Denise Napoli

The health care reform law signed by President Obama last month clears the way for about 32 million previously uninsured Americans to get coverage in coming years, but the changes will bring new challenges for hospitalists, physicians told

“We have long supported efforts to expand health care coverage to all Americans, and in that respect, this legislation is a step in the right direction,” said Dr. Eric M. Siegal, chair of the Society of Hospital Medicine's public policy committee. “One cannot bring 30-plus million Americans into the system and expect costs to decrease if one doesn't also address the inefficiencies and perverse incentives that are driving health care costs ever higher.”

Dr. Alpesh Amin, executive director of the hospitalist program at University of California, Irvine, agreed. “It's going to make the hospitalists much busier,” he said in an interview. “Volume is going to go up,” and that could pose a problem for a specialty facing a shortage of physicians available to fill existing positions.

Although health care reform includes a Medicare payment incentive designed to bolster the supply of primary care physicians, hospitalists will not be eligible for those bonuses, Dr. Siegal noted. Only services rendered in the ambulatory and nursing home setting will qualify.

Another concern: The new law does not address the sustainable growth rate formula that is used to adjust physician Medicare payments and that many physicians see as flawed. Under the formula, Medicare physicians' fees were cut 21% on April 1 as Congress—which has postponed but not eliminated the cuts for several years—adjourned for a spring recess without acting on the SGR. At press time, the Centers for Medicare and Medicaid Services (CMS) was holding Medicare claims for 10 business days until Congress could reconvene and address the issue, probably on a temporary basis.

“This is simply unacceptable,” Dr. Siegal said. “If the government expects physicians to dramatically alter the way that we practice to deliver better health care, the absolute minimum that we should expect in return is a stable and predictable reimbursement methodology.”

Hospitalists could benefit from continuation of the Physician Quality Reporting Initiative. PQRI participants stand to receive incentive payments of 1% in 2011 and 0.5% from 2012 to 2014. Physicians who don't participate will be penalized starting in 2015. “The PQRI looks like it is here to stay,” Dr. Siegal said. “We know that less than 20% of physicians currently participate, and hospitalists will obviously need to gear up to participate if they want to avoid being penalized.”

Other benefits of the reform law relate to the discharge process, Dr. Amin said. “As a hospitalist, I'm discharging patients out of the hospital who may not have any good follow-up,” he said. “And when they don't have good follow-up because they don't have insurance, there's a higher chance of readmission.”

Discharge without follow-up could become much less likely once an additional 32 million Americans get health insurance, he said. “If there's follow-up available, that's a wonderful thing. We'll be able to feel comfortable about putting patients back out in their community.”

Dr. Patrick Conway, director of hospital medicine at Cincinnati Children's Hospital, agreed. “Decreasing the number of uninsured will benefit most hospitals and hospitalists,” said Dr. Conway, a former chief medical officer at the Department of Health and Human Services (HHS).

Hospitalists will see more hospital-based demonstration projects focusing on quality, value, and comparative effectiveness research, he predicted. Also, a new Center for Medicare and Medicaid Innovation within CMS will test novel payment methodologies aimed at improving quality and reducing costs. “Hospitalists will play key roles in many of these programs,” Dr. Conway said.

The health care reform law also aims to bring transparency to relationships between pharmaceutical companies and physicians and hospitals. Under the incorporated Physician Payments Sunshine Act, sponsored by Sen. Chuck Grassley (R-Iowa) and Sen. Herb Kohl (D-Wis.), makers of medical supplies, pharmaceuticals, biologics, and devices must report any payments or transfers worth more than $100 a year that go to physicians and hospitals, starting in 2013. Manufacturers also will have to report any and all physician ownership stakes. The HHS will be required to make this information available to the public.

Also, starting in 2012, manufacturers will have to report to the HHS all drug samples given to physicians, if the drugs are covered by Medicare or Medicaid.

Finally, the reforms establish an Independent Payment Advisory Board, which will recommend Medicare spending reductions whenever annual spending on Medicare exceeds a yet-to-be determined rate. Precise details about how this board will function remain to be addressed via federal regulation.

According to Dr. Siegal, that's no surprise. “A lot of the implementation of these bills is subject to interpretation by CMS,” he noted. “The next 12-18 months will be phenomenally busy as CMS struggles to turn 2,000-plus pages of legislation into actionable statutes.”

He added that “it will be absolutely critical for hospital medicine to be represented in this process, and for us to lend our expertise to ensure that we get the outcomes that are intended. Only then will we really know if the bills are likely to deliver.”

The health care reform law signed by President Obama last month clears the way for about 32 million previously uninsured Americans to get coverage in coming years, but the changes will bring new challenges for hospitalists, physicians told

“We have long supported efforts to expand health care coverage to all Americans, and in that respect, this legislation is a step in the right direction,” said Dr. Eric M. Siegal, chair of the Society of Hospital Medicine's public policy committee. “One cannot bring 30-plus million Americans into the system and expect costs to decrease if one doesn't also address the inefficiencies and perverse incentives that are driving health care costs ever higher.”

Dr. Alpesh Amin, executive director of the hospitalist program at University of California, Irvine, agreed. “It's going to make the hospitalists much busier,” he said in an interview. “Volume is going to go up,” and that could pose a problem for a specialty facing a shortage of physicians available to fill existing positions.

Although health care reform includes a Medicare payment incentive designed to bolster the supply of primary care physicians, hospitalists will not be eligible for those bonuses, Dr. Siegal noted. Only services rendered in the ambulatory and nursing home setting will qualify.

Another concern: The new law does not address the sustainable growth rate formula that is used to adjust physician Medicare payments and that many physicians see as flawed. Under the formula, Medicare physicians' fees were cut 21% on April 1 as Congress—which has postponed but not eliminated the cuts for several years—adjourned for a spring recess without acting on the SGR. At press time, the Centers for Medicare and Medicaid Services (CMS) was holding Medicare claims for 10 business days until Congress could reconvene and address the issue, probably on a temporary basis.

“This is simply unacceptable,” Dr. Siegal said. “If the government expects physicians to dramatically alter the way that we practice to deliver better health care, the absolute minimum that we should expect in return is a stable and predictable reimbursement methodology.”

Hospitalists could benefit from continuation of the Physician Quality Reporting Initiative. PQRI participants stand to receive incentive payments of 1% in 2011 and 0.5% from 2012 to 2014. Physicians who don't participate will be penalized starting in 2015. “The PQRI looks like it is here to stay,” Dr. Siegal said. “We know that less than 20% of physicians currently participate, and hospitalists will obviously need to gear up to participate if they want to avoid being penalized.”

Other benefits of the reform law relate to the discharge process, Dr. Amin said. “As a hospitalist, I'm discharging patients out of the hospital who may not have any good follow-up,” he said. “And when they don't have good follow-up because they don't have insurance, there's a higher chance of readmission.”

Discharge without follow-up could become much less likely once an additional 32 million Americans get health insurance, he said. “If there's follow-up available, that's a wonderful thing. We'll be able to feel comfortable about putting patients back out in their community.”

Dr. Patrick Conway, director of hospital medicine at Cincinnati Children's Hospital, agreed. “Decreasing the number of uninsured will benefit most hospitals and hospitalists,” said Dr. Conway, a former chief medical officer at the Department of Health and Human Services (HHS).

Hospitalists will see more hospital-based demonstration projects focusing on quality, value, and comparative effectiveness research, he predicted. Also, a new Center for Medicare and Medicaid Innovation within CMS will test novel payment methodologies aimed at improving quality and reducing costs. “Hospitalists will play key roles in many of these programs,” Dr. Conway said.

The health care reform law also aims to bring transparency to relationships between pharmaceutical companies and physicians and hospitals. Under the incorporated Physician Payments Sunshine Act, sponsored by Sen. Chuck Grassley (R-Iowa) and Sen. Herb Kohl (D-Wis.), makers of medical supplies, pharmaceuticals, biologics, and devices must report any payments or transfers worth more than $100 a year that go to physicians and hospitals, starting in 2013. Manufacturers also will have to report any and all physician ownership stakes. The HHS will be required to make this information available to the public.

Also, starting in 2012, manufacturers will have to report to the HHS all drug samples given to physicians, if the drugs are covered by Medicare or Medicaid.

Finally, the reforms establish an Independent Payment Advisory Board, which will recommend Medicare spending reductions whenever annual spending on Medicare exceeds a yet-to-be determined rate. Precise details about how this board will function remain to be addressed via federal regulation.

According to Dr. Siegal, that's no surprise. “A lot of the implementation of these bills is subject to interpretation by CMS,” he noted. “The next 12-18 months will be phenomenally busy as CMS struggles to turn 2,000-plus pages of legislation into actionable statutes.”

He added that “it will be absolutely critical for hospital medicine to be represented in this process, and for us to lend our expertise to ensure that we get the outcomes that are intended. Only then will we really know if the bills are likely to deliver.”

The health care reform law signed by President Obama last month clears the way for about 32 million previously uninsured Americans to get coverage in coming years, but the changes will bring new challenges for hospitalists, physicians told

“We have long supported efforts to expand health care coverage to all Americans, and in that respect, this legislation is a step in the right direction,” said Dr. Eric M. Siegal, chair of the Society of Hospital Medicine's public policy committee. “One cannot bring 30-plus million Americans into the system and expect costs to decrease if one doesn't also address the inefficiencies and perverse incentives that are driving health care costs ever higher.”

Dr. Alpesh Amin, executive director of the hospitalist program at University of California, Irvine, agreed. “It's going to make the hospitalists much busier,” he said in an interview. “Volume is going to go up,” and that could pose a problem for a specialty facing a shortage of physicians available to fill existing positions.

Although health care reform includes a Medicare payment incentive designed to bolster the supply of primary care physicians, hospitalists will not be eligible for those bonuses, Dr. Siegal noted. Only services rendered in the ambulatory and nursing home setting will qualify.

Another concern: The new law does not address the sustainable growth rate formula that is used to adjust physician Medicare payments and that many physicians see as flawed. Under the formula, Medicare physicians' fees were cut 21% on April 1 as Congress—which has postponed but not eliminated the cuts for several years—adjourned for a spring recess without acting on the SGR. At press time, the Centers for Medicare and Medicaid Services (CMS) was holding Medicare claims for 10 business days until Congress could reconvene and address the issue, probably on a temporary basis.

“This is simply unacceptable,” Dr. Siegal said. “If the government expects physicians to dramatically alter the way that we practice to deliver better health care, the absolute minimum that we should expect in return is a stable and predictable reimbursement methodology.”

Hospitalists could benefit from continuation of the Physician Quality Reporting Initiative. PQRI participants stand to receive incentive payments of 1% in 2011 and 0.5% from 2012 to 2014. Physicians who don't participate will be penalized starting in 2015. “The PQRI looks like it is here to stay,” Dr. Siegal said. “We know that less than 20% of physicians currently participate, and hospitalists will obviously need to gear up to participate if they want to avoid being penalized.”

Other benefits of the reform law relate to the discharge process, Dr. Amin said. “As a hospitalist, I'm discharging patients out of the hospital who may not have any good follow-up,” he said. “And when they don't have good follow-up because they don't have insurance, there's a higher chance of readmission.”

Discharge without follow-up could become much less likely once an additional 32 million Americans get health insurance, he said. “If there's follow-up available, that's a wonderful thing. We'll be able to feel comfortable about putting patients back out in their community.”

Dr. Patrick Conway, director of hospital medicine at Cincinnati Children's Hospital, agreed. “Decreasing the number of uninsured will benefit most hospitals and hospitalists,” said Dr. Conway, a former chief medical officer at the Department of Health and Human Services (HHS).

