Doug Brunk

SAN DIEGO — About half of postmenopausal women who take bisphosphonates for osteoporosis take at least three concomitant medications and 15% take six or more, researchers led by Dr. Sydney Lou Bonnick reported during a poster session at the annual meeting of the International Society for Clinical Densitometry.

“Patients receiving bisphosphonate therapy for postmenopausal osteoporosis have a substantial pill burden,” the researchers wrote in their poster. “Adherence to therapy may be improved if physicians consider prescribing more convenient, less frequently dosed medications.”

Dr. Bonnick, medical director of the Clinical Research Center of North Texas in Denton, and her associates obtained patient prescription information from November 1999 to June 2004 from NDCHealth, a database that contains records from 14,000 retail pharmacies in the United States. They identified women aged 50 years and older who were receiving alendronate or risedronate, which were the bisphosphonates approved for osteoporosis treatment during the study period.

It was disclosed that GlaxoSmithKline, maker of once-monthly Boniva (ibandronate) supported the study.

Concomitant medications were defined as a minimum of a 2-week supply of medications prescribed in the same month as a minimum of a 2-week supply of bisphosphonates.

Between November 1999 and June 2004 the number of women in the database using bisphosphonates rose from 78,909 to 250,286.

Of the women prescribed concomitant medications, 74% were on two or more additional medications, 52% were on three or more, and 15% were on six or more. The percentage of women taking six or more concomitant medications increased from 12% to 19% during the study period.

The most common concomitant drugs taken were cholesterol reducers, synthetic thyroid hormones, calcium channel blockers, ?-blockers, ACE inhibitors, and systemic antiarthritis medications.

SAN DIEGO — About half of postmenopausal women who take bisphosphonates for osteoporosis take at least three concomitant medications and 15% take six or more, researchers led by Dr. Sydney Lou Bonnick reported during a poster session at the annual meeting of the International Society for Clinical Densitometry.

“Patients receiving bisphosphonate therapy for postmenopausal osteoporosis have a substantial pill burden,” the researchers wrote in their poster. “Adherence to therapy may be improved if physicians consider prescribing more convenient, less frequently dosed medications.”

Dr. Bonnick, medical director of the Clinical Research Center of North Texas in Denton, and her associates obtained patient prescription information from November 1999 to June 2004 from NDCHealth, a database that contains records from 14,000 retail pharmacies in the United States. They identified women aged 50 years and older who were receiving alendronate or risedronate, which were the bisphosphonates approved for osteoporosis treatment during the study period.

It was disclosed that GlaxoSmithKline, maker of once-monthly Boniva (ibandronate) supported the study.

Concomitant medications were defined as a minimum of a 2-week supply of medications prescribed in the same month as a minimum of a 2-week supply of bisphosphonates.

Between November 1999 and June 2004 the number of women in the database using bisphosphonates rose from 78,909 to 250,286.

Of the women prescribed concomitant medications, 74% were on two or more additional medications, 52% were on three or more, and 15% were on six or more. The percentage of women taking six or more concomitant medications increased from 12% to 19% during the study period.

The most common concomitant drugs taken were cholesterol reducers, synthetic thyroid hormones, calcium channel blockers, ?-blockers, ACE inhibitors, and systemic antiarthritis medications.

SAN DIEGO — About half of postmenopausal women who take bisphosphonates for osteoporosis take at least three concomitant medications and 15% take six or more, researchers led by Dr. Sydney Lou Bonnick reported during a poster session at the annual meeting of the International Society for Clinical Densitometry.

“Patients receiving bisphosphonate therapy for postmenopausal osteoporosis have a substantial pill burden,” the researchers wrote in their poster. “Adherence to therapy may be improved if physicians consider prescribing more convenient, less frequently dosed medications.”

Dr. Bonnick, medical director of the Clinical Research Center of North Texas in Denton, and her associates obtained patient prescription information from November 1999 to June 2004 from NDCHealth, a database that contains records from 14,000 retail pharmacies in the United States. They identified women aged 50 years and older who were receiving alendronate or risedronate, which were the bisphosphonates approved for osteoporosis treatment during the study period.

It was disclosed that GlaxoSmithKline, maker of once-monthly Boniva (ibandronate) supported the study.

Concomitant medications were defined as a minimum of a 2-week supply of medications prescribed in the same month as a minimum of a 2-week supply of bisphosphonates.

Between November 1999 and June 2004 the number of women in the database using bisphosphonates rose from 78,909 to 250,286.

Of the women prescribed concomitant medications, 74% were on two or more additional medications, 52% were on three or more, and 15% were on six or more. The percentage of women taking six or more concomitant medications increased from 12% to 19% during the study period.

The most common concomitant drugs taken were cholesterol reducers, synthetic thyroid hormones, calcium channel blockers, ?-blockers, ACE inhibitors, and systemic antiarthritis medications.

One-quarter of nursing home residents who enrolled in a hospice program for end-of-life care required hospitalization in the 30 days prior to their deaths, compared with 43% of residents who did not enroll in a hospice program, results from a large analysis have shown.

The finding provides further evidence that offering hospice as an end-of-life option for nursing home residents is beneficial, lead study author Pedro L. Gozalo, Ph.D., said in an interview.

“Prognosis is the big problem: when to figure out whether a person is close to death or not,” said Dr. Gozalo, of the Center for Gerontology and Health Care Research in the department of community health at Brown University, Providence, R.I. “Some medical directors feel more aggressive about trying to cure people at the end of life than others. In the end, it's always a matter of personal belief from the medical director's perspective as to whether the person is still at a stage where life can be prolonged substantially. But once it's clear that the person is entering the last stages in life, then hospice appears to be a valid alternative that can save unnecessary hospitalizations.”

He and his associate, Susan C. Miller, Ph.D., used Minimum Data Set and Centers for Medicare and Medicaid Services files to review the records of 183,742 nursing home residents in Kansas, Maine, New York, Ohio, and South Dakota who died between 1995 and 1997 (Health Services Research 2006;doi:10.1111/j.1475-6773.2006.00623.x). These states were chosen because they represent the kind of wide variation in hospice enrollment seen from state to state. “For example, Maine has a totally different utilization pattern than New York, even though they are relatively close geographically,” Dr. Gozalo said. “The same goes for Kansas and Ohio. We felt that [these states] represented a good sample of the overall states.”

Of the 183,742 nursing home residents in the study, the majority (169,127) did not enroll into hospice during their last 30 days of life, while 14,615 did. As expected, the rates of hospice enrollment varied widely and were as follows: 12.5% in Ohio, 11.6% in Kansas, 6.6% in New York, 5.4% in South Dakota, and 2.4% in Maine. Almost twice as many hospice residents had do-not-hospitalize and do-not-resuscitate orders and had diagnoses of cancer, compared with nonhospice residents (47% vs. 22%, respectively).

Compared with nonhospice nursing home residents, those who enrolled into hospice were more likely to live in a nursing home that was for-profit and part of a chain, had a higher private-pay/Medicare-pay ratio, had a lower percentage of nonwhite residents, and had a special care unit; in addition, it was more likely that their nearest hospice provider was for-profit and/or based in a hospital.

The researchers also found that in the 30 days before death, 26% of the hospice patients (3,730) and 43% of the nonhospice patients (73,410) were hospitalized.

When they adjusted for characteristics that might influence a patient to select hospice care, Dr. Gozalo and Dr. Miller found that about one-quarter of the hospice patients chose it because they preferred less-aggressive care. “That means the brunt of the observed effect is real,” not solely influenced by one's preference for hospice care, Dr. Gozalo said.

“It would benefit medical directors to enter into cooperative agreements with hospice providers, to refer people to hospice early enough so that they can take advantage of these benefits,” he concluded.

The researchers acknowledged certain limitations of the study, including the fact that it did not distinguish hospice treatment by its length of exposure and that the data came from only five states.

The study was funded by the Agency for Healthcare Research and Quality.

One-quarter of nursing home residents who enrolled in a hospice program for end-of-life care required hospitalization in the 30 days prior to their deaths, compared with 43% of residents who did not enroll in a hospice program, results from a large analysis have shown.

The finding provides further evidence that offering hospice as an end-of-life option for nursing home residents is beneficial, lead study author Pedro L. Gozalo, Ph.D., said in an interview.

“Prognosis is the big problem: when to figure out whether a person is close to death or not,” said Dr. Gozalo, of the Center for Gerontology and Health Care Research in the department of community health at Brown University, Providence, R.I. “Some medical directors feel more aggressive about trying to cure people at the end of life than others. In the end, it's always a matter of personal belief from the medical director's perspective as to whether the person is still at a stage where life can be prolonged substantially. But once it's clear that the person is entering the last stages in life, then hospice appears to be a valid alternative that can save unnecessary hospitalizations.”

