Timothy F. Kirn

INCLINE VILLAGE, NEV. — Cognitive errors often contribute to failure to properly diagnose appendicitis, John Rose, M.D., said at an annual emergency medicine meeting sponsored by the University of California, Davis.

Diagnostic algorithms tend not to be very helpful for appendicitis because the clinical signs and tests are so variable. By keeping in mind common cognitive errors, unusual presentations, and the predictive value of tests, a physician may recognize an atypical case of appendicitis that would otherwise be missed, he said.

Cognitive errors—in which the physician's train of thought is dictated by an initial impression or a positive finding—include the framing effect, the freezing effect, and the availability error, said Dr. Rose of the department of emergency medicine at the university.

The framing effect involves getting an initial impression and letting it guide subsequent thought processes rather than keeping an open mind—something that detectives are trained not to do. “Half the time when you do this, you are right, and then you get a little overconfident because you are right, and then you get burned,” he said.

The freezing effect occurs when a physician latches onto a positive finding and loses sight of the bigger picture. This occurred in the case of a 29-year-old woman who came in with right lower quadrant pain and a temperature. She had a normal pelvic exam, but an ultrasound showed an ovarian cyst. She was sent home with a diagnosis of an ovarian cyst, and later came back with a ruptured appendix. Just because a diagnostic test is positive doesn't mean it has pinpointed the cause of the patient's complaint, he cautioned.

The availability error means judging a case too quickly based on how readily a diagnosis comes to mind. Dr. Rose offered the example of a 55-year-old woman who came in with gastric pain and vomiting. Her belly exam was normal, and family members had just had stomach flu. She was diagnosed with viral gastroenteritis, despite not having any diarrhea. Hers turned out to be an atypical presentation of a myocardial infarction.

Another reason physicians may misdiagnose appendicitis is failure to appreciate unusual presentations. The classic findings of right lower quadrant pain, abdominal rigidity, and migration of pain from the periumbilical region to the right lower quadrant occur in only about 50% of patients with appendicitis. Lower left quadrant pain is present in 7% of cases, suprapubic pain in 10%, and diarrhea in 9%. Anorexia is seen in less than half of patients, according to some series. About 25% of patients have no fever. Overall in appendicitis, the diagnostic accuracy of physicians by history and physical exam is 80%.

“Remember to think: 'Maybe that suprapubic pain isn't a UTI. Maybe it's an appendix,'” Dr. Rose advised. “Remember to think outside the box.”

Another factor that contributes to missed diagnosis of appendicitis is relying too much on tests with little predictive value, notably the WBC count.

The “likelihood ratio,” which represents a combination of sensitivity and specificity, is thought to be a more intuitive way of expressing a test's predictive value. It indicates the likelihood that a given result would be expected in a patient with the disorder, compared with the likelihood the result would be expected in a patient without the disorder. Likelihood ratios of 1 or 2 mean a test is not very good.

In appendicitis, the white cell count has a likelihood ratio of 1–2 because only 80% of appendicitis patients have an elevated white cell count—as do 70% of patients with other reasons for their abdominal pain, Dr. Rose said.

Plain x-ray and ultrasound studies also have low likelihood ratios, but CT has a high ratio. Focused helical CT with contrast has a positive likelihood ratio of 49, but even without contrast, it has a high ratio of 29, he said.

INCLINE VILLAGE, NEV. — Cognitive errors often contribute to failure to properly diagnose appendicitis, John Rose, M.D., said at an annual emergency medicine meeting sponsored by the University of California, Davis.

Diagnostic algorithms tend not to be very helpful for appendicitis because the clinical signs and tests are so variable. By keeping in mind common cognitive errors, unusual presentations, and the predictive value of tests, a physician may recognize an atypical case of appendicitis that would otherwise be missed, he said.

Cognitive errors—in which the physician's train of thought is dictated by an initial impression or a positive finding—include the framing effect, the freezing effect, and the availability error, said Dr. Rose of the department of emergency medicine at the university.

The framing effect involves getting an initial impression and letting it guide subsequent thought processes rather than keeping an open mind—something that detectives are trained not to do. “Half the time when you do this, you are right, and then you get a little overconfident because you are right, and then you get burned,” he said.

The freezing effect occurs when a physician latches onto a positive finding and loses sight of the bigger picture. This occurred in the case of a 29-year-old woman who came in with right lower quadrant pain and a temperature. She had a normal pelvic exam, but an ultrasound showed an ovarian cyst. She was sent home with a diagnosis of an ovarian cyst, and later came back with a ruptured appendix. Just because a diagnostic test is positive doesn't mean it has pinpointed the cause of the patient's complaint, he cautioned.

The availability error means judging a case too quickly based on how readily a diagnosis comes to mind. Dr. Rose offered the example of a 55-year-old woman who came in with gastric pain and vomiting. Her belly exam was normal, and family members had just had stomach flu. She was diagnosed with viral gastroenteritis, despite not having any diarrhea. Hers turned out to be an atypical presentation of a myocardial infarction.

Another reason physicians may misdiagnose appendicitis is failure to appreciate unusual presentations. The classic findings of right lower quadrant pain, abdominal rigidity, and migration of pain from the periumbilical region to the right lower quadrant occur in only about 50% of patients with appendicitis. Lower left quadrant pain is present in 7% of cases, suprapubic pain in 10%, and diarrhea in 9%. Anorexia is seen in less than half of patients, according to some series. About 25% of patients have no fever. Overall in appendicitis, the diagnostic accuracy of physicians by history and physical exam is 80%.

“Remember to think: 'Maybe that suprapubic pain isn't a UTI. Maybe it's an appendix,'” Dr. Rose advised. “Remember to think outside the box.”

Another factor that contributes to missed diagnosis of appendicitis is relying too much on tests with little predictive value, notably the WBC count.

The “likelihood ratio,” which represents a combination of sensitivity and specificity, is thought to be a more intuitive way of expressing a test's predictive value. It indicates the likelihood that a given result would be expected in a patient with the disorder, compared with the likelihood the result would be expected in a patient without the disorder. Likelihood ratios of 1 or 2 mean a test is not very good.

