Damian McNamara

MIAMI BEACH — Public health officials are stepping up efforts to combat cysticercosis, a parasitic infection with dire neurologic consequences that is on the rise in the United States, according to James H. Maguire, M.D., chief of the parasitic diseases branch of the National Center for Infectious Diseases at the Centers for Disease Control and Prevention, Atlanta.

Each year in the United States, there are an estimated 1,000 new cases of cysticercosis, a leading cause of adult-onset epilepsy in endemic areas such as Central America and Africa, Dr. Maguire said at the annual meeting of the American Society of Tropical Medicine and Hygiene.

Cysticercosis is acquired after accidental ingestion of the eggs of the pork tapeworm Taenia solium. Infected people shed the eggs in their feces; infection spreads through contaminated food, water, or surfaces. Once the eggs hatch in the stomach, they penetrate the intestine and travel through the bloodstream. The eggs produce characteristic cysts anywhere in the body; cysts in the brain cause neurocysticercosis and produce seizures and other neurologic sequelae, according to Dr. Maguire.

“The real message is if someone comes in with seizures and they have a single lesion on CT or MRI, it could be cysticercosis,” Dr. Maguire said. Physicians need a high index of suspicion; an accurate diagnosis could spare a patient neurosurgery.

If a central nervous system cyst blocks the flow of cerebrospinal fluid, hydrocephaly can ensue. Surgery or shunt placement is indicated in some of these patients, but in most cases the cysts resolve on their own. Other neurologic sequelae include a permanent, stroke-like syndrome. Even the scar left behind by a former cyst can become the focus for future seizures, Dr. Maguire warned.

Patients are generally treated with antiparasitic drugs in combination with anti-inflammatory agents.

Infection typically comes from eating contaminated pork, fruits, and vegetables, but T. solium is also spread through contact with infected people or fecal matter. Federal standards for the U.S. pork industry protect most Americans, Dr. Maguire said.

Larval stage infection with T. solium leads to symptomatic cysticercosis, but people with an adult tapeworm can be unknowing sources of infection. Four cases of neurocysticercosis in New York City among Orthodox Jews—who do not eat pork—were initially puzzling to investigators (N. Engl. J. Med. 1992;327:692-5).

Only one had traveled to an endemic area. Of six domestic employees tested; one was found to have an active infection and another had a positive serologic test. “If a person is infected by someone with an adult tapeworm, contact tracing becomes very important,” Dr. Maguire said.

Cysticercosis is becoming increasingly recognized in U.S.-born residents, although it is still primarily a disease of immigrants from countries such as Mexico, Central America, sub-Saharan Africa, India, and East Asia, Dr. Maguire said.

Increasingly, prevalence of cysticercosis is reported in New Mexico, New York, and especially California, states with a large number of immigrants. However, “We saw 6-12 cases per year in Boston when I worked there—not a hotbed of immigration,” he added.

MIAMI BEACH — Public health officials are stepping up efforts to combat cysticercosis, a parasitic infection with dire neurologic consequences that is on the rise in the United States, according to James H. Maguire, M.D., chief of the parasitic diseases branch of the National Center for Infectious Diseases at the Centers for Disease Control and Prevention, Atlanta.

Each year in the United States, there are an estimated 1,000 new cases of cysticercosis, a leading cause of adult-onset epilepsy in endemic areas such as Central America and Africa, Dr. Maguire said at the annual meeting of the American Society of Tropical Medicine and Hygiene.

Cysticercosis is acquired after accidental ingestion of the eggs of the pork tapeworm Taenia solium. Infected people shed the eggs in their feces; infection spreads through contaminated food, water, or surfaces. Once the eggs hatch in the stomach, they penetrate the intestine and travel through the bloodstream. The eggs produce characteristic cysts anywhere in the body; cysts in the brain cause neurocysticercosis and produce seizures and other neurologic sequelae, according to Dr. Maguire.

“The real message is if someone comes in with seizures and they have a single lesion on CT or MRI, it could be cysticercosis,” Dr. Maguire said. Physicians need a high index of suspicion; an accurate diagnosis could spare a patient neurosurgery.

If a central nervous system cyst blocks the flow of cerebrospinal fluid, hydrocephaly can ensue. Surgery or shunt placement is indicated in some of these patients, but in most cases the cysts resolve on their own. Other neurologic sequelae include a permanent, stroke-like syndrome. Even the scar left behind by a former cyst can become the focus for future seizures, Dr. Maguire warned.

Patients are generally treated with antiparasitic drugs in combination with anti-inflammatory agents.

Infection typically comes from eating contaminated pork, fruits, and vegetables, but T. solium is also spread through contact with infected people or fecal matter. Federal standards for the U.S. pork industry protect most Americans, Dr. Maguire said.

Larval stage infection with T. solium leads to symptomatic cysticercosis, but people with an adult tapeworm can be unknowing sources of infection. Four cases of neurocysticercosis in New York City among Orthodox Jews—who do not eat pork—were initially puzzling to investigators (N. Engl. J. Med. 1992;327:692-5).

Only one had traveled to an endemic area. Of six domestic employees tested; one was found to have an active infection and another had a positive serologic test. “If a person is infected by someone with an adult tapeworm, contact tracing becomes very important,” Dr. Maguire said.

Cysticercosis is becoming increasingly recognized in U.S.-born residents, although it is still primarily a disease of immigrants from countries such as Mexico, Central America, sub-Saharan Africa, India, and East Asia, Dr. Maguire said.

Increasingly, prevalence of cysticercosis is reported in New Mexico, New York, and especially California, states with a large number of immigrants. However, “We saw 6-12 cases per year in Boston when I worked there—not a hotbed of immigration,” he added.

MIAMI BEACH — Public health officials are stepping up efforts to combat cysticercosis, a parasitic infection with dire neurologic consequences that is on the rise in the United States, according to James H. Maguire, M.D., chief of the parasitic diseases branch of the National Center for Infectious Diseases at the Centers for Disease Control and Prevention, Atlanta.

Each year in the United States, there are an estimated 1,000 new cases of cysticercosis, a leading cause of adult-onset epilepsy in endemic areas such as Central America and Africa, Dr. Maguire said at the annual meeting of the American Society of Tropical Medicine and Hygiene.

Cysticercosis is acquired after accidental ingestion of the eggs of the pork tapeworm Taenia solium. Infected people shed the eggs in their feces; infection spreads through contaminated food, water, or surfaces. Once the eggs hatch in the stomach, they penetrate the intestine and travel through the bloodstream. The eggs produce characteristic cysts anywhere in the body; cysts in the brain cause neurocysticercosis and produce seizures and other neurologic sequelae, according to Dr. Maguire.

“The real message is if someone comes in with seizures and they have a single lesion on CT or MRI, it could be cysticercosis,” Dr. Maguire said. Physicians need a high index of suspicion; an accurate diagnosis could spare a patient neurosurgery.

If a central nervous system cyst blocks the flow of cerebrospinal fluid, hydrocephaly can ensue. Surgery or shunt placement is indicated in some of these patients, but in most cases the cysts resolve on their own. Other neurologic sequelae include a permanent, stroke-like syndrome. Even the scar left behind by a former cyst can become the focus for future seizures, Dr. Maguire warned.

Patients are generally treated with antiparasitic drugs in combination with anti-inflammatory agents.

Infection typically comes from eating contaminated pork, fruits, and vegetables, but T. solium is also spread through contact with infected people or fecal matter. Federal standards for the U.S. pork industry protect most Americans, Dr. Maguire said.

Larval stage infection with T. solium leads to symptomatic cysticercosis, but people with an adult tapeworm can be unknowing sources of infection. Four cases of neurocysticercosis in New York City among Orthodox Jews—who do not eat pork—were initially puzzling to investigators (N. Engl. J. Med. 1992;327:692-5).

Only one had traveled to an endemic area. Of six domestic employees tested; one was found to have an active infection and another had a positive serologic test. “If a person is infected by someone with an adult tapeworm, contact tracing becomes very important,” Dr. Maguire said.

Cysticercosis is becoming increasingly recognized in U.S.-born residents, although it is still primarily a disease of immigrants from countries such as Mexico, Central America, sub-Saharan Africa, India, and East Asia, Dr. Maguire said.

Increasingly, prevalence of cysticercosis is reported in New Mexico, New York, and especially California, states with a large number of immigrants. However, “We saw 6-12 cases per year in Boston when I worked there—not a hotbed of immigration,” he added.

BOCA RATON, FLA. — A punch biopsy revealed a malignant neoplasm that was diagnosed as Merkel cell carcinoma. The patient was referred to the University of Florida for further evaluation.

The surgeon at the university wanted to do a wide excision of the lesion and sentinel lymph node. A lymph node dissection was planned in the event that the sentinel node came back positive.

The patient's candidiasis had not improved after 10 days of treatment with ketoconazole, so surgeons referred him to dermatology. The dermatologist examined the 1-cm-by-1-cm raised nodular mass in the patient's left groin surrounded by 10 cm2 of “candidiasis.” The dermatologist suspected extramammary Paget's disease.

