Debra Wood

ORLANDO, FLA. — Age greater than 70 years, abnormal preoperative neurologic status, and prior cardiac surgery are independent risk factors for stroke related to coronary artery bypass graft, Scott Woods, M.D., said at the annual meeting of the American Academy of Family Physicians.

“If you have a patient who needs CABG and has none of these three predictors, which are easy to determine by exam and history in the office, the risk of stroke is 1%,” said Dr. Woods, director of epidemiology at the Bethesda Family Practice Residency Program, Cincinnati. “But if he has all three risk factors, the chance is one in three.”

Cerebrovascular accidents (CVAs) are well-known adverse events associated with CABG surgery, occurring in about 3% of all cases, Dr. Woods said.

“If the predictors of this catastrophic event could be found, we could possibly avoid the events for those at greatest risk,” he said. “That was the purpose of our project.”

Dr. Woods conducted a nested case-control study to identify the risk factors. He used a 9-year, prospective cohort that included 6,245 patients who had CABG between October 1993 and June 2002.

Cases were matched to controls in a one-to-three ratio: There were 171 patients who had a stroke and 513 controls. The CVA rate at the facility was 2.7%, very close to the national average. The study population was primarily white, with few Hispanic and Asian patients.

Dr. Woods considered 38 variables, including medical history and operative factors, such as pump time and perfusion time. Regression analysis uncovered three independent predictors of stroke.

Age older than 70 years was associated with a 4.6-fold increase in risk. Abnormal neurologic findings such as slurred speech or hemiparesis prior to surgery upped the chance of a stroke by a factor of 4.24, and previous cardiac surgery was associated with a 1.75-fold increase in risk.

The research also indicated that if the patient had one of the two stronger predictors—age over 70 or abnormal neurologic findings—the risk was 1 in 25 (4%) that he or she would suffer a CVA associated with the surgery. A patient aged 70 years or older who also had an abnormal neurologic finding during the preoperative exam had a one in five (20%) risk of suffering a CVA. If all three risk factors were present, the chance of suffering a CVA was one in three (33%).

If the patient's risk of stroke is 20% or 33%, “you certainly need to counsel them on it,” Dr. Woods said. The patient may find the risk to be too high. “Obviously, it's a judgment call.”

ORLANDO, FLA. — Age greater than 70 years, abnormal preoperative neurologic status, and prior cardiac surgery are independent risk factors for stroke related to coronary artery bypass graft, Scott Woods, M.D., said at the annual meeting of the American Academy of Family Physicians.

“If you have a patient who needs CABG and has none of these three predictors, which are easy to determine by exam and history in the office, the risk of stroke is 1%,” said Dr. Woods, director of epidemiology at the Bethesda Family Practice Residency Program, Cincinnati. “But if he has all three risk factors, the chance is one in three.”

Cerebrovascular accidents (CVAs) are well-known adverse events associated with CABG surgery, occurring in about 3% of all cases, Dr. Woods said.

“If the predictors of this catastrophic event could be found, we could possibly avoid the events for those at greatest risk,” he said. “That was the purpose of our project.”

Dr. Woods conducted a nested case-control study to identify the risk factors. He used a 9-year, prospective cohort that included 6,245 patients who had CABG between October 1993 and June 2002.

Cases were matched to controls in a one-to-three ratio: There were 171 patients who had a stroke and 513 controls. The CVA rate at the facility was 2.7%, very close to the national average. The study population was primarily white, with few Hispanic and Asian patients.

Dr. Woods considered 38 variables, including medical history and operative factors, such as pump time and perfusion time. Regression analysis uncovered three independent predictors of stroke.

Age older than 70 years was associated with a 4.6-fold increase in risk. Abnormal neurologic findings such as slurred speech or hemiparesis prior to surgery upped the chance of a stroke by a factor of 4.24, and previous cardiac surgery was associated with a 1.75-fold increase in risk.

The research also indicated that if the patient had one of the two stronger predictors—age over 70 or abnormal neurologic findings—the risk was 1 in 25 (4%) that he or she would suffer a CVA associated with the surgery. A patient aged 70 years or older who also had an abnormal neurologic finding during the preoperative exam had a one in five (20%) risk of suffering a CVA. If all three risk factors were present, the chance of suffering a CVA was one in three (33%).

If the patient's risk of stroke is 20% or 33%, “you certainly need to counsel them on it,” Dr. Woods said. The patient may find the risk to be too high. “Obviously, it's a judgment call.”

ORLANDO, FLA. — Age greater than 70 years, abnormal preoperative neurologic status, and prior cardiac surgery are independent risk factors for stroke related to coronary artery bypass graft, Scott Woods, M.D., said at the annual meeting of the American Academy of Family Physicians.

“If you have a patient who needs CABG and has none of these three predictors, which are easy to determine by exam and history in the office, the risk of stroke is 1%,” said Dr. Woods, director of epidemiology at the Bethesda Family Practice Residency Program, Cincinnati. “But if he has all three risk factors, the chance is one in three.”

Cerebrovascular accidents (CVAs) are well-known adverse events associated with CABG surgery, occurring in about 3% of all cases, Dr. Woods said.

“If the predictors of this catastrophic event could be found, we could possibly avoid the events for those at greatest risk,” he said. “That was the purpose of our project.”

Dr. Woods conducted a nested case-control study to identify the risk factors. He used a 9-year, prospective cohort that included 6,245 patients who had CABG between October 1993 and June 2002.

Cases were matched to controls in a one-to-three ratio: There were 171 patients who had a stroke and 513 controls. The CVA rate at the facility was 2.7%, very close to the national average. The study population was primarily white, with few Hispanic and Asian patients.

Dr. Woods considered 38 variables, including medical history and operative factors, such as pump time and perfusion time. Regression analysis uncovered three independent predictors of stroke.

Age older than 70 years was associated with a 4.6-fold increase in risk. Abnormal neurologic findings such as slurred speech or hemiparesis prior to surgery upped the chance of a stroke by a factor of 4.24, and previous cardiac surgery was associated with a 1.75-fold increase in risk.