In appendicitis, the white cell count has a likelihood ratio of 1–2 because only 80% of appendicitis patients have an elevated white cell count—as do 70% of patients with other reasons for their abdominal pain, Dr. Rose said.

Plain x-ray and ultrasound studies also have low likelihood ratios, but CT has a high ratio. Focused helical CT with contrast has a positive likelihood ratio of 49, but even without contrast, it has a high ratio of 29, he said.

INCLINE VILLAGE, NEV. — Cognitive errors often contribute to failure to properly diagnose appendicitis, John Rose, M.D., said at an annual emergency medicine meeting sponsored by the University of California, Davis.

Diagnostic algorithms tend not to be very helpful for appendicitis because the clinical signs and tests are so variable. By keeping in mind common cognitive errors, unusual presentations, and the predictive value of tests, a physician may recognize an atypical case of appendicitis that would otherwise be missed, he said.

Cognitive errors—in which the physician's train of thought is dictated by an initial impression or a positive finding—include the framing effect, the freezing effect, and the availability error, said Dr. Rose of the department of emergency medicine at the university.

The framing effect involves getting an initial impression and letting it guide subsequent thought processes rather than keeping an open mind—something that detectives are trained not to do. “Half the time when you do this, you are right, and then you get a little overconfident because you are right, and then you get burned,” he said.

The freezing effect occurs when a physician latches onto a positive finding and loses sight of the bigger picture. This occurred in the case of a 29-year-old woman who came in with right lower quadrant pain and a temperature. She had a normal pelvic exam, but an ultrasound showed an ovarian cyst. She was sent home with a diagnosis of an ovarian cyst, and later came back with a ruptured appendix. Just because a diagnostic test is positive doesn't mean it has pinpointed the cause of the patient's complaint, he cautioned.

The availability error means judging a case too quickly based on how readily a diagnosis comes to mind. Dr. Rose offered the example of a 55-year-old woman who came in with gastric pain and vomiting. Her belly exam was normal, and family members had just had stomach flu. She was diagnosed with viral gastroenteritis, despite not having any diarrhea. Hers turned out to be an atypical presentation of a myocardial infarction.

Another reason physicians may misdiagnose appendicitis is failure to appreciate unusual presentations. The classic findings of right lower quadrant pain, abdominal rigidity, and migration of pain from the periumbilical region to the right lower quadrant occur in only about 50% of patients with appendicitis. Lower left quadrant pain is present in 7% of cases, suprapubic pain in 10%, and diarrhea in 9%. Anorexia is seen in less than half of patients, according to some series. About 25% of patients have no fever. Overall in appendicitis, the diagnostic accuracy of physicians by history and physical exam is 80%.

“Remember to think: 'Maybe that suprapubic pain isn't a UTI. Maybe it's an appendix,'” Dr. Rose advised. “Remember to think outside the box.”

Another factor that contributes to missed diagnosis of appendicitis is relying too much on tests with little predictive value, notably the WBC count.

The “likelihood ratio,” which represents a combination of sensitivity and specificity, is thought to be a more intuitive way of expressing a test's predictive value. It indicates the likelihood that a given result would be expected in a patient with the disorder, compared with the likelihood the result would be expected in a patient without the disorder. Likelihood ratios of 1 or 2 mean a test is not very good.

In appendicitis, the white cell count has a likelihood ratio of 1–2 because only 80% of appendicitis patients have an elevated white cell count—as do 70% of patients with other reasons for their abdominal pain, Dr. Rose said.

Plain x-ray and ultrasound studies also have low likelihood ratios, but CT has a high ratio. Focused helical CT with contrast has a positive likelihood ratio of 49, but even without contrast, it has a high ratio of 29, he said.

CHICAGO — Two new studies cast doubt on the utility of one of the hottest new treatments for gastroesophageal reflux disease: the endoluminal gastric plication procedure known as EndoCinch.

Both studies were sham-surgery studies presented at the annual Digestive Disease Week.

Until now, there have mostly been highly positive reports from uncontrolled case series on the procedure, approved in 2000. One positive, small clinical trial was reported at Digestive Disease Week last year.

“It's quite amazing that thousands of these procedures have already been done,” said one of the study investigators, Matthijs Schwartz, M.D., at a press briefing.

“Probably, we should stop doing this procedure and wait for it to be improved,” Dr. Schwartz added.

The main investigator for the other study, Per-Ola Park, M.D., was similarly blunt. “Our conclusion from our study is that the EndoCinch procedure should not be used,” he said.

In Dr. Park's study, 47 patients with symptomatic gastroesophageal reflux for at least 1 year were randomized to receive either the EndoCinch procedure or a sham endoscopy. The patients were followed for 1 year.

All but 3 of the 22 patients who had the EndoCinch procedure experienced disease relapse, and almost all of those had relapse within 1 month of the procedure. In fact, there was no significant difference in time to relapse between the two groups, with about 80% of the patients in both groups experiencing relapse within a month.

The remainder of the sham-endoscopy patients had relapse after 1 month, said Dr. Park of Sahlgrenska University Hospital, Gothenburg, Sweden.

Relapse was defined as the need for proton pump inhibitor relief for heartburn, more than 1 day of severe heartburn, 2 consecutive days of moderate heartburn symptoms, or 3 days of mild symptoms.

At 12 months, there was no difference in ambulatory 24-hour pH monitoring, drug use, or health-related quality of life.

Dr. Schwartz's study found that patients who received the real procedure had a reduced need to use a proton pump inhibitor for the first 3 months after the procedure, relative to the sham-treated patients.

But there was no improvement in regurgitation frequency or severity or in esophageal acid exposure, relative to the sham group.

The study included 15 patients who underwent the procedure, 17 patients who had a sham endoscopy, and 13 patients who served as a second control group. It is well known that sham-treated patients in such studies often do quite well, noted Dr. Schwartz, director of endoscopy at the University Medical Center, Utrecht, the Netherlands.