The patient underwent removal of the lesion and sentinel node. Pathology revealed that the tumor was not Merkel cell, but an infiltrative apocrine adenocarcinoma. The rash was confirmed to be extramammary Paget's disease, and the sentinel node was positive, said Justin Wasserman, a fourth-year medical student at the university.

“Due to the patient's age and his comorbidity—he had Alzheimer's disease—his family did not want him to have additional surgery,” Mr. Wasserman said at the annual meeting of the Florida Society of Dermatologic Surgeons. So the patient did not undergo lymph node dissection. The extramammary Paget's disease was treated topically with imiquimod.

This case illustrates that, “groin rashes that have been adequately treated without improvement should be biopsied,” Mr. Wasserman said.

The patient was prescribed a 16-week course of imiquimod to be applied three times a week to the visible areas and about 2 inches beyond. After 8 weeks, there was some irritation to the area, but the rash had cleared almost completely except for a small area on the left lateral edge. The patient was instructed to discontinue imiquimod for 6 weeks. If at that time any rash still remained, he was instructed to restart and use the cream three times a week for an additional 16 weeks.

BOCA RATON, FLA. — A punch biopsy revealed a malignant neoplasm that was diagnosed as Merkel cell carcinoma. The patient was referred to the University of Florida for further evaluation.

The surgeon at the university wanted to do a wide excision of the lesion and sentinel lymph node. A lymph node dissection was planned in the event that the sentinel node came back positive.

The patient's candidiasis had not improved after 10 days of treatment with ketoconazole, so surgeons referred him to dermatology. The dermatologist examined the 1-cm-by-1-cm raised nodular mass in the patient's left groin surrounded by 10 cm2 of “candidiasis.” The dermatologist suspected extramammary Paget's disease.

The patient underwent removal of the lesion and sentinel node. Pathology revealed that the tumor was not Merkel cell, but an infiltrative apocrine adenocarcinoma. The rash was confirmed to be extramammary Paget's disease, and the sentinel node was positive, said Justin Wasserman, a fourth-year medical student at the university.

“Due to the patient's age and his comorbidity—he had Alzheimer's disease—his family did not want him to have additional surgery,” Mr. Wasserman said at the annual meeting of the Florida Society of Dermatologic Surgeons. So the patient did not undergo lymph node dissection. The extramammary Paget's disease was treated topically with imiquimod.

This case illustrates that, “groin rashes that have been adequately treated without improvement should be biopsied,” Mr. Wasserman said.

The patient was prescribed a 16-week course of imiquimod to be applied three times a week to the visible areas and about 2 inches beyond. After 8 weeks, there was some irritation to the area, but the rash had cleared almost completely except for a small area on the left lateral edge. The patient was instructed to discontinue imiquimod for 6 weeks. If at that time any rash still remained, he was instructed to restart and use the cream three times a week for an additional 16 weeks.

BOCA RATON, FLA. — A punch biopsy revealed a malignant neoplasm that was diagnosed as Merkel cell carcinoma. The patient was referred to the University of Florida for further evaluation.

The surgeon at the university wanted to do a wide excision of the lesion and sentinel lymph node. A lymph node dissection was planned in the event that the sentinel node came back positive.

The patient's candidiasis had not improved after 10 days of treatment with ketoconazole, so surgeons referred him to dermatology. The dermatologist examined the 1-cm-by-1-cm raised nodular mass in the patient's left groin surrounded by 10 cm2 of “candidiasis.” The dermatologist suspected extramammary Paget's disease.

The patient underwent removal of the lesion and sentinel node. Pathology revealed that the tumor was not Merkel cell, but an infiltrative apocrine adenocarcinoma. The rash was confirmed to be extramammary Paget's disease, and the sentinel node was positive, said Justin Wasserman, a fourth-year medical student at the university.

“Due to the patient's age and his comorbidity—he had Alzheimer's disease—his family did not want him to have additional surgery,” Mr. Wasserman said at the annual meeting of the Florida Society of Dermatologic Surgeons. So the patient did not undergo lymph node dissection. The extramammary Paget's disease was treated topically with imiquimod.

This case illustrates that, “groin rashes that have been adequately treated without improvement should be biopsied,” Mr. Wasserman said.

The patient was prescribed a 16-week course of imiquimod to be applied three times a week to the visible areas and about 2 inches beyond. After 8 weeks, there was some irritation to the area, but the rash had cleared almost completely except for a small area on the left lateral edge. The patient was instructed to discontinue imiquimod for 6 weeks. If at that time any rash still remained, he was instructed to restart and use the cream three times a week for an additional 16 weeks.

MIAMI BEACH — The next edition of “Health Information for International Travel,” also known as the Centers for Disease Control and Prevention's “Yellow Book,” will be more clinically oriented and will include new chapters on specific diseases, such as SARS, according to a sneak preview at the annual meeting of the American Society of Tropical Medicine and Hygiene.

Clinical presentation and treatment information will be added to the new and traditional chapters. Previously, the book addressed only prevention, risk, descriptions, and occurrence of travel-related diseases, according to Christie Reed, M.D., of the CDC's Division of Global Migration and Quarantine.

Travel increased exponentially in the 1990s, as did the volume of people migrating around the world, Dr. Reed said, adding, “Yesterday's migrant can become today's traveler.” Many immigrants to the United States return to their countries of origin to visit family and friends, for example, and present unique challenges in travel-related health.

One of the main goals of the CDC's Travelers' Health division is to share information, primarily through the Yellow Book and the Internet (www.cdc.gov/travel

The 2005-2006 edition will include more information from experts outside the CDC and a new bibliography on evidence-based medicine for travelers. New chapters are expected to include:

▸ Norovirus.

▸ Severe acute respiratory syndrome.

▸ Pneumococcus.

▸ Legionella.

▸ Jet lag.

▸ Fish poisoning.

▸ Sunburn.

▸ Health-seeking travelers. “This includes people traveling for surgery, dental care, etc. The standards for health care may not be the same in other places as they are in the U.S.,” Dr. Reed said.

There will also be expanded sections on preconception, pregnancy, and breastfeeding issues for travelers. In addition, there will be more information on travel for immunocompromised people, not just for those with HIV infection, as in past editions.

New maps will highlight regions of increased risks associated with Japanese encephalitis and yellow fever.

The new edition is expected to be available in May, to coincide with 9th Conference of the International Society of Travel Medicine in Lisbon, Portugal.

Although the next edition of the Yellow Book is nearly complete, online information is updated continuously. Dr. Reed encouraged physicians to submit any travel health-related information or concerns using the site's “contact us” option.

MIAMI BEACH — The next edition of “Health Information for International Travel,” also known as the Centers for Disease Control and Prevention's “Yellow Book,” will be more clinically oriented and will include new chapters on specific diseases, such as SARS, according to a sneak preview at the annual meeting of the American Society of Tropical Medicine and Hygiene.

Clinical presentation and treatment information will be added to the new and traditional chapters. Previously, the book addressed only prevention, risk, descriptions, and occurrence of travel-related diseases, according to Christie Reed, M.D., of the CDC's Division of Global Migration and Quarantine.

Travel increased exponentially in the 1990s, as did the volume of people migrating around the world, Dr. Reed said, adding, “Yesterday's migrant can become today's traveler.” Many immigrants to the United States return to their countries of origin to visit family and friends, for example, and present unique challenges in travel-related health.

One of the main goals of the CDC's Travelers' Health division is to share information, primarily through the Yellow Book and the Internet (www.cdc.gov/travel

The 2005-2006 edition will include more information from experts outside the CDC and a new bibliography on evidence-based medicine for travelers. New chapters are expected to include:

▸ Norovirus.

▸ Severe acute respiratory syndrome.

▸ Pneumococcus.

▸ Legionella.

▸ Jet lag.

▸ Fish poisoning.

▸ Sunburn.

▸ Health-seeking travelers. “This includes people traveling for surgery, dental care, etc. The standards for health care may not be the same in other places as they are in the U.S.,” Dr. Reed said.

There will also be expanded sections on preconception, pregnancy, and breastfeeding issues for travelers. In addition, there will be more information on travel for immunocompromised people, not just for those with HIV infection, as in past editions.

New maps will highlight regions of increased risks associated with Japanese encephalitis and yellow fever.

The new edition is expected to be available in May, to coincide with 9th Conference of the International Society of Travel Medicine in Lisbon, Portugal.

Although the next edition of the Yellow Book is nearly complete, online information is updated continuously. Dr. Reed encouraged physicians to submit any travel health-related information or concerns using the site's “contact us” option.

MIAMI BEACH — The next edition of “Health Information for International Travel,” also known as the Centers for Disease Control and Prevention's “Yellow Book,” will be more clinically oriented and will include new chapters on specific diseases, such as SARS, according to a sneak preview at the annual meeting of the American Society of Tropical Medicine and Hygiene.

Clinical presentation and treatment information will be added to the new and traditional chapters. Previously, the book addressed only prevention, risk, descriptions, and occurrence of travel-related diseases, according to Christie Reed, M.D., of the CDC's Division of Global Migration and Quarantine.

