Now that you’re HIPAA compliant or have requested an extra year to get into compliance, it’s time to take a look at your practice management software, according to Dr. David Kibbe.

A new, noncommercial Web site created by Dr. Kibbe and sponsored by 15 medical societies and by several health information technology associations aims to help physicians make sure their practice management systems are ready for the electronic transactions and code set requirements of the Health Insurance Portability and Accountability Act (HIPAA). The American College of Obstetricians and Gynecologists is among the sponsors.

The administrative simplification portion of HIPAA contains standards governing three major areas in health care: transactions, privacy, and security. Physicians were recently able to receive a 1-year extension in complying with the electronic transactions and code set requirements of HIPAA by filing a model compliance plan with the Centers for Medicare and Medicaid Services. A portion of HIPAA protecting the privacy of patient’s personal health information is already in effect. HIPAA’s health information security standards have been proposed, but are not finalized.

The site, www.hipaa.org/pmsdirectory, allows physicians to search a listing of more than three dozen company profiles created by practice management system (PMS) vendors. Eventually, the list is likely to grow to more than 400 companies, said Dr. Kibbe, director of health information technology for the American Academy of Family Physicians.

Each vendor profile includes the company name, address, phone number, a HIPAA contact, and a description of the company’s products and whether the products are HIPAA ready. So far, the site has gotten about 10,000 hits.

Physicians may be under the impression that their PMS vendors are providing HIPAA-ready products, but this may not be the case. Under HIPAA, it is ultimately the physician’s responsibility to make sure that the vendors providing their practice management systems are compliant with the act’s guidelines, Dr. Kibbe pointed out. “This Web site makes it simple for doctors.”

There are hundreds of companies in the PMS vendor community, and some of them are only “marginally viable” when it comes to HIPAA readiness, said Bruce Kleaveland, chief operating officer of Physician Micro Systems Inc., a physician-owned company based in Seattle that sells software for billing and scheduling, and electronic medical records.

Mr. Kleaveland recommends that physicians who have, or are considering purchasing, a PMS system, should ask their vendors if their products are HIPAA ready Ask very specific questions to make sure such vendors understand your concerns about compliance with the electronic transactions and code sets portion of HIPAA, as opposed to the medical privacy rule.

Under the electronic transactions and code sets portion of HIPAA, all claims and bills sent to payers electronically must be of a certain format. The privacy portion of HIPAA contains no specific technical requirement that vendors must follow, Mr. Kleaveland explained. Of course, any software products purchased should provide for the confidentiality of patient information, he noted.

Finally, physicians should sign a contract with the vendor, making sure that the HIPAA readiness of its products is noted in the document, Mr. Kleaveland said. Similarly, it is a good idea for doctors using billing services to sign contracts with these services, making sure it is noted that the service is complying with HIPAA and will protect patients’ private medical information.

Despite the communal angst surrounding HIPAA, it is actually good news for physicians, Dr. Kibbe said. Once the conversion to HIPAA-ready software is complete, doctors will save time and money.

For example, the average family medicine practice (2.5 physicians) currently spends an estimated 19 minutes tracking down insurance eligibility information on a patient. With the installation of HIPAA-ready PMS software, it takes 30 seconds for the automated system to track down the information, saving the average family practice an estimated $4,500 a year on that task alone. The average family medicine practice can be expected to save approximately $48,600 a year, according to research published in Dr. Kibbe’s book “Field Guide to HIPAA Implementation,” published by the American Medical Association Press. Physicians in other specialties such as internal medicine and pediatrics would probably see similar cost savings, if they also practice in a small group setting.

Memphis, Tennessee. Minneapolis, Minnesota. Warsaw, Indiana. Ansonia, Connecticut. The first three cities on this list are identified as major hubs for medical device manufacturing. However, HMP Industries, a generations-old screw machine shop, happens to be located in a sleepy town in Southern Connecticut. It also happens to be looking to put itself on the map in the field of medical device manufacturing. The company says it is making its mark by upgrading its massive bank of more than 100 conventional machines to CNC equipment, including a variety of multi-axis CNC Swiss-type lathes.

This new focus on higher-end medical device products and the acquisition of the type of sophisticated equipment needed to make these components forced HMP to reevaluate its programming approach. To survive in the medical device manufacturing arena, the company’s management realized that quoting, programming and setting up parts much faster would be imperative to its success.