Even though his study found a reduction in proton pump inhibitor use—the study's main outcome—Dr. Schwartz said he was skeptical of that result because it was only for 3 months. “I've seen many of these patients after 3 months, and many do relapse,” he said.

Although both investigators urged caution about continued clinical use of the procedure, both also said they were fairly sure that the procedure could be improved.

Dr. Schwartz noted that in his study, the investigators used three plications to create pleats in the gastric cardia, as has become common clinical practice. But previous studies have used four or five, and in his practice, he has gone back to add plications in patients who have not had a good initial result.

Dr. Park said he would still like to see the EndoCinch procedure be made to work because it is reversible, unlike some of the other gastroesophageal reflux procedures, such as the Stretta procedure, which uses microwaves to create scar tissue.

“Perhaps if we come back with more sutures, it will work,” he said during the briefing.

Dr. Park's study was sponsored by C.R. Bard Inc., maker of the EndoCinch kit.

EMILY BRANNAN, ILLUSTRATION

CHICAGO — Two new studies cast doubt on the utility of one of the hottest new treatments for gastroesophageal reflux disease: the endoluminal gastric plication procedure known as EndoCinch.

Both studies were sham-surgery studies presented at the annual Digestive Disease Week.

Until now, there have mostly been highly positive reports from uncontrolled case series on the procedure, approved in 2000. One positive, small clinical trial was reported at Digestive Disease Week last year.

“It's quite amazing that thousands of these procedures have already been done,” said one of the study investigators, Matthijs Schwartz, M.D., at a press briefing.

“Probably, we should stop doing this procedure and wait for it to be improved,” Dr. Schwartz added.

The main investigator for the other study, Per-Ola Park, M.D., was similarly blunt. “Our conclusion from our study is that the EndoCinch procedure should not be used,” he said.

In Dr. Park's study, 47 patients with symptomatic gastroesophageal reflux for at least 1 year were randomized to receive either the EndoCinch procedure or a sham endoscopy. The patients were followed for 1 year.

All but 3 of the 22 patients who had the EndoCinch procedure experienced disease relapse, and almost all of those had relapse within 1 month of the procedure. In fact, there was no significant difference in time to relapse between the two groups, with about 80% of the patients in both groups experiencing relapse within a month.

The remainder of the sham-endoscopy patients had relapse after 1 month, said Dr. Park of Sahlgrenska University Hospital, Gothenburg, Sweden.

Relapse was defined as the need for proton pump inhibitor relief for heartburn, more than 1 day of severe heartburn, 2 consecutive days of moderate heartburn symptoms, or 3 days of mild symptoms.

At 12 months, there was no difference in ambulatory 24-hour pH monitoring, drug use, or health-related quality of life.

Dr. Schwartz's study found that patients who received the real procedure had a reduced need to use a proton pump inhibitor for the first 3 months after the procedure, relative to the sham-treated patients.

But there was no improvement in regurgitation frequency or severity or in esophageal acid exposure, relative to the sham group.

The study included 15 patients who underwent the procedure, 17 patients who had a sham endoscopy, and 13 patients who served as a second control group. It is well known that sham-treated patients in such studies often do quite well, noted Dr. Schwartz, director of endoscopy at the University Medical Center, Utrecht, the Netherlands.

Even though his study found a reduction in proton pump inhibitor use—the study's main outcome—Dr. Schwartz said he was skeptical of that result because it was only for 3 months. “I've seen many of these patients after 3 months, and many do relapse,” he said.

Although both investigators urged caution about continued clinical use of the procedure, both also said they were fairly sure that the procedure could be improved.

Dr. Schwartz noted that in his study, the investigators used three plications to create pleats in the gastric cardia, as has become common clinical practice. But previous studies have used four or five, and in his practice, he has gone back to add plications in patients who have not had a good initial result.

Dr. Park said he would still like to see the EndoCinch procedure be made to work because it is reversible, unlike some of the other gastroesophageal reflux procedures, such as the Stretta procedure, which uses microwaves to create scar tissue.

“Perhaps if we come back with more sutures, it will work,” he said during the briefing.

Dr. Park's study was sponsored by C.R. Bard Inc., maker of the EndoCinch kit.

EMILY BRANNAN, ILLUSTRATION

CHICAGO — Two new studies cast doubt on the utility of one of the hottest new treatments for gastroesophageal reflux disease: the endoluminal gastric plication procedure known as EndoCinch.

Both studies were sham-surgery studies presented at the annual Digestive Disease Week.

Until now, there have mostly been highly positive reports from uncontrolled case series on the procedure, approved in 2000. One positive, small clinical trial was reported at Digestive Disease Week last year.

“It's quite amazing that thousands of these procedures have already been done,” said one of the study investigators, Matthijs Schwartz, M.D., at a press briefing.

“Probably, we should stop doing this procedure and wait for it to be improved,” Dr. Schwartz added.

The main investigator for the other study, Per-Ola Park, M.D., was similarly blunt. “Our conclusion from our study is that the EndoCinch procedure should not be used,” he said.

In Dr. Park's study, 47 patients with symptomatic gastroesophageal reflux for at least 1 year were randomized to receive either the EndoCinch procedure or a sham endoscopy. The patients were followed for 1 year.

All but 3 of the 22 patients who had the EndoCinch procedure experienced disease relapse, and almost all of those had relapse within 1 month of the procedure. In fact, there was no significant difference in time to relapse between the two groups, with about 80% of the patients in both groups experiencing relapse within a month.

The remainder of the sham-endoscopy patients had relapse after 1 month, said Dr. Park of Sahlgrenska University Hospital, Gothenburg, Sweden.

Relapse was defined as the need for proton pump inhibitor relief for heartburn, more than 1 day of severe heartburn, 2 consecutive days of moderate heartburn symptoms, or 3 days of mild symptoms.

At 12 months, there was no difference in ambulatory 24-hour pH monitoring, drug use, or health-related quality of life.

