Sherry Boschert

SAN DIEGO – When choosing a therapy for physical fatigue in patients being treated for depression, it is important to consider the presence or absence of residual sadness, Dr. Stephen C. Ellen said at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

Two strategies exist for treating patients on antidepressants who complain that activities make them feel more physically tired, winded, or older than they felt before depression set in, despite getting help for the depression. Both bupropion and stimulants will boost dopamine and norepinephrine in the cortex, striatum, and spinal cord. Modafinil will boost histamine in the cortex, he said.

Dr. Ellen is a speaker for GlaxoSmithKline, which makes Wellbutrin (bupropion). He also serves as a consultant and speaker for Cephalon Inc., which makes Provigil (modafinil).

If the patient's antidepressant therapy has virtually eliminated the sadness and mood issues, choose modafinil or methylphenidate (for example, Ritalin) or another stimulant to treat the residual physical fatigue. If some sadness still remains, however, bupropion may boost antidepressant effects and reduce fatigue, said Dr. Ellen of the University of Massachusetts, Worcester.

Modafinil or stimulants work much better at “waking somebody up” from residual symptoms of depression than does bupropion, he said. Bupropion “is brightening, but I don't think it is particularly wake promoting.”

Physical fatigue is common in patients with depression or obstructive sleep apnea, and the two problems overlap. One in six depressed people has obstructive sleep apnea, and one in five people with obstructive sleep apnea is depressed, he noted. A 2003 study of 60 patients found that the more severe the depression in a patient with sleep apnea, the greater the level of fatigue.

In patients with both depression and obstructive sleep apnea, the fatigue usually derives from the depression. “So if you're still getting words that sound like fatigue” after treatment, consider switching to a stronger antidepressant or increasing the dose, Dr. Ellen advised.

Bupropion is widely used to treat fatigue in patients with depression but it “takes a while to kick in,” typically 4–6 weeks, he said. Some reports suggest that bupropion may be less likely than other antidepressants to destabilize a patient with bipolar disorder, but other reports suggest that the risk is no different with bupropion.

A case series of 42 patients treated for depression with selective serotonin reuptake inhibitors found that energy levels stayed the same or improved in patients who received adjuvant bupropion but worsened in nearly half of patients who remained on monotherapy, Dr. Ellen said.

Stimulants are not commonly used to treat fatigue in depressed patients, but they can quickly provide a boost in alertness with short-term use. Most studies of stimulants for fatigue focus on patients with HIV or AIDS. There are no controlled trials of stimulants for fatigue associated with depression, “but that shouldn't throw you off, because there's not a single controlled study of [bupropion for this indication] either, and we use that like crazy,” he said.

Stimulants, however, can cause cardiovascular or CNS side effects and have a high risk for abuse with long-term use. Patients may develop psychological or physical dependence on them, and tolerance to the drug develops rapidly, Dr. Ellen said.

Adding modafinil to antidepressant therapy appears to significantly reduce patients' fatigue scores if the drug is given in proper doses. The best effects are seen with 100–200 mg/day. Less benefit comes from a dosage of 300 mg/day, and a dosage of 400 mg/day can increase fatigue, he said.

Modafinil's effects on fatigue in depression appear to be independent of mood, and the onset of action usually is immediate, he noted.

SAN DIEGO – When choosing a therapy for physical fatigue in patients being treated for depression, it is important to consider the presence or absence of residual sadness, Dr. Stephen C. Ellen said at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

Two strategies exist for treating patients on antidepressants who complain that activities make them feel more physically tired, winded, or older than they felt before depression set in, despite getting help for the depression. Both bupropion and stimulants will boost dopamine and norepinephrine in the cortex, striatum, and spinal cord. Modafinil will boost histamine in the cortex, he said.

Dr. Ellen is a speaker for GlaxoSmithKline, which makes Wellbutrin (bupropion). He also serves as a consultant and speaker for Cephalon Inc., which makes Provigil (modafinil).

If the patient's antidepressant therapy has virtually eliminated the sadness and mood issues, choose modafinil or methylphenidate (for example, Ritalin) or another stimulant to treat the residual physical fatigue. If some sadness still remains, however, bupropion may boost antidepressant effects and reduce fatigue, said Dr. Ellen of the University of Massachusetts, Worcester.

Modafinil or stimulants work much better at “waking somebody up” from residual symptoms of depression than does bupropion, he said. Bupropion “is brightening, but I don't think it is particularly wake promoting.”

Physical fatigue is common in patients with depression or obstructive sleep apnea, and the two problems overlap. One in six depressed people has obstructive sleep apnea, and one in five people with obstructive sleep apnea is depressed, he noted. A 2003 study of 60 patients found that the more severe the depression in a patient with sleep apnea, the greater the level of fatigue.

In patients with both depression and obstructive sleep apnea, the fatigue usually derives from the depression. “So if you're still getting words that sound like fatigue” after treatment, consider switching to a stronger antidepressant or increasing the dose, Dr. Ellen advised.

Bupropion is widely used to treat fatigue in patients with depression but it “takes a while to kick in,” typically 4–6 weeks, he said. Some reports suggest that bupropion may be less likely than other antidepressants to destabilize a patient with bipolar disorder, but other reports suggest that the risk is no different with bupropion.

A case series of 42 patients treated for depression with selective serotonin reuptake inhibitors found that energy levels stayed the same or improved in patients who received adjuvant bupropion but worsened in nearly half of patients who remained on monotherapy, Dr. Ellen said.

Stimulants are not commonly used to treat fatigue in depressed patients, but they can quickly provide a boost in alertness with short-term use. Most studies of stimulants for fatigue focus on patients with HIV or AIDS. There are no controlled trials of stimulants for fatigue associated with depression, “but that shouldn't throw you off, because there's not a single controlled study of [bupropion for this indication] either, and we use that like crazy,” he said.

Stimulants, however, can cause cardiovascular or CNS side effects and have a high risk for abuse with long-term use. Patients may develop psychological or physical dependence on them, and tolerance to the drug develops rapidly, Dr. Ellen said.

Adding modafinil to antidepressant therapy appears to significantly reduce patients' fatigue scores if the drug is given in proper doses. The best effects are seen with 100–200 mg/day. Less benefit comes from a dosage of 300 mg/day, and a dosage of 400 mg/day can increase fatigue, he said.

Modafinil's effects on fatigue in depression appear to be independent of mood, and the onset of action usually is immediate, he noted.

SAN DIEGO – When choosing a therapy for physical fatigue in patients being treated for depression, it is important to consider the presence or absence of residual sadness, Dr. Stephen C. Ellen said at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

Two strategies exist for treating patients on antidepressants who complain that activities make them feel more physically tired, winded, or older than they felt before depression set in, despite getting help for the depression. Both bupropion and stimulants will boost dopamine and norepinephrine in the cortex, striatum, and spinal cord. Modafinil will boost histamine in the cortex, he said.

Dr. Ellen is a speaker for GlaxoSmithKline, which makes Wellbutrin (bupropion). He also serves as a consultant and speaker for Cephalon Inc., which makes Provigil (modafinil).

If the patient's antidepressant therapy has virtually eliminated the sadness and mood issues, choose modafinil or methylphenidate (for example, Ritalin) or another stimulant to treat the residual physical fatigue. If some sadness still remains, however, bupropion may boost antidepressant effects and reduce fatigue, said Dr. Ellen of the University of Massachusetts, Worcester.

Modafinil or stimulants work much better at “waking somebody up” from residual symptoms of depression than does bupropion, he said. Bupropion “is brightening, but I don't think it is particularly wake promoting.”

Physical fatigue is common in patients with depression or obstructive sleep apnea, and the two problems overlap. One in six depressed people has obstructive sleep apnea, and one in five people with obstructive sleep apnea is depressed, he noted. A 2003 study of 60 patients found that the more severe the depression in a patient with sleep apnea, the greater the level of fatigue.

In patients with both depression and obstructive sleep apnea, the fatigue usually derives from the depression. “So if you're still getting words that sound like fatigue” after treatment, consider switching to a stronger antidepressant or increasing the dose, Dr. Ellen advised.

Bupropion is widely used to treat fatigue in patients with depression but it “takes a while to kick in,” typically 4–6 weeks, he said. Some reports suggest that bupropion may be less likely than other antidepressants to destabilize a patient with bipolar disorder, but other reports suggest that the risk is no different with bupropion.

A case series of 42 patients treated for depression with selective serotonin reuptake inhibitors found that energy levels stayed the same or improved in patients who received adjuvant bupropion but worsened in nearly half of patients who remained on monotherapy, Dr. Ellen said.

Stimulants are not commonly used to treat fatigue in depressed patients, but they can quickly provide a boost in alertness with short-term use. Most studies of stimulants for fatigue focus on patients with HIV or AIDS. There are no controlled trials of stimulants for fatigue associated with depression, “but that shouldn't throw you off, because there's not a single controlled study of [bupropion for this indication] either, and we use that like crazy,” he said.

Stimulants, however, can cause cardiovascular or CNS side effects and have a high risk for abuse with long-term use. Patients may develop psychological or physical dependence on them, and tolerance to the drug develops rapidly, Dr. Ellen said.

Adding modafinil to antidepressant therapy appears to significantly reduce patients' fatigue scores if the drug is given in proper doses. The best effects are seen with 100–200 mg/day. Less benefit comes from a dosage of 300 mg/day, and a dosage of 400 mg/day can increase fatigue, he said.