The company turned to PartMaker CAD/CAM from PartMaker Inc., a division of Delcam. Implemented in the summer of 2006, the system purchased by HMP programs the company’s range of CNC equipment, including its Tsugami BU20SY, Star SR-20R, Star SB-16 and Kia LMS machines as well as its Fadal machining center, among others.

“Using PartMaker has definitely opened opportunities to us in our medical device business because the software allows us to quote and program faster,” says Steve Whitman, president at HMP. “This means we can deliver faster and meet the short lead times dictated by our medical customers.”

Since opening its doors more than 85 years ago, HMP Industries traditionally focused on making parts for the hand-tool industry on its cam-driven screw machines.

“As the ‘big box’ stores became more dominant and outsourced manufacturing to lower cost markets overseas, we needed to look to other growing markets,” Mr. Whitman says. “We identified the medical market as a prime target because of its growth and its need for the precision machining skills we developed over the years for other industries.”

Making this transition required HMP to look closely at a number of its manufacturing processes, from job quoting through part programming to machine setup of new jobs as the move to medical introduced new materials and parts with more intricate and complex geometries. These parts also require tighter tolerances as well as shorter lead times for both quotes and finished product deliveries.

Prior to implementing the software, HMP’s technical staff had been programming the CNC Swiss as well as the other CNC machines with a combination of manual programming techniques and “cutting and pasting” output from other CAM systems. The approach was particularly inefficient for the Swiss machines.

According to the company, PartMaker has improved productivity by speeding programming time, reducing machine setup time and reducing scrap. Gary Svenson, the chief CNC programmer at HMP, estimates that the new package has reduced the amount of time it takes him to program a part by about 70 percent from the previous method. Additionally, because PartMaker allows him to visually prove out a part on screen with its array of process verification tools, he has also been able to reduce the amount of time required to set up new jobs. Mr. Svenson estimates that the software has in fact reduced machine setup time by about one third.

“When you program parts by hand, you spend a lot of time dry running a part on the machine during setup,” Mr. Svenson says. “With PartMaker, this time is greatly reduced because you know what to expect–you see the part being simulated on screen.”

The 3D simulation capability allows the programmer to verify the machining of a part off-line before sending a program to the machine tool. The fact that the software is equipped with postprocessors for the company’s array of machine tools (including all of its Swiss models) offers HMP engineers the assurance that the program will run correctly when it is sent to the machine tool. More accurate part programs are sent to the machine, thus reducing scrap because fewer parts need to be cut before going into final production.

“The software has been helpful in programming some of our more complicated medical parts with more complex geometries,” Mr. Svenson explains. “This was especially important when you take into account the cost of the material for these parts, which are titanium or 17-4-PH stainless steel.”

The capabilities of the new software have allowed the company to maximize the capabilities of its CNC Swiss machines. HMP says it can use the fullest extent of its machines’ numerous axes in an intuitive manner through the Visual Programming strategy. This approach makes programming the milling and turning capabilities of machines such as HMP’s Star SR-20R or Tsugami BU-20SY much easier. The software breaks a complex part into individual face windows. Each window contains features being machined in a particular plane. For example in one window, all turning operations on the machine’s main spindle are programmed graphically. In another window, milling using the machine’s C axis with a horizontally oriented tool may be programmed, while in another a group of features using the machine’s Y axis with a vertically oriented tool may be programmed.

Katharine “Casey” Kickertz, 31 Procurement transplant coordinator

EDUCATION: B.S. in nursing

WHAT SHE DOES: Coordinates organ donation and transplantation

HARDEST PART: “Staying focused on the positive. It is easy to start feeling down with the sadness we see.”

HOW PEOPLE REACT TO HER JOB: “‘Ohh!’ Complete with a funny look and a step back.”

Malcolm Dicks, 33 Logistics specialist

EDUCATION: B.S. in biology; M.S. in emergency services administration

HIS WORK MOTTO: “Keep it simple. Like anything, the more you complicate things, especially with logistics, the more it will fail.”

BEST ADVICE:” Everything is hard in the beginning, but sometimes when you get done, you might find you liked the challenge and want to do it again.”