Hospitalists will see more hospital-based demonstration projects focusing on quality, value, and comparative effectiveness research, he predicted. Also, a new Center for Medicare and Medicaid Innovation within CMS will test novel payment methodologies aimed at improving quality and reducing costs. “Hospitalists will play key roles in many of these programs,” Dr. Conway said.

The health care reform law also aims to bring transparency to relationships between pharmaceutical companies and physicians and hospitals. Under the incorporated Physician Payments Sunshine Act, sponsored by Sen. Chuck Grassley (R-Iowa) and Sen. Herb Kohl (D-Wis.), makers of medical supplies, pharmaceuticals, biologics, and devices must report any payments or transfers worth more than $100 a year that go to physicians and hospitals, starting in 2013. Manufacturers also will have to report any and all physician ownership stakes. The HHS will be required to make this information available to the public.

Also, starting in 2012, manufacturers will have to report to the HHS all drug samples given to physicians, if the drugs are covered by Medicare or Medicaid.

Finally, the reforms establish an Independent Payment Advisory Board, which will recommend Medicare spending reductions whenever annual spending on Medicare exceeds a yet-to-be determined rate. Precise details about how this board will function remain to be addressed via federal regulation.

According to Dr. Siegal, that's no surprise. “A lot of the implementation of these bills is subject to interpretation by CMS,” he noted. “The next 12-18 months will be phenomenally busy as CMS struggles to turn 2,000-plus pages of legislation into actionable statutes.”

He added that “it will be absolutely critical for hospital medicine to be represented in this process, and for us to lend our expertise to ensure that we get the outcomes that are intended. Only then will we really know if the bills are likely to deliver.”

Major Finding: Over an average follow-up of 4 years, 4.9% of the statin group developed diabetes, compared with 4.5% of the control patients.

Data Source: A meta-analysis of 13 placebo-controlled trials.

Disclosures: Although there was no funding for the meta-analysis, Dr. Sattar reported that the trials included in it were supported by the pharmaceutical industry. Many of the authors of the current study have financial ties to AstraZeneca, Merck & Co, Pfizer, Sanofi-Aventis, Roche, Bristol-Myers Squibb, and other drug manufacturers.

For every 255 patients on statins for 4 years, there is 1 additional case of diabetes—a risk too small to change current recommendations for statins in patients with cardiovascular disease, or with moderate to high risk of developing heart disease.

However, the increased risk “should be taken into account if statin therapy is considered for patients at low cardiovascular risk,” Naveed Sattar, Ph.D., and colleagues wrote (Lancet 2010 Feb. 16 [10.1016/S0140-6736(09)61965-6

Dr. Sattar of the Glasgow Cardiovascular Research Centre at the University of Glasgow, Scotland, searched Medline, Embase, and Cochrane Central Register of Controlled Trials for studies with the term “statin” as a title word and keyword between 1994 and 2009. The investigators included in their analysis English-language studies with at least 1,000 patients and a mean follow-up of at least 1 year, and excluded trials in patients with organ transplants, with diabetes, or on hemodialysis.

Overall, the researchers looked at 13 placebo-controlled and standard care-controlled trials with a total of 91,140 nondiabetic patients, including JUPITER (Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin), CORONA (Controlled Rosuvastatin Multinational Study in Heart Failure), and the MEGA trial (Management of Elevated Cholesterol in the Primary Prevention Group of Adult Japanese).

There were a total of 45,521 patients taking statin therapy, and 45,619 controls. Over an average follow-up of 4 years, 2,226 patients (4.9%) in the statin group developed diabetes, as did 2,052 control patients (4.5%).

The 174 extra cases amounted to a 9% increase in diabetes likelihood, or “one additional case of diabetes per 255 (95% [confidence interval] 150–852) patients taking statin therapy for 4 years,” wrote Dr. Sattar and colleagues, for an incidence of 12.2 cases per 1,000 patient-years with statin treatment, and 11.3 cases per 1,000 patient-years for controls.

The risk was similarly elevated even in a subanalysis of only those patients in placebo-controlled trials (n = 75,507, odds ratio 1.10, 95% CI 1.01–1.20), though “the association weakened slightly … when we analysed only trials that used fasting glucose measurements [to identify diabetes patients]—possibly because of a loss of statistical power” (n = 75,033, OR 1.07, 0.97–1.17).

No mechanism has yet been implicated for the increased risk of diabetes among statin users. The authors of the current analysis postulate that the risk could be due to confounders—for example, patients not on statin therapy suffer cardiovascular events and subsequently are likely to change their diet and exercise habits.

In an accompanying editorial, Dr. Christopher P. Cannon of Brigham and Women's Hospital and Harvard University, Boston, pointed to a 2005 article by Dr. Sattar, which “estimated that 5.4 deaths or myocardial infarctions would be avoided over those 4 years [taking statins], and nearly the same number of strokes or coronary revascularisation procedures would also be avoided.

“Therefore the benefit in preventing total vascular events to the risk of diabetes is a ratio of about 9:1 in favour of the cardiovascular benefit,” he wrote.

Major Finding: Over an average follow-up of 4 years, 4.9% of the statin group developed diabetes, compared with 4.5% of the control patients.

Data Source: A meta-analysis of 13 placebo-controlled trials.

Disclosures: Although there was no funding for the meta-analysis, Dr. Sattar reported that the trials included in it were supported by the pharmaceutical industry. Many of the authors of the current study have financial ties to AstraZeneca, Merck & Co, Pfizer, Sanofi-Aventis, Roche, Bristol-Myers Squibb, and other drug manufacturers.

For every 255 patients on statins for 4 years, there is 1 additional case of diabetes—a risk too small to change current recommendations for statins in patients with cardiovascular disease, or with moderate to high risk of developing heart disease.

However, the increased risk “should be taken into account if statin therapy is considered for patients at low cardiovascular risk,” Naveed Sattar, Ph.D., and colleagues wrote (Lancet 2010 Feb. 16 [10.1016/S0140-6736(09)61965-6

Dr. Sattar of the Glasgow Cardiovascular Research Centre at the University of Glasgow, Scotland, searched Medline, Embase, and Cochrane Central Register of Controlled Trials for studies with the term “statin” as a title word and keyword between 1994 and 2009. The investigators included in their analysis English-language studies with at least 1,000 patients and a mean follow-up of at least 1 year, and excluded trials in patients with organ transplants, with diabetes, or on hemodialysis.

Overall, the researchers looked at 13 placebo-controlled and standard care-controlled trials with a total of 91,140 nondiabetic patients, including JUPITER (Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin), CORONA (Controlled Rosuvastatin Multinational Study in Heart Failure), and the MEGA trial (Management of Elevated Cholesterol in the Primary Prevention Group of Adult Japanese).

There were a total of 45,521 patients taking statin therapy, and 45,619 controls. Over an average follow-up of 4 years, 2,226 patients (4.9%) in the statin group developed diabetes, as did 2,052 control patients (4.5%).

The 174 extra cases amounted to a 9% increase in diabetes likelihood, or “one additional case of diabetes per 255 (95% [confidence interval] 150–852) patients taking statin therapy for 4 years,” wrote Dr. Sattar and colleagues, for an incidence of 12.2 cases per 1,000 patient-years with statin treatment, and 11.3 cases per 1,000 patient-years for controls.

The risk was similarly elevated even in a subanalysis of only those patients in placebo-controlled trials (n = 75,507, odds ratio 1.10, 95% CI 1.01–1.20), though “the association weakened slightly … when we analysed only trials that used fasting glucose measurements [to identify diabetes patients]—possibly because of a loss of statistical power” (n = 75,033, OR 1.07, 0.97–1.17).

No mechanism has yet been implicated for the increased risk of diabetes among statin users. The authors of the current analysis postulate that the risk could be due to confounders—for example, patients not on statin therapy suffer cardiovascular events and subsequently are likely to change their diet and exercise habits.

In an accompanying editorial, Dr. Christopher P. Cannon of Brigham and Women's Hospital and Harvard University, Boston, pointed to a 2005 article by Dr. Sattar, which “estimated that 5.4 deaths or myocardial infarctions would be avoided over those 4 years [taking statins], and nearly the same number of strokes or coronary revascularisation procedures would also be avoided.

“Therefore the benefit in preventing total vascular events to the risk of diabetes is a ratio of about 9:1 in favour of the cardiovascular benefit,” he wrote.

Major Finding: Over an average follow-up of 4 years, 4.9% of the statin group developed diabetes, compared with 4.5% of the control patients.

Data Source: A meta-analysis of 13 placebo-controlled trials.

Disclosures: Although there was no funding for the meta-analysis, Dr. Sattar reported that the trials included in it were supported by the pharmaceutical industry. Many of the authors of the current study have financial ties to AstraZeneca, Merck & Co, Pfizer, Sanofi-Aventis, Roche, Bristol-Myers Squibb, and other drug manufacturers.

For every 255 patients on statins for 4 years, there is 1 additional case of diabetes—a risk too small to change current recommendations for statins in patients with cardiovascular disease, or with moderate to high risk of developing heart disease.

However, the increased risk “should be taken into account if statin therapy is considered for patients at low cardiovascular risk,” Naveed Sattar, Ph.D., and colleagues wrote (Lancet 2010 Feb. 16 [10.1016/S0140-6736(09)61965-6

Dr. Sattar of the Glasgow Cardiovascular Research Centre at the University of Glasgow, Scotland, searched Medline, Embase, and Cochrane Central Register of Controlled Trials for studies with the term “statin” as a title word and keyword between 1994 and 2009. The investigators included in their analysis English-language studies with at least 1,000 patients and a mean follow-up of at least 1 year, and excluded trials in patients with organ transplants, with diabetes, or on hemodialysis.

Overall, the researchers looked at 13 placebo-controlled and standard care-controlled trials with a total of 91,140 nondiabetic patients, including JUPITER (Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin), CORONA (Controlled Rosuvastatin Multinational Study in Heart Failure), and the MEGA trial (Management of Elevated Cholesterol in the Primary Prevention Group of Adult Japanese).

There were a total of 45,521 patients taking statin therapy, and 45,619 controls. Over an average follow-up of 4 years, 2,226 patients (4.9%) in the statin group developed diabetes, as did 2,052 control patients (4.5%).

The 174 extra cases amounted to a 9% increase in diabetes likelihood, or “one additional case of diabetes per 255 (95% [confidence interval] 150–852) patients taking statin therapy for 4 years,” wrote Dr. Sattar and colleagues, for an incidence of 12.2 cases per 1,000 patient-years with statin treatment, and 11.3 cases per 1,000 patient-years for controls.

The risk was similarly elevated even in a subanalysis of only those patients in placebo-controlled trials (n = 75,507, odds ratio 1.10, 95% CI 1.01–1.20), though “the association weakened slightly … when we analysed only trials that used fasting glucose measurements [to identify diabetes patients]—possibly because of a loss of statistical power” (n = 75,033, OR 1.07, 0.97–1.17).

No mechanism has yet been implicated for the increased risk of diabetes among statin users. The authors of the current analysis postulate that the risk could be due to confounders—for example, patients not on statin therapy suffer cardiovascular events and subsequently are likely to change their diet and exercise habits.

In an accompanying editorial, Dr. Christopher P. Cannon of Brigham and Women's Hospital and Harvard University, Boston, pointed to a 2005 article by Dr. Sattar, which “estimated that 5.4 deaths or myocardial infarctions would be avoided over those 4 years [taking statins], and nearly the same number of strokes or coronary revascularisation procedures would also be avoided.