Dr. Schwartz's study found that patients who received the real procedure had a reduced need to use a proton pump inhibitor for the first 3 months after the procedure, relative to the sham-treated patients.

But there was no improvement in regurgitation frequency or severity or in esophageal acid exposure, relative to the sham group.

The study included 15 patients who underwent the procedure, 17 patients who had a sham endoscopy, and 13 patients who served as a second control group. It is well known that sham-treated patients in such studies often do quite well, noted Dr. Schwartz, director of endoscopy at the University Medical Center, Utrecht, the Netherlands.

Even though his study found a reduction in proton pump inhibitor use—the study's main outcome—Dr. Schwartz said he was skeptical of that result because it was only for 3 months. “I've seen many of these patients after 3 months, and many do relapse,” he said.

Although both investigators urged caution about continued clinical use of the procedure, both also said they were fairly sure that the procedure could be improved.

Dr. Schwartz noted that in his study, the investigators used three plications to create pleats in the gastric cardia, as has become common clinical practice. But previous studies have used four or five, and in his practice, he has gone back to add plications in patients who have not had a good initial result.

Dr. Park said he would still like to see the EndoCinch procedure be made to work because it is reversible, unlike some of the other gastroesophageal reflux procedures, such as the Stretta procedure, which uses microwaves to create scar tissue.

“Perhaps if we come back with more sutures, it will work,” he said during the briefing.

Dr. Park's study was sponsored by C.R. Bard Inc., maker of the EndoCinch kit.

EMILY BRANNAN, ILLUSTRATION

CHICAGO — The polymer injection treatment for gastroesophageal reflux disease, known as Enteryx, outperformed sham surgery and lasted up to 3 years, investigators said in presenting two separate studies at the annual Digestive Disease Week.

Enteryx, a liquid that solidifies into a spongy implant, is injected into the deep muscle layer at or below the esophagogastric junction to increase the competence of the lower esophageal sphincter.

In one of the two studies, investigators led by Jacques Deviere, M.D., compared Enteryx treatment with sham surgery; all patients were dependent on proton-pump inhibitor (PPI) therapy prior to the start of the study.

At 3 months, 68% of 32 patients given the polymer injection treatment were completely off PPI drugs, and another 13% had reduced their use by at least 50%.

In contrast, in the sham surgery group of 32 patients, 41% discontinued PPI use and another 12% reduced PPI use by at least 50%, said Dr. Deviere, chief of the department of gastroenterology at Erasme Hospital of the Free University of Brussels.

In the second uncontrolled study, which involved a 3-year follow-up of 60 patients, the percentage of patients who benefited peaked at 1 year, when 71% were completely off PPI therapy, and another 13% had reduced their PPI use by 50%.

At 3 years, 48% were off PPIs, and another 17% had reduced PPI use by 50%, said Glen A. Lehman, M.D., professor of medicine at Indiana University, Indianapolis.

These two studies are major steps forward toward the adoption of Enteryx treatment—approved by the Food and Drug Administration in 2003—into routine practice, commented Gary W. Falk, M.D., a professor of medicine at the Cleveland Clinic Foundation.

But the specific indications for this treatment are still not clear, because the patients in the trials conducted to date have not been defined except that they have been chronic, PPI-dependent patients.

Moreover, caution needs to be exercised in evaluating the treatment because the material that is implanted appears to be permanent, and head-to-head trials with other therapies still need to be performed, Dr. Falk added.

At least 3,000 patients have received Enteryx treatment so far, according to available estimates.

But it is also not exactly clear how the treatment works, Dr. Falk noted.

In all the trials reported so far, including the two new trials, the treatment has not appreciably changed the esophageal pH of most patients it has helped, he added.

It may be that the pH is not changed, but the treatment is reducing the amount of acid escaping from the stomach into the esophagus, Dr. Falk suggested.

Regarding the fall-off in efficacy over time seen in the 3-year follow-up, Dr. Lehman said he could not predict whether that trend would continue.

The study measured esophageal pH at 12 months, but there were no pH measurements taken after that. Moreover, none of the patients were examined endoscopically at 3 years to see if the implant was still present and how it was faring.

Dr. Lehman suggested that the fall-off could be due to patients' becoming unwilling to tolerate discomfort that they initially considered an improvement.

In his study, quality-of-life heartburn scores improved by a median of 76% relative to scores at baseline during a washout period when patients were withdrawn from PPI treatment.

That percentage improvement continued throughout the 3 years, Dr. Lehman noted.

The majority of patients treated with Enteryx experience a transient retrosternal, burning chest pain, and/or dysphagia at first, the investigators noted. However, there were no serious, device-related adverse events in Dr. Lehman's follow-up trial.

In the controlled trial, one patient treated with Enteryx needed an esophageal dilatation procedure because of continuing dysphagia.

The two trials were sponsored by Boston Scientific Corp., Natick, Mass., maker of the Enteryx procedure kit.

CHICAGO — The polymer injection treatment for gastroesophageal reflux disease, known as Enteryx, outperformed sham surgery and lasted up to 3 years, investigators said in presenting two separate studies at the annual Digestive Disease Week.

Enteryx, a liquid that solidifies into a spongy implant, is injected into the deep muscle layer at or below the esophagogastric junction to increase the competence of the lower esophageal sphincter.

In one of the two studies, investigators led by Jacques Deviere, M.D., compared Enteryx treatment with sham surgery; all patients were dependent on proton-pump inhibitor (PPI) therapy prior to the start of the study.

At 3 months, 68% of 32 patients given the polymer injection treatment were completely off PPI drugs, and another 13% had reduced their use by at least 50%.

In contrast, in the sham surgery group of 32 patients, 41% discontinued PPI use and another 12% reduced PPI use by at least 50%, said Dr. Deviere, chief of the department of gastroenterology at Erasme Hospital of the Free University of Brussels.

In the second uncontrolled study, which involved a 3-year follow-up of 60 patients, the percentage of patients who benefited peaked at 1 year, when 71% were completely off PPI therapy, and another 13% had reduced their PPI use by 50%.