Sureka Khandagle, 36, Humanitarian aid worker

EDUCATION: B.A., M.A. in international relations

SECRET TO SUCCESS: “Maintaining a sense of humor and remaining flexible.”

ADVICE FOR TEENS: “Study abroad, learn a different language, broaden your horizons.”

Katrina Harris, 30 Addictions counselor

EDUCATION: B.A. in psychology; M.S. in kinesiology; substance-abuse counseling certificate

WHAT SHE WISHES MORE TEENS KNEW ABOUT ADDICTION: “With [many] substances, it only takes one try to become addicted. Once that happens, it is extremely difficult to break the habit.”

ABOUT HER JOB: “Some people say they admire that I am able to help these individuals…. Others can’t understand why I … choose to work with this population. I use that response as an opportunity to try to educate people about the disease of addiction.”

Discuss

* Before reading, ask: What makes a career “lifesaving” ? What are some lifesaving careers? (List students’ answers.)

* How are each of the careers described in the article “lifesaving”?

* Did any of the profiled careers surprise you? Why?

Do

Return to your students’ list of lifesaving careers. Ask students to select one career from the list to research. Students should prepare a presentation about that job–the job description, training requirements, and lifesaving aspect. As part of their research, students should interview someone in that position to gain insight into how their interview subject improves and even saves people’s lives.

A consensus forged in the 1990s about how to manage medical costs in workers’ compensation is crumbling, with notable and lasting impact on managed care, according to senior executives of managed-care firms and vendor financial reports. The competitive landscape is changing.

Case management, the premier service line in workers’ compensation a decade ago, is way off its peak. Volume referrals of up to $3,000 per claim are no longer assured. The major vendors have been reporting flat or declining revenues from this line for several years. No one predicts a significant reversal of this trend.

The business of discounting medical provider fees, an old workhorse of managed-care vendors, has also been altered by lower state fee schedules. It is harder to negotiate discounts below these schedules, resulting in lower profit margins for vendors.

Partly in response, managed-care firms have pitched into pharmacy cost management, formerly the exclusive province of specialty firms. Drugs have grown from a negligible item to over one-tenth of medical costs. Vendor margins from drug discounting are particularly high. Just this summer, one of the leading provider network firms, a division of Aetna, introduced a drug management service

Services that are growing in demand include better access to clinical quality, more extensive use of analytics and the execution of medical transactions online

An easy-to-apply indicator of changes in the managed-care marketplace is the attitude of a buyer about occupational medicine providers. Consider Frito-Lay’s directive to its operating units.

Each facility is required, in the words of the company, “to cultivate a relationship with at least one occupational medicine provider to whom all injured employees shall be referred to treatment. The provider must be willing to visit the Frito-Lay facility annually to familiarize themselves with our work environment, safety practices, the physical requirement of our jobs, the availability of transitional duty assignments, and our communication expectation between the medical provider, Frito-Lay and Sedgwick CMS (its third-party administrator).”

Frito-Lay has embraced an access-to-quality strategy. The strategy, in concept, has been around for years, but provider network managers, TPAs and insurers have largely downplayed it. This is true no longer. Those interviewed for this article frequently attributed the uptick in interest in access to quality to the failure of price discount networks to contain soaring medical costs.

AIM Mutual, a Mass.-based workers’ compensation insurer, has been building a medical provider network based primarily on access to high-quality doctors. In concert with a relatively young managed-care vendor, Best Doctors, AIM has arrangements with $5 occupational medicine clinics covering the state, and access to dozens of specialist physicians chosen mainly on their reputation with the medical community.

Then there’s the example of Dionne LeBeau, who coordinates the workers’ comp program for Wild Oats, a Boulder, Colo.,-based grocery chain with stores throughout the country. Despite three major insurers servicing the company’s claims over the past few years, no earner has ever sent her a performance report on the medical provider networks to which Wild Oats sends injured workers. As a result, LeBeau has had to keep tabs on more than 100 occupational medicine clinics and largely manages the search and evaluation of these clinics herself.

Even Aetna, the group health insurer with a large discount workers’ comp provider network, is making aggressive and advanced use of analytics in profiling medical providers to get a sense which ones provide the highest quality care. The carrier is making use of its medical claims database to construct profiles of doctors, allowing it to compare surgeons by their rates of readmission and how many ancillary services they order, according to Pat Scullion, president, and Shawn Fisher, chief strategist, of Aetna.