“Therefore the benefit in preventing total vascular events to the risk of diabetes is a ratio of about 9:1 in favour of the cardiovascular benefit,” he wrote.

Major Finding: Early arthroscopic surgery does not have any effect beyond short-term pain relief.

Data Source: Prospective study of 20 patients with marked intraoperative chondral lesions; mean follow-up 3 years.

Disclosures: None.

Arthroscopic surgery for femoroacetabular impingement did not eliminate the need for total hip arthroplasty in 10 of 20 patients with advanced chondral lesions. The joint had to be replaced within 3 years of undergoing the less-extensive procedure.

The “discouraging” data indicate that arthroscopic surgery in patients with femoroacetabular impingement (FAI) involving more severe, generalized chondral lesions (grade II or greater on the Outerbridge scale) does not obviate the need for total hip arthroplasty (THA) or even lengthen the interval before the joint replacement procedure is required. “It seems obvious that these patients should not be treated by arthroscopic means,” reported Dr. Monika Horisberger and her associates of the University Hospital Basel (Switzerland).

They looked at 150 patients with cam and mixed FAI. Of these, “20 patients showed intraoperative marked chondral lesions of Outerbridge grade II or greater not restricted to the direct impingement zone, and were therefore included in the study,” they wrote (J. Arthro. 2010 Feb. 11 [doi:10.1016/j.arthro.2009.09.003

Preoperatively, according to the Tönnis classification, “[nine] hips had grade I osteoarthritis, [six] had grade II osteoarthritis, and [five] had grade III osteoarthritis.” The mean age was 47.3 years (range, 22-65 years) and the mean follow-up was 3.0 years (range, 1.5-4.1 years). Half of the patients were male, and one patient died of causes unrelated to the study.

Intraoperatively, all 20 patients were found to have “marked” generalized chondral damage as well as labral lesions. “Grade IV chondral lesions were localized at the impingement zone (ventral-cranial acetabulum) in 14 cases (70%) and at the corresponding femur in 3 cases (15%),” wrote the authors. “Microfracturing was performed in these areas in a total of 15 cases (75%).”

At the study's end, total hip arthroplasty had already been performed in eight patients, and two patients were scheduled to undergo the procedure after the study's conclusion. Preoperatively, three of these patients had Tönnis grade I osteoarthritis, two had grade II osteoarthritis, and five had grade III osteoarthritis. A higher preoperative Tönnis grade increased the risk for subsequent THA significantly (P = .03).

The remaining nine patients who had not undergone THA and were not planning the surgery did experience significant improvements in range of motion (internal rotation improved from 0.25 degrees preoperatively to 24.5 degrees following arthroscopy, P less than .001), flexion (from 110.8 to 125.0 degrees; P = .005) and pain on the visual analog scale (from 6.0 to 1.8; P = .002).

However, the authors said, it is unclear whether the index surgery slowed the degenerative process for the long term or whether a major part of improvement might have been because of the effect of articular debridement or therapy for labral tears rather than the correction of the causative lesion.

Dr. Horisberger conceded that the study does have weaknesses: Nevertheless, “If preoperative examinations underestimate the real extent of chondral damage found on arthroscopy, particularly if extended grade IV lesions at the femoral head are seen, THA should be recommended without further joint-preserving treatment attempts,” they asserted.

Major Finding: Early arthroscopic surgery does not have any effect beyond short-term pain relief.

Data Source: Prospective study of 20 patients with marked intraoperative chondral lesions; mean follow-up 3 years.

Disclosures: None.

Arthroscopic surgery for femoroacetabular impingement did not eliminate the need for total hip arthroplasty in 10 of 20 patients with advanced chondral lesions. The joint had to be replaced within 3 years of undergoing the less-extensive procedure.

The “discouraging” data indicate that arthroscopic surgery in patients with femoroacetabular impingement (FAI) involving more severe, generalized chondral lesions (grade II or greater on the Outerbridge scale) does not obviate the need for total hip arthroplasty (THA) or even lengthen the interval before the joint replacement procedure is required. “It seems obvious that these patients should not be treated by arthroscopic means,” reported Dr. Monika Horisberger and her associates of the University Hospital Basel (Switzerland).

They looked at 150 patients with cam and mixed FAI. Of these, “20 patients showed intraoperative marked chondral lesions of Outerbridge grade II or greater not restricted to the direct impingement zone, and were therefore included in the study,” they wrote (J. Arthro. 2010 Feb. 11 [doi:10.1016/j.arthro.2009.09.003

Preoperatively, according to the Tönnis classification, “[nine] hips had grade I osteoarthritis, [six] had grade II osteoarthritis, and [five] had grade III osteoarthritis.” The mean age was 47.3 years (range, 22-65 years) and the mean follow-up was 3.0 years (range, 1.5-4.1 years). Half of the patients were male, and one patient died of causes unrelated to the study.

Intraoperatively, all 20 patients were found to have “marked” generalized chondral damage as well as labral lesions. “Grade IV chondral lesions were localized at the impingement zone (ventral-cranial acetabulum) in 14 cases (70%) and at the corresponding femur in 3 cases (15%),” wrote the authors. “Microfracturing was performed in these areas in a total of 15 cases (75%).”

At the study's end, total hip arthroplasty had already been performed in eight patients, and two patients were scheduled to undergo the procedure after the study's conclusion. Preoperatively, three of these patients had Tönnis grade I osteoarthritis, two had grade II osteoarthritis, and five had grade III osteoarthritis. A higher preoperative Tönnis grade increased the risk for subsequent THA significantly (P = .03).

The remaining nine patients who had not undergone THA and were not planning the surgery did experience significant improvements in range of motion (internal rotation improved from 0.25 degrees preoperatively to 24.5 degrees following arthroscopy, P less than .001), flexion (from 110.8 to 125.0 degrees; P = .005) and pain on the visual analog scale (from 6.0 to 1.8; P = .002).

However, the authors said, it is unclear whether the index surgery slowed the degenerative process for the long term or whether a major part of improvement might have been because of the effect of articular debridement or therapy for labral tears rather than the correction of the causative lesion.

Dr. Horisberger conceded that the study does have weaknesses: Nevertheless, “If preoperative examinations underestimate the real extent of chondral damage found on arthroscopy, particularly if extended grade IV lesions at the femoral head are seen, THA should be recommended without further joint-preserving treatment attempts,” they asserted.

Major Finding: Early arthroscopic surgery does not have any effect beyond short-term pain relief.

Data Source: Prospective study of 20 patients with marked intraoperative chondral lesions; mean follow-up 3 years.

Disclosures: None.

Arthroscopic surgery for femoroacetabular impingement did not eliminate the need for total hip arthroplasty in 10 of 20 patients with advanced chondral lesions. The joint had to be replaced within 3 years of undergoing the less-extensive procedure.

The “discouraging” data indicate that arthroscopic surgery in patients with femoroacetabular impingement (FAI) involving more severe, generalized chondral lesions (grade II or greater on the Outerbridge scale) does not obviate the need for total hip arthroplasty (THA) or even lengthen the interval before the joint replacement procedure is required. “It seems obvious that these patients should not be treated by arthroscopic means,” reported Dr. Monika Horisberger and her associates of the University Hospital Basel (Switzerland).

They looked at 150 patients with cam and mixed FAI. Of these, “20 patients showed intraoperative marked chondral lesions of Outerbridge grade II or greater not restricted to the direct impingement zone, and were therefore included in the study,” they wrote (J. Arthro. 2010 Feb. 11 [doi:10.1016/j.arthro.2009.09.003

Preoperatively, according to the Tönnis classification, “[nine] hips had grade I osteoarthritis, [six] had grade II osteoarthritis, and [five] had grade III osteoarthritis.” The mean age was 47.3 years (range, 22-65 years) and the mean follow-up was 3.0 years (range, 1.5-4.1 years). Half of the patients were male, and one patient died of causes unrelated to the study.

Intraoperatively, all 20 patients were found to have “marked” generalized chondral damage as well as labral lesions. “Grade IV chondral lesions were localized at the impingement zone (ventral-cranial acetabulum) in 14 cases (70%) and at the corresponding femur in 3 cases (15%),” wrote the authors. “Microfracturing was performed in these areas in a total of 15 cases (75%).”

At the study's end, total hip arthroplasty had already been performed in eight patients, and two patients were scheduled to undergo the procedure after the study's conclusion. Preoperatively, three of these patients had Tönnis grade I osteoarthritis, two had grade II osteoarthritis, and five had grade III osteoarthritis. A higher preoperative Tönnis grade increased the risk for subsequent THA significantly (P = .03).

The remaining nine patients who had not undergone THA and were not planning the surgery did experience significant improvements in range of motion (internal rotation improved from 0.25 degrees preoperatively to 24.5 degrees following arthroscopy, P less than .001), flexion (from 110.8 to 125.0 degrees; P = .005) and pain on the visual analog scale (from 6.0 to 1.8; P = .002).

However, the authors said, it is unclear whether the index surgery slowed the degenerative process for the long term or whether a major part of improvement might have been because of the effect of articular debridement or therapy for labral tears rather than the correction of the causative lesion.

Dr. Horisberger conceded that the study does have weaknesses: Nevertheless, “If preoperative examinations underestimate the real extent of chondral damage found on arthroscopy, particularly if extended grade IV lesions at the femoral head are seen, THA should be recommended without further joint-preserving treatment attempts,” they asserted.

The 37 million “family caregivers” who care for chronically ill patients in the United States have become “an integral part of the health care system” and deserve recognition from physicians for that role, according to a position paper issued by the American College of Physicians.

Family caregivers—defined broadly as relatives, partners, friends, and neighbors—provide care for 90% of dependent community-dwelling patients with acute and chronic physical illnesses, cognitive impairment, and/or mental health conditions, according to the authors (J. Gen. Intern. Med. 2010 Jan. 12 [Epub doi:10.1007/s11606-009-1206-3]).

“Coping with physical, emotional, spiritual and financial challenges affects caregiver health and quality of life as well as patients' health and quality of life,” they wrote.

Rheumatologist Robert G. Lahita, chairman of the department of medicine at Newark (N.J.) Beth Israel Medical Center, agreed. “Diseases like systemic lupus erythematosus, rheumatoid arthritis, and other illnesses like polymyositis can be included in those illnesses addressed by this important paper,” he commented in an interview.

Indeed, “ambulatory care is the norm in our specialty,” added Dr. Lahita, and “the rheumatologist provides care outside the medical center in most cases.”

According to the report, “physician accessibility and excellent communication are fundamental to supporting the patient and family caregiver”—a potentially difficult mandate, given the current climate of rushed office visits and time constrictions.

The 37 million “family caregivers” who care for chronically ill patients in the United States have become “an integral part of the health care system” and deserve recognition from physicians for that role, according to a position paper issued by the American College of Physicians.

Family caregivers—defined broadly as relatives, partners, friends, and neighbors—provide care for 90% of dependent community-dwelling patients with acute and chronic physical illnesses, cognitive impairment, and/or mental health conditions, according to the authors (J. Gen. Intern. Med. 2010 Jan. 12 [Epub doi:10.1007/s11606-009-1206-3]).

“Coping with physical, emotional, spiritual and financial challenges affects caregiver health and quality of life as well as patients' health and quality of life,” they wrote.

Rheumatologist Robert G. Lahita, chairman of the department of medicine at Newark (N.J.) Beth Israel Medical Center, agreed. “Diseases like systemic lupus erythematosus, rheumatoid arthritis, and other illnesses like polymyositis can be included in those illnesses addressed by this important paper,” he commented in an interview.