The research also indicated that if the patient had one of the two stronger predictors—age over 70 or abnormal neurologic findings—the risk was 1 in 25 (4%) that he or she would suffer a CVA associated with the surgery. A patient aged 70 years or older who also had an abnormal neurologic finding during the preoperative exam had a one in five (20%) risk of suffering a CVA. If all three risk factors were present, the chance of suffering a CVA was one in three (33%).

If the patient's risk of stroke is 20% or 33%, “you certainly need to counsel them on it,” Dr. Woods said. The patient may find the risk to be too high. “Obviously, it's a judgment call.”

ORLANDO, FLA. — Women receiving prostaglandin-assisted induction of labor were less likely to receive a cesarean delivery than were women in spontaneous labor, according to a study presented by James M. Nicholson, M.D., at the annual meeting of the American Academy of Family Physicians.

“Active Management of Risk in Pregnancy at Term basically involves applying preventive technology to the field of obstetrics in terms of improving outcomes,” said Dr. Nicholson of the department of family practice at the University of Pennsylvania, Philadelphia.

While in private practice at a small New England hospital, Dr. Nicholson noted that the cesarean rates at the facility fell to around 10%, at a time when the national cesarean delivery rate never dropped below 20%. The number of deliveries at the small hospital remained the same, with a stable cadre of providers. Seven family physicians, five obstetricians, and one certified nurse-midwife practiced at the facility.

“What did change was our induction of labor rates per year. As the induction rates seemed to go up, the C-section rates seemed to go down,” said Dr. Nicholson, adding that the physicians also began using prostaglandin E2 (PGE2).

Dr. Nicholson conducted a retrospective, 4-year cohort study. From 1993 to 1997, the hospital had 2,199 deliveries. He included women who had at least one prenatal visit, were at 38 weeks' gestation, had no maternal or fetal health reasons mandating a cesarean delivery, and were carrying a single fetus, for a total of 1,871 deliveries.

Dr. Nicholson analyzed provider labor induction and PGE2 usage rates. Four family physicians and one obstetrician used both induction and PGE2 at a high rate, equal to or greater than 21%. Dr. Nicholson classified the 791 women cared for by these five physicians as “highly exposed.”

Three family physicians, four obstetricians and one midwife used labor induction and PGE2 in less than 21% of their deliveries. The group of 1,080 women that they cared for were classified as “somewhat exposed.”

Anemia and single status were more common in the highly exposed group. In the less exposed group, there was a greater number of women with short stature, excess weight gain, and epidurals.

In the highly exposed group, more women had an unripe cervix at time of admission, so physicians used more PGE2 and more often induced labor. The gestational age was significantly lower, 39.1 weeks vs. 40 weeks, in the less-exposed group.

The elective induction rate was 21.2% in the highly exposed group and 8.1% in the less exposed group. The rate for impending cephalopelvic disproportion was 6.2% in the highly exposed and 2.8% in the less exposed cohorts. The rate for impending uteroplacental insufficiency was 3.8% in the highly exposed and 1.8% in the less exposed groups. Gestational age between 41 weeks and 42 weeks was 9% in the highly exposed and 5.9% in the less exposed cohorts.

The cesarean rate was 5.3% in the highly exposed group and 11.8% in the less exposed group. There were also lower rates of fetal intolerance, cephalopelvic disproportion, and malpresentation in the highly exposed cohort.

Second stage labor was shorter in the highly exposed group. The rate of babies requiring neonatal intensive care was 2.3% in the highly exposed group vs. 4.2% in the less exposed group.

“The babies came out healthier,” Dr. Nicholson said.

The percentage of nulliparous women requiring a cesarean section was 7.5% in the highly exposed group and 26% in the less exposed group. No multiparous women in the highly exposed group received a cesarean section, but 10.4% of the women in the less exposed group did. In women who had had a prior cesarean delivery, the rate was 7.4% in the highly exposed cohort and 32.7% in the less exposed cohort.

“We were able to show there was an association between higher provider usage of preventive care by induction and a lower cesarean rate,” Dr. Nicholson said.

He also completed two retrospective studies using Active Management of Risk in Pregnancy at Term in an urban population and presented those results at the World Conference of Family Doctors, which met at the same time and in the same Orlando convention center. Both of those studies compared the outcomes of 100 women exposed to induction and PGE1 or PGE2 to 300 randomly selected controls who received the current obstetric standard of care.

Again, the women in the highly exposed cohorts delivered an average of 1 week earlier than the standard-of-care group. Exposure to Active Management of Risk in Pregnancy at Term was associated with a higher labor induction rate and lower cesarean delivery rate in both urban studies.

It also was associated with lower rates of neonatal intensive care unit admission, major perineal trauma, and passage of thick meconium.

ORLANDO, FLA. — Women receiving prostaglandin-assisted induction of labor were less likely to receive a cesarean delivery than were women in spontaneous labor, according to a study presented by James M. Nicholson, M.D., at the annual meeting of the American Academy of Family Physicians.

“Active Management of Risk in Pregnancy at Term basically involves applying preventive technology to the field of obstetrics in terms of improving outcomes,” said Dr. Nicholson of the department of family practice at the University of Pennsylvania, Philadelphia.

While in private practice at a small New England hospital, Dr. Nicholson noted that the cesarean rates at the facility fell to around 10%, at a time when the national cesarean delivery rate never dropped below 20%. The number of deliveries at the small hospital remained the same, with a stable cadre of providers. Seven family physicians, five obstetricians, and one certified nurse-midwife practiced at the facility.

“What did change was our induction of labor rates per year. As the induction rates seemed to go up, the C-section rates seemed to go down,” said Dr. Nicholson, adding that the physicians also began using prostaglandin E2 (PGE2).

Dr. Nicholson conducted a retrospective, 4-year cohort study. From 1993 to 1997, the hospital had 2,199 deliveries. He included women who had at least one prenatal visit, were at 38 weeks' gestation, had no maternal or fetal health reasons mandating a cesarean delivery, and were carrying a single fetus, for a total of 1,871 deliveries.

Dr. Nicholson analyzed provider labor induction and PGE2 usage rates. Four family physicians and one obstetrician used both induction and PGE2 at a high rate, equal to or greater than 21%. Dr. Nicholson classified the 791 women cared for by these five physicians as “highly exposed.”

