do not convince them of a link between the animal- and human-associated resistant E. coli strains. The study fails to provide clear epidemiologic linkage between the strains, they noted (Clin. Infect. Dis. 2005;40:258–9).

ORLANDO, FLA. — NOD2 gene variants in children with Crohn's disease appear to predict disease onset in the first decade of life, James Markowitz, M.D., reported at the annual meeting of the American College of Gastroenterology.

Of 102 children aged 16 years or younger with newly diagnosed Crohn's disease, 38 had one or more NOD2 mutations. Similar frequencies of serologic markers for inflammatory bowel disease were found in those with and without NOD2 mutations, but 50% of the subjects with NOD2 mutations were aged 10 or younger at diagnosis, compared with 20% of those with wild-type alleles, said Dr. Markowitz, professor of pediatrics at New York University, New York.

At diagnosis there were no detectable differences in disease activity as measured by pediatric Crohn's Disease Activity Index, or in rates of growth failure, poor weight gain, extraintestinal disease manifestations, or infliximab and steroid use within 30 days after diagnosis in those with and without NOD2 mutations.

There did, however, appear to be important racial differences in the presence of NOD2 mutations: Whites comprised 86% of the study population, but they comprised 97% of the study population with NOD2 mutations, he noted.

ORLANDO, FLA. — NOD2 gene variants in children with Crohn's disease appear to predict disease onset in the first decade of life, James Markowitz, M.D., reported at the annual meeting of the American College of Gastroenterology.

Of 102 children aged 16 years or younger with newly diagnosed Crohn's disease, 38 had one or more NOD2 mutations. Similar frequencies of serologic markers for inflammatory bowel disease were found in those with and without NOD2 mutations, but 50% of the subjects with NOD2 mutations were aged 10 or younger at diagnosis, compared with 20% of those with wild-type alleles, said Dr. Markowitz, professor of pediatrics at New York University, New York.

At diagnosis there were no detectable differences in disease activity as measured by pediatric Crohn's Disease Activity Index, or in rates of growth failure, poor weight gain, extraintestinal disease manifestations, or infliximab and steroid use within 30 days after diagnosis in those with and without NOD2 mutations.

There did, however, appear to be important racial differences in the presence of NOD2 mutations: Whites comprised 86% of the study population, but they comprised 97% of the study population with NOD2 mutations, he noted.

ORLANDO, FLA. — NOD2 gene variants in children with Crohn's disease appear to predict disease onset in the first decade of life, James Markowitz, M.D., reported at the annual meeting of the American College of Gastroenterology.

Of 102 children aged 16 years or younger with newly diagnosed Crohn's disease, 38 had one or more NOD2 mutations. Similar frequencies of serologic markers for inflammatory bowel disease were found in those with and without NOD2 mutations, but 50% of the subjects with NOD2 mutations were aged 10 or younger at diagnosis, compared with 20% of those with wild-type alleles, said Dr. Markowitz, professor of pediatrics at New York University, New York.

At diagnosis there were no detectable differences in disease activity as measured by pediatric Crohn's Disease Activity Index, or in rates of growth failure, poor weight gain, extraintestinal disease manifestations, or infliximab and steroid use within 30 days after diagnosis in those with and without NOD2 mutations.

There did, however, appear to be important racial differences in the presence of NOD2 mutations: Whites comprised 86% of the study population, but they comprised 97% of the study population with NOD2 mutations, he noted.

ORLANDO, FLA. — Supraesophageal manifestations of reflux disease pose a treatment challenge, Reza Shaker, M.D., said at the annual meeting of the American College of Gastroenterology.

There is a misperception that when reflux is treated, other related disorders—such as laryngitis—will disappear as well, but that's not always the case, said Dr. Shaker, chief of gastroenterology and hepatology at the Medical College of Wisconsin, Milwaukee.

When faced with a patient who has lingering laryngitis, throat clearing, and other conditions presumed to be associated with gastroesophageal reflux disease, he recommends the following:

▸ Interview the patient carefully. A thorough history is imperative for ensuring the correct diagnosis. Most patients won't present with cut-and-dried signs and symptoms of GERD. More often, there is a little redness in the area of the supraesophageal structures. Studies show that the presence or absence of symptoms may not be as specific for diagnosis as previously thought.

▸ Evaluate the therapeutic options. Reevaluate the use and value of therapy; the treatment must be tailored to individual patient needs. Although some patients need simple acid suppressive therapy, others with mild disease could respond well to reflux precautionary measures, such as having an empty stomach at bedtime, he said. Others need a combination approach, and still others will require surgery.

Surgeons, however, are increasingly requiring that patients have shown a prior response to medical therapy, indicating that the diagnosis is correct.

In evaluating the effectiveness of the current therapy, check to see if acid has been adequately suppressed. The use of esophageal acid monitoring can be helpful. Also, ensure proper timing of medication dosing. “How many patients do we encounter who take their medicine at the wrong time in the morning and then drink a cup of coffee?” he asked.

Also, confirm that the dosage is adequate.

▸ Recommend the use of precautionary measures. A key difference between the esophageal and supraesophageal structures is that nonacidic and minimally acidic materials can cause injury to the supraesophageal structures. Having an empty stomach before bedtime is important.

Patients should be evaluated for delayed gastric emptying, which occurs in about 40% of GERD patients. This may not be important when dealing with complications of the esophagus in this age of proton pump inhibitors, but it can create a reservoir for acid and nonacid material that can be harmful to the supraesophageal area.

▸ Consider referral to an ear, nose, and throat specialist. Remember that reflux is not exclusive for aerodigestive tract disorder, and consider referring patients who fail to respond to therapy to an ENT physician for additional evaluation, he advised.

ORLANDO, FLA. — Supraesophageal manifestations of reflux disease pose a treatment challenge, Reza Shaker, M.D., said at the annual meeting of the American College of Gastroenterology.

There is a misperception that when reflux is treated, other related disorders—such as laryngitis—will disappear as well, but that's not always the case, said Dr. Shaker, chief of gastroenterology and hepatology at the Medical College of Wisconsin, Milwaukee.

When faced with a patient who has lingering laryngitis, throat clearing, and other conditions presumed to be associated with gastroesophageal reflux disease, he recommends the following:

▸ Interview the patient carefully. A thorough history is imperative for ensuring the correct diagnosis. Most patients won't present with cut-and-dried signs and symptoms of GERD. More often, there is a little redness in the area of the supraesophageal structures. Studies show that the presence or absence of symptoms may not be as specific for diagnosis as previously thought.