Modafinil's effects on fatigue in depression appear to be independent of mood, and the onset of action usually is immediate, he noted.

SAN FRANCISCO – Estimates of the number of U.S. residents who have been infected with hepatitis C virus missed about 1.1 million cases, bringing the true total of infections close to 5.2 million, Dr. Brian R. Edlin said at the annual meeting of the American Association for the Study of Liver Diseases.

“The projected burden of disease in the coming decades may be underestimated,” which could skew planning for public health interventions and future health care services, said Dr. Edlin of Cornell University, New York.

Previous estimates used data from the National Health and Nutrition Examination Survey (NHANES), which samples the noninstitutionalized civilian population but excludes several populations at high risk for hepatitis C virus (HCV) infection.

Estimates based on NHANES data from 1988 to 1994 suggested that 3.9 million U.S. residents had HCV antibodies in their blood and 2.7 million were currently infected. NHANES data from 1999 to 2002, which will be published soon, pegged the number of U.S. residents with HCV antibodies at 4.1 million and the number currently infected at 3.2 million, Dr. Edlin said.

He and his associates analyzed other data to estimate the prevalence of HCV antibodies in five groups excluded from NHANES: people who are incarcerated, homeless, hospitalized, in nursing homes, or on active military duty. Data came from the U.S. Census, the Centers for Medicare and Medicaid Services, the Bureau of Justice Statistics, and the published literature. There are no representative samples for any of these five populations, he said.

Data on prisoners in four states suggested that 32% had HCV antibodies. Six studies of homeless populations found HCV antibodies in 22%-53%, for an overall prevalence of 35%. In seven studies of hospitalized patients, the prevalence ranged from 12% to 21%, with 17% overall having HCV antibodies. Nearly 5% of nursing home residents in one small study had HCV antibodies, as did 0.5% of active military personnel in two large studies.

The numbers add up to 1.1 million more people with HCV antibodies on top of estimates based on NHANES data; most are incarcerated or homeless.

SAN FRANCISCO – Estimates of the number of U.S. residents who have been infected with hepatitis C virus missed about 1.1 million cases, bringing the true total of infections close to 5.2 million, Dr. Brian R. Edlin said at the annual meeting of the American Association for the Study of Liver Diseases.

“The projected burden of disease in the coming decades may be underestimated,” which could skew planning for public health interventions and future health care services, said Dr. Edlin of Cornell University, New York.

Previous estimates used data from the National Health and Nutrition Examination Survey (NHANES), which samples the noninstitutionalized civilian population but excludes several populations at high risk for hepatitis C virus (HCV) infection.

Estimates based on NHANES data from 1988 to 1994 suggested that 3.9 million U.S. residents had HCV antibodies in their blood and 2.7 million were currently infected. NHANES data from 1999 to 2002, which will be published soon, pegged the number of U.S. residents with HCV antibodies at 4.1 million and the number currently infected at 3.2 million, Dr. Edlin said.

He and his associates analyzed other data to estimate the prevalence of HCV antibodies in five groups excluded from NHANES: people who are incarcerated, homeless, hospitalized, in nursing homes, or on active military duty. Data came from the U.S. Census, the Centers for Medicare and Medicaid Services, the Bureau of Justice Statistics, and the published literature. There are no representative samples for any of these five populations, he said.

Data on prisoners in four states suggested that 32% had HCV antibodies. Six studies of homeless populations found HCV antibodies in 22%-53%, for an overall prevalence of 35%. In seven studies of hospitalized patients, the prevalence ranged from 12% to 21%, with 17% overall having HCV antibodies. Nearly 5% of nursing home residents in one small study had HCV antibodies, as did 0.5% of active military personnel in two large studies.

The numbers add up to 1.1 million more people with HCV antibodies on top of estimates based on NHANES data; most are incarcerated or homeless.

SAN FRANCISCO – Estimates of the number of U.S. residents who have been infected with hepatitis C virus missed about 1.1 million cases, bringing the true total of infections close to 5.2 million, Dr. Brian R. Edlin said at the annual meeting of the American Association for the Study of Liver Diseases.

“The projected burden of disease in the coming decades may be underestimated,” which could skew planning for public health interventions and future health care services, said Dr. Edlin of Cornell University, New York.

Previous estimates used data from the National Health and Nutrition Examination Survey (NHANES), which samples the noninstitutionalized civilian population but excludes several populations at high risk for hepatitis C virus (HCV) infection.

Estimates based on NHANES data from 1988 to 1994 suggested that 3.9 million U.S. residents had HCV antibodies in their blood and 2.7 million were currently infected. NHANES data from 1999 to 2002, which will be published soon, pegged the number of U.S. residents with HCV antibodies at 4.1 million and the number currently infected at 3.2 million, Dr. Edlin said.

He and his associates analyzed other data to estimate the prevalence of HCV antibodies in five groups excluded from NHANES: people who are incarcerated, homeless, hospitalized, in nursing homes, or on active military duty. Data came from the U.S. Census, the Centers for Medicare and Medicaid Services, the Bureau of Justice Statistics, and the published literature. There are no representative samples for any of these five populations, he said.

Data on prisoners in four states suggested that 32% had HCV antibodies. Six studies of homeless populations found HCV antibodies in 22%-53%, for an overall prevalence of 35%. In seven studies of hospitalized patients, the prevalence ranged from 12% to 21%, with 17% overall having HCV antibodies. Nearly 5% of nursing home residents in one small study had HCV antibodies, as did 0.5% of active military personnel in two large studies.

The numbers add up to 1.1 million more people with HCV antibodies on top of estimates based on NHANES data; most are incarcerated or homeless.

SAN FRANCISCO – A high rate of sexual dysfunction in 112 men with chronic hepatitis C infection was independent of depression and led to reduced quality of life, Dr. David W. Wan reported at the annual meeting of the American Association for the Study of Liver Diseases.

He and his associates administered three validated questionnaires to assess sexual function, depression, and quality of life in a prospective study of 112 patients with, and 239 men without, hepatitis C virus who were recruited from GI and primary care clinics. The men with HCV did not have decompensated cirrhosis and were not being treated with interferon-ribavirin regimens.

The HCV-infected patients were significantly younger than control patients (median ages 55 and 62, respectively) but they had significantly worse scores in all eight domains of the Brief Male Sexual Function Inventory (BMSFI), said Dr. Wan of New York University, New York.

The BMSFI assessed sexual drive, erection, ejaculation, and overall sexual satisfaction. The scores indicated that 54% in the HCV group were not sexually satisfied, compared with 29% of the control group. The difference remained significant after controlling for age, race, marital status, education, annual income, employment status, and use of alcohol or tobacco.

The HCV group had significantly worse scores on the Beck Depression Inventory, compared with controls, but within the HCV group the severity of depression did not correlate with sexual dissatisfaction.

Men with HCV who were not sexually satisfied scored significantly worse in all eight domains of health-related quality of life in the Medical Outcomes Study Short Form 36 (SF-36), compared with HCV-positive men who were not sexually dissatisfied.

The HCV group as a whole scored significantly worse, compared with controls in two domains of the SF-36–physical functioning and mental health. The SF-36 also assessed social functioning, physical role limitation, emotional role limitation, energy and fatigue, pain, and general health perception.

Although sexual dysfunction has been reported previously in patients with HCV, little is known about its association with the disease. HCV infection is associated with severe endocrine disorders such as thyroid disease and diabetes. The current study excluded patients from either group if they had diabetes, HIV or thyroid disease, cancer, prostate surgery, or alcohol or drug abuse, or if they were on methadone.

SAN FRANCISCO – A high rate of sexual dysfunction in 112 men with chronic hepatitis C infection was independent of depression and led to reduced quality of life, Dr. David W. Wan reported at the annual meeting of the American Association for the Study of Liver Diseases.

He and his associates administered three validated questionnaires to assess sexual function, depression, and quality of life in a prospective study of 112 patients with, and 239 men without, hepatitis C virus who were recruited from GI and primary care clinics. The men with HCV did not have decompensated cirrhosis and were not being treated with interferon-ribavirin regimens.

The HCV-infected patients were significantly younger than control patients (median ages 55 and 62, respectively) but they had significantly worse scores in all eight domains of the Brief Male Sexual Function Inventory (BMSFI), said Dr. Wan of New York University, New York.

The BMSFI assessed sexual drive, erection, ejaculation, and overall sexual satisfaction. The scores indicated that 54% in the HCV group were not sexually satisfied, compared with 29% of the control group. The difference remained significant after controlling for age, race, marital status, education, annual income, employment status, and use of alcohol or tobacco.

The HCV group had significantly worse scores on the Beck Depression Inventory, compared with controls, but within the HCV group the severity of depression did not correlate with sexual dissatisfaction.

Men with HCV who were not sexually satisfied scored significantly worse in all eight domains of health-related quality of life in the Medical Outcomes Study Short Form 36 (SF-36), compared with HCV-positive men who were not sexually dissatisfied.

The HCV group as a whole scored significantly worse, compared with controls in two domains of the SF-36–physical functioning and mental health. The SF-36 also assessed social functioning, physical role limitation, emotional role limitation, energy and fatigue, pain, and general health perception.

Although sexual dysfunction has been reported previously in patients with HCV, little is known about its association with the disease. HCV infection is associated with severe endocrine disorders such as thyroid disease and diabetes. The current study excluded patients from either group if they had diabetes, HIV or thyroid disease, cancer, prostate surgery, or alcohol or drug abuse, or if they were on methadone.