At 3 years, 48% were off PPIs, and another 17% had reduced PPI use by 50%, said Glen A. Lehman, M.D., professor of medicine at Indiana University, Indianapolis.

These two studies are major steps forward toward the adoption of Enteryx treatment—approved by the Food and Drug Administration in 2003—into routine practice, commented Gary W. Falk, M.D., a professor of medicine at the Cleveland Clinic Foundation.

But the specific indications for this treatment are still not clear, because the patients in the trials conducted to date have not been defined except that they have been chronic, PPI-dependent patients.

Moreover, caution needs to be exercised in evaluating the treatment because the material that is implanted appears to be permanent, and head-to-head trials with other therapies still need to be performed, Dr. Falk added.

At least 3,000 patients have received Enteryx treatment so far, according to available estimates.

But it is also not exactly clear how the treatment works, Dr. Falk noted.

In all the trials reported so far, including the two new trials, the treatment has not appreciably changed the esophageal pH of most patients it has helped, he added.

It may be that the pH is not changed, but the treatment is reducing the amount of acid escaping from the stomach into the esophagus, Dr. Falk suggested.

Regarding the fall-off in efficacy over time seen in the 3-year follow-up, Dr. Lehman said he could not predict whether that trend would continue.

The study measured esophageal pH at 12 months, but there were no pH measurements taken after that. Moreover, none of the patients were examined endoscopically at 3 years to see if the implant was still present and how it was faring.

Dr. Lehman suggested that the fall-off could be due to patients' becoming unwilling to tolerate discomfort that they initially considered an improvement.

In his study, quality-of-life heartburn scores improved by a median of 76% relative to scores at baseline during a washout period when patients were withdrawn from PPI treatment.

That percentage improvement continued throughout the 3 years, Dr. Lehman noted.

The majority of patients treated with Enteryx experience a transient retrosternal, burning chest pain, and/or dysphagia at first, the investigators noted. However, there were no serious, device-related adverse events in Dr. Lehman's follow-up trial.

In the controlled trial, one patient treated with Enteryx needed an esophageal dilatation procedure because of continuing dysphagia.

The two trials were sponsored by Boston Scientific Corp., Natick, Mass., maker of the Enteryx procedure kit.

CHICAGO — The polymer injection treatment for gastroesophageal reflux disease, known as Enteryx, outperformed sham surgery and lasted up to 3 years, investigators said in presenting two separate studies at the annual Digestive Disease Week.

Enteryx, a liquid that solidifies into a spongy implant, is injected into the deep muscle layer at or below the esophagogastric junction to increase the competence of the lower esophageal sphincter.

In one of the two studies, investigators led by Jacques Deviere, M.D., compared Enteryx treatment with sham surgery; all patients were dependent on proton-pump inhibitor (PPI) therapy prior to the start of the study.

At 3 months, 68% of 32 patients given the polymer injection treatment were completely off PPI drugs, and another 13% had reduced their use by at least 50%.

In contrast, in the sham surgery group of 32 patients, 41% discontinued PPI use and another 12% reduced PPI use by at least 50%, said Dr. Deviere, chief of the department of gastroenterology at Erasme Hospital of the Free University of Brussels.

In the second uncontrolled study, which involved a 3-year follow-up of 60 patients, the percentage of patients who benefited peaked at 1 year, when 71% were completely off PPI therapy, and another 13% had reduced their PPI use by 50%.

At 3 years, 48% were off PPIs, and another 17% had reduced PPI use by 50%, said Glen A. Lehman, M.D., professor of medicine at Indiana University, Indianapolis.

These two studies are major steps forward toward the adoption of Enteryx treatment—approved by the Food and Drug Administration in 2003—into routine practice, commented Gary W. Falk, M.D., a professor of medicine at the Cleveland Clinic Foundation.

But the specific indications for this treatment are still not clear, because the patients in the trials conducted to date have not been defined except that they have been chronic, PPI-dependent patients.

Moreover, caution needs to be exercised in evaluating the treatment because the material that is implanted appears to be permanent, and head-to-head trials with other therapies still need to be performed, Dr. Falk added.

At least 3,000 patients have received Enteryx treatment so far, according to available estimates.

But it is also not exactly clear how the treatment works, Dr. Falk noted.

In all the trials reported so far, including the two new trials, the treatment has not appreciably changed the esophageal pH of most patients it has helped, he added.

It may be that the pH is not changed, but the treatment is reducing the amount of acid escaping from the stomach into the esophagus, Dr. Falk suggested.

Regarding the fall-off in efficacy over time seen in the 3-year follow-up, Dr. Lehman said he could not predict whether that trend would continue.

The study measured esophageal pH at 12 months, but there were no pH measurements taken after that. Moreover, none of the patients were examined endoscopically at 3 years to see if the implant was still present and how it was faring.

Dr. Lehman suggested that the fall-off could be due to patients' becoming unwilling to tolerate discomfort that they initially considered an improvement.

In his study, quality-of-life heartburn scores improved by a median of 76% relative to scores at baseline during a washout period when patients were withdrawn from PPI treatment.

That percentage improvement continued throughout the 3 years, Dr. Lehman noted.

The majority of patients treated with Enteryx experience a transient retrosternal, burning chest pain, and/or dysphagia at first, the investigators noted. However, there were no serious, device-related adverse events in Dr. Lehman's follow-up trial.

In the controlled trial, one patient treated with Enteryx needed an esophageal dilatation procedure because of continuing dysphagia.

The two trials were sponsored by Boston Scientific Corp., Natick, Mass., maker of the Enteryx procedure kit.

CHICAGO — The polymer injection treatment for gastroesophageal reflux disease, known as Enteryx, outperformed sham surgery and lasted up to 3 years, investigators said in presenting two studies at the annual Digestive Disease Week.

Enteryx, a liquid that solidifies into a spongy implant, is injected into the deep muscle layer at or below the esophagogastric junction to increase the competence of the lower esophageal sphincter.