▸ Evaluate the therapeutic options. Reevaluate the use and value of therapy; the treatment must be tailored to individual patient needs. Although some patients need simple acid suppressive therapy, others with mild disease could respond well to reflux precautionary measures, such as having an empty stomach at bedtime, he said. Others need a combination approach, and still others will require surgery.

Surgeons, however, are increasingly requiring that patients have shown a prior response to medical therapy, indicating that the diagnosis is correct.

In evaluating the effectiveness of the current therapy, check to see if acid has been adequately suppressed. The use of esophageal acid monitoring can be helpful. Also, ensure proper timing of medication dosing. “How many patients do we encounter who take their medicine at the wrong time in the morning and then drink a cup of coffee?” he asked.

Also, confirm that the dosage is adequate.

▸ Recommend the use of precautionary measures. A key difference between the esophageal and supraesophageal structures is that nonacidic and minimally acidic materials can cause injury to the supraesophageal structures. Having an empty stomach before bedtime is important.

Patients should be evaluated for delayed gastric emptying, which occurs in about 40% of GERD patients. This may not be important when dealing with complications of the esophagus in this age of proton pump inhibitors, but it can create a reservoir for acid and nonacid material that can be harmful to the supraesophageal area.

▸ Consider referral to an ear, nose, and throat specialist. Remember that reflux is not exclusive for aerodigestive tract disorder, and consider referring patients who fail to respond to therapy to an ENT physician for additional evaluation, he advised.

ORLANDO, FLA. — Supraesophageal manifestations of reflux disease pose a treatment challenge, Reza Shaker, M.D., said at the annual meeting of the American College of Gastroenterology.

There is a misperception that when reflux is treated, other related disorders—such as laryngitis—will disappear as well, but that's not always the case, said Dr. Shaker, chief of gastroenterology and hepatology at the Medical College of Wisconsin, Milwaukee.

When faced with a patient who has lingering laryngitis, throat clearing, and other conditions presumed to be associated with gastroesophageal reflux disease, he recommends the following:

▸ Interview the patient carefully. A thorough history is imperative for ensuring the correct diagnosis. Most patients won't present with cut-and-dried signs and symptoms of GERD. More often, there is a little redness in the area of the supraesophageal structures. Studies show that the presence or absence of symptoms may not be as specific for diagnosis as previously thought.

▸ Evaluate the therapeutic options. Reevaluate the use and value of therapy; the treatment must be tailored to individual patient needs. Although some patients need simple acid suppressive therapy, others with mild disease could respond well to reflux precautionary measures, such as having an empty stomach at bedtime, he said. Others need a combination approach, and still others will require surgery.

Surgeons, however, are increasingly requiring that patients have shown a prior response to medical therapy, indicating that the diagnosis is correct.

In evaluating the effectiveness of the current therapy, check to see if acid has been adequately suppressed. The use of esophageal acid monitoring can be helpful. Also, ensure proper timing of medication dosing. “How many patients do we encounter who take their medicine at the wrong time in the morning and then drink a cup of coffee?” he asked.

Also, confirm that the dosage is adequate.

▸ Recommend the use of precautionary measures. A key difference between the esophageal and supraesophageal structures is that nonacidic and minimally acidic materials can cause injury to the supraesophageal structures. Having an empty stomach before bedtime is important.

Patients should be evaluated for delayed gastric emptying, which occurs in about 40% of GERD patients. This may not be important when dealing with complications of the esophagus in this age of proton pump inhibitors, but it can create a reservoir for acid and nonacid material that can be harmful to the supraesophageal area.

▸ Consider referral to an ear, nose, and throat specialist. Remember that reflux is not exclusive for aerodigestive tract disorder, and consider referring patients who fail to respond to therapy to an ENT physician for additional evaluation, he advised.

ORLANDO, FLA. — House calls are no longer a thing of the past.

Technology, which was largely responsible for the demise of physician house calls, is now the catalyst for their revival, Thomas A. Cornwell, M.D., said at the annual meeting of the American Academy of Family Physicians.

It is possible to provide quality care and make a good living doing house calls, he said. As a family physician with a full-time house calls practice in Chicago, he has made more than 16,000 house calls to more than 2,500 homebound patients. The job is rewarding, he said, but that is only one of the reasons he promotes house calls as a practice opportunity.

Another reason to consider offering house calls is the increasing need. The baby boomers are aging, and it is expected that the number of adults older than 85 years will quadruple by 2050.

About half of those in this age group typically require assistance with activities of daily living. Many homebound patients don't receive regular doctor visits, while similar patients in nursing homes average 11–12 visits per year.

Patients who receive medical care in the home also tend to receive better care. Diagnostic accuracy is enhanced when the patient is seen in his or her own environment, Dr. Cornwell explained.

For example, the physician can get a better sense of the patient's personality through pictures and religious symbols, which can be useful for improving communication. And a better sense of medical issues can be achieved by taking note of medications/medication bottles, the food available in the home, the presence of foul odors like urine, and potential fall risks.

He described one patient who had been receiving no benefit from an inhaler. A trip to the doctor's office would most likely have resulted in prescription changes or increased dosages, but a home visit and an examination of the inhaler and equipment used by the patient revealed that the patient was failing to remove the cap from the inhaler before use.

In one study, a home visit that was made following an office-based geriatric assessment yielded an average of two new diagnoses and four additional treatment recommendations, he noted.

Another benefit of providing house calls is the reduced need for hospitalization. Regular physician visits can prevent the need for inpatient care, which can improve outcomes. Numerous studies have shown that the elderly do not fare well in the hospital; several studies, for example, show that up to half of those who are admitted have functional decline not related to the admitting diagnosis.

Additional benefits of providing house calls include increased practice reputation and growth; tremendous potential for societal health care savings, mainly as a result of fewer hospitalizations and more patients remaining at home until their death; attractive financial incentives, including low overhead and recent increases in reimbursement for home care; and low liability, with a survey of more than 200 house calls doctors showing that none were aware of any lawsuits stemming from house calls, and a Web-based search in 2003 revealing only two such lawsuits, one of which was dismissed.

Patients tend to be very satisfied with physician visits at their home, Dr. Cornwell said.

Technological advances—such as the availability of home infusion therapy and portable equipment for x-rays and ultrasound—make home care viable for physicians. But you don't have to be technologically equipped to this level, because more than 95% of the care provided by a physician in the home is primary care, he said.

“What you have to be is a good primary care doctor,” he added.

House-Calls Practice: Getting Started

A successful house-calls practice requires research and thorough planning, Dr. Cornwell said.

First, set goals and objectives. A review of the reasons for providing house calls—such as increased demand, professional and financial rewards, increased practice growth, potential societal benefits, and improved care—can be helpful for initiating discussion regarding your goals and objectives, he said.

