Doug Brunk

SAN DIEGO — A survey of STD and HIV risk among adult patients at a primary care clinic showed that 44% had never been asked about sexual health and 18% had never had a prostate or pelvic exam.

Most surveys on risk behavior have targeted higher-risk populations in STD clinics, and few have addressed risk behaviors in a primary care setting, Dr. Diana Nurutdinova, the lead author, said in an interview during a poster session at the annual meeting of the Infectious Diseases Society of America.

“In a primary care setting, there are a lot of missed opportunities for STD and HIV testing and counseling as well as assessing for risky behaviors,” said Dr. Nurutdinova of the department of medicine at the St. Louis Veterans Affairs Medical Center.

She and her associates at Washington University in St. Louis offered a self-administered survey to 718 primary care patients aged 18 and older. The survey had questions about demographics, sexual practices, risk-taking behavior, condom use, and prior history of STD/HIV testing.

The patients' mean age was 48 years, and 34% reported a past history of STD.

Dr. Nurutdinova said that 44% had never been asked about their sexual health by their primary care physicians and 18% had never had a prostate or pelvic exam. More than half (55%) reported being sexually active in the past 3 months. Of these, 24% were married, 58% reported never using a condom in the past 3 months, and 33% said they would not use a condom for their next sexual encounter.

In addition, 31% said that they had never been tested for HIV, 32% did not know their partner's HIV status, and 47% reported feeling comfortable discussing STDs with their primary care physicians.

Most participants had STD/HIV risk factors, but “a large fraction of this population reported never discussing their sexual health with a primary care provider,” the researchers wrote. “Ongoing routine assessment of behavioral risk is needed in the primary care setting.”

SAN DIEGO — A survey of STD and HIV risk among adult patients at a primary care clinic showed that 44% had never been asked about sexual health and 18% had never had a prostate or pelvic exam.

Most surveys on risk behavior have targeted higher-risk populations in STD clinics, and few have addressed risk behaviors in a primary care setting, Dr. Diana Nurutdinova, the lead author, said in an interview during a poster session at the annual meeting of the Infectious Diseases Society of America.

“In a primary care setting, there are a lot of missed opportunities for STD and HIV testing and counseling as well as assessing for risky behaviors,” said Dr. Nurutdinova of the department of medicine at the St. Louis Veterans Affairs Medical Center.

She and her associates at Washington University in St. Louis offered a self-administered survey to 718 primary care patients aged 18 and older. The survey had questions about demographics, sexual practices, risk-taking behavior, condom use, and prior history of STD/HIV testing.

The patients' mean age was 48 years, and 34% reported a past history of STD.

Dr. Nurutdinova said that 44% had never been asked about their sexual health by their primary care physicians and 18% had never had a prostate or pelvic exam. More than half (55%) reported being sexually active in the past 3 months. Of these, 24% were married, 58% reported never using a condom in the past 3 months, and 33% said they would not use a condom for their next sexual encounter.

In addition, 31% said that they had never been tested for HIV, 32% did not know their partner's HIV status, and 47% reported feeling comfortable discussing STDs with their primary care physicians.

Most participants had STD/HIV risk factors, but “a large fraction of this population reported never discussing their sexual health with a primary care provider,” the researchers wrote. “Ongoing routine assessment of behavioral risk is needed in the primary care setting.”

SAN DIEGO — A survey of STD and HIV risk among adult patients at a primary care clinic showed that 44% had never been asked about sexual health and 18% had never had a prostate or pelvic exam.

Most surveys on risk behavior have targeted higher-risk populations in STD clinics, and few have addressed risk behaviors in a primary care setting, Dr. Diana Nurutdinova, the lead author, said in an interview during a poster session at the annual meeting of the Infectious Diseases Society of America.

“In a primary care setting, there are a lot of missed opportunities for STD and HIV testing and counseling as well as assessing for risky behaviors,” said Dr. Nurutdinova of the department of medicine at the St. Louis Veterans Affairs Medical Center.

She and her associates at Washington University in St. Louis offered a self-administered survey to 718 primary care patients aged 18 and older. The survey had questions about demographics, sexual practices, risk-taking behavior, condom use, and prior history of STD/HIV testing.

The patients' mean age was 48 years, and 34% reported a past history of STD.

Dr. Nurutdinova said that 44% had never been asked about their sexual health by their primary care physicians and 18% had never had a prostate or pelvic exam. More than half (55%) reported being sexually active in the past 3 months. Of these, 24% were married, 58% reported never using a condom in the past 3 months, and 33% said they would not use a condom for their next sexual encounter.

In addition, 31% said that they had never been tested for HIV, 32% did not know their partner's HIV status, and 47% reported feeling comfortable discussing STDs with their primary care physicians.

Most participants had STD/HIV risk factors, but “a large fraction of this population reported never discussing their sexual health with a primary care provider,” the researchers wrote. “Ongoing routine assessment of behavioral risk is needed in the primary care setting.”

During his dermatology residency at Duke University, Durham, N.C., in the mid-1970s, Dr. Manny Rothstein received a plastic two-handed back scratcher in the mail as a promotional giveaway from a drug company.

He initially shrugged off the gesture and stored the gadget on a shelf but began to notice that back scratchers come in all shapes and sizes. He became so infatuated by this that he developed an itch to collect them. "It occurred to me, how many different ways can you make a long stick with a hand on the end? I was just amazed," said Dr. Rothstein, a dermatologist who practices in Fayetteville, N.C. "Every time I turned around, I found another one. It just sort of blossomed."

Today, his collection includes more than 620 back scratchers from 64 countries. He exhibits them in display cases that line the walls of his office. "My wife won't dare let me bring them home," he said. "She is really supportive of my hobby, but she jokingly said that when I die she's going to burn them. I tried to tell her that the Smithsonian is dying to have them, but she doesn't believe me."

The collection includes back scratchers made of ceramic, blown glass, jade, brass, silverware, buffalo ribs (cowboy back scratchers), corn cobs (hillbilly back scratchers), and leather. Most are mass produced but many are handmade. The largest ones were 3- to 4-feet long—too big for a display case—and were stolen from his office this summer. They were made from a plaster mold of a bear footprint and a caribou horn served as the handle.

Patients visiting his office for the first time will say things like, "Can I go in the other room and see what else you have? Can I bring my mother in from the waiting room and let her see them?" Dr. Rothstein said. "It's fun. It's unique."

USA Today selected one of the back scratchers as a winner of its "Tackiest Souvenir" contest, and Guinness World Records considers Dr. Rothstein's collection as the largest of its kind. In fact, the Guinness World Records 2001 book lists his collection in the Top Ten List of Weirdest New Records.

About once every 2 weeks Dr. Rothstein receives a new back scratcher as a gift from patients who return from vacation. "Patients don't mind getting them for me when they travel because they're inexpensive and they're light," he said.

He buys about one per month on eBay and has more than 100 duplicate back scratchers. "Since there's nobody else who collects them, I can't trade with anybody," he said. "Sometimes, I give them away. I'm thinking I could probably sell a lot of them on eBay, but I haven't had the time to take pictures of them and send them in."

The Doctor's Museum in Bailey, N.C., has offered to house his collection when Dr. Rothstein retires. But for now, the "fun of the hunt" for new back scratchers continues. "Every time I see one I don't have, I'm amazed," he said. "How many different ways can you do this?"

Connecting Through Magic

As a youngster growing up in Wilkes-Barre, Pa., Dr. Jay Ungar became hooked on magic after a friend's father pulled a nickel out from behind his ear. He then visited the local library and read every book he could find about magic. "It was so exciting to discover a whole world out there that you just couldn't explain," recalled Dr. Ungar, who is now an internist and geriatrician based in Longmeadow, Mass., and at Tufts University in Boston.

During his internship and residency at Baystate Medical Center in Springfield, Mass., Dr. Ungar rekindled his childhood interest and began taking lessons from professional magicians. "I found that medicine was so high powered and intense that when I came home from work, I needed to decompress, and magic was a wonderful way to do that," he explained.

Over the years, he discovered that magic became a unique way to bond with his patients. He adopted the alter ego of Ragnu (the OK) and began performing magic tricks for his patients at the end of their visits, such as changing dollar bills into fifties and—for smokers trying to kick their habit—transforming packs of cigarettes into packs of chewing gum. "Most adults are like kids when they watch magic," he said. "The tension that many feel when they're in the doctor's office seems to evaporate." The real magic, he added, "is not so much in the tricks, but in the connection they create."

He acknowledged that his approach is "a little risky" with new patients because he realizes that medicine is a serious business, and he would never want anyone to feel medically shortchanged. He'll perform a magic trick "when I feel the situation and timing are correct," said Dr. Ungar, author of the book "Bringing Magic to Life" (

www.bringingmagictolife.com

Current patients often come in and say, "Doc, I'm fine. Can we get to the neat stuff already?"

Dr. Ungar/Ragnu the OK often performs for charities, including the Jimmy Fund and the Children's Miracle Network, and for youngsters and seniors at local hospitals and nursing homes.

In the future, Dr. Ungar hopes to mentor more aspiring magicians and magician/physicians "in this whole conspiracy of fun," he said. He noted that magic and medicine "are meant to accomplish the same goal: making people feel better. What a bonus it is to do it in spades!"

Fascinated by Thoroughbreds

In May of 1963, when Dr. J. David Richardson was a high school senior in Morehead, Ky., a thoroughbred horse named Never Bend, which his uncle had trained, came within a head's length of winning the Kentucky Derby.

"He was a great horse and became a great stallion later," recalled Dr. Richardson, who is now vice chair of the department of surgery at the University of Louisville (Ky.). "I thought, 'this is pretty nifty stuff.'"

During his residency in San Antonio, Tex., he tried his best to arrange vacation time and medical rotations around race meets at Keeneland in Lexington or Churchill Downs in Louisville. "I remember I did a pathology rotation one year in October so I thought I'd have some free time to go to the Keeneland meet," he said. "I'd get my work done in the morning, so I could go to the races in the afternoon."

Gambling wasn't the primary aspect of thoroughbred racing that attracted him but rather being around the horses, watching them grow and develop, and learning about their behavior from people like his uncle, the late trainer Woody Stephens. Mr. Stephens was elected to the National Museum of Racing and Hall of Fame in 1976 and trained five straight Belmont Stakes winners in the early 1980s.

"Horses come in all stripes, like people," Dr. Richardson said. "Some are smart, some are dumb, and some are more talented than others but—by and large—they're honest animals."

Dr. Richardson's experience as a horse owner and breeder began in the late 1970s, when he joined the surgery faculty at the University of Louisville. He formed a business partnership with senior surgeon Dr. Hiram C. Polk that stands to this day. A filly they bred named Mrs. Revere won 13 races between 1984 and 1986.

"She was one of the best two or three fillies in the country," said Dr. Richardson, who is a general and thoracic surgeon. "I think she won about 10 stakes races and over $500,000. If she won the same races today she'd probably make $2 million. She still holds the record for stakes wins at Churchill Downs."