In one of the two studies, investigators led by Jacques Deviere, M.D., compared Enteryx treatment with sham surgery; all patients were dependent on proton-pump inhibitor (PPI) therapy prior to the start of the study. At 3 months, 68% of 32 patients given the polymer injection treatment were completely off PPI drugs, and another 13% had reduced their use by at least 50%.

In contrast, in the sham surgery group of 32 patients, 41% discontinued PPI use and another 12% reduced PPI use by at least 50%, said Dr. Deviere, chief of the department of gastroenterology at Erasme Hospital of the Free University of Brussels.

In the second uncontrolled study, which involved a 3-year follow-up of 60 patients, the percentage of patients who benefited peaked at 1 year, when 71% were completely off PPI therapy, and another 13% had reduced their PPI use by 50%. At 3 years, 48% were off PPIs, and another 17% had reduced PPI use by 50%, said Glen A. Lehman, M.D., professor of medicine at Indiana University, Indianapolis.

These two studies are major steps forward toward the adoption of Enteryx treatment—approved by the Food and Drug Administration in 2003—into routine practice, commented Gary W. Falk, M.D., a professor of medicine at the Cleveland Clinic Foundation.

But the specific indications for this treatment are still not clear, because the subjects in the trials conducted to date have not been defined except that they have been chronic, PPI-dependent patients.

Moreover, caution needs to be exercised in evaluating the treatment because the material that is implanted appears to be permanent, and head-to-head trials with other therapies still need to be performed, Dr. Falk added.

At least 3,000 patients have received Enteryx treatment so far, according to available estimates.

But it is also not exactly clear how the treatment works, Dr. Falk noted. In all the trials reported so far, including the two new trials, the treatment has not appreciably changed the esophageal pH of most patients it has helped.

It may be that the pH is not changed, but the treatment is reducing the amount of acid escaping from the stomach into the esophagus, he suggested.

Regarding the fall-off in efficacy over time seen in the 3-year follow-up, Dr. Lehman said he could not predict whether that trend would continue. The study measured esophageal pH at 12 months, but there were no pH measurements after that. Moreover, none of the patients was examined endoscopically at 3 years to see if the implant was still present and how it was faring.

Dr. Lehman suggested that the fall-off could be due to patients' becoming unwilling to tolerate discomfort that they initially considered an improvement.

In his study, quality-of-life heartburn scores improved by a median of 76% relative to scores at baseline during a washout period when patients were withdrawn from PPI treatment. That percentage improvement continued throughout the 3 years, he noted.

The majority of patients treated with Enteryx experience a transient retrosternal, burning chest pain and/or dysphagia at first, the investigators noted. However, there were no serious, device-related adverse events in Dr. Lehman's follow-up trial. In the controlled trial, one patient treated with Enteryx needed an esophageal dilatation procedure because of continuing dysphagia.

The two trials were sponsored by Boston Scientific Corp., Natick, Mass., the manufacturer of the Enteryx procedure kit.

CHICAGO — The polymer injection treatment for gastroesophageal reflux disease, known as Enteryx, outperformed sham surgery and lasted up to 3 years, investigators said in presenting two studies at the annual Digestive Disease Week.

Enteryx, a liquid that solidifies into a spongy implant, is injected into the deep muscle layer at or below the esophagogastric junction to increase the competence of the lower esophageal sphincter.

In one of the two studies, investigators led by Jacques Deviere, M.D., compared Enteryx treatment with sham surgery; all patients were dependent on proton-pump inhibitor (PPI) therapy prior to the start of the study. At 3 months, 68% of 32 patients given the polymer injection treatment were completely off PPI drugs, and another 13% had reduced their use by at least 50%.

In contrast, in the sham surgery group of 32 patients, 41% discontinued PPI use and another 12% reduced PPI use by at least 50%, said Dr. Deviere, chief of the department of gastroenterology at Erasme Hospital of the Free University of Brussels.

In the second uncontrolled study, which involved a 3-year follow-up of 60 patients, the percentage of patients who benefited peaked at 1 year, when 71% were completely off PPI therapy, and another 13% had reduced their PPI use by 50%. At 3 years, 48% were off PPIs, and another 17% had reduced PPI use by 50%, said Glen A. Lehman, M.D., professor of medicine at Indiana University, Indianapolis.

These two studies are major steps forward toward the adoption of Enteryx treatment—approved by the Food and Drug Administration in 2003—into routine practice, commented Gary W. Falk, M.D., a professor of medicine at the Cleveland Clinic Foundation.

But the specific indications for this treatment are still not clear, because the subjects in the trials conducted to date have not been defined except that they have been chronic, PPI-dependent patients.

Moreover, caution needs to be exercised in evaluating the treatment because the material that is implanted appears to be permanent, and head-to-head trials with other therapies still need to be performed, Dr. Falk added.

At least 3,000 patients have received Enteryx treatment so far, according to available estimates.

But it is also not exactly clear how the treatment works, Dr. Falk noted. In all the trials reported so far, including the two new trials, the treatment has not appreciably changed the esophageal pH of most patients it has helped.

It may be that the pH is not changed, but the treatment is reducing the amount of acid escaping from the stomach into the esophagus, he suggested.

Regarding the fall-off in efficacy over time seen in the 3-year follow-up, Dr. Lehman said he could not predict whether that trend would continue. The study measured esophageal pH at 12 months, but there were no pH measurements after that. Moreover, none of the patients was examined endoscopically at 3 years to see if the implant was still present and how it was faring.

Dr. Lehman suggested that the fall-off could be due to patients' becoming unwilling to tolerate discomfort that they initially considered an improvement.

In his study, quality-of-life heartburn scores improved by a median of 76% relative to scores at baseline during a washout period when patients were withdrawn from PPI treatment. That percentage improvement continued throughout the 3 years, he noted.

The majority of patients treated with Enteryx experience a transient retrosternal, burning chest pain and/or dysphagia at first, the investigators noted. However, there were no serious, device-related adverse events in Dr. Lehman's follow-up trial. In the controlled trial, one patient treated with Enteryx needed an esophageal dilatation procedure because of continuing dysphagia.