He and his associate, Susan C. Miller, Ph.D., used Minimum Data Set and Centers for Medicare and Medicaid Services files to review the records of 183,742 nursing home residents in Kansas, Maine, New York, Ohio, and South Dakota who died between 1995 and 1997 (Health Services Research 2006;doi:10.1111/j.1475-6773.2006.00623.x). These states were chosen because they represent the kind of wide variation in hospice enrollment seen from state to state. “For example, Maine has a totally different utilization pattern than New York, even though they are relatively close geographically,” Dr. Gozalo said. “The same goes for Kansas and Ohio. We felt that [these states] represented a good sample of the overall states.”

Of the 183,742 nursing home residents in the study, the majority (169,127) did not enroll into hospice during their last 30 days of life, while 14,615 did. As expected, the rates of hospice enrollment varied widely and were as follows: 12.5% in Ohio, 11.6% in Kansas, 6.6% in New York, 5.4% in South Dakota, and 2.4% in Maine. Almost twice as many hospice residents had do-not-hospitalize and do-not-resuscitate orders and had diagnoses of cancer, compared with nonhospice residents (47% vs. 22%, respectively).

Compared with nonhospice nursing home residents, those who enrolled into hospice were more likely to live in a nursing home that was for-profit and part of a chain, had a higher private-pay/Medicare-pay ratio, had a lower percentage of nonwhite residents, and had a special care unit; in addition, it was more likely that their nearest hospice provider was for-profit and/or based in a hospital.

The researchers also found that in the 30 days before death, 26% of the hospice patients (3,730) and 43% of the nonhospice patients (73,410) were hospitalized.

When they adjusted for characteristics that might influence a patient to select hospice care, Dr. Gozalo and Dr. Miller found that about one-quarter of the hospice patients chose it because they preferred less-aggressive care. “That means the brunt of the observed effect is real,” not solely influenced by one's preference for hospice care, Dr. Gozalo said.

“It would benefit medical directors to enter into cooperative agreements with hospice providers, to refer people to hospice early enough so that they can take advantage of these benefits,” he concluded.

The researchers acknowledged certain limitations of the study, including the fact that it did not distinguish hospice treatment by its length of exposure and that the data came from only five states.

The study was funded by the Agency for Healthcare Research and Quality.

One-quarter of nursing home residents who enrolled in a hospice program for end-of-life care required hospitalization in the 30 days prior to their deaths, compared with 43% of residents who did not enroll in a hospice program, results from a large analysis have shown.

The finding provides further evidence that offering hospice as an end-of-life option for nursing home residents is beneficial, lead study author Pedro L. Gozalo, Ph.D., said in an interview.

“Prognosis is the big problem: when to figure out whether a person is close to death or not,” said Dr. Gozalo, of the Center for Gerontology and Health Care Research in the department of community health at Brown University, Providence, R.I. “Some medical directors feel more aggressive about trying to cure people at the end of life than others. In the end, it's always a matter of personal belief from the medical director's perspective as to whether the person is still at a stage where life can be prolonged substantially. But once it's clear that the person is entering the last stages in life, then hospice appears to be a valid alternative that can save unnecessary hospitalizations.”

He and his associate, Susan C. Miller, Ph.D., used Minimum Data Set and Centers for Medicare and Medicaid Services files to review the records of 183,742 nursing home residents in Kansas, Maine, New York, Ohio, and South Dakota who died between 1995 and 1997 (Health Services Research 2006;doi:10.1111/j.1475-6773.2006.00623.x). These states were chosen because they represent the kind of wide variation in hospice enrollment seen from state to state. “For example, Maine has a totally different utilization pattern than New York, even though they are relatively close geographically,” Dr. Gozalo said. “The same goes for Kansas and Ohio. We felt that [these states] represented a good sample of the overall states.”

Of the 183,742 nursing home residents in the study, the majority (169,127) did not enroll into hospice during their last 30 days of life, while 14,615 did. As expected, the rates of hospice enrollment varied widely and were as follows: 12.5% in Ohio, 11.6% in Kansas, 6.6% in New York, 5.4% in South Dakota, and 2.4% in Maine. Almost twice as many hospice residents had do-not-hospitalize and do-not-resuscitate orders and had diagnoses of cancer, compared with nonhospice residents (47% vs. 22%, respectively).

Compared with nonhospice nursing home residents, those who enrolled into hospice were more likely to live in a nursing home that was for-profit and part of a chain, had a higher private-pay/Medicare-pay ratio, had a lower percentage of nonwhite residents, and had a special care unit; in addition, it was more likely that their nearest hospice provider was for-profit and/or based in a hospital.

The researchers also found that in the 30 days before death, 26% of the hospice patients (3,730) and 43% of the nonhospice patients (73,410) were hospitalized.

When they adjusted for characteristics that might influence a patient to select hospice care, Dr. Gozalo and Dr. Miller found that about one-quarter of the hospice patients chose it because they preferred less-aggressive care. “That means the brunt of the observed effect is real,” not solely influenced by one's preference for hospice care, Dr. Gozalo said.

“It would benefit medical directors to enter into cooperative agreements with hospice providers, to refer people to hospice early enough so that they can take advantage of these benefits,” he concluded.

The researchers acknowledged certain limitations of the study, including the fact that it did not distinguish hospice treatment by its length of exposure and that the data came from only five states.

The study was funded by the Agency for Healthcare Research and Quality.

LOS ANGELES — Only 21% of internal medicine residents feel “very confident” in their ability to manage patients with acute pancreatitis, a survey administered at a large, urban medical center has found.

“We certainly need to do a better job in our training institutions of equipping our residents with the knowledge and making them feel comfortable in diagnosing and managing the complications of acute pancreatitis,” Dr. Sameer A. Barkatullah said in an interview during a poster session at the annual Digestive Disease Week.

“The big areas of concern were initial diagnostic work-up and also recognizing the complications of pancreatitis. Those seem to be two big areas where residents didn't know as much as perhaps they should.”

In what is thought to be the first study of its kind, Dr. Barkatullah and his associates administered a 23-item questionnaire about acute pancreatitis to 58 internal medicine residents at Rush University Medical Center, Chicago. The multiple-choice questions covered the use of lab tests and radiologic imaging, assessment of severity, use of antibiotics, nutrition, and indication. Nearly two-thirds of the residents (62%) did not recognize hematocrit as the key predictor of acute pancreatitis severity on admission, and 38% could not identify the initial appropriate lab tests to be ordered.

Dr. Barkatullah, a second-year internal medicine resident in the section of gastroenterology and nutrition at Rush University Medical Center, also reported that about 25% of respondents believed that administration of empiric antibiotics for all cases of acute pancreatitis was the standard of care, and 21% thought that the diagnosis was made by identifying inflammation on CT scan.

“In the setting of acute biliary pancreatitis, only 66% identified right upper quadrant ultrasound as the preferred initial imaging modality, and only 59% could identify the appropriate timing and utility of endoscopic retrograde cholangiopancreatography,” the researchers wrote in their poster.

Gaps in knowledge about identifying and managing severe pancreatitis were also seen. For example, most of the residents (81%) underestimated the incidence of pancreatic necrosis, and only 36% believed that early feeding decreases morbidity and mortality in cases of necrotizing pancreatitis. Also, only 55% correlated necrotizing pancreatitis with systematic inflammatory response syndrome.

Two-thirds of the residents surveyed (66%) did not identify appropriate surgical interventions for acute pancreatitis, and only 21% reported being “very confident” in managing the condition.

LOS ANGELES — Only 21% of internal medicine residents feel “very confident” in their ability to manage patients with acute pancreatitis, a survey administered at a large, urban medical center has found.

“We certainly need to do a better job in our training institutions of equipping our residents with the knowledge and making them feel comfortable in diagnosing and managing the complications of acute pancreatitis,” Dr. Sameer A. Barkatullah said in an interview during a poster session at the annual Digestive Disease Week.

“The big areas of concern were initial diagnostic work-up and also recognizing the complications of pancreatitis. Those seem to be two big areas where residents didn't know as much as perhaps they should.”

In what is thought to be the first study of its kind, Dr. Barkatullah and his associates administered a 23-item questionnaire about acute pancreatitis to 58 internal medicine residents at Rush University Medical Center, Chicago. The multiple-choice questions covered the use of lab tests and radiologic imaging, assessment of severity, use of antibiotics, nutrition, and indication. Nearly two-thirds of the residents (62%) did not recognize hematocrit as the key predictor of acute pancreatitis severity on admission, and 38% could not identify the initial appropriate lab tests to be ordered.