Indeed, “ambulatory care is the norm in our specialty,” added Dr. Lahita, and “the rheumatologist provides care outside the medical center in most cases.”

According to the report, “physician accessibility and excellent communication are fundamental to supporting the patient and family caregiver”—a potentially difficult mandate, given the current climate of rushed office visits and time constrictions.

The 37 million “family caregivers” who care for chronically ill patients in the United States have become “an integral part of the health care system” and deserve recognition from physicians for that role, according to a position paper issued by the American College of Physicians.

Family caregivers—defined broadly as relatives, partners, friends, and neighbors—provide care for 90% of dependent community-dwelling patients with acute and chronic physical illnesses, cognitive impairment, and/or mental health conditions, according to the authors (J. Gen. Intern. Med. 2010 Jan. 12 [Epub doi:10.1007/s11606-009-1206-3]).

“Coping with physical, emotional, spiritual and financial challenges affects caregiver health and quality of life as well as patients' health and quality of life,” they wrote.

Rheumatologist Robert G. Lahita, chairman of the department of medicine at Newark (N.J.) Beth Israel Medical Center, agreed. “Diseases like systemic lupus erythematosus, rheumatoid arthritis, and other illnesses like polymyositis can be included in those illnesses addressed by this important paper,” he commented in an interview.

Indeed, “ambulatory care is the norm in our specialty,” added Dr. Lahita, and “the rheumatologist provides care outside the medical center in most cases.”

According to the report, “physician accessibility and excellent communication are fundamental to supporting the patient and family caregiver”—a potentially difficult mandate, given the current climate of rushed office visits and time constrictions.

Even in patients whose last negative colonoscopy was more than 10 years before, advanced adenomas were rare, Dr. Hermann Brenner and colleagues reported.

The finding suggests that “extension of screening intervals, which could strongly enhance acceptance and cost-effectiveness of endoscopy-based screening and reduce its discomfort, might be achieved while maintaining high levels of safety,” they wrote (Gastroenterology [doi:10.1053/j.gastro.2009.10.054]).

A previous case-control study, also led by Dr. Brenner of the division of clinical epidemiology and aging research at the German Cancer Research Center in Heidelberg, Germany, found a significant 67% reduction in risk for colorectal cancer among people who had a negative colonoscopy between 10 and 19 years prior, and a nonsignificant reduction in risk among people whose negative screening was 20 or more years before (Gut 2006;55:1145-50).

However, that study had been restricted to colorectal cancer only and had not looked at adenoma rates.

“The current study provides evidence that a similarly very low risk is also seen if advanced colorectal adenomas are included in a combined end point of advanced neoplasms,” wrote the authors. “Taken together, these patterns support suggestions that a very low risk of clinically relevant colorectal neoplasms prevails far beyond 5 or 10 years after a negative colonoscopy, the most commonly recommended intervals for endoscopic screening examinations of the large bowel.”

In the current study, Dr. Brenner and his colleagues looked at 2,701 patients who had never had a colonoscopy, as well as 533 patients who had a history of one or more prior negative colonoscopies (and no prior positive colonoscopy). “Three-quarters of participants with previous negative colonoscopies had just one previous colonoscopy, almost 20% had two previous colonoscopies, and only 5% had three or more previous colonoscopies,” wrote the authors.

All patients completed a questionnaire that asked about colonoscopy history, and then they underwent colonoscopy.

All of the participants were age 55 years or older. In the colonoscopy-naive group, the mean age was 63.8 years and about half of the participants were female. In the group of patients who had a history of negative colonoscopy, there was a slightly greater proportion of women (57.6%) and the mean age was slightly older (65.1 years). The mean time since last colonoscopy was 11.9 years.

Patients were excluded from the study if they had a history of inflammatory bowel disease or a preceding colonoscopy within the same year as the study.

“Among participants without previous colonoscopy, the most advanced finding at screening colonoscopy was colorectal cancer in 41 cases (1.5%), advanced adenoma in 267 cases (9.9%), and other adenoma in 494 cases (18.3%),” they wrote.

In patients with a previous negative colonoscopy, no patients had colorectal cancer, and 25 (4.7%) had advanced neoplasm.

“These numbers are far and significantly below the numbers that would have been expected based on the age- and sex-specific prevalences in participants undergoing first-time colonoscopy,” wrote the authors—8.4 cases for colorectal cancer and 59.4 for advanced neoplasm, in a cohort of this size.

Additionally, “among those with a negative colonoscopy more than 15 years ago, the prevalence was still more than 40% lower than among those with no previous colonoscopy, even though this difference failed to reach statistical significance,” they added.

The authors conceded that one weakness of the study was that data regarding prior colonoscopy and results were self-reported; however, “in about 95% of self-reported negative colonoscopies, lack of polypectomy was confirmed by medical records,” they added.

The authors reported no conflicts of interest related to this study, which was supported only by a grant from the Central Research Institute of Ambulatory Health Care in Germany, Berlin.

Even in patients whose last negative colonoscopy was more than 10 years before, advanced adenomas were rare, Dr. Hermann Brenner and colleagues reported.

The finding suggests that “extension of screening intervals, which could strongly enhance acceptance and cost-effectiveness of endoscopy-based screening and reduce its discomfort, might be achieved while maintaining high levels of safety,” they wrote (Gastroenterology [doi:10.1053/j.gastro.2009.10.054]).

A previous case-control study, also led by Dr. Brenner of the division of clinical epidemiology and aging research at the German Cancer Research Center in Heidelberg, Germany, found a significant 67% reduction in risk for colorectal cancer among people who had a negative colonoscopy between 10 and 19 years prior, and a nonsignificant reduction in risk among people whose negative screening was 20 or more years before (Gut 2006;55:1145-50).

However, that study had been restricted to colorectal cancer only and had not looked at adenoma rates.

“The current study provides evidence that a similarly very low risk is also seen if advanced colorectal adenomas are included in a combined end point of advanced neoplasms,” wrote the authors. “Taken together, these patterns support suggestions that a very low risk of clinically relevant colorectal neoplasms prevails far beyond 5 or 10 years after a negative colonoscopy, the most commonly recommended intervals for endoscopic screening examinations of the large bowel.”

In the current study, Dr. Brenner and his colleagues looked at 2,701 patients who had never had a colonoscopy, as well as 533 patients who had a history of one or more prior negative colonoscopies (and no prior positive colonoscopy). “Three-quarters of participants with previous negative colonoscopies had just one previous colonoscopy, almost 20% had two previous colonoscopies, and only 5% had three or more previous colonoscopies,” wrote the authors.

All patients completed a questionnaire that asked about colonoscopy history, and then they underwent colonoscopy.

All of the participants were age 55 years or older. In the colonoscopy-naive group, the mean age was 63.8 years and about half of the participants were female. In the group of patients who had a history of negative colonoscopy, there was a slightly greater proportion of women (57.6%) and the mean age was slightly older (65.1 years). The mean time since last colonoscopy was 11.9 years.

Patients were excluded from the study if they had a history of inflammatory bowel disease or a preceding colonoscopy within the same year as the study.

“Among participants without previous colonoscopy, the most advanced finding at screening colonoscopy was colorectal cancer in 41 cases (1.5%), advanced adenoma in 267 cases (9.9%), and other adenoma in 494 cases (18.3%),” they wrote.

In patients with a previous negative colonoscopy, no patients had colorectal cancer, and 25 (4.7%) had advanced neoplasm.

“These numbers are far and significantly below the numbers that would have been expected based on the age- and sex-specific prevalences in participants undergoing first-time colonoscopy,” wrote the authors—8.4 cases for colorectal cancer and 59.4 for advanced neoplasm, in a cohort of this size.

Additionally, “among those with a negative colonoscopy more than 15 years ago, the prevalence was still more than 40% lower than among those with no previous colonoscopy, even though this difference failed to reach statistical significance,” they added.

The authors conceded that one weakness of the study was that data regarding prior colonoscopy and results were self-reported; however, “in about 95% of self-reported negative colonoscopies, lack of polypectomy was confirmed by medical records,” they added.

The authors reported no conflicts of interest related to this study, which was supported only by a grant from the Central Research Institute of Ambulatory Health Care in Germany, Berlin.

Even in patients whose last negative colonoscopy was more than 10 years before, advanced adenomas were rare, Dr. Hermann Brenner and colleagues reported.

The finding suggests that “extension of screening intervals, which could strongly enhance acceptance and cost-effectiveness of endoscopy-based screening and reduce its discomfort, might be achieved while maintaining high levels of safety,” they wrote (Gastroenterology [doi:10.1053/j.gastro.2009.10.054]).

A previous case-control study, also led by Dr. Brenner of the division of clinical epidemiology and aging research at the German Cancer Research Center in Heidelberg, Germany, found a significant 67% reduction in risk for colorectal cancer among people who had a negative colonoscopy between 10 and 19 years prior, and a nonsignificant reduction in risk among people whose negative screening was 20 or more years before (Gut 2006;55:1145-50).

However, that study had been restricted to colorectal cancer only and had not looked at adenoma rates.

“The current study provides evidence that a similarly very low risk is also seen if advanced colorectal adenomas are included in a combined end point of advanced neoplasms,” wrote the authors. “Taken together, these patterns support suggestions that a very low risk of clinically relevant colorectal neoplasms prevails far beyond 5 or 10 years after a negative colonoscopy, the most commonly recommended intervals for endoscopic screening examinations of the large bowel.”

In the current study, Dr. Brenner and his colleagues looked at 2,701 patients who had never had a colonoscopy, as well as 533 patients who had a history of one or more prior negative colonoscopies (and no prior positive colonoscopy). “Three-quarters of participants with previous negative colonoscopies had just one previous colonoscopy, almost 20% had two previous colonoscopies, and only 5% had three or more previous colonoscopies,” wrote the authors.

All patients completed a questionnaire that asked about colonoscopy history, and then they underwent colonoscopy.

All of the participants were age 55 years or older. In the colonoscopy-naive group, the mean age was 63.8 years and about half of the participants were female. In the group of patients who had a history of negative colonoscopy, there was a slightly greater proportion of women (57.6%) and the mean age was slightly older (65.1 years). The mean time since last colonoscopy was 11.9 years.

Patients were excluded from the study if they had a history of inflammatory bowel disease or a preceding colonoscopy within the same year as the study.

“Among participants without previous colonoscopy, the most advanced finding at screening colonoscopy was colorectal cancer in 41 cases (1.5%), advanced adenoma in 267 cases (9.9%), and other adenoma in 494 cases (18.3%),” they wrote.

In patients with a previous negative colonoscopy, no patients had colorectal cancer, and 25 (4.7%) had advanced neoplasm.

“These numbers are far and significantly below the numbers that would have been expected based on the age- and sex-specific prevalences in participants undergoing first-time colonoscopy,” wrote the authors—8.4 cases for colorectal cancer and 59.4 for advanced neoplasm, in a cohort of this size.

Additionally, “among those with a negative colonoscopy more than 15 years ago, the prevalence was still more than 40% lower than among those with no previous colonoscopy, even though this difference failed to reach statistical significance,” they added.

The authors conceded that one weakness of the study was that data regarding prior colonoscopy and results were self-reported; however, “in about 95% of self-reported negative colonoscopies, lack of polypectomy was confirmed by medical records,” they added.

The authors reported no conflicts of interest related to this study, which was supported only by a grant from the Central Research Institute of Ambulatory Health Care in Germany, Berlin.