Today he owns about 30 thoroughbreds that are boarded at commercial farms: seven in partnership with Dr. Polk, five on his own, and the rest with other partners. "The business plan is to try to sell colts and keep some well-bred fillies for brood mares," he said. "It's got to pay for itself, so we try to sell enough horses to do that."

He considers the breeding side of the business "fascinating, to plan matings and see how they go," he said. "I enjoy picking up physical characteristics that you think are going to match, and looking at the stallions. You pick the matings, you name the horses, you watch them grow, you sell them, and you root for the people who bought them."

He acknowledged that owning and breeding thoroughbreds is high-risk business and likened it to surgery.

"There's risk and reward to it, and you have to try to figure that out," Dr. Richardson said. "If you're a surgeon, you realize that you can do the best job possible and sometimes you don't get the outcome that you wanted. That's sure true in horse racing. You have to be patient and lucky at times, frankly."

Dr. Rothstein's office shelves are home to his collection of back scratchers.

Over several decades, dermatologist Manny Rothstein has collected more than 620 back scratchers from 64 different countries. Photos courtesy Dr. Manny Rothstein

During his dermatology residency at Duke University, Durham, N.C., in the mid-1970s, Dr. Manny Rothstein received a plastic two-handed back scratcher in the mail as a promotional giveaway from a drug company.

He initially shrugged off the gesture and stored the gadget on a shelf but began to notice that back scratchers come in all shapes and sizes. He became so infatuated by this that he developed an itch to collect them. "It occurred to me, how many different ways can you make a long stick with a hand on the end? I was just amazed," said Dr. Rothstein, a dermatologist who practices in Fayetteville, N.C. "Every time I turned around, I found another one. It just sort of blossomed."

Today, his collection includes more than 620 back scratchers from 64 countries. He exhibits them in display cases that line the walls of his office. "My wife won't dare let me bring them home," he said. "She is really supportive of my hobby, but she jokingly said that when I die she's going to burn them. I tried to tell her that the Smithsonian is dying to have them, but she doesn't believe me."

The collection includes back scratchers made of ceramic, blown glass, jade, brass, silverware, buffalo ribs (cowboy back scratchers), corn cobs (hillbilly back scratchers), and leather. Most are mass produced but many are handmade. The largest ones were 3- to 4-feet long—too big for a display case—and were stolen from his office this summer. They were made from a plaster mold of a bear footprint and a caribou horn served as the handle.

Patients visiting his office for the first time will say things like, "Can I go in the other room and see what else you have? Can I bring my mother in from the waiting room and let her see them?" Dr. Rothstein said. "It's fun. It's unique."

USA Today selected one of the back scratchers as a winner of its "Tackiest Souvenir" contest, and Guinness World Records considers Dr. Rothstein's collection as the largest of its kind. In fact, the Guinness World Records 2001 book lists his collection in the Top Ten List of Weirdest New Records.

About once every 2 weeks Dr. Rothstein receives a new back scratcher as a gift from patients who return from vacation. "Patients don't mind getting them for me when they travel because they're inexpensive and they're light," he said.

He buys about one per month on eBay and has more than 100 duplicate back scratchers. "Since there's nobody else who collects them, I can't trade with anybody," he said. "Sometimes, I give them away. I'm thinking I could probably sell a lot of them on eBay, but I haven't had the time to take pictures of them and send them in."

The Doctor's Museum in Bailey, N.C., has offered to house his collection when Dr. Rothstein retires. But for now, the "fun of the hunt" for new back scratchers continues. "Every time I see one I don't have, I'm amazed," he said. "How many different ways can you do this?"

Connecting Through Magic

As a youngster growing up in Wilkes-Barre, Pa., Dr. Jay Ungar became hooked on magic after a friend's father pulled a nickel out from behind his ear. He then visited the local library and read every book he could find about magic. "It was so exciting to discover a whole world out there that you just couldn't explain," recalled Dr. Ungar, who is now an internist and geriatrician based in Longmeadow, Mass., and at Tufts University in Boston.

During his internship and residency at Baystate Medical Center in Springfield, Mass., Dr. Ungar rekindled his childhood interest and began taking lessons from professional magicians. "I found that medicine was so high powered and intense that when I came home from work, I needed to decompress, and magic was a wonderful way to do that," he explained.

Over the years, he discovered that magic became a unique way to bond with his patients. He adopted the alter ego of Ragnu (the OK) and began performing magic tricks for his patients at the end of their visits, such as changing dollar bills into fifties and—for smokers trying to kick their habit—transforming packs of cigarettes into packs of chewing gum. "Most adults are like kids when they watch magic," he said. "The tension that many feel when they're in the doctor's office seems to evaporate." The real magic, he added, "is not so much in the tricks, but in the connection they create."

He acknowledged that his approach is "a little risky" with new patients because he realizes that medicine is a serious business, and he would never want anyone to feel medically shortchanged. He'll perform a magic trick "when I feel the situation and timing are correct," said Dr. Ungar, author of the book "Bringing Magic to Life" (

www.bringingmagictolife.com

Current patients often come in and say, "Doc, I'm fine. Can we get to the neat stuff already?"

Dr. Ungar/Ragnu the OK often performs for charities, including the Jimmy Fund and the Children's Miracle Network, and for youngsters and seniors at local hospitals and nursing homes.

In the future, Dr. Ungar hopes to mentor more aspiring magicians and magician/physicians "in this whole conspiracy of fun," he said. He noted that magic and medicine "are meant to accomplish the same goal: making people feel better. What a bonus it is to do it in spades!"

Fascinated by Thoroughbreds

In May of 1963, when Dr. J. David Richardson was a high school senior in Morehead, Ky., a thoroughbred horse named Never Bend, which his uncle had trained, came within a head's length of winning the Kentucky Derby.

"He was a great horse and became a great stallion later," recalled Dr. Richardson, who is now vice chair of the department of surgery at the University of Louisville (Ky.). "I thought, 'this is pretty nifty stuff.'"

During his residency in San Antonio, Tex., he tried his best to arrange vacation time and medical rotations around race meets at Keeneland in Lexington or Churchill Downs in Louisville. "I remember I did a pathology rotation one year in October so I thought I'd have some free time to go to the Keeneland meet," he said. "I'd get my work done in the morning, so I could go to the races in the afternoon."

Gambling wasn't the primary aspect of thoroughbred racing that attracted him but rather being around the horses, watching them grow and develop, and learning about their behavior from people like his uncle, the late trainer Woody Stephens. Mr. Stephens was elected to the National Museum of Racing and Hall of Fame in 1976 and trained five straight Belmont Stakes winners in the early 1980s.

"Horses come in all stripes, like people," Dr. Richardson said. "Some are smart, some are dumb, and some are more talented than others but—by and large—they're honest animals."

Dr. Richardson's experience as a horse owner and breeder began in the late 1970s, when he joined the surgery faculty at the University of Louisville. He formed a business partnership with senior surgeon Dr. Hiram C. Polk that stands to this day. A filly they bred named Mrs. Revere won 13 races between 1984 and 1986.

"She was one of the best two or three fillies in the country," said Dr. Richardson, who is a general and thoracic surgeon. "I think she won about 10 stakes races and over $500,000. If she won the same races today she'd probably make $2 million. She still holds the record for stakes wins at Churchill Downs."

Today he owns about 30 thoroughbreds that are boarded at commercial farms: seven in partnership with Dr. Polk, five on his own, and the rest with other partners. "The business plan is to try to sell colts and keep some well-bred fillies for brood mares," he said. "It's got to pay for itself, so we try to sell enough horses to do that."

He considers the breeding side of the business "fascinating, to plan matings and see how they go," he said. "I enjoy picking up physical characteristics that you think are going to match, and looking at the stallions. You pick the matings, you name the horses, you watch them grow, you sell them, and you root for the people who bought them."

He acknowledged that owning and breeding thoroughbreds is high-risk business and likened it to surgery.

"There's risk and reward to it, and you have to try to figure that out," Dr. Richardson said. "If you're a surgeon, you realize that you can do the best job possible and sometimes you don't get the outcome that you wanted. That's sure true in horse racing. You have to be patient and lucky at times, frankly."

Dr. Rothstein's office shelves are home to his collection of back scratchers.

Over several decades, dermatologist Manny Rothstein has collected more than 620 back scratchers from 64 different countries. Photos courtesy Dr. Manny Rothstein

During his dermatology residency at Duke University, Durham, N.C., in the mid-1970s, Dr. Manny Rothstein received a plastic two-handed back scratcher in the mail as a promotional giveaway from a drug company.

He initially shrugged off the gesture and stored the gadget on a shelf but began to notice that back scratchers come in all shapes and sizes. He became so infatuated by this that he developed an itch to collect them. "It occurred to me, how many different ways can you make a long stick with a hand on the end? I was just amazed," said Dr. Rothstein, a dermatologist who practices in Fayetteville, N.C. "Every time I turned around, I found another one. It just sort of blossomed."

Today, his collection includes more than 620 back scratchers from 64 countries. He exhibits them in display cases that line the walls of his office. "My wife won't dare let me bring them home," he said. "She is really supportive of my hobby, but she jokingly said that when I die she's going to burn them. I tried to tell her that the Smithsonian is dying to have them, but she doesn't believe me."

The collection includes back scratchers made of ceramic, blown glass, jade, brass, silverware, buffalo ribs (cowboy back scratchers), corn cobs (hillbilly back scratchers), and leather. Most are mass produced but many are handmade. The largest ones were 3- to 4-feet long—too big for a display case—and were stolen from his office this summer. They were made from a plaster mold of a bear footprint and a caribou horn served as the handle.

Patients visiting his office for the first time will say things like, "Can I go in the other room and see what else you have? Can I bring my mother in from the waiting room and let her see them?" Dr. Rothstein said. "It's fun. It's unique."

USA Today selected one of the back scratchers as a winner of its "Tackiest Souvenir" contest, and Guinness World Records considers Dr. Rothstein's collection as the largest of its kind. In fact, the Guinness World Records 2001 book lists his collection in the Top Ten List of Weirdest New Records.

About once every 2 weeks Dr. Rothstein receives a new back scratcher as a gift from patients who return from vacation. "Patients don't mind getting them for me when they travel because they're inexpensive and they're light," he said.

He buys about one per month on eBay and has more than 100 duplicate back scratchers. "Since there's nobody else who collects them, I can't trade with anybody," he said. "Sometimes, I give them away. I'm thinking I could probably sell a lot of them on eBay, but I haven't had the time to take pictures of them and send them in."

The Doctor's Museum in Bailey, N.C., has offered to house his collection when Dr. Rothstein retires. But for now, the "fun of the hunt" for new back scratchers continues. "Every time I see one I don't have, I'm amazed," he said. "How many different ways can you do this?"

Connecting Through Magic

As a youngster growing up in Wilkes-Barre, Pa., Dr. Jay Ungar became hooked on magic after a friend's father pulled a nickel out from behind his ear. He then visited the local library and read every book he could find about magic. "It was so exciting to discover a whole world out there that you just couldn't explain," recalled Dr. Ungar, who is now an internist and geriatrician based in Longmeadow, Mass., and at Tufts University in Boston.