Dr. Barkatullah, a second-year internal medicine resident in the section of gastroenterology and nutrition at Rush University Medical Center, also reported that about 25% of respondents believed that administration of empiric antibiotics for all cases of acute pancreatitis was the standard of care, and 21% thought that the diagnosis was made by identifying inflammation on CT scan.

“In the setting of acute biliary pancreatitis, only 66% identified right upper quadrant ultrasound as the preferred initial imaging modality, and only 59% could identify the appropriate timing and utility of endoscopic retrograde cholangiopancreatography,” the researchers wrote in their poster.

Gaps in knowledge about identifying and managing severe pancreatitis were also seen. For example, most of the residents (81%) underestimated the incidence of pancreatic necrosis, and only 36% believed that early feeding decreases morbidity and mortality in cases of necrotizing pancreatitis. Also, only 55% correlated necrotizing pancreatitis with systematic inflammatory response syndrome.

Two-thirds of the residents surveyed (66%) did not identify appropriate surgical interventions for acute pancreatitis, and only 21% reported being “very confident” in managing the condition.

LOS ANGELES — Only 21% of internal medicine residents feel “very confident” in their ability to manage patients with acute pancreatitis, a survey administered at a large, urban medical center has found.

“We certainly need to do a better job in our training institutions of equipping our residents with the knowledge and making them feel comfortable in diagnosing and managing the complications of acute pancreatitis,” Dr. Sameer A. Barkatullah said in an interview during a poster session at the annual Digestive Disease Week.

“The big areas of concern were initial diagnostic work-up and also recognizing the complications of pancreatitis. Those seem to be two big areas where residents didn't know as much as perhaps they should.”

In what is thought to be the first study of its kind, Dr. Barkatullah and his associates administered a 23-item questionnaire about acute pancreatitis to 58 internal medicine residents at Rush University Medical Center, Chicago. The multiple-choice questions covered the use of lab tests and radiologic imaging, assessment of severity, use of antibiotics, nutrition, and indication. Nearly two-thirds of the residents (62%) did not recognize hematocrit as the key predictor of acute pancreatitis severity on admission, and 38% could not identify the initial appropriate lab tests to be ordered.

Dr. Barkatullah, a second-year internal medicine resident in the section of gastroenterology and nutrition at Rush University Medical Center, also reported that about 25% of respondents believed that administration of empiric antibiotics for all cases of acute pancreatitis was the standard of care, and 21% thought that the diagnosis was made by identifying inflammation on CT scan.

“In the setting of acute biliary pancreatitis, only 66% identified right upper quadrant ultrasound as the preferred initial imaging modality, and only 59% could identify the appropriate timing and utility of endoscopic retrograde cholangiopancreatography,” the researchers wrote in their poster.

Gaps in knowledge about identifying and managing severe pancreatitis were also seen. For example, most of the residents (81%) underestimated the incidence of pancreatic necrosis, and only 36% believed that early feeding decreases morbidity and mortality in cases of necrotizing pancreatitis. Also, only 55% correlated necrotizing pancreatitis with systematic inflammatory response syndrome.

Two-thirds of the residents surveyed (66%) did not identify appropriate surgical interventions for acute pancreatitis, and only 21% reported being “very confident” in managing the condition.

SAN DIEGO — White patients and those with private insurance are more likely to undergo laparoscopic surgery for appendicitis in New York state, according to results from a large analysis.

“In the case of race, this disparity is largely explained by the fact that minority patients tend to present to hospitals that perform fewer laparoscopic procedures for appendicitis,” Dr. Frederic M. Pieracci said at the annual meeting of the Surgical Infection Society.

However, this hospital clustering effect “does not fully explain differences in likelihood of laparoscopic surgery based on insurance status,” said Dr. Pieracci of the departments of surgery and public health at Weill Medical College of Cornell University in New York City.

The researchers chose to study race- and insurance-related patterns of appendectomy use “because appendicitis is common, because two surgical options exist, and though the clinical outcome is still debated, it is generally felt that the laparoscopic approach is more technologically advanced,” he explained. “Finally, utilization of laparoscopic appendectomy has increased markedly over the last 10 years.”

He and his associates analyzed the New York State Statewide Planning and Research Cooperative System (SPARCS) database to locate 26,104 patients who underwent appendectomy for acute appendicitis in 2003 and 2004. Required by state law, SPARCS contains data on all patients discharged from 207 nonfederal, acute care hospitals in New York. Of the 26,104 patients, 9,648 (37%) underwent laparoscopic appendectomy, while 16,456 (63%) underwent open appendectomy.

The mean age of patients was 39 years; 56% were male, 63% were white, and 59% had private insurance. Nearly three-quarters of laparoscopic appendectomies (72%) were performed at a teaching hospital.

After the researchers adjusted for age, gender, insurance status, hospital teaching status, and degree of appendicitis, they found that white patients were 24% more likely to undergo laparoscopic surgery than were nonwhite patients. But no significant difference was observed when the researchers controlled for a sixth variable: presenting to the hospital for laparoscopic appendectomy.

When Dr. Pieracci and his associates controlled for the same six variables in the insurance component of the analysis, they found that privately insured patients were 22% more likely to undergo laparoscopic appendectomy than were those without private insurance.

“The strengths of the study are that it includes recent data, it had nearly complete race information, and we [included] individual hospital use of laparoscopic appendectomy,” Dr. Pieracci said. “However, the study is limited in that it provides information for New York state only, it excluded pediatric patients, it did not account for patient comorbidities, and we were unable to capture conversion from laparoscopic to open,” he said.

White patients were 24% more likely to undergo laparoscopic surgery than were nonwhite patients. DR. PIERACCI

SAN DIEGO — White patients and those with private insurance are more likely to undergo laparoscopic surgery for appendicitis in New York state, according to results from a large analysis.

“In the case of race, this disparity is largely explained by the fact that minority patients tend to present to hospitals that perform fewer laparoscopic procedures for appendicitis,” Dr. Frederic M. Pieracci said at the annual meeting of the Surgical Infection Society.

However, this hospital clustering effect “does not fully explain differences in likelihood of laparoscopic surgery based on insurance status,” said Dr. Pieracci of the departments of surgery and public health at Weill Medical College of Cornell University in New York City.

The researchers chose to study race- and insurance-related patterns of appendectomy use “because appendicitis is common, because two surgical options exist, and though the clinical outcome is still debated, it is generally felt that the laparoscopic approach is more technologically advanced,” he explained. “Finally, utilization of laparoscopic appendectomy has increased markedly over the last 10 years.”

He and his associates analyzed the New York State Statewide Planning and Research Cooperative System (SPARCS) database to locate 26,104 patients who underwent appendectomy for acute appendicitis in 2003 and 2004. Required by state law, SPARCS contains data on all patients discharged from 207 nonfederal, acute care hospitals in New York. Of the 26,104 patients, 9,648 (37%) underwent laparoscopic appendectomy, while 16,456 (63%) underwent open appendectomy.

The mean age of patients was 39 years; 56% were male, 63% were white, and 59% had private insurance. Nearly three-quarters of laparoscopic appendectomies (72%) were performed at a teaching hospital.

After the researchers adjusted for age, gender, insurance status, hospital teaching status, and degree of appendicitis, they found that white patients were 24% more likely to undergo laparoscopic surgery than were nonwhite patients. But no significant difference was observed when the researchers controlled for a sixth variable: presenting to the hospital for laparoscopic appendectomy.

When Dr. Pieracci and his associates controlled for the same six variables in the insurance component of the analysis, they found that privately insured patients were 22% more likely to undergo laparoscopic appendectomy than were those without private insurance.

“The strengths of the study are that it includes recent data, it had nearly complete race information, and we [included] individual hospital use of laparoscopic appendectomy,” Dr. Pieracci said. “However, the study is limited in that it provides information for New York state only, it excluded pediatric patients, it did not account for patient comorbidities, and we were unable to capture conversion from laparoscopic to open,” he said.

White patients were 24% more likely to undergo laparoscopic surgery than were nonwhite patients. DR. PIERACCI

SAN DIEGO — White patients and those with private insurance are more likely to undergo laparoscopic surgery for appendicitis in New York state, according to results from a large analysis.

“In the case of race, this disparity is largely explained by the fact that minority patients tend to present to hospitals that perform fewer laparoscopic procedures for appendicitis,” Dr. Frederic M. Pieracci said at the annual meeting of the Surgical Infection Society.