Next, he advised, consider four important issues:

▸ Geography. Determine the area to be serviced using town limits or zip codes, and adhere strictly to this, he advised. Straying outside the preset boundaries can be tempting early on, but will cause logistical problems as the practice expands.

▸ Time to be spent on house calls. Some physicians start slowly, adding half days or full days for house calls during the workweek, or fitting house calls in on the way home from work. Others have full-time house-calls practices. Determine in advance how much time you are going to spend doing house calls, he said.

▸ Types of patients you will see on house calls. Will you see only current patients who are homebound, or will you accept new homebound patients into your practice?

▸ The need for a medical assistant. A house-calls practice typically involves low overhead, but the expense of hiring a medical assistant to coordinate and attend home visits can be a worthwhile expense, particularly in a practice that covers a fairly large geographical area, Dr. Cornwell noted.

In addition to taking vital signs and assisting with electrocardiograms, phlebotomy, and minor procedures, a medical assistant can perform various administrative tasks, such as planning the day, calling patients, filing insurance forms, and/or driving the physician from call to call while the physician makes notes, dictates, or arranges care with home health personnel, he explained.

In his own practice, which covers a large territory and provides a number of ancillary services, medical assistants have been of great value. The cost of a medical assistant is covered by seeing one additional patient each day, which is possible because of the time that the assistant saves, he said.

Offering House Calls Can Be Profitable

With careful attention to costs and billing, providing house calls can be profitable.

Controlling overhead is particularly important, but can be one of the simpler aspects of a house-calls practice. Start-up costs are typically low. Unlike those in an office-based practice, expenses like rent, staffing, and furnishings for the office and examination room can be drastically reduced or eliminated, Dr. Cornwell explained.

As for income, he offered this scenario as an example of how a house-calls practice can generate revenue: On a typical day, and with proper scheduling, it is possible to make eight house calls. Dr. Cornwell makes 10. Based on a year's worth of data in his area, he said the typical reimbursement per patient for a 30-minute visit is $133.

With a 5-day workweek for 49 weeks of the year, this rate would generate $260,680 per year, or just under $235,000 if the practice is made up of primarily Medicare patients.

If overhead can be kept at 40%, annual take-home pay would be about $140,000. If one additional patient is seen each day, annual take home pay in a Medicare-predominant practice would be about $158,000.

Proper billing for procedures performed, extra time spent with the patient (such as for discussing end-of-life care), and ancillary services can generate additional revenue. If the practice is affiliated with a not-for-profit health system, as is the case for Dr. Cornwell, donations are also easily generated, and community grant money can often be obtained.

In his 7 years in a house-calls practice, the program has generated more than $1.5 million in donations, Dr. Cornwell said.

He described one $300,000 donation, which was a patient assistance endowment. The interest from the donation is used to provide medical equipment and supplies for patients in financial need.

ORLANDO, FLA. — House calls are no longer a thing of the past.

Technology, which was largely responsible for the demise of physician house calls, is now the catalyst for their revival, Thomas A. Cornwell, M.D., said at the annual meeting of the American Academy of Family Physicians.

It is possible to provide quality care and make a good living doing house calls, he said. As a family physician with a full-time house calls practice in Chicago, he has made more than 16,000 house calls to more than 2,500 homebound patients. The job is rewarding, he said, but that is only one of the reasons he promotes house calls as a practice opportunity.

Another reason to consider offering house calls is the increasing need. The baby boomers are aging, and it is expected that the number of adults older than 85 years will quadruple by 2050.

About half of those in this age group typically require assistance with activities of daily living. Many homebound patients don't receive regular doctor visits, while similar patients in nursing homes average 11–12 visits per year.

Patients who receive medical care in the home also tend to receive better care. Diagnostic accuracy is enhanced when the patient is seen in his or her own environment, Dr. Cornwell explained.

For example, the physician can get a better sense of the patient's personality through pictures and religious symbols, which can be useful for improving communication. And a better sense of medical issues can be achieved by taking note of medications/medication bottles, the food available in the home, the presence of foul odors like urine, and potential fall risks.

He described one patient who had been receiving no benefit from an inhaler. A trip to the doctor's office would most likely have resulted in prescription changes or increased dosages, but a home visit and an examination of the inhaler and equipment used by the patient revealed that the patient was failing to remove the cap from the inhaler before use.

In one study, a home visit that was made following an office-based geriatric assessment yielded an average of two new diagnoses and four additional treatment recommendations, he noted.

Another benefit of providing house calls is the reduced need for hospitalization. Regular physician visits can prevent the need for inpatient care, which can improve outcomes. Numerous studies have shown that the elderly do not fare well in the hospital; several studies, for example, show that up to half of those who are admitted have functional decline not related to the admitting diagnosis.

Additional benefits of providing house calls include increased practice reputation and growth; tremendous potential for societal health care savings, mainly as a result of fewer hospitalizations and more patients remaining at home until their death; attractive financial incentives, including low overhead and recent increases in reimbursement for home care; and low liability, with a survey of more than 200 house calls doctors showing that none were aware of any lawsuits stemming from house calls, and a Web-based search in 2003 revealing only two such lawsuits, one of which was dismissed.

Patients tend to be very satisfied with physician visits at their home, Dr. Cornwell said.

Technological advances—such as the availability of home infusion therapy and portable equipment for x-rays and ultrasound—make home care viable for physicians. But you don't have to be technologically equipped to this level, because more than 95% of the care provided by a physician in the home is primary care, he said.

“What you have to be is a good primary care doctor,” he added.

House-Calls Practice: Getting Started

A successful house-calls practice requires research and thorough planning, Dr. Cornwell said.

First, set goals and objectives. A review of the reasons for providing house calls—such as increased demand, professional and financial rewards, increased practice growth, potential societal benefits, and improved care—can be helpful for initiating discussion regarding your goals and objectives, he said.

Next, he advised, consider four important issues:

▸ Geography. Determine the area to be serviced using town limits or zip codes, and adhere strictly to this, he advised. Straying outside the preset boundaries can be tempting early on, but will cause logistical problems as the practice expands.

▸ Time to be spent on house calls. Some physicians start slowly, adding half days or full days for house calls during the workweek, or fitting house calls in on the way home from work. Others have full-time house-calls practices. Determine in advance how much time you are going to spend doing house calls, he said.

▸ Types of patients you will see on house calls. Will you see only current patients who are homebound, or will you accept new homebound patients into your practice?