Travel increased exponentially in the 1990s, as did the volume of people migrating around the world, Dr. Reed said, adding, “Yesterday's migrant can become today's traveler.” Many immigrants to the United States return to their countries of origin to visit family and friends, for example, and present unique challenges in travel-related health.

One of the main goals of the CDC's Travelers' Health division is to share information, primarily through the Yellow Book and the Internet (www.cdc.gov/travel

The 2005-2006 edition will include more information from experts outside the CDC and a new bibliography on evidence-based medicine for travelers. New chapters are expected to include:

▸ Norovirus.

▸ Severe acute respiratory syndrome.

▸ Pneumococcus.

▸ Legionella.

▸ Jet lag.

▸ Fish poisoning.

▸ Sunburn.

▸ Health-seeking travelers. “This includes people traveling for surgery, dental care, etc. The standards for health care may not be the same in other places as they are in the U.S.,” Dr. Reed said.

There will also be expanded sections on preconception, pregnancy, and breastfeeding issues for travelers. In addition, there will be more information on travel for immunocompromised people, not just for those with HIV infection, as in past editions.

New maps will highlight regions of increased risks associated with Japanese encephalitis and yellow fever.

The new edition is expected to be available in May, to coincide with 9th Conference of the International Society of Travel Medicine in Lisbon, Portugal.

Although the next edition of the Yellow Book is nearly complete, online information is updated continuously. Dr. Reed encouraged physicians to submit any travel health-related information or concerns using the site's “contact us” option.

MIAMI BEACH — Public health officials are stepping up efforts to combat cysticercosis, a parasitic infection with dire neurologic consequences that is on the rise in the United States, according to James H. Maguire, M.D., chief of the parasitic diseases branch of the National Center for Infectious Diseases at the Centers for Disease Control and Prevention, Atlanta.

Each year in the United States, there are an estimated 1,000 new cases of cysticercosis, a leading cause of adult-onset epilepsy in endemic areas such as Central America and Africa, Dr. Maguire said at the annual meeting of the American Society of Tropical Medicine and Hygiene.

Cysticercosis is acquired after accidental ingestion of the eggs of the pork tapeworm Taenia solium.

Infected people shed the eggs in their feces and infection can spread through contaminated food, water, or surfaces.

Once the eggs hatch in the stomach, they penetrate the intestine and travel through the bloodstream. The eggs produce characteristic cysts anywhere in the body; cysts in the brain cause neurocysticercosis and produce seizures and other neurologic sequelae, according to Dr. Maguire.

“It's a nasty infection,” Dr. Maguire told FAMILY PRACTICE NEWS. “The real message is if someone comes in with seizures and they have a single lesion on CT or MRI, it could be cysticercosis.”

Physicians need a high index of suspicion; an accurate diagnosis could spare a patient neurosurgery, he added.

If a central nervous system cyst blocks the flow of cerebrospinal fluid, hydrocephaly can ensue. Surgery or shunt placement is indicated in some of these patients, but in most cases the cysts resolve on their own.

Other neurologic sequelae include a permanent, stroke-like syndrome. Even the scar left behind by a former cyst can become the focus for future seizures, Dr. Maguire warned.

Patients are generally treated with antiparasitic drugs in combination with anti-inflammatory agents.

Infection typically comes from eating contaminated pork, fruits, and vegetables, but T. solium is also spread through contact with infected people or fecal matter.

Federal standards for the U.S. pork industry protect most people in this country, Dr. Maguire said.

Larval stage infection with T. solium leads to symptomatic cysticercosis, but people with an adult tapeworm can be unknowing sources of infection. Four cases of neurocysticercosis in New York City among Orthodox Jews—who do not eat pork—were initially puzzling to investigators (N. Engl. J. Med. 1992;327:692-5).

Only one had traveled to an endemic area. However, six domestic employees were tested; one was found to have had an active infection with taenia species and another had a positive serologic test.

“If a person is infected by someone with an adult tapeworm, contact tracing becomes very important,” Dr. Maguire said.

A strategy for preventing the infection is to “go after the disease at its source” in endemic areas and improve immigrant health, Dr. Maguire said.

The World Health Organization and other agencies have an active cysticercosis eradication program.

As part of a strategy to eradicate the infection at its source, pigs are being vaccinated against the parasite, but adoption is not yet widespread.

Cysticercosis is becoming increasingly recognized in U.S.-born residents, although it is still primarily a disease of immigrants from countries such as Mexico, Central America, sub-Saharan Africa, India, and East Asia, Dr. Maguire said.

Increasingly, prevalence of cysticercosis is reported in New Mexico, New York, and especially California, states with a large number of immigrants. However, “We saw 6-12 cases per year in Boston when I worked there—not a hotbed of immigration,” he added.

MIAMI BEACH — Public health officials are stepping up efforts to combat cysticercosis, a parasitic infection with dire neurologic consequences that is on the rise in the United States, according to James H. Maguire, M.D., chief of the parasitic diseases branch of the National Center for Infectious Diseases at the Centers for Disease Control and Prevention, Atlanta.

Each year in the United States, there are an estimated 1,000 new cases of cysticercosis, a leading cause of adult-onset epilepsy in endemic areas such as Central America and Africa, Dr. Maguire said at the annual meeting of the American Society of Tropical Medicine and Hygiene.

Cysticercosis is acquired after accidental ingestion of the eggs of the pork tapeworm Taenia solium.

Infected people shed the eggs in their feces and infection can spread through contaminated food, water, or surfaces.

Once the eggs hatch in the stomach, they penetrate the intestine and travel through the bloodstream. The eggs produce characteristic cysts anywhere in the body; cysts in the brain cause neurocysticercosis and produce seizures and other neurologic sequelae, according to Dr. Maguire.

“It's a nasty infection,” Dr. Maguire told FAMILY PRACTICE NEWS. “The real message is if someone comes in with seizures and they have a single lesion on CT or MRI, it could be cysticercosis.”

Physicians need a high index of suspicion; an accurate diagnosis could spare a patient neurosurgery, he added.

If a central nervous system cyst blocks the flow of cerebrospinal fluid, hydrocephaly can ensue. Surgery or shunt placement is indicated in some of these patients, but in most cases the cysts resolve on their own.

Other neurologic sequelae include a permanent, stroke-like syndrome. Even the scar left behind by a former cyst can become the focus for future seizures, Dr. Maguire warned.

Patients are generally treated with antiparasitic drugs in combination with anti-inflammatory agents.

Infection typically comes from eating contaminated pork, fruits, and vegetables, but T. solium is also spread through contact with infected people or fecal matter.

Federal standards for the U.S. pork industry protect most people in this country, Dr. Maguire said.

Larval stage infection with T. solium leads to symptomatic cysticercosis, but people with an adult tapeworm can be unknowing sources of infection. Four cases of neurocysticercosis in New York City among Orthodox Jews—who do not eat pork—were initially puzzling to investigators (N. Engl. J. Med. 1992;327:692-5).

Only one had traveled to an endemic area. However, six domestic employees were tested; one was found to have had an active infection with taenia species and another had a positive serologic test.

“If a person is infected by someone with an adult tapeworm, contact tracing becomes very important,” Dr. Maguire said.

A strategy for preventing the infection is to “go after the disease at its source” in endemic areas and improve immigrant health, Dr. Maguire said.

The World Health Organization and other agencies have an active cysticercosis eradication program.

As part of a strategy to eradicate the infection at its source, pigs are being vaccinated against the parasite, but adoption is not yet widespread.

Cysticercosis is becoming increasingly recognized in U.S.-born residents, although it is still primarily a disease of immigrants from countries such as Mexico, Central America, sub-Saharan Africa, India, and East Asia, Dr. Maguire said.

Increasingly, prevalence of cysticercosis is reported in New Mexico, New York, and especially California, states with a large number of immigrants. However, “We saw 6-12 cases per year in Boston when I worked there—not a hotbed of immigration,” he added.

MIAMI BEACH — Public health officials are stepping up efforts to combat cysticercosis, a parasitic infection with dire neurologic consequences that is on the rise in the United States, according to James H. Maguire, M.D., chief of the parasitic diseases branch of the National Center for Infectious Diseases at the Centers for Disease Control and Prevention, Atlanta.

Each year in the United States, there are an estimated 1,000 new cases of cysticercosis, a leading cause of adult-onset epilepsy in endemic areas such as Central America and Africa, Dr. Maguire said at the annual meeting of the American Society of Tropical Medicine and Hygiene.

Cysticercosis is acquired after accidental ingestion of the eggs of the pork tapeworm Taenia solium.

Infected people shed the eggs in their feces and infection can spread through contaminated food, water, or surfaces.

Once the eggs hatch in the stomach, they penetrate the intestine and travel through the bloodstream. The eggs produce characteristic cysts anywhere in the body; cysts in the brain cause neurocysticercosis and produce seizures and other neurologic sequelae, according to Dr. Maguire.

“It's a nasty infection,” Dr. Maguire told FAMILY PRACTICE NEWS. “The real message is if someone comes in with seizures and they have a single lesion on CT or MRI, it could be cysticercosis.”