During his internship and residency at Baystate Medical Center in Springfield, Mass., Dr. Ungar rekindled his childhood interest and began taking lessons from professional magicians. "I found that medicine was so high powered and intense that when I came home from work, I needed to decompress, and magic was a wonderful way to do that," he explained.

Over the years, he discovered that magic became a unique way to bond with his patients. He adopted the alter ego of Ragnu (the OK) and began performing magic tricks for his patients at the end of their visits, such as changing dollar bills into fifties and—for smokers trying to kick their habit—transforming packs of cigarettes into packs of chewing gum. "Most adults are like kids when they watch magic," he said. "The tension that many feel when they're in the doctor's office seems to evaporate." The real magic, he added, "is not so much in the tricks, but in the connection they create."

He acknowledged that his approach is "a little risky" with new patients because he realizes that medicine is a serious business, and he would never want anyone to feel medically shortchanged. He'll perform a magic trick "when I feel the situation and timing are correct," said Dr. Ungar, author of the book "Bringing Magic to Life" (

www.bringingmagictolife.com

Current patients often come in and say, "Doc, I'm fine. Can we get to the neat stuff already?"

Dr. Ungar/Ragnu the OK often performs for charities, including the Jimmy Fund and the Children's Miracle Network, and for youngsters and seniors at local hospitals and nursing homes.

In the future, Dr. Ungar hopes to mentor more aspiring magicians and magician/physicians "in this whole conspiracy of fun," he said. He noted that magic and medicine "are meant to accomplish the same goal: making people feel better. What a bonus it is to do it in spades!"

Fascinated by Thoroughbreds

In May of 1963, when Dr. J. David Richardson was a high school senior in Morehead, Ky., a thoroughbred horse named Never Bend, which his uncle had trained, came within a head's length of winning the Kentucky Derby.

"He was a great horse and became a great stallion later," recalled Dr. Richardson, who is now vice chair of the department of surgery at the University of Louisville (Ky.). "I thought, 'this is pretty nifty stuff.'"

During his residency in San Antonio, Tex., he tried his best to arrange vacation time and medical rotations around race meets at Keeneland in Lexington or Churchill Downs in Louisville. "I remember I did a pathology rotation one year in October so I thought I'd have some free time to go to the Keeneland meet," he said. "I'd get my work done in the morning, so I could go to the races in the afternoon."

Gambling wasn't the primary aspect of thoroughbred racing that attracted him but rather being around the horses, watching them grow and develop, and learning about their behavior from people like his uncle, the late trainer Woody Stephens. Mr. Stephens was elected to the National Museum of Racing and Hall of Fame in 1976 and trained five straight Belmont Stakes winners in the early 1980s.

"Horses come in all stripes, like people," Dr. Richardson said. "Some are smart, some are dumb, and some are more talented than others but—by and large—they're honest animals."

Dr. Richardson's experience as a horse owner and breeder began in the late 1970s, when he joined the surgery faculty at the University of Louisville. He formed a business partnership with senior surgeon Dr. Hiram C. Polk that stands to this day. A filly they bred named Mrs. Revere won 13 races between 1984 and 1986.

"She was one of the best two or three fillies in the country," said Dr. Richardson, who is a general and thoracic surgeon. "I think she won about 10 stakes races and over $500,000. If she won the same races today she'd probably make $2 million. She still holds the record for stakes wins at Churchill Downs."

Today he owns about 30 thoroughbreds that are boarded at commercial farms: seven in partnership with Dr. Polk, five on his own, and the rest with other partners. "The business plan is to try to sell colts and keep some well-bred fillies for brood mares," he said. "It's got to pay for itself, so we try to sell enough horses to do that."

He considers the breeding side of the business "fascinating, to plan matings and see how they go," he said. "I enjoy picking up physical characteristics that you think are going to match, and looking at the stallions. You pick the matings, you name the horses, you watch them grow, you sell them, and you root for the people who bought them."

He acknowledged that owning and breeding thoroughbreds is high-risk business and likened it to surgery.

"There's risk and reward to it, and you have to try to figure that out," Dr. Richardson said. "If you're a surgeon, you realize that you can do the best job possible and sometimes you don't get the outcome that you wanted. That's sure true in horse racing. You have to be patient and lucky at times, frankly."

Dr. Rothstein's office shelves are home to his collection of back scratchers.

Over several decades, dermatologist Manny Rothstein has collected more than 620 back scratchers from 64 different countries. Photos courtesy Dr. Manny Rothstein

SAN DIEGO — Cervical cancer screening in STD clinics is feasible and highly effective, according to results from a 2-year single clinic study.

"From previous studies we know that women who attend STD clinics are at greater risk for having abnormal cervical cytology, but screening is often perceived as a barrier, that clinics are very busy, and there are other conflicting interests that bring the patient there," Dr. Susan S. Philip said in an interview during a poster session at the annual meeting of the Infectious Diseases Society of America. "I'd like to argue that it's feasible and it's a good idea to screen women who come to STD clinics for cervical cancer Pap testing."

Between 2004 and 2006 she and her associates offered Pap testing to 10,275 females with a mean age of 27 years who visited San Francisco's public STD clinic and who reported having no Pap test in the previous year. The researchers compared the rates of screening by clinicians trained in family planning versus those who lacked such training. They also analyzed certain demographic characteristics of the study population and defined abnormal Pap results as atypical squamous cell of undetermined significance (ASCUS), low-grade squamous intraepithelial lesion (LGSIL), or high-grade squamous intraepithelial lesion (HGSIL).

Of the 10,275 visits by females for STD testing, 2,158 (21%) included Pap testing, reported Dr. Philip of the STD prevention and control services at the San Francisco Department of Public Health. "That number seems low, but some of those women may have presented with other urgent STD-related needs, so testing was deferred," she explained.

Of clinicians trained in family planning, 25% offered Pap tests to the women, compared with 18% of clinicians who were not, a difference that was statistically significant. "Perhaps we need to see about additional training for those clinicians who are not historically trained in family planning to increase their comfort with the Pap test," Dr. Philip said.

Only 11 of the 2,158 Pap specimens (0.51%) were unsatisfactory by laboratory standards. "We feared that the rate of unsatisfactory specimens would be higher in our STD clinic, maybe because we weren't all trained in family planning or because other conditions were going on at the cervix of the woman in terms of chlamydia or gonorrhea," Dr. Philip said. But "we showed it's possible to get a good sample from these women."

Of the 2,147 satisfactory Pap specimens, 1,944 (90.5%) were normal and 203 (9.5%) were abnormal. Of the abnormal specimens, 124 (61%) were reported as ASCUS, 68 (33.5%) reported as LGSIL, and 11 (5%) reported as HGSIL. Overall, 21.2% of Asian/Pacific Islanders, 16.3% of African Americans, 15.8% of Hispanics, and 1.5% of whites had abnormal Pap results.

Dr. Philip acknowledged certain limitations of the study, including its observational design and the fact that 73% of patients who visit the clinic are men.

"Data from our clinic might not be generalizable to other STD clinic populations, but we encourage people to integrate cervical cancer screening in their own clinic," she said.

ELSEVIER GLOBAL MEDICAL NEWS

SAN DIEGO — Cervical cancer screening in STD clinics is feasible and highly effective, according to results from a 2-year single clinic study.

"From previous studies we know that women who attend STD clinics are at greater risk for having abnormal cervical cytology, but screening is often perceived as a barrier, that clinics are very busy, and there are other conflicting interests that bring the patient there," Dr. Susan S. Philip said in an interview during a poster session at the annual meeting of the Infectious Diseases Society of America. "I'd like to argue that it's feasible and it's a good idea to screen women who come to STD clinics for cervical cancer Pap testing."

Between 2004 and 2006 she and her associates offered Pap testing to 10,275 females with a mean age of 27 years who visited San Francisco's public STD clinic and who reported having no Pap test in the previous year. The researchers compared the rates of screening by clinicians trained in family planning versus those who lacked such training. They also analyzed certain demographic characteristics of the study population and defined abnormal Pap results as atypical squamous cell of undetermined significance (ASCUS), low-grade squamous intraepithelial lesion (LGSIL), or high-grade squamous intraepithelial lesion (HGSIL).

Of the 10,275 visits by females for STD testing, 2,158 (21%) included Pap testing, reported Dr. Philip of the STD prevention and control services at the San Francisco Department of Public Health. "That number seems low, but some of those women may have presented with other urgent STD-related needs, so testing was deferred," she explained.

Of clinicians trained in family planning, 25% offered Pap tests to the women, compared with 18% of clinicians who were not, a difference that was statistically significant. "Perhaps we need to see about additional training for those clinicians who are not historically trained in family planning to increase their comfort with the Pap test," Dr. Philip said.

Only 11 of the 2,158 Pap specimens (0.51%) were unsatisfactory by laboratory standards. "We feared that the rate of unsatisfactory specimens would be higher in our STD clinic, maybe because we weren't all trained in family planning or because other conditions were going on at the cervix of the woman in terms of chlamydia or gonorrhea," Dr. Philip said. But "we showed it's possible to get a good sample from these women."

Of the 2,147 satisfactory Pap specimens, 1,944 (90.5%) were normal and 203 (9.5%) were abnormal. Of the abnormal specimens, 124 (61%) were reported as ASCUS, 68 (33.5%) reported as LGSIL, and 11 (5%) reported as HGSIL. Overall, 21.2% of Asian/Pacific Islanders, 16.3% of African Americans, 15.8% of Hispanics, and 1.5% of whites had abnormal Pap results.

Dr. Philip acknowledged certain limitations of the study, including its observational design and the fact that 73% of patients who visit the clinic are men.

"Data from our clinic might not be generalizable to other STD clinic populations, but we encourage people to integrate cervical cancer screening in their own clinic," she said.

ELSEVIER GLOBAL MEDICAL NEWS

SAN DIEGO — Cervical cancer screening in STD clinics is feasible and highly effective, according to results from a 2-year single clinic study.

"From previous studies we know that women who attend STD clinics are at greater risk for having abnormal cervical cytology, but screening is often perceived as a barrier, that clinics are very busy, and there are other conflicting interests that bring the patient there," Dr. Susan S. Philip said in an interview during a poster session at the annual meeting of the Infectious Diseases Society of America. "I'd like to argue that it's feasible and it's a good idea to screen women who come to STD clinics for cervical cancer Pap testing."

Between 2004 and 2006 she and her associates offered Pap testing to 10,275 females with a mean age of 27 years who visited San Francisco's public STD clinic and who reported having no Pap test in the previous year. The researchers compared the rates of screening by clinicians trained in family planning versus those who lacked such training. They also analyzed certain demographic characteristics of the study population and defined abnormal Pap results as atypical squamous cell of undetermined significance (ASCUS), low-grade squamous intraepithelial lesion (LGSIL), or high-grade squamous intraepithelial lesion (HGSIL).

Of the 10,275 visits by females for STD testing, 2,158 (21%) included Pap testing, reported Dr. Philip of the STD prevention and control services at the San Francisco Department of Public Health. "That number seems low, but some of those women may have presented with other urgent STD-related needs, so testing was deferred," she explained.