Canadian patients whose previous negative colonoscopies were performed by gastroenterologists are less likely to have subsequent colorectal cancer than are patients whose screens were done by other specialists, including general surgeons, Dr. Linda Rabeneck and her colleagues reported.

Despite previous studies finding a significantly decreased risk of colorectal cancer (CRC) even 10 years following a negative colonoscopy, “a small but clinically meaningful number of incident CRCs occur,” wrote Dr. Rabeneck of the University of Toronto (Clin. Gastroenterol. Hepatol. 2010 March [doi:10.1016/j.cgh.2009.10.022]).

These cancers could include missed lesions because of poor bowel preparation, suboptimal colonoscopy technique, incomplete polypectomy, or even truly new cancers, the authors write. However, “The issue of whether endoscopist characteristics, including colonoscopy volume and specialty, are important in this context has not been previously addressed in a large-scale … population-based study that reflects usual clinical practice.”

Dr. Rabeneck and her colleagues studied 110,402 Ontario residents aged 50-80 years who had a negative complete colonoscopy between Jan. 1, 1992, and Dec. 31, 1997. Participants had no history of colorectal cancer, no past diagnosis of inflammatory bowel disease, and no colonic resection within 5 years of the index colonoscopy.

Patients were followed up for colorectal cancer diagnosis from the date of the index negative colonoscopy through Dec. 31, 2006. During the study's 15-year follow-up period, colorectal cancer “was diagnosed in 1,596 persons, of whom 1,426 had the index colonoscopy in a hospital [86%], and 170 had the procedure in a private office/clinic,” wrote the authors.

Among patients who had colonoscopies performed in a hospital, 38% of endoscopists were general surgeons and 17% were gastroenterologists, with the remainder classified as “other”: primarily internists, family physicians, and “general physicians.” Regarding these hospital-based patients, the authors wrote: “For those who had their procedures performed by a general surgeon, the risk of incident CRC was increased by almost 40% (hazard ratio 1.389), compared with those who had their procedures performed by a gastroenterologist.”

Patients whose hospital-based colonoscopies were performed by physicians classified in the “other” category (primarily internists) also were at higher risk for a subsequent colorectal cancer diagnosis (HR 1.275).

In the office-based setting, however, “in which only 14% of procedures were performed, and where only 8.1% of procedures were performed by a gastroenterologist … endoscopist specialty was not significantly associated with incident CRC.” Nor was there any association between the volume of colonoscopies previously performed by the endoscopist and incident CRC in either setting, after adjustment for patient age, sex, and comorbidity.

The authors attempted to explain the disparate findings between the office and hospital settings by pointing out that patients seen in the private office/clinics were younger, more likely to be men, and had less comorbidity. Therefore, “It is likely that the procedures in the private office/clinics were technically easier to perform,” they said.

“Most general surgery trainees have 2 months of dedicated endoscopy training in their programs. Gastroenterology trainees have dedicated endoscopy training for a minimum of 16 months during their programs,” they added. “Having extensive formal training matters more when the procedures are more challenging to perform.”

The authors reported no conflicts of interest related to this study.

Canadian patients whose previous negative colonoscopies were performed by gastroenterologists are less likely to have subsequent colorectal cancer than are patients whose screens were done by other specialists, including general surgeons, Dr. Linda Rabeneck and her colleagues reported.

Despite previous studies finding a significantly decreased risk of colorectal cancer (CRC) even 10 years following a negative colonoscopy, “a small but clinically meaningful number of incident CRCs occur,” wrote Dr. Rabeneck of the University of Toronto (Clin. Gastroenterol. Hepatol. 2010 March [doi:10.1016/j.cgh.2009.10.022]).

These cancers could include missed lesions because of poor bowel preparation, suboptimal colonoscopy technique, incomplete polypectomy, or even truly new cancers, the authors write. However, “The issue of whether endoscopist characteristics, including colonoscopy volume and specialty, are important in this context has not been previously addressed in a large-scale … population-based study that reflects usual clinical practice.”

Dr. Rabeneck and her colleagues studied 110,402 Ontario residents aged 50-80 years who had a negative complete colonoscopy between Jan. 1, 1992, and Dec. 31, 1997. Participants had no history of colorectal cancer, no past diagnosis of inflammatory bowel disease, and no colonic resection within 5 years of the index colonoscopy.

Patients were followed up for colorectal cancer diagnosis from the date of the index negative colonoscopy through Dec. 31, 2006. During the study's 15-year follow-up period, colorectal cancer “was diagnosed in 1,596 persons, of whom 1,426 had the index colonoscopy in a hospital [86%], and 170 had the procedure in a private office/clinic,” wrote the authors.

Among patients who had colonoscopies performed in a hospital, 38% of endoscopists were general surgeons and 17% were gastroenterologists, with the remainder classified as “other”: primarily internists, family physicians, and “general physicians.” Regarding these hospital-based patients, the authors wrote: “For those who had their procedures performed by a general surgeon, the risk of incident CRC was increased by almost 40% (hazard ratio 1.389), compared with those who had their procedures performed by a gastroenterologist.”

Patients whose hospital-based colonoscopies were performed by physicians classified in the “other” category (primarily internists) also were at higher risk for a subsequent colorectal cancer diagnosis (HR 1.275).

In the office-based setting, however, “in which only 14% of procedures were performed, and where only 8.1% of procedures were performed by a gastroenterologist … endoscopist specialty was not significantly associated with incident CRC.” Nor was there any association between the volume of colonoscopies previously performed by the endoscopist and incident CRC in either setting, after adjustment for patient age, sex, and comorbidity.

The authors attempted to explain the disparate findings between the office and hospital settings by pointing out that patients seen in the private office/clinics were younger, more likely to be men, and had less comorbidity. Therefore, “It is likely that the procedures in the private office/clinics were technically easier to perform,” they said.

“Most general surgery trainees have 2 months of dedicated endoscopy training in their programs. Gastroenterology trainees have dedicated endoscopy training for a minimum of 16 months during their programs,” they added. “Having extensive formal training matters more when the procedures are more challenging to perform.”

The authors reported no conflicts of interest related to this study.

Canadian patients whose previous negative colonoscopies were performed by gastroenterologists are less likely to have subsequent colorectal cancer than are patients whose screens were done by other specialists, including general surgeons, Dr. Linda Rabeneck and her colleagues reported.

Despite previous studies finding a significantly decreased risk of colorectal cancer (CRC) even 10 years following a negative colonoscopy, “a small but clinically meaningful number of incident CRCs occur,” wrote Dr. Rabeneck of the University of Toronto (Clin. Gastroenterol. Hepatol. 2010 March [doi:10.1016/j.cgh.2009.10.022]).

These cancers could include missed lesions because of poor bowel preparation, suboptimal colonoscopy technique, incomplete polypectomy, or even truly new cancers, the authors write. However, “The issue of whether endoscopist characteristics, including colonoscopy volume and specialty, are important in this context has not been previously addressed in a large-scale … population-based study that reflects usual clinical practice.”

Dr. Rabeneck and her colleagues studied 110,402 Ontario residents aged 50-80 years who had a negative complete colonoscopy between Jan. 1, 1992, and Dec. 31, 1997. Participants had no history of colorectal cancer, no past diagnosis of inflammatory bowel disease, and no colonic resection within 5 years of the index colonoscopy.

Patients were followed up for colorectal cancer diagnosis from the date of the index negative colonoscopy through Dec. 31, 2006. During the study's 15-year follow-up period, colorectal cancer “was diagnosed in 1,596 persons, of whom 1,426 had the index colonoscopy in a hospital [86%], and 170 had the procedure in a private office/clinic,” wrote the authors.

Among patients who had colonoscopies performed in a hospital, 38% of endoscopists were general surgeons and 17% were gastroenterologists, with the remainder classified as “other”: primarily internists, family physicians, and “general physicians.” Regarding these hospital-based patients, the authors wrote: “For those who had their procedures performed by a general surgeon, the risk of incident CRC was increased by almost 40% (hazard ratio 1.389), compared with those who had their procedures performed by a gastroenterologist.”

Patients whose hospital-based colonoscopies were performed by physicians classified in the “other” category (primarily internists) also were at higher risk for a subsequent colorectal cancer diagnosis (HR 1.275).

In the office-based setting, however, “in which only 14% of procedures were performed, and where only 8.1% of procedures were performed by a gastroenterologist … endoscopist specialty was not significantly associated with incident CRC.” Nor was there any association between the volume of colonoscopies previously performed by the endoscopist and incident CRC in either setting, after adjustment for patient age, sex, and comorbidity.

The authors attempted to explain the disparate findings between the office and hospital settings by pointing out that patients seen in the private office/clinics were younger, more likely to be men, and had less comorbidity. Therefore, “It is likely that the procedures in the private office/clinics were technically easier to perform,” they said.

“Most general surgery trainees have 2 months of dedicated endoscopy training in their programs. Gastroenterology trainees have dedicated endoscopy training for a minimum of 16 months during their programs,” they added. “Having extensive formal training matters more when the procedures are more challenging to perform.”

The authors reported no conflicts of interest related to this study.

Major Finding: Fewer falls occurred after expedited cataract surgery (76 out of 274 patients), compared with standard surgery (87 out of 271 patients), but the difference was not significant.

Data Source: A meta-analysis of two studies with a total of 535 women who had cataract surgery.

Disclosures: None of the authors had relevant financial conflicts of interest.

“Expedited” cataract surgery occurring within 4 weeks of diagnosis did not significantly reduce falls among elderly women, according to a meta-analysis of two randomized, controlled trials.

That's despite a sevenfold improvement in sight following surgery, compared with elderly cataract patients who were scheduled for surgery but had to wait as long as 12 months.

Nevertheless, “extensive wait times for cataract surgery are a global health care issue” and a major cause of preventable blindness, wrote the authors of the current analysis.

“Focusing resources on expedited cataract surgery would reduce the extensive waiting lists, influencing the health of the elderly population,” they said (J. Cataract Refract. Surg. 2010;36:13-9).

The authors, led by Ediriweera Desapriya, Ph.D., of the department of developmental neurosciences and child health at the University of British Columbia, Vancouver, sorted through 234 studies found in 12 databases, including Medline, that mentioned “expedited cataract surgery.” Only three looked at outcome measures for both improvement of vision and reduction of injury. Just two studies, comprising 535 women over age 70, looked at falls specifically.

“Expedited” surgery was defined as occurring within 4 weeks of diagnosis in the two studies that were included in the falls analysis (Br. J. Ophthalmol. 2005;89:53-9; Age and Ageing 2006;35:66-71); the third study, which appeared only in the vision analysis, extended the definition to 6 weeks (Lancet 1998;352:925-9).

“Routine” surgery in the first two trials occurred at 12 months after diagnosis and had not occurred yet at the time of analysis; in the vision-only study, it took place at 7-12 months.

Looking at all three studies, which included 372 patients in the routine surgery group and 365 who received expedited surgeries, “expedited cataract surgery was associated with significantly enhanced visual acuity” at 6 months in the surgery group, compared with patients who had not yet had the procedure (odds ratio 7.22, 95% confidence interval 3.15-16.55).

In the two studies that looked at falls, although there was a trend toward fewer falls after expedited surgery (76/274 patients, 28%), compared with standard surgery (87/271 patients, 32%), with an OR of 0.81, the result did not reach significance (CI 0.55-1.17).

The authors acknowledged that a meta-analysis of only two studies may seem inadequate, but “when definitive and large trials have not been performed to evaluate the impact of expedited cataract surgery on the incidence of falls, a meta-analysis of all available trials could help resolve some important issues, reducing the need for large, costly new trials.”