Physicians need a high index of suspicion; an accurate diagnosis could spare a patient neurosurgery, he added.

If a central nervous system cyst blocks the flow of cerebrospinal fluid, hydrocephaly can ensue. Surgery or shunt placement is indicated in some of these patients, but in most cases the cysts resolve on their own.

Other neurologic sequelae include a permanent, stroke-like syndrome. Even the scar left behind by a former cyst can become the focus for future seizures, Dr. Maguire warned.

Patients are generally treated with antiparasitic drugs in combination with anti-inflammatory agents.

Infection typically comes from eating contaminated pork, fruits, and vegetables, but T. solium is also spread through contact with infected people or fecal matter.

Federal standards for the U.S. pork industry protect most people in this country, Dr. Maguire said.

Larval stage infection with T. solium leads to symptomatic cysticercosis, but people with an adult tapeworm can be unknowing sources of infection. Four cases of neurocysticercosis in New York City among Orthodox Jews—who do not eat pork—were initially puzzling to investigators (N. Engl. J. Med. 1992;327:692-5).

Only one had traveled to an endemic area. However, six domestic employees were tested; one was found to have had an active infection with taenia species and another had a positive serologic test.

“If a person is infected by someone with an adult tapeworm, contact tracing becomes very important,” Dr. Maguire said.

A strategy for preventing the infection is to “go after the disease at its source” in endemic areas and improve immigrant health, Dr. Maguire said.

The World Health Organization and other agencies have an active cysticercosis eradication program.

As part of a strategy to eradicate the infection at its source, pigs are being vaccinated against the parasite, but adoption is not yet widespread.

Cysticercosis is becoming increasingly recognized in U.S.-born residents, although it is still primarily a disease of immigrants from countries such as Mexico, Central America, sub-Saharan Africa, India, and East Asia, Dr. Maguire said.

Increasingly, prevalence of cysticercosis is reported in New Mexico, New York, and especially California, states with a large number of immigrants. However, “We saw 6-12 cases per year in Boston when I worked there—not a hotbed of immigration,” he added.

ORLANDO, FLA. — Giving patients with diabetes printed reports with individualized cardiovascular risk profiles helped the patients improve their cholesterol levels in a randomized study.

“It's like a report card. It makes a difference when you present information visually and you discuss it—shared decision making is more effective,” Ilka Lowensteyn, Ph.D., said during a poster presentation at the annual scientific sessions of the American Diabetes Association.

Patients with diabetes from 230 primary care offices were randomized to receive printed, individualized risk profiles (691 participants) or usual care (697 participants). Each one-page report included a bar graph showing the patient's 10-year risk of cardiovascular disease based on Framingham equations, as well as the estimated benefits of risk factor reduction. The report also includes a table that calculates cardiovascular age based on risk factors.

Patients can easily see how a reduction in each risk factor translates to years of life saved, said Dr. Lowensteyn, director of clinical research, Arcadie Health Assessment Associates Inc., Montreal.

“It's very impressive for patients. And it allows physicians to get a 'buy-in' from patients,” he said. An individual profile might show that a patient with diabetes needs to change three things: smoking, cholesterol, and lipids. A physician discussing the risk profile could then ask, “Which one do you want to tackle first?” he said.

The participants, aged 30-70 years, were demographically similar between the two groups.

Exercise and dietary changes were prescribed for 3 months if cardiovascular risk was moderate at baseline, and could be continued thereafter if risk did not increase.

Patients were eligible for statin treatment if their LDL cholesterol level was 100 mg/dL or more or their total cholesterol/HDL cholesterol ratio was 4 or greater.

Physicians were free to prescribe any statin and patients were responsible for filling the prescription, so the study was a relatively real-world assessment compared with a clinical trial. The study was sponsored and jointly developed by Pfizer Canada Inc.

Profiles were updated every 3 months for up to 1 year, providing participants in the intervention group with regular feedback and trend data regarding their efforts to reduce risk factors.

“The big impact was on cholesterol,” Dr. Lowensteyn said. After 12 months of statin therapy, patients in the risk profile group had significantly greater reductions in total cholesterol (26.3%, vs. 23.8% with usual care), LDL cholesterol (36.6%, vs. 33.6% with usual care), total cholesterol/HDL cholesterol ratio (27.2%, vs. 24.9% with usual care), and projected 10-year cardiovascular disease risk (33.8%, vs. 30.8% with usual care).

Cardiovascular risk profiles are worthwhile even if they confer only a modest improvement in statin compliance among diabetic patients, Dr. Lowensteyn said. “Even if it's an extra 10% still on medication at the end of the year, that is great.”

ORLANDO, FLA. — Giving patients with diabetes printed reports with individualized cardiovascular risk profiles helped the patients improve their cholesterol levels in a randomized study.

“It's like a report card. It makes a difference when you present information visually and you discuss it—shared decision making is more effective,” Ilka Lowensteyn, Ph.D., said during a poster presentation at the annual scientific sessions of the American Diabetes Association.

Patients with diabetes from 230 primary care offices were randomized to receive printed, individualized risk profiles (691 participants) or usual care (697 participants). Each one-page report included a bar graph showing the patient's 10-year risk of cardiovascular disease based on Framingham equations, as well as the estimated benefits of risk factor reduction. The report also includes a table that calculates cardiovascular age based on risk factors.

Patients can easily see how a reduction in each risk factor translates to years of life saved, said Dr. Lowensteyn, director of clinical research, Arcadie Health Assessment Associates Inc., Montreal.

“It's very impressive for patients. And it allows physicians to get a 'buy-in' from patients,” he said. An individual profile might show that a patient with diabetes needs to change three things: smoking, cholesterol, and lipids. A physician discussing the risk profile could then ask, “Which one do you want to tackle first?” he said.

The participants, aged 30-70 years, were demographically similar between the two groups.

Exercise and dietary changes were prescribed for 3 months if cardiovascular risk was moderate at baseline, and could be continued thereafter if risk did not increase.

Patients were eligible for statin treatment if their LDL cholesterol level was 100 mg/dL or more or their total cholesterol/HDL cholesterol ratio was 4 or greater.

Physicians were free to prescribe any statin and patients were responsible for filling the prescription, so the study was a relatively real-world assessment compared with a clinical trial. The study was sponsored and jointly developed by Pfizer Canada Inc.

Profiles were updated every 3 months for up to 1 year, providing participants in the intervention group with regular feedback and trend data regarding their efforts to reduce risk factors.

“The big impact was on cholesterol,” Dr. Lowensteyn said. After 12 months of statin therapy, patients in the risk profile group had significantly greater reductions in total cholesterol (26.3%, vs. 23.8% with usual care), LDL cholesterol (36.6%, vs. 33.6% with usual care), total cholesterol/HDL cholesterol ratio (27.2%, vs. 24.9% with usual care), and projected 10-year cardiovascular disease risk (33.8%, vs. 30.8% with usual care).

Cardiovascular risk profiles are worthwhile even if they confer only a modest improvement in statin compliance among diabetic patients, Dr. Lowensteyn said. “Even if it's an extra 10% still on medication at the end of the year, that is great.”

ORLANDO, FLA. — Giving patients with diabetes printed reports with individualized cardiovascular risk profiles helped the patients improve their cholesterol levels in a randomized study.

“It's like a report card. It makes a difference when you present information visually and you discuss it—shared decision making is more effective,” Ilka Lowensteyn, Ph.D., said during a poster presentation at the annual scientific sessions of the American Diabetes Association.

Patients with diabetes from 230 primary care offices were randomized to receive printed, individualized risk profiles (691 participants) or usual care (697 participants). Each one-page report included a bar graph showing the patient's 10-year risk of cardiovascular disease based on Framingham equations, as well as the estimated benefits of risk factor reduction. The report also includes a table that calculates cardiovascular age based on risk factors.

Patients can easily see how a reduction in each risk factor translates to years of life saved, said Dr. Lowensteyn, director of clinical research, Arcadie Health Assessment Associates Inc., Montreal.

“It's very impressive for patients. And it allows physicians to get a 'buy-in' from patients,” he said. An individual profile might show that a patient with diabetes needs to change three things: smoking, cholesterol, and lipids. A physician discussing the risk profile could then ask, “Which one do you want to tackle first?” he said.

The participants, aged 30-70 years, were demographically similar between the two groups.

Exercise and dietary changes were prescribed for 3 months if cardiovascular risk was moderate at baseline, and could be continued thereafter if risk did not increase.

Patients were eligible for statin treatment if their LDL cholesterol level was 100 mg/dL or more or their total cholesterol/HDL cholesterol ratio was 4 or greater.

Physicians were free to prescribe any statin and patients were responsible for filling the prescription, so the study was a relatively real-world assessment compared with a clinical trial. The study was sponsored and jointly developed by Pfizer Canada Inc.

Profiles were updated every 3 months for up to 1 year, providing participants in the intervention group with regular feedback and trend data regarding their efforts to reduce risk factors.