Of clinicians trained in family planning, 25% offered Pap tests to the women, compared with 18% of clinicians who were not, a difference that was statistically significant. "Perhaps we need to see about additional training for those clinicians who are not historically trained in family planning to increase their comfort with the Pap test," Dr. Philip said.

Only 11 of the 2,158 Pap specimens (0.51%) were unsatisfactory by laboratory standards. "We feared that the rate of unsatisfactory specimens would be higher in our STD clinic, maybe because we weren't all trained in family planning or because other conditions were going on at the cervix of the woman in terms of chlamydia or gonorrhea," Dr. Philip said. But "we showed it's possible to get a good sample from these women."

Of the 2,147 satisfactory Pap specimens, 1,944 (90.5%) were normal and 203 (9.5%) were abnormal. Of the abnormal specimens, 124 (61%) were reported as ASCUS, 68 (33.5%) reported as LGSIL, and 11 (5%) reported as HGSIL. Overall, 21.2% of Asian/Pacific Islanders, 16.3% of African Americans, 15.8% of Hispanics, and 1.5% of whites had abnormal Pap results.

Dr. Philip acknowledged certain limitations of the study, including its observational design and the fact that 73% of patients who visit the clinic are men.

"Data from our clinic might not be generalizable to other STD clinic populations, but we encourage people to integrate cervical cancer screening in their own clinic," she said.

ELSEVIER GLOBAL MEDICAL NEWS

SAN DIEGO — Cases of Rocky Mountain spotted fever increased nearly threefold between 2001 and 2005, John Openshaw reported at the annual meeting of the Infectious Diseases Society of America.

The rising number of suburban homes that encroach on rural areas is one possible reason for the spike in reported cases.

"Increased physician awareness and increased surveillance efforts are [also] involved," Mr. Openshaw said during a press briefing. "The true explanation is likely a combination of many factors."

Rocky Mountain spotted fever is caused by the Rickettsia rickettsii bacteria, which are typically spread through tick bites. Early signs include acute onset of fever and other flulike symptoms followed by rash.

"The biggest problem is that people don't often remember being bitten by a tick, and by the time the classic rash appears, the disease has already progressed significantly, and it may be too late," Dr. David Swerdlow, previous team leader for the rickettsial zoonoses branch of the Centers for Disease Control and Prevention, said in a prepared statement.

Researchers analyzed data from the National Electronic Telecommunications System for Surveillance and found that during 2001-2005, there were 6,598 cases of Rocky Mountain spotted fever reported in 45 states, said Mr. Openshaw, a medical student at the University of Pennsylvania, Philadelphia, who worked on the study during a CDC Applied Epidemiology Fellowship in 2006. The disease resulted in death in 22 people (0.3%).

The number of cases in the United States increased nearly threefold over the period, from 695 cases in 2001 to 1,936 cases in 2005. The incidence was higher in suburban areas than rural ones, and the largest increase was in the southern Atlantic states.

Despite the increase in cases, the rates of hospitalization fell from 29% in 2001 to 18% in 2005, while the rates of complications from the disease fell from 8% to 4%. Immunocompromised patients were most likely to be hospitalized with the disease (41%), followed by adults over the age of 70 (40%) and children under the age of 5 (35%).

Mr. Openshaw also reported that 53 counties in the United States had a fivefold increase in the incidence of Rocky Mountain spotted fever. About half of the 1,079 counties reporting disease were newly affected during the study period.

The disease was reported in every state, except Alaska, California, Hawaii, Maine, and Washington.

SAN DIEGO — Cases of Rocky Mountain spotted fever increased nearly threefold between 2001 and 2005, John Openshaw reported at the annual meeting of the Infectious Diseases Society of America.

The rising number of suburban homes that encroach on rural areas is one possible reason for the spike in reported cases.

"Increased physician awareness and increased surveillance efforts are [also] involved," Mr. Openshaw said during a press briefing. "The true explanation is likely a combination of many factors."

Rocky Mountain spotted fever is caused by the Rickettsia rickettsii bacteria, which are typically spread through tick bites. Early signs include acute onset of fever and other flulike symptoms followed by rash.

"The biggest problem is that people don't often remember being bitten by a tick, and by the time the classic rash appears, the disease has already progressed significantly, and it may be too late," Dr. David Swerdlow, previous team leader for the rickettsial zoonoses branch of the Centers for Disease Control and Prevention, said in a prepared statement.

Researchers analyzed data from the National Electronic Telecommunications System for Surveillance and found that during 2001-2005, there were 6,598 cases of Rocky Mountain spotted fever reported in 45 states, said Mr. Openshaw, a medical student at the University of Pennsylvania, Philadelphia, who worked on the study during a CDC Applied Epidemiology Fellowship in 2006. The disease resulted in death in 22 people (0.3%).

The number of cases in the United States increased nearly threefold over the period, from 695 cases in 2001 to 1,936 cases in 2005. The incidence was higher in suburban areas than rural ones, and the largest increase was in the southern Atlantic states.

Despite the increase in cases, the rates of hospitalization fell from 29% in 2001 to 18% in 2005, while the rates of complications from the disease fell from 8% to 4%. Immunocompromised patients were most likely to be hospitalized with the disease (41%), followed by adults over the age of 70 (40%) and children under the age of 5 (35%).

Mr. Openshaw also reported that 53 counties in the United States had a fivefold increase in the incidence of Rocky Mountain spotted fever. About half of the 1,079 counties reporting disease were newly affected during the study period.

The disease was reported in every state, except Alaska, California, Hawaii, Maine, and Washington.

SAN DIEGO — Cases of Rocky Mountain spotted fever increased nearly threefold between 2001 and 2005, John Openshaw reported at the annual meeting of the Infectious Diseases Society of America.

The rising number of suburban homes that encroach on rural areas is one possible reason for the spike in reported cases.

"Increased physician awareness and increased surveillance efforts are [also] involved," Mr. Openshaw said during a press briefing. "The true explanation is likely a combination of many factors."

Rocky Mountain spotted fever is caused by the Rickettsia rickettsii bacteria, which are typically spread through tick bites. Early signs include acute onset of fever and other flulike symptoms followed by rash.

"The biggest problem is that people don't often remember being bitten by a tick, and by the time the classic rash appears, the disease has already progressed significantly, and it may be too late," Dr. David Swerdlow, previous team leader for the rickettsial zoonoses branch of the Centers for Disease Control and Prevention, said in a prepared statement.

Researchers analyzed data from the National Electronic Telecommunications System for Surveillance and found that during 2001-2005, there were 6,598 cases of Rocky Mountain spotted fever reported in 45 states, said Mr. Openshaw, a medical student at the University of Pennsylvania, Philadelphia, who worked on the study during a CDC Applied Epidemiology Fellowship in 2006. The disease resulted in death in 22 people (0.3%).

The number of cases in the United States increased nearly threefold over the period, from 695 cases in 2001 to 1,936 cases in 2005. The incidence was higher in suburban areas than rural ones, and the largest increase was in the southern Atlantic states.

Despite the increase in cases, the rates of hospitalization fell from 29% in 2001 to 18% in 2005, while the rates of complications from the disease fell from 8% to 4%. Immunocompromised patients were most likely to be hospitalized with the disease (41%), followed by adults over the age of 70 (40%) and children under the age of 5 (35%).

Mr. Openshaw also reported that 53 counties in the United States had a fivefold increase in the incidence of Rocky Mountain spotted fever. About half of the 1,079 counties reporting disease were newly affected during the study period.

The disease was reported in every state, except Alaska, California, Hawaii, Maine, and Washington.

CORONADO, CALIF. — Some day patients may reach for Lipitor or Celebrex as a melanoma prevention agent, Dr. Michael E. Ming speculated at the annual meeting of the Pacific Dermatologic Association.

He described the ideal chemopreventive agent for melanoma as one that is effective, has an acceptable toxicity profile, and is already widely available.

One class of agents that could potentially meet those criteria if effectiveness in humans can be demonstrated is statins, which may prevent melanoma by decreasing production of intermediate products such as farnesyl pyrophosphate and geranylgeranyl pyrophosphate in the pathway from 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) to cholesterol.

"These intermediate products may activate proteins important in cell growth and cell cycle progression, so decreased production of these products may lead to decreased activity of mutant forms of those proteins," said Dr. Ming, director of the pigmented lesion clinic at the University of Pennsylvania, Philadelphia.

Supportive evidence comes from several laboratory studies on melanoma cell lines and in mice, and from one clinical trial with melanoma as a secondary outcome (JAMA 1998;279:1615-22), and from a Dutch case-control study of statins and cancer in general (J. Clin. Oncol. 2004;22:2388-94). Other studies, however, have not shown a link between melanoma and statins, including meta-analyses and systematic reviews (JAMA 2006;295:74-80 and Cochrane Database Syst. Rev. 2005:CD003697), and it is difficult to say at this time whether statins are effective preventive agents against melanoma.

Nonsteroidal anti-inflammatory drugs (NSAIDs) represent another class of agents that may protect against melanoma, most likely through inhibition of cyclooxygenase-2 (COX-2), which in turn reduces prostaglandin production, Dr. Ming said.

Supportive evidence comes from a few laboratory studies on melanoma cell lines, including one case-control study in women (Oncol. Rep. 2001;8:655-7) and one case-control study in patients who already had melanoma (Dermatol. Surg. 2005;31:748-52). So far, though, the body of literature on this topic is too small and inadequate to state definitively that there is a link between NSAID use and lower rates of melanoma. In addition, some studies fail to show that COX-2 is expressed in all melanomas (Melanoma Res. 2001;11:587-99).

Other available agents that might help prevent melanoma include vitamins A, C, D, and E, but the current evidence in the medical literature is unclear, and it is difficult to draw meaningful conclusions, said Dr. Ming, who had no relevant conflicts of interest to disclose.

He emphasized that no candidate agent has been definitively established as having chemopreventive properties against melanoma. "Are there agents we can use against melanoma?" he asked. "The answer you have to say right now is not yet, but maybe soon."

'These intermediate products may activate proteins important in cell growth and cell cycle progression.' DR. MING

CORONADO, CALIF. — Some day patients may reach for Lipitor or Celebrex as a melanoma prevention agent, Dr. Michael E. Ming speculated at the annual meeting of the Pacific Dermatologic Association.

He described the ideal chemopreventive agent for melanoma as one that is effective, has an acceptable toxicity profile, and is already widely available.

One class of agents that could potentially meet those criteria if effectiveness in humans can be demonstrated is statins, which may prevent melanoma by decreasing production of intermediate products such as farnesyl pyrophosphate and geranylgeranyl pyrophosphate in the pathway from 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) to cholesterol.

"These intermediate products may activate proteins important in cell growth and cell cycle progression, so decreased production of these products may lead to decreased activity of mutant forms of those proteins," said Dr. Ming, director of the pigmented lesion clinic at the University of Pennsylvania, Philadelphia.

Supportive evidence comes from several laboratory studies on melanoma cell lines and in mice, and from one clinical trial with melanoma as a secondary outcome (JAMA 1998;279:1615-22), and from a Dutch case-control study of statins and cancer in general (J. Clin. Oncol. 2004;22:2388-94). Other studies, however, have not shown a link between melanoma and statins, including meta-analyses and systematic reviews (JAMA 2006;295:74-80 and Cochrane Database Syst. Rev. 2005:CD003697), and it is difficult to say at this time whether statins are effective preventive agents against melanoma.