LAWMAKERS STEP IN

Lawmakers have also played a part in forcing the managed-care industry to offer better access to quality. In Texas, a law effective this year authorizes employer choice of medical providers if the insurer implemented a Health Care Network, or HCN, which must include an adequate number of doctors and hospitals who comply with “evidence-based medicine,” and show a commitment to return-to-work.

In California, state-approved Medical Provider Networks need to have an adequate mix of doctors who follow medical treatment guidelines set by the state and specialize in work-related injuries and in specialized areas of medicine. MPNs are required to meet access-to-care standards for common occupational injuries and work-related illnesses. Further, the regulations require MPNs to allow employees a choice of network providers after a first visit.

Peter Madeja, CEO of Genex, a vendor to health insurers, said the new provider-network laws of Texas and California were a big step to making quality more accessible by improving doctor selection. West Virgina has also passed a law requiring networks to demonstrate better access to quality.

Instrument Specialists Inc. (ISI) is a diverse and growing medical service/supply company. Starting in 1978 as an instrument repair company, ISI grew over the years to include complete repair services of flexible & rigid endoscopes, power instruments, electronics, and other surgical equipment. Repair services range from minor repairs with one-day turn-around to complete refurbishing of instruments. In addition, a complete line of products for hand surgery is manufactured and distributed by ISI. Contact ISI at 800-537-1945 or www.isisurgery.com for more information.

Irina Payne, a family medicine specialist, has established her practice with OU Physicians. Payne is board-eligible in family medicine and has specific interest in adult preventive medicine and management of chronic pain. She completed her residency at the OU College of Medicine and received her medical degree from Moscow Medical Academy, Moscow, Russia.

WASHINGTON — Wonder why adoption of a national electronic prescribing and electronic health record system is taking so long? A new study provides the answer: fewer than 1-in-10 physicians are using “fully operational” automation systems that provide electronic health records and e-prescribing capabilities.

Such systems would allow doctors to collect patient information, display test results, enter medical orders and prescriptions and get instant help in making treatment decisions, noted researchers from Massachusetts General Hospital and George Washington University. But in a major study funded by the Robert Wood Johnson Foundation and the federal government’s National Coordinator for Health Information Technology, those researchers found scant evidence that physicians have embraced electronic health record [EHR] technology in their efforts to improve patient care.

In their report, titled Health Information Technology in the United States: The Information Base for Progress, researchers estimated that roughly 1-in-4 physicians have at least begun using EHRs in their treatment. But widespread adoption is still far off, they contend.

We are pitifully behind where we should be, said study co-author David Blumenthal, M.D., director of the Institute for Health Policy. “We must find ways to get more physicians to embrace this technology if we are to make major strides in improving health care quality.”

Behind the sluggish adoption rate of e-health systems among practitioners, according to the study, are “multiple financial, technical and legal barriers.”

“The fact that physicians have to conform to multiple e-prescribing standards is a hindrance to adoption,” said Mark Merritt, president of the Pharmaceutical Care Management Association. Congress must adopt a national e-prescribing standard that will encourage widespread adoption by physicians, resulting in greater quality, safety and reduced costs.”

When I wrote “Urgent Updates to Prenatal Care,”1 it was my intent to share with the profession some specific information about treating pregnant women. I received several e-mails thanking me for the information I had shared, including a few with specific questions. I also received a few e-mails that greatly disagreed with my comment about not performing a side-posture adjustment on a pregnant woman. I usually keep my articles fairly short and to the point; however, clearly more detail was needed in my last article.

As I have stated before, what I write is in my opinion.2 In this instance, “Urgent Updates to Prenatal Care” was based upon a review of courses I had taken, the materials I had seen and OBs with whom I had discussed care. I believe what I wrote is reasonable. Let me also add that I have taken the class for hospital chiropractic, I have worked in a hospital, and I work now with two OB/GYNs. I am proudly a chiropractor, but I work with and understand the mindset of MDs. I know medical doctors are very careful about anything that could be contraindicated, and that to ignore any pertinent information is negligence. 1 did discuss rotational moves with the OBs I work with. They thought it made perfect sense not to do a rotational-type adjustment, as there is a potential risk. Shouldn’t midwives and OBs be the ones to advise us of the risks during pregnancy, since this is their entire patient base? If OBs and midwives suggest there is a potential risk, why isn’t that good enough? Why take the chance?