The two trials were sponsored by Boston Scientific Corp., Natick, Mass., the manufacturer of the Enteryx procedure kit.

CHICAGO — The polymer injection treatment for gastroesophageal reflux disease, known as Enteryx, outperformed sham surgery and lasted up to 3 years, investigators said in presenting two studies at the annual Digestive Disease Week.

Enteryx, a liquid that solidifies into a spongy implant, is injected into the deep muscle layer at or below the esophagogastric junction to increase the competence of the lower esophageal sphincter.

In one of the two studies, investigators led by Jacques Deviere, M.D., compared Enteryx treatment with sham surgery; all patients were dependent on proton-pump inhibitor (PPI) therapy prior to the start of the study. At 3 months, 68% of 32 patients given the polymer injection treatment were completely off PPI drugs, and another 13% had reduced their use by at least 50%.

In contrast, in the sham surgery group of 32 patients, 41% discontinued PPI use and another 12% reduced PPI use by at least 50%, said Dr. Deviere, chief of the department of gastroenterology at Erasme Hospital of the Free University of Brussels.

In the second uncontrolled study, which involved a 3-year follow-up of 60 patients, the percentage of patients who benefited peaked at 1 year, when 71% were completely off PPI therapy, and another 13% had reduced their PPI use by 50%. At 3 years, 48% were off PPIs, and another 17% had reduced PPI use by 50%, said Glen A. Lehman, M.D., professor of medicine at Indiana University, Indianapolis.

These two studies are major steps forward toward the adoption of Enteryx treatment—approved by the Food and Drug Administration in 2003—into routine practice, commented Gary W. Falk, M.D., a professor of medicine at the Cleveland Clinic Foundation.

But the specific indications for this treatment are still not clear, because the subjects in the trials conducted to date have not been defined except that they have been chronic, PPI-dependent patients.

Moreover, caution needs to be exercised in evaluating the treatment because the material that is implanted appears to be permanent, and head-to-head trials with other therapies still need to be performed, Dr. Falk added.

At least 3,000 patients have received Enteryx treatment so far, according to available estimates.

But it is also not exactly clear how the treatment works, Dr. Falk noted. In all the trials reported so far, including the two new trials, the treatment has not appreciably changed the esophageal pH of most patients it has helped.

It may be that the pH is not changed, but the treatment is reducing the amount of acid escaping from the stomach into the esophagus, he suggested.

Regarding the fall-off in efficacy over time seen in the 3-year follow-up, Dr. Lehman said he could not predict whether that trend would continue. The study measured esophageal pH at 12 months, but there were no pH measurements after that. Moreover, none of the patients was examined endoscopically at 3 years to see if the implant was still present and how it was faring.

Dr. Lehman suggested that the fall-off could be due to patients' becoming unwilling to tolerate discomfort that they initially considered an improvement.

In his study, quality-of-life heartburn scores improved by a median of 76% relative to scores at baseline during a washout period when patients were withdrawn from PPI treatment. That percentage improvement continued throughout the 3 years, he noted.

The majority of patients treated with Enteryx experience a transient retrosternal, burning chest pain and/or dysphagia at first, the investigators noted. However, there were no serious, device-related adverse events in Dr. Lehman's follow-up trial. In the controlled trial, one patient treated with Enteryx needed an esophageal dilatation procedure because of continuing dysphagia.

The two trials were sponsored by Boston Scientific Corp., Natick, Mass., the manufacturer of the Enteryx procedure kit.

CHICAGO — A preliminary analysis of hospital admissions suggests that selective serotonin reuptake inhibitors may be associated with a significant risk of gastrointestinal bleeding, Michael Jones, M.D., said at the annual Digestive Disease Week.

In a case-control study of all patients admitted with gastrointestinal bleeding to three hospitals over an 18-month period, 17% of the 417 patients with bleeding were using a selective serotonin reuptake inhibitor (SSRI) at the time. Of 500 age- and sex-matched controls—patients without bleeding who were admitted on the same date—12% used SSRIs. There was a significant association between SSRI use and bleeding risk.

“The true magnitude of the risk is yet to be determined,” Dr. Jones, of the division of gastroenterology at Northwestern University at Chicago, said at a press briefing.

Because the study was a retrospective investigation, it is not exactly clean, he allowed. The bleeding patients tended to be taking other medications associated with GI bleeding as well as the SSRI. For instance, 17% were taking an NSAID or a cyclooxygenase-2 inhibitor, 41% were taking aspirin or clopidogrel, and 24% were on Coumadin or enoxaparin. In addition, 34% were taking a proton-pump inhibitor or an H2 blocker. Those percentages were higher than the percentages in the control patients in the study, funded by Tap Pharmaceuticals.

SSRIs are widely used because they are perceived to be safe, not because they are necessarily more effective than tricyclic antidepressants, Dr. Jones said.

This study is not the first to note a bleeding risk for SSRIs, Dr. Jones noted. Studies from Europe and Canada have tended to report a higher risk than this study might indicate. Those studies reported that the risk of upper GI bleeding with an SSRI was three times normal.

The present study, funded by Tap Pharmaceutical Products Inc., differed from the previous reports also in that it found a risk of lower intestinal tract bleeding, as well as upper. The odds ratio that a patient in the study taking an SSRI would experience lower GI bleeding was 2.4 relative to those not on an SSRI.

The bleeding risk of the SSRIs probably is intrinsic to the properties that make them therapeutic. Platelets do not produce their own serotonin. They need to take it up from the circulation, and the drugs may be blocking the platelet receptors. Serotonin is necessary for platelet aggregation.

CHICAGO — A preliminary analysis of hospital admissions suggests that selective serotonin reuptake inhibitors may be associated with a significant risk of gastrointestinal bleeding, Michael Jones, M.D., said at the annual Digestive Disease Week.