▸ The need for a medical assistant. A house-calls practice typically involves low overhead, but the expense of hiring a medical assistant to coordinate and attend home visits can be a worthwhile expense, particularly in a practice that covers a fairly large geographical area, Dr. Cornwell noted.

In addition to taking vital signs and assisting with electrocardiograms, phlebotomy, and minor procedures, a medical assistant can perform various administrative tasks, such as planning the day, calling patients, filing insurance forms, and/or driving the physician from call to call while the physician makes notes, dictates, or arranges care with home health personnel, he explained.

In his own practice, which covers a large territory and provides a number of ancillary services, medical assistants have been of great value. The cost of a medical assistant is covered by seeing one additional patient each day, which is possible because of the time that the assistant saves, he said.

Offering House Calls Can Be Profitable

With careful attention to costs and billing, providing house calls can be profitable.

Controlling overhead is particularly important, but can be one of the simpler aspects of a house-calls practice. Start-up costs are typically low. Unlike those in an office-based practice, expenses like rent, staffing, and furnishings for the office and examination room can be drastically reduced or eliminated, Dr. Cornwell explained.

As for income, he offered this scenario as an example of how a house-calls practice can generate revenue: On a typical day, and with proper scheduling, it is possible to make eight house calls. Dr. Cornwell makes 10. Based on a year's worth of data in his area, he said the typical reimbursement per patient for a 30-minute visit is $133.

With a 5-day workweek for 49 weeks of the year, this rate would generate $260,680 per year, or just under $235,000 if the practice is made up of primarily Medicare patients.

If overhead can be kept at 40%, annual take-home pay would be about $140,000. If one additional patient is seen each day, annual take home pay in a Medicare-predominant practice would be about $158,000.

Proper billing for procedures performed, extra time spent with the patient (such as for discussing end-of-life care), and ancillary services can generate additional revenue. If the practice is affiliated with a not-for-profit health system, as is the case for Dr. Cornwell, donations are also easily generated, and community grant money can often be obtained.

In his 7 years in a house-calls practice, the program has generated more than $1.5 million in donations, Dr. Cornwell said.

He described one $300,000 donation, which was a patient assistance endowment. The interest from the donation is used to provide medical equipment and supplies for patients in financial need.

ORLANDO, FLA. — House calls are no longer a thing of the past.

Technology, which was largely responsible for the demise of physician house calls, is now the catalyst for their revival, Thomas A. Cornwell, M.D., said at the annual meeting of the American Academy of Family Physicians.

It is possible to provide quality care and make a good living doing house calls, he said. As a family physician with a full-time house calls practice in Chicago, he has made more than 16,000 house calls to more than 2,500 homebound patients. The job is rewarding, he said, but that is only one of the reasons he promotes house calls as a practice opportunity.

Another reason to consider offering house calls is the increasing need. The baby boomers are aging, and it is expected that the number of adults older than 85 years will quadruple by 2050.

About half of those in this age group typically require assistance with activities of daily living. Many homebound patients don't receive regular doctor visits, while similar patients in nursing homes average 11–12 visits per year.

Patients who receive medical care in the home also tend to receive better care. Diagnostic accuracy is enhanced when the patient is seen in his or her own environment, Dr. Cornwell explained.

For example, the physician can get a better sense of the patient's personality through pictures and religious symbols, which can be useful for improving communication. And a better sense of medical issues can be achieved by taking note of medications/medication bottles, the food available in the home, the presence of foul odors like urine, and potential fall risks.

He described one patient who had been receiving no benefit from an inhaler. A trip to the doctor's office would most likely have resulted in prescription changes or increased dosages, but a home visit and an examination of the inhaler and equipment used by the patient revealed that the patient was failing to remove the cap from the inhaler before use.

In one study, a home visit that was made following an office-based geriatric assessment yielded an average of two new diagnoses and four additional treatment recommendations, he noted.

Another benefit of providing house calls is the reduced need for hospitalization. Regular physician visits can prevent the need for inpatient care, which can improve outcomes. Numerous studies have shown that the elderly do not fare well in the hospital; several studies, for example, show that up to half of those who are admitted have functional decline not related to the admitting diagnosis.

Additional benefits of providing house calls include increased practice reputation and growth; tremendous potential for societal health care savings, mainly as a result of fewer hospitalizations and more patients remaining at home until their death; attractive financial incentives, including low overhead and recent increases in reimbursement for home care; and low liability, with a survey of more than 200 house calls doctors showing that none were aware of any lawsuits stemming from house calls, and a Web-based search in 2003 revealing only two such lawsuits, one of which was dismissed.

Patients tend to be very satisfied with physician visits at their home, Dr. Cornwell said.

Technological advances—such as the availability of home infusion therapy and portable equipment for x-rays and ultrasound—make home care viable for physicians. But you don't have to be technologically equipped to this level, because more than 95% of the care provided by a physician in the home is primary care, he said.

“What you have to be is a good primary care doctor,” he added.

House-Calls Practice: Getting Started

A successful house-calls practice requires research and thorough planning, Dr. Cornwell said.

First, set goals and objectives. A review of the reasons for providing house calls—such as increased demand, professional and financial rewards, increased practice growth, potential societal benefits, and improved care—can be helpful for initiating discussion regarding your goals and objectives, he said.

Next, he advised, consider four important issues:

▸ Geography. Determine the area to be serviced using town limits or zip codes, and adhere strictly to this, he advised. Straying outside the preset boundaries can be tempting early on, but will cause logistical problems as the practice expands.

▸ Time to be spent on house calls. Some physicians start slowly, adding half days or full days for house calls during the workweek, or fitting house calls in on the way home from work. Others have full-time house-calls practices. Determine in advance how much time you are going to spend doing house calls, he said.

▸ Types of patients you will see on house calls. Will you see only current patients who are homebound, or will you accept new homebound patients into your practice?

▸ The need for a medical assistant. A house-calls practice typically involves low overhead, but the expense of hiring a medical assistant to coordinate and attend home visits can be a worthwhile expense, particularly in a practice that covers a fairly large geographical area, Dr. Cornwell noted.

In addition to taking vital signs and assisting with electrocardiograms, phlebotomy, and minor procedures, a medical assistant can perform various administrative tasks, such as planning the day, calling patients, filing insurance forms, and/or driving the physician from call to call while the physician makes notes, dictates, or arranges care with home health personnel, he explained.

In his own practice, which covers a large territory and provides a number of ancillary services, medical assistants have been of great value. The cost of a medical assistant is covered by seeing one additional patient each day, which is possible because of the time that the assistant saves, he said.

Offering House Calls Can Be Profitable

With careful attention to costs and billing, providing house calls can be profitable.