SAN FRANCISCO – A high rate of sexual dysfunction in 112 men with chronic hepatitis C infection was independent of depression and led to reduced quality of life, Dr. David W. Wan reported at the annual meeting of the American Association for the Study of Liver Diseases.

He and his associates administered three validated questionnaires to assess sexual function, depression, and quality of life in a prospective study of 112 patients with, and 239 men without, hepatitis C virus who were recruited from GI and primary care clinics. The men with HCV did not have decompensated cirrhosis and were not being treated with interferon-ribavirin regimens.

The HCV-infected patients were significantly younger than control patients (median ages 55 and 62, respectively) but they had significantly worse scores in all eight domains of the Brief Male Sexual Function Inventory (BMSFI), said Dr. Wan of New York University, New York.

The BMSFI assessed sexual drive, erection, ejaculation, and overall sexual satisfaction. The scores indicated that 54% in the HCV group were not sexually satisfied, compared with 29% of the control group. The difference remained significant after controlling for age, race, marital status, education, annual income, employment status, and use of alcohol or tobacco.

The HCV group had significantly worse scores on the Beck Depression Inventory, compared with controls, but within the HCV group the severity of depression did not correlate with sexual dissatisfaction.

Men with HCV who were not sexually satisfied scored significantly worse in all eight domains of health-related quality of life in the Medical Outcomes Study Short Form 36 (SF-36), compared with HCV-positive men who were not sexually dissatisfied.

The HCV group as a whole scored significantly worse, compared with controls in two domains of the SF-36–physical functioning and mental health. The SF-36 also assessed social functioning, physical role limitation, emotional role limitation, energy and fatigue, pain, and general health perception.

Although sexual dysfunction has been reported previously in patients with HCV, little is known about its association with the disease. HCV infection is associated with severe endocrine disorders such as thyroid disease and diabetes. The current study excluded patients from either group if they had diabetes, HIV or thyroid disease, cancer, prostate surgery, or alcohol or drug abuse, or if they were on methadone.

SAN FRANCISCO — Infectious disease specialists at one institution provided over $93,000 worth of curbside consultations without reimbursement, Dr. Christopher J. Grace said at the annual meeting of the Infectious Diseases Society of America.

Members of the specialty "need to get a handle on this. We're giving away the farm," said Dr. Grace of the University of Vermont, Burlington.

A 1-year prospective study at Fletcher Allen Health Care, a 500-bed community and tertiary care center in Burlington, found that infectious disease specialists gave 1,001 curbside consultations, defined as advice or suggestions given to another physician without seeing the patient. Curbside consults took place in person or by telephone, letter, or e-mail.

Without the physicians or nurses who requested the curbside consultations knowing it, the infectious disease specialists assigned a CPT code to each event based on whether the patient in question was an inpatient or outpatient, whether the consultation dealt with initial care or subsequent care, and how complex the case was. They then gave a physician-work relative value unit, or RVU (used by the Centers for Medicare and Medicaid Services [CMS] to calculate reimbursements) to each curbside consultation based on the CPT code, and multiplied the aggregate RVUs by the 2005 CMS conversion factor of $37.89 per RVU to estimate costs.

In 98% of cases, curbside consultations focused on a specific patient, rather than on theoretical patients or general topics. Among consultations for patients, 34% were for inpatients and 66% were for outpatients. Events were coded as initial consultations in 96% of cases.

The main clinical topics of consultations focused on skin disease in 16% of cases, pulmonary disease in 8%, bone or joint infection in 8%, and bacteremia in 7%.

The curbside consultations accounted for 21% of all infectious disease consultations that year and were equally as complex as formal consultations, Dr. Grace said.

The curbside consultations generated a total of 2,462 RVUs, which would have meant $93,285 "if we were paid the standard Medicare reimbursement fee," he said.

Formal consultations in the same time period generated 9,409 RVUs worth $356,507. The number of RVUs per consultation was higher for curbside (2.46) than for formal consultations (1.22) because the former had a higher proportion of initial consultations.

Who asked for curbside consultations? Questions came about equally from the health center's staff and from community physicians with medical privileges at the center. More questions came from general internists than other specialists.

A physician in the audience urged Dr. Grace to share the results with colleagues in other specialties at his institution. "When you do, they'll be horrified that they're using you this way. It tends to bring your formal consults up," he said, based on his own experience.

Dr. Grace noted that some physicians requesting the curbside consultations practiced 20–150 miles away, making formal consultations more difficult.

Hospitals, insurers, and others need to integrate curbside consultations into productivity measures and compensation measures, he said.

Many in the audience agreed. "We all should have done this 30 years ago, and we'd have more leverage with the payers," one physician said.

Another suggested refusing to do curbside consultations. "At some point we just need to draw the line. If you offend the people who are curbsiding you, you lose nothing," he suggested.

The definition of curbside consultation in the study excluded consultations for infection control, antibiotic restriction efforts, follow-up on formal consultations, education of students or residents, and curbside consultations that converted to formal consultations on the same day.

SAN FRANCISCO — Infectious disease specialists at one institution provided over $93,000 worth of curbside consultations without reimbursement, Dr. Christopher J. Grace said at the annual meeting of the Infectious Diseases Society of America.

Members of the specialty "need to get a handle on this. We're giving away the farm," said Dr. Grace of the University of Vermont, Burlington.

A 1-year prospective study at Fletcher Allen Health Care, a 500-bed community and tertiary care center in Burlington, found that infectious disease specialists gave 1,001 curbside consultations, defined as advice or suggestions given to another physician without seeing the patient. Curbside consults took place in person or by telephone, letter, or e-mail.

Without the physicians or nurses who requested the curbside consultations knowing it, the infectious disease specialists assigned a CPT code to each event based on whether the patient in question was an inpatient or outpatient, whether the consultation dealt with initial care or subsequent care, and how complex the case was. They then gave a physician-work relative value unit, or RVU (used by the Centers for Medicare and Medicaid Services [CMS] to calculate reimbursements) to each curbside consultation based on the CPT code, and multiplied the aggregate RVUs by the 2005 CMS conversion factor of $37.89 per RVU to estimate costs.

In 98% of cases, curbside consultations focused on a specific patient, rather than on theoretical patients or general topics. Among consultations for patients, 34% were for inpatients and 66% were for outpatients. Events were coded as initial consultations in 96% of cases.

The main clinical topics of consultations focused on skin disease in 16% of cases, pulmonary disease in 8%, bone or joint infection in 8%, and bacteremia in 7%.

The curbside consultations accounted for 21% of all infectious disease consultations that year and were equally as complex as formal consultations, Dr. Grace said.

The curbside consultations generated a total of 2,462 RVUs, which would have meant $93,285 "if we were paid the standard Medicare reimbursement fee," he said.

Formal consultations in the same time period generated 9,409 RVUs worth $356,507. The number of RVUs per consultation was higher for curbside (2.46) than for formal consultations (1.22) because the former had a higher proportion of initial consultations.

Who asked for curbside consultations? Questions came about equally from the health center's staff and from community physicians with medical privileges at the center. More questions came from general internists than other specialists.

A physician in the audience urged Dr. Grace to share the results with colleagues in other specialties at his institution. "When you do, they'll be horrified that they're using you this way. It tends to bring your formal consults up," he said, based on his own experience.

Dr. Grace noted that some physicians requesting the curbside consultations practiced 20–150 miles away, making formal consultations more difficult.

Hospitals, insurers, and others need to integrate curbside consultations into productivity measures and compensation measures, he said.

Many in the audience agreed. "We all should have done this 30 years ago, and we'd have more leverage with the payers," one physician said.

Another suggested refusing to do curbside consultations. "At some point we just need to draw the line. If you offend the people who are curbsiding you, you lose nothing," he suggested.

The definition of curbside consultation in the study excluded consultations for infection control, antibiotic restriction efforts, follow-up on formal consultations, education of students or residents, and curbside consultations that converted to formal consultations on the same day.

SAN FRANCISCO — Infectious disease specialists at one institution provided over $93,000 worth of curbside consultations without reimbursement, Dr. Christopher J. Grace said at the annual meeting of the Infectious Diseases Society of America.

Members of the specialty "need to get a handle on this. We're giving away the farm," said Dr. Grace of the University of Vermont, Burlington.

A 1-year prospective study at Fletcher Allen Health Care, a 500-bed community and tertiary care center in Burlington, found that infectious disease specialists gave 1,001 curbside consultations, defined as advice or suggestions given to another physician without seeing the patient. Curbside consults took place in person or by telephone, letter, or e-mail.

Without the physicians or nurses who requested the curbside consultations knowing it, the infectious disease specialists assigned a CPT code to each event based on whether the patient in question was an inpatient or outpatient, whether the consultation dealt with initial care or subsequent care, and how complex the case was. They then gave a physician-work relative value unit, or RVU (used by the Centers for Medicare and Medicaid Services [CMS] to calculate reimbursements) to each curbside consultation based on the CPT code, and multiplied the aggregate RVUs by the 2005 CMS conversion factor of $37.89 per RVU to estimate costs.

In 98% of cases, curbside consultations focused on a specific patient, rather than on theoretical patients or general topics. Among consultations for patients, 34% were for inpatients and 66% were for outpatients. Events were coded as initial consultations in 96% of cases.