“The big impact was on cholesterol,” Dr. Lowensteyn said. After 12 months of statin therapy, patients in the risk profile group had significantly greater reductions in total cholesterol (26.3%, vs. 23.8% with usual care), LDL cholesterol (36.6%, vs. 33.6% with usual care), total cholesterol/HDL cholesterol ratio (27.2%, vs. 24.9% with usual care), and projected 10-year cardiovascular disease risk (33.8%, vs. 30.8% with usual care).

Cardiovascular risk profiles are worthwhile even if they confer only a modest improvement in statin compliance among diabetic patients, Dr. Lowensteyn said. “Even if it's an extra 10% still on medication at the end of the year, that is great.”

MARCO ISLAND, FLA. – An intervention significantly increases depression-free days and improves physical functioning in the elderly–even 12 months later, Wayne J. Katon, M.D., reported at the annual meeting of the Academy of Psychosomatic Medicine.

New 2-year data from the Improving Mood–Promoting Access to Collaborative Treatment for Late Life Depression (IMPACT) study show that the clinical benefits of the intervention persist well beyond the initial 1-year treatment period.

“We saw improvements in functioning, pain, and overall quality of life,” said Dr. Katon, a psychiatrist at the University of Washington, Seattle. “We were surprised at the extent of the benefit in year 2, which was equal to the benefit we found in year 1.”

In addition, the intervention proved cost effective at most of the sites. (See sidebar, page 13.)

An estimated 10%-20% of older primary care patients meet the criteria for depression, and the percentage increases to up to 25% with chronic illness. But few depressed elderly patients receive appropriate care because of the burden of comorbidities, poor physical function, and often “an understanding” that they are depressed because of those comorbidities, said Dr. Katon, professor, vice chair, and director of the division of health services and psychiatric epidemiology at the university.

An initial report on IMPACT–a multicenter study of 1,801 depressed older adults–had shown that 45% of the 906 patients randomized to the intervention group had a 50% or greater improvement in depressive symptoms at 12 months (JAMA 2002;288:2836-45). In contrast, only 19% of the 895 patients randomized to usual care showed the same level of improvement.

The researchers recruited patients from 18 primary care clinics in five states. The participants were 66% female and 24% nonwhite, and all were 60 years or older (mean age 71). Many met criteria for major depression (17%), dysthymia (30%), or both (53%). Participants had a mean of 3.2 chronic illnesses, which included chronic pain, osteoarthritis, incontinence, and diabetes.

“A lot of these people would not be admitted into other depression studies because of the extent of their comorbidities,” Dr. Katon said.

Participants randomized to the intervention group had access to a dedicated depression care manager. This manager provided education, behavioral activation, support of antidepressant therapy (prescribed by the patients' primary care physicians), or brief psychotherapy using the Problem Solving Treatment in Primary Care protocol. Depression care managers tracked outcomes using the depression module of the Patient Health Questionnaire (PHQ-9) and adjusted treatment accordingly.

“Stepped care allowed us to add an antidepressant if needed or to add psychotherapy as needed,” Dr. Katon explained.

Physicians for patients in the usual care group were only told that the patient met criteria for depression or dysthymia. Physicians in the usual care arm could start patients on antidepressants or refer for psychotherapy or medication.

Patients were assessed at baseline and at 3, 6, 12, and 24 months. By 1 year, the intervention group was more likely to get some antidepressant treatment (odds ratio 2.98) and report more satisfaction with depression care (OR 3.38). Intervention patients got better more quickly over the 12-month period.

Dr. Katon, lead investigator Jürgen Unützer, M.D. (professor of psychiatry at the university), and their colleagues followed patients for an additional year after the intervention.

In other studies that included mixed-age patients, the 12-month intervention versus usual care differences tended to come together, Dr. Katon said. But in the elderly population, the usual care patients improved for about 6 months, and then their improvements reached a plateau, whereas the intervention group did gradually better during the entire 24 months.

The intervention group patients had 107 additional depression-free days, compared with the usual care patients.

“That is about a one-third-of-a-year difference,” Dr. Katon said. “We're sorry we did not take this study to a third year, since we saw equal benefit in intervention, compared with usual care patients in the second year.”

Of the 107 depression-free days gained by the intervention group, 53 were in the first year, and 54 were in the second.

The John A. Hartman Foundation and the California HealthCare Foundation funded the IMPACT study.

Visit www.impact.ucla.edu

Intervention Proves Cost Effective

The IMPACT researchers calculated total outpatient costs as $11,083 in the usual care group, compared with $11,378 in the intervention group.

Thus, there is an increase of $295 in the intervention group over 24 months. In year 1, there was $383 more in ambulatory costs for intervention patients, compared with usual care–but in year 2, there was an $88 cost savings associated with the intervention.

“For a small bump in cost, you get 53 depression-free days in year 1, and in the second year, you actually save money for the 54 days [gained],” Dr. Katon said.

To ascertain total costs, the researchers considered the cost of usual care as $0 for reference and calculated intervention-specific costs as a mean $591 per patient over the 2 years. Comparing other mean costs for intervention group vs. usual care, antidepressant medication was $416 higher for intervention patients; other medication costs were $126 lower (a net savings); outpatient specialty mental health care was $86 lower; and other outpatient costs were $501 lower for intervention patients.

Intervention-specific costs included psychiatrist and primary care supervision time, nurse time, overhead costs, and educational materials. Other ambulatory medical costs included primary care and specialty visits, emergency department use, urgent care visits, and laboratory and imaging charges. Researchers excluded costs of inpatient care and patient time. The cost of patient time is “difficult to do in the elderly, because most are not working,” Dr. Katon said.

Some figures were estimated. For example, 17%-24% of health care data were not available, Dr. Katon said. In addition, some organizations did not have pharmacy data. In cases where data were missing, imputation–which estimates costs by considering demographics, prior health care use, and other factors–was used to estimate costs.

The researchers estimated the incremental cost per quality-adjusted life year (QALY) for the intervention group. The range was $2,521 to $5,000. “It is widely accepted that anything that is under $10,000 per QALY for health care should be implemented immediately,” Dr. Katon said.

New interventions typically cost more with increased effectiveness, Dr. Katon said. “The holy grail is that an intervention that costs less with increased effectiveness should be implemented immediately.” For three of the eight organizations, the intervention saved money over the 2 years, with greater benefit, he added.

Reimbursement for collaborative care remains an issue. Psychiatrist supervision with the primary care physicians and depression care manager was not reimbursable, nor were the depression care manager's consultations with other providers (nonpatient treatment time). Follow-up telephone calls, likewise, were not reimbursed.

Despite the reimbursement issues, interest in the IMPACT model has been strong. “We're getting called all the time from health care organizations all over the United States with questions about how to implement this,” Dr. Katon said.

MARCO ISLAND, FLA. – An intervention significantly increases depression-free days and improves physical functioning in the elderly–even 12 months later, Wayne J. Katon, M.D., reported at the annual meeting of the Academy of Psychosomatic Medicine.

New 2-year data from the Improving Mood–Promoting Access to Collaborative Treatment for Late Life Depression (IMPACT) study show that the clinical benefits of the intervention persist well beyond the initial 1-year treatment period.

“We saw improvements in functioning, pain, and overall quality of life,” said Dr. Katon, a psychiatrist at the University of Washington, Seattle. “We were surprised at the extent of the benefit in year 2, which was equal to the benefit we found in year 1.”

In addition, the intervention proved cost effective at most of the sites. (See sidebar, page 13.)

An estimated 10%-20% of older primary care patients meet the criteria for depression, and the percentage increases to up to 25% with chronic illness. But few depressed elderly patients receive appropriate care because of the burden of comorbidities, poor physical function, and often “an understanding” that they are depressed because of those comorbidities, said Dr. Katon, professor, vice chair, and director of the division of health services and psychiatric epidemiology at the university.

An initial report on IMPACT–a multicenter study of 1,801 depressed older adults–had shown that 45% of the 906 patients randomized to the intervention group had a 50% or greater improvement in depressive symptoms at 12 months (JAMA 2002;288:2836-45). In contrast, only 19% of the 895 patients randomized to usual care showed the same level of improvement.

The researchers recruited patients from 18 primary care clinics in five states. The participants were 66% female and 24% nonwhite, and all were 60 years or older (mean age 71). Many met criteria for major depression (17%), dysthymia (30%), or both (53%). Participants had a mean of 3.2 chronic illnesses, which included chronic pain, osteoarthritis, incontinence, and diabetes.

“A lot of these people would not be admitted into other depression studies because of the extent of their comorbidities,” Dr. Katon said.

Participants randomized to the intervention group had access to a dedicated depression care manager. This manager provided education, behavioral activation, support of antidepressant therapy (prescribed by the patients' primary care physicians), or brief psychotherapy using the Problem Solving Treatment in Primary Care protocol. Depression care managers tracked outcomes using the depression module of the Patient Health Questionnaire (PHQ-9) and adjusted treatment accordingly.

“Stepped care allowed us to add an antidepressant if needed or to add psychotherapy as needed,” Dr. Katon explained.