Three family physicians, four obstetricians and one midwife used labor induction and PGE2 in less than 21% of their deliveries. The group of 1,080 women that they cared for were classified as “somewhat exposed.”

Anemia and single status were more common in the highly exposed group. In the less exposed group, there was a greater number of women with short stature, excess weight gain, and epidurals.

In the highly exposed group, more women had an unripe cervix at time of admission, so physicians used more PGE2 and more often induced labor. The gestational age was significantly lower, 39.1 weeks vs. 40 weeks, in the less-exposed group.

The elective induction rate was 21.2% in the highly exposed group and 8.1% in the less exposed group. The rate for impending cephalopelvic disproportion was 6.2% in the highly exposed and 2.8% in the less exposed cohorts. The rate for impending uteroplacental insufficiency was 3.8% in the highly exposed and 1.8% in the less exposed groups. Gestational age between 41 weeks and 42 weeks was 9% in the highly exposed and 5.9% in the less exposed cohorts.

The cesarean rate was 5.3% in the highly exposed group and 11.8% in the less exposed group. There were also lower rates of fetal intolerance, cephalopelvic disproportion, and malpresentation in the highly exposed cohort.

Second stage labor was shorter in the highly exposed group. The rate of babies requiring neonatal intensive care was 2.3% in the highly exposed group vs. 4.2% in the less exposed group.

“The babies came out healthier,” Dr. Nicholson said.

The percentage of nulliparous women requiring a cesarean section was 7.5% in the highly exposed group and 26% in the less exposed group. No multiparous women in the highly exposed group received a cesarean section, but 10.4% of the women in the less exposed group did. In women who had had a prior cesarean delivery, the rate was 7.4% in the highly exposed cohort and 32.7% in the less exposed cohort.

“We were able to show there was an association between higher provider usage of preventive care by induction and a lower cesarean rate,” Dr. Nicholson said.

He also completed two retrospective studies using Active Management of Risk in Pregnancy at Term in an urban population and presented those results at the World Conference of Family Doctors, which met at the same time and in the same Orlando convention center. Both of those studies compared the outcomes of 100 women exposed to induction and PGE1 or PGE2 to 300 randomly selected controls who received the current obstetric standard of care.

Again, the women in the highly exposed cohorts delivered an average of 1 week earlier than the standard-of-care group. Exposure to Active Management of Risk in Pregnancy at Term was associated with a higher labor induction rate and lower cesarean delivery rate in both urban studies.

It also was associated with lower rates of neonatal intensive care unit admission, major perineal trauma, and passage of thick meconium.

ORLANDO, FLA. — Women receiving prostaglandin-assisted induction of labor were less likely to receive a cesarean delivery than were women in spontaneous labor, according to a study presented by James M. Nicholson, M.D., at the annual meeting of the American Academy of Family Physicians.

“Active Management of Risk in Pregnancy at Term basically involves applying preventive technology to the field of obstetrics in terms of improving outcomes,” said Dr. Nicholson of the department of family practice at the University of Pennsylvania, Philadelphia.

While in private practice at a small New England hospital, Dr. Nicholson noted that the cesarean rates at the facility fell to around 10%, at a time when the national cesarean delivery rate never dropped below 20%. The number of deliveries at the small hospital remained the same, with a stable cadre of providers. Seven family physicians, five obstetricians, and one certified nurse-midwife practiced at the facility.

“What did change was our induction of labor rates per year. As the induction rates seemed to go up, the C-section rates seemed to go down,” said Dr. Nicholson, adding that the physicians also began using prostaglandin E2 (PGE2).

Dr. Nicholson conducted a retrospective, 4-year cohort study. From 1993 to 1997, the hospital had 2,199 deliveries. He included women who had at least one prenatal visit, were at 38 weeks' gestation, had no maternal or fetal health reasons mandating a cesarean delivery, and were carrying a single fetus, for a total of 1,871 deliveries.

Dr. Nicholson analyzed provider labor induction and PGE2 usage rates. Four family physicians and one obstetrician used both induction and PGE2 at a high rate, equal to or greater than 21%. Dr. Nicholson classified the 791 women cared for by these five physicians as “highly exposed.”

Three family physicians, four obstetricians and one midwife used labor induction and PGE2 in less than 21% of their deliveries. The group of 1,080 women that they cared for were classified as “somewhat exposed.”

Anemia and single status were more common in the highly exposed group. In the less exposed group, there was a greater number of women with short stature, excess weight gain, and epidurals.

In the highly exposed group, more women had an unripe cervix at time of admission, so physicians used more PGE2 and more often induced labor. The gestational age was significantly lower, 39.1 weeks vs. 40 weeks, in the less-exposed group.

The elective induction rate was 21.2% in the highly exposed group and 8.1% in the less exposed group. The rate for impending cephalopelvic disproportion was 6.2% in the highly exposed and 2.8% in the less exposed cohorts. The rate for impending uteroplacental insufficiency was 3.8% in the highly exposed and 1.8% in the less exposed groups. Gestational age between 41 weeks and 42 weeks was 9% in the highly exposed and 5.9% in the less exposed cohorts.

The cesarean rate was 5.3% in the highly exposed group and 11.8% in the less exposed group. There were also lower rates of fetal intolerance, cephalopelvic disproportion, and malpresentation in the highly exposed cohort.

Second stage labor was shorter in the highly exposed group. The rate of babies requiring neonatal intensive care was 2.3% in the highly exposed group vs. 4.2% in the less exposed group.

“The babies came out healthier,” Dr. Nicholson said.

The percentage of nulliparous women requiring a cesarean section was 7.5% in the highly exposed group and 26% in the less exposed group. No multiparous women in the highly exposed group received a cesarean section, but 10.4% of the women in the less exposed group did. In women who had had a prior cesarean delivery, the rate was 7.4% in the highly exposed cohort and 32.7% in the less exposed cohort.

“We were able to show there was an association between higher provider usage of preventive care by induction and a lower cesarean rate,” Dr. Nicholson said.

He also completed two retrospective studies using Active Management of Risk in Pregnancy at Term in an urban population and presented those results at the World Conference of Family Doctors, which met at the same time and in the same Orlando convention center. Both of those studies compared the outcomes of 100 women exposed to induction and PGE1 or PGE2 to 300 randomly selected controls who received the current obstetric standard of care.