Controlling overhead is particularly important, but can be one of the simpler aspects of a house-calls practice. Start-up costs are typically low. Unlike those in an office-based practice, expenses like rent, staffing, and furnishings for the office and examination room can be drastically reduced or eliminated, Dr. Cornwell explained.

As for income, he offered this scenario as an example of how a house-calls practice can generate revenue: On a typical day, and with proper scheduling, it is possible to make eight house calls. Dr. Cornwell makes 10. Based on a year's worth of data in his area, he said the typical reimbursement per patient for a 30-minute visit is $133.

With a 5-day workweek for 49 weeks of the year, this rate would generate $260,680 per year, or just under $235,000 if the practice is made up of primarily Medicare patients.

If overhead can be kept at 40%, annual take-home pay would be about $140,000. If one additional patient is seen each day, annual take home pay in a Medicare-predominant practice would be about $158,000.

Proper billing for procedures performed, extra time spent with the patient (such as for discussing end-of-life care), and ancillary services can generate additional revenue. If the practice is affiliated with a not-for-profit health system, as is the case for Dr. Cornwell, donations are also easily generated, and community grant money can often be obtained.

In his 7 years in a house-calls practice, the program has generated more than $1.5 million in donations, Dr. Cornwell said.

He described one $300,000 donation, which was a patient assistance endowment. The interest from the donation is used to provide medical equipment and supplies for patients in financial need.

ORLANDO, FLA. — Supraesophageal manifestations of reflux disease pose a treatment challenge, Reza Shaker, M.D., said at the annual meeting of the American College of Gastroenterology.

There is a misperception that when reflux is treated, other related disorders—such as laryngitis—will disappear as well, but that's not always the case, said Dr. Shaker, chief of gastroenterology and hepatology at the Medical College of Wisconsin, Milwaukee.

When faced with a patient who has lingering laryngitis, throat clearing, and other conditions presumed to be associated with gastroesophageal reflux disease, he recommends the following:

▸ Interview the patient carefully. A thorough history is imperative for ensuring the correct diagnosis. Most patients won't present with cut-and-dried signs and symptoms of GERD. More often, there is a little redness in the area of the supraesophageal structures. Studies show that the presence or absence of symptoms may not be as specific for diagnosis as previously thought.

▸ Evaluate the therapeutic options. Reevaluate the use and value of therapy; the treatment must be tailored to individual patient needs. Although some patients need simple acid suppressive therapy, others with mild disease could respond well to reflux precautionary measures, such as having an empty stomach at bedtime, he said. Others need a combination approach, and still others will require surgery.

Surgeons, however, are increasingly requiring that patients have shown a prior response to medical therapy, indicating that the diagnosis is correct.

In evaluating the effectiveness of the current therapy, check to see if acid has been adequately suppressed. The use of esophageal acid monitoring can be helpful. Also, ensure proper timing of medication dosing. “How many patients do we encounter who take their medicine at the wrong time in the morning and then drink a cup of coffee?” he asked.

In addition, confirm that the dosage is adequate.

▸ Recommend the use of precautionary measures. A key difference between the esophageal and supraesophageal structures is that nonacidic and minimally acidic materials can cause injury to the supraesophageal structures. Having an empty stomach before bedtime is an important preventive strategy.

Patients should be evaluated for delayed gastric emptying, which occurs in about 40% of GERD patients. This may not be important when dealing with complications of the esophagus in this age of proton pump inhibitors, but it can create a reservoir for acid and nonacid material that can be harmful to the supraesophageal area.

▸ Consider referral to an ear, nose, and throat specialist. Remember that reflux is not exclusive for aerodigestive tract disorder, and consider referring patients who fail to respond to therapy to an ENT physician for additional evaluation, he advised.

ORLANDO, FLA. — Supraesophageal manifestations of reflux disease pose a treatment challenge, Reza Shaker, M.D., said at the annual meeting of the American College of Gastroenterology.

There is a misperception that when reflux is treated, other related disorders—such as laryngitis—will disappear as well, but that's not always the case, said Dr. Shaker, chief of gastroenterology and hepatology at the Medical College of Wisconsin, Milwaukee.

When faced with a patient who has lingering laryngitis, throat clearing, and other conditions presumed to be associated with gastroesophageal reflux disease, he recommends the following:

▸ Interview the patient carefully. A thorough history is imperative for ensuring the correct diagnosis. Most patients won't present with cut-and-dried signs and symptoms of GERD. More often, there is a little redness in the area of the supraesophageal structures. Studies show that the presence or absence of symptoms may not be as specific for diagnosis as previously thought.

▸ Evaluate the therapeutic options. Reevaluate the use and value of therapy; the treatment must be tailored to individual patient needs. Although some patients need simple acid suppressive therapy, others with mild disease could respond well to reflux precautionary measures, such as having an empty stomach at bedtime, he said. Others need a combination approach, and still others will require surgery.

Surgeons, however, are increasingly requiring that patients have shown a prior response to medical therapy, indicating that the diagnosis is correct.

In evaluating the effectiveness of the current therapy, check to see if acid has been adequately suppressed. The use of esophageal acid monitoring can be helpful. Also, ensure proper timing of medication dosing. “How many patients do we encounter who take their medicine at the wrong time in the morning and then drink a cup of coffee?” he asked.

In addition, confirm that the dosage is adequate.

▸ Recommend the use of precautionary measures. A key difference between the esophageal and supraesophageal structures is that nonacidic and minimally acidic materials can cause injury to the supraesophageal structures. Having an empty stomach before bedtime is an important preventive strategy.

Patients should be evaluated for delayed gastric emptying, which occurs in about 40% of GERD patients. This may not be important when dealing with complications of the esophagus in this age of proton pump inhibitors, but it can create a reservoir for acid and nonacid material that can be harmful to the supraesophageal area.

▸ Consider referral to an ear, nose, and throat specialist. Remember that reflux is not exclusive for aerodigestive tract disorder, and consider referring patients who fail to respond to therapy to an ENT physician for additional evaluation, he advised.

ORLANDO, FLA. — Supraesophageal manifestations of reflux disease pose a treatment challenge, Reza Shaker, M.D., said at the annual meeting of the American College of Gastroenterology.

There is a misperception that when reflux is treated, other related disorders—such as laryngitis—will disappear as well, but that's not always the case, said Dr. Shaker, chief of gastroenterology and hepatology at the Medical College of Wisconsin, Milwaukee.