The main clinical topics of consultations focused on skin disease in 16% of cases, pulmonary disease in 8%, bone or joint infection in 8%, and bacteremia in 7%.

The curbside consultations accounted for 21% of all infectious disease consultations that year and were equally as complex as formal consultations, Dr. Grace said.

The curbside consultations generated a total of 2,462 RVUs, which would have meant $93,285 "if we were paid the standard Medicare reimbursement fee," he said.

Formal consultations in the same time period generated 9,409 RVUs worth $356,507. The number of RVUs per consultation was higher for curbside (2.46) than for formal consultations (1.22) because the former had a higher proportion of initial consultations.

Who asked for curbside consultations? Questions came about equally from the health center's staff and from community physicians with medical privileges at the center. More questions came from general internists than other specialists.

A physician in the audience urged Dr. Grace to share the results with colleagues in other specialties at his institution. "When you do, they'll be horrified that they're using you this way. It tends to bring your formal consults up," he said, based on his own experience.

Dr. Grace noted that some physicians requesting the curbside consultations practiced 20–150 miles away, making formal consultations more difficult.

Hospitals, insurers, and others need to integrate curbside consultations into productivity measures and compensation measures, he said.

Many in the audience agreed. "We all should have done this 30 years ago, and we'd have more leverage with the payers," one physician said.

Another suggested refusing to do curbside consultations. "At some point we just need to draw the line. If you offend the people who are curbsiding you, you lose nothing," he suggested.

The definition of curbside consultation in the study excluded consultations for infection control, antibiotic restriction efforts, follow-up on formal consultations, education of students or residents, and curbside consultations that converted to formal consultations on the same day.

SAN DIEGO — Identify and treat abdominal pelvic pain or dyspareunia originating from bladder problems before performing supracervical hysterectomy for menometrorrhagia, Maurice K. Chung, M.D., advised at an international congress of the Society of Laparoendoscopic Surgeons.

By selecting only patients who are free of pain and dyspareunia and by transecting the uterus and part of the upper cervix, he said, postoperative spotting or bleeding can be avoided.

Patients who still have abdominal pelvic pain or dyspareunia after management of bladder problems should not be candidates for supracervical hysterectomy because of the risk that pain symptoms will persist after the procedure, leading to a second surgery to remove the cervix, said Dr. Chung, who has a private practice in Toledo, Ohio.

He reported on 42 laparoscopic supracervical hysterectomies he performed for menometrorrhagia from 2002 to 2004. Of the 42 women, 13 also presented with abdominal pelvic pain and dyspareunia underwent potassium sensitivity tests, which were positive in 12 patients, pointing to bladder problems as the cause of the pain. He treated all 13 medically for bladder problems until they were pain free before proceeding to laparoscopic supracervical hysterectomy.

Thirteen of the 42 patients had adenomyosis, and 6 of those had symptoms of abdominal pelvic pain or dyspareunia, in addition to menometrorrhagia. Five of the six had positive potassium-sensitivity tests, and medical treatment resolved their pain before proceeding to surgery.

The laparoscopic supracervical hysterectomies included endoscopic suturing of the bilateral ascending uterine arteries at the mid-cervix. Patients were followed for 6 months to 2 years.

In general, about 10% of women who undergo laparoscopic supracervical hysterectomy report postoperative spotting or bleeding. Twelve women in the current study underwent concomitant bilateral salpingo-oophorectomy. No bleeding or spotting would be expected after this surgery unless the patient started hormone therapy.

None of the 42 patients reported any postoperative bleeding or spotting, which Dr. Chung said was most likely due to a careful selection of patients. Selecting patients for surgery who have only menometrorrhagia will increase the rate of amenorrhea, he said.

SAN DIEGO — Identify and treat abdominal pelvic pain or dyspareunia originating from bladder problems before performing supracervical hysterectomy for menometrorrhagia, Maurice K. Chung, M.D., advised at an international congress of the Society of Laparoendoscopic Surgeons.

By selecting only patients who are free of pain and dyspareunia and by transecting the uterus and part of the upper cervix, he said, postoperative spotting or bleeding can be avoided.

Patients who still have abdominal pelvic pain or dyspareunia after management of bladder problems should not be candidates for supracervical hysterectomy because of the risk that pain symptoms will persist after the procedure, leading to a second surgery to remove the cervix, said Dr. Chung, who has a private practice in Toledo, Ohio.

He reported on 42 laparoscopic supracervical hysterectomies he performed for menometrorrhagia from 2002 to 2004. Of the 42 women, 13 also presented with abdominal pelvic pain and dyspareunia underwent potassium sensitivity tests, which were positive in 12 patients, pointing to bladder problems as the cause of the pain. He treated all 13 medically for bladder problems until they were pain free before proceeding to laparoscopic supracervical hysterectomy.

Thirteen of the 42 patients had adenomyosis, and 6 of those had symptoms of abdominal pelvic pain or dyspareunia, in addition to menometrorrhagia. Five of the six had positive potassium-sensitivity tests, and medical treatment resolved their pain before proceeding to surgery.

The laparoscopic supracervical hysterectomies included endoscopic suturing of the bilateral ascending uterine arteries at the mid-cervix. Patients were followed for 6 months to 2 years.

In general, about 10% of women who undergo laparoscopic supracervical hysterectomy report postoperative spotting or bleeding. Twelve women in the current study underwent concomitant bilateral salpingo-oophorectomy. No bleeding or spotting would be expected after this surgery unless the patient started hormone therapy.

None of the 42 patients reported any postoperative bleeding or spotting, which Dr. Chung said was most likely due to a careful selection of patients. Selecting patients for surgery who have only menometrorrhagia will increase the rate of amenorrhea, he said.

SAN DIEGO — Identify and treat abdominal pelvic pain or dyspareunia originating from bladder problems before performing supracervical hysterectomy for menometrorrhagia, Maurice K. Chung, M.D., advised at an international congress of the Society of Laparoendoscopic Surgeons.

By selecting only patients who are free of pain and dyspareunia and by transecting the uterus and part of the upper cervix, he said, postoperative spotting or bleeding can be avoided.

Patients who still have abdominal pelvic pain or dyspareunia after management of bladder problems should not be candidates for supracervical hysterectomy because of the risk that pain symptoms will persist after the procedure, leading to a second surgery to remove the cervix, said Dr. Chung, who has a private practice in Toledo, Ohio.

He reported on 42 laparoscopic supracervical hysterectomies he performed for menometrorrhagia from 2002 to 2004. Of the 42 women, 13 also presented with abdominal pelvic pain and dyspareunia underwent potassium sensitivity tests, which were positive in 12 patients, pointing to bladder problems as the cause of the pain. He treated all 13 medically for bladder problems until they were pain free before proceeding to laparoscopic supracervical hysterectomy.

Thirteen of the 42 patients had adenomyosis, and 6 of those had symptoms of abdominal pelvic pain or dyspareunia, in addition to menometrorrhagia. Five of the six had positive potassium-sensitivity tests, and medical treatment resolved their pain before proceeding to surgery.

The laparoscopic supracervical hysterectomies included endoscopic suturing of the bilateral ascending uterine arteries at the mid-cervix. Patients were followed for 6 months to 2 years.

In general, about 10% of women who undergo laparoscopic supracervical hysterectomy report postoperative spotting or bleeding. Twelve women in the current study underwent concomitant bilateral salpingo-oophorectomy. No bleeding or spotting would be expected after this surgery unless the patient started hormone therapy.

None of the 42 patients reported any postoperative bleeding or spotting, which Dr. Chung said was most likely due to a careful selection of patients. Selecting patients for surgery who have only menometrorrhagia will increase the rate of amenorrhea, he said.

SAN DIEGO — Complications occurred in 11% of 2,051 patients who underwent laparoscopic myomectomy, which compares favorably with a complication rate of 35% for myomectomy performed by laparotomy—a figure that has been reported in the literature, Rocco Spagnolo, M.D., said at an international congress of the Society of Laparoendoscopic Surgeons.

The new data come from the first large series of cases studied with a focus on complications from laparoscopic myomectomy. The multicenter Italian study reviewed patient records retrospectively and recorded complications prospectively, he said.

Experienced surgeons who had completed the learning curve for the procedure performed the surgeries using the same techniques.

Patients underwent single or multiple myomectomies for symptomatic myomas measuring at least 4 cm in diameter to treat abnormal bleeding in 45% of cases, pain or a pelvic mass in 28%, and infertility in 27%.

Minor complications such as fever, cystitis, and lesions due to uterine manipulation occurred in 9% of patients. Major complications were seen in 2%, according to Dr. Spagnolo of Rome.

Among the most serious complications were hemorrhages in 14 patients (0.7%), 3 of whom required transfusions (0.1%). Postoperative hematomas occurred in 0.5% of patients, one in the broad ligament and the others in the myomectomy scar. One patient suffered a bowel injury. Constant hypotension during surgery led to postoperative acute renal failure in one patient.

Surgeons found unexpected sarcomas in two patients. In one of these cases they immediately converted to laparotomy. In the other case, although the mass looked like an adenomyoma and a frozen section was negative for malignancy, the cancer was diagnosed later upon histologic examination.

Five other cases were converted to laparotomy: three due to anesthesia problems and two because of a lack of space and limited mobility. One case was converted to laparoscopic hysterectomy due to a large intraligamentous myoma occupying most of the lateral part of the uterus.