Physicians for patients in the usual care group were only told that the patient met criteria for depression or dysthymia. Physicians in the usual care arm could start patients on antidepressants or refer for psychotherapy or medication.

Patients were assessed at baseline and at 3, 6, 12, and 24 months. By 1 year, the intervention group was more likely to get some antidepressant treatment (odds ratio 2.98) and report more satisfaction with depression care (OR 3.38). Intervention patients got better more quickly over the 12-month period.

Dr. Katon, lead investigator Jürgen Unützer, M.D. (professor of psychiatry at the university), and their colleagues followed patients for an additional year after the intervention.

In other studies that included mixed-age patients, the 12-month intervention versus usual care differences tended to come together, Dr. Katon said. But in the elderly population, the usual care patients improved for about 6 months, and then their improvements reached a plateau, whereas the intervention group did gradually better during the entire 24 months.

The intervention group patients had 107 additional depression-free days, compared with the usual care patients.

“That is about a one-third-of-a-year difference,” Dr. Katon said. “We're sorry we did not take this study to a third year, since we saw equal benefit in intervention, compared with usual care patients in the second year.”

Of the 107 depression-free days gained by the intervention group, 53 were in the first year, and 54 were in the second.

The John A. Hartman Foundation and the California HealthCare Foundation funded the IMPACT study.

Visit www.impact.ucla.edu

Intervention Proves Cost Effective

The IMPACT researchers calculated total outpatient costs as $11,083 in the usual care group, compared with $11,378 in the intervention group.

Thus, there is an increase of $295 in the intervention group over 24 months. In year 1, there was $383 more in ambulatory costs for intervention patients, compared with usual care–but in year 2, there was an $88 cost savings associated with the intervention.

“For a small bump in cost, you get 53 depression-free days in year 1, and in the second year, you actually save money for the 54 days [gained],” Dr. Katon said.

To ascertain total costs, the researchers considered the cost of usual care as $0 for reference and calculated intervention-specific costs as a mean $591 per patient over the 2 years. Comparing other mean costs for intervention group vs. usual care, antidepressant medication was $416 higher for intervention patients; other medication costs were $126 lower (a net savings); outpatient specialty mental health care was $86 lower; and other outpatient costs were $501 lower for intervention patients.

Intervention-specific costs included psychiatrist and primary care supervision time, nurse time, overhead costs, and educational materials. Other ambulatory medical costs included primary care and specialty visits, emergency department use, urgent care visits, and laboratory and imaging charges. Researchers excluded costs of inpatient care and patient time. The cost of patient time is “difficult to do in the elderly, because most are not working,” Dr. Katon said.

Some figures were estimated. For example, 17%-24% of health care data were not available, Dr. Katon said. In addition, some organizations did not have pharmacy data. In cases where data were missing, imputation–which estimates costs by considering demographics, prior health care use, and other factors–was used to estimate costs.

The researchers estimated the incremental cost per quality-adjusted life year (QALY) for the intervention group. The range was $2,521 to $5,000. “It is widely accepted that anything that is under $10,000 per QALY for health care should be implemented immediately,” Dr. Katon said.

New interventions typically cost more with increased effectiveness, Dr. Katon said. “The holy grail is that an intervention that costs less with increased effectiveness should be implemented immediately.” For three of the eight organizations, the intervention saved money over the 2 years, with greater benefit, he added.

Reimbursement for collaborative care remains an issue. Psychiatrist supervision with the primary care physicians and depression care manager was not reimbursable, nor were the depression care manager's consultations with other providers (nonpatient treatment time). Follow-up telephone calls, likewise, were not reimbursed.

Despite the reimbursement issues, interest in the IMPACT model has been strong. “We're getting called all the time from health care organizations all over the United States with questions about how to implement this,” Dr. Katon said.

MARCO ISLAND, FLA. – An intervention significantly increases depression-free days and improves physical functioning in the elderly–even 12 months later, Wayne J. Katon, M.D., reported at the annual meeting of the Academy of Psychosomatic Medicine.

New 2-year data from the Improving Mood–Promoting Access to Collaborative Treatment for Late Life Depression (IMPACT) study show that the clinical benefits of the intervention persist well beyond the initial 1-year treatment period.

“We saw improvements in functioning, pain, and overall quality of life,” said Dr. Katon, a psychiatrist at the University of Washington, Seattle. “We were surprised at the extent of the benefit in year 2, which was equal to the benefit we found in year 1.”

In addition, the intervention proved cost effective at most of the sites. (See sidebar, page 13.)

An estimated 10%-20% of older primary care patients meet the criteria for depression, and the percentage increases to up to 25% with chronic illness. But few depressed elderly patients receive appropriate care because of the burden of comorbidities, poor physical function, and often “an understanding” that they are depressed because of those comorbidities, said Dr. Katon, professor, vice chair, and director of the division of health services and psychiatric epidemiology at the university.

An initial report on IMPACT–a multicenter study of 1,801 depressed older adults–had shown that 45% of the 906 patients randomized to the intervention group had a 50% or greater improvement in depressive symptoms at 12 months (JAMA 2002;288:2836-45). In contrast, only 19% of the 895 patients randomized to usual care showed the same level of improvement.

The researchers recruited patients from 18 primary care clinics in five states. The participants were 66% female and 24% nonwhite, and all were 60 years or older (mean age 71). Many met criteria for major depression (17%), dysthymia (30%), or both (53%). Participants had a mean of 3.2 chronic illnesses, which included chronic pain, osteoarthritis, incontinence, and diabetes.

“A lot of these people would not be admitted into other depression studies because of the extent of their comorbidities,” Dr. Katon said.

Participants randomized to the intervention group had access to a dedicated depression care manager. This manager provided education, behavioral activation, support of antidepressant therapy (prescribed by the patients' primary care physicians), or brief psychotherapy using the Problem Solving Treatment in Primary Care protocol. Depression care managers tracked outcomes using the depression module of the Patient Health Questionnaire (PHQ-9) and adjusted treatment accordingly.

“Stepped care allowed us to add an antidepressant if needed or to add psychotherapy as needed,” Dr. Katon explained.

Physicians for patients in the usual care group were only told that the patient met criteria for depression or dysthymia. Physicians in the usual care arm could start patients on antidepressants or refer for psychotherapy or medication.

Patients were assessed at baseline and at 3, 6, 12, and 24 months. By 1 year, the intervention group was more likely to get some antidepressant treatment (odds ratio 2.98) and report more satisfaction with depression care (OR 3.38). Intervention patients got better more quickly over the 12-month period.

Dr. Katon, lead investigator Jürgen Unützer, M.D. (professor of psychiatry at the university), and their colleagues followed patients for an additional year after the intervention.

In other studies that included mixed-age patients, the 12-month intervention versus usual care differences tended to come together, Dr. Katon said. But in the elderly population, the usual care patients improved for about 6 months, and then their improvements reached a plateau, whereas the intervention group did gradually better during the entire 24 months.

The intervention group patients had 107 additional depression-free days, compared with the usual care patients.

“That is about a one-third-of-a-year difference,” Dr. Katon said. “We're sorry we did not take this study to a third year, since we saw equal benefit in intervention, compared with usual care patients in the second year.”

Of the 107 depression-free days gained by the intervention group, 53 were in the first year, and 54 were in the second.

The John A. Hartman Foundation and the California HealthCare Foundation funded the IMPACT study.

Visit www.impact.ucla.edu

Intervention Proves Cost Effective

The IMPACT researchers calculated total outpatient costs as $11,083 in the usual care group, compared with $11,378 in the intervention group.

Thus, there is an increase of $295 in the intervention group over 24 months. In year 1, there was $383 more in ambulatory costs for intervention patients, compared with usual care–but in year 2, there was an $88 cost savings associated with the intervention.

“For a small bump in cost, you get 53 depression-free days in year 1, and in the second year, you actually save money for the 54 days [gained],” Dr. Katon said.

To ascertain total costs, the researchers considered the cost of usual care as $0 for reference and calculated intervention-specific costs as a mean $591 per patient over the 2 years. Comparing other mean costs for intervention group vs. usual care, antidepressant medication was $416 higher for intervention patients; other medication costs were $126 lower (a net savings); outpatient specialty mental health care was $86 lower; and other outpatient costs were $501 lower for intervention patients.

Intervention-specific costs included psychiatrist and primary care supervision time, nurse time, overhead costs, and educational materials. Other ambulatory medical costs included primary care and specialty visits, emergency department use, urgent care visits, and laboratory and imaging charges. Researchers excluded costs of inpatient care and patient time. The cost of patient time is “difficult to do in the elderly, because most are not working,” Dr. Katon said.

Some figures were estimated. For example, 17%-24% of health care data were not available, Dr. Katon said. In addition, some organizations did not have pharmacy data. In cases where data were missing, imputation–which estimates costs by considering demographics, prior health care use, and other factors–was used to estimate costs.

The researchers estimated the incremental cost per quality-adjusted life year (QALY) for the intervention group. The range was $2,521 to $5,000. “It is widely accepted that anything that is under $10,000 per QALY for health care should be implemented immediately,” Dr. Katon said.