The investigators found that two studies reported differences in predicted falls between men and women who have undergone cataract surgery. The age of the subjects could be a factor, as the literature shows the rate of falls increases after age 70, they wrote. Also, fragile, more easily broken bones that can result from “clinical conditions that primarily affect women in their postmenopausal years, such as osteoporosis, may increase the damage caused by falls and other injuries,” the authors said. Such conditions may “influence the overall results of this intervention,” they said.

In noting the limitations of their analysis, the authors said that both selected trials “had insufficient power, and the dropout rate was 7.8%. Significant cases were lost to follow-up in both trials (10.7%).”

Major Finding: Fewer falls occurred after expedited cataract surgery (76 out of 274 patients), compared with standard surgery (87 out of 271 patients), but the difference was not significant.

Data Source: A meta-analysis of two studies with a total of 535 women who had cataract surgery.

Disclosures: None of the authors had relevant financial conflicts of interest.

“Expedited” cataract surgery occurring within 4 weeks of diagnosis did not significantly reduce falls among elderly women, according to a meta-analysis of two randomized, controlled trials.

That's despite a sevenfold improvement in sight following surgery, compared with elderly cataract patients who were scheduled for surgery but had to wait as long as 12 months.

Nevertheless, “extensive wait times for cataract surgery are a global health care issue” and a major cause of preventable blindness, wrote the authors of the current analysis.

“Focusing resources on expedited cataract surgery would reduce the extensive waiting lists, influencing the health of the elderly population,” they said (J. Cataract Refract. Surg. 2010;36:13-9).

The authors, led by Ediriweera Desapriya, Ph.D., of the department of developmental neurosciences and child health at the University of British Columbia, Vancouver, sorted through 234 studies found in 12 databases, including Medline, that mentioned “expedited cataract surgery.” Only three looked at outcome measures for both improvement of vision and reduction of injury. Just two studies, comprising 535 women over age 70, looked at falls specifically.

“Expedited” surgery was defined as occurring within 4 weeks of diagnosis in the two studies that were included in the falls analysis (Br. J. Ophthalmol. 2005;89:53-9; Age and Ageing 2006;35:66-71); the third study, which appeared only in the vision analysis, extended the definition to 6 weeks (Lancet 1998;352:925-9).

“Routine” surgery in the first two trials occurred at 12 months after diagnosis and had not occurred yet at the time of analysis; in the vision-only study, it took place at 7-12 months.

Looking at all three studies, which included 372 patients in the routine surgery group and 365 who received expedited surgeries, “expedited cataract surgery was associated with significantly enhanced visual acuity” at 6 months in the surgery group, compared with patients who had not yet had the procedure (odds ratio 7.22, 95% confidence interval 3.15-16.55).

In the two studies that looked at falls, although there was a trend toward fewer falls after expedited surgery (76/274 patients, 28%), compared with standard surgery (87/271 patients, 32%), with an OR of 0.81, the result did not reach significance (CI 0.55-1.17).

The authors acknowledged that a meta-analysis of only two studies may seem inadequate, but “when definitive and large trials have not been performed to evaluate the impact of expedited cataract surgery on the incidence of falls, a meta-analysis of all available trials could help resolve some important issues, reducing the need for large, costly new trials.”

The investigators found that two studies reported differences in predicted falls between men and women who have undergone cataract surgery. The age of the subjects could be a factor, as the literature shows the rate of falls increases after age 70, they wrote. Also, fragile, more easily broken bones that can result from “clinical conditions that primarily affect women in their postmenopausal years, such as osteoporosis, may increase the damage caused by falls and other injuries,” the authors said. Such conditions may “influence the overall results of this intervention,” they said.

In noting the limitations of their analysis, the authors said that both selected trials “had insufficient power, and the dropout rate was 7.8%. Significant cases were lost to follow-up in both trials (10.7%).”

Major Finding: Fewer falls occurred after expedited cataract surgery (76 out of 274 patients), compared with standard surgery (87 out of 271 patients), but the difference was not significant.

Data Source: A meta-analysis of two studies with a total of 535 women who had cataract surgery.

Disclosures: None of the authors had relevant financial conflicts of interest.

“Expedited” cataract surgery occurring within 4 weeks of diagnosis did not significantly reduce falls among elderly women, according to a meta-analysis of two randomized, controlled trials.

That's despite a sevenfold improvement in sight following surgery, compared with elderly cataract patients who were scheduled for surgery but had to wait as long as 12 months.

Nevertheless, “extensive wait times for cataract surgery are a global health care issue” and a major cause of preventable blindness, wrote the authors of the current analysis.

“Focusing resources on expedited cataract surgery would reduce the extensive waiting lists, influencing the health of the elderly population,” they said (J. Cataract Refract. Surg. 2010;36:13-9).

The authors, led by Ediriweera Desapriya, Ph.D., of the department of developmental neurosciences and child health at the University of British Columbia, Vancouver, sorted through 234 studies found in 12 databases, including Medline, that mentioned “expedited cataract surgery.” Only three looked at outcome measures for both improvement of vision and reduction of injury. Just two studies, comprising 535 women over age 70, looked at falls specifically.

“Expedited” surgery was defined as occurring within 4 weeks of diagnosis in the two studies that were included in the falls analysis (Br. J. Ophthalmol. 2005;89:53-9; Age and Ageing 2006;35:66-71); the third study, which appeared only in the vision analysis, extended the definition to 6 weeks (Lancet 1998;352:925-9).

“Routine” surgery in the first two trials occurred at 12 months after diagnosis and had not occurred yet at the time of analysis; in the vision-only study, it took place at 7-12 months.

Looking at all three studies, which included 372 patients in the routine surgery group and 365 who received expedited surgeries, “expedited cataract surgery was associated with significantly enhanced visual acuity” at 6 months in the surgery group, compared with patients who had not yet had the procedure (odds ratio 7.22, 95% confidence interval 3.15-16.55).

In the two studies that looked at falls, although there was a trend toward fewer falls after expedited surgery (76/274 patients, 28%), compared with standard surgery (87/271 patients, 32%), with an OR of 0.81, the result did not reach significance (CI 0.55-1.17).

The authors acknowledged that a meta-analysis of only two studies may seem inadequate, but “when definitive and large trials have not been performed to evaluate the impact of expedited cataract surgery on the incidence of falls, a meta-analysis of all available trials could help resolve some important issues, reducing the need for large, costly new trials.”

The investigators found that two studies reported differences in predicted falls between men and women who have undergone cataract surgery. The age of the subjects could be a factor, as the literature shows the rate of falls increases after age 70, they wrote. Also, fragile, more easily broken bones that can result from “clinical conditions that primarily affect women in their postmenopausal years, such as osteoporosis, may increase the damage caused by falls and other injuries,” the authors said. Such conditions may “influence the overall results of this intervention,” they said.

In noting the limitations of their analysis, the authors said that both selected trials “had insufficient power, and the dropout rate was 7.8%. Significant cases were lost to follow-up in both trials (10.7%).”

Even in patients whose last negative colonoscopy was more than 10 years before, advanced adenomas were rare, Dr. Hermann Brenner and his colleagues reported.

The finding suggests that “extension of screening intervals, which could strongly enhance acceptance and cost-effectiveness of endoscopy-based screening and reduce its discomfort, might be achieved while maintaining high levels of safety,” they wrote (Gastroenterology 2010 March [doi:10.1053/j.gastro.2009.10.054

A previous case-control study, also led by Dr. Brenner of the division of clinical epidemiology and aging research at the German Cancer Research Center in Heidelberg, Germany, found a significant 67% reduction in risk of colorectal cancer among people who had a negative colonoscopy between 10 and 19 years prior, and a nonsignificant 54% reduction in risk among people whose negative screening was 20 or more years before (Gut 2006;55:1145-50). However, that study had been restricted to colorectal cancer and had not looked at adenoma rates.

“The current study provides evidence that a similarly very low risk is also seen if advanced colorectal adenomas are included in a combined end point of advanced neoplasms,” the authors wrote. “Taken together, these patterns support suggestions that a very low risk of clinically relevant colorectal neoplasms prevails far beyond 5 or 10 years after a negative colonoscopy, the most commonly recommended intervals for endoscopic screening examination of the large bowel.”

In the current study, Dr. Brenner and his colleagues looked at 2,701 patients who had never had a colonoscopy, as well as 533 patients with a history of one or more prior negative colonoscopies. “Three-quarters of participants with previous negative colonoscopies had just one previous colonoscopy, almost 20% had two previous colonoscopies, and only 5% had three or more previous colonoscopies,” the authors wrote.

All of the participants were age 55 or older. In the colonoscopy-naive group, the mean age was 63.8 years and about half of the participants were female. In the group with a history of negative colonoscopy, there were a slightly greater proportion of women (57.6%) and the mean age was slightly older (65.1 years). The mean time since last colonoscopy was 11.9 years.

“Among participants without previous colonoscopy, the most advanced finding at screening colonoscopy was colorectal cancer in 41 cases (1.5%), advanced adenoma in 267 cases (9.9%), and other adenoma in 494 cases (18.3%),” the authors wrote.

In patients with a previous negative colonoscopy, no patients had colorectal cancer, and 25 (4.7%) had advanced neoplasm.

“These numbers are far and significantly below the numbers that would have been expected based on the age- and sex-specific prevalences in participants undergoing first-time colonoscopy,” wrote the authors—8.4 cases for colorectal cancer and 59.4 for advanced neoplasm, in a cohort of this size.

Additionally, “among those with a negative colonoscopy more than 15 years ago, the prevalence was still more than 40% lower than among those with no previous colonoscopy, even though this difference failed to reach statistical significance,” they added.

Disclosures: The authors reported no conflicts of interest related to the study, funded by a grant from the Central Research Institute of Ambulatory Health Care in Berlin, Germany.

Even in patients whose last negative colonoscopy was more than 10 years before, advanced adenomas were rare, Dr. Hermann Brenner and his colleagues reported.

The finding suggests that “extension of screening intervals, which could strongly enhance acceptance and cost-effectiveness of endoscopy-based screening and reduce its discomfort, might be achieved while maintaining high levels of safety,” they wrote (Gastroenterology 2010 March [doi:10.1053/j.gastro.2009.10.054

A previous case-control study, also led by Dr. Brenner of the division of clinical epidemiology and aging research at the German Cancer Research Center in Heidelberg, Germany, found a significant 67% reduction in risk of colorectal cancer among people who had a negative colonoscopy between 10 and 19 years prior, and a nonsignificant 54% reduction in risk among people whose negative screening was 20 or more years before (Gut 2006;55:1145-50). However, that study had been restricted to colorectal cancer and had not looked at adenoma rates.

“The current study provides evidence that a similarly very low risk is also seen if advanced colorectal adenomas are included in a combined end point of advanced neoplasms,” the authors wrote. “Taken together, these patterns support suggestions that a very low risk of clinically relevant colorectal neoplasms prevails far beyond 5 or 10 years after a negative colonoscopy, the most commonly recommended intervals for endoscopic screening examination of the large bowel.”

In the current study, Dr. Brenner and his colleagues looked at 2,701 patients who had never had a colonoscopy, as well as 533 patients with a history of one or more prior negative colonoscopies. “Three-quarters of participants with previous negative colonoscopies had just one previous colonoscopy, almost 20% had two previous colonoscopies, and only 5% had three or more previous colonoscopies,” the authors wrote.