Nonsteroidal anti-inflammatory drugs (NSAIDs) represent another class of agents that may protect against melanoma, most likely through inhibition of cyclooxygenase-2 (COX-2), which in turn reduces prostaglandin production, Dr. Ming said.

Supportive evidence comes from a few laboratory studies on melanoma cell lines, including one case-control study in women (Oncol. Rep. 2001;8:655-7) and one case-control study in patients who already had melanoma (Dermatol. Surg. 2005;31:748-52). So far, though, the body of literature on this topic is too small and inadequate to state definitively that there is a link between NSAID use and lower rates of melanoma. In addition, some studies fail to show that COX-2 is expressed in all melanomas (Melanoma Res. 2001;11:587-99).

Other available agents that might help prevent melanoma include vitamins A, C, D, and E, but the current evidence in the medical literature is unclear, and it is difficult to draw meaningful conclusions, said Dr. Ming, who had no relevant conflicts of interest to disclose.

He emphasized that no candidate agent has been definitively established as having chemopreventive properties against melanoma. "Are there agents we can use against melanoma?" he asked. "The answer you have to say right now is not yet, but maybe soon."

'These intermediate products may activate proteins important in cell growth and cell cycle progression.' DR. MING

CORONADO, CALIF. — Some day patients may reach for Lipitor or Celebrex as a melanoma prevention agent, Dr. Michael E. Ming speculated at the annual meeting of the Pacific Dermatologic Association.

He described the ideal chemopreventive agent for melanoma as one that is effective, has an acceptable toxicity profile, and is already widely available.

One class of agents that could potentially meet those criteria if effectiveness in humans can be demonstrated is statins, which may prevent melanoma by decreasing production of intermediate products such as farnesyl pyrophosphate and geranylgeranyl pyrophosphate in the pathway from 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) to cholesterol.

"These intermediate products may activate proteins important in cell growth and cell cycle progression, so decreased production of these products may lead to decreased activity of mutant forms of those proteins," said Dr. Ming, director of the pigmented lesion clinic at the University of Pennsylvania, Philadelphia.

Supportive evidence comes from several laboratory studies on melanoma cell lines and in mice, and from one clinical trial with melanoma as a secondary outcome (JAMA 1998;279:1615-22), and from a Dutch case-control study of statins and cancer in general (J. Clin. Oncol. 2004;22:2388-94). Other studies, however, have not shown a link between melanoma and statins, including meta-analyses and systematic reviews (JAMA 2006;295:74-80 and Cochrane Database Syst. Rev. 2005:CD003697), and it is difficult to say at this time whether statins are effective preventive agents against melanoma.

Nonsteroidal anti-inflammatory drugs (NSAIDs) represent another class of agents that may protect against melanoma, most likely through inhibition of cyclooxygenase-2 (COX-2), which in turn reduces prostaglandin production, Dr. Ming said.

Supportive evidence comes from a few laboratory studies on melanoma cell lines, including one case-control study in women (Oncol. Rep. 2001;8:655-7) and one case-control study in patients who already had melanoma (Dermatol. Surg. 2005;31:748-52). So far, though, the body of literature on this topic is too small and inadequate to state definitively that there is a link between NSAID use and lower rates of melanoma. In addition, some studies fail to show that COX-2 is expressed in all melanomas (Melanoma Res. 2001;11:587-99).

Other available agents that might help prevent melanoma include vitamins A, C, D, and E, but the current evidence in the medical literature is unclear, and it is difficult to draw meaningful conclusions, said Dr. Ming, who had no relevant conflicts of interest to disclose.

He emphasized that no candidate agent has been definitively established as having chemopreventive properties against melanoma. "Are there agents we can use against melanoma?" he asked. "The answer you have to say right now is not yet, but maybe soon."

'These intermediate products may activate proteins important in cell growth and cell cycle progression.' DR. MING

SAN DIEGO — In the winter of 2006 and the spring of 2007, adenovirus 14 caused a community outbreak of respiratory disease in Oregon, with a fatality rate of 19%, Dr. Paul Lewis said at the annual meeting of the Infectious Diseases Society of America.

“This seemed to come out of nowhere,” Dr. Lewis, a public health physician with the state of Oregon and a pediatric infectious disease physician with Oregon Health and Science University, Portland, said of the outbreak. “In patients with serious respiratory illness without an identified etiology, clinicians should think about viruses.”

The cluster was first identified in the spring of 2007 by his associate, Dr. David Gilbert, who was making rounds in the intensive care unit at Providence Portland Medical Center and thought it was odd that 4 of 13 patients had adenovirus infections, which are typically mild and self-limited.

“We called other hospitals in the Portland area, [and] we almost fell out of our chairs because they all had seen recent severe and fatal cases of adenovirus,” Dr. Lewis said.

The researchers studied 45 cases of adenovirus that were detected in Oregon medical laboratories between November 2006 and April 2007. The adenovirus isolates were typed by hexon gene sequencing or by a novel adenovirus 14-specific real-time polymerase chain reaction assay.

More than 75% of all adenovirus cases were in male patients. Of the 45 cases, 31 (69%) were adenovirus 14, a serotype first identified in 1953 but seen infrequently and never in outbreaks since that time.

Patients infected with adenovirus 14 were significantly older than patients infected with other adenovirus isolates (a mean of 59 years vs. 1 year, respectively). They also had significantly higher rates of hospitalization (71% vs. 14%, respectively).

Clinical features of patients with adenovirus 14 included fever (84%), tachypnea (77%), hypoxia (48%), and hypotension (43%). Of the 24 chest x-rays obtained, 21 (88%) had abnormal findings. Lobar consolidation was the most common pattern.

Dr. Lewis noted that 22 (71%) of the adenovirus 14 patients required hospitalization, and 6 (19%) died. Of the hospitalized patients, 16 (73%) required ICU care, 13 (59%) mechanical ventilation, and 8 (36%) blood pressure support with vasopressors.

“Infection control was a great concern,” he said. “Many patients were isolated with [severe acute respiratory syndrome]-like precaution. There was a health care worker at an ICU taking care of one of these patients who was subsequently admitted to that ICU with adenovirus 14. That's our only known possible case of transmission, but we cannot be sure it was not acquired in the community.” Treatment included “lots of empiric antibiotics.” Cidofovir was used in six patients, two of whom died.

Dr. Lewis said there are 51 known adenovirus serotypes. Types 1, 2, and 5 are nearly universal in children, whereas types 3, 4, and 7 are common in adults. No adenovirus vaccine is available in the United States. Previous vaccines developed for the military do not cover adenovirus 14.

Lobar consolidation is shown in a patient on day one of hospitalization.

The same patient is shown above at day four of hospitalization. Photos courtesy Dr. Paul Lewis

SAN DIEGO — In the winter of 2006 and the spring of 2007, adenovirus 14 caused a community outbreak of respiratory disease in Oregon, with a fatality rate of 19%, Dr. Paul Lewis said at the annual meeting of the Infectious Diseases Society of America.

“This seemed to come out of nowhere,” Dr. Lewis, a public health physician with the state of Oregon and a pediatric infectious disease physician with Oregon Health and Science University, Portland, said of the outbreak. “In patients with serious respiratory illness without an identified etiology, clinicians should think about viruses.”

The cluster was first identified in the spring of 2007 by his associate, Dr. David Gilbert, who was making rounds in the intensive care unit at Providence Portland Medical Center and thought it was odd that 4 of 13 patients had adenovirus infections, which are typically mild and self-limited.

“We called other hospitals in the Portland area, [and] we almost fell out of our chairs because they all had seen recent severe and fatal cases of adenovirus,” Dr. Lewis said.

The researchers studied 45 cases of adenovirus that were detected in Oregon medical laboratories between November 2006 and April 2007. The adenovirus isolates were typed by hexon gene sequencing or by a novel adenovirus 14-specific real-time polymerase chain reaction assay.

More than 75% of all adenovirus cases were in male patients. Of the 45 cases, 31 (69%) were adenovirus 14, a serotype first identified in 1953 but seen infrequently and never in outbreaks since that time.

Patients infected with adenovirus 14 were significantly older than patients infected with other adenovirus isolates (a mean of 59 years vs. 1 year, respectively). They also had significantly higher rates of hospitalization (71% vs. 14%, respectively).

Clinical features of patients with adenovirus 14 included fever (84%), tachypnea (77%), hypoxia (48%), and hypotension (43%). Of the 24 chest x-rays obtained, 21 (88%) had abnormal findings. Lobar consolidation was the most common pattern.

Dr. Lewis noted that 22 (71%) of the adenovirus 14 patients required hospitalization, and 6 (19%) died. Of the hospitalized patients, 16 (73%) required ICU care, 13 (59%) mechanical ventilation, and 8 (36%) blood pressure support with vasopressors.

“Infection control was a great concern,” he said. “Many patients were isolated with [severe acute respiratory syndrome]-like precaution. There was a health care worker at an ICU taking care of one of these patients who was subsequently admitted to that ICU with adenovirus 14. That's our only known possible case of transmission, but we cannot be sure it was not acquired in the community.” Treatment included “lots of empiric antibiotics.” Cidofovir was used in six patients, two of whom died.

Dr. Lewis said there are 51 known adenovirus serotypes. Types 1, 2, and 5 are nearly universal in children, whereas types 3, 4, and 7 are common in adults. No adenovirus vaccine is available in the United States. Previous vaccines developed for the military do not cover adenovirus 14.

Lobar consolidation is shown in a patient on day one of hospitalization.

The same patient is shown above at day four of hospitalization. Photos courtesy Dr. Paul Lewis

SAN DIEGO — In the winter of 2006 and the spring of 2007, adenovirus 14 caused a community outbreak of respiratory disease in Oregon, with a fatality rate of 19%, Dr. Paul Lewis said at the annual meeting of the Infectious Diseases Society of America.

“This seemed to come out of nowhere,” Dr. Lewis, a public health physician with the state of Oregon and a pediatric infectious disease physician with Oregon Health and Science University, Portland, said of the outbreak. “In patients with serious respiratory illness without an identified etiology, clinicians should think about viruses.”

The cluster was first identified in the spring of 2007 by his associate, Dr. David Gilbert, who was making rounds in the intensive care unit at Providence Portland Medical Center and thought it was odd that 4 of 13 patients had adenovirus infections, which are typically mild and self-limited.

“We called other hospitals in the Portland area, [and] we almost fell out of our chairs because they all had seen recent severe and fatal cases of adenovirus,” Dr. Lewis said.

The researchers studied 45 cases of adenovirus that were detected in Oregon medical laboratories between November 2006 and April 2007. The adenovirus isolates were typed by hexon gene sequencing or by a novel adenovirus 14-specific real-time polymerase chain reaction assay.

More than 75% of all adenovirus cases were in male patients. Of the 45 cases, 31 (69%) were adenovirus 14, a serotype first identified in 1953 but seen infrequently and never in outbreaks since that time.