However, this hospital clustering effect “does not fully explain differences in likelihood of laparoscopic surgery based on insurance status,” said Dr. Pieracci of the departments of surgery and public health at Weill Medical College of Cornell University in New York City.

The researchers chose to study race- and insurance-related patterns of appendectomy use “because appendicitis is common, because two surgical options exist, and though the clinical outcome is still debated, it is generally felt that the laparoscopic approach is more technologically advanced,” he explained. “Finally, utilization of laparoscopic appendectomy has increased markedly over the last 10 years.”

He and his associates analyzed the New York State Statewide Planning and Research Cooperative System (SPARCS) database to locate 26,104 patients who underwent appendectomy for acute appendicitis in 2003 and 2004. Required by state law, SPARCS contains data on all patients discharged from 207 nonfederal, acute care hospitals in New York. Of the 26,104 patients, 9,648 (37%) underwent laparoscopic appendectomy, while 16,456 (63%) underwent open appendectomy.

The mean age of patients was 39 years; 56% were male, 63% were white, and 59% had private insurance. Nearly three-quarters of laparoscopic appendectomies (72%) were performed at a teaching hospital.

After the researchers adjusted for age, gender, insurance status, hospital teaching status, and degree of appendicitis, they found that white patients were 24% more likely to undergo laparoscopic surgery than were nonwhite patients. But no significant difference was observed when the researchers controlled for a sixth variable: presenting to the hospital for laparoscopic appendectomy.

When Dr. Pieracci and his associates controlled for the same six variables in the insurance component of the analysis, they found that privately insured patients were 22% more likely to undergo laparoscopic appendectomy than were those without private insurance.

“The strengths of the study are that it includes recent data, it had nearly complete race information, and we [included] individual hospital use of laparoscopic appendectomy,” Dr. Pieracci said. “However, the study is limited in that it provides information for New York state only, it excluded pediatric patients, it did not account for patient comorbidities, and we were unable to capture conversion from laparoscopic to open,” he said.

White patients were 24% more likely to undergo laparoscopic surgery than were nonwhite patients. DR. PIERACCI

LA JOLLA, CALIF. — Fluoroscopy is more reliable than a surgeon's estimate or goniometric measurement to assess range of motion of the first metatarsophalangeal joint in patients with hallux rigidus treated with cheilectomy, a small study showed.

While fluoroscopy showed a 23-degree improvement in dorsiflexion intraoperatively, only 11 degrees of motion improvement was maintained at 6 months, Dr. Richard M. Marks said at the annual meeting of the American Orthopaedic Foot and Ankle Society.

“I think there are several questions that still need to be raised from this study,” said Dr. Marks, director of the foot and ankle surgery division at the Medical College of Wisconsin in Milwaukee. “Does motion continue to diminish over time? Does motion correlate with a patient's outcome? Does this motion correlate with the grade of arthritis preoperatively?”

He and his associate, Dr. Michael Khazzam, studied 25 patients who underwent cheilectomy through a dorsal incision for the treatment of hallux rigidus. The average age of patients was 46 years, and 15 were female.

A single surgeon performed the cheilectomy and evaluated the range of motion in the first metatarsophalangeal joint. Range of motion evaluations were obtained by surgeon's estimate, by direct goniometric measurement, and by fluoroscopic measurement preoperatively, immediately after surgery, and 6 months postoperatively.

The surgeon's estimated range of motion showed a 39.8-degree improvement intraoperatively vs. preoperatively, a 21.2-degree improvement 6 months postoperatively vs. preoperatively, and an 18.6-degree decrease in range of motion postoperatively vs. intraoperatively.

The goniometric range of motion measurements showed a 28.4-degree improvement intraoperatively vs. preoperatively, a 10-degree improvement 6 months postoperatively vs. preoperatively, and an 18.4-degree decrease in range of motion postoperatively vs. intraoperatively.

The fluoroscopic range of motion measurements showed a 22.9-degree improvement intraoperatively vs. preoperatively, an 11-degree improvement 6 months postoperatively vs. preoperatively, and an 11.9-degree decrease in range of motion postoperatively vs. intraoperatively.

“We found fluoroscopy to be the reliable measurement tool,” Dr. Marks said. Fluoroscopy showed that “we were able to achieve 23 degrees more motion intraoperatively up to a peak of 68 degrees. However, at 6 months 12 degrees were lost, so we had a net gain of 11 degrees of motion, or an increase of 48% compared to our intraoperative findings.”

Limitations of the study, he added, include the small number of patients and the small time frame of follow-up.

Questions still remain, such as 'Does motion continue to diminish over time?' DR. MARKS

Shown above are radiographic findings precheilectomy (left) and postcheilectomy (right) in 1 of the 25 study participants. “We found fluoroscopy to be the reliable measurement tool,” Dr. Richard M. Marks said. “We had a net gain of 11 degrees of motion, or an increase of 48% compared to our intraoperative findings.” Photos courtesy Dr. Richard M. Marks

LA JOLLA, CALIF. — Fluoroscopy is more reliable than a surgeon's estimate or goniometric measurement to assess range of motion of the first metatarsophalangeal joint in patients with hallux rigidus treated with cheilectomy, a small study showed.

While fluoroscopy showed a 23-degree improvement in dorsiflexion intraoperatively, only 11 degrees of motion improvement was maintained at 6 months, Dr. Richard M. Marks said at the annual meeting of the American Orthopaedic Foot and Ankle Society.

“I think there are several questions that still need to be raised from this study,” said Dr. Marks, director of the foot and ankle surgery division at the Medical College of Wisconsin in Milwaukee. “Does motion continue to diminish over time? Does motion correlate with a patient's outcome? Does this motion correlate with the grade of arthritis preoperatively?”

He and his associate, Dr. Michael Khazzam, studied 25 patients who underwent cheilectomy through a dorsal incision for the treatment of hallux rigidus. The average age of patients was 46 years, and 15 were female.

A single surgeon performed the cheilectomy and evaluated the range of motion in the first metatarsophalangeal joint. Range of motion evaluations were obtained by surgeon's estimate, by direct goniometric measurement, and by fluoroscopic measurement preoperatively, immediately after surgery, and 6 months postoperatively.

The surgeon's estimated range of motion showed a 39.8-degree improvement intraoperatively vs. preoperatively, a 21.2-degree improvement 6 months postoperatively vs. preoperatively, and an 18.6-degree decrease in range of motion postoperatively vs. intraoperatively.

The goniometric range of motion measurements showed a 28.4-degree improvement intraoperatively vs. preoperatively, a 10-degree improvement 6 months postoperatively vs. preoperatively, and an 18.4-degree decrease in range of motion postoperatively vs. intraoperatively.

The fluoroscopic range of motion measurements showed a 22.9-degree improvement intraoperatively vs. preoperatively, an 11-degree improvement 6 months postoperatively vs. preoperatively, and an 11.9-degree decrease in range of motion postoperatively vs. intraoperatively.

“We found fluoroscopy to be the reliable measurement tool,” Dr. Marks said. Fluoroscopy showed that “we were able to achieve 23 degrees more motion intraoperatively up to a peak of 68 degrees. However, at 6 months 12 degrees were lost, so we had a net gain of 11 degrees of motion, or an increase of 48% compared to our intraoperative findings.”

Limitations of the study, he added, include the small number of patients and the small time frame of follow-up.

Questions still remain, such as 'Does motion continue to diminish over time?' DR. MARKS

Shown above are radiographic findings precheilectomy (left) and postcheilectomy (right) in 1 of the 25 study participants. “We found fluoroscopy to be the reliable measurement tool,” Dr. Richard M. Marks said. “We had a net gain of 11 degrees of motion, or an increase of 48% compared to our intraoperative findings.” Photos courtesy Dr. Richard M. Marks

LA JOLLA, CALIF. — Fluoroscopy is more reliable than a surgeon's estimate or goniometric measurement to assess range of motion of the first metatarsophalangeal joint in patients with hallux rigidus treated with cheilectomy, a small study showed.

While fluoroscopy showed a 23-degree improvement in dorsiflexion intraoperatively, only 11 degrees of motion improvement was maintained at 6 months, Dr. Richard M. Marks said at the annual meeting of the American Orthopaedic Foot and Ankle Society.

“I think there are several questions that still need to be raised from this study,” said Dr. Marks, director of the foot and ankle surgery division at the Medical College of Wisconsin in Milwaukee. “Does motion continue to diminish over time? Does motion correlate with a patient's outcome? Does this motion correlate with the grade of arthritis preoperatively?”