Again, the women in the highly exposed cohorts delivered an average of 1 week earlier than the standard-of-care group. Exposure to Active Management of Risk in Pregnancy at Term was associated with a higher labor induction rate and lower cesarean delivery rate in both urban studies.

It also was associated with lower rates of neonatal intensive care unit admission, major perineal trauma, and passage of thick meconium.

ORLANDO, FLA. — A growing number of Americans choose exotic animals as pets without knowing that even handling these unusual creatures may result in serious dermatologic diseases, Dr. Ted Rosen said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

“Pets can cause significant difficulties,” said Dr. Rosen, a professor in the department of dermatology at Baylor College of Medicine in Houston.

About 60% of U.S. households own at least one pet. One million to 2 million of those homes harbor an exotic pet—exotics that can carry pathogens that result in human disease.

Dr. Rosen highlighted disease concerns associated with some of the more common exotic pets:

▸ Hedgehogs. About 40,000 hedgehogs live in U.S. homes. The most popular species fits in the palm of the hand. Hedgehogs have quills, are vicious, and eat cockroaches.

“The most important thing about hedgehogs is they carry a very specific subspecies of Trichophyton mentagrophytes that is incredibly inflammatory,” Dr. Rosen said. “It is absolutely, astonishingly horrible. You get this from contacting the hedgehog.”

Some people are allergic to hedgehogs. They may develop contact urticaria related to hypersensitivity to the animal's saliva. Hedgehogs spit on their quills. These little animals are associated with human salmonellosis, and they carry various mycobacteria.

▸ Chinchillas. About 80,000 households own chinchillas, which carry Microsporum gypseum and Trichophyton mentagrophytes associated with inflammatory tinea capitis. These animals also harbor Aspergillus niger. They are susceptible to infections with gram-negative pathogens.

▸ Iguanas. About 750,000 iguanas are in U.S. homes. They shed Salmonella associated with human salmonellosis. Iguanas carry Serratia marscens in their oral flora, which can cause cellulitis after a playful nip or bite. The cellulitis may be bullous and present similarly to streptococcus or staphylococcus infection. However, iguana-associated S. marscens inhibits the activity of many drugs and is resistant to cephalosporins. The drug of choice is a quinolone or trimethoprim-sulfamethoxazole. Compounding the problem is the fact that breeders administer broad-spectrum antibiotics to keep the flora down and alter the reptile's color.

Allergic reactions to iguanas include allergic rhinitis and urticaria.

▸ Flying squirrels. Flying squirrels carry Rickettsia prowazeki, which is associated with typhus fever. The pet's owner can inhale the bacteria. Symptoms include fever; an extensive, nonspecific, blanching erythema eruption; headache; nausea and vomiting; myalgia; and photophobia.

Flying squirrels also carry unusual species of Staphylococcus that can be transmitted to people through wounds or small cuts. The infections are not easily treated and can cause sepsis.

▸ Gerbils. More than a million of these animals live in the United States. In nature, they are a major reservoir of Leishmania and Giardia lamblia and S. aureus.

As pets, they harbor avian mites, often acquired at the pet store. The bird infects the gerbil, which in turn infects humans.

▸ Prairie dogs. These animals are now banned as pets in the United States, after an outbreak of monkeypox in humans last year. The prairie dogs likely acquired the infection from Gambian rats. Prairie dogs can also carry plague and tularemia.

▸ Cockatoos and macaws. These birds are natural hosts for Cryptococcus neoformans, which may or may not make the pet sick. The bacteria can be transmitted to humans, with immunosuppressed patients at greatest risk. One of Dr. Rosen's patients died from a C. neoformans infection that he picked up from his pet cockatoo.

ORLANDO, FLA. — A growing number of Americans choose exotic animals as pets without knowing that even handling these unusual creatures may result in serious dermatologic diseases, Dr. Ted Rosen said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

“Pets can cause significant difficulties,” said Dr. Rosen, a professor in the department of dermatology at Baylor College of Medicine in Houston.

About 60% of U.S. households own at least one pet. One million to 2 million of those homes harbor an exotic pet—exotics that can carry pathogens that result in human disease.

Dr. Rosen highlighted disease concerns associated with some of the more common exotic pets:

▸ Hedgehogs. About 40,000 hedgehogs live in U.S. homes. The most popular species fits in the palm of the hand. Hedgehogs have quills, are vicious, and eat cockroaches.

“The most important thing about hedgehogs is they carry a very specific subspecies of Trichophyton mentagrophytes that is incredibly inflammatory,” Dr. Rosen said. “It is absolutely, astonishingly horrible. You get this from contacting the hedgehog.”

Some people are allergic to hedgehogs. They may develop contact urticaria related to hypersensitivity to the animal's saliva. Hedgehogs spit on their quills. These little animals are associated with human salmonellosis, and they carry various mycobacteria.

▸ Chinchillas. About 80,000 households own chinchillas, which carry Microsporum gypseum and Trichophyton mentagrophytes associated with inflammatory tinea capitis. These animals also harbor Aspergillus niger. They are susceptible to infections with gram-negative pathogens.

▸ Iguanas. About 750,000 iguanas are in U.S. homes. They shed Salmonella associated with human salmonellosis. Iguanas carry Serratia marscens in their oral flora, which can cause cellulitis after a playful nip or bite. The cellulitis may be bullous and present similarly to streptococcus or staphylococcus infection. However, iguana-associated S. marscens inhibits the activity of many drugs and is resistant to cephalosporins. The drug of choice is a quinolone or trimethoprim-sulfamethoxazole. Compounding the problem is the fact that breeders administer broad-spectrum antibiotics to keep the flora down and alter the reptile's color.

Allergic reactions to iguanas include allergic rhinitis and urticaria.

▸ Flying squirrels. Flying squirrels carry Rickettsia prowazeki, which is associated with typhus fever. The pet's owner can inhale the bacteria. Symptoms include fever; an extensive, nonspecific, blanching erythema eruption; headache; nausea and vomiting; myalgia; and photophobia.