I do believe pregnant women need chiropractic. Facilitating a healthy pregnancy and restoring a normal physiological environment for natural birth is well within the chiropractic scope of practice.3 Pregnancy is perhaps the most traumatic experience a woman’s body will ever undergo.4 The body begins to change from the moment of conception. Given the progressive postural stresses and ligamentous laxity, pregnancy creates a myriad of distinct aches and pains. The most common of these is lower back pain, especially in the second and third trimester.5

“Because of these physiological and biomechanical compensations, practitioner care must be taken to select the specific analysis and adjustment most appropriate for the complex changes during the various stages of pregnancy. The increased potential for spinal instability in the mother and the resulting subluxations in the woman’s spine throughout pregnancy affect the health and well-being of both her and her baby.”6

Pregnant women are probably some of the best candidates for chiropractic. However, the normal battery of techniques is not always appropriate for care. “The obstetrician [physician in general includes chiropractor] must be aware of the normal physiology of pregnancy and the unique response of the pregnant patient to stress and trauma.”7

I did not state that side posture itself causes placental abruption. I said that rotational motion brings an increased risk for placental abruption. Since one or both of these can occur during an “aggressive” side-posture adjustment, I advise to adjust in a different way. To quote what I did say, “Using a higher-force technique can cause more problems than relief, so less force is the standard. Also, straightline-of-correction techniques should be used - Thompson, Activator or Nimmo. If you are in the habit of performing a diversified side-posture roll, it is time to learn a new technique. Remember, a pregnant body is chemically and biomechanically different from a nonpregnant body, and the usual battery of techniques is not always appropriate.”

I am aware that the Gonstead technique uses a straight line of correction when performing a side-posture adjustment. However, there are cautions about very careful patient positioning, as anything less would lead to insufficient correction or a negative response from the patient.” A chiropractor who practices nonforce technique said it like this: “DNFT achieves the goals of traditional chiropractic to relieve pain and discomfort created by structural misalignments without all the rack ‘em, stack ‘em and cracking force on the spine.”91 can recall a comment made in my technique classes at Palmer: “Anyone can make a back crack. Monkeys can be taught to do that. The art of chiropractic is knowing how to adjust, knowing when to adjust, and knowing when not to adjust.” A patient information brochure on pregnancy notes, “Modifications to the table or adjusting technique are made during each stage of pregnancy.”‘” Clearly, I am not alone in my belief that some degree of caution is reasonable and responsible.

Of course, I know that not all doctors adjust aggressively. I have no way of determining another doctor’s individual skill or level of aggressiveness. Again, I prefer to play it safe. There are enough other techniques available to the practitioner - why take the chance? The caution raised is not a question of force, it is a question of rotation of the pelvis during pregnancy. As I stated in my previous article, even prenatal exercise and yoga classes are now cautioning against rotational-type motions, as there is a risk of abruption.” “There are obvious concerns for uterine injuries in the pregnant woman. Particularly worrisome is the specter of placental abruption, which complicates 1 to 6 percent of minor injuries and up to 50 percent of major injuries. It is hypothesized that the abruption is likely caused by deformation of the elastic myometrium around the relatively inelastic placenta.”12

In this case report, an elderly combat veteran with a chronic course of post-traumatic stress disorder (PTSD) that was untreated for nearly 60 years was evaluated and treated with a combination of medication and graded exposure psychotherapy. To the best of our knowledge, there have been no reports on graded exposure in the elderly. The course of treatment lessened the key symptom domains of PTSD. Comorbid depression was also lessened. Although a single case report, it would appear that elderly patients do respond to psychotherapeutic techniques such as graded exposure therapy. Given the large percentage of the elderly population that has witnessed combat and due to the continuing military conflicts that the United States has been involved in over recent decades, treatments for PTSD in an aging population will be necessary.