He and his associate, Dr. Michael Khazzam, studied 25 patients who underwent cheilectomy through a dorsal incision for the treatment of hallux rigidus. The average age of patients was 46 years, and 15 were female.

A single surgeon performed the cheilectomy and evaluated the range of motion in the first metatarsophalangeal joint. Range of motion evaluations were obtained by surgeon's estimate, by direct goniometric measurement, and by fluoroscopic measurement preoperatively, immediately after surgery, and 6 months postoperatively.

The surgeon's estimated range of motion showed a 39.8-degree improvement intraoperatively vs. preoperatively, a 21.2-degree improvement 6 months postoperatively vs. preoperatively, and an 18.6-degree decrease in range of motion postoperatively vs. intraoperatively.

The goniometric range of motion measurements showed a 28.4-degree improvement intraoperatively vs. preoperatively, a 10-degree improvement 6 months postoperatively vs. preoperatively, and an 18.4-degree decrease in range of motion postoperatively vs. intraoperatively.

The fluoroscopic range of motion measurements showed a 22.9-degree improvement intraoperatively vs. preoperatively, an 11-degree improvement 6 months postoperatively vs. preoperatively, and an 11.9-degree decrease in range of motion postoperatively vs. intraoperatively.

“We found fluoroscopy to be the reliable measurement tool,” Dr. Marks said. Fluoroscopy showed that “we were able to achieve 23 degrees more motion intraoperatively up to a peak of 68 degrees. However, at 6 months 12 degrees were lost, so we had a net gain of 11 degrees of motion, or an increase of 48% compared to our intraoperative findings.”

Limitations of the study, he added, include the small number of patients and the small time frame of follow-up.

Questions still remain, such as 'Does motion continue to diminish over time?' DR. MARKS

Shown above are radiographic findings precheilectomy (left) and postcheilectomy (right) in 1 of the 25 study participants. “We found fluoroscopy to be the reliable measurement tool,” Dr. Richard M. Marks said. “We had a net gain of 11 degrees of motion, or an increase of 48% compared to our intraoperative findings.” Photos courtesy Dr. Richard M. Marks

So far this year, 13 cases of human plague have been reported in four states. This marks 2006 as the year with the largest number of reported cases in the United States since 1994.

According to the Centers for Disease Control and Prevention, the chief cause of the increase is thought to be related to the increased reproduction rates and survival of rodents and fleas in the southwestern United States in the past 2 years caused by wet, early springs and intervening cool summers (MMWR 2006;55:1–3). Human infection is usually acquired through bites from rodent fleas infected with Yersinia pestis.

The mean age of the 13 people infected with the plague was 43 years (range 13–79 years), and more than half (8) were female. The dates of illness ranged from Feb. 16 to Aug. 14, and most cases were reported in New Mexico (seven), followed by Colorado (three), California (two), and Texas (one). Two people died from the illness.

More than half of the cases (eight) were bubonic plague, while the rest were primary septicemic plague. Two patients developed secondary plague pneumonia.

Suspected modes of transmission among six of the patients summarized in the report included one who handled raw rabbit meat, one who skinned rabbit carcasses while hunting, and one who had a dog and a rock squirrel on her property with serologic evidence of past infection with Y. pestis.

The report advises clinicians to consider a diagnosis in patients who “have unexplained fever, suspected sepsis, or pneumonia with or without lymphadenopathy or a classic bubo, and live in or have traveled to a plague-endemic region” such as the western United States. Streptomycin and the tetracyclines are effective against the plague. The report noted that gentamicin and fluoroquinolones have been used successfully to treat the plague, but have not been approved by the Food and Drug Administration for this indication.

So far this year, 13 cases of human plague have been reported in four states. This marks 2006 as the year with the largest number of reported cases in the United States since 1994.

According to the Centers for Disease Control and Prevention, the chief cause of the increase is thought to be related to the increased reproduction rates and survival of rodents and fleas in the southwestern United States in the past 2 years caused by wet, early springs and intervening cool summers (MMWR 2006;55:1–3). Human infection is usually acquired through bites from rodent fleas infected with Yersinia pestis.

The mean age of the 13 people infected with the plague was 43 years (range 13–79 years), and more than half (8) were female. The dates of illness ranged from Feb. 16 to Aug. 14, and most cases were reported in New Mexico (seven), followed by Colorado (three), California (two), and Texas (one). Two people died from the illness.

More than half of the cases (eight) were bubonic plague, while the rest were primary septicemic plague. Two patients developed secondary plague pneumonia.

Suspected modes of transmission among six of the patients summarized in the report included one who handled raw rabbit meat, one who skinned rabbit carcasses while hunting, and one who had a dog and a rock squirrel on her property with serologic evidence of past infection with Y. pestis.

The report advises clinicians to consider a diagnosis in patients who “have unexplained fever, suspected sepsis, or pneumonia with or without lymphadenopathy or a classic bubo, and live in or have traveled to a plague-endemic region” such as the western United States. Streptomycin and the tetracyclines are effective against the plague. The report noted that gentamicin and fluoroquinolones have been used successfully to treat the plague, but have not been approved by the Food and Drug Administration for this indication.

So far this year, 13 cases of human plague have been reported in four states. This marks 2006 as the year with the largest number of reported cases in the United States since 1994.

According to the Centers for Disease Control and Prevention, the chief cause of the increase is thought to be related to the increased reproduction rates and survival of rodents and fleas in the southwestern United States in the past 2 years caused by wet, early springs and intervening cool summers (MMWR 2006;55:1–3). Human infection is usually acquired through bites from rodent fleas infected with Yersinia pestis.

The mean age of the 13 people infected with the plague was 43 years (range 13–79 years), and more than half (8) were female. The dates of illness ranged from Feb. 16 to Aug. 14, and most cases were reported in New Mexico (seven), followed by Colorado (three), California (two), and Texas (one). Two people died from the illness.

More than half of the cases (eight) were bubonic plague, while the rest were primary septicemic plague. Two patients developed secondary plague pneumonia.

Suspected modes of transmission among six of the patients summarized in the report included one who handled raw rabbit meat, one who skinned rabbit carcasses while hunting, and one who had a dog and a rock squirrel on her property with serologic evidence of past infection with Y. pestis.

The report advises clinicians to consider a diagnosis in patients who “have unexplained fever, suspected sepsis, or pneumonia with or without lymphadenopathy or a classic bubo, and live in or have traveled to a plague-endemic region” such as the western United States. Streptomycin and the tetracyclines are effective against the plague. The report noted that gentamicin and fluoroquinolones have been used successfully to treat the plague, but have not been approved by the Food and Drug Administration for this indication.

TUCSON, ARIZ. — Although only 49 cases of lymphocytic choriomeningitis virus have been reported in the medical literature worldwide, Dr. Marilyn Baird Mets has a hunch that the prevalence could be much higher.

Since 1997, she has seen seven children with the condition present to Children's Memorial Hospital, Chicago, where she is head of ophthalmology. Three other clinicians have called her with reports of positive cases: one from the western suburbs of Chicago, one from Los Angeles, and one from Fort Collins, Colo.

“This virus is out there,” Dr. Mets said at the annual meeting of the Teratology Society.

“Obstetricians should be telling their patients not to work around rats in medical labs during their pregnancy [and] not to get a hamster for their 4-year-old if they're going to have other children. It's a preventable disease, but people need to know about it,” she said

Discovered in 1933 and classified in the 1960s as a prototype for the arena virus, lymphocytic choriomeningitis virus (LCMV) is harbored in mice and transferred vertically by uterine infection.

“There is documented infection to humans from wild mice, lab mice, rats, and hamsters,” said Dr. Mets, also professor of ophthalmology and surgery at Northwestern University, Chicago.

“Transmission is thought to be airborne or contamination of food by infected mouse urine,” she said. “There has also been experimental transmission demonstrated by ticks, fleas, mosquitos, and bedbugs.”

About one-third of adults who acquire LCMV are asymptomatic. Of the remaining two-thirds, about half have central nervous system disease. Illness occurs in a biphasic pattern. “First, there's an acute febrile illness with myalgias and headache,” she said. “Later on, meningeal signs may develop, and rarely encephalitis, myocarditis, parotitis, orchitis, and pneumonia. Very rarely, fatal systemic disease is reported.” It's the causative agent in about 10% of aseptic meningitis cases.

LCMV was first described as a fetal pathogen in Great Britain in 1955. The first case of congenital LCMV in the United States was reported in 1993. The baby was born with a birth weight of 2,898 grams. During pregnancy the mother lived in a well-maintained inner-city apartment. At 5 months' gestation, she had a febrile illness that lasted a week. The child was born with hydrocephalus and microphthalmos of the right eye. The right eye had leukocoria, a cloudy vitreous, and exudative retinitis.