Flying squirrels also carry unusual species of Staphylococcus that can be transmitted to people through wounds or small cuts. The infections are not easily treated and can cause sepsis.

▸ Gerbils. More than a million of these animals live in the United States. In nature, they are a major reservoir of Leishmania and Giardia lamblia and S. aureus.

As pets, they harbor avian mites, often acquired at the pet store. The bird infects the gerbil, which in turn infects humans.

▸ Prairie dogs. These animals are now banned as pets in the United States, after an outbreak of monkeypox in humans last year. The prairie dogs likely acquired the infection from Gambian rats. Prairie dogs can also carry plague and tularemia.

▸ Cockatoos and macaws. These birds are natural hosts for Cryptococcus neoformans, which may or may not make the pet sick. The bacteria can be transmitted to humans, with immunosuppressed patients at greatest risk. One of Dr. Rosen's patients died from a C. neoformans infection that he picked up from his pet cockatoo.

ORLANDO, FLA. — A growing number of Americans choose exotic animals as pets without knowing that even handling these unusual creatures may result in serious dermatologic diseases, Dr. Ted Rosen said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

“Pets can cause significant difficulties,” said Dr. Rosen, a professor in the department of dermatology at Baylor College of Medicine in Houston.

About 60% of U.S. households own at least one pet. One million to 2 million of those homes harbor an exotic pet—exotics that can carry pathogens that result in human disease.

Dr. Rosen highlighted disease concerns associated with some of the more common exotic pets:

▸ Hedgehogs. About 40,000 hedgehogs live in U.S. homes. The most popular species fits in the palm of the hand. Hedgehogs have quills, are vicious, and eat cockroaches.

“The most important thing about hedgehogs is they carry a very specific subspecies of Trichophyton mentagrophytes that is incredibly inflammatory,” Dr. Rosen said. “It is absolutely, astonishingly horrible. You get this from contacting the hedgehog.”

Some people are allergic to hedgehogs. They may develop contact urticaria related to hypersensitivity to the animal's saliva. Hedgehogs spit on their quills. These little animals are associated with human salmonellosis, and they carry various mycobacteria.

▸ Chinchillas. About 80,000 households own chinchillas, which carry Microsporum gypseum and Trichophyton mentagrophytes associated with inflammatory tinea capitis. These animals also harbor Aspergillus niger. They are susceptible to infections with gram-negative pathogens.

▸ Iguanas. About 750,000 iguanas are in U.S. homes. They shed Salmonella associated with human salmonellosis. Iguanas carry Serratia marscens in their oral flora, which can cause cellulitis after a playful nip or bite. The cellulitis may be bullous and present similarly to streptococcus or staphylococcus infection. However, iguana-associated S. marscens inhibits the activity of many drugs and is resistant to cephalosporins. The drug of choice is a quinolone or trimethoprim-sulfamethoxazole. Compounding the problem is the fact that breeders administer broad-spectrum antibiotics to keep the flora down and alter the reptile's color.

Allergic reactions to iguanas include allergic rhinitis and urticaria.

▸ Flying squirrels. Flying squirrels carry Rickettsia prowazeki, which is associated with typhus fever. The pet's owner can inhale the bacteria. Symptoms include fever; an extensive, nonspecific, blanching erythema eruption; headache; nausea and vomiting; myalgia; and photophobia.

Flying squirrels also carry unusual species of Staphylococcus that can be transmitted to people through wounds or small cuts. The infections are not easily treated and can cause sepsis.

▸ Gerbils. More than a million of these animals live in the United States. In nature, they are a major reservoir of Leishmania and Giardia lamblia and S. aureus.

As pets, they harbor avian mites, often acquired at the pet store. The bird infects the gerbil, which in turn infects humans.

▸ Prairie dogs. These animals are now banned as pets in the United States, after an outbreak of monkeypox in humans last year. The prairie dogs likely acquired the infection from Gambian rats. Prairie dogs can also carry plague and tularemia.

▸ Cockatoos and macaws. These birds are natural hosts for Cryptococcus neoformans, which may or may not make the pet sick. The bacteria can be transmitted to humans, with immunosuppressed patients at greatest risk. One of Dr. Rosen's patients died from a C. neoformans infection that he picked up from his pet cockatoo.

ORLANDO, FLA. — Fetal gender may affect maternal asthma symptoms during pregnancy, according to results of a prospective study of 153 pregnant women.

“We found if you had female baby, things were happening, and the asthma tended to be worse. We found lung function was reduced in the last trimester if the woman was pregnant with a baby girl, and that she needed more inhaled steroids to control the asthma,” study investigator Peter G. Gibson, M.B., said at a press conference during the 100th International Conference of the American Thoracic Society.

The study, presented in poster form at the meeting, included 120 asthmatic women and 33 women without asthma. The team assessed patients at 18 and 30 weeks' gestation and recorded their use of inhaled corticosteroids, lung function, morning and night symptoms, use of reliever medications, and activity limitations.

Sixty percent of women pregnant with a male fetus remained free of asthma symptoms throughout gestation. Although 61% of women with a female fetus were symptom free at 18 weeks, by week 30 only 28% of the women were still symptom free. Nighttime symptoms and use of inhaled glucocorticoids increased significantly during the 12-week period, said Dr. Gibson, professor in the department of respiratory and sleep medicine at Hunter Medical Research Institute at John Hunter Hospital in Newcastle, Australia.

Dr. Gibson noted that women carrying female fetuses had elevated monocyte counts and suggested that female fetuses may somehow trigger increased inflammation in pregnant women.

In a prior study, Dr. Gibson found that girls born to asthmatic mothers who did not use inhaled steroids during pregnancy suffered from low birth weight, which did not happen if the mother used inhaled steroids or delivered a male child. “Guidelines for management of asthma in pregnancy recommend the use of inhaled steroids for women who have sufficient symptoms,” Dr. Gibson said.

ORLANDO, FLA. — Fetal gender may affect maternal asthma symptoms during pregnancy, according to results of a prospective study of 153 pregnant women.

“We found if you had female baby, things were happening, and the asthma tended to be worse. We found lung function was reduced in the last trimester if the woman was pregnant with a baby girl, and that she needed more inhaled steroids to control the asthma,” study investigator Peter G. Gibson, M.B., said at a press conference during the 100th International Conference of the American Thoracic Society.