When faced with a patient who has lingering laryngitis, throat clearing, and other conditions presumed to be associated with gastroesophageal reflux disease, he recommends the following:

▸ Interview the patient carefully. A thorough history is imperative for ensuring the correct diagnosis. Most patients won't present with cut-and-dried signs and symptoms of GERD. More often, there is a little redness in the area of the supraesophageal structures. Studies show that the presence or absence of symptoms may not be as specific for diagnosis as previously thought.

▸ Evaluate the therapeutic options. Reevaluate the use and value of therapy; the treatment must be tailored to individual patient needs. Although some patients need simple acid suppressive therapy, others with mild disease could respond well to reflux precautionary measures, such as having an empty stomach at bedtime, he said. Others need a combination approach, and still others will require surgery.

Surgeons, however, are increasingly requiring that patients have shown a prior response to medical therapy, indicating that the diagnosis is correct.

In evaluating the effectiveness of the current therapy, check to see if acid has been adequately suppressed. The use of esophageal acid monitoring can be helpful. Also, ensure proper timing of medication dosing. “How many patients do we encounter who take their medicine at the wrong time in the morning and then drink a cup of coffee?” he asked.

In addition, confirm that the dosage is adequate.

▸ Recommend the use of precautionary measures. A key difference between the esophageal and supraesophageal structures is that nonacidic and minimally acidic materials can cause injury to the supraesophageal structures. Having an empty stomach before bedtime is an important preventive strategy.

Patients should be evaluated for delayed gastric emptying, which occurs in about 40% of GERD patients. This may not be important when dealing with complications of the esophagus in this age of proton pump inhibitors, but it can create a reservoir for acid and nonacid material that can be harmful to the supraesophageal area.

▸ Consider referral to an ear, nose, and throat specialist. Remember that reflux is not exclusive for aerodigestive tract disorder, and consider referring patients who fail to respond to therapy to an ENT physician for additional evaluation, he advised.

Genetic Factors May Affect HIV Risk

Fewer copies of specific immune response genes may increase an individual's risk of contracting HIV and AIDS.

A low copy number of the gene encoding CCL3L1—a potent HIV-1-suppressive chemokine and ligand for the HIV coreceptor CCR5—was associated with markedly increased HIV/AIDS susceptibility in a study of more than 4,300 blood samples from HIV-positive and HIV-negative individuals of varying ancestral origins. The average number of CCL3L1-encoding gene copies varied in each group; those within a particular ancestral group with fewer copies than the average for that group were more susceptible to HIV infection and rapid progression to AIDS, and those with more than the average number of copies were less susceptible, reported Enrique Gonzalez, M.D., of the University of Texas Health Sciences Center, San Antonio, and his colleagues.

For example, each additional copy lowered the risk of HIV by 4.5%–10.5%, depending on the group. Susceptibility was increased in those with disease-accelerating CCR5 genotypes, the investigators said (Science Express 2005;1126:1–10).

The findings could potentially be used to develop screening tests to identify increased susceptibility to HIV/AIDS and to adapt treatment and vaccine trials accordingly, the investigators said.

Resistant UTIs

Urinary tract infections caused by drug-resistant Escherichia coli may have an animal origin, Meena Ramchandani, M.D., of the University of California, Berkeley, and colleagues reported.

A number of cases across the United States caused by a trimethoprim-sulfamethoxazole (TMP-SMZ)-resistant E. coli strain belonging to a single clonal group sparked concerns about a possible association with contaminated food products. An investigation of 495 animal isolates showed that 128 had an electrophoretic pattern indistinguishable from that of the resistant strain in humans, and 14 of those were TMP-SMZ resistant. One, from a cow, was 94% similar to the pattern of a uropathogenic E. coli strain recovered from a human patient (Clin. Infect. Dis. 2005;40:251–7).

The possibility that contaminated food products are the source of drug-resistant UTIs has serious public health implications, the investigators concluded, noting that the introduction of the clonal group E. coli strain in this study doubled the prevalence of TMP-SMZ-resistant UTIs in one community.

But in an editorial, Thomas Hooten, M.D., and Mansour Samadpour, M.D., of the University of Washington, Seattle, said that although they agree with the basic premise of the article, the findings do not convince them that there is a link between the animal- and human-associated resistant E. coli strains. The study fails to provide clear epidemiologic linkage between the strains, they noted, adding that further study is warranted (Clin. Infect. Dis. 2005;40:258–9).

Acute Laryngitis Treatment

Antibiotics should not be used for the treatment of acute laryngitis in adults, according to a Cochrane Review.

The reviews of two placebo-controlled trials showed that any small improvements in the symptoms of laryngitis in patients treated with penicillin V or erythromycin are outweighed by the risks involved in using unnecessary antibiotics. Some patients reported slight improvements during the recovery phase in coughing and voice disturbance, but patients in the treatment and control groups recovered in the same amount of time, Ludovic Reveiz, M.D., of Bogota, Colombia, and his colleagues found (Cochrane Database Syst. Rev. [1]:CD 004783, Jan. 24, 2005).

Rat-Bite Fever

Two recent cases of fatal Streptobacillus moniliformis infection—or rat-bite fever—underscore the importance of considering this diagnosis in sick patients with rat exposures, and also the need to prevent infection among those with routine rat exposures, according to the Centers for Disease Control and Prevention.

Both patients were previously healthy adults, and S. moniliformis infection was confirmed by the CDC. One 52-year-old woman died within 12 hours after being admitted with symptoms. She was bitten by a rat 4 days prior at the pet store at which she worked and had developed symptoms 2 days prior (MMWR 2005;53:1198–201).

The second patient was a 19-year-old rat owner who was pronounced dead on arrival at a hospital after 3 days of symptoms. Such rapidly fatal cases of rat bite fever have been reported in children, but not in adults, except when there are systemic complications such as endocarditis or meningitis. The recent cases suggest that prevention of severe disease depends on promoting risk reduction and symptom recognition.

Genetic Factors May Affect HIV Risk

Fewer copies of specific immune response genes may increase an individual's risk of contracting HIV and AIDS.

A low copy number of the gene encoding CCL3L1—a potent HIV-1-suppressive chemokine and ligand for the HIV coreceptor CCR5—was associated with markedly increased HIV/AIDS susceptibility in a study of more than 4,300 blood samples from HIV-positive and HIV-negative individuals of varying ancestral origins. The average number of CCL3L1-encoding gene copies varied in each group; those within a particular ancestral group with fewer copies than the average for that group were more susceptible to HIV infection and rapid progression to AIDS, and those with more than the average number of copies were less susceptible, reported Enrique Gonzalez, M.D., of the University of Texas Health Sciences Center, San Antonio, and his colleagues.

For example, each additional copy lowered the risk of HIV by 4.5%–10.5%, depending on the group. Susceptibility was increased in those with disease-accelerating CCR5 genotypes, the investigators said (Science Express 2005;1126:1–10).