A review of 26 infants with LCMV published in 1997 revealed that 88% had chorioretinopathy, 45% had hydrocephalus, and 13% had microcephaly.

Diagnosis is made by IgG indirect fluorescent antibody, which is commercially available. “Or you can get an IgG ELISA at the [Centers for Disease Control and Prevention],” Dr. Mets said. The differential diagnosis includes toxoplasmosis, rubella, cytomegalovirus, herpes simplex virus, enteroviruses, syphilis, parvovirus B19, and West Nile virus.

There is documented human infection from wild mice, lab mice, rats, and hamsters. DR. METS

An optical scan shows that the retinal pigment of the epithelium has been dramatically disturbed in the eye of a 22-month-old child with congenital LCMV. Courtesy Dr. Marilyn Baird Mets

TUCSON, ARIZ. — Although only 49 cases of lymphocytic choriomeningitis virus have been reported in the medical literature worldwide, Dr. Marilyn Baird Mets has a hunch that the prevalence could be much higher.

Since 1997, she has seen seven children with the condition present to Children's Memorial Hospital, Chicago, where she is head of ophthalmology. Three other clinicians have called her with reports of positive cases: one from the western suburbs of Chicago, one from Los Angeles, and one from Fort Collins, Colo.

“This virus is out there,” Dr. Mets said at the annual meeting of the Teratology Society.

“Obstetricians should be telling their patients not to work around rats in medical labs during their pregnancy [and] not to get a hamster for their 4-year-old if they're going to have other children. It's a preventable disease, but people need to know about it,” she said

Discovered in 1933 and classified in the 1960s as a prototype for the arena virus, lymphocytic choriomeningitis virus (LCMV) is harbored in mice and transferred vertically by uterine infection.

“There is documented infection to humans from wild mice, lab mice, rats, and hamsters,” said Dr. Mets, also professor of ophthalmology and surgery at Northwestern University, Chicago.

“Transmission is thought to be airborne or contamination of food by infected mouse urine,” she said. “There has also been experimental transmission demonstrated by ticks, fleas, mosquitos, and bedbugs.”

About one-third of adults who acquire LCMV are asymptomatic. Of the remaining two-thirds, about half have central nervous system disease. Illness occurs in a biphasic pattern. “First, there's an acute febrile illness with myalgias and headache,” she said. “Later on, meningeal signs may develop, and rarely encephalitis, myocarditis, parotitis, orchitis, and pneumonia. Very rarely, fatal systemic disease is reported.” It's the causative agent in about 10% of aseptic meningitis cases.

LCMV was first described as a fetal pathogen in Great Britain in 1955. The first case of congenital LCMV in the United States was reported in 1993. The baby was born with a birth weight of 2,898 grams. During pregnancy the mother lived in a well-maintained inner-city apartment. At 5 months' gestation, she had a febrile illness that lasted a week. The child was born with hydrocephalus and microphthalmos of the right eye. The right eye had leukocoria, a cloudy vitreous, and exudative retinitis.

A review of 26 infants with LCMV published in 1997 revealed that 88% had chorioretinopathy, 45% had hydrocephalus, and 13% had microcephaly.

Diagnosis is made by IgG indirect fluorescent antibody, which is commercially available. “Or you can get an IgG ELISA at the [Centers for Disease Control and Prevention],” Dr. Mets said. The differential diagnosis includes toxoplasmosis, rubella, cytomegalovirus, herpes simplex virus, enteroviruses, syphilis, parvovirus B19, and West Nile virus.

There is documented human infection from wild mice, lab mice, rats, and hamsters. DR. METS

An optical scan shows that the retinal pigment of the epithelium has been dramatically disturbed in the eye of a 22-month-old child with congenital LCMV. Courtesy Dr. Marilyn Baird Mets

TUCSON, ARIZ. — Although only 49 cases of lymphocytic choriomeningitis virus have been reported in the medical literature worldwide, Dr. Marilyn Baird Mets has a hunch that the prevalence could be much higher.

Since 1997, she has seen seven children with the condition present to Children's Memorial Hospital, Chicago, where she is head of ophthalmology. Three other clinicians have called her with reports of positive cases: one from the western suburbs of Chicago, one from Los Angeles, and one from Fort Collins, Colo.

“This virus is out there,” Dr. Mets said at the annual meeting of the Teratology Society.

“Obstetricians should be telling their patients not to work around rats in medical labs during their pregnancy [and] not to get a hamster for their 4-year-old if they're going to have other children. It's a preventable disease, but people need to know about it,” she said

Discovered in 1933 and classified in the 1960s as a prototype for the arena virus, lymphocytic choriomeningitis virus (LCMV) is harbored in mice and transferred vertically by uterine infection.

“There is documented infection to humans from wild mice, lab mice, rats, and hamsters,” said Dr. Mets, also professor of ophthalmology and surgery at Northwestern University, Chicago.

“Transmission is thought to be airborne or contamination of food by infected mouse urine,” she said. “There has also been experimental transmission demonstrated by ticks, fleas, mosquitos, and bedbugs.”

About one-third of adults who acquire LCMV are asymptomatic. Of the remaining two-thirds, about half have central nervous system disease. Illness occurs in a biphasic pattern. “First, there's an acute febrile illness with myalgias and headache,” she said. “Later on, meningeal signs may develop, and rarely encephalitis, myocarditis, parotitis, orchitis, and pneumonia. Very rarely, fatal systemic disease is reported.” It's the causative agent in about 10% of aseptic meningitis cases.

LCMV was first described as a fetal pathogen in Great Britain in 1955. The first case of congenital LCMV in the United States was reported in 1993. The baby was born with a birth weight of 2,898 grams. During pregnancy the mother lived in a well-maintained inner-city apartment. At 5 months' gestation, she had a febrile illness that lasted a week. The child was born with hydrocephalus and microphthalmos of the right eye. The right eye had leukocoria, a cloudy vitreous, and exudative retinitis.

A review of 26 infants with LCMV published in 1997 revealed that 88% had chorioretinopathy, 45% had hydrocephalus, and 13% had microcephaly.

Diagnosis is made by IgG indirect fluorescent antibody, which is commercially available. “Or you can get an IgG ELISA at the [Centers for Disease Control and Prevention],” Dr. Mets said. The differential diagnosis includes toxoplasmosis, rubella, cytomegalovirus, herpes simplex virus, enteroviruses, syphilis, parvovirus B19, and West Nile virus.

There is documented human infection from wild mice, lab mice, rats, and hamsters. DR. METS

An optical scan shows that the retinal pigment of the epithelium has been dramatically disturbed in the eye of a 22-month-old child with congenital LCMV. Courtesy Dr. Marilyn Baird Mets

CARLSBAD, CALIF. — The home use of lasers and light sources for hair removal, photorejuvenation, acne treatment, and other cosmetic procedures is here to stay, Dr. Melanie C. Grossman said at a symposium on laser and cosmetic surgery, sponsored by SkinCare Physicians.

“The major issue [with these devices] will be safety and efficacy,” said Dr. Grossman, a dermatologist who practices in New York City. “Once the devices are in the hands of consumers, there will be problems.”

Some patients will not follow the instructions that come with the devices. Others will use the devices in concert with other procedures. “I already see people using topicals that are quite strong coming in with burns after using microdermabrators at home. These side effects will just increase.”

She said although the proliferation of in-home devices has not affected her clinical practice so far, the companies that make in-home devices may “take our business away or they may increase consumer awareness of our business. Most likely, they will change the nature of our practices.”

CARLSBAD, CALIF. — The home use of lasers and light sources for hair removal, photorejuvenation, acne treatment, and other cosmetic procedures is here to stay, Dr. Melanie C. Grossman said at a symposium on laser and cosmetic surgery, sponsored by SkinCare Physicians.

“The major issue [with these devices] will be safety and efficacy,” said Dr. Grossman, a dermatologist who practices in New York City. “Once the devices are in the hands of consumers, there will be problems.”

Some patients will not follow the instructions that come with the devices. Others will use the devices in concert with other procedures. “I already see people using topicals that are quite strong coming in with burns after using microdermabrators at home. These side effects will just increase.”

She said although the proliferation of in-home devices has not affected her clinical practice so far, the companies that make in-home devices may “take our business away or they may increase consumer awareness of our business. Most likely, they will change the nature of our practices.”

CARLSBAD, CALIF. — The home use of lasers and light sources for hair removal, photorejuvenation, acne treatment, and other cosmetic procedures is here to stay, Dr. Melanie C. Grossman said at a symposium on laser and cosmetic surgery, sponsored by SkinCare Physicians.