The study, presented in poster form at the meeting, included 120 asthmatic women and 33 women without asthma. The team assessed patients at 18 and 30 weeks' gestation and recorded their use of inhaled corticosteroids, lung function, morning and night symptoms, use of reliever medications, and activity limitations.

Sixty percent of women pregnant with a male fetus remained free of asthma symptoms throughout gestation. Although 61% of women with a female fetus were symptom free at 18 weeks, by week 30 only 28% of the women were still symptom free. Nighttime symptoms and use of inhaled glucocorticoids increased significantly during the 12-week period, said Dr. Gibson, professor in the department of respiratory and sleep medicine at Hunter Medical Research Institute at John Hunter Hospital in Newcastle, Australia.

Dr. Gibson noted that women carrying female fetuses had elevated monocyte counts and suggested that female fetuses may somehow trigger increased inflammation in pregnant women.

In a prior study, Dr. Gibson found that girls born to asthmatic mothers who did not use inhaled steroids during pregnancy suffered from low birth weight, which did not happen if the mother used inhaled steroids or delivered a male child. “Guidelines for management of asthma in pregnancy recommend the use of inhaled steroids for women who have sufficient symptoms,” Dr. Gibson said.

ORLANDO, FLA. — Fetal gender may affect maternal asthma symptoms during pregnancy, according to results of a prospective study of 153 pregnant women.

“We found if you had female baby, things were happening, and the asthma tended to be worse. We found lung function was reduced in the last trimester if the woman was pregnant with a baby girl, and that she needed more inhaled steroids to control the asthma,” study investigator Peter G. Gibson, M.B., said at a press conference during the 100th International Conference of the American Thoracic Society.

The study, presented in poster form at the meeting, included 120 asthmatic women and 33 women without asthma. The team assessed patients at 18 and 30 weeks' gestation and recorded their use of inhaled corticosteroids, lung function, morning and night symptoms, use of reliever medications, and activity limitations.

Sixty percent of women pregnant with a male fetus remained free of asthma symptoms throughout gestation. Although 61% of women with a female fetus were symptom free at 18 weeks, by week 30 only 28% of the women were still symptom free. Nighttime symptoms and use of inhaled glucocorticoids increased significantly during the 12-week period, said Dr. Gibson, professor in the department of respiratory and sleep medicine at Hunter Medical Research Institute at John Hunter Hospital in Newcastle, Australia.

Dr. Gibson noted that women carrying female fetuses had elevated monocyte counts and suggested that female fetuses may somehow trigger increased inflammation in pregnant women.

In a prior study, Dr. Gibson found that girls born to asthmatic mothers who did not use inhaled steroids during pregnancy suffered from low birth weight, which did not happen if the mother used inhaled steroids or delivered a male child. “Guidelines for management of asthma in pregnancy recommend the use of inhaled steroids for women who have sufficient symptoms,” Dr. Gibson said.

ORLANDO, FLA. — The type of fish a woman consumes during pregnancy may affect the risk of her child developing asthma, Frank D. Gilliland, M.D., said at the 100th International Conference of the American Thoracic Society.

“We found maternal oily-fish intake was strongly protective in mothers who had a family history of asthma,” Dr. Gilliland, of the department of preventive medicine at the University of Southern California, Los Angeles said during a press conference at the meeting. The children “had a 70% reduction in their risk of asthma, and this was not observed in children with no family history.”

Oily fish, which are rich in omega-3 fatty acids, include yellowtail and cold-water fish like salmon, trout, and orange roughy. Eating oily fish on a regular basis a few times a month seemed sufficient to confer benefit, and the more oily fish a pregnant woman ate, the lower the risk of asthma in her child.

Using data from the Children's Health Study, a population-based study of school-aged children in 12 Southern California communities, Dr. Gilliland and associates conducted a nested, countermatched, case-control study to evaluate whether maternal fish consumption affected their children's asthma risk. Cases included those of children diagnosed with asthma by age 5; asthma-free children served as controls. The researchers completed telephone interviews with the children's mothers, collecting dietary and environmental exposure information.

Last year the Food and Drug Administration issued a consumer advisory about methylmercury in fish and shellfish. The advisory recommends that pregnant women strictly avoid fish that are high in mercury, and limit consumption of fish that are low in mercury, like salmon, to 12 ounces per week. Nearly all fish and shellfish contain trace amounts of mercury, but swordfish, shark, and other large fish tend to have greater amounts of the neurotoxin. Women could follow the FDA guidelines and still obtain the asthma-protective effect seen in this study. Favorable results were observed in women who ate as few as two servings of oily fish per month.

Dr. Gilliland suggested that omega-3's anti-inflammatory properties might reduce the child's asthma risk by decreasing inflammation in the developing fetus. “Some data suggest maternal omega-3 fatty-acid intake alters the immune phenotype of the fetus at birth,” Dr. Gilliland said.

The results did not hold when women consumed canned or non-oily fish during pregnancy.

ORLANDO, FLA. — The type of fish a woman consumes during pregnancy may affect the risk of her child developing asthma, Frank D. Gilliland, M.D., said at the 100th International Conference of the American Thoracic Society.

“We found maternal oily-fish intake was strongly protective in mothers who had a family history of asthma,” Dr. Gilliland, of the department of preventive medicine at the University of Southern California, Los Angeles said during a press conference at the meeting. The children “had a 70% reduction in their risk of asthma, and this was not observed in children with no family history.”

Oily fish, which are rich in omega-3 fatty acids, include yellowtail and cold-water fish like salmon, trout, and orange roughy. Eating oily fish on a regular basis a few times a month seemed sufficient to confer benefit, and the more oily fish a pregnant woman ate, the lower the risk of asthma in her child.

Using data from the Children's Health Study, a population-based study of school-aged children in 12 Southern California communities, Dr. Gilliland and associates conducted a nested, countermatched, case-control study to evaluate whether maternal fish consumption affected their children's asthma risk. Cases included those of children diagnosed with asthma by age 5; asthma-free children served as controls. The researchers completed telephone interviews with the children's mothers, collecting dietary and environmental exposure information.