In a case-control study of all patients admitted with gastrointestinal bleeding to three hospitals over an 18-month period, 17% of the 417 patients with bleeding were using a selective serotonin reuptake inhibitor (SSRI) at the time. Of 500 age- and sex-matched controls—patients without bleeding who were admitted on the same date—12% used SSRIs. There was a significant association between SSRI use and bleeding risk.

“The true magnitude of the risk is yet to be determined,” Dr. Jones, of the division of gastroenterology at Northwestern University at Chicago, said at a press briefing.

Because the study was a retrospective investigation, it is not exactly clean, he allowed. The bleeding patients tended to be taking other medications associated with GI bleeding as well as the SSRI. For instance, 17% were taking an NSAID or a cyclooxygenase-2 inhibitor, 41% were taking aspirin or clopidogrel, and 24% were on Coumadin or enoxaparin. In addition, 34% were taking a proton-pump inhibitor or an H2 blocker. Those percentages were higher than the percentages in the control patients in the study, funded by Tap Pharmaceuticals.

SSRIs are widely used because they are perceived to be safe, not because they are necessarily more effective than tricyclic antidepressants, Dr. Jones said.

This study is not the first to note a bleeding risk for SSRIs, Dr. Jones noted. Studies from Europe and Canada have tended to report a higher risk than this study might indicate. Those studies reported that the risk of upper GI bleeding with an SSRI was three times normal.

The present study, funded by Tap Pharmaceutical Products Inc., differed from the previous reports also in that it found a risk of lower intestinal tract bleeding, as well as upper. The odds ratio that a patient in the study taking an SSRI would experience lower GI bleeding was 2.4 relative to those not on an SSRI.

The bleeding risk of the SSRIs probably is intrinsic to the properties that make them therapeutic. Platelets do not produce their own serotonin. They need to take it up from the circulation, and the drugs may be blocking the platelet receptors. Serotonin is necessary for platelet aggregation.

CHICAGO — A preliminary analysis of hospital admissions suggests that selective serotonin reuptake inhibitors may be associated with a significant risk of gastrointestinal bleeding, Michael Jones, M.D., said at the annual Digestive Disease Week.

In a case-control study of all patients admitted with gastrointestinal bleeding to three hospitals over an 18-month period, 17% of the 417 patients with bleeding were using a selective serotonin reuptake inhibitor (SSRI) at the time. Of 500 age- and sex-matched controls—patients without bleeding who were admitted on the same date—12% used SSRIs. There was a significant association between SSRI use and bleeding risk.

“The true magnitude of the risk is yet to be determined,” Dr. Jones, of the division of gastroenterology at Northwestern University at Chicago, said at a press briefing.

Because the study was a retrospective investigation, it is not exactly clean, he allowed. The bleeding patients tended to be taking other medications associated with GI bleeding as well as the SSRI. For instance, 17% were taking an NSAID or a cyclooxygenase-2 inhibitor, 41% were taking aspirin or clopidogrel, and 24% were on Coumadin or enoxaparin. In addition, 34% were taking a proton-pump inhibitor or an H2 blocker. Those percentages were higher than the percentages in the control patients in the study, funded by Tap Pharmaceuticals.

SSRIs are widely used because they are perceived to be safe, not because they are necessarily more effective than tricyclic antidepressants, Dr. Jones said.

This study is not the first to note a bleeding risk for SSRIs, Dr. Jones noted. Studies from Europe and Canada have tended to report a higher risk than this study might indicate. Those studies reported that the risk of upper GI bleeding with an SSRI was three times normal.

The present study, funded by Tap Pharmaceutical Products Inc., differed from the previous reports also in that it found a risk of lower intestinal tract bleeding, as well as upper. The odds ratio that a patient in the study taking an SSRI would experience lower GI bleeding was 2.4 relative to those not on an SSRI.

The bleeding risk of the SSRIs probably is intrinsic to the properties that make them therapeutic. Platelets do not produce their own serotonin. They need to take it up from the circulation, and the drugs may be blocking the platelet receptors. Serotonin is necessary for platelet aggregation.

CHICAGO — Early high-dose omeprazole infusion speeds resolution of upper gastrointestinal bleeding and reduces the need for endoscopic treatment, according to preliminary results of a prospective trial from Hong Kong.

“Preemptive use of high-dose omeprazole has a hemostatic effect. It hastens resolution of active bleeding, and, in fact, reduces the need for endoscopic therapy,” James Y. Lau, M.D., said at the annual Digestive Disease Week. “It potentially enables early discharge of patients and reduces hospital resource utilization.”

In Dr. Lau's randomized, controlled trial, only 15% of 179 patients treated with omeprazole needed endoscopic therapy, compared with 31% of 190 patients who received placebo.

The study was conducted between February 2004 and November 2004; 648 individuals with upper gastrointestinal bleeding were considered for enrollment in the study. Patients were excluded if they were chronic aspirin users, needed urgent endoscopic therapy, or were considered too unhealthy (such as those with cirrhosis), said Dr. Lau of Prince of Wales Hospital of the Chinese University of Hong Kong.

The treated patients received an 80-mg bolus of intravenous omeprazole, followed by an infusion of 8 mg per hour for 72 hours.

Endoscopy was conducted when it was scheduled in the endoscopy clinic, generally in the morning, after the drug or placebo was begun and the patient had been admitted to the hospital.

Endoscopic treatment was considered necessary when patients were found to still have actively bleeding ulcers or ulcers with nonbleeding but visible vessels, or when there was a clot found that could be lifted to treat an oozing vessel underneath. Treatment consisted of epinephrine injection followed by heater-probe coagulation.

Overall, 220 of the patients were found on endoscopy to have, or to have had, a bleeding gastric ulcer. In that group, 17% of 110 omeprazole-treated patients needed endoscopic treatment, versus 35% of 112 placebo-treated patients. Moreover, only 3 omeprazole-treated patients with a gastric ulcer had active bleeding at the time of endoscopy, compared with 18 of the placebo patients.

Omeprazole appears to help stop bleeding in gastric ulcers because a neutral pH facilitates platelet aggregation, Dