Timothy F. Kirn

SAN FRANCISCO – An antidepressant often is better than a high-fiber bulking agent as first-line treatment for irritable bowel syndrome, at least for the diarrhea-predominant form of the disorder, Philip S. Schoenfeld, M.D., said at the annual meeting of the American College of Physicians.

Results from 14 well-designed clinical trials of the use of bulking agents for irritable bowel syndrome (IBS) “consistently show … that they are no better than placebo,” said Dr. Schoenfeld, chief of the division of gastroenterology at the Ann Arbor (Mich.) Veterans Affairs Medical Center.

Worse, bulking agents usually cause uncomfortable bloating. In one study of psyllium (Metamucil), placebo patients actually did better than treated patients, said Dr. Schoenfeld, who was a member of the American College of Gastroenterology's task force that reviewed treatment evidence in 2002.

The only time to try a bulking agent is with a patient with constipation-predominant IBS who does not normally have bloating discomfort with the constipation, he said.

Tricyclic antidepressants, on the other hand, are good agents for pain control. Several studies have shown that tricyclics reduce abdominal pain. The most recent study–which met the criteria for good study design spelled out by the International Congress of Gastroenterology's Rome guidelines–showed a significant reduction of symptoms, Dr. Schoenfeld said.

The study used low-dose desipramine, which Dr. Schoenfeld said he prefers to use first. He uses it in patients with diarrhea-predominant IBS because tricyclics can cause constipation.

About one-quarter of patients don't tolerate tricyclic therapy; they can be switched to a selective serotonin-reuptake inhibitor (SSRI), with advice to use loperamide as needed.

Of the three well-designed trials that have tested the use of an SSRI, one showed significant symptom improvement, one showed a trend to improvement, and one showed decreased health care utilization, he said.

Although IBS has been called a diagnosis of exclusion, in practice it does not really need to be. That approach leads to a lot of expensive tests–40% of IBS patients, for example, get endoscopy at the time of initial diagnosis, Dr. Schoenfeld said.

In the absence of specific danger signs, such as fecal blood, the incidence of other serious conditions in patients with IBS-like symptoms is generally about the same as in the general population (less than 1%). The exception is celiac sprue, which occurs about 10 times more often in patients with diarrhea-predominant IBS-like symptoms than it does in the general population.

Dr. Schoenfeld said that he prefers to test for serum celiac sprue using the tissue transglutaminase antibody test, because its sensitivity is almost 100%. There are false positives, but a negative test rules out the disorder.

In clinical trials, tegaserod maleate (Zelnorm) was effective in about 40% of patients. Yet about 30% of placebo patients had improvement, as they often do in IBS trials, so the absolute difference was only about 10%.

Tegaserod is worth a try in constipation-predominant, female patients; when it works, symptoms improve rapidly. But Dr. Schoenfeld does not continue a trial for very long because the drug is expensive. “It's not a miracle drug, and if they haven't improved in about a month they are unlikely to improve,” he said.

He usually stops the drug after 8 weeks, as specified on the product label. IBS patients generally have flares and quiescent periods, and studies have shown the average flare lasts 6–8 weeks. Moreover, evidence indicates that response to the drug, when reinitiated, is exactly the same as the initial response.

Dr. Schoenfeld has a consultantship with Novartis Pharmaceuticals Corp., the maker of Zelnorm.

SAN FRANCISCO – An antidepressant often is better than a high-fiber bulking agent as first-line treatment for irritable bowel syndrome, at least for the diarrhea-predominant form of the disorder, Philip S. Schoenfeld, M.D., said at the annual meeting of the American College of Physicians.

Results from 14 well-designed clinical trials of the use of bulking agents for irritable bowel syndrome (IBS) “consistently show … that they are no better than placebo,” said Dr. Schoenfeld, chief of the division of gastroenterology at the Ann Arbor (Mich.) Veterans Affairs Medical Center.

Worse, bulking agents usually cause uncomfortable bloating. In one study of psyllium (Metamucil), placebo patients actually did better than treated patients, said Dr. Schoenfeld, who was a member of the American College of Gastroenterology's task force that reviewed treatment evidence in 2002.

The only time to try a bulking agent is with a patient with constipation-predominant IBS who does not normally have bloating discomfort with the constipation, he said.

Tricyclic antidepressants, on the other hand, are good agents for pain control. Several studies have shown that tricyclics reduce abdominal pain. The most recent study–which met the criteria for good study design spelled out by the International Congress of Gastroenterology's Rome guidelines–showed a significant reduction of symptoms, Dr. Schoenfeld said.

The study used low-dose desipramine, which Dr. Schoenfeld said he prefers to use first. He uses it in patients with diarrhea-predominant IBS because tricyclics can cause constipation.

About one-quarter of patients don't tolerate tricyclic therapy; they can be switched to a selective serotonin-reuptake inhibitor (SSRI), with advice to use loperamide as needed.

Of the three well-designed trials that have tested the use of an SSRI, one showed significant symptom improvement, one showed a trend to improvement, and one showed decreased health care utilization, he said.

Although IBS has been called a diagnosis of exclusion, in practice it does not really need to be. That approach leads to a lot of expensive tests–40% of IBS patients, for example, get endoscopy at the time of initial diagnosis, Dr. Schoenfeld said.

In the absence of specific danger signs, such as fecal blood, the incidence of other serious conditions in patients with IBS-like symptoms is generally about the same as in the general population (less than 1%). The exception is celiac sprue, which occurs about 10 times more often in patients with diarrhea-predominant IBS-like symptoms than it does in the general population.

Dr. Schoenfeld said that he prefers to test for serum celiac sprue using the tissue transglutaminase antibody test, because its sensitivity is almost 100%. There are false positives, but a negative test rules out the disorder.

In clinical trials, tegaserod maleate (Zelnorm) was effective in about 40% of patients. Yet about 30% of placebo patients had improvement, as they often do in IBS trials, so the absolute difference was only about 10%.

Tegaserod is worth a try in constipation-predominant, female patients; when it works, symptoms improve rapidly. But Dr. Schoenfeld does not continue a trial for very long because the drug is expensive. “It's not a miracle drug, and if they haven't improved in about a month they are unlikely to improve,” he said.

He usually stops the drug after 8 weeks, as specified on the product label. IBS patients generally have flares and quiescent periods, and studies have shown the average flare lasts 6–8 weeks. Moreover, evidence indicates that response to the drug, when reinitiated, is exactly the same as the initial response.

Dr. Schoenfeld has a consultantship with Novartis Pharmaceuticals Corp., the maker of Zelnorm.

SAN FRANCISCO – An antidepressant often is better than a high-fiber bulking agent as first-line treatment for irritable bowel syndrome, at least for the diarrhea-predominant form of the disorder, Philip S. Schoenfeld, M.D., said at the annual meeting of the American College of Physicians.

Results from 14 well-designed clinical trials of the use of bulking agents for irritable bowel syndrome (IBS) “consistently show … that they are no better than placebo,” said Dr. Schoenfeld, chief of the division of gastroenterology at the Ann Arbor (Mich.) Veterans Affairs Medical Center.

Worse, bulking agents usually cause uncomfortable bloating. In one study of psyllium (Metamucil), placebo patients actually did better than treated patients, said Dr. Schoenfeld, who was a member of the American College of Gastroenterology's task force that reviewed treatment evidence in 2002.

The only time to try a bulking agent is with a patient with constipation-predominant IBS who does not normally have bloating discomfort with the constipation, he said.

Tricyclic antidepressants, on the other hand, are good agents for pain control. Several studies have shown that tricyclics reduce abdominal pain. The most recent study–which met the criteria for good study design spelled out by the International Congress of Gastroenterology's Rome guidelines–showed a significant reduction of symptoms, Dr. Schoenfeld said.

The study used low-dose desipramine, which Dr. Schoenfeld said he prefers to use first. He uses it in patients with diarrhea-predominant IBS because tricyclics can cause constipation.

About one-quarter of patients don't tolerate tricyclic therapy; they can be switched to a selective serotonin-reuptake inhibitor (SSRI), with advice to use loperamide as needed.

Of the three well-designed trials that have tested the use of an SSRI, one showed significant symptom improvement, one showed a trend to improvement, and one showed decreased health care utilization, he said.

Although IBS has been called a diagnosis of exclusion, in practice it does not really need to be. That approach leads to a lot of expensive tests–40% of IBS patients, for example, get endoscopy at the time of initial diagnosis, Dr. Schoenfeld said.

In the absence of specific danger signs, such as fecal blood, the incidence of other serious conditions in patients with IBS-like symptoms is generally about the same as in the general population (less than 1%). The exception is celiac sprue, which occurs about 10 times more often in patients with diarrhea-predominant IBS-like symptoms than it does in the general population.

Dr. Schoenfeld said that he prefers to test for serum celiac sprue using the tissue transglutaminase antibody test, because its sensitivity is almost 100%. There are false positives, but a negative test rules out the disorder.

In clinical trials, tegaserod maleate (Zelnorm) was effective in about 40% of patients. Yet about 30% of placebo patients had improvement, as they often do in IBS trials, so the absolute difference was only about 10%.

Tegaserod is worth a try in constipation-predominant, female patients; when it works, symptoms improve rapidly. But Dr. Schoenfeld does not continue a trial for very long because the drug is expensive. “It's not a miracle drug, and if they haven't improved in about a month they are unlikely to improve,” he said.

He usually stops the drug after 8 weeks, as specified on the product label. IBS patients generally have flares and quiescent periods, and studies have shown the average flare lasts 6–8 weeks. Moreover, evidence indicates that response to the drug, when reinitiated, is exactly the same as the initial response.

Dr. Schoenfeld has a consultantship with Novartis Pharmaceuticals Corp., the maker of Zelnorm.

LOS ANGELES – If one goes to Google on the Internet and types in the word “sex,” the first Web site listed is the place where about 60,000 adolescents a day go for their sex information, with the kinds of questions they are not likely to want to ask their parents.

The site is called Sex, Etc., and its content is written by adolescents, under the supervision of experts at Rutgers University.

Sex, Etc. started as a newsletter in 1994, and 2.2 million copies of the newsletter are still distributed annually. But, because some of the topics touched on have included masturbation, lesbianism, and even French kissing, the newsletter has been banned by some school districts, which is one of the reasons why the Web site was started.

And, it is on the Internet that Sex, Etc. is now having its biggest impact, Nora Gelperin said at the annual meeting of the Society for Adolescent Medicine.

The number of daily visitors to the Sex, Etc. Web site has grown from an average of a little more than 10,000 a day in December 2002 to an average 60,000 a day now, 70% of whom are individuals aged younger than 21 years.

The fact that so many young people turn to this source is evidence of its need, said Ms. Gelperin, director of training and education, Network for Family Life Education at Rutgers, the State University of New Jersey, Piscataway.

Adolescents today live in a confusing culture where sex is freely discussed but much basic information is scarce. Sexual content appears on television at the same time that an increasing number of school districts are adopting abstinence-only sex education programs, she said.

“Teachers aren't free to talk about anything more than the plumbing, and parents generally aren't saying anything at all,” Ms. Gelperin said.

According to one survey, 97% of persons 15–24 years of age have gone on the Internet for any reason, two-thirds have gone on the Internet for health information of any kind, and 4 of 10 who have searched out health information there have changed some kind of behavior as a result, Dr. Gelperin noted.

Currently, the Web site has more than 200 teen-written articles online, more than 250 frequently asked questions and answers, and a glossary of about 440 different terms, ranging from “areola” and “vulva” to “choad” and “smash” (choad is slang for a penis that is wider than it is long and smash is slang for sex). There are interactive diagrams of male and female anatomy, and also an “ask-the-experts” service, for which questions are answered within 72 hours, and a “help-now” service for crisis questions, which are answered in 24 hours.

According to the site's records, the most frequently asked questions by males involve masturbation and penis size. The most frequently asked questions by females are about “can I get pregnant if …” and painful sex. Questions have included whether it is normal to shave one's pubic area and whether it is true that the yellow dye in Mountain Dew soda kills sperm.

Females ask about twice as many questions as males, and the average age of those who submit questions is 16 years, the records indicate.

Although the ask-the-experts questions are not answered by adolescents, most of the rest of the content in the newsletter and on the Web site is written by teens, and that is something the Rutgers administrators consider very important because adolescents listen to each other differently from the way they listen to adults, Ms. Gelperin said.

On the other hand, anyone who visits the site cannot help but notice the Rutgers logo on the home page, and that is what gives the site credibility in the visitors' minds, she said.

“Kids are looking for information, looking everywhere, and they are very savvy,” Ms. Gelperin said. “But just think about the myths around when you were an adolescent. They are still around today.”

LOS ANGELES – If one goes to Google on the Internet and types in the word “sex,” the first Web site listed is the place where about 60,000 adolescents a day go for their sex information, with the kinds of questions they are not likely to want to ask their parents.

The site is called Sex, Etc., and its content is written by adolescents, under the supervision of experts at Rutgers University.

Sex, Etc. started as a newsletter in 1994, and 2.2 million copies of the newsletter are still distributed annually. But, because some of the topics touched on have included masturbation, lesbianism, and even French kissing, the newsletter has been banned by some school districts, which is one of the reasons why the Web site was started.

And, it is on the Internet that Sex, Etc. is now having its biggest impact, Nora Gelperin said at the annual meeting of the Society for Adolescent Medicine.

The number of daily visitors to the Sex, Etc. Web site has grown from an average of a little more than 10,000 a day in December 2002 to an average 60,000 a day now, 70% of whom are individuals aged younger than 21 years.

The fact that so many young people turn to this source is evidence of its need, said Ms. Gelperin, director of training and education, Network for Family Life Education at Rutgers, the State University of New Jersey, Piscataway.

Adolescents today live in a confusing culture where sex is freely discussed but much basic information is scarce. Sexual content appears on television at the same time that an increasing number of school districts are adopting abstinence-only sex education programs, she said.

“Teachers aren't free to talk about anything more than the plumbing, and parents generally aren't saying anything at all,” Ms. Gelperin said.

According to one survey, 97% of persons 15–24 years of age have gone on the Internet for any reason, two-thirds have gone on the Internet for health information of any kind, and 4 of 10 who have searched out health information there have changed some kind of behavior as a result, Dr. Gelperin noted.

Currently, the Web site has more than 200 teen-written articles online, more than 250 frequently asked questions and answers, and a glossary of about 440 different terms, ranging from “areola” and “vulva” to “choad” and “smash” (choad is slang for a penis that is wider than it is long and smash is slang for sex). There are interactive diagrams of male and female anatomy, and also an “ask-the-experts” service, for which questions are answered within 72 hours, and a “help-now” service for crisis questions, which are answered in 24 hours.

According to the site's records, the most frequently asked questions by males involve masturbation and penis size. The most frequently asked questions by females are about “can I get pregnant if …” and painful sex. Questions have included whether it is normal to shave one's pubic area and whether it is true that the yellow dye in Mountain Dew soda kills sperm.

Females ask about twice as many questions as males, and the average age of those who submit questions is 16 years, the records indicate.

Although the ask-the-experts questions are not answered by adolescents, most of the rest of the content in the newsletter and on the Web site is written by teens, and that is something the Rutgers administrators consider very important because adolescents listen to each other differently from the way they listen to adults, Ms. Gelperin said.

On the other hand, anyone who visits the site cannot help but notice the Rutgers logo on the home page, and that is what gives the site credibility in the visitors' minds, she said.

“Kids are looking for information, looking everywhere, and they are very savvy,” Ms. Gelperin said. “But just think about the myths around when you were an adolescent. They are still around today.”

LOS ANGELES – If one goes to Google on the Internet and types in the word “sex,” the first Web site listed is the place where about 60,000 adolescents a day go for their sex information, with the kinds of questions they are not likely to want to ask their parents.

The site is called Sex, Etc., and its content is written by adolescents, under the supervision of experts at Rutgers University.

Sex, Etc. started as a newsletter in 1994, and 2.2 million copies of the newsletter are still distributed annually. But, because some of the topics touched on have included masturbation, lesbianism, and even French kissing, the newsletter has been banned by some school districts, which is one of the reasons why the Web site was started.

And, it is on the Internet that Sex, Etc. is now having its biggest impact, Nora Gelperin said at the annual meeting of the Society for Adolescent Medicine.

The number of daily visitors to the Sex, Etc. Web site has grown from an average of a little more than 10,000 a day in December 2002 to an average 60,000 a day now, 70% of whom are individuals aged younger than 21 years.

The fact that so many young people turn to this source is evidence of its need, said Ms. Gelperin, director of training and education, Network for Family Life Education at Rutgers, the State University of New Jersey, Piscataway.

Adolescents today live in a confusing culture where sex is freely discussed but much basic information is scarce. Sexual content appears on television at the same time that an increasing number of school districts are adopting abstinence-only sex education programs, she said.

“Teachers aren't free to talk about anything more than the plumbing, and parents generally aren't saying anything at all,” Ms. Gelperin said.

According to one survey, 97% of persons 15–24 years of age have gone on the Internet for any reason, two-thirds have gone on the Internet for health information of any kind, and 4 of 10 who have searched out health information there have changed some kind of behavior as a result, Dr. Gelperin noted.

Currently, the Web site has more than 200 teen-written articles online, more than 250 frequently asked questions and answers, and a glossary of about 440 different terms, ranging from “areola” and “vulva” to “choad” and “smash” (choad is slang for a penis that is wider than it is long and smash is slang for sex). There are interactive diagrams of male and female anatomy, and also an “ask-the-experts” service, for which questions are answered within 72 hours, and a “help-now” service for crisis questions, which are answered in 24 hours.

According to the site's records, the most frequently asked questions by males involve masturbation and penis size. The most frequently asked questions by females are about “can I get pregnant if …” and painful sex. Questions have included whether it is normal to shave one's pubic area and whether it is true that the yellow dye in Mountain Dew soda kills sperm.

Females ask about twice as many questions as males, and the average age of those who submit questions is 16 years, the records indicate.

Although the ask-the-experts questions are not answered by adolescents, most of the rest of the content in the newsletter and on the Web site is written by teens, and that is something the Rutgers administrators consider very important because adolescents listen to each other differently from the way they listen to adults, Ms. Gelperin said.

On the other hand, anyone who visits the site cannot help but notice the Rutgers logo on the home page, and that is what gives the site credibility in the visitors' minds, she said.

“Kids are looking for information, looking everywhere, and they are very savvy,” Ms. Gelperin said. “But just think about the myths around when you were an adolescent. They are still around today.”

CHICAGO — Individuals with gastroesophageal reflux fare better when they see a doctor than when they treat themselves with over-the-counter medications, but for the majority of those patients, symptoms are not totally resolved, Roger Jones, M.D., said at the annual Digestive Disease Week.

In a multinational survey of 1,908 individuals with gastroesophageal reflux disease (GERD), 81% of those who had never seen a doctor for the condition but who took over-the-counter medications continued to have unresolved symptoms.

That compared with 68% of patients with a formal diagnosis taking a prescription medicine, Dr. Jones, a professor of general practice at the Guy's, King's, and St. Thomas' School of Medicine, London, said.

The researchers surveyed persons who had previously been identified by a larger telephone survey conducted in the United States and three European countries. Half of the people in the group had been given a formal diagnosis of GERD, and the other half were individuals who reported two or more episodes of heartburn in the week prior to being contacted, but who had never consulted a physician.

Of those without a diagnosis, 78% (721) reported taking over-the-counter medications. About two-thirds (65%) of those who had taken over-the-counter medications said their symptoms were improved since first taking medication. Still, 81% had residual symptoms.

Of those with a diagnosis, 74% (727 patients) had a prescription, and 80% of those had some improvement since first taking their prescribed medication. Eighty-seven percent of 537 patients receiving a proton pump inhibitor either alone or in combination reported improvement. Ninety-one percent of those taking only a proton pump inhibitor reported some improvement. Still, 68% of those taking a prescription drug continued to have residual symptoms.

The investigators had no trouble finding individuals with heartburn for their survey, Dr. Jones noted. Previous surveys have suggested that as many as one-third of adults experience symptoms.

Previous studies have also noted that the most common reason proton pump inhibitors do not work as well as they might is a lack of full compliance with a daily regimen, he said.

CHICAGO — Individuals with gastroesophageal reflux fare better when they see a doctor than when they treat themselves with over-the-counter medications, but for the majority of those patients, symptoms are not totally resolved, Roger Jones, M.D., said at the annual Digestive Disease Week.

In a multinational survey of 1,908 individuals with gastroesophageal reflux disease (GERD), 81% of those who had never seen a doctor for the condition but who took over-the-counter medications continued to have unresolved symptoms.

That compared with 68% of patients with a formal diagnosis taking a prescription medicine, Dr. Jones, a professor of general practice at the Guy's, King's, and St. Thomas' School of Medicine, London, said.

The researchers surveyed persons who had previously been identified by a larger telephone survey conducted in the United States and three European countries. Half of the people in the group had been given a formal diagnosis of GERD, and the other half were individuals who reported two or more episodes of heartburn in the week prior to being contacted, but who had never consulted a physician.

Of those without a diagnosis, 78% (721) reported taking over-the-counter medications. About two-thirds (65%) of those who had taken over-the-counter medications said their symptoms were improved since first taking medication. Still, 81% had residual symptoms.

Of those with a diagnosis, 74% (727 patients) had a prescription, and 80% of those had some improvement since first taking their prescribed medication. Eighty-seven percent of 537 patients receiving a proton pump inhibitor either alone or in combination reported improvement. Ninety-one percent of those taking only a proton pump inhibitor reported some improvement. Still, 68% of those taking a prescription drug continued to have residual symptoms.

The investigators had no trouble finding individuals with heartburn for their survey, Dr. Jones noted. Previous surveys have suggested that as many as one-third of adults experience symptoms.

Previous studies have also noted that the most common reason proton pump inhibitors do not work as well as they might is a lack of full compliance with a daily regimen, he said.

CHICAGO — Individuals with gastroesophageal reflux fare better when they see a doctor than when they treat themselves with over-the-counter medications, but for the majority of those patients, symptoms are not totally resolved, Roger Jones, M.D., said at the annual Digestive Disease Week.

In a multinational survey of 1,908 individuals with gastroesophageal reflux disease (GERD), 81% of those who had never seen a doctor for the condition but who took over-the-counter medications continued to have unresolved symptoms.

That compared with 68% of patients with a formal diagnosis taking a prescription medicine, Dr. Jones, a professor of general practice at the Guy's, King's, and St. Thomas' School of Medicine, London, said.

The researchers surveyed persons who had previously been identified by a larger telephone survey conducted in the United States and three European countries. Half of the people in the group had been given a formal diagnosis of GERD, and the other half were individuals who reported two or more episodes of heartburn in the week prior to being contacted, but who had never consulted a physician.

Of those without a diagnosis, 78% (721) reported taking over-the-counter medications. About two-thirds (65%) of those who had taken over-the-counter medications said their symptoms were improved since first taking medication. Still, 81% had residual symptoms.

Of those with a diagnosis, 74% (727 patients) had a prescription, and 80% of those had some improvement since first taking their prescribed medication. Eighty-seven percent of 537 patients receiving a proton pump inhibitor either alone or in combination reported improvement. Ninety-one percent of those taking only a proton pump inhibitor reported some improvement. Still, 68% of those taking a prescription drug continued to have residual symptoms.

The investigators had no trouble finding individuals with heartburn for their survey, Dr. Jones noted. Previous surveys have suggested that as many as one-third of adults experience symptoms.

Previous studies have also noted that the most common reason proton pump inhibitors do not work as well as they might is a lack of full compliance with a daily regimen, he said.

SAN FRANCISCO — Antibiotics are necessary for some cases of rhinosinusitis, but many patients will improve with a simple saline nasal wash, Ralph Gonzales, M.D., said at the annual meeting of the American College of Physicians.

A nasal wash will clear out concretions blocking the sinus os and sinus cavities, allowing the sinuses to drain. “I recommend them for most patients,” said Dr. Gonzales of the department of medicine at the University of California, San Francisco.

“When you get people actually using it, I have had very positive reports,” he added.

The wash can be done with contact lens cleaner solution. Patients should hold a small amount in a cupped hand, close one nostril, and draw it in, hard enough to irrigate the sinuses but not so forcefully that they swallow it, Dr. Gonzales said. He has them perform the wash two to three times a day, during which time they can use an NSAID for pain if needed.

According to guidelines, physicians should reserve antibiotics—after evaluation for a possible bacterial infection—for those cases with moderately severe symptoms that have lasted at least 7–10 days, he said.

The evidence that antibiotic treatment is beneficial in acute rhinosinusitis is not definitive, he said. Some studies have not demonstrated an advantage over placebo. However, the studies that have been most rigorous in diagnosis have tended to show somewhat greater cure or improvement rates, suggesting that there really are some patients that need antibiotics.

Dr. Gonzales pointed out that sinusitis can be serious, even life threatening. Patients with focal unilateral maxillary pain and fever may have orbital cellulitis. In these cases there is often redness and tenderness around the maxillary sinus; Staphylococcus aureus is often the cause. These infections can be aggressive, sometimes fatal.

SAN FRANCISCO — Antibiotics are necessary for some cases of rhinosinusitis, but many patients will improve with a simple saline nasal wash, Ralph Gonzales, M.D., said at the annual meeting of the American College of Physicians.

A nasal wash will clear out concretions blocking the sinus os and sinus cavities, allowing the sinuses to drain. “I recommend them for most patients,” said Dr. Gonzales of the department of medicine at the University of California, San Francisco.

“When you get people actually using it, I have had very positive reports,” he added.

The wash can be done with contact lens cleaner solution. Patients should hold a small amount in a cupped hand, close one nostril, and draw it in, hard enough to irrigate the sinuses but not so forcefully that they swallow it, Dr. Gonzales said. He has them perform the wash two to three times a day, during which time they can use an NSAID for pain if needed.

According to guidelines, physicians should reserve antibiotics—after evaluation for a possible bacterial infection—for those cases with moderately severe symptoms that have lasted at least 7–10 days, he said.

The evidence that antibiotic treatment is beneficial in acute rhinosinusitis is not definitive, he said. Some studies have not demonstrated an advantage over placebo. However, the studies that have been most rigorous in diagnosis have tended to show somewhat greater cure or improvement rates, suggesting that there really are some patients that need antibiotics.

Dr. Gonzales pointed out that sinusitis can be serious, even life threatening. Patients with focal unilateral maxillary pain and fever may have orbital cellulitis. In these cases there is often redness and tenderness around the maxillary sinus; Staphylococcus aureus is often the cause. These infections can be aggressive, sometimes fatal.

SAN FRANCISCO — Antibiotics are necessary for some cases of rhinosinusitis, but many patients will improve with a simple saline nasal wash, Ralph Gonzales, M.D., said at the annual meeting of the American College of Physicians.

A nasal wash will clear out concretions blocking the sinus os and sinus cavities, allowing the sinuses to drain. “I recommend them for most patients,” said Dr. Gonzales of the department of medicine at the University of California, San Francisco.

“When you get people actually using it, I have had very positive reports,” he added.

The wash can be done with contact lens cleaner solution. Patients should hold a small amount in a cupped hand, close one nostril, and draw it in, hard enough to irrigate the sinuses but not so forcefully that they swallow it, Dr. Gonzales said. He has them perform the wash two to three times a day, during which time they can use an NSAID for pain if needed.

According to guidelines, physicians should reserve antibiotics—after evaluation for a possible bacterial infection—for those cases with moderately severe symptoms that have lasted at least 7–10 days, he said.

The evidence that antibiotic treatment is beneficial in acute rhinosinusitis is not definitive, he said. Some studies have not demonstrated an advantage over placebo. However, the studies that have been most rigorous in diagnosis have tended to show somewhat greater cure or improvement rates, suggesting that there really are some patients that need antibiotics.

Dr. Gonzales pointed out that sinusitis can be serious, even life threatening. Patients with focal unilateral maxillary pain and fever may have orbital cellulitis. In these cases there is often redness and tenderness around the maxillary sinus; Staphylococcus aureus is often the cause. These infections can be aggressive, sometimes fatal.

NAPLES, FLA. — Several longstanding myths and misconceptions about the botulinum toxin type A technique have recently been refuted, James M. Spencer, M.D., said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

"When botulinum toxin first came out, we were told a number of things about using it," he said.

Some of the directives propagated included: It must be reconstituted with nonpreserved saline; the protein is fragile and cannot be shaken or made to foam; and, it must be used within 4 hours of reconstitution, again because the protein is fragile. "None of these are true," said Dr. Spencer, who is director of Mohs micrographic surgery at Mount Sinai Medical Center, New York, and maintains a private practice in St. Petersburg, Fla.

Preserved saline is actually preferable, he said. The preservative in saline is usually benzyl alcohol, which not only kills bacteria but is a mild anesthetic.

In a recently published study, 93 subjects were treated with botulinum toxin type A (Botox). Sixty of those patients received Botox reconstituted with preserved saline. They had a lot less pain, as measured by a visual analog scale, than did the patients who received Botox in preservative-free saline—a mean score of 1.2 out of 10 for those treated in the face with preserved-saline Botox vs. a mean 4.5 for those treated with preservative-free Botox (Aesthetic Plast. Surg. 2005;29:113–5).

"The other good thing about using the preservative is that you don't have to throw it away in 4 hours, because it is preserved," he added.

In a Brazilian study, 88 patients were treated with Botox that was reconstituted the day before, or for various periods of time up to 6 weeks before. There was no difference in efficacy when the patients were followed every 2 weeks for 4 months, with blinded observers evaluating their maximum frown (Dermatol. Surg. 2003;29:523–9).

In a third study, investigators treated patients with Botox that was reconstituted gently, or with Botox that was shaken vigorously. Again, there was no difference in efficacy, at 2 months and 4 months, Dr. Spencer said (Dermatol. Surg. 2003;29:530–1).

Many physicians also got the idea that patients could not lie down for 4 hours after a treatment. Dr. Spencer said he once told patients that, though he is not sure where he picked up this notion, and in trying to trace it, he could find nothing about its provenance.

"It turns out that is ridiculous," he said. "I've been looking for the holes in the skull that Botox would drain through to get to the brain. And, in fact, those holes are not there. There is no reason not to have patients lay down.

"Somebody must have said that, and we all believed it," he added.

Since Botox has been available, there has been a trend toward using higher and higher doses, with even the most reputable experts advocating doses as high as 80 units for the glabella, Dr. Spencer said. Dosing has not been well studied, until now.

There is one study that compared doses of 10 units, 20 units, 30 units, and 40 units to treat the glabella. And another study looked at Botox dosing for the lateral canthus for crow's feet, using escalating doses.

The glabella study said that 10 units was ineffective, but that there was no difference between 20 units and 40 units in either initial effect or duration of action (Dermatol. Surg. 2005;31:414–22). The lateral canthus study likewise reported that efficacy improved with higher dosing, but only to a point, which was about 12 units (6 units per side) (Dermatol. Surg. 2005;31:257–62).

"What these two papers said is that the clinical effect and duration of action plateaus at some point, so I am not sure that these higher doses make any sense," Dr. Spencer said.

NAPLES, FLA. — Several longstanding myths and misconceptions about the botulinum toxin type A technique have recently been refuted, James M. Spencer, M.D., said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

"When botulinum toxin first came out, we were told a number of things about using it," he said.

Some of the directives propagated included: It must be reconstituted with nonpreserved saline; the protein is fragile and cannot be shaken or made to foam; and, it must be used within 4 hours of reconstitution, again because the protein is fragile. "None of these are true," said Dr. Spencer, who is director of Mohs micrographic surgery at Mount Sinai Medical Center, New York, and maintains a private practice in St. Petersburg, Fla.

Preserved saline is actually preferable, he said. The preservative in saline is usually benzyl alcohol, which not only kills bacteria but is a mild anesthetic.

In a recently published study, 93 subjects were treated with botulinum toxin type A (Botox). Sixty of those patients received Botox reconstituted with preserved saline. They had a lot less pain, as measured by a visual analog scale, than did the patients who received Botox in preservative-free saline—a mean score of 1.2 out of 10 for those treated in the face with preserved-saline Botox vs. a mean 4.5 for those treated with preservative-free Botox (Aesthetic Plast. Surg. 2005;29:113–5).

"The other good thing about using the preservative is that you don't have to throw it away in 4 hours, because it is preserved," he added.

In a Brazilian study, 88 patients were treated with Botox that was reconstituted the day before, or for various periods of time up to 6 weeks before. There was no difference in efficacy when the patients were followed every 2 weeks for 4 months, with blinded observers evaluating their maximum frown (Dermatol. Surg. 2003;29:523–9).

In a third study, investigators treated patients with Botox that was reconstituted gently, or with Botox that was shaken vigorously. Again, there was no difference in efficacy, at 2 months and 4 months, Dr. Spencer said (Dermatol. Surg. 2003;29:530–1).

Many physicians also got the idea that patients could not lie down for 4 hours after a treatment. Dr. Spencer said he once told patients that, though he is not sure where he picked up this notion, and in trying to trace it, he could find nothing about its provenance.

"It turns out that is ridiculous," he said. "I've been looking for the holes in the skull that Botox would drain through to get to the brain. And, in fact, those holes are not there. There is no reason not to have patients lay down.

"Somebody must have said that, and we all believed it," he added.

Since Botox has been available, there has been a trend toward using higher and higher doses, with even the most reputable experts advocating doses as high as 80 units for the glabella, Dr. Spencer said. Dosing has not been well studied, until now.

There is one study that compared doses of 10 units, 20 units, 30 units, and 40 units to treat the glabella. And another study looked at Botox dosing for the lateral canthus for crow's feet, using escalating doses.

The glabella study said that 10 units was ineffective, but that there was no difference between 20 units and 40 units in either initial effect or duration of action (Dermatol. Surg. 2005;31:414–22). The lateral canthus study likewise reported that efficacy improved with higher dosing, but only to a point, which was about 12 units (6 units per side) (Dermatol. Surg. 2005;31:257–62).

"What these two papers said is that the clinical effect and duration of action plateaus at some point, so I am not sure that these higher doses make any sense," Dr. Spencer said.

NAPLES, FLA. — Several longstanding myths and misconceptions about the botulinum toxin type A technique have recently been refuted, James M. Spencer, M.D., said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

"When botulinum toxin first came out, we were told a number of things about using it," he said.

Some of the directives propagated included: It must be reconstituted with nonpreserved saline; the protein is fragile and cannot be shaken or made to foam; and, it must be used within 4 hours of reconstitution, again because the protein is fragile. "None of these are true," said Dr. Spencer, who is director of Mohs micrographic surgery at Mount Sinai Medical Center, New York, and maintains a private practice in St. Petersburg, Fla.

Preserved saline is actually preferable, he said. The preservative in saline is usually benzyl alcohol, which not only kills bacteria but is a mild anesthetic.

In a recently published study, 93 subjects were treated with botulinum toxin type A (Botox). Sixty of those patients received Botox reconstituted with preserved saline. They had a lot less pain, as measured by a visual analog scale, than did the patients who received Botox in preservative-free saline—a mean score of 1.2 out of 10 for those treated in the face with preserved-saline Botox vs. a mean 4.5 for those treated with preservative-free Botox (Aesthetic Plast. Surg. 2005;29:113–5).

"The other good thing about using the preservative is that you don't have to throw it away in 4 hours, because it is preserved," he added.

In a Brazilian study, 88 patients were treated with Botox that was reconstituted the day before, or for various periods of time up to 6 weeks before. There was no difference in efficacy when the patients were followed every 2 weeks for 4 months, with blinded observers evaluating their maximum frown (Dermatol. Surg. 2003;29:523–9).

In a third study, investigators treated patients with Botox that was reconstituted gently, or with Botox that was shaken vigorously. Again, there was no difference in efficacy, at 2 months and 4 months, Dr. Spencer said (Dermatol. Surg. 2003;29:530–1).

Many physicians also got the idea that patients could not lie down for 4 hours after a treatment. Dr. Spencer said he once told patients that, though he is not sure where he picked up this notion, and in trying to trace it, he could find nothing about its provenance.

"It turns out that is ridiculous," he said. "I've been looking for the holes in the skull that Botox would drain through to get to the brain. And, in fact, those holes are not there. There is no reason not to have patients lay down.

"Somebody must have said that, and we all believed it," he added.

Since Botox has been available, there has been a trend toward using higher and higher doses, with even the most reputable experts advocating doses as high as 80 units for the glabella, Dr. Spencer said. Dosing has not been well studied, until now.

There is one study that compared doses of 10 units, 20 units, 30 units, and 40 units to treat the glabella. And another study looked at Botox dosing for the lateral canthus for crow's feet, using escalating doses.

The glabella study said that 10 units was ineffective, but that there was no difference between 20 units and 40 units in either initial effect or duration of action (Dermatol. Surg. 2005;31:414–22). The lateral canthus study likewise reported that efficacy improved with higher dosing, but only to a point, which was about 12 units (6 units per side) (Dermatol. Surg. 2005;31:257–62).

"What these two papers said is that the clinical effect and duration of action plateaus at some point, so I am not sure that these higher doses make any sense," Dr. Spencer said.

NAPLES, FLA. — The best place to acquire surgical blades and materials for abrading is not necessarily the medical supply house, said Daniel M. Siegel, M.D.

The hardware store has supplies for medical procedures that are usually much cheaper, and often actually work better.

"During medical school, internship, and residency, I used to think about gadgets I grew up with that could be used in the medical office," explained the dermatologist and son of a hardware store owner.

The old double-edged razor blade is a case in point of the hardware store item being both cheaper and better, Dr. Siegel said. The classic blade is the old Gillette Blue Blade. Those blades are much sharper and much thinner (4/10,000th of an inch) than a scalpel, said Dr. Siegel of State University of New York Downstate Medical Center, New York.

Their thinness makes them easier to handle, and they can be bent and bowed to curettage (but practice on an orange first). Their sharpness allows the user to cut more cleanly with less collateral damage. This has even been touted in the literature, Dr. Siegel said, citing a paper that said one can perform excision biopsies of melanocytic nevi with less scarring. "Only a diamond knife is sharper."

The thicker, carpet-cutting blades sold in the hardware store are ideal for harvesting split thickness skin grafts because of their stiffness. The razor blades sometimes are covered with anticorrosive oil that is bacteriostatic, but the carpet blades need to be cleaned with Betadine and alcohol, he said.

Sandpaper, sanding sponges, and even drywall screens can be handy for—what else?—abrading, Dr. Siegel said. Sandpaper, which he makes wet with Betadine, can be used on warts, small scars, and even onychomycotic nails. The sponges are handy because they can be used and then washed in a dishwasher or washing machine. Drywall screen can be quite rough but it works well for treating larger areas, hypertrophic scars, or actinic keratoses, because it can be rinsed during use.

Dr. Siegel even suggested that sandpaper could be used for cosmetic dermabrasion, perhaps to advantage.

"It clogs quickly, so you have to use a lot of it," he said. "But it is difficult to do any real harm because it is a slow-moving, not very aggressive abrader."

For microdermabrasion, he suggested using Lava soap, which contains pumice from volcanic lava. Lava soap can be used before phototherapy or a peel, to remove some of the stratum corneum.

Dr. Siegel said he has made his own silicone gel sheeting using silicone caulking. He spreads it between two sheets of wax paper or into a plastic bag to flatten it out, and then lets it dry overnight.

As with all the hardware items, the cost of this sheeting is much less than the medical-grade sheeting, Dr. Siegel stressed. In fact, the first time he used the caulking was specifically for a patient who needed an economic alternative.

Among the other items available at the hardware store that Dr. Siegel mentioned using were electrical tape (to put over imiquimod), duct tape (on warts), foam tapes (to protect areas during cryotherapy), headlamps (only about $20), and dimethyl sulfoxide (DMSO).

DMSO can be bought in many hardware stores. He mixes it with 50% water then adds whatever medication he wants to have better penetration, such as fluconazole (Diflucan). He even suggested that someone might want to try adding it to ciclopirox (Penlac) for infected nails.

"You may actually get something that works," he said.

NAPLES, FLA. — The best place to acquire surgical blades and materials for abrading is not necessarily the medical supply house, said Daniel M. Siegel, M.D.

The hardware store has supplies for medical procedures that are usually much cheaper, and often actually work better.

"During medical school, internship, and residency, I used to think about gadgets I grew up with that could be used in the medical office," explained the dermatologist and son of a hardware store owner.

The old double-edged razor blade is a case in point of the hardware store item being both cheaper and better, Dr. Siegel said. The classic blade is the old Gillette Blue Blade. Those blades are much sharper and much thinner (4/10,000th of an inch) than a scalpel, said Dr. Siegel of State University of New York Downstate Medical Center, New York.

Their thinness makes them easier to handle, and they can be bent and bowed to curettage (but practice on an orange first). Their sharpness allows the user to cut more cleanly with less collateral damage. This has even been touted in the literature, Dr. Siegel said, citing a paper that said one can perform excision biopsies of melanocytic nevi with less scarring. "Only a diamond knife is sharper."

The thicker, carpet-cutting blades sold in the hardware store are ideal for harvesting split thickness skin grafts because of their stiffness. The razor blades sometimes are covered with anticorrosive oil that is bacteriostatic, but the carpet blades need to be cleaned with Betadine and alcohol, he said.

Sandpaper, sanding sponges, and even drywall screens can be handy for—what else?—abrading, Dr. Siegel said. Sandpaper, which he makes wet with Betadine, can be used on warts, small scars, and even onychomycotic nails. The sponges are handy because they can be used and then washed in a dishwasher or washing machine. Drywall screen can be quite rough but it works well for treating larger areas, hypertrophic scars, or actinic keratoses, because it can be rinsed during use.

Dr. Siegel even suggested that sandpaper could be used for cosmetic dermabrasion, perhaps to advantage.

"It clogs quickly, so you have to use a lot of it," he said. "But it is difficult to do any real harm because it is a slow-moving, not very aggressive abrader."

For microdermabrasion, he suggested using Lava soap, which contains pumice from volcanic lava. Lava soap can be used before phototherapy or a peel, to remove some of the stratum corneum.

Dr. Siegel said he has made his own silicone gel sheeting using silicone caulking. He spreads it between two sheets of wax paper or into a plastic bag to flatten it out, and then lets it dry overnight.

As with all the hardware items, the cost of this sheeting is much less than the medical-grade sheeting, Dr. Siegel stressed. In fact, the first time he used the caulking was specifically for a patient who needed an economic alternative.

Among the other items available at the hardware store that Dr. Siegel mentioned using were electrical tape (to put over imiquimod), duct tape (on warts), foam tapes (to protect areas during cryotherapy), headlamps (only about $20), and dimethyl sulfoxide (DMSO).

DMSO can be bought in many hardware stores. He mixes it with 50% water then adds whatever medication he wants to have better penetration, such as fluconazole (Diflucan). He even suggested that someone might want to try adding it to ciclopirox (Penlac) for infected nails.

"You may actually get something that works," he said.

NAPLES, FLA. — The best place to acquire surgical blades and materials for abrading is not necessarily the medical supply house, said Daniel M. Siegel, M.D.

The hardware store has supplies for medical procedures that are usually much cheaper, and often actually work better.

"During medical school, internship, and residency, I used to think about gadgets I grew up with that could be used in the medical office," explained the dermatologist and son of a hardware store owner.

The old double-edged razor blade is a case in point of the hardware store item being both cheaper and better, Dr. Siegel said. The classic blade is the old Gillette Blue Blade. Those blades are much sharper and much thinner (4/10,000th of an inch) than a scalpel, said Dr. Siegel of State University of New York Downstate Medical Center, New York.

Their thinness makes them easier to handle, and they can be bent and bowed to curettage (but practice on an orange first). Their sharpness allows the user to cut more cleanly with less collateral damage. This has even been touted in the literature, Dr. Siegel said, citing a paper that said one can perform excision biopsies of melanocytic nevi with less scarring. "Only a diamond knife is sharper."

The thicker, carpet-cutting blades sold in the hardware store are ideal for harvesting split thickness skin grafts because of their stiffness. The razor blades sometimes are covered with anticorrosive oil that is bacteriostatic, but the carpet blades need to be cleaned with Betadine and alcohol, he said.

Sandpaper, sanding sponges, and even drywall screens can be handy for—what else?—abrading, Dr. Siegel said. Sandpaper, which he makes wet with Betadine, can be used on warts, small scars, and even onychomycotic nails. The sponges are handy because they can be used and then washed in a dishwasher or washing machine. Drywall screen can be quite rough but it works well for treating larger areas, hypertrophic scars, or actinic keratoses, because it can be rinsed during use.

Dr. Siegel even suggested that sandpaper could be used for cosmetic dermabrasion, perhaps to advantage.

"It clogs quickly, so you have to use a lot of it," he said. "But it is difficult to do any real harm because it is a slow-moving, not very aggressive abrader."

For microdermabrasion, he suggested using Lava soap, which contains pumice from volcanic lava. Lava soap can be used before phototherapy or a peel, to remove some of the stratum corneum.