The findings could potentially be used to develop screening tests to identify increased susceptibility to HIV/AIDS and to adapt treatment and vaccine trials accordingly, the investigators said.

Resistant UTIs

Urinary tract infections caused by drug-resistant Escherichia coli may have an animal origin, Meena Ramchandani, M.D., of the University of California, Berkeley, and colleagues reported.

A number of cases across the United States caused by a trimethoprim-sulfamethoxazole (TMP-SMZ)-resistant E. coli strain belonging to a single clonal group sparked concerns about a possible association with contaminated food products. An investigation of 495 animal isolates showed that 128 had an electrophoretic pattern indistinguishable from that of the resistant strain in humans, and 14 of those were TMP-SMZ resistant. One, from a cow, was 94% similar to the pattern of a uropathogenic E. coli strain recovered from a human patient (Clin. Infect. Dis. 2005;40:251–7).

The possibility that contaminated food products are the source of drug-resistant UTIs has serious public health implications, the investigators concluded, noting that the introduction of the clonal group E. coli strain in this study doubled the prevalence of TMP-SMZ-resistant UTIs in one community.

But in an editorial, Thomas Hooten, M.D., and Mansour Samadpour, M.D., of the University of Washington, Seattle, said that although they agree with the basic premise of the article, the findings do not convince them that there is a link between the animal- and human-associated resistant E. coli strains. The study fails to provide clear epidemiologic linkage between the strains, they noted, adding that further study is warranted (Clin. Infect. Dis. 2005;40:258–9).

Acute Laryngitis Treatment

Antibiotics should not be used for the treatment of acute laryngitis in adults, according to a Cochrane Review.

The reviews of two placebo-controlled trials showed that any small improvements in the symptoms of laryngitis in patients treated with penicillin V or erythromycin are outweighed by the risks involved in using unnecessary antibiotics. Some patients reported slight improvements during the recovery phase in coughing and voice disturbance, but patients in the treatment and control groups recovered in the same amount of time, Ludovic Reveiz, M.D., of Bogota, Colombia, and his colleagues found (Cochrane Database Syst. Rev. [1]:CD 004783, Jan. 24, 2005).

Rat-Bite Fever

Two recent cases of fatal Streptobacillus moniliformis infection—or rat-bite fever—underscore the importance of considering this diagnosis in sick patients with rat exposures, and also the need to prevent infection among those with routine rat exposures, according to the Centers for Disease Control and Prevention.

Both patients were previously healthy adults, and S. moniliformis infection was confirmed by the CDC. One 52-year-old woman died within 12 hours after being admitted with symptoms. She was bitten by a rat 4 days prior at the pet store at which she worked and had developed symptoms 2 days prior (MMWR 2005;53:1198–201).

The second patient was a 19-year-old rat owner who was pronounced dead on arrival at a hospital after 3 days of symptoms. Such rapidly fatal cases of rat bite fever have been reported in children, but not in adults, except when there are systemic complications such as endocarditis or meningitis. The recent cases suggest that prevention of severe disease depends on promoting risk reduction and symptom recognition.

Genetic Factors May Affect HIV Risk

Fewer copies of specific immune response genes may increase an individual's risk of contracting HIV and AIDS.

A low copy number of the gene encoding CCL3L1—a potent HIV-1-suppressive chemokine and ligand for the HIV coreceptor CCR5—was associated with markedly increased HIV/AIDS susceptibility in a study of more than 4,300 blood samples from HIV-positive and HIV-negative individuals of varying ancestral origins. The average number of CCL3L1-encoding gene copies varied in each group; those within a particular ancestral group with fewer copies than the average for that group were more susceptible to HIV infection and rapid progression to AIDS, and those with more than the average number of copies were less susceptible, reported Enrique Gonzalez, M.D., of the University of Texas Health Sciences Center, San Antonio, and his colleagues.

For example, each additional copy lowered the risk of HIV by 4.5%–10.5%, depending on the group. Susceptibility was increased in those with disease-accelerating CCR5 genotypes, the investigators said (Science Express 2005;1126:1–10).

The findings could potentially be used to develop screening tests to identify increased susceptibility to HIV/AIDS and to adapt treatment and vaccine trials accordingly, the investigators said.

Resistant UTIs

Urinary tract infections caused by drug-resistant Escherichia coli may have an animal origin, Meena Ramchandani, M.D., of the University of California, Berkeley, and colleagues reported.

A number of cases across the United States caused by a trimethoprim-sulfamethoxazole (TMP-SMZ)-resistant E. coli strain belonging to a single clonal group sparked concerns about a possible association with contaminated food products. An investigation of 495 animal isolates showed that 128 had an electrophoretic pattern indistinguishable from that of the resistant strain in humans, and 14 of those were TMP-SMZ resistant. One, from a cow, was 94% similar to the pattern of a uropathogenic E. coli strain recovered from a human patient (Clin. Infect. Dis. 2005;40:251–7).

The possibility that contaminated food products are the source of drug-resistant UTIs has serious public health implications, the investigators concluded, noting that the introduction of the clonal group E. coli strain in this study doubled the prevalence of TMP-SMZ-resistant UTIs in one community.

But in an editorial, Thomas Hooten, M.D., and Mansour Samadpour, M.D., of the University of Washington, Seattle, said that although they agree with the basic premise of the article, the findings do not convince them that there is a link between the animal- and human-associated resistant E. coli strains. The study fails to provide clear epidemiologic linkage between the strains, they noted, adding that further study is warranted (Clin. Infect. Dis. 2005;40:258–9).

Acute Laryngitis Treatment

Antibiotics should not be used for the treatment of acute laryngitis in adults, according to a Cochrane Review.

The reviews of two placebo-controlled trials showed that any small improvements in the symptoms of laryngitis in patients treated with penicillin V or erythromycin are outweighed by the risks involved in using unnecessary antibiotics. Some patients reported slight improvements during the recovery phase in coughing and voice disturbance, but patients in the treatment and control groups recovered in the same amount of time, Ludovic Reveiz, M.D., of Bogota, Colombia, and his colleagues found (Cochrane Database Syst. Rev. [1]:CD 004783, Jan. 24, 2005).

Rat-Bite Fever

Two recent cases of fatal Streptobacillus moniliformis infection—or rat-bite fever—underscore the importance of considering this diagnosis in sick patients with rat exposures, and also the need to prevent infection among those with routine rat exposures, according to the Centers for Disease Control and Prevention.