All of the participants were age 55 or older. In the colonoscopy-naive group, the mean age was 63.8 years and about half of the participants were female. In the group with a history of negative colonoscopy, there were a slightly greater proportion of women (57.6%) and the mean age was slightly older (65.1 years). The mean time since last colonoscopy was 11.9 years.

“Among participants without previous colonoscopy, the most advanced finding at screening colonoscopy was colorectal cancer in 41 cases (1.5%), advanced adenoma in 267 cases (9.9%), and other adenoma in 494 cases (18.3%),” the authors wrote.

In patients with a previous negative colonoscopy, no patients had colorectal cancer, and 25 (4.7%) had advanced neoplasm.

“These numbers are far and significantly below the numbers that would have been expected based on the age- and sex-specific prevalences in participants undergoing first-time colonoscopy,” wrote the authors—8.4 cases for colorectal cancer and 59.4 for advanced neoplasm, in a cohort of this size.

Additionally, “among those with a negative colonoscopy more than 15 years ago, the prevalence was still more than 40% lower than among those with no previous colonoscopy, even though this difference failed to reach statistical significance,” they added.

Disclosures: The authors reported no conflicts of interest related to the study, funded by a grant from the Central Research Institute of Ambulatory Health Care in Berlin, Germany.

Even in patients whose last negative colonoscopy was more than 10 years before, advanced adenomas were rare, Dr. Hermann Brenner and his colleagues reported.

The finding suggests that “extension of screening intervals, which could strongly enhance acceptance and cost-effectiveness of endoscopy-based screening and reduce its discomfort, might be achieved while maintaining high levels of safety,” they wrote (Gastroenterology 2010 March [doi:10.1053/j.gastro.2009.10.054

A previous case-control study, also led by Dr. Brenner of the division of clinical epidemiology and aging research at the German Cancer Research Center in Heidelberg, Germany, found a significant 67% reduction in risk of colorectal cancer among people who had a negative colonoscopy between 10 and 19 years prior, and a nonsignificant 54% reduction in risk among people whose negative screening was 20 or more years before (Gut 2006;55:1145-50). However, that study had been restricted to colorectal cancer and had not looked at adenoma rates.

“The current study provides evidence that a similarly very low risk is also seen if advanced colorectal adenomas are included in a combined end point of advanced neoplasms,” the authors wrote. “Taken together, these patterns support suggestions that a very low risk of clinically relevant colorectal neoplasms prevails far beyond 5 or 10 years after a negative colonoscopy, the most commonly recommended intervals for endoscopic screening examination of the large bowel.”

In the current study, Dr. Brenner and his colleagues looked at 2,701 patients who had never had a colonoscopy, as well as 533 patients with a history of one or more prior negative colonoscopies. “Three-quarters of participants with previous negative colonoscopies had just one previous colonoscopy, almost 20% had two previous colonoscopies, and only 5% had three or more previous colonoscopies,” the authors wrote.

All of the participants were age 55 or older. In the colonoscopy-naive group, the mean age was 63.8 years and about half of the participants were female. In the group with a history of negative colonoscopy, there were a slightly greater proportion of women (57.6%) and the mean age was slightly older (65.1 years). The mean time since last colonoscopy was 11.9 years.

“Among participants without previous colonoscopy, the most advanced finding at screening colonoscopy was colorectal cancer in 41 cases (1.5%), advanced adenoma in 267 cases (9.9%), and other adenoma in 494 cases (18.3%),” the authors wrote.

In patients with a previous negative colonoscopy, no patients had colorectal cancer, and 25 (4.7%) had advanced neoplasm.

“These numbers are far and significantly below the numbers that would have been expected based on the age- and sex-specific prevalences in participants undergoing first-time colonoscopy,” wrote the authors—8.4 cases for colorectal cancer and 59.4 for advanced neoplasm, in a cohort of this size.

Additionally, “among those with a negative colonoscopy more than 15 years ago, the prevalence was still more than 40% lower than among those with no previous colonoscopy, even though this difference failed to reach statistical significance,” they added.

Disclosures: The authors reported no conflicts of interest related to the study, funded by a grant from the Central Research Institute of Ambulatory Health Care in Berlin, Germany.

Patients whose previous negative colonoscopies were performed by gastroenterologists are less likely to have subsequent colorectal cancer than are patients whose screens were done by other specialists, including general surgeons, Dr. Linda Rabeneck and her colleagues reported.

Despite previous studies finding a significantly decreased risk of colorectal cancer (CRC) even 10 years after a negative colonoscopy, “a small but clinically meaningful number of incident CRCs occur,” wrote Dr. Rabeneck of the University of Toronto (Clin. Gastroenterol. Hepatol. 2010 March [doi:10.1016/j.cgh.2009.10.022

These cancers could include missed lesions because of poor bowel preparation, suboptimal colonoscopy technique, incomplete polypectomy, or even truly new cancers, the authors wrote. However, “the issue of whether endoscopist characteristics, including colonoscopy volume and specialty, are important in this context has not been previously addressed in a large-scale … population-based study that reflects usual clinical practice.”

Dr. Rabeneck and her colleagues studied 110,402 Ontario residents aged 50-80 years who had a negative complete colonoscopy between Jan. 1, 1992, and Dec. 31, 1997. Slightly more than half (55.2%) were female. Participants had no history of colorectal cancer, no past diagnosis of inflammatory bowel disease, and no colonic resection within 5 years of the index colonoscopy.

Patients were followed up for colorectal cancer diagnosis from the date of the index negative colonoscopy through Dec. 31, 2006. During the study's 15-year follow-up period, colorectal cancer “was diagnosed in 1,596 persons, of whom 1,426 had the index colonoscopy in a hospital [86%], and 170 had the procedure in a private office/clinic,” the authors wrote.

Among the patients who had colonoscopies performed in a hospital, 38% of endoscopists were general surgeons, 17% were gastroenterologists, and the remainder of physicians was classified as “other”: primarily internists, family physicians, and “general physicians.” Regarding these hospital-based patients, the authors wrote: “For those who had their procedures performed by a general surgeon, the risk of incident CRC was increased by almost 40% (hazard ratio 1.389), compared with those who had their procedures performed by a gastroenterologist.”

Patients whose hospital-based colonoscopies were performed by physicians classified in the “other” category (primarily internists) also were at higher risk for a subsequent colorectal cancer diagnosis (HR 1.275).

In the office-based setting, however, “endoscopist specialty was not significantly associated with incident CRC.”

Nor was there any association between the volume of colonoscopies previously performed by the endoscopist and incident CRC in either setting, after adjustment for patient age, sex, and comorbidity.

The authors attempted to explain the disparate findings between the office and hospital settings by pointing out that patients seen in the private office/clinics were younger, more likely to be men, and had less comorbidity. Therefore, “it is likely that the procedures in the private office/clinics were technically easier to perform,” they said.

“Having extensive formal training matters more when the procedures are more challenging to perform,” they added.

Dr. Rabeneck and her coauthors also pointed out that there is a risk that the study may not pertain “to the current era.” However, “there has been no change in endoscopy training requirements since the study period,” they wrote. “In addition, the proportion of colonoscopies performed by gastroenterologists has increased only modestly (to 26% in 2008),” compared with the 16% figure at the time of this analysis.

Disclosures: The authors reported no relevant conflicts of interest.

Patients whose previous negative colonoscopies were performed by gastroenterologists are less likely to have subsequent colorectal cancer than are patients whose screens were done by other specialists, including general surgeons, Dr. Linda Rabeneck and her colleagues reported.

Despite previous studies finding a significantly decreased risk of colorectal cancer (CRC) even 10 years after a negative colonoscopy, “a small but clinically meaningful number of incident CRCs occur,” wrote Dr. Rabeneck of the University of Toronto (Clin. Gastroenterol. Hepatol. 2010 March [doi:10.1016/j.cgh.2009.10.022

These cancers could include missed lesions because of poor bowel preparation, suboptimal colonoscopy technique, incomplete polypectomy, or even truly new cancers, the authors wrote. However, “the issue of whether endoscopist characteristics, including colonoscopy volume and specialty, are important in this context has not been previously addressed in a large-scale … population-based study that reflects usual clinical practice.”

Dr. Rabeneck and her colleagues studied 110,402 Ontario residents aged 50-80 years who had a negative complete colonoscopy between Jan. 1, 1992, and Dec. 31, 1997. Slightly more than half (55.2%) were female. Participants had no history of colorectal cancer, no past diagnosis of inflammatory bowel disease, and no colonic resection within 5 years of the index colonoscopy.

Patients were followed up for colorectal cancer diagnosis from the date of the index negative colonoscopy through Dec. 31, 2006. During the study's 15-year follow-up period, colorectal cancer “was diagnosed in 1,596 persons, of whom 1,426 had the index colonoscopy in a hospital [86%], and 170 had the procedure in a private office/clinic,” the authors wrote.

Among the patients who had colonoscopies performed in a hospital, 38% of endoscopists were general surgeons, 17% were gastroenterologists, and the remainder of physicians was classified as “other”: primarily internists, family physicians, and “general physicians.” Regarding these hospital-based patients, the authors wrote: “For those who had their procedures performed by a general surgeon, the risk of incident CRC was increased by almost 40% (hazard ratio 1.389), compared with those who had their procedures performed by a gastroenterologist.”

Patients whose hospital-based colonoscopies were performed by physicians classified in the “other” category (primarily internists) also were at higher risk for a subsequent colorectal cancer diagnosis (HR 1.275).

In the office-based setting, however, “endoscopist specialty was not significantly associated with incident CRC.”

Nor was there any association between the volume of colonoscopies previously performed by the endoscopist and incident CRC in either setting, after adjustment for patient age, sex, and comorbidity.

The authors attempted to explain the disparate findings between the office and hospital settings by pointing out that patients seen in the private office/clinics were younger, more likely to be men, and had less comorbidity. Therefore, “it is likely that the procedures in the private office/clinics were technically easier to perform,” they said.

“Having extensive formal training matters more when the procedures are more challenging to perform,” they added.

Dr. Rabeneck and her coauthors also pointed out that there is a risk that the study may not pertain “to the current era.” However, “there has been no change in endoscopy training requirements since the study period,” they wrote. “In addition, the proportion of colonoscopies performed by gastroenterologists has increased only modestly (to 26% in 2008),” compared with the 16% figure at the time of this analysis.

Disclosures: The authors reported no relevant conflicts of interest.

Patients whose previous negative colonoscopies were performed by gastroenterologists are less likely to have subsequent colorectal cancer than are patients whose screens were done by other specialists, including general surgeons, Dr. Linda Rabeneck and her colleagues reported.

Despite previous studies finding a significantly decreased risk of colorectal cancer (CRC) even 10 years after a negative colonoscopy, “a small but clinically meaningful number of incident CRCs occur,” wrote Dr. Rabeneck of the University of Toronto (Clin. Gastroenterol. Hepatol. 2010 March [doi:10.1016/j.cgh.2009.10.022

These cancers could include missed lesions because of poor bowel preparation, suboptimal colonoscopy technique, incomplete polypectomy, or even truly new cancers, the authors wrote. However, “the issue of whether endoscopist characteristics, including colonoscopy volume and specialty, are important in this context has not been previously addressed in a large-scale … population-based study that reflects usual clinical practice.”

Dr. Rabeneck and her colleagues studied 110,402 Ontario residents aged 50-80 years who had a negative complete colonoscopy between Jan. 1, 1992, and Dec. 31, 1997. Slightly more than half (55.2%) were female. Participants had no history of colorectal cancer, no past diagnosis of inflammatory bowel disease, and no colonic resection within 5 years of the index colonoscopy.