Dr. Siegel said he has made his own silicone gel sheeting using silicone caulking. He spreads it between two sheets of wax paper or into a plastic bag to flatten it out, and then lets it dry overnight.

As with all the hardware items, the cost of this sheeting is much less than the medical-grade sheeting, Dr. Siegel stressed. In fact, the first time he used the caulking was specifically for a patient who needed an economic alternative.

Among the other items available at the hardware store that Dr. Siegel mentioned using were electrical tape (to put over imiquimod), duct tape (on warts), foam tapes (to protect areas during cryotherapy), headlamps (only about $20), and dimethyl sulfoxide (DMSO).

DMSO can be bought in many hardware stores. He mixes it with 50% water then adds whatever medication he wants to have better penetration, such as fluconazole (Diflucan). He even suggested that someone might want to try adding it to ciclopirox (Penlac) for infected nails.

"You may actually get something that works," he said.

CHICAGO — Many individuals diagnosed with irritable bowel syndrome could actually have pelvic floor dysfunction, a condition that can be much more remediable, according to a study conducted at the Mayo Clinic.

Considerable overlap exists in the symptoms of pelvic floor dysfunction and irritable bowel syndrome (IBS), particularly constipation-predominant irritable bowel syndrome, even though the Rome diagnostic criteria for functional bowel disorders considers the two distinctly separate entities, Christopher N. Andrews, M.D., the main investigator of the study, said in a poster presentation at the annual Digestive Disease Week.

The study showed that few patients who present with symptoms of straining, lumpy or hard stools, or a sensation of incomplete evacuation get a pelvic floor work-up as they should, because those with pelvic floor dysfunction probably could be helped by biofeedback training of the pelvic floor muscles, Dr. Andrews said in an interview.

The study included 450 patients being seen at the Mayo Clinic, Rochester, Minn.; 77% of participants were women. The patients either had diagnosed IBS or were undergoing a scintigraphic GI transit study. The patients filled out a symptom questionnaire to help the investigators determine whether they had symptoms the Rome criteria listed in conjunction with pelvic floor dysfunction. Study investigators reviewed the patients' medical records to see if the subjects had been given any anorectal defecation testing.

A total of 194 of the patients had at least two symptoms of pelvic floor dysfunction as outlined by the Rome criteria. But only 50 patients (11%) had undergone pelvic floor dysfunction testing, usually balloon-expulsion manometry. Of those 50 patients, 13 (26%) had an abnormal test result.

Patients with constipation-predominant IBS were more likely to get testing, but they were also more likely to have overlapping symptoms and an abnormal test result.

Of the 78 patients with constipation-predominant IBS, 76 had at least two symptoms of pelvic floor dysfunction. Of those patients, 24 (32%) underwent testing, and among those tested, 8 (33%) had an abnormal test result.

Anorectal defecation testing of patients with IBS-type symptoms is thought to have become more common at highly specialized centers in recent years, Dr. Andrews said in the interview. But if the rate of testing is so low at the Mayo Clinic, then it is probably not done often enough anywhere.

One problem that may discourage testing is that there are different tests but no real standards concerning which to use, he added.

The Rome criteria symptoms used to define pelvic floor dysfunction include: straining when defecating more than 25% of the time, lumpy or hard stools more than 25% of the time, incomplete evacuation more than 25% of the time, sensation of anorectal blocking more than 25% of the time, manual maneuvers to facilitate defecation more than 25% of the time, or one or fewer defecations per week.

CHICAGO — Many individuals diagnosed with irritable bowel syndrome could actually have pelvic floor dysfunction, a condition that can be much more remediable, according to a study conducted at the Mayo Clinic.

Considerable overlap exists in the symptoms of pelvic floor dysfunction and irritable bowel syndrome (IBS), particularly constipation-predominant irritable bowel syndrome, even though the Rome diagnostic criteria for functional bowel disorders considers the two distinctly separate entities, Christopher N. Andrews, M.D., the main investigator of the study, said in a poster presentation at the annual Digestive Disease Week.

The study showed that few patients who present with symptoms of straining, lumpy or hard stools, or a sensation of incomplete evacuation get a pelvic floor work-up as they should, because those with pelvic floor dysfunction probably could be helped by biofeedback training of the pelvic floor muscles, Dr. Andrews said in an interview.

The study included 450 patients being seen at the Mayo Clinic, Rochester, Minn.; 77% of participants were women. The patients either had diagnosed IBS or were undergoing a scintigraphic GI transit study. The patients filled out a symptom questionnaire to help the investigators determine whether they had symptoms the Rome criteria listed in conjunction with pelvic floor dysfunction. Study investigators reviewed the patients' medical records to see if the subjects had been given any anorectal defecation testing.

A total of 194 of the patients had at least two symptoms of pelvic floor dysfunction as outlined by the Rome criteria. But only 50 patients (11%) had undergone pelvic floor dysfunction testing, usually balloon-expulsion manometry. Of those 50 patients, 13 (26%) had an abnormal test result.

Patients with constipation-predominant IBS were more likely to get testing, but they were also more likely to have overlapping symptoms and an abnormal test result.

Of the 78 patients with constipation-predominant IBS, 76 had at least two symptoms of pelvic floor dysfunction. Of those patients, 24 (32%) underwent testing, and among those tested, 8 (33%) had an abnormal test result.

Anorectal defecation testing of patients with IBS-type symptoms is thought to have become more common at highly specialized centers in recent years, Dr. Andrews said in the interview. But if the rate of testing is so low at the Mayo Clinic, then it is probably not done often enough anywhere.

One problem that may discourage testing is that there are different tests but no real standards concerning which to use, he added.

The Rome criteria symptoms used to define pelvic floor dysfunction include: straining when defecating more than 25% of the time, lumpy or hard stools more than 25% of the time, incomplete evacuation more than 25% of the time, sensation of anorectal blocking more than 25% of the time, manual maneuvers to facilitate defecation more than 25% of the time, or one or fewer defecations per week.

CHICAGO — Many individuals diagnosed with irritable bowel syndrome could actually have pelvic floor dysfunction, a condition that can be much more remediable, according to a study conducted at the Mayo Clinic.

Considerable overlap exists in the symptoms of pelvic floor dysfunction and irritable bowel syndrome (IBS), particularly constipation-predominant irritable bowel syndrome, even though the Rome diagnostic criteria for functional bowel disorders considers the two distinctly separate entities, Christopher N. Andrews, M.D., the main investigator of the study, said in a poster presentation at the annual Digestive Disease Week.

The study showed that few patients who present with symptoms of straining, lumpy or hard stools, or a sensation of incomplete evacuation get a pelvic floor work-up as they should, because those with pelvic floor dysfunction probably could be helped by biofeedback training of the pelvic floor muscles, Dr. Andrews said in an interview.

The study included 450 patients being seen at the Mayo Clinic, Rochester, Minn.; 77% of participants were women. The patients either had diagnosed IBS or were undergoing a scintigraphic GI transit study. The patients filled out a symptom questionnaire to help the investigators determine whether they had symptoms the Rome criteria listed in conjunction with pelvic floor dysfunction. Study investigators reviewed the patients' medical records to see if the subjects had been given any anorectal defecation testing.

A total of 194 of the patients had at least two symptoms of pelvic floor dysfunction as outlined by the Rome criteria. But only 50 patients (11%) had undergone pelvic floor dysfunction testing, usually balloon-expulsion manometry. Of those 50 patients, 13 (26%) had an abnormal test result.

Patients with constipation-predominant IBS were more likely to get testing, but they were also more likely to have overlapping symptoms and an abnormal test result.

Of the 78 patients with constipation-predominant IBS, 76 had at least two symptoms of pelvic floor dysfunction. Of those patients, 24 (32%) underwent testing, and among those tested, 8 (33%) had an abnormal test result.

Anorectal defecation testing of patients with IBS-type symptoms is thought to have become more common at highly specialized centers in recent years, Dr. Andrews said in the interview. But if the rate of testing is so low at the Mayo Clinic, then it is probably not done often enough anywhere.

One problem that may discourage testing is that there are different tests but no real standards concerning which to use, he added.

The Rome criteria symptoms used to define pelvic floor dysfunction include: straining when defecating more than 25% of the time, lumpy or hard stools more than 25% of the time, incomplete evacuation more than 25% of the time, sensation of anorectal blocking more than 25% of the time, manual maneuvers to facilitate defecation more than 25% of the time, or one or fewer defecations per week.

INDIAN WELLS, CALIF. — Women who conceive through in vitro fertilization and have a “vanishing twin” are still at risk of having the remaining twin born at a low birth weight for gestational age, Mohamed Mitwally, M.D., said at the annual meeting of the Pacific Coast Reproductive Society.

In a review of 945 live-birth deliveries of infants conceived through in vitro fertilization (IVF), 40 patients experienced spontaneous reduction of fetuses in a multiple gestation and then gave birth to one infant.

Those infants weighed a mean 2,842 g at a mean 271 days' gestation. That compared with a mean birth weight of 3,206 g in 514 women who gave birth to singletons and had not experienced fetal reduction, either spontaneous or selective, and a mean birth weight of 3,166 g in 15 patients who delivered singleton infants after selective fetal reductions.

The finding was somewhat unexpected; the main purpose of the study was to investigate if selective fetal reduction really improved birth weight and risk of preterm delivery, said Dr. Mitwally of the division of reproductive endocrinology and infertility at Wayne State University, Detroit.

The study showed that selective fetal reduction did result in better birth weight and less risk of preterm birth, without increased pregnancy loss, except perhaps when twins were reduced to singletons. The reason the study observed no benefit from selectively reducing twins may have been that there were only a few cases in which twins were reduced, Dr. Mitwally said.

The rest of the literature on fetal reduction, including a recent metaanalysis, “supports the findings of this study,” said Sae Sohn, M.D., a fertility specialist who practices in Greenbrae, Calif., and who commented on the study at the meeting.

INDIAN WELLS, CALIF. — Women who conceive through in vitro fertilization and have a “vanishing twin” are still at risk of having the remaining twin born at a low birth weight for gestational age, Mohamed Mitwally, M.D., said at the annual meeting of the Pacific Coast Reproductive Society.

In a review of 945 live-birth deliveries of infants conceived through in vitro fertilization (IVF), 40 patients experienced spontaneous reduction of fetuses in a multiple gestation and then gave birth to one infant.

Those infants weighed a mean 2,842 g at a mean 271 days' gestation. That compared with a mean birth weight of 3,206 g in 514 women who gave birth to singletons and had not experienced fetal reduction, either spontaneous or selective, and a mean birth weight of 3,166 g in 15 patients who delivered singleton infants after selective fetal reductions.

The finding was somewhat unexpected; the main purpose of the study was to investigate if selective fetal reduction really improved birth weight and risk of preterm delivery, said Dr. Mitwally of the division of reproductive endocrinology and infertility at Wayne State University, Detroit.

The study showed that selective fetal reduction did result in better birth weight and less risk of preterm birth, without increased pregnancy loss, except perhaps when twins were reduced to singletons. The reason the study observed no benefit from selectively reducing twins may have been that there were only a few cases in which twins were reduced, Dr. Mitwally said.

The rest of the literature on fetal reduction, including a recent metaanalysis, “supports the findings of this study,” said Sae Sohn, M.D., a fertility specialist who practices in Greenbrae, Calif., and who commented on the study at the meeting.

INDIAN WELLS, CALIF. — Women who conceive through in vitro fertilization and have a “vanishing twin” are still at risk of having the remaining twin born at a low birth weight for gestational age, Mohamed Mitwally, M.D., said at the annual meeting of the Pacific Coast Reproductive Society.

In a review of 945 live-birth deliveries of infants conceived through in vitro fertilization (IVF), 40 patients experienced spontaneous reduction of fetuses in a multiple gestation and then gave birth to one infant.

Those infants weighed a mean 2,842 g at a mean 271 days' gestation. That compared with a mean birth weight of 3,206 g in 514 women who gave birth to singletons and had not experienced fetal reduction, either spontaneous or selective, and a mean birth weight of 3,166 g in 15 patients who delivered singleton infants after selective fetal reductions.

The finding was somewhat unexpected; the main purpose of the study was to investigate if selective fetal reduction really improved birth weight and risk of preterm delivery, said Dr. Mitwally of the division of reproductive endocrinology and infertility at Wayne State University, Detroit.

The study showed that selective fetal reduction did result in better birth weight and less risk of preterm birth, without increased pregnancy loss, except perhaps when twins were reduced to singletons. The reason the study observed no benefit from selectively reducing twins may have been that there were only a few cases in which twins were reduced, Dr. Mitwally said.

The rest of the literature on fetal reduction, including a recent metaanalysis, “supports the findings of this study,” said Sae Sohn, M.D., a fertility specialist who practices in Greenbrae, Calif., and who commented on the study at the meeting.

CHICAGO — The increasing prevalence of Crohn's disease in Japan correlates closely with decreased consumption of rice, Ryosuke Shoda, M.D., said at the annual Digestive Disease Week.

Crohn's disease was once almost unknown in Japan, Dr. Shoda said in a poster presentation that reviewed the epidemiology of Crohn's disease and trends in the consumption of fiber from rice and other sources in the Japanese diet. In the early 1960s and before, rice was the main source of dietary fiber in Japan, providing the average citizen with about 28 g of fiber per day. Today, the average intake of fiber from rice is 12–15 g/day.

Meanwhile, the prevalence of Crohn's disease went from virtually nothing in the 1960s to 2.9 per 100,000 persons in the mid-1980s and to about 14 per 100,000 today, said Dr. Shoda, chief of the department of general internal medicine at the International Medical Center of Japan, Tokyo.

Data on fiber consumption and Crohn's disease from the Japanese Ministry of Health, Welfare, and Labor from 1966 to 1993 show that the rising prevalence of Crohn's disease closely paralleled the decreasing intake of fiber and rice and the increasing intake of fiber from wheat and grains, Dr. Shoda said.

Of nine sources of fiber studied, rice was the only one that was independently correlated with the prevalence of Crohn's disease. The other sources were wheat and grain, potatoes, fruit, vegetables, beans, seaweed, sweets, and seeds. When changes in the consumption of animal fat were included in the analysis, rice remained the only independent factor.

Breakfast is the meal that has changed the most in Japan and is probably the most responsible for the decline in rice consumption, Dr. Shoda said in an interview.

Many people in Japan now eat bread rather than rice with breakfast.

CHICAGO — The increasing prevalence of Crohn's disease in Japan correlates closely with decreased consumption of rice, Ryosuke Shoda, M.D., said at the annual Digestive Disease Week.

Crohn's disease was once almost unknown in Japan, Dr. Shoda said in a poster presentation that reviewed the epidemiology of Crohn's disease and trends in the consumption of fiber from rice and other sources in the Japanese diet. In the early 1960s and before, rice was the main source of dietary fiber in Japan, providing the average citizen with about 28 g of fiber per day. Today, the average intake of fiber from rice is 12–15 g/day.

Meanwhile, the prevalence of Crohn's disease went from virtually nothing in the 1960s to 2.9 per 100,000 persons in the mid-1980s and to about 14 per 100,000 today, said Dr. Shoda, chief of the department of general internal medicine at the International Medical Center of Japan, Tokyo.

Data on fiber consumption and Crohn's disease from the Japanese Ministry of Health, Welfare, and Labor from 1966 to 1993 show that the rising prevalence of Crohn's disease closely paralleled the decreasing intake of fiber and rice and the increasing intake of fiber from wheat and grains, Dr. Shoda said.

Of nine sources of fiber studied, rice was the only one that was independently correlated with the prevalence of Crohn's disease. The other sources were wheat and grain, potatoes, fruit, vegetables, beans, seaweed, sweets, and seeds. When changes in the consumption of animal fat were included in the analysis, rice remained the only independent factor.

Breakfast is the meal that has changed the most in Japan and is probably the most responsible for the decline in rice consumption, Dr. Shoda said in an interview.

Many people in Japan now eat bread rather than rice with breakfast.

CHICAGO — The increasing prevalence of Crohn's disease in Japan correlates closely with decreased consumption of rice, Ryosuke Shoda, M.D., said at the annual Digestive Disease Week.

Crohn's disease was once almost unknown in Japan, Dr. Shoda said in a poster presentation that reviewed the epidemiology of Crohn's disease and trends in the consumption of fiber from rice and other sources in the Japanese diet. In the early 1960s and before, rice was the main source of dietary fiber in Japan, providing the average citizen with about 28 g of fiber per day. Today, the average intake of fiber from rice is 12–15 g/day.

Meanwhile, the prevalence of Crohn's disease went from virtually nothing in the 1960s to 2.9 per 100,000 persons in the mid-1980s and to about 14 per 100,000 today, said Dr. Shoda, chief of the department of general internal medicine at the International Medical Center of Japan, Tokyo.

Data on fiber consumption and Crohn's disease from the Japanese Ministry of Health, Welfare, and Labor from 1966 to 1993 show that the rising prevalence of Crohn's disease closely paralleled the decreasing intake of fiber and rice and the increasing intake of fiber from wheat and grains, Dr. Shoda said.

Of nine sources of fiber studied, rice was the only one that was independently correlated with the prevalence of Crohn's disease. The other sources were wheat and grain, potatoes, fruit, vegetables, beans, seaweed, sweets, and seeds. When changes in the consumption of animal fat were included in the analysis, rice remained the only independent factor.

Breakfast is the meal that has changed the most in Japan and is probably the most responsible for the decline in rice consumption, Dr. Shoda said in an interview.

Many people in Japan now eat bread rather than rice with breakfast.

SAN FRANCISCO — An antidepressant often is better than a high-fiber bulking agent as first-line treatment for irritable bowel syndrome, at least for the diarrhea-predominant form of the disorder, Philip S. Schoenfeld, M.D., said at the annual meeting of the American College of Physicians.

Results from 14 well-designed clinical trials of the use of bulking agents for irritable bowel syndrome (IBS) “consistently show … that they are no better than placebo,” said Dr. Schoenfeld, chief of the division of gastroenterology at the Ann Arbor (Mich.) Veterans Affairs Medical Center.