Two patients were readmitted for surgery. One with severe hemorrhage underwent laparoscopic hysterectomy, and the other had a hematoma in the broad ligament drained.

Among the 185 pregnancies that occurred after the surgery, one patient had a uterine rupture. A majority (65%) of patients who wanted to become pregnant were able to do so.

SAN DIEGO — Complications occurred in 11% of 2,051 patients who underwent laparoscopic myomectomy, which compares favorably with a complication rate of 35% for myomectomy performed by laparotomy—a figure that has been reported in the literature, Rocco Spagnolo, M.D., said at an international congress of the Society of Laparoendoscopic Surgeons.

The new data come from the first large series of cases studied with a focus on complications from laparoscopic myomectomy. The multicenter Italian study reviewed patient records retrospectively and recorded complications prospectively, he said.

Experienced surgeons who had completed the learning curve for the procedure performed the surgeries using the same techniques.

Patients underwent single or multiple myomectomies for symptomatic myomas measuring at least 4 cm in diameter to treat abnormal bleeding in 45% of cases, pain or a pelvic mass in 28%, and infertility in 27%.

Minor complications such as fever, cystitis, and lesions due to uterine manipulation occurred in 9% of patients. Major complications were seen in 2%, according to Dr. Spagnolo of Rome.

Among the most serious complications were hemorrhages in 14 patients (0.7%), 3 of whom required transfusions (0.1%). Postoperative hematomas occurred in 0.5% of patients, one in the broad ligament and the others in the myomectomy scar. One patient suffered a bowel injury. Constant hypotension during surgery led to postoperative acute renal failure in one patient.

Surgeons found unexpected sarcomas in two patients. In one of these cases they immediately converted to laparotomy. In the other case, although the mass looked like an adenomyoma and a frozen section was negative for malignancy, the cancer was diagnosed later upon histologic examination.

Five other cases were converted to laparotomy: three due to anesthesia problems and two because of a lack of space and limited mobility. One case was converted to laparoscopic hysterectomy due to a large intraligamentous myoma occupying most of the lateral part of the uterus.

Two patients were readmitted for surgery. One with severe hemorrhage underwent laparoscopic hysterectomy, and the other had a hematoma in the broad ligament drained.

Among the 185 pregnancies that occurred after the surgery, one patient had a uterine rupture. A majority (65%) of patients who wanted to become pregnant were able to do so.

SAN DIEGO — Complications occurred in 11% of 2,051 patients who underwent laparoscopic myomectomy, which compares favorably with a complication rate of 35% for myomectomy performed by laparotomy—a figure that has been reported in the literature, Rocco Spagnolo, M.D., said at an international congress of the Society of Laparoendoscopic Surgeons.

The new data come from the first large series of cases studied with a focus on complications from laparoscopic myomectomy. The multicenter Italian study reviewed patient records retrospectively and recorded complications prospectively, he said.

Experienced surgeons who had completed the learning curve for the procedure performed the surgeries using the same techniques.

Patients underwent single or multiple myomectomies for symptomatic myomas measuring at least 4 cm in diameter to treat abnormal bleeding in 45% of cases, pain or a pelvic mass in 28%, and infertility in 27%.

Minor complications such as fever, cystitis, and lesions due to uterine manipulation occurred in 9% of patients. Major complications were seen in 2%, according to Dr. Spagnolo of Rome.

Among the most serious complications were hemorrhages in 14 patients (0.7%), 3 of whom required transfusions (0.1%). Postoperative hematomas occurred in 0.5% of patients, one in the broad ligament and the others in the myomectomy scar. One patient suffered a bowel injury. Constant hypotension during surgery led to postoperative acute renal failure in one patient.

Surgeons found unexpected sarcomas in two patients. In one of these cases they immediately converted to laparotomy. In the other case, although the mass looked like an adenomyoma and a frozen section was negative for malignancy, the cancer was diagnosed later upon histologic examination.

Five other cases were converted to laparotomy: three due to anesthesia problems and two because of a lack of space and limited mobility. One case was converted to laparoscopic hysterectomy due to a large intraligamentous myoma occupying most of the lateral part of the uterus.

Two patients were readmitted for surgery. One with severe hemorrhage underwent laparoscopic hysterectomy, and the other had a hematoma in the broad ligament drained.

Among the 185 pregnancies that occurred after the surgery, one patient had a uterine rupture. A majority (65%) of patients who wanted to become pregnant were able to do so.

SAN FRANCISCO — Pregnant women given a single dose of nevirapine during pregnancy to prevent vertical transmission of HIV were more likely to fail their own HIV treatment if it was started within 6 months of taking the nevirapine, Shahin Lockman, M.D., reported.

The randomized study of 218 women and 30 infants in Botswana found that, for the cohorts as a whole, the peripartum nevirapine dose led to higher rates of virologic failure in women and their infants, compared with women who received a peripartum dose of placebo and their infants, she said at the annual meeting of the Infectious Diseases Society of America.

Most resource-poor nations include nevirapine in their first-line treatment regimens for women and infants. More than 500,000 women each year are believed to receive single-dose nevirapine during pregnancy. This is a simple and affordable measure that halves the risk of vertical transmission, but previous data suggest that it can cause resistance to subsequent nevirapine therapy in 25%–70% of women and 40%–90% of infants, said Dr. Lockman of Brigham and Women's Hospital, Boston.

The current data came from the Mashi study of 12,000 HIV-infected women and 491 infants randomized to receive a single peripartum dose of nevirapine or placebo plus a short course of zidovudine starting at 34 weeks' gestation. Infants received 1 month of zidovudine if formula-fed or 6 months of zidovudine if breast-fed.

Women who developed an AIDS-defining illness or whose CD4 counts fell below 200 cells/mm

Of the 218 women who started antiretroviral therapy and had adequate follow-up, 18% of 112 who previously received single-dose nevirapine and 5% of 106 who previously received single-dose placebo developed virologic failure by 6 months after starting the combination antiretroviral regimen.

At 12 months, 20% of the nevirapine group and 10% of the placebo group had developed virologic failure, defined as an HIV RNA load greater than 400 copies/mL. At 24 months, 28% of the nevirapine group and 11% of the placebo group had failed combination therapy. All differences were statistically significant.

Further analysis showed that the failures occurred in women who started their antiretroviral therapy within 6 months of receiving the single dose of nevirapine but not in women whose therapy began at least 6 months after the single nevirapine dose.

Of the 60 women who started combination antiretroviral therapy within 6 months of the peripartum dose, 42% of the 24 women in the nevirapine group and none of the 36 women in the placebo group developed virologic failure by 6 months. Virologic failure was seen at 12 and 24 months in 46% of the nevirapine group and 3% of the placebo group. All differences were highly significant.

Virologic failure rates did not differ significantly between the nevirapine and placebo groups in the 158 women who started combination therapy at least 6 months after the peripartum dose.

A total of 30 HIV-infected infants were given the same combination antiretroviral therapy. Of 15 infants whose mothers got single-dose nevirapine during pregnancy, 10 developed virologic failure during 2 years of follow-up, compared with 2 of 15 infants in the placebo group. Two infants in the nevirapine group and three in the placebo group died.

Infants in the nevirapine group showed a smaller increase in CD4 counts on combination therapy vs. those in the placebo group. For mothers, the CD4 counts did not differ significantly between groups.

Only nevirapine exposure predicted the risk of virologic failure in women and infants. Other factors such as maternal age, clinic location, or infant feeding strategy (breast vs. formula) were not predictors.

SAN FRANCISCO — Pregnant women given a single dose of nevirapine during pregnancy to prevent vertical transmission of HIV were more likely to fail their own HIV treatment if it was started within 6 months of taking the nevirapine, Shahin Lockman, M.D., reported.

The randomized study of 218 women and 30 infants in Botswana found that, for the cohorts as a whole, the peripartum nevirapine dose led to higher rates of virologic failure in women and their infants, compared with women who received a peripartum dose of placebo and their infants, she said at the annual meeting of the Infectious Diseases Society of America.

Most resource-poor nations include nevirapine in their first-line treatment regimens for women and infants. More than 500,000 women each year are believed to receive single-dose nevirapine during pregnancy. This is a simple and affordable measure that halves the risk of vertical transmission, but previous data suggest that it can cause resistance to subsequent nevirapine therapy in 25%–70% of women and 40%–90% of infants, said Dr. Lockman of Brigham and Women's Hospital, Boston.

The current data came from the Mashi study of 12,000 HIV-infected women and 491 infants randomized to receive a single peripartum dose of nevirapine or placebo plus a short course of zidovudine starting at 34 weeks' gestation. Infants received 1 month of zidovudine if formula-fed or 6 months of zidovudine if breast-fed.

Women who developed an AIDS-defining illness or whose CD4 counts fell below 200 cells/mm

Of the 218 women who started antiretroviral therapy and had adequate follow-up, 18% of 112 who previously received single-dose nevirapine and 5% of 106 who previously received single-dose placebo developed virologic failure by 6 months after starting the combination antiretroviral regimen.

At 12 months, 20% of the nevirapine group and 10% of the placebo group had developed virologic failure, defined as an HIV RNA load greater than 400 copies/mL. At 24 months, 28% of the nevirapine group and 11% of the placebo group had failed combination therapy. All differences were statistically significant.