Patients were followed up for colorectal cancer diagnosis from the date of the index negative colonoscopy through Dec. 31, 2006. During the study's 15-year follow-up period, colorectal cancer “was diagnosed in 1,596 persons, of whom 1,426 had the index colonoscopy in a hospital [86%], and 170 had the procedure in a private office/clinic,” the authors wrote.

Among the patients who had colonoscopies performed in a hospital, 38% of endoscopists were general surgeons, 17% were gastroenterologists, and the remainder of physicians was classified as “other”: primarily internists, family physicians, and “general physicians.” Regarding these hospital-based patients, the authors wrote: “For those who had their procedures performed by a general surgeon, the risk of incident CRC was increased by almost 40% (hazard ratio 1.389), compared with those who had their procedures performed by a gastroenterologist.”

Patients whose hospital-based colonoscopies were performed by physicians classified in the “other” category (primarily internists) also were at higher risk for a subsequent colorectal cancer diagnosis (HR 1.275).

In the office-based setting, however, “endoscopist specialty was not significantly associated with incident CRC.”

Nor was there any association between the volume of colonoscopies previously performed by the endoscopist and incident CRC in either setting, after adjustment for patient age, sex, and comorbidity.

The authors attempted to explain the disparate findings between the office and hospital settings by pointing out that patients seen in the private office/clinics were younger, more likely to be men, and had less comorbidity. Therefore, “it is likely that the procedures in the private office/clinics were technically easier to perform,” they said.

“Having extensive formal training matters more when the procedures are more challenging to perform,” they added.

Dr. Rabeneck and her coauthors also pointed out that there is a risk that the study may not pertain “to the current era.” However, “there has been no change in endoscopy training requirements since the study period,” they wrote. “In addition, the proportion of colonoscopies performed by gastroenterologists has increased only modestly (to 26% in 2008),” compared with the 16% figure at the time of this analysis.

Disclosures: The authors reported no relevant conflicts of interest.

Major Finding: Fewer falls occurred after expedited surgery (76 out of 274 patients), compared with standard surgery (87 out of 271 patients), for an OR of 0.81; the result did not reach significance (CI 0.55-1.17).

Data Source: A metaanalysis of two studies with a total of 535 women who had cataract surgery.

Disclosures: None of the investigators had any conflicts to report.

“Expedited” cataract surgery occurring within 4 weeks of diagnosis did not significantly reduce falls among elderly women, according to a metaanalysis of two randomized controlled trials.

That's despite a sevenfold improvement in sight following surgery, compared with elderly cataract patients who were scheduled for surgery but were stuck on 12-month wait lists.

Nevertheless, “extensive wait times for cataract surgery are a global health care issue” and a major cause of preventable blindness, wrote the authors of the current analysis. “Focusing resources on expedited cataract surgery would reduce the extensive waiting lists, influencing the health of the elderly population” (J. Cataract Refract. Surg. 2010;36:13-9).

The authors, led by Ediriweera Desapriya, Ph.D., of the department of developmental neurosciences and child health at the University of British Columbia, Vancouver, sorted through 234 studies found in 12 databases, including Medline, that mentioned “expedited cataract surgery.” Only three looked at outcome measures for both improvement of vision and reduction of injury. Just two studies, comprising 535 women over age 70, looked at falls specifically.

“Expedited” surgery was defined as occurring within 4 weeks of diagnosis in the two studies included in the falls analysis (Br. J. Ophthalmol. 2005;89:53-9; Age and Ageing 2006;35:66-71); the third study, which appeared only in the vision analysis, extended the definition to 6 weeks (Lancet 1998;352:925-9). “Routine” surgery in the first two trials occurred at 12 months after diagnosis and had not occurred yet at the time of analysis; in the vision-only study, it took place at 7-12 months.

Looking at all three studies, which included 372 patients in the routine surgery group and 365 expedited surgeries, “Expedited cataract surgery was associated with significantly enhanced visual acuity” at 6 months, compared with patients who had not yet had the procedure (odds ratio, 7.22; 95% confidence interval 3.15-16.55).

In the two studies that looked at falls, although there was a trend toward fewer falls after expedited surgery (76 out of 274 patients), compared with standard surgery (87 out of 271 patients), for an OR of 0.81, the result did not reach significance (CI 0.55-1.17). Both studies in the falls analysis were based on patient diaries.

Although a metaanalysis of only two studies may seem inadequate, the authors wrote: “When definitive and large trials have not been performed to evaluate the impact of expedited cataract surgery on the incidence of falls, a meta-analysis of all available trials could help resolve some important issues, reducing the need for large, costly new trials.”

The two studies reported differences in predicted falls between men and women who have undergone cataract surgery. The age of the subjects could be a factor as the literature shows the rate of falls increases after age 70, they wrote. Also, fragile, more easily broken bones that can result from “clinical conditions that primarily affect women in their postmenopausal years, such as osteoporosis, may increase the damage caused by falls and other injuries,” the authors said.

In noting the limitations of their analysis, the authors said both selected trials “had insufficient power, and the dropout rate was 7.8%. Significant cases were lost to follow-up in both trials (10.7%).” the authors said. “Future high-quality [randomized clinical trials] are recommended,” they said.

Major Finding: Fewer falls occurred after expedited surgery (76 out of 274 patients), compared with standard surgery (87 out of 271 patients), for an OR of 0.81; the result did not reach significance (CI 0.55-1.17).

Data Source: A metaanalysis of two studies with a total of 535 women who had cataract surgery.

Disclosures: None of the investigators had any conflicts to report.

“Expedited” cataract surgery occurring within 4 weeks of diagnosis did not significantly reduce falls among elderly women, according to a metaanalysis of two randomized controlled trials.

That's despite a sevenfold improvement in sight following surgery, compared with elderly cataract patients who were scheduled for surgery but were stuck on 12-month wait lists.

Nevertheless, “extensive wait times for cataract surgery are a global health care issue” and a major cause of preventable blindness, wrote the authors of the current analysis. “Focusing resources on expedited cataract surgery would reduce the extensive waiting lists, influencing the health of the elderly population” (J. Cataract Refract. Surg. 2010;36:13-9).

The authors, led by Ediriweera Desapriya, Ph.D., of the department of developmental neurosciences and child health at the University of British Columbia, Vancouver, sorted through 234 studies found in 12 databases, including Medline, that mentioned “expedited cataract surgery.” Only three looked at outcome measures for both improvement of vision and reduction of injury. Just two studies, comprising 535 women over age 70, looked at falls specifically.

“Expedited” surgery was defined as occurring within 4 weeks of diagnosis in the two studies included in the falls analysis (Br. J. Ophthalmol. 2005;89:53-9; Age and Ageing 2006;35:66-71); the third study, which appeared only in the vision analysis, extended the definition to 6 weeks (Lancet 1998;352:925-9). “Routine” surgery in the first two trials occurred at 12 months after diagnosis and had not occurred yet at the time of analysis; in the vision-only study, it took place at 7-12 months.

Looking at all three studies, which included 372 patients in the routine surgery group and 365 expedited surgeries, “Expedited cataract surgery was associated with significantly enhanced visual acuity” at 6 months, compared with patients who had not yet had the procedure (odds ratio, 7.22; 95% confidence interval 3.15-16.55).

In the two studies that looked at falls, although there was a trend toward fewer falls after expedited surgery (76 out of 274 patients), compared with standard surgery (87 out of 271 patients), for an OR of 0.81, the result did not reach significance (CI 0.55-1.17). Both studies in the falls analysis were based on patient diaries.

Although a metaanalysis of only two studies may seem inadequate, the authors wrote: “When definitive and large trials have not been performed to evaluate the impact of expedited cataract surgery on the incidence of falls, a meta-analysis of all available trials could help resolve some important issues, reducing the need for large, costly new trials.”

The two studies reported differences in predicted falls between men and women who have undergone cataract surgery. The age of the subjects could be a factor as the literature shows the rate of falls increases after age 70, they wrote. Also, fragile, more easily broken bones that can result from “clinical conditions that primarily affect women in their postmenopausal years, such as osteoporosis, may increase the damage caused by falls and other injuries,” the authors said.

In noting the limitations of their analysis, the authors said both selected trials “had insufficient power, and the dropout rate was 7.8%. Significant cases were lost to follow-up in both trials (10.7%).” the authors said. “Future high-quality [randomized clinical trials] are recommended,” they said.

Major Finding: Fewer falls occurred after expedited surgery (76 out of 274 patients), compared with standard surgery (87 out of 271 patients), for an OR of 0.81; the result did not reach significance (CI 0.55-1.17).

Data Source: A metaanalysis of two studies with a total of 535 women who had cataract surgery.

Disclosures: None of the investigators had any conflicts to report.

“Expedited” cataract surgery occurring within 4 weeks of diagnosis did not significantly reduce falls among elderly women, according to a metaanalysis of two randomized controlled trials.

That's despite a sevenfold improvement in sight following surgery, compared with elderly cataract patients who were scheduled for surgery but were stuck on 12-month wait lists.

Nevertheless, “extensive wait times for cataract surgery are a global health care issue” and a major cause of preventable blindness, wrote the authors of the current analysis. “Focusing resources on expedited cataract surgery would reduce the extensive waiting lists, influencing the health of the elderly population” (J. Cataract Refract. Surg. 2010;36:13-9).

The authors, led by Ediriweera Desapriya, Ph.D., of the department of developmental neurosciences and child health at the University of British Columbia, Vancouver, sorted through 234 studies found in 12 databases, including Medline, that mentioned “expedited cataract surgery.” Only three looked at outcome measures for both improvement of vision and reduction of injury. Just two studies, comprising 535 women over age 70, looked at falls specifically.

“Expedited” surgery was defined as occurring within 4 weeks of diagnosis in the two studies included in the falls analysis (Br. J. Ophthalmol. 2005;89:53-9; Age and Ageing 2006;35:66-71); the third study, which appeared only in the vision analysis, extended the definition to 6 weeks (Lancet 1998;352:925-9). “Routine” surgery in the first two trials occurred at 12 months after diagnosis and had not occurred yet at the time of analysis; in the vision-only study, it took place at 7-12 months.

Looking at all three studies, which included 372 patients in the routine surgery group and 365 expedited surgeries, “Expedited cataract surgery was associated with significantly enhanced visual acuity” at 6 months, compared with patients who had not yet had the procedure (odds ratio, 7.22; 95% confidence interval 3.15-16.55).

In the two studies that looked at falls, although there was a trend toward fewer falls after expedited surgery (76 out of 274 patients), compared with standard surgery (87 out of 271 patients), for an OR of 0.81, the result did not reach significance (CI 0.55-1.17). Both studies in the falls analysis were based on patient diaries.

Although a metaanalysis of only two studies may seem inadequate, the authors wrote: “When definitive and large trials have not been performed to evaluate the impact of expedited cataract surgery on the incidence of falls, a meta-analysis of all available trials could help resolve some important issues, reducing the need for large, costly new trials.”

The two studies reported differences in predicted falls between men and women who have undergone cataract surgery. The age of the subjects could be a factor as the literature shows the rate of falls increases after age 70, they wrote. Also, fragile, more easily broken bones that can result from “clinical conditions that primarily affect women in their postmenopausal years, such as osteoporosis, may increase the damage caused by falls and other injuries,” the authors said.

In noting the limitations of their analysis, the authors said both selected trials “had insufficient power, and the dropout rate was 7.8%. Significant cases were lost to follow-up in both trials (10.7%).” the authors said. “Future high-quality [randomized clinical trials] are recommended,” they said.