Worse, bulking agents usually cause uncomfortable bloating. In one study of psyllium (Metamucil), placebo patients actually did better than treated patients, said Dr. Schoenfeld, who was a member of the American College of Gastroenterology's task force that reviewed treatment evidence in 2002.

The only time to try a bulking agent is with a patient with constipation-predominant IBS who does not normally have bloating discomfort with the constipation, he said.

Tricyclic antidepressants, on the other hand, are good agents for pain control. Several studies have shown that tricyclics reduce abdominal pain. The most recent study—which met the criteria for good study design spelled out by the International Congress of Gastroenterology's Rome guidelines—showed a significant reduction of symptoms, Dr. Schoenfeld said.

The study used low-dose desipramine, which Dr. Schoenfeld said he prefers to use first. He uses it in patients with diarrhea-predominant IBS because tricyclics can cause constipation.

About one-quarter of patients don't tolerate tricyclic therapy; they can be switched to a selective serotonin-reuptake inhibitor (SSRI), with advice to use loperamide as needed.

Of the three well-designed trials that have tested the use of an SSRI, one showed significant symptom improvement, one showed a trend to improvement, and one showed decreased health care utilization.

Although IBS has been called a diagnosis of exclusion, in practice it does not really need to be. That approach leads to a lot of expensive tests—40% of IBS patients, for example, get endoscopy at the time of initial diagnosis, Dr. Schoenfeld said.

In the absence of specific danger signs, such as fecal blood, the incidence of other serious conditions in patients with IBS-like symptoms is generally about the same as in the general population (less than 1%). The exception is celiac sprue, which occurs about 10 times more often in patients with diarrhea-predominant IBS-like symptoms than it does in the general population.

Dr. Schoenfeld said that he prefers to test for serum celiac sprue using the tissue transglutaminase antibody test, because its sensitivity is almost 100%. There are false positives, but a negative test rules out the disorder.

In clinical trials, tegaserod maleate (Zelnorm) was effective in about 40% of patients. Yet about 30% of placebo patients had improvement, as they often do in IBS trials, so the absolute difference was only about 10%.

Tegaserod is worth a try in constipation-predominant, female patients; when it works, symptoms improve rapidly. But Dr. Schoenfeld does not continue a trial for very long because the drug is expensive. “It's not a miracle drug, and if they haven't improved in about a month they are unlikely to improve,” he said.

He usually stops the drug after 8 weeks, as specified on the product label. IBS patients generally have flares and quiescent periods, and studies have shown the average flare lasts 6–8 weeks. Moreover, evidence indicates that response to the drug, when reinitiated, is exactly the same as the initial response.

Dr. Schoenfeld has a consultantship with Novartis Pharmaceuticals Corp., the maker of Zelnorm.

SAN FRANCISCO — An antidepressant often is better than a high-fiber bulking agent as first-line treatment for irritable bowel syndrome, at least for the diarrhea-predominant form of the disorder, Philip S. Schoenfeld, M.D., said at the annual meeting of the American College of Physicians.

Results from 14 well-designed clinical trials of the use of bulking agents for irritable bowel syndrome (IBS) “consistently show … that they are no better than placebo,” said Dr. Schoenfeld, chief of the division of gastroenterology at the Ann Arbor (Mich.) Veterans Affairs Medical Center.

Worse, bulking agents usually cause uncomfortable bloating. In one study of psyllium (Metamucil), placebo patients actually did better than treated patients, said Dr. Schoenfeld, who was a member of the American College of Gastroenterology's task force that reviewed treatment evidence in 2002.

The only time to try a bulking agent is with a patient with constipation-predominant IBS who does not normally have bloating discomfort with the constipation, he said.

Tricyclic antidepressants, on the other hand, are good agents for pain control. Several studies have shown that tricyclics reduce abdominal pain. The most recent study—which met the criteria for good study design spelled out by the International Congress of Gastroenterology's Rome guidelines—showed a significant reduction of symptoms, Dr. Schoenfeld said.

The study used low-dose desipramine, which Dr. Schoenfeld said he prefers to use first. He uses it in patients with diarrhea-predominant IBS because tricyclics can cause constipation.

About one-quarter of patients don't tolerate tricyclic therapy; they can be switched to a selective serotonin-reuptake inhibitor (SSRI), with advice to use loperamide as needed.

Of the three well-designed trials that have tested the use of an SSRI, one showed significant symptom improvement, one showed a trend to improvement, and one showed decreased health care utilization.

Although IBS has been called a diagnosis of exclusion, in practice it does not really need to be. That approach leads to a lot of expensive tests—40% of IBS patients, for example, get endoscopy at the time of initial diagnosis, Dr. Schoenfeld said.

In the absence of specific danger signs, such as fecal blood, the incidence of other serious conditions in patients with IBS-like symptoms is generally about the same as in the general population (less than 1%). The exception is celiac sprue, which occurs about 10 times more often in patients with diarrhea-predominant IBS-like symptoms than it does in the general population.

Dr. Schoenfeld said that he prefers to test for serum celiac sprue using the tissue transglutaminase antibody test, because its sensitivity is almost 100%. There are false positives, but a negative test rules out the disorder.

In clinical trials, tegaserod maleate (Zelnorm) was effective in about 40% of patients. Yet about 30% of placebo patients had improvement, as they often do in IBS trials, so the absolute difference was only about 10%.

Tegaserod is worth a try in constipation-predominant, female patients; when it works, symptoms improve rapidly. But Dr. Schoenfeld does not continue a trial for very long because the drug is expensive. “It's not a miracle drug, and if they haven't improved in about a month they are unlikely to improve,” he said.

He usually stops the drug after 8 weeks, as specified on the product label. IBS patients generally have flares and quiescent periods, and studies have shown the average flare lasts 6–8 weeks. Moreover, evidence indicates that response to the drug, when reinitiated, is exactly the same as the initial response.

Dr. Schoenfeld has a consultantship with Novartis Pharmaceuticals Corp., the maker of Zelnorm.

SAN FRANCISCO — An antidepressant often is better than a high-fiber bulking agent as first-line treatment for irritable bowel syndrome, at least for the diarrhea-predominant form of the disorder, Philip S. Schoenfeld, M.D., said at the annual meeting of the American College of Physicians.

Results from 14 well-designed clinical trials of the use of bulking agents for irritable bowel syndrome (IBS) “consistently show … that they are no better than placebo,” said Dr. Schoenfeld, chief of the division of gastroenterology at the Ann Arbor (Mich.) Veterans Affairs Medical Center.

Worse, bulking agents usually cause uncomfortable bloating. In one study of psyllium (Metamucil), placebo patients actually did better than treated patients, said Dr. Schoenfeld, who was a member of the American College of Gastroenterology's task force that reviewed treatment evidence in 2002.

The only time to try a bulking agent is with a patient with constipation-predominant IBS who does not normally have bloating discomfort with the constipation, he said.

Tricyclic antidepressants, on the other hand, are good agents for pain control. Several studies have shown that tricyclics reduce abdominal pain. The most recent study—which met the criteria for good study design spelled out by the International Congress of Gastroenterology's Rome guidelines—showed a significant reduction of symptoms, Dr. Schoenfeld said.

The study used low-dose desipramine, which Dr. Schoenfeld said he prefers to use first. He uses it in patients with diarrhea-predominant IBS because tricyclics can cause constipation.

About one-quarter of patients don't tolerate tricyclic therapy; they can be switched to a selective serotonin-reuptake inhibitor (SSRI), with advice to use loperamide as needed.

Of the three well-designed trials that have tested the use of an SSRI, one showed significant symptom improvement, one showed a trend to improvement, and one showed decreased health care utilization.

Although IBS has been called a diagnosis of exclusion, in practice it does not really need to be. That approach leads to a lot of expensive tests—40% of IBS patients, for example, get endoscopy at the time of initial diagnosis, Dr. Schoenfeld said.

In the absence of specific danger signs, such as fecal blood, the incidence of other serious conditions in patients with IBS-like symptoms is generally about the same as in the general population (less than 1%). The exception is celiac sprue, which occurs about 10 times more often in patients with diarrhea-predominant IBS-like symptoms than it does in the general population.

Dr. Schoenfeld said that he prefers to test for serum celiac sprue using the tissue transglutaminase antibody test, because its sensitivity is almost 100%. There are false positives, but a negative test rules out the disorder.

In clinical trials, tegaserod maleate (Zelnorm) was effective in about 40% of patients. Yet about 30% of placebo patients had improvement, as they often do in IBS trials, so the absolute difference was only about 10%.

Tegaserod is worth a try in constipation-predominant, female patients; when it works, symptoms improve rapidly. But Dr. Schoenfeld does not continue a trial for very long because the drug is expensive. “It's not a miracle drug, and if they haven't improved in about a month they are unlikely to improve,” he said.

He usually stops the drug after 8 weeks, as specified on the product label. IBS patients generally have flares and quiescent periods, and studies have shown the average flare lasts 6–8 weeks. Moreover, evidence indicates that response to the drug, when reinitiated, is exactly the same as the initial response.

Dr. Schoenfeld has a consultantship with Novartis Pharmaceuticals Corp., the maker of Zelnorm.