Further analysis showed that the failures occurred in women who started their antiretroviral therapy within 6 months of receiving the single dose of nevirapine but not in women whose therapy began at least 6 months after the single nevirapine dose.

Of the 60 women who started combination antiretroviral therapy within 6 months of the peripartum dose, 42% of the 24 women in the nevirapine group and none of the 36 women in the placebo group developed virologic failure by 6 months. Virologic failure was seen at 12 and 24 months in 46% of the nevirapine group and 3% of the placebo group. All differences were highly significant.

Virologic failure rates did not differ significantly between the nevirapine and placebo groups in the 158 women who started combination therapy at least 6 months after the peripartum dose.

A total of 30 HIV-infected infants were given the same combination antiretroviral therapy. Of 15 infants whose mothers got single-dose nevirapine during pregnancy, 10 developed virologic failure during 2 years of follow-up, compared with 2 of 15 infants in the placebo group. Two infants in the nevirapine group and three in the placebo group died.

Infants in the nevirapine group showed a smaller increase in CD4 counts on combination therapy vs. those in the placebo group. For mothers, the CD4 counts did not differ significantly between groups.

Only nevirapine exposure predicted the risk of virologic failure in women and infants. Other factors such as maternal age, clinic location, or infant feeding strategy (breast vs. formula) were not predictors.

SAN FRANCISCO — Pregnant women given a single dose of nevirapine during pregnancy to prevent vertical transmission of HIV were more likely to fail their own HIV treatment if it was started within 6 months of taking the nevirapine, Shahin Lockman, M.D., reported.

The randomized study of 218 women and 30 infants in Botswana found that, for the cohorts as a whole, the peripartum nevirapine dose led to higher rates of virologic failure in women and their infants, compared with women who received a peripartum dose of placebo and their infants, she said at the annual meeting of the Infectious Diseases Society of America.

Most resource-poor nations include nevirapine in their first-line treatment regimens for women and infants. More than 500,000 women each year are believed to receive single-dose nevirapine during pregnancy. This is a simple and affordable measure that halves the risk of vertical transmission, but previous data suggest that it can cause resistance to subsequent nevirapine therapy in 25%–70% of women and 40%–90% of infants, said Dr. Lockman of Brigham and Women's Hospital, Boston.

The current data came from the Mashi study of 12,000 HIV-infected women and 491 infants randomized to receive a single peripartum dose of nevirapine or placebo plus a short course of zidovudine starting at 34 weeks' gestation. Infants received 1 month of zidovudine if formula-fed or 6 months of zidovudine if breast-fed.

Women who developed an AIDS-defining illness or whose CD4 counts fell below 200 cells/mm

Of the 218 women who started antiretroviral therapy and had adequate follow-up, 18% of 112 who previously received single-dose nevirapine and 5% of 106 who previously received single-dose placebo developed virologic failure by 6 months after starting the combination antiretroviral regimen.

At 12 months, 20% of the nevirapine group and 10% of the placebo group had developed virologic failure, defined as an HIV RNA load greater than 400 copies/mL. At 24 months, 28% of the nevirapine group and 11% of the placebo group had failed combination therapy. All differences were statistically significant.

Further analysis showed that the failures occurred in women who started their antiretroviral therapy within 6 months of receiving the single dose of nevirapine but not in women whose therapy began at least 6 months after the single nevirapine dose.

Of the 60 women who started combination antiretroviral therapy within 6 months of the peripartum dose, 42% of the 24 women in the nevirapine group and none of the 36 women in the placebo group developed virologic failure by 6 months. Virologic failure was seen at 12 and 24 months in 46% of the nevirapine group and 3% of the placebo group. All differences were highly significant.

Virologic failure rates did not differ significantly between the nevirapine and placebo groups in the 158 women who started combination therapy at least 6 months after the peripartum dose.

A total of 30 HIV-infected infants were given the same combination antiretroviral therapy. Of 15 infants whose mothers got single-dose nevirapine during pregnancy, 10 developed virologic failure during 2 years of follow-up, compared with 2 of 15 infants in the placebo group. Two infants in the nevirapine group and three in the placebo group died.

Infants in the nevirapine group showed a smaller increase in CD4 counts on combination therapy vs. those in the placebo group. For mothers, the CD4 counts did not differ significantly between groups.

Only nevirapine exposure predicted the risk of virologic failure in women and infants. Other factors such as maternal age, clinic location, or infant feeding strategy (breast vs. formula) were not predictors.

SAN FRANCISCO — If the first bone density reading after starting bisphosphonate therapy shows bone loss, don't stop or alter therapy, Steven R. Cummings, M.D., advised at a meeting on osteoporosis sponsored by the University of California, San Francisco.

In all likelihood the therapy is working, but “noise” in the bone density test results in a lower measurement. The next time the patient's bone density is taken, it probably will be higher, said Dr. Cummings, professor emeritus of epidemiology and biostatistics at the university and director of clinical research at the California Pacific Medical Center Research Institute.

He and his associates analyzed data from the 6,459-patient Fracture Intervention Trial and found that among women who lost at least 4% of hip bone density in the first year of treatment with alendronate, 92% gained an average of 5% of hip bone density in the second year of therapy. The study involved postmenopausal women, aged 55–80 years, who were randomized to receive alendronate at 5 mg/day for 2 years and 10 mg/day thereafter, or placebo for up to 4.5 years.

“If you were to change treatment or add another drug” after that first follow-up, “they would gain bone and you would look like a hero, but in fact they would have improved even without” any changes, he said.

Among women who gained up to 4% of hip bone density in the first year on alendronate, 67% continued to gain an average of 1% bone density in the second year on therapy.

Of the women who gained a lot of hip bone—8% or more—the first year, 64% lost an average of 1% of hip bone the second year. So patients with the largest gains in bone density during the first year ought to be told: “Watch out—the next year you're likely to lose bone,” he said.

Continuing therapy also is important for reducing the risk of fracture. A comparison of the 18% of women who lost bone after a year of alendronate with the 18% of women who lost the most bone while on placebo indicated a 50% reduction in fracture risk among patients who gained bone density on treatment. A slightly greater reduction in fracture risk was seen in women who lost up to 4% of bone if they were taking alendronate, compared with placebo.

The greatest overall benefits occurred in women who lost more than 4% of bone density in the first year. In this subgroup, taking alendronate reduced the risk of fracture by 80%–90%, compared with placebo. “Stopping treatment in those patients who lose bone is exactly the wrong thing to do,” said Dr. Cummings, who is a consultant and speaker for two companies that make bisphosphonate medications.

If a patient consistently loses bone density over multiple follow-up measurements in a period of years, then it would be reasonable to reassess treatment options, he said.

SAN FRANCISCO — If the first bone density reading after starting bisphosphonate therapy shows bone loss, don't stop or alter therapy, Steven R. Cummings, M.D., advised at a meeting on osteoporosis sponsored by the University of California, San Francisco.

In all likelihood the therapy is working, but “noise” in the bone density test results in a lower measurement. The next time the patient's bone density is taken, it probably will be higher, said Dr. Cummings, professor emeritus of epidemiology and biostatistics at the university and director of clinical research at the California Pacific Medical Center Research Institute.

He and his associates analyzed data from the 6,459-patient Fracture Intervention Trial and found that among women who lost at least 4% of hip bone density in the first year of treatment with alendronate, 92% gained an average of 5% of hip bone density in the second year of therapy. The study involved postmenopausal women, aged 55–80 years, who were randomized to receive alendronate at 5 mg/day for 2 years and 10 mg/day thereafter, or placebo for up to 4.5 years.

“If you were to change treatment or add another drug” after that first follow-up, “they would gain bone and you would look like a hero, but in fact they would have improved even without” any changes, he said.

Among women who gained up to 4% of hip bone density in the first year on alendronate, 67% continued to gain an average of 1% bone density in the second year on therapy.

Of the women who gained a lot of hip bone—8% or more—the first year, 64% lost an average of 1% of hip bone the second year. So patients with the largest gains in bone density during the first year ought to be told: “Watch out—the next year you're likely to lose bone,” he said.

Continuing therapy also is important for reducing the risk of fracture. A comparison of the 18% of women who lost bone after a year of alendronate with the 18% of women who lost the most bone while on placebo indicated a 50% reduction in fracture risk among patients who gained bone density on treatment. A slightly greater reduction in fracture risk was seen in women who lost up to 4% of bone if they were taking alendronate, compared with placebo.

The greatest overall benefits occurred in women who lost more than 4% of bone density in the first year. In this subgroup, taking alendronate reduced the risk of fracture by 80%–90%, compared with placebo. “Stopping treatment in those patients who lose bone is exactly the wrong thing to do,” said Dr. Cummings, who is a consultant and speaker for two companies that make bisphosphonate medications.

If a patient consistently loses bone density over multiple follow-up measurements in a period of years, then it would be reasonable to reassess treatment options, he said.

SAN FRANCISCO — If the first bone density reading after starting bisphosphonate therapy shows bone loss, don't stop or alter therapy, Steven R. Cummings, M.D., advised at a meeting on osteoporosis sponsored by the University of California, San Francisco.

In all likelihood the therapy is working, but “noise” in the bone density test results in a lower measurement. The next time the patient's bone density is taken, it probably will be higher, said Dr. Cummings, professor emeritus of epidemiology and biostatistics at the university and director of clinical research at the California Pacific Medical Center Research Institute.