Last year the Food and Drug Administration issued a consumer advisory about methylmercury in fish and shellfish. The advisory recommends that pregnant women strictly avoid fish that are high in mercury, and limit consumption of fish that are low in mercury, like salmon, to 12 ounces per week. Nearly all fish and shellfish contain trace amounts of mercury, but swordfish, shark, and other large fish tend to have greater amounts of the neurotoxin. Women could follow the FDA guidelines and still obtain the asthma-protective effect seen in this study. Favorable results were observed in women who ate as few as two servings of oily fish per month.

Dr. Gilliland suggested that omega-3's anti-inflammatory properties might reduce the child's asthma risk by decreasing inflammation in the developing fetus. “Some data suggest maternal omega-3 fatty-acid intake alters the immune phenotype of the fetus at birth,” Dr. Gilliland said.

The results did not hold when women consumed canned or non-oily fish during pregnancy.

ORLANDO, FLA. — The type of fish a woman consumes during pregnancy may affect the risk of her child developing asthma, Frank D. Gilliland, M.D., said at the 100th International Conference of the American Thoracic Society.

“We found maternal oily-fish intake was strongly protective in mothers who had a family history of asthma,” Dr. Gilliland, of the department of preventive medicine at the University of Southern California, Los Angeles said during a press conference at the meeting. The children “had a 70% reduction in their risk of asthma, and this was not observed in children with no family history.”

Oily fish, which are rich in omega-3 fatty acids, include yellowtail and cold-water fish like salmon, trout, and orange roughy. Eating oily fish on a regular basis a few times a month seemed sufficient to confer benefit, and the more oily fish a pregnant woman ate, the lower the risk of asthma in her child.

Using data from the Children's Health Study, a population-based study of school-aged children in 12 Southern California communities, Dr. Gilliland and associates conducted a nested, countermatched, case-control study to evaluate whether maternal fish consumption affected their children's asthma risk. Cases included those of children diagnosed with asthma by age 5; asthma-free children served as controls. The researchers completed telephone interviews with the children's mothers, collecting dietary and environmental exposure information.

Last year the Food and Drug Administration issued a consumer advisory about methylmercury in fish and shellfish. The advisory recommends that pregnant women strictly avoid fish that are high in mercury, and limit consumption of fish that are low in mercury, like salmon, to 12 ounces per week. Nearly all fish and shellfish contain trace amounts of mercury, but swordfish, shark, and other large fish tend to have greater amounts of the neurotoxin. Women could follow the FDA guidelines and still obtain the asthma-protective effect seen in this study. Favorable results were observed in women who ate as few as two servings of oily fish per month.

Dr. Gilliland suggested that omega-3's anti-inflammatory properties might reduce the child's asthma risk by decreasing inflammation in the developing fetus. “Some data suggest maternal omega-3 fatty-acid intake alters the immune phenotype of the fetus at birth,” Dr. Gilliland said.

The results did not hold when women consumed canned or non-oily fish during pregnancy.

ORLANDO, FLA. — Isolated cases of abnormal liver function tests are a common finding in family medicine. Daniel J. Tambunan, M.D., shared three rules for dealing with elevated liver enzymes at the annual meeting of the American Academy of Family Physicians.

“You could go to the extreme and order a million-dollar work-up, but I am trying to propose something more user-friendly and a much a more efficient way to find out what is causing the elevated liver enzymes,” said Dr. Tambunan, assistant director of the Florida Hospital Family Practice Residency program in Orlando.

First, he recommends inquiring about alcohol (60% to 70% of abnormal results are secondary to alcohol use), prescribed medications, (including antibiotics and anticonvulsants), and over-the-counter medications, such as acetaminophen, or herbal remedies (especially Kava).

Second, if the level is less than two times the upper limit of normal, recheck the liver enzymes in 6–8 weeks and advise the patient not to drink alcohol. If the enzymes remain elevated, complete the work-up.

Third, if the initial enzyme levels are more than two times the upper limit of normal, do a work-up; initial tests for elevated AST/ALT should include a hepatitis B and C panel (ALT levels will wax and wane in hepatitis C), iron and total iron-binding capacity, serum electrophoresis, and serum ceruplasmin.

For elevated alkaline phosphatase, “First thing I do … is to do a GGT [gamma glutamyl transferase],” Dr. Tambunan said. “If the GGT comes back elevated, it suggests that the majority of the alkaline [phosphatase] is elevated due to the liver,” and an ultrasound should be performed to look for gallstones or an obstruction and in women a antimitochondrial antibody test should be ordered to check for primary biliary cirrhosis.

If the initial lab work points to bone, then order parathyroid, THS, and PSA tests and a bone scan looking for Paget's disease in women and prostate cancer in men.

For elevated bilirubin levels, obtain direct and indirect bilirubin levels. If indirect is slightly elevated, suspect Gilbert disease, or if markedly elevated liver disease. If direct is elevated, treat (cholestasis) or if very elevated suspect a biliary obstruction.

ORLANDO, FLA. — Isolated cases of abnormal liver function tests are a common finding in family medicine. Daniel J. Tambunan, M.D., shared three rules for dealing with elevated liver enzymes at the annual meeting of the American Academy of Family Physicians.

“You could go to the extreme and order a million-dollar work-up, but I am trying to propose something more user-friendly and a much a more efficient way to find out what is causing the elevated liver enzymes,” said Dr. Tambunan, assistant director of the Florida Hospital Family Practice Residency program in Orlando.

First, he recommends inquiring about alcohol (60% to 70% of abnormal results are secondary to alcohol use), prescribed medications, (including antibiotics and anticonvulsants), and over-the-counter medications, such as acetaminophen, or herbal remedies (especially Kava).

Second, if the level is less than two times the upper limit of normal, recheck the liver enzymes in 6–8 weeks and advise the patient not to drink alcohol. If the enzymes remain elevated, complete the work-up.

Third, if the initial enzyme levels are more than two times the upper limit of normal, do a work-up; initial tests for elevated AST/ALT should include a hepatitis B and C panel (ALT levels will wax and wane in hepatitis C), iron and total iron-binding capacity, serum electrophoresis, and serum ceruplasmin.