“The major issue [with these devices] will be safety and efficacy,” said Dr. Grossman, a dermatologist who practices in New York City. “Once the devices are in the hands of consumers, there will be problems.”

Some patients will not follow the instructions that come with the devices. Others will use the devices in concert with other procedures. “I already see people using topicals that are quite strong coming in with burns after using microdermabrators at home. These side effects will just increase.”

She said although the proliferation of in-home devices has not affected her clinical practice so far, the companies that make in-home devices may “take our business away or they may increase consumer awareness of our business. Most likely, they will change the nature of our practices.”

LOS ANGELES — Endoscopic ultrasonography and magnetic resonance plus MRI-pancreatography are becoming preferred methods for helping clinicians diagnose chronic pancreatitis. But it's probably not necessary to use both of these imaging techniques, Dr. Julio Iglesias-Garcia reported at the annual Digestive Disease Week.

“There is a good correlation between endoscopic ultrasound and [magnetic resonance plus MRI-pancreatography] for the evaluation of patients with suspected chronic pancreatitis, also in the global evaluation of the diagnosis of the disease and also in the evaluation of both parenchymal and ductal characteristics,” said Dr. Iglesias-Garcia of University Hospital of Santiago de Compostela, Spain. “Probably one of [these tests] would be enough for the evaluation of these patients.” He based his remarks on a study of 26 consecutive patients evaluated for suspected chronic pancreatitis.

The mean age of patients was 48 years, and 14 were male.

Each patient underwent endoscopic ultrasonography (EUS) and magnetic resonance plus MRI-pancreatography (MRI-MRP), with the tests performed 2–7 days apart.

For EUS, chronic pancreatitis was defined as the presence of at least three parenchymal and ductal criteria. For MRI-MRP, chronic pancreatitis was defined as the presence of at least one parenchymal and one ductal change.

Dr. Iglesias-Garcia and his associates performed concordance and correlation studies between the two techniques.

The researchers found that both techniques diagnosed chronic pancreatitis in 17 patients (65.4%) and consistently excluded diagnosis of the disease in 4 patients (15.4%).

“EUS and MRI-MRP provided the same diagnosis in 21 patients (80.8%). The MRI-MRP finding was considered equivocal in the remaining five patients, three of them with normal EUS and two with EUS criteria. Diagnostic concordance was highly significant,” the researchers wrote.

In another study presented at the meeting, Dr. Surakit Pungpapong and his colleagues found that combining EUS with a test for pancreatic juice interleukin 8 (IL-8) concentration is highly predictive of diagnosing chronic pancreatitis.

“To diagnose chronic pancreatitis, EUS and pancreatic juice collection for IL-8 concentration can be performed sequentially under the same sedation at the same time,” said Dr. Pungpapong, an internist with the Mayo Clinic, Jacksonville, Fla.

“Both tests are complementary when used together, resulting in higher sensitivity and specificity.”

Between January 2003 and December 2004, he and his associates enrolled 79 patients who presented to the pancreas clinic at Mayo Clinic Jacksonville with abdominal pain suggestive of chronic pancreatitis.

Each patient underwent EUS with radial and linear echoendoscopes as well as pancreatic juice collection for IL-8 concentration. (A level of 20 pg/mL indicated disease.)

Of the 79 patients, 38 were diagnosed with chronic pancreatitis, and the remaining 41 served as comparators. The mean age of patients found to have disease was 56 years, whereas the mean age of the comparators was 49 years.

The researchers found that EUS had an accuracy of 80%, a sensitivity of 71%, and a specificity of 88%, whereas the pancreatic juice IL-8 concentration marker had an accuracy of 71%, a sensitivity of 47%, and a specificity of 93%.

When Dr. Pungpapong and his associates combined the findings of the two tests, the sensitivity and specificity increased to 82% (either EUS or IL-8 positive) and 100% (both EUS and IL-8 positive), respectively.

He emphasized that a larger study is needed to confirm the findings.

'There is a good correlation between endoscopic ultrasound and [MRI-MRP].' DR. IGLESIAS-GARCIA

LOS ANGELES — Endoscopic ultrasonography and magnetic resonance plus MRI-pancreatography are becoming preferred methods for helping clinicians diagnose chronic pancreatitis. But it's probably not necessary to use both of these imaging techniques, Dr. Julio Iglesias-Garcia reported at the annual Digestive Disease Week.

“There is a good correlation between endoscopic ultrasound and [magnetic resonance plus MRI-pancreatography] for the evaluation of patients with suspected chronic pancreatitis, also in the global evaluation of the diagnosis of the disease and also in the evaluation of both parenchymal and ductal characteristics,” said Dr. Iglesias-Garcia of University Hospital of Santiago de Compostela, Spain. “Probably one of [these tests] would be enough for the evaluation of these patients.” He based his remarks on a study of 26 consecutive patients evaluated for suspected chronic pancreatitis.

The mean age of patients was 48 years, and 14 were male.

Each patient underwent endoscopic ultrasonography (EUS) and magnetic resonance plus MRI-pancreatography (MRI-MRP), with the tests performed 2–7 days apart.

For EUS, chronic pancreatitis was defined as the presence of at least three parenchymal and ductal criteria. For MRI-MRP, chronic pancreatitis was defined as the presence of at least one parenchymal and one ductal change.

Dr. Iglesias-Garcia and his associates performed concordance and correlation studies between the two techniques.

The researchers found that both techniques diagnosed chronic pancreatitis in 17 patients (65.4%) and consistently excluded diagnosis of the disease in 4 patients (15.4%).

“EUS and MRI-MRP provided the same diagnosis in 21 patients (80.8%). The MRI-MRP finding was considered equivocal in the remaining five patients, three of them with normal EUS and two with EUS criteria. Diagnostic concordance was highly significant,” the researchers wrote.

In another study presented at the meeting, Dr. Surakit Pungpapong and his colleagues found that combining EUS with a test for pancreatic juice interleukin 8 (IL-8) concentration is highly predictive of diagnosing chronic pancreatitis.

“To diagnose chronic pancreatitis, EUS and pancreatic juice collection for IL-8 concentration can be performed sequentially under the same sedation at the same time,” said Dr. Pungpapong, an internist with the Mayo Clinic, Jacksonville, Fla.

“Both tests are complementary when used together, resulting in higher sensitivity and specificity.”

Between January 2003 and December 2004, he and his associates enrolled 79 patients who presented to the pancreas clinic at Mayo Clinic Jacksonville with abdominal pain suggestive of chronic pancreatitis.

Each patient underwent EUS with radial and linear echoendoscopes as well as pancreatic juice collection for IL-8 concentration. (A level of 20 pg/mL indicated disease.)

Of the 79 patients, 38 were diagnosed with chronic pancreatitis, and the remaining 41 served as comparators. The mean age of patients found to have disease was 56 years, whereas the mean age of the comparators was 49 years.

The researchers found that EUS had an accuracy of 80%, a sensitivity of 71%, and a specificity of 88%, whereas the pancreatic juice IL-8 concentration marker had an accuracy of 71%, a sensitivity of 47%, and a specificity of 93%.

When Dr. Pungpapong and his associates combined the findings of the two tests, the sensitivity and specificity increased to 82% (either EUS or IL-8 positive) and 100% (both EUS and IL-8 positive), respectively.

He emphasized that a larger study is needed to confirm the findings.

'There is a good correlation between endoscopic ultrasound and [MRI-MRP].' DR. IGLESIAS-GARCIA

LOS ANGELES — Endoscopic ultrasonography and magnetic resonance plus MRI-pancreatography are becoming preferred methods for helping clinicians diagnose chronic pancreatitis. But it's probably not necessary to use both of these imaging techniques, Dr. Julio Iglesias-Garcia reported at the annual Digestive Disease Week.

“There is a good correlation between endoscopic ultrasound and [magnetic resonance plus MRI-pancreatography] for the evaluation of patients with suspected chronic pancreatitis, also in the global evaluation of the diagnosis of the disease and also in the evaluation of both parenchymal and ductal characteristics,” said Dr. Iglesias-Garcia of University Hospital of Santiago de Compostela, Spain. “Probably one of [these tests] would be enough for the evaluation of these patients.” He based his remarks on a study of 26 consecutive patients evaluated for suspected chronic pancreatitis.

The mean age of patients was 48 years, and 14 were male.

Each patient underwent endoscopic ultrasonography (EUS) and magnetic resonance plus MRI-pancreatography (MRI-MRP), with the tests performed 2–7 days apart.