Patients infected with adenovirus 14 were significantly older than patients infected with other adenovirus isolates (a mean of 59 years vs. 1 year, respectively). They also had significantly higher rates of hospitalization (71% vs. 14%, respectively).

Clinical features of patients with adenovirus 14 included fever (84%), tachypnea (77%), hypoxia (48%), and hypotension (43%). Of the 24 chest x-rays obtained, 21 (88%) had abnormal findings. Lobar consolidation was the most common pattern.

Dr. Lewis noted that 22 (71%) of the adenovirus 14 patients required hospitalization, and 6 (19%) died. Of the hospitalized patients, 16 (73%) required ICU care, 13 (59%) mechanical ventilation, and 8 (36%) blood pressure support with vasopressors.

“Infection control was a great concern,” he said. “Many patients were isolated with [severe acute respiratory syndrome]-like precaution. There was a health care worker at an ICU taking care of one of these patients who was subsequently admitted to that ICU with adenovirus 14. That's our only known possible case of transmission, but we cannot be sure it was not acquired in the community.” Treatment included “lots of empiric antibiotics.” Cidofovir was used in six patients, two of whom died.

Dr. Lewis said there are 51 known adenovirus serotypes. Types 1, 2, and 5 are nearly universal in children, whereas types 3, 4, and 7 are common in adults. No adenovirus vaccine is available in the United States. Previous vaccines developed for the military do not cover adenovirus 14.

Lobar consolidation is shown in a patient on day one of hospitalization.

The same patient is shown above at day four of hospitalization. Photos courtesy Dr. Paul Lewis

SAN DIEGO — In pregnancy, maternal hepatitis C virus infection may have a negative impact on both maternal and neonatal health, results from a population-based study in Washington State demonstrated.

“Further prospective studies are needed, but I think this brings up the question of whether screening needs to be reevaluated in pregnant women,” Dr. Steven Pergam said at the annual meeting of the Infectious Diseases Society of America.

“Current recommendations by the American College of Obstetricians and Gynecologists and the Centers for Disease Control and Prevention have recommended screening high-risk patients. This is based mainly on the risk of perinatal transmission. Universal screening has been modeled in a number of studies and it has not been felt to be cost effective,” Dr. Pergam added.

He and his colleagues used Washington State singleton birth records and Comprehensive Hospital Abstract Reporting System data from 2003–2005 to identify hepatitis C virus (HCV) infection in mothers. “HCV information was added to the Washington State birth database in 2003, providing us a great opportunity to look at some of these outcomes,” said Dr. Pergam, a fellow in infectious diseases at the University of Washington, Seattle.

The researchers matched HCV-positive mothers in a ratio of 1:4 with HCV-negative mothers who were randomly selected from the same data set and evaluated maternal and neonatal outcomes associated with HCV.

Of the 240,131 singleton births studied, 506 were born to HCV-positive mothers with a mean age of 30 years and were matched with 2,022 born to HCV-negative mothers with a mean age of 28 years.

HCV-positive mothers who had excess weight gain during pregnancy, according to Institute of Medicine Guidelines, were 2.5 times more likely than their HCV-negative counterparts to develop gestational diabetes.

Compared with infants born to HCV-negative mothers, infants born to HCV-positive mothers were 2.2 times more likely to have low birth weight, 1.5 times more likely to be small for gestational age, 2.8 times more likely to require neonatal intensive care unit admission, and 2.4 times more likely to require assisted ventilation.

A subanalysis of infants born to 124 drug-using HCV-positive mothers revealed that the adverse outcomes of low birth weight, and being small for gestational age fall out as associated adverse outcomes. “It's not surprising that drug use would be a driving factor in these issues,” he said.

'I think this brings up the question of whether screening needs to be reevaluated in pregnant women.' DR. PERGAM

SAN DIEGO — In pregnancy, maternal hepatitis C virus infection may have a negative impact on both maternal and neonatal health, results from a population-based study in Washington State demonstrated.

“Further prospective studies are needed, but I think this brings up the question of whether screening needs to be reevaluated in pregnant women,” Dr. Steven Pergam said at the annual meeting of the Infectious Diseases Society of America.

“Current recommendations by the American College of Obstetricians and Gynecologists and the Centers for Disease Control and Prevention have recommended screening high-risk patients. This is based mainly on the risk of perinatal transmission. Universal screening has been modeled in a number of studies and it has not been felt to be cost effective,” Dr. Pergam added.

He and his colleagues used Washington State singleton birth records and Comprehensive Hospital Abstract Reporting System data from 2003–2005 to identify hepatitis C virus (HCV) infection in mothers. “HCV information was added to the Washington State birth database in 2003, providing us a great opportunity to look at some of these outcomes,” said Dr. Pergam, a fellow in infectious diseases at the University of Washington, Seattle.

The researchers matched HCV-positive mothers in a ratio of 1:4 with HCV-negative mothers who were randomly selected from the same data set and evaluated maternal and neonatal outcomes associated with HCV.

Of the 240,131 singleton births studied, 506 were born to HCV-positive mothers with a mean age of 30 years and were matched with 2,022 born to HCV-negative mothers with a mean age of 28 years.

HCV-positive mothers who had excess weight gain during pregnancy, according to Institute of Medicine Guidelines, were 2.5 times more likely than their HCV-negative counterparts to develop gestational diabetes.

Compared with infants born to HCV-negative mothers, infants born to HCV-positive mothers were 2.2 times more likely to have low birth weight, 1.5 times more likely to be small for gestational age, 2.8 times more likely to require neonatal intensive care unit admission, and 2.4 times more likely to require assisted ventilation.

A subanalysis of infants born to 124 drug-using HCV-positive mothers revealed that the adverse outcomes of low birth weight, and being small for gestational age fall out as associated adverse outcomes. “It's not surprising that drug use would be a driving factor in these issues,” he said.

'I think this brings up the question of whether screening needs to be reevaluated in pregnant women.' DR. PERGAM

SAN DIEGO — In pregnancy, maternal hepatitis C virus infection may have a negative impact on both maternal and neonatal health, results from a population-based study in Washington State demonstrated.

“Further prospective studies are needed, but I think this brings up the question of whether screening needs to be reevaluated in pregnant women,” Dr. Steven Pergam said at the annual meeting of the Infectious Diseases Society of America.

“Current recommendations by the American College of Obstetricians and Gynecologists and the Centers for Disease Control and Prevention have recommended screening high-risk patients. This is based mainly on the risk of perinatal transmission. Universal screening has been modeled in a number of studies and it has not been felt to be cost effective,” Dr. Pergam added.

He and his colleagues used Washington State singleton birth records and Comprehensive Hospital Abstract Reporting System data from 2003–2005 to identify hepatitis C virus (HCV) infection in mothers. “HCV information was added to the Washington State birth database in 2003, providing us a great opportunity to look at some of these outcomes,” said Dr. Pergam, a fellow in infectious diseases at the University of Washington, Seattle.

The researchers matched HCV-positive mothers in a ratio of 1:4 with HCV-negative mothers who were randomly selected from the same data set and evaluated maternal and neonatal outcomes associated with HCV.

Of the 240,131 singleton births studied, 506 were born to HCV-positive mothers with a mean age of 30 years and were matched with 2,022 born to HCV-negative mothers with a mean age of 28 years.

HCV-positive mothers who had excess weight gain during pregnancy, according to Institute of Medicine Guidelines, were 2.5 times more likely than their HCV-negative counterparts to develop gestational diabetes.

Compared with infants born to HCV-negative mothers, infants born to HCV-positive mothers were 2.2 times more likely to have low birth weight, 1.5 times more likely to be small for gestational age, 2.8 times more likely to require neonatal intensive care unit admission, and 2.4 times more likely to require assisted ventilation.

A subanalysis of infants born to 124 drug-using HCV-positive mothers revealed that the adverse outcomes of low birth weight, and being small for gestational age fall out as associated adverse outcomes. “It's not surprising that drug use would be a driving factor in these issues,” he said.

'I think this brings up the question of whether screening needs to be reevaluated in pregnant women.' DR. PERGAM

SAN DIEGO – The RNS System, an investigational device that delivers responsive stimulation to the brain of patients with uncontrolled seizures, shows promise in clinical trials, but the technical learning curve is steep, Dr. Ryder Gwinn said at the annual meeting of the Congress of Neurological Surgeons.

“Programming experience is growing but it's still not where we need to be,” said Dr. Gwinn, director of surgical epilepsy at the Swedish Neuroscience Institute, Seattle. “I am very frequently changing parameters in order to reach seizure freedom. However, I believe that the system will become much easier to use as a result of the clinical trials currently underway.”

Dr. Ryder disclosed he is a steering committee member for the devices' maker, NeuroPace Inc., but has not received consulting fees outside of the study budget. He has no personal financial interest in the company.

The RNS System is a fully implanted, microprocessor-controlled device that uses up to nine contacts for stimulation. About the size of an iPod, it detects electrographic patterns from intracranial electrodes and delivers up to five separate programmable therapies. It stores up to 32 minutes of electrocorticogram data that can be downloaded to a laptop at any time.

Benefits of the device include focal treatment that leaves functional neuronal circuits intact, Dr. Gwinn said. In addition, a decision to treat “can be made without significant concern for functional consequences, and it doesn't preclude later alternative treatments.”

Concerns about the use of such technology include the fact that localization of focus could be critical to success. “Early seizure detection is important for contingent stimulation, and potentially abnormal tissue or aberrantly organized circuits would be left intact,” he noted.

In a recent feasibility study, Dr. Gwinn and his associates at 11 centers used the RNS System in 65 patients aged 18–65 years who had simple or complex partial seizures.

Patients were eligible for the trial if they had failed treatment with a minimum of two antiepileptic drugs; had a minimum of four seizures per month for 3 months; and had an established region of epileptiform activity. The primary end points were safety and preliminary evidence of efficacy. Response was defined as seizure reduction by more than 50%.

Of the 65 patients implanted with the RNS System, 50 received stimulation, one patient had a device that was never turned on, and 14 patients were in a sham-stimulation group (therapy off).

After a mean 847 days of follow-up, the researchers observed a responder rate of 32% in patients with complex partial seizures, 63% in patients with generalized tonic-clonic seizures, and 26% in those with total, disabling seizures (simple partial motor seizures, complex partial seizures, and generalized tonic-clonic seizures combined).

As of June 5, 2007, there were 15 serious adverse events, including one case of focal status epilepticus, one case of erosion from the leads, and one case of tissue infection, all of which resolved. Other adverse events included one case each of increase in seizure severity, confusion, sensitivity to visual stimuli, and sudden unexplained death in epilepsy (SUDEP). None of these adverse events were thought to be definitively related to the use of the device.

The researchers concluded contingent stimulation appears to benefit patients with uncontrolled seizures. “More stimulation seems to be better, but early stimulation is often not enough to have an impact,” Dr. Gwinn said. “No parameters so far can reliably eradicate seizures altogether.”

Dr. Gwinn and his associates at 28 centers are currently enrolling patients aged 18–70 years in a similar but larger pivotal study. The recruitment goal is 240 patients.

For now, the therapy appears to be safe. “Stimulation has been applied to all lobes, including the medial temporal lobe,” he said.