New interventions typically cost more with increased effectiveness, Dr. Katon said. “The holy grail is that an intervention that costs less with increased effectiveness should be implemented immediately.” For three of the eight organizations, the intervention saved money over the 2 years, with greater benefit, he added.

Reimbursement for collaborative care remains an issue. Psychiatrist supervision with the primary care physicians and depression care manager was not reimbursable, nor were the depression care manager's consultations with other providers (nonpatient treatment time). Follow-up telephone calls, likewise, were not reimbursed.

Despite the reimbursement issues, interest in the IMPACT model has been strong. “We're getting called all the time from health care organizations all over the United States with questions about how to implement this,” Dr. Katon said.

MIAMI BEACH — Hantavirus survivors commonly experience fatigue, shortness of breath, and myalgias up to 5 years after infection, according to the final summary of a longitudinal, prospective study.

Proteinuria, which may be clinically significant as a predictor of renal disease, is also common in hantavirus survivors, and its incidence rises over time post infection, Diane Goade, M.D., said during a presentation at the annual meeting of the American Society of Tropical Medicine and Hygiene.

Hantavirus pulmonary syndrome is an emerging infectious disease characterized by acute, severe febrile illness and a high mortality rate.

At the time of Dr. Goade's presentation, 363 cases had been identified in the United States.

Infected rodents spread the disease through their urine, feces, or saliva.

“We know very little about the long-term effects of this illness. What we found at the end of 5 years was quite striking, even though this was a young cohort who was relatively healthy,” said Dr. Goade, who is with the University of New Mexico, Albuquerque.

The study included 33 survivors of acute hantavirus infection. Researchers assessed participants annually using a wide range of clinical measures, including CBC, viral antibody assays, patient history, and self-reported fatigue and exercise capacity. “We were basically doing a major fishing expedition,” Dr. Goade explained.

The participants were 18 males and 15 females ranging in age from 10 to 54 years. There were 18 non-Hispanic whites, 5 Hispanics, 9 African Americans, and 1 Native American.

Sin Nombre virus—the most common pathogen responsible for hantavirus in the United States—accounted for the infections in 32 participants; the other patient was infected with Bayou virus.

At 5 years, mild to moderate pulmonary changes were common and affected the patients' ability to exercise. Although most pulmonary function parameters were normal, the researchers found a triad of pulmonary abnormalities: decreased small airway flow in 79% of patients, increased residual volume in 76%, and decreased oxygen diffusion capacity in 66%.

Slightly more than half (55%) reported arthralgias and problems with short-term memory; 67% reported inadvertent weight gain (between 2.5 kg and 30 kg); and 84% each reported myalgias and shortness of breath.

Fatigue and decreased exercise tolerance were each reported by 90%, “including a high school wrestling coach who used to run 5 miles a day, who can now only walk about 2 miles a day,” Dr. Goade said.

“Proteinuria is increasingly common in the convalescent period and is of concern,” Dr. Goade said.

After 5 years, 24-hour urinalysis showed that 11 of the 33 hantavirus survivors had proteinuria, which is “an astounding number in young, relatively healthy people.”

“The further out we go in this longitudinal study, the more renal effects we see,” she added.

Proteinuria typically begins about 1 year after the infection and continues to increase. Age, race, gender, and severity of initial infection were not predictive of renal consequences.

“This started out as a fishing expedition, and we were quite surprised by what we found,” Dr. Goade commented.

MIAMI BEACH — Hantavirus survivors commonly experience fatigue, shortness of breath, and myalgias up to 5 years after infection, according to the final summary of a longitudinal, prospective study.

Proteinuria, which may be clinically significant as a predictor of renal disease, is also common in hantavirus survivors, and its incidence rises over time post infection, Diane Goade, M.D., said during a presentation at the annual meeting of the American Society of Tropical Medicine and Hygiene.

Hantavirus pulmonary syndrome is an emerging infectious disease characterized by acute, severe febrile illness and a high mortality rate.

At the time of Dr. Goade's presentation, 363 cases had been identified in the United States.

Infected rodents spread the disease through their urine, feces, or saliva.

“We know very little about the long-term effects of this illness. What we found at the end of 5 years was quite striking, even though this was a young cohort who was relatively healthy,” said Dr. Goade, who is with the University of New Mexico, Albuquerque.

The study included 33 survivors of acute hantavirus infection. Researchers assessed participants annually using a wide range of clinical measures, including CBC, viral antibody assays, patient history, and self-reported fatigue and exercise capacity. “We were basically doing a major fishing expedition,” Dr. Goade explained.

The participants were 18 males and 15 females ranging in age from 10 to 54 years. There were 18 non-Hispanic whites, 5 Hispanics, 9 African Americans, and 1 Native American.

Sin Nombre virus—the most common pathogen responsible for hantavirus in the United States—accounted for the infections in 32 participants; the other patient was infected with Bayou virus.

At 5 years, mild to moderate pulmonary changes were common and affected the patients' ability to exercise. Although most pulmonary function parameters were normal, the researchers found a triad of pulmonary abnormalities: decreased small airway flow in 79% of patients, increased residual volume in 76%, and decreased oxygen diffusion capacity in 66%.

Slightly more than half (55%) reported arthralgias and problems with short-term memory; 67% reported inadvertent weight gain (between 2.5 kg and 30 kg); and 84% each reported myalgias and shortness of breath.

Fatigue and decreased exercise tolerance were each reported by 90%, “including a high school wrestling coach who used to run 5 miles a day, who can now only walk about 2 miles a day,” Dr. Goade said.

“Proteinuria is increasingly common in the convalescent period and is of concern,” Dr. Goade said.

After 5 years, 24-hour urinalysis showed that 11 of the 33 hantavirus survivors had proteinuria, which is “an astounding number in young, relatively healthy people.”

“The further out we go in this longitudinal study, the more renal effects we see,” she added.

Proteinuria typically begins about 1 year after the infection and continues to increase. Age, race, gender, and severity of initial infection were not predictive of renal consequences.

“This started out as a fishing expedition, and we were quite surprised by what we found,” Dr. Goade commented.

MIAMI BEACH — Hantavirus survivors commonly experience fatigue, shortness of breath, and myalgias up to 5 years after infection, according to the final summary of a longitudinal, prospective study.

Proteinuria, which may be clinically significant as a predictor of renal disease, is also common in hantavirus survivors, and its incidence rises over time post infection, Diane Goade, M.D., said during a presentation at the annual meeting of the American Society of Tropical Medicine and Hygiene.

Hantavirus pulmonary syndrome is an emerging infectious disease characterized by acute, severe febrile illness and a high mortality rate.

At the time of Dr. Goade's presentation, 363 cases had been identified in the United States.

Infected rodents spread the disease through their urine, feces, or saliva.

“We know very little about the long-term effects of this illness. What we found at the end of 5 years was quite striking, even though this was a young cohort who was relatively healthy,” said Dr. Goade, who is with the University of New Mexico, Albuquerque.

The study included 33 survivors of acute hantavirus infection. Researchers assessed participants annually using a wide range of clinical measures, including CBC, viral antibody assays, patient history, and self-reported fatigue and exercise capacity. “We were basically doing a major fishing expedition,” Dr. Goade explained.

The participants were 18 males and 15 females ranging in age from 10 to 54 years. There were 18 non-Hispanic whites, 5 Hispanics, 9 African Americans, and 1 Native American.

Sin Nombre virus—the most common pathogen responsible for hantavirus in the United States—accounted for the infections in 32 participants; the other patient was infected with Bayou virus.

At 5 years, mild to moderate pulmonary changes were common and affected the patients' ability to exercise. Although most pulmonary function parameters were normal, the researchers found a triad of pulmonary abnormalities: decreased small airway flow in 79% of patients, increased residual volume in 76%, and decreased oxygen diffusion capacity in 66%.

Slightly more than half (55%) reported arthralgias and problems with short-term memory; 67% reported inadvertent weight gain (between 2.5 kg and 30 kg); and 84% each reported myalgias and shortness of breath.

Fatigue and decreased exercise tolerance were each reported by 90%, “including a high school wrestling coach who used to run 5 miles a day, who can now only walk about 2 miles a day,” Dr. Goade said.

“Proteinuria is increasingly common in the convalescent period and is of concern,” Dr. Goade said.

After 5 years, 24-hour urinalysis showed that 11 of the 33 hantavirus survivors had proteinuria, which is “an astounding number in young, relatively healthy people.”

“The further out we go in this longitudinal study, the more renal effects we see,” she added.

Proteinuria typically begins about 1 year after the infection and continues to increase. Age, race, gender, and severity of initial infection were not predictive of renal consequences.

“This started out as a fishing expedition, and we were quite surprised by what we found,” Dr. Goade commented.

MIAMI BEACH — Public health officials are stepping up efforts to combat cysticercosis, a parasitic infection with dire neurologic consequences that is on the rise in the United States, according to James H. Maguire, M.D., chief of the parasitic diseases branch of the National Center for Infectious Diseases at the Centers for Disease Control and Prevention, Atlanta.