He and his associates analyzed data from the 6,459-patient Fracture Intervention Trial and found that among women who lost at least 4% of hip bone density in the first year of treatment with alendronate, 92% gained an average of 5% of hip bone density in the second year of therapy. The study involved postmenopausal women, aged 55–80 years, who were randomized to receive alendronate at 5 mg/day for 2 years and 10 mg/day thereafter, or placebo for up to 4.5 years.

“If you were to change treatment or add another drug” after that first follow-up, “they would gain bone and you would look like a hero, but in fact they would have improved even without” any changes, he said.

Among women who gained up to 4% of hip bone density in the first year on alendronate, 67% continued to gain an average of 1% bone density in the second year on therapy.

Of the women who gained a lot of hip bone—8% or more—the first year, 64% lost an average of 1% of hip bone the second year. So patients with the largest gains in bone density during the first year ought to be told: “Watch out—the next year you're likely to lose bone,” he said.

Continuing therapy also is important for reducing the risk of fracture. A comparison of the 18% of women who lost bone after a year of alendronate with the 18% of women who lost the most bone while on placebo indicated a 50% reduction in fracture risk among patients who gained bone density on treatment. A slightly greater reduction in fracture risk was seen in women who lost up to 4% of bone if they were taking alendronate, compared with placebo.

The greatest overall benefits occurred in women who lost more than 4% of bone density in the first year. In this subgroup, taking alendronate reduced the risk of fracture by 80%–90%, compared with placebo. “Stopping treatment in those patients who lose bone is exactly the wrong thing to do,” said Dr. Cummings, who is a consultant and speaker for two companies that make bisphosphonate medications.

If a patient consistently loses bone density over multiple follow-up measurements in a period of years, then it would be reasonable to reassess treatment options, he said.

SAN FRANCISCO — A yet to be released tool developed by the World Health Organization should help physicians calculate an individual's absolute risk for bone fracture and provide a basis for counseling patients regarding treatment, experts said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

The expected WHO model will estimate an individual's risk of developing a fragility fracture over the next decade, based on factors that may include age, bone mineral density of the femoral neck, a history of previous fracture, family history of fracture, smoking and alcohol use, steroid use, and the presence of rheumatoid arthritis.

At this point no one knows exactly which factors will be included in the model, said Steven T. Harris, M.D., clinical professor of medicine at the University of California, San Francisco.

Calculating absolute risk for fracture greatly assists therapeutic decision making, he said.

For example, a 2001 model looked at the 10-year probability of fractures in the hip, forearm, humerus, or spine based simply on age and bone density. A 45-year-old with a T score of −3 (which is consistent with osteoporosis) has about a 10% risk of fracture over the next 10 years, but the fracture risk increases to 30% in a 75-year-old with the same bone density.

The WHO model “is going to be far better than telling someone they have osteoporosis, giving them a prescription, and saying goodbye,” Dr. Harris said. “Getting people engaged in conversation about what their risk is, and what can be done with contemporary treatment, is going to make therapy a lot more rational.”

If a clinician could tell a 55-year-old patient who is osteopenic that the patient's absolute risk for fracture is 10% over the next 10 years, and that contemporary treatments could reduce that risk to 5%, that should help the patient decide whether the potential improvement is worth the cost or inconvenience associated with therapy.

Calculations of absolute risk also are likely to be used by insurers in the near future to decide whether to cover medical therapy for improving bone density. It may be that therapy for someone with a 20% risk of fracture will be covered, but patients with a 10% risk will have to pay for the medications themselves.

The new WHO index is due to be released “imminently,” which probably means in the first half of 2006, Steven R. Cummings, M.D., said in a separate presentation at the meeting.

He noted that the WHO's fracture risk index is based on data from about 60,000 women in 12 cohorts of patients, mostly Europeans, and needs to be validated in other populations, including that of the United States.

He lauded the project's objective of establishing a set of universal factors that could be used to identify absolute fracture risk. “I think this is a very noble goal that will probably have important clinical value,” said Dr. Cummings, professor emeritus of epidemiology and biostatistics at the university and director of clinical research at the California Pacific Medical Center Research Institute.

Some studies have been using the index to compare the value of bone density measurements with the value of other risk factors in predicting future fractures. Using the index alone without measuring bone density seems to be pretty good at predicting hip fractures, and is modestly valuable in predicting other fractures.

Having “an index of risk factors may be useful, particularly in places where you don't have bone density testing, or if you're deciding whether or not” to measure a patient's bone density, he said.

Adding bone density measurement to other factors in the index substantially strengthens the ability to predict hip fracture and mildly strengthens the ability to predict other fractures, but the opposite does not seem to be true.

“It's not clear that adding risk factors, once you know the bone density, will substantially improve the clinical judgments you can make about treatment with medication,” Dr. Cummings said.

SAN FRANCISCO — A yet to be released tool developed by the World Health Organization should help physicians calculate an individual's absolute risk for bone fracture and provide a basis for counseling patients regarding treatment, experts said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

The expected WHO model will estimate an individual's risk of developing a fragility fracture over the next decade, based on factors that may include age, bone mineral density of the femoral neck, a history of previous fracture, family history of fracture, smoking and alcohol use, steroid use, and the presence of rheumatoid arthritis.

At this point no one knows exactly which factors will be included in the model, said Steven T. Harris, M.D., clinical professor of medicine at the University of California, San Francisco.

Calculating absolute risk for fracture greatly assists therapeutic decision making, he said.

For example, a 2001 model looked at the 10-year probability of fractures in the hip, forearm, humerus, or spine based simply on age and bone density. A 45-year-old with a T score of −3 (which is consistent with osteoporosis) has about a 10% risk of fracture over the next 10 years, but the fracture risk increases to 30% in a 75-year-old with the same bone density.

The WHO model “is going to be far better than telling someone they have osteoporosis, giving them a prescription, and saying goodbye,” Dr. Harris said. “Getting people engaged in conversation about what their risk is, and what can be done with contemporary treatment, is going to make therapy a lot more rational.”

If a clinician could tell a 55-year-old patient who is osteopenic that the patient's absolute risk for fracture is 10% over the next 10 years, and that contemporary treatments could reduce that risk to 5%, that should help the patient decide whether the potential improvement is worth the cost or inconvenience associated with therapy.

Calculations of absolute risk also are likely to be used by insurers in the near future to decide whether to cover medical therapy for improving bone density. It may be that therapy for someone with a 20% risk of fracture will be covered, but patients with a 10% risk will have to pay for the medications themselves.

The new WHO index is due to be released “imminently,” which probably means in the first half of 2006, Steven R. Cummings, M.D., said in a separate presentation at the meeting.

He noted that the WHO's fracture risk index is based on data from about 60,000 women in 12 cohorts of patients, mostly Europeans, and needs to be validated in other populations, including that of the United States.

He lauded the project's objective of establishing a set of universal factors that could be used to identify absolute fracture risk. “I think this is a very noble goal that will probably have important clinical value,” said Dr. Cummings, professor emeritus of epidemiology and biostatistics at the university and director of clinical research at the California Pacific Medical Center Research Institute.

Some studies have been using the index to compare the value of bone density measurements with the value of other risk factors in predicting future fractures. Using the index alone without measuring bone density seems to be pretty good at predicting hip fractures, and is modestly valuable in predicting other fractures.

Having “an index of risk factors may be useful, particularly in places where you don't have bone density testing, or if you're deciding whether or not” to measure a patient's bone density, he said.

Adding bone density measurement to other factors in the index substantially strengthens the ability to predict hip fracture and mildly strengthens the ability to predict other fractures, but the opposite does not seem to be true.

“It's not clear that adding risk factors, once you know the bone density, will substantially improve the clinical judgments you can make about treatment with medication,” Dr. Cummings said.

SAN FRANCISCO — A yet to be released tool developed by the World Health Organization should help physicians calculate an individual's absolute risk for bone fracture and provide a basis for counseling patients regarding treatment, experts said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

The expected WHO model will estimate an individual's risk of developing a fragility fracture over the next decade, based on factors that may include age, bone mineral density of the femoral neck, a history of previous fracture, family history of fracture, smoking and alcohol use, steroid use, and the presence of rheumatoid arthritis.

At this point no one knows exactly which factors will be included in the model, said Steven T. Harris, M.D., clinical professor of medicine at the University of California, San Francisco.

Calculating absolute risk for fracture greatly assists therapeutic decision making, he said.

For example, a 2001 model looked at the 10-year probability of fractures in the hip, forearm, humerus, or spine based simply on age and bone density. A 45-year-old with a T score of −3 (which is consistent with osteoporosis) has about a 10% risk of fracture over the next 10 years, but the fracture risk increases to 30% in a 75-year-old with the same bone density.

The WHO model “is going to be far better than telling someone they have osteoporosis, giving them a prescription, and saying goodbye,” Dr. Harris said. “Getting people engaged in conversation about what their risk is, and what can be done with contemporary treatment, is going to make therapy a lot more rational.”

If a clinician could tell a 55-year-old patient who is osteopenic that the patient's absolute risk for fracture is 10% over the next 10 years, and that contemporary treatments could reduce that risk to 5%, that should help the patient decide whether the potential improvement is worth the cost or inconvenience associated with therapy.

Calculations of absolute risk also are likely to be used by insurers in the near future to decide whether to cover medical therapy for improving bone density. It may be that therapy for someone with a 20% risk of fracture will be covered, but patients with a 10% risk will have to pay for the medications themselves.