Both patients were previously healthy adults, and S. moniliformis infection was confirmed by the CDC. One 52-year-old woman died within 12 hours after being admitted with symptoms. She was bitten by a rat 4 days prior at the pet store at which she worked and had developed symptoms 2 days prior (MMWR 2005;53:1198–201).

The second patient was a 19-year-old rat owner who was pronounced dead on arrival at a hospital after 3 days of symptoms. Such rapidly fatal cases of rat bite fever have been reported in children, but not in adults, except when there are systemic complications such as endocarditis or meningitis. The recent cases suggest that prevention of severe disease depends on promoting risk reduction and symptom recognition.

FAJARDO, P.R. — A new strategy for performing hemiarthroplasty for arthritis in the thumb carpometacarpal joint, appears to reduce pain and improve function.

The procedure involves using a pyrolytic carbon metacarpophalangeal (MCP) metacarpal head implant, Robert Beckenbaugh, M.D., said at the annual meeting of the American Association for Hand Surgery.

Previous implants of the thumb's carpometacarpal joint have involved using a round zirconium prosthesis that provided relief of pain and discomfort and ranked high in patient satisfaction. However, significant subsidence of the zirconium balls occurred.

A German surgeon, attempting to address this adverse event and create a stronger joint, developed the new procedure using the pyrocarbon implant, he explained.

Initial experience with 12 patients suggests that the procedure leads to early functional improvements during the postoperative course, and excellent mobility and pain relief up to 7 months later, said Dr. Beckenbaugh of the Mayo Clinic, Rochester, Minn.

The implant is inserted into the base of the thumb metacarpal, and the acetabulum for the implant is prepared in the distal end of the trapezium. The patient remains in a cast for 6 weeks.

Impressed by the 1-year results reported from Germany, Dr. Beckenbaugh traveled there to learn the technique. Early results suggest such outcomes are occurring in his patients as well.

In his case series of 12 patients with rheumatoid arthritis, psoriatic arthritis, or osteoarthritis, after at least 3 months follow-up, half reported 100% pain relief postoperatively, and the other half reported only occasional pain. There has been no change in grip strength, but the improvements in pain have been significant.

One patient, a 45-year-old with severe rheumatoid arthritis and no use of her thumb, reported good function and no pain at 7 months follow-up. She had good stability of the carpometacarpal joint.

Another patient who had 2 years of unsuccessful conservative treatment for osteoarthritis, underwent the procedure and experienced significant pain reduction and now has no difficulty opposing her thumb to her index or small fingers.

This preliminary experience with the pyrocarbon implant suggests that it is of benefit for patients with carpometacarpal arthritis, Dr. Beckenbaugh concluded.

FAJARDO, P.R. — A new strategy for performing hemiarthroplasty for arthritis in the thumb carpometacarpal joint, appears to reduce pain and improve function.

The procedure involves using a pyrolytic carbon metacarpophalangeal (MCP) metacarpal head implant, Robert Beckenbaugh, M.D., said at the annual meeting of the American Association for Hand Surgery.

Previous implants of the thumb's carpometacarpal joint have involved using a round zirconium prosthesis that provided relief of pain and discomfort and ranked high in patient satisfaction. However, significant subsidence of the zirconium balls occurred.

A German surgeon, attempting to address this adverse event and create a stronger joint, developed the new procedure using the pyrocarbon implant, he explained.

Initial experience with 12 patients suggests that the procedure leads to early functional improvements during the postoperative course, and excellent mobility and pain relief up to 7 months later, said Dr. Beckenbaugh of the Mayo Clinic, Rochester, Minn.

The implant is inserted into the base of the thumb metacarpal, and the acetabulum for the implant is prepared in the distal end of the trapezium. The patient remains in a cast for 6 weeks.

Impressed by the 1-year results reported from Germany, Dr. Beckenbaugh traveled there to learn the technique. Early results suggest such outcomes are occurring in his patients as well.

In his case series of 12 patients with rheumatoid arthritis, psoriatic arthritis, or osteoarthritis, after at least 3 months follow-up, half reported 100% pain relief postoperatively, and the other half reported only occasional pain. There has been no change in grip strength, but the improvements in pain have been significant.

One patient, a 45-year-old with severe rheumatoid arthritis and no use of her thumb, reported good function and no pain at 7 months follow-up. She had good stability of the carpometacarpal joint.

Another patient who had 2 years of unsuccessful conservative treatment for osteoarthritis, underwent the procedure and experienced significant pain reduction and now has no difficulty opposing her thumb to her index or small fingers.

This preliminary experience with the pyrocarbon implant suggests that it is of benefit for patients with carpometacarpal arthritis, Dr. Beckenbaugh concluded.

FAJARDO, P.R. — A new strategy for performing hemiarthroplasty for arthritis in the thumb carpometacarpal joint, appears to reduce pain and improve function.

The procedure involves using a pyrolytic carbon metacarpophalangeal (MCP) metacarpal head implant, Robert Beckenbaugh, M.D., said at the annual meeting of the American Association for Hand Surgery.

Previous implants of the thumb's carpometacarpal joint have involved using a round zirconium prosthesis that provided relief of pain and discomfort and ranked high in patient satisfaction. However, significant subsidence of the zirconium balls occurred.

A German surgeon, attempting to address this adverse event and create a stronger joint, developed the new procedure using the pyrocarbon implant, he explained.

Initial experience with 12 patients suggests that the procedure leads to early functional improvements during the postoperative course, and excellent mobility and pain relief up to 7 months later, said Dr. Beckenbaugh of the Mayo Clinic, Rochester, Minn.

The implant is inserted into the base of the thumb metacarpal, and the acetabulum for the implant is prepared in the distal end of the trapezium. The patient remains in a cast for 6 weeks.

Impressed by the 1-year results reported from Germany, Dr. Beckenbaugh traveled there to learn the technique. Early results suggest such outcomes are occurring in his patients as well.

In his case series of 12 patients with rheumatoid arthritis, psoriatic arthritis, or osteoarthritis, after at least 3 months follow-up, half reported 100% pain relief postoperatively, and the other half reported only occasional pain. There has been no change in grip strength, but the improvements in pain have been significant.

One patient, a 45-year-old with severe rheumatoid arthritis and no use of her thumb, reported good function and no pain at 7 months follow-up. She had good stability of the carpometacarpal joint.

Another patient who had 2 years of unsuccessful conservative treatment for osteoarthritis, underwent the procedure and experienced significant pain reduction and now has no difficulty opposing her thumb to her index or small fingers.

This preliminary experience with the pyrocarbon implant suggests that it is of benefit for patients with carpometacarpal arthritis, Dr. Beckenbaugh concluded.