The iPod-sized RNS System implanted in a patient's cranium is seen on x-ray. Courtesy Dr. Ryder Gwinn

SAN DIEGO – The RNS System, an investigational device that delivers responsive stimulation to the brain of patients with uncontrolled seizures, shows promise in clinical trials, but the technical learning curve is steep, Dr. Ryder Gwinn said at the annual meeting of the Congress of Neurological Surgeons.

“Programming experience is growing but it's still not where we need to be,” said Dr. Gwinn, director of surgical epilepsy at the Swedish Neuroscience Institute, Seattle. “I am very frequently changing parameters in order to reach seizure freedom. However, I believe that the system will become much easier to use as a result of the clinical trials currently underway.”

Dr. Ryder disclosed he is a steering committee member for the devices' maker, NeuroPace Inc., but has not received consulting fees outside of the study budget. He has no personal financial interest in the company.

The RNS System is a fully implanted, microprocessor-controlled device that uses up to nine contacts for stimulation. About the size of an iPod, it detects electrographic patterns from intracranial electrodes and delivers up to five separate programmable therapies. It stores up to 32 minutes of electrocorticogram data that can be downloaded to a laptop at any time.

Benefits of the device include focal treatment that leaves functional neuronal circuits intact, Dr. Gwinn said. In addition, a decision to treat “can be made without significant concern for functional consequences, and it doesn't preclude later alternative treatments.”

Concerns about the use of such technology include the fact that localization of focus could be critical to success. “Early seizure detection is important for contingent stimulation, and potentially abnormal tissue or aberrantly organized circuits would be left intact,” he noted.

In a recent feasibility study, Dr. Gwinn and his associates at 11 centers used the RNS System in 65 patients aged 18–65 years who had simple or complex partial seizures.

Patients were eligible for the trial if they had failed treatment with a minimum of two antiepileptic drugs; had a minimum of four seizures per month for 3 months; and had an established region of epileptiform activity. The primary end points were safety and preliminary evidence of efficacy. Response was defined as seizure reduction by more than 50%.

Of the 65 patients implanted with the RNS System, 50 received stimulation, one patient had a device that was never turned on, and 14 patients were in a sham-stimulation group (therapy off).

After a mean 847 days of follow-up, the researchers observed a responder rate of 32% in patients with complex partial seizures, 63% in patients with generalized tonic-clonic seizures, and 26% in those with total, disabling seizures (simple partial motor seizures, complex partial seizures, and generalized tonic-clonic seizures combined).

As of June 5, 2007, there were 15 serious adverse events, including one case of focal status epilepticus, one case of erosion from the leads, and one case of tissue infection, all of which resolved. Other adverse events included one case each of increase in seizure severity, confusion, sensitivity to visual stimuli, and sudden unexplained death in epilepsy (SUDEP). None of these adverse events were thought to be definitively related to the use of the device.

The researchers concluded contingent stimulation appears to benefit patients with uncontrolled seizures. “More stimulation seems to be better, but early stimulation is often not enough to have an impact,” Dr. Gwinn said. “No parameters so far can reliably eradicate seizures altogether.”

Dr. Gwinn and his associates at 28 centers are currently enrolling patients aged 18–70 years in a similar but larger pivotal study. The recruitment goal is 240 patients.

For now, the therapy appears to be safe. “Stimulation has been applied to all lobes, including the medial temporal lobe,” he said.

The iPod-sized RNS System implanted in a patient's cranium is seen on x-ray. Courtesy Dr. Ryder Gwinn

SAN DIEGO – The RNS System, an investigational device that delivers responsive stimulation to the brain of patients with uncontrolled seizures, shows promise in clinical trials, but the technical learning curve is steep, Dr. Ryder Gwinn said at the annual meeting of the Congress of Neurological Surgeons.

“Programming experience is growing but it's still not where we need to be,” said Dr. Gwinn, director of surgical epilepsy at the Swedish Neuroscience Institute, Seattle. “I am very frequently changing parameters in order to reach seizure freedom. However, I believe that the system will become much easier to use as a result of the clinical trials currently underway.”

Dr. Ryder disclosed he is a steering committee member for the devices' maker, NeuroPace Inc., but has not received consulting fees outside of the study budget. He has no personal financial interest in the company.

The RNS System is a fully implanted, microprocessor-controlled device that uses up to nine contacts for stimulation. About the size of an iPod, it detects electrographic patterns from intracranial electrodes and delivers up to five separate programmable therapies. It stores up to 32 minutes of electrocorticogram data that can be downloaded to a laptop at any time.

Benefits of the device include focal treatment that leaves functional neuronal circuits intact, Dr. Gwinn said. In addition, a decision to treat “can be made without significant concern for functional consequences, and it doesn't preclude later alternative treatments.”

Concerns about the use of such technology include the fact that localization of focus could be critical to success. “Early seizure detection is important for contingent stimulation, and potentially abnormal tissue or aberrantly organized circuits would be left intact,” he noted.

In a recent feasibility study, Dr. Gwinn and his associates at 11 centers used the RNS System in 65 patients aged 18–65 years who had simple or complex partial seizures.

Patients were eligible for the trial if they had failed treatment with a minimum of two antiepileptic drugs; had a minimum of four seizures per month for 3 months; and had an established region of epileptiform activity. The primary end points were safety and preliminary evidence of efficacy. Response was defined as seizure reduction by more than 50%.

Of the 65 patients implanted with the RNS System, 50 received stimulation, one patient had a device that was never turned on, and 14 patients were in a sham-stimulation group (therapy off).

After a mean 847 days of follow-up, the researchers observed a responder rate of 32% in patients with complex partial seizures, 63% in patients with generalized tonic-clonic seizures, and 26% in those with total, disabling seizures (simple partial motor seizures, complex partial seizures, and generalized tonic-clonic seizures combined).

As of June 5, 2007, there were 15 serious adverse events, including one case of focal status epilepticus, one case of erosion from the leads, and one case of tissue infection, all of which resolved. Other adverse events included one case each of increase in seizure severity, confusion, sensitivity to visual stimuli, and sudden unexplained death in epilepsy (SUDEP). None of these adverse events were thought to be definitively related to the use of the device.

The researchers concluded contingent stimulation appears to benefit patients with uncontrolled seizures. “More stimulation seems to be better, but early stimulation is often not enough to have an impact,” Dr. Gwinn said. “No parameters so far can reliably eradicate seizures altogether.”

Dr. Gwinn and his associates at 28 centers are currently enrolling patients aged 18–70 years in a similar but larger pivotal study. The recruitment goal is 240 patients.

For now, the therapy appears to be safe. “Stimulation has been applied to all lobes, including the medial temporal lobe,” he said.

The iPod-sized RNS System implanted in a patient's cranium is seen on x-ray. Courtesy Dr. Ryder Gwinn

SAN DIEGO — The way Dr. Raymond J. Gibbons sees it, the best way to practice appropriate single-photon emission computed tomography myocardial perfusion imaging is to apply the appropriateness criteria established by the American College of Cardiology Foundation and the American Society of Nuclear Cardiology.

These criteria grade clinical scenarios with respect to whether they are appropriate or inappropriate uses of SPECT myocardial perfusion imaging (J. Am. Coll. Cardiol. 2005;46:1587–605). When Dr. Gibbons and his associates at the Mayo Clinic Nuclear Cardiology Laboratory in Rochester, Minn., applied the criteria to several hundred patients in their nuclear cardiology laboratory, they discovered that 64% of the SPECT myocardial perfusion imaging studies they did were appropriate, 11% could not be classified, 11% were of uncertain appropriateness, and about 14% were inappropriate.

“We need to reduce this number of inappropriate tests,” Dr. Gibbons said at the annual meeting of the American Society of Nuclear Cardiology. “I would urge all of you to do this same study in your own laboratory. The goal should be to educate ordering physicians to reduce this segment of the pie.”

In Dr. Gibbon's study, four inappropriate indications for SPECT myocardial perfusion imaging accounted for almost all of the inappropriate studies. These included studies in asymptomatic low-risk patients; preoperative studies in patients who were undergoing intermediate-risk surgery and had good exercise capacity; studies in symptomatic patients with a low pretest likelihood of coronary artery disease, an interpretable ECG; and who are able to exercise, and studies conducted as preoperative testing in patients undergoing low-risk surgery.

“Together, these four indications accounted for 88% of the inappropriate studies,” said Dr. Gibbons, who is a codirector of Mayo's Nuclear Cardiology Laboratory. “We have initiated a program to try to educate our physicians and nurses to reduce these inappropriate studies.”

Dr. Gibbons, a former president of the American Heart Association, expressed concern about the future of health care and imaging in the United States. In the summer of 2007 the House of Representatives passed State Children's Health Insurance Program and Medicare reform legislation that eliminated a 9.9% decrease in physician payment in 2008 and a 5% decrease in 2009. That's the good news. The bad news is that in 2010 the sustainable growth rate formula will be replaced with a new system with six separate targets, one of which is imaging.

“Growth in those targets will be limited to the growth in gross domestic product,” Dr. Gibbons said. “Given the interest in CT and MR, and the dramatic growth in cardiac imaging, this will have a draconian effect if it goes into law.”

'We have initiated a program to try to educate our physicians and nurses to reduce these inappropriate studies.' DR. GIBBONS

SAN DIEGO — The way Dr. Raymond J. Gibbons sees it, the best way to practice appropriate single-photon emission computed tomography myocardial perfusion imaging is to apply the appropriateness criteria established by the American College of Cardiology Foundation and the American Society of Nuclear Cardiology.

These criteria grade clinical scenarios with respect to whether they are appropriate or inappropriate uses of SPECT myocardial perfusion imaging (J. Am. Coll. Cardiol. 2005;46:1587–605). When Dr. Gibbons and his associates at the Mayo Clinic Nuclear Cardiology Laboratory in Rochester, Minn., applied the criteria to several hundred patients in their nuclear cardiology laboratory, they discovered that 64% of the SPECT myocardial perfusion imaging studies they did were appropriate, 11% could not be classified, 11% were of uncertain appropriateness, and about 14% were inappropriate.

“We need to reduce this number of inappropriate tests,” Dr. Gibbons said at the annual meeting of the American Society of Nuclear Cardiology. “I would urge all of you to do this same study in your own laboratory. The goal should be to educate ordering physicians to reduce this segment of the pie.”

In Dr. Gibbon's study, four inappropriate indications for SPECT myocardial perfusion imaging accounted for almost all of the inappropriate studies. These included studies in asymptomatic low-risk patients; preoperative studies in patients who were undergoing intermediate-risk surgery and had good exercise capacity; studies in symptomatic patients with a low pretest likelihood of coronary artery disease, an interpretable ECG; and who are able to exercise, and studies conducted as preoperative testing in patients undergoing low-risk surgery.

“Together, these four indications accounted for 88% of the inappropriate studies,” said Dr. Gibbons, who is a codirector of Mayo's Nuclear Cardiology Laboratory. “We have initiated a program to try to educate our physicians and nurses to reduce these inappropriate studies.”