The new WHO index is due to be released “imminently,” which probably means in the first half of 2006, Steven R. Cummings, M.D., said in a separate presentation at the meeting.

He noted that the WHO's fracture risk index is based on data from about 60,000 women in 12 cohorts of patients, mostly Europeans, and needs to be validated in other populations, including that of the United States.

He lauded the project's objective of establishing a set of universal factors that could be used to identify absolute fracture risk. “I think this is a very noble goal that will probably have important clinical value,” said Dr. Cummings, professor emeritus of epidemiology and biostatistics at the university and director of clinical research at the California Pacific Medical Center Research Institute.

Some studies have been using the index to compare the value of bone density measurements with the value of other risk factors in predicting future fractures. Using the index alone without measuring bone density seems to be pretty good at predicting hip fractures, and is modestly valuable in predicting other fractures.

Having “an index of risk factors may be useful, particularly in places where you don't have bone density testing, or if you're deciding whether or not” to measure a patient's bone density, he said.

Adding bone density measurement to other factors in the index substantially strengthens the ability to predict hip fracture and mildly strengthens the ability to predict other fractures, but the opposite does not seem to be true.

“It's not clear that adding risk factors, once you know the bone density, will substantially improve the clinical judgments you can make about treatment with medication,” Dr. Cummings said.

SAN FRANCISCO — Invasive methicillin-resistant Staphylococcus aureus was more likely to cause skin and soft tissue disease or joint infections if acquired in the community rather than in a hospital, according to preliminary data from a large surveillance study.

Skin or soft tissue infection occurred in 34% of community-associated methicillin-resistant S. aureus (MRSA), compared with 10% of hospital-associated MRSA in the study of 6,413 cases of invasive MRSA in nine U.S. sites with a population of about 16 million people.

Endocarditis was more common with community-associated MRSA than with hospital-associated MRSA (12% vs. 4%), as were internal or deep-seated abscesses (9% vs. 4%) and septic arthritis, Susan M. Ray, M.D., said at the annual meeting of the Infectious Diseases Society of America.

“These differences may be explained by virulence factors in the staph strain, and/or by delay in presentation for care,” said Dr. Ray of Emory University, Atlanta. “The clinical evaluation of community-associated MRSA should include the investigation of deep-seated foci of infections.”

Patients with hospital-associated invasive MRSA were more likely to have uncomplicated bacteremia.

A previous analysis of 2001–2002 data from the Centers for Disease Control and Prevention reported that about 17% of MRSA cases in three sites were community associated, and about 7% of these were invasive disease (with a culture from a normally sterile site).

The current study analyzed federal data from 2004 and 2005 in nine geographic areas for culture-positive invasive MRSA infections. Surveillance officers reviewed patient records to classify 86% of cases as hospital-associated based on risk-factor criteria; all others were deemed community-associated infections (14%) or uncertain (less than 0.5%).

The rate of community-associated MRSA varied widely by geography, comprising 24% of invasive MRSA cases in Maryland but only 3% of cases in New York.

Compared with hospital-associated invasive MRSA, higher rates of community-associated MRSA were seen in children, smokers, and men with a history of intravenous drug use, HIV, or AIDS. Community-associated MRSA was less likely to be resistant to antimicrobials besides methicillin or to be resistant to multiple classes of antibiotics compared with hospital-associated MRSA.

Community-associated MRSA accounted for 35% of invasive MRSA in children aged 3 years or younger, 50% of cases in 4- to 19-year-olds, 25% of patients aged 20–49 years, and 7% of those aged 50 years or older.

Cases were defined as hospital-associated MRSA if records showed at least one of the following: previous MRSA colonization or infection; a culture obtained more than 48 hours after hospitalization; the presence of an invasive device at the time of evaluation; or a history within the past year of hospitalization, surgery, dialysis, or residence in a long-term care facility.

Investigators in the study began collecting isolates from a sample of cases in 2005. “In the future, this will allow us to compare the epidemiologic classification of community-associated MRSA with its microbiologic characteristics,” Dr. Ray said.

SAN FRANCISCO — Invasive methicillin-resistant Staphylococcus aureus was more likely to cause skin and soft tissue disease or joint infections if acquired in the community rather than in a hospital, according to preliminary data from a large surveillance study.

Skin or soft tissue infection occurred in 34% of community-associated methicillin-resistant S. aureus (MRSA), compared with 10% of hospital-associated MRSA in the study of 6,413 cases of invasive MRSA in nine U.S. sites with a population of about 16 million people.

Endocarditis was more common with community-associated MRSA than with hospital-associated MRSA (12% vs. 4%), as were internal or deep-seated abscesses (9% vs. 4%) and septic arthritis, Susan M. Ray, M.D., said at the annual meeting of the Infectious Diseases Society of America.

“These differences may be explained by virulence factors in the staph strain, and/or by delay in presentation for care,” said Dr. Ray of Emory University, Atlanta. “The clinical evaluation of community-associated MRSA should include the investigation of deep-seated foci of infections.”

Patients with hospital-associated invasive MRSA were more likely to have uncomplicated bacteremia.

A previous analysis of 2001–2002 data from the Centers for Disease Control and Prevention reported that about 17% of MRSA cases in three sites were community associated, and about 7% of these were invasive disease (with a culture from a normally sterile site).

The current study analyzed federal data from 2004 and 2005 in nine geographic areas for culture-positive invasive MRSA infections. Surveillance officers reviewed patient records to classify 86% of cases as hospital-associated based on risk-factor criteria; all others were deemed community-associated infections (14%) or uncertain (less than 0.5%).

The rate of community-associated MRSA varied widely by geography, comprising 24% of invasive MRSA cases in Maryland but only 3% of cases in New York.

Compared with hospital-associated invasive MRSA, higher rates of community-associated MRSA were seen in children, smokers, and men with a history of intravenous drug use, HIV, or AIDS. Community-associated MRSA was less likely to be resistant to antimicrobials besides methicillin or to be resistant to multiple classes of antibiotics compared with hospital-associated MRSA.

Community-associated MRSA accounted for 35% of invasive MRSA in children aged 3 years or younger, 50% of cases in 4- to 19-year-olds, 25% of patients aged 20–49 years, and 7% of those aged 50 years or older.

Cases were defined as hospital-associated MRSA if records showed at least one of the following: previous MRSA colonization or infection; a culture obtained more than 48 hours after hospitalization; the presence of an invasive device at the time of evaluation; or a history within the past year of hospitalization, surgery, dialysis, or residence in a long-term care facility.

Investigators in the study began collecting isolates from a sample of cases in 2005. “In the future, this will allow us to compare the epidemiologic classification of community-associated MRSA with its microbiologic characteristics,” Dr. Ray said.

SAN FRANCISCO — Invasive methicillin-resistant Staphylococcus aureus was more likely to cause skin and soft tissue disease or joint infections if acquired in the community rather than in a hospital, according to preliminary data from a large surveillance study.

Skin or soft tissue infection occurred in 34% of community-associated methicillin-resistant S. aureus (MRSA), compared with 10% of hospital-associated MRSA in the study of 6,413 cases of invasive MRSA in nine U.S. sites with a population of about 16 million people.

Endocarditis was more common with community-associated MRSA than with hospital-associated MRSA (12% vs. 4%), as were internal or deep-seated abscesses (9% vs. 4%) and septic arthritis, Susan M. Ray, M.D., said at the annual meeting of the Infectious Diseases Society of America.

“These differences may be explained by virulence factors in the staph strain, and/or by delay in presentation for care,” said Dr. Ray of Emory University, Atlanta. “The clinical evaluation of community-associated MRSA should include the investigation of deep-seated foci of infections.”

Patients with hospital-associated invasive MRSA were more likely to have uncomplicated bacteremia.

A previous analysis of 2001–2002 data from the Centers for Disease Control and Prevention reported that about 17% of MRSA cases in three sites were community associated, and about 7% of these were invasive disease (with a culture from a normally sterile site).

The current study analyzed federal data from 2004 and 2005 in nine geographic areas for culture-positive invasive MRSA infections. Surveillance officers reviewed patient records to classify 86% of cases as hospital-associated based on risk-factor criteria; all others were deemed community-associated infections (14%) or uncertain (less than 0.5%).

The rate of community-associated MRSA varied widely by geography, comprising 24% of invasive MRSA cases in Maryland but only 3% of cases in New York.

Compared with hospital-associated invasive MRSA, higher rates of community-associated MRSA were seen in children, smokers, and men with a history of intravenous drug use, HIV, or AIDS. Community-associated MRSA was less likely to be resistant to antimicrobials besides methicillin or to be resistant to multiple classes of antibiotics compared with hospital-associated MRSA.

Community-associated MRSA accounted for 35% of invasive MRSA in children aged 3 years or younger, 50% of cases in 4- to 19-year-olds, 25% of patients aged 20–49 years, and 7% of those aged 50 years or older.

Cases were defined as hospital-associated MRSA if records showed at least one of the following: previous MRSA colonization or infection; a culture obtained more than 48 hours after hospitalization; the presence of an invasive device at the time of evaluation; or a history within the past year of hospitalization, surgery, dialysis, or residence in a long-term care facility.

Investigators in the study began collecting isolates from a sample of cases in 2005. “In the future, this will allow us to compare the epidemiologic classification of community-associated MRSA with its microbiologic characteristics,” Dr. Ray said.