Cysticercosis is becoming increasingly recognized in U.S.-born residents, although it is still primarily a disease of immigrants from countries such as Mexico, Central America, sub-Saharan Africa, India, and East Asia, Dr. Maguire said at the annual meeting of the American Society of Tropical Medicine and Hygiene.

Cysticercosis is being reported in New Mexico, New York, and especially California, states with a large number of immigrants. However, “We saw 6-12 cases per year in Boston when I worked there—not a hotbed of immigration,” he added. Each year in the United States, there are an estimated 1,000 new cases of cysticercosis, which is a leading cause of adult-onset epilepsy in endemic areas such as Central America and Africa.

“The real message is if someone comes in with seizures and they have a single lesion on CT or MRI, it could be cysticercosis,” Dr. Maguire commented. Physicians need a high index of suspicion; an accurate diagnosis could spare a patient neurosurgery.

Cysticercosis is acquired after accidental ingestion of the eggs of the pork tapeworm Taenia solium. Infected people shed the eggs in their feces and infection can spread through contaminated food, water, or surfaces.

Once the eggs hatch in the stomach, they penetrate the intestine and travel through the bloodstream. The eggs produce characteristic cysts anywhere in the body; cysts in the brain cause neurocysticercosis and produce seizures and other neurologic sequelae, according to Dr. Maguire.

“It's a nasty infection,” Dr. Maguire said during an interview with this newspaper.

If a central nervous system cyst blocks the flow of cerebrospinal fluid, hydrocephaly can ensue. Surgery or shunt placement is indicated in some of these patients, but in most cases the cysts resolve on their own.

Other neurologic sequelae include a permanent, stroke-like syndrome. Even the scar left behind by a former cyst can become the focus for future seizures, Dr. Maguire warned.

Patients are generally treated with antiparasitic drugs in combination with anti-inflammatory agents.

Infection typically comes from eating contaminated pork, fruits, and vegetables, but T. solium is also spread through contact with infected people or fecal matter. Federal standards for the U.S. pork industry protect most Americans, Dr. Maguire said.

Larval stage infection with T. solium leads to symptomatic cysticercosis, but people with an adult tapeworm can be unknowing sources of infection.

Four cases of neurocysticercosis in New York City among Orthodox Jews—who do not eat pork—were initially puzzling to investigators. Only one had traveled to an endemic area. However, six domestic employees were tested; one was found to have had an active infection with taenia species and another had a positive serologic test.

“If a person is infected by someone with an adult tapeworm, contact tracing becomes very important,” Dr. Maguire said.

A strategy for preventing the infection is to “go after the disease at its source” in endemic areas and improve immigrant health, Dr. Maguire said.

The World Health Organization and other agencies have an active cysticercosis eradication program. As part of a strategy to eradicate the infection at its source, pigs are being vaccinated against the parasite, but adoption of the program is not yet widespread.

MIAMI BEACH — Public health officials are stepping up efforts to combat cysticercosis, a parasitic infection with dire neurologic consequences that is on the rise in the United States, according to James H. Maguire, M.D., chief of the parasitic diseases branch of the National Center for Infectious Diseases at the Centers for Disease Control and Prevention, Atlanta.

Cysticercosis is becoming increasingly recognized in U.S.-born residents, although it is still primarily a disease of immigrants from countries such as Mexico, Central America, sub-Saharan Africa, India, and East Asia, Dr. Maguire said at the annual meeting of the American Society of Tropical Medicine and Hygiene.

Cysticercosis is being reported in New Mexico, New York, and especially California, states with a large number of immigrants. However, “We saw 6-12 cases per year in Boston when I worked there—not a hotbed of immigration,” he added. Each year in the United States, there are an estimated 1,000 new cases of cysticercosis, which is a leading cause of adult-onset epilepsy in endemic areas such as Central America and Africa.

“The real message is if someone comes in with seizures and they have a single lesion on CT or MRI, it could be cysticercosis,” Dr. Maguire commented. Physicians need a high index of suspicion; an accurate diagnosis could spare a patient neurosurgery.

Cysticercosis is acquired after accidental ingestion of the eggs of the pork tapeworm Taenia solium. Infected people shed the eggs in their feces and infection can spread through contaminated food, water, or surfaces.

Once the eggs hatch in the stomach, they penetrate the intestine and travel through the bloodstream. The eggs produce characteristic cysts anywhere in the body; cysts in the brain cause neurocysticercosis and produce seizures and other neurologic sequelae, according to Dr. Maguire.

“It's a nasty infection,” Dr. Maguire said during an interview with this newspaper.

If a central nervous system cyst blocks the flow of cerebrospinal fluid, hydrocephaly can ensue. Surgery or shunt placement is indicated in some of these patients, but in most cases the cysts resolve on their own.

Other neurologic sequelae include a permanent, stroke-like syndrome. Even the scar left behind by a former cyst can become the focus for future seizures, Dr. Maguire warned.

Patients are generally treated with antiparasitic drugs in combination with anti-inflammatory agents.

Infection typically comes from eating contaminated pork, fruits, and vegetables, but T. solium is also spread through contact with infected people or fecal matter. Federal standards for the U.S. pork industry protect most Americans, Dr. Maguire said.

Larval stage infection with T. solium leads to symptomatic cysticercosis, but people with an adult tapeworm can be unknowing sources of infection.

Four cases of neurocysticercosis in New York City among Orthodox Jews—who do not eat pork—were initially puzzling to investigators. Only one had traveled to an endemic area. However, six domestic employees were tested; one was found to have had an active infection with taenia species and another had a positive serologic test.

“If a person is infected by someone with an adult tapeworm, contact tracing becomes very important,” Dr. Maguire said.

A strategy for preventing the infection is to “go after the disease at its source” in endemic areas and improve immigrant health, Dr. Maguire said.

The World Health Organization and other agencies have an active cysticercosis eradication program. As part of a strategy to eradicate the infection at its source, pigs are being vaccinated against the parasite, but adoption of the program is not yet widespread.

MIAMI BEACH — Public health officials are stepping up efforts to combat cysticercosis, a parasitic infection with dire neurologic consequences that is on the rise in the United States, according to James H. Maguire, M.D., chief of the parasitic diseases branch of the National Center for Infectious Diseases at the Centers for Disease Control and Prevention, Atlanta.

Cysticercosis is becoming increasingly recognized in U.S.-born residents, although it is still primarily a disease of immigrants from countries such as Mexico, Central America, sub-Saharan Africa, India, and East Asia, Dr. Maguire said at the annual meeting of the American Society of Tropical Medicine and Hygiene.

Cysticercosis is being reported in New Mexico, New York, and especially California, states with a large number of immigrants. However, “We saw 6-12 cases per year in Boston when I worked there—not a hotbed of immigration,” he added. Each year in the United States, there are an estimated 1,000 new cases of cysticercosis, which is a leading cause of adult-onset epilepsy in endemic areas such as Central America and Africa.

“The real message is if someone comes in with seizures and they have a single lesion on CT or MRI, it could be cysticercosis,” Dr. Maguire commented. Physicians need a high index of suspicion; an accurate diagnosis could spare a patient neurosurgery.

Cysticercosis is acquired after accidental ingestion of the eggs of the pork tapeworm Taenia solium. Infected people shed the eggs in their feces and infection can spread through contaminated food, water, or surfaces.

Once the eggs hatch in the stomach, they penetrate the intestine and travel through the bloodstream. The eggs produce characteristic cysts anywhere in the body; cysts in the brain cause neurocysticercosis and produce seizures and other neurologic sequelae, according to Dr. Maguire.

“It's a nasty infection,” Dr. Maguire said during an interview with this newspaper.

If a central nervous system cyst blocks the flow of cerebrospinal fluid, hydrocephaly can ensue. Surgery or shunt placement is indicated in some of these patients, but in most cases the cysts resolve on their own.

Other neurologic sequelae include a permanent, stroke-like syndrome. Even the scar left behind by a former cyst can become the focus for future seizures, Dr. Maguire warned.

Patients are generally treated with antiparasitic drugs in combination with anti-inflammatory agents.

Infection typically comes from eating contaminated pork, fruits, and vegetables, but T. solium is also spread through contact with infected people or fecal matter. Federal standards for the U.S. pork industry protect most Americans, Dr. Maguire said.

Larval stage infection with T. solium leads to symptomatic cysticercosis, but people with an adult tapeworm can be unknowing sources of infection.

Four cases of neurocysticercosis in New York City among Orthodox Jews—who do not eat pork—were initially puzzling to investigators. Only one had traveled to an endemic area. However, six domestic employees were tested; one was found to have had an active infection with taenia species and another had a positive serologic test.

“If a person is infected by someone with an adult tapeworm, contact tracing becomes very important,” Dr. Maguire said.

A strategy for preventing the infection is to “go after the disease at its source” in endemic areas and improve immigrant health, Dr. Maguire said.

The World Health Organization and other agencies have an active cysticercosis eradication program. As part of a strategy to eradicate the infection at its source, pigs are being vaccinated against the parasite, but adoption of the program is not yet widespread.