Dr. Gibbons, a former president of the American Heart Association, expressed concern about the future of health care and imaging in the United States. In the summer of 2007 the House of Representatives passed State Children's Health Insurance Program and Medicare reform legislation that eliminated a 9.9% decrease in physician payment in 2008 and a 5% decrease in 2009. That's the good news. The bad news is that in 2010 the sustainable growth rate formula will be replaced with a new system with six separate targets, one of which is imaging.

“Growth in those targets will be limited to the growth in gross domestic product,” Dr. Gibbons said. “Given the interest in CT and MR, and the dramatic growth in cardiac imaging, this will have a draconian effect if it goes into law.”

'We have initiated a program to try to educate our physicians and nurses to reduce these inappropriate studies.' DR. GIBBONS

SAN DIEGO — The way Dr. Raymond J. Gibbons sees it, the best way to practice appropriate single-photon emission computed tomography myocardial perfusion imaging is to apply the appropriateness criteria established by the American College of Cardiology Foundation and the American Society of Nuclear Cardiology.

These criteria grade clinical scenarios with respect to whether they are appropriate or inappropriate uses of SPECT myocardial perfusion imaging (J. Am. Coll. Cardiol. 2005;46:1587–605). When Dr. Gibbons and his associates at the Mayo Clinic Nuclear Cardiology Laboratory in Rochester, Minn., applied the criteria to several hundred patients in their nuclear cardiology laboratory, they discovered that 64% of the SPECT myocardial perfusion imaging studies they did were appropriate, 11% could not be classified, 11% were of uncertain appropriateness, and about 14% were inappropriate.

“We need to reduce this number of inappropriate tests,” Dr. Gibbons said at the annual meeting of the American Society of Nuclear Cardiology. “I would urge all of you to do this same study in your own laboratory. The goal should be to educate ordering physicians to reduce this segment of the pie.”

In Dr. Gibbon's study, four inappropriate indications for SPECT myocardial perfusion imaging accounted for almost all of the inappropriate studies. These included studies in asymptomatic low-risk patients; preoperative studies in patients who were undergoing intermediate-risk surgery and had good exercise capacity; studies in symptomatic patients with a low pretest likelihood of coronary artery disease, an interpretable ECG; and who are able to exercise, and studies conducted as preoperative testing in patients undergoing low-risk surgery.

“Together, these four indications accounted for 88% of the inappropriate studies,” said Dr. Gibbons, who is a codirector of Mayo's Nuclear Cardiology Laboratory. “We have initiated a program to try to educate our physicians and nurses to reduce these inappropriate studies.”

Dr. Gibbons, a former president of the American Heart Association, expressed concern about the future of health care and imaging in the United States. In the summer of 2007 the House of Representatives passed State Children's Health Insurance Program and Medicare reform legislation that eliminated a 9.9% decrease in physician payment in 2008 and a 5% decrease in 2009. That's the good news. The bad news is that in 2010 the sustainable growth rate formula will be replaced with a new system with six separate targets, one of which is imaging.

“Growth in those targets will be limited to the growth in gross domestic product,” Dr. Gibbons said. “Given the interest in CT and MR, and the dramatic growth in cardiac imaging, this will have a draconian effect if it goes into law.”

'We have initiated a program to try to educate our physicians and nurses to reduce these inappropriate studies.' DR. GIBBONS

SAN DIEGO — Respiratory syncytial virus was the most common virus detected in young children with bronchiolitis, but nearly 40% were infected with other viruses, results from a single-center study showed.

“The results suggest that further study is warranted to learn more about the potential impact of viral pathogens associated with bronchiolitis,” Hilary Stempel said at the annual meeting of the Infectious Diseases Society of America.

Ms. Stempel, a clinical research associate in infectious diseases with Children's Hospital and Regional Medical Center, Seattle, said that she and her associates undertook the study because guidelines from the American Academy of Pediatrics recommend that the diagnosis of bronchiolitis should be made on the basis of history and physical, and that clinicians should not routinely order laboratory tests for the diagnosis (Pediatrics 2006;118:1774-93).

The rationale for this position, according to the guidelines, is that “the knowledge gained from such testing rarely alters management decisions or outcomes for the vast majority of children with clinically diagnosed bronchiolitis.”

However, the guidelines do state that “virologic testing may be useful when cohorting of patients is feasible.”

That particular statement interested the researchers at the hospital, where “patient cohorting is still a necessity,” Ms. Stempel said. “So we decided to explore the implications of viral testing for children with bronchiolitis.”

Researchers collected residual nasal wash specimens from 189 children aged 0-3 years who were evaluated for bronchiolitis from October 2003 through April 2004. All specimens were evaluated with quantitative real time polymerase chain reaction testing and fluorescent antibody assay.

The median age of the 189 children was 7 months, 54% were male, and 26% had an underlying disease such as asthma or a cardiac condition.

Most samples (72%) were acquired from the general pediatric ward, while 21% were acquired from the emergency department, and 7% from the intensive care unit.

Ms. Stempel reported that a total of 220 respiratory viral pathogens were detected in 177 of the 189 children (94%). The majority of the 220 viruses were RSV (145), followed by adenovirus (28), human metapneumovirus (hMPV) (20), coronavirus (14), parainfluenza (12) and influenza (1).

Forty-three samples contained two or more viruses. Of these, 35 (81%) involved RSV. Other coinfections included hMPV and parainfluenza (4 samples), hMPV and adenovirus (3 samples) and parainfluenza and adenovirus (1 sample).

Limitations of the study include its retrospective design and the fact that rhinovirus assay was not performed. Also, “the study ended in April 2004 and did not extend through the entire parainfluenza season,” Ms. Stempel said. “This may have lowered the number of parainfluenza infections that we detected.”

Ms. Stempel disclosed that one of the study coauthors, Dr. Janet A. Englund, has received research support and consulting fees from MedImmune and Sanofi Pasteur.

'We decided to explore the implications of viral testing for children with bronchiolitis.' MS. STEMPEL

SAN DIEGO — Respiratory syncytial virus was the most common virus detected in young children with bronchiolitis, but nearly 40% were infected with other viruses, results from a single-center study showed.

“The results suggest that further study is warranted to learn more about the potential impact of viral pathogens associated with bronchiolitis,” Hilary Stempel said at the annual meeting of the Infectious Diseases Society of America.

Ms. Stempel, a clinical research associate in infectious diseases with Children's Hospital and Regional Medical Center, Seattle, said that she and her associates undertook the study because guidelines from the American Academy of Pediatrics recommend that the diagnosis of bronchiolitis should be made on the basis of history and physical, and that clinicians should not routinely order laboratory tests for the diagnosis (Pediatrics 2006;118:1774-93).

The rationale for this position, according to the guidelines, is that “the knowledge gained from such testing rarely alters management decisions or outcomes for the vast majority of children with clinically diagnosed bronchiolitis.”

However, the guidelines do state that “virologic testing may be useful when cohorting of patients is feasible.”

That particular statement interested the researchers at the hospital, where “patient cohorting is still a necessity,” Ms. Stempel said. “So we decided to explore the implications of viral testing for children with bronchiolitis.”

Researchers collected residual nasal wash specimens from 189 children aged 0-3 years who were evaluated for bronchiolitis from October 2003 through April 2004. All specimens were evaluated with quantitative real time polymerase chain reaction testing and fluorescent antibody assay.

The median age of the 189 children was 7 months, 54% were male, and 26% had an underlying disease such as asthma or a cardiac condition.

Most samples (72%) were acquired from the general pediatric ward, while 21% were acquired from the emergency department, and 7% from the intensive care unit.

Ms. Stempel reported that a total of 220 respiratory viral pathogens were detected in 177 of the 189 children (94%). The majority of the 220 viruses were RSV (145), followed by adenovirus (28), human metapneumovirus (hMPV) (20), coronavirus (14), parainfluenza (12) and influenza (1).

Forty-three samples contained two or more viruses. Of these, 35 (81%) involved RSV. Other coinfections included hMPV and parainfluenza (4 samples), hMPV and adenovirus (3 samples) and parainfluenza and adenovirus (1 sample).

Limitations of the study include its retrospective design and the fact that rhinovirus assay was not performed. Also, “the study ended in April 2004 and did not extend through the entire parainfluenza season,” Ms. Stempel said. “This may have lowered the number of parainfluenza infections that we detected.”

Ms. Stempel disclosed that one of the study coauthors, Dr. Janet A. Englund, has received research support and consulting fees from MedImmune and Sanofi Pasteur.

'We decided to explore the implications of viral testing for children with bronchiolitis.' MS. STEMPEL

SAN DIEGO — Respiratory syncytial virus was the most common virus detected in young children with bronchiolitis, but nearly 40% were infected with other viruses, results from a single-center study showed.

“The results suggest that further study is warranted to learn more about the potential impact of viral pathogens associated with bronchiolitis,” Hilary Stempel said at the annual meeting of the Infectious Diseases Society of America.

Ms. Stempel, a clinical research associate in infectious diseases with Children's Hospital and Regional Medical Center, Seattle, said that she and her associates undertook the study because guidelines from the American Academy of Pediatrics recommend that the diagnosis of bronchiolitis should be made on the basis of history and physical, and that clinicians should not routinely order laboratory tests for the diagnosis (Pediatrics 2006;118:1774-93).

The rationale for this position, according to the guidelines, is that “the knowledge gained from such testing rarely alters management decisions or outcomes for the vast majority of children with clinically diagnosed bronchiolitis.”

However, the guidelines do state that “virologic testing may be useful when cohorting of patients is feasible.”

That particular statement interested the researchers at the hospital, where “patient cohorting is still a necessity,” Ms. Stempel said. “So we decided to explore the implications of viral testing for children with bronchiolitis.”

Researchers collected residual nasal wash specimens from 189 children aged 0-3 years who were evaluated for bronchiolitis from October 2003 through April 2004. All specimens were evaluated with quantitative real time polymerase chain reaction testing and fluorescent antibody assay.

The median age of the 189 children was 7 months, 54% were male, and 26% had an underlying disease such as asthma or a cardiac condition.

Most samples (72%) were acquired from the general pediatric ward, while 21% were acquired from the emergency department, and 7% from the intensive care unit.

Ms. Stempel reported that a total of 220 respiratory viral pathogens were detected in 177 of the 189 children (94%). The majority of the 220 viruses were RSV (145), followed by adenovirus (28), human metapneumovirus (hMPV) (20), coronavirus (14), parainfluenza (12) and influenza (1).

Forty-three samples contained two or more viruses. Of these, 35 (81%) involved RSV. Other coinfections included hMPV and parainfluenza (4 samples), hMPV and adenovirus (3 samples) and parainfluenza and adenovirus (1 sample).

Limitations of the study include its retrospective design and the fact that rhinovirus assay was not performed. Also, “the study ended in April 2004 and did not extend through the entire parainfluenza season,” Ms. Stempel said. “This may have lowered the number of parainfluenza infections that we detected.”

Ms. Stempel disclosed that one of the study coauthors, Dr. Janet A. Englund, has received research support and consulting fees from MedImmune and Sanofi Pasteur.

'We decided to explore the implications of viral testing for children with bronchiolitis.' MS. STEMPEL