It was only several years after the cannons of the American Civil War fell silent that Dr. Jacob Da Costa wrote an article describing “irritable heart” in former soldiers. A generation later, the phenomenon called “shell shock” was written about the horrific battles of World War I. Still later “combat neurosis” was used to describe this entity in World War II, until the Diagnostic and Statistical Manual of Mental Disorders III changed the name of this syndrome to post-traumatic stress disorder (PTSD). As PTSD became increasingly more relevant in the 20th century, figures in the field of psychology no less significant than Freud, Jung, and Piaget pondered the mechanisms of this disorder.1

At the dawn of the 21st century, PTSD continues to play an important role in the mental health care system. Temporally closer to our time will be the scourge of combat-related trauma victims of World War II, the Korean Conflict, and the Vietnam Conflict. Nonetheless, the generation that fought in the Persian Gulf War Conflicts and the War on Terror will quickly rise and present for treatment in increasing numbers over the coming years. Recent research has established that 25% of elderly men have experienced combat and that 50 to 70% of the general American population over a lifetime will experience a trauma meeting diagnostic criteria for PTSD.2 PTSD in the elderly population also has several distinguishing features that have been noted.

Despite the commonly held belief that PTSD symptoms ameliorate with age, retirement tends to worsen symptoms of PTSD.3 Factors involved in this are thought to be the loss of the ability to submerge the earlier trauma in the world of business or family life. Also, retirement age individuals experience other stressors such as the loss of friends to illness and death and a general decline in economic resources.3 Elderly patients with PTSD also are noted to suffer a greater burden of somatic complaints due to the illness.4 Anxiety disorders frequently affect the cardiovascular system, central nervous system, and endocrine system via the hypothalamic pituitary axis.4 Another aspect of PTSD in the elderly patient that bodes poorly is its persistence as a diagnosis.5

For the above reasons, as the general population continues to grow older, PTSD in the elderly will undoubtedly become more prevalent. Society will need newer and better treatment modalities as PTSD can prove to be a protracted and treatment-resistant disorder with significant morbidity, comorbidity in psychiatric and somatic health, and mortality.

Case Report

C.R. is an 82-year-old married Caucasian male with multiple medical problems who presented with a chief complaint of “nightmares and flashbacks of the Battle of the Bulge (Ardennes Offensive).”

History of Present Illness

C.R. served one term in the army from 1942 to 1946 in the European theater of World War II. He vividly remembers the campaign that began in the Ardennes Forest of Belgium during the winter of 1944 to 1945. During the interview, he expressed his fear of not surviving this battle and the horrors he experienced while in combat.

After his return from the war, he began re-experiencing explosions, witnessing dismembered or dead army soldiers, and running through the forests in the snow and ice. Another particularly disturbing memory that repeatedly surfaced was of a severely injured comrade asking for a “mercy killing” to “put him out of his misery.” He described these phenomena as “flashbacks” and stated that they occurred only occasionally since his discharge from active military duty in 1946 but intensified greatly during the early years of the Korean conflict.

C.R. reported frequent nightmares since the early 1950s that were usually about themes of the war-dogs chasing him through the forest, bullets whizzing nearby and striking trees, and dismembered corpses. Commonly, the dreams had no substance but he woke up with feelings of dread and terror and usually sweating and shaking. C.R. reported that the nightmares occurred about two nights per week since that time. These dreams continued in frequency and intensity up to the time he presented for treatment over 50 years later. He described these symptoms as “something I thought was normal for people who had been in battle and would have to deal with for the rest of my life.” It was his opinion that the exposure to men in military service during the Korean conflict exacerbated his symptoms and established their permanence. The patient admitted that he had difficulties discussing the trauma of the Ardennes Offensive and avoided the topic with his family. In addition, he has avoided sports events and malls which disappointed his wife who enjoyed sports and shopping. He described being bothered by loud noises and had given up hunting many years ago as the combination of being in a wooded location with loud firearms exacerbated his symptoms and triggered “flashbacks.” C.R. reported that he becomes startled easily and spoke of sitting in the corners of restaurants so other patrons would not be directly behind him. One major reason for his seeking treatment was due to his noticing an increasing irritability that he was concerned over as he had several times verbally “snapped” at his wife. The symptoms C.R. discussed-re-experiencing phenomena, avoidance, and hyperarousability-met diagnostic criteria for PTSD.