For EUS, chronic pancreatitis was defined as the presence of at least three parenchymal and ductal criteria. For MRI-MRP, chronic pancreatitis was defined as the presence of at least one parenchymal and one ductal change.

Dr. Iglesias-Garcia and his associates performed concordance and correlation studies between the two techniques.

The researchers found that both techniques diagnosed chronic pancreatitis in 17 patients (65.4%) and consistently excluded diagnosis of the disease in 4 patients (15.4%).

“EUS and MRI-MRP provided the same diagnosis in 21 patients (80.8%). The MRI-MRP finding was considered equivocal in the remaining five patients, three of them with normal EUS and two with EUS criteria. Diagnostic concordance was highly significant,” the researchers wrote.

In another study presented at the meeting, Dr. Surakit Pungpapong and his colleagues found that combining EUS with a test for pancreatic juice interleukin 8 (IL-8) concentration is highly predictive of diagnosing chronic pancreatitis.

“To diagnose chronic pancreatitis, EUS and pancreatic juice collection for IL-8 concentration can be performed sequentially under the same sedation at the same time,” said Dr. Pungpapong, an internist with the Mayo Clinic, Jacksonville, Fla.

“Both tests are complementary when used together, resulting in higher sensitivity and specificity.”

Between January 2003 and December 2004, he and his associates enrolled 79 patients who presented to the pancreas clinic at Mayo Clinic Jacksonville with abdominal pain suggestive of chronic pancreatitis.

Each patient underwent EUS with radial and linear echoendoscopes as well as pancreatic juice collection for IL-8 concentration. (A level of 20 pg/mL indicated disease.)

Of the 79 patients, 38 were diagnosed with chronic pancreatitis, and the remaining 41 served as comparators. The mean age of patients found to have disease was 56 years, whereas the mean age of the comparators was 49 years.

The researchers found that EUS had an accuracy of 80%, a sensitivity of 71%, and a specificity of 88%, whereas the pancreatic juice IL-8 concentration marker had an accuracy of 71%, a sensitivity of 47%, and a specificity of 93%.

When Dr. Pungpapong and his associates combined the findings of the two tests, the sensitivity and specificity increased to 82% (either EUS or IL-8 positive) and 100% (both EUS and IL-8 positive), respectively.

He emphasized that a larger study is needed to confirm the findings.

'There is a good correlation between endoscopic ultrasound and [MRI-MRP].' DR. IGLESIAS-GARCIA

CARLSBAD, CALIF. — Treating pigmented lesions by combining different lasers "is tempting, since the single-modality approach remains imperfect," Dr. Jerome M. Garden said at a symposium on laser and cosmetic surgery sponsored by SkinCare Physicians.

The number of available options is "wide open. You can use different wavelengths and different pulse durations. But there is a serious potential for greater side effects," and it's worthwhile to ask, "Is it worth it, and is there something as good and maybe safer?" he said.

As a case in point, he discussed a recent study in which researchers used the CO₂ laser and the Q-switched alexandrite laser to treat congenital nevomelanocytic nevi in 11 patients (Dermatol. Surg. 2005;31:518–21). The nevi were first treated with one or two CO₂ laser passes to peel off the dermis. This was followed by treatment with the Q-switched alexandrite laser.

The average improvement was 51%–70%, but nearly 30% of patients had hypertrophic scarring. The researchers were "able to get rid of the nevus, but [they] also scarred the whole area, which is something you're not trying to do," said Dr. Garden of the department of dermatology at Northwestern University, Chicago.

In a more recent study, researchers used the 532-nm Nd:YAG laser followed by the 1064-nm Q-switched Nd:YAG laser to treat patients with acquired bilateral Hori's nevus (Dermatol. Surg. 2006; 32:34–40). Patients' right cheeks were treated with the 532-nm laser plus the 1064-nm laser, while the left cheeks were treated with the 1064-nm laser alone. The combination treatment yielded more effective results, but the combined approach also caused more postinflammatory hyperpigmentation.

"I think the reason was that there was just more heat to the area," Dr. Garden said.

He shared his own experience with one patient whose pigmented lesions he treated with a Q-switched ruby laser and a long-pulsed diode laser. The patient got some reduction in color, but also experienced hypertrophic scarring. "It's interesting that [this combination approach] is helpful. Unfortunately, because we are tossing in more energy, it's also very scary in terms of the outcome," he said.

Dr. Garden disclosed that he has received equipment from Candela, Hoya ConBio, Palomar, and Sinon. He has also received research funding from Candela.

CARLSBAD, CALIF. — Treating pigmented lesions by combining different lasers "is tempting, since the single-modality approach remains imperfect," Dr. Jerome M. Garden said at a symposium on laser and cosmetic surgery sponsored by SkinCare Physicians.

The number of available options is "wide open. You can use different wavelengths and different pulse durations. But there is a serious potential for greater side effects," and it's worthwhile to ask, "Is it worth it, and is there something as good and maybe safer?" he said.

As a case in point, he discussed a recent study in which researchers used the CO₂ laser and the Q-switched alexandrite laser to treat congenital nevomelanocytic nevi in 11 patients (Dermatol. Surg. 2005;31:518–21). The nevi were first treated with one or two CO₂ laser passes to peel off the dermis. This was followed by treatment with the Q-switched alexandrite laser.

The average improvement was 51%–70%, but nearly 30% of patients had hypertrophic scarring. The researchers were "able to get rid of the nevus, but [they] also scarred the whole area, which is something you're not trying to do," said Dr. Garden of the department of dermatology at Northwestern University, Chicago.

In a more recent study, researchers used the 532-nm Nd:YAG laser followed by the 1064-nm Q-switched Nd:YAG laser to treat patients with acquired bilateral Hori's nevus (Dermatol. Surg. 2006; 32:34–40). Patients' right cheeks were treated with the 532-nm laser plus the 1064-nm laser, while the left cheeks were treated with the 1064-nm laser alone. The combination treatment yielded more effective results, but the combined approach also caused more postinflammatory hyperpigmentation.

"I think the reason was that there was just more heat to the area," Dr. Garden said.

He shared his own experience with one patient whose pigmented lesions he treated with a Q-switched ruby laser and a long-pulsed diode laser. The patient got some reduction in color, but also experienced hypertrophic scarring. "It's interesting that [this combination approach] is helpful. Unfortunately, because we are tossing in more energy, it's also very scary in terms of the outcome," he said.

Dr. Garden disclosed that he has received equipment from Candela, Hoya ConBio, Palomar, and Sinon. He has also received research funding from Candela.

CARLSBAD, CALIF. — Treating pigmented lesions by combining different lasers "is tempting, since the single-modality approach remains imperfect," Dr. Jerome M. Garden said at a symposium on laser and cosmetic surgery sponsored by SkinCare Physicians.

The number of available options is "wide open. You can use different wavelengths and different pulse durations. But there is a serious potential for greater side effects," and it's worthwhile to ask, "Is it worth it, and is there something as good and maybe safer?" he said.

As a case in point, he discussed a recent study in which researchers used the CO₂ laser and the Q-switched alexandrite laser to treat congenital nevomelanocytic nevi in 11 patients (Dermatol. Surg. 2005;31:518–21). The nevi were first treated with one or two CO₂ laser passes to peel off the dermis. This was followed by treatment with the Q-switched alexandrite laser.

The average improvement was 51%–70%, but nearly 30% of patients had hypertrophic scarring. The researchers were "able to get rid of the nevus, but [they] also scarred the whole area, which is something you're not trying to do," said Dr. Garden of the department of dermatology at Northwestern University, Chicago.

In a more recent study, researchers used the 532-nm Nd:YAG laser followed by the 1064-nm Q-switched Nd:YAG laser to treat patients with acquired bilateral Hori's nevus (Dermatol. Surg. 2006; 32:34–40). Patients' right cheeks were treated with the 532-nm laser plus the 1064-nm laser, while the left cheeks were treated with the 1064-nm laser alone. The combination treatment yielded more effective results, but the combined approach also caused more postinflammatory hyperpigmentation.

"I think the reason was that there was just more heat to the area," Dr. Garden said.

He shared his own experience with one patient whose pigmented lesions he treated with a Q-switched ruby laser and a long-pulsed diode laser. The patient got some reduction in color, but also experienced hypertrophic scarring. "It's interesting that [this combination approach] is helpful. Unfortunately, because we are tossing in more energy, it's also very scary in terms of the outcome," he said.

Dr. Garden disclosed that he has received equipment from Candela, Hoya ConBio, Palomar, and Sinon. He has also received research funding from Candela.