For elevated alkaline phosphatase, “First thing I do … is to do a GGT [gamma glutamyl transferase],” Dr. Tambunan said. “If the GGT comes back elevated, it suggests that the majority of the alkaline [phosphatase] is elevated due to the liver,” and an ultrasound should be performed to look for gallstones or an obstruction and in women a antimitochondrial antibody test should be ordered to check for primary biliary cirrhosis.

If the initial lab work points to bone, then order parathyroid, THS, and PSA tests and a bone scan looking for Paget's disease in women and prostate cancer in men.

For elevated bilirubin levels, obtain direct and indirect bilirubin levels. If indirect is slightly elevated, suspect Gilbert disease, or if markedly elevated liver disease. If direct is elevated, treat (cholestasis) or if very elevated suspect a biliary obstruction.

ORLANDO, FLA. — Isolated cases of abnormal liver function tests are a common finding in family medicine. Daniel J. Tambunan, M.D., shared three rules for dealing with elevated liver enzymes at the annual meeting of the American Academy of Family Physicians.

“You could go to the extreme and order a million-dollar work-up, but I am trying to propose something more user-friendly and a much a more efficient way to find out what is causing the elevated liver enzymes,” said Dr. Tambunan, assistant director of the Florida Hospital Family Practice Residency program in Orlando.

First, he recommends inquiring about alcohol (60% to 70% of abnormal results are secondary to alcohol use), prescribed medications, (including antibiotics and anticonvulsants), and over-the-counter medications, such as acetaminophen, or herbal remedies (especially Kava).

Second, if the level is less than two times the upper limit of normal, recheck the liver enzymes in 6–8 weeks and advise the patient not to drink alcohol. If the enzymes remain elevated, complete the work-up.

Third, if the initial enzyme levels are more than two times the upper limit of normal, do a work-up; initial tests for elevated AST/ALT should include a hepatitis B and C panel (ALT levels will wax and wane in hepatitis C), iron and total iron-binding capacity, serum electrophoresis, and serum ceruplasmin.

For elevated alkaline phosphatase, “First thing I do … is to do a GGT [gamma glutamyl transferase],” Dr. Tambunan said. “If the GGT comes back elevated, it suggests that the majority of the alkaline [phosphatase] is elevated due to the liver,” and an ultrasound should be performed to look for gallstones or an obstruction and in women a antimitochondrial antibody test should be ordered to check for primary biliary cirrhosis.

If the initial lab work points to bone, then order parathyroid, THS, and PSA tests and a bone scan looking for Paget's disease in women and prostate cancer in men.

For elevated bilirubin levels, obtain direct and indirect bilirubin levels. If indirect is slightly elevated, suspect Gilbert disease, or if markedly elevated liver disease. If direct is elevated, treat (cholestasis) or if very elevated suspect a biliary obstruction.

ORLANDO, FLA. — West Virginia family physicians who were surveyed expressed apprehension and frustration about treating chronic, nonmalignant pain, reported Charles D. Ponte, Pharm.D., at the American Academy of Family Physicians' annual conference.

“Chronic, nonmalignant pain is very problematic for physicians,” said Dr. Ponte, professor of clinical pharmacy and family medicine at West Virginia University.

Dr. Ponte and his colleagues sent a 20-item survey to 537 members of the West Virginia Academy of Family Physicians. The investigators received 185 completed surveys.

More than three-quarters of respondents indicated that they experience anxiety when prescribing medication for chronic, nonmalignant pain. Regulatory scrutiny impacts prescribing practices, 65% of respondents said.

Treating chronic, nonmalignant pain is frustrating, said 85% of the physicians, while 89% called it time-consuming. Sixty percent of respondents did not think their formal medical training prepared them to effectively manage pain.

The survey also indicated some gaps between respondents' answers and current standards of care. For example, 65% of respondents would prescribe transdermal fentanyl to an opioid-naive patient, and 36% thought propoxyphene was appropriate for an elderly patient.

ORLANDO, FLA. — West Virginia family physicians who were surveyed expressed apprehension and frustration about treating chronic, nonmalignant pain, reported Charles D. Ponte, Pharm.D., at the American Academy of Family Physicians' annual conference.

“Chronic, nonmalignant pain is very problematic for physicians,” said Dr. Ponte, professor of clinical pharmacy and family medicine at West Virginia University.

Dr. Ponte and his colleagues sent a 20-item survey to 537 members of the West Virginia Academy of Family Physicians. The investigators received 185 completed surveys.

More than three-quarters of respondents indicated that they experience anxiety when prescribing medication for chronic, nonmalignant pain. Regulatory scrutiny impacts prescribing practices, 65% of respondents said.

Treating chronic, nonmalignant pain is frustrating, said 85% of the physicians, while 89% called it time-consuming. Sixty percent of respondents did not think their formal medical training prepared them to effectively manage pain.

The survey also indicated some gaps between respondents' answers and current standards of care. For example, 65% of respondents would prescribe transdermal fentanyl to an opioid-naive patient, and 36% thought propoxyphene was appropriate for an elderly patient.

ORLANDO, FLA. — West Virginia family physicians who were surveyed expressed apprehension and frustration about treating chronic, nonmalignant pain, reported Charles D. Ponte, Pharm.D., at the American Academy of Family Physicians' annual conference.

“Chronic, nonmalignant pain is very problematic for physicians,” said Dr. Ponte, professor of clinical pharmacy and family medicine at West Virginia University.

Dr. Ponte and his colleagues sent a 20-item survey to 537 members of the West Virginia Academy of Family Physicians. The investigators received 185 completed surveys.

More than three-quarters of respondents indicated that they experience anxiety when prescribing medication for chronic, nonmalignant pain. Regulatory scrutiny impacts prescribing practices, 65% of respondents said.

Treating chronic, nonmalignant pain is frustrating, said 85% of the physicians, while 89% called it time-consuming. Sixty percent of respondents did not think their formal medical training prepared them to effectively manage pain.

The survey also indicated some gaps between respondents' answers and current standards of care. For example, 65% of respondents would prescribe transdermal fentanyl to an opioid-naive patient, and 36% thought propoxyphene was appropriate for an elderly patient.