In May 2006, the Illinois Department of Public Health (IDPH) informed CDC about a possible increase in Acanthamoeba keratitis (AK) at an ophthalmology center in Illinois during the preceding 3 years. The University of Illinois at Chicago (UIC) was investigating this possible increase. In October 2006, IDPH updated CDC about the ongoing UIC investigation. At that time, CDC informally contacted multiple ophthalmology centers in the United States to assess whether the potential increase in cases extended beyond Illinois. Responses from the ophthalmology centers were inconclusive. In January 2007, CDC initiated a retrospective survey of 22 ophthalmology centers nationwide to assess whether cases were increasing throughout the United States. In March 2007, data received from 13 centers demonstrated an increase in culture-confirmed cases of AK with wide geographic distribution. The increase in cases had begun in 2004 and continued to the present. On March 16, 2007, CDC initiated a multistate investigation to look for risk factors associated with this increase in AK cases. This report summarizes recent preliminary results of that investigation, which, indicated an association with AK in soft contact lens wearers who used Advanced Medical Optics (Santa Ana, California) Complete[R] MoisturePlus[TM] (AMOCMP) multipurpose cleaning solution. CDC and the Food and Drug Administration (FDA) are taking steps to notify the public and the medical and public health communities of this preliminary association. The manufacturer has undertaken a voluntary recall of the product.

AK, a rare but potentially blinding infection of the cornea, is caused by a ubiquitous, free-living ameba (Acanthamoeba) that is found commonly in the environment, including water (e.g., tap and recreational water), soil, sewage systems, cooling towers, and heating/ventilation/air conditioning (HVAC) systems. AK primarily affects otherwise healthy persons who wear contact lenses; an estimated 85% of U.S. cases occur in contact lens wearers (including wearers who follow recommended contact lens-care practices) (1). Persons who improperly store, handle, or disinfect their lenses (e.g., by using tap water or homemade solutions for cleaning); swim, use hot tubs, or shower while wearing lenses; come in contact with contaminated water; have minor damage to their corneas; or have previous corneal trauma are at increased risk for infection (2). Based on an analysis of cases reported to CDC during 1985-1987, the incidence of AK in the United States has been estimated at one to two cases per million contact lens users (3,4). An estimated 30 million persons in the United States wear soft contact lenses (5).

Initial case finding for this investigation was facilitated through postings on the Epidemic Information Exchange (Epi-X), on ophthalmology/optometry/infection control listservs and websites, and through queries of clinical microbiology laboratories. As of May 24, 2007, a total of 138 patients with onset of symptoms on or after January 1, 2005, and positive Acanthamoeba cultures from corneal specimens had been reported to CDC by public health authorities and ophthalmologists from 35 states and Puerto Rico. Standardized telephone interviews of patients, ophthalmologists, and primary eye-care providers are being conducted by state and local health officials and CDC. Laboratory testing of clinical specimens, contact lenses, bottles of solution, and contact lens cases received from AK patients, including typing of Acanthamoeba spp. isolates, is ongoing. An initial analysis was conducted using data from the first 46 completed patient interviews.

Among the 46 culture-confirmed patients who were interviewed, the median age was 40 years (range: 15-77 years); six (13%) were aged <18 years. Twenty-seven (59%) were female. Of the 37 of these patients for whom clinical data were available, medical therapy was unsuccessful for nine (24%), and they were required or expected to undergo corneal transplantation. Of the 46 patients, 39 (85%) wore soft contact lenses, three (7%) wore rigid lenses, and four (9%) reported no contact lens use. Among the 42 contact lens users, 16 (38%) reported swimming while wearing contact lenses and 35 (83%) reported showering while wearing contact lenses during the month before symptom onset.

Among the 39 soft contact lens users, 36 reported using one or more specific types of contact lens solution, 21 of these (58%) reported any use of AMOCMP in the month before symptom onset, 20 (56%) reported using AMOCMP as their primary solution, and 14 (39%) reported using AMOCMP as their exclusive solution. Exposure data from the 36 patients who wore soft contact lenses and used any type of contact lens solution were compared with exposure data from controls who were interviewed as part of the 2006 CDC Fusariurn keratitis outbreak investigation (6). These controls, who were selected as geographically matched controls for the Fusarium keratitis cases, represented a sample of adult soft contact lens wearers from different U.S. states who were asked about product use and behaviors during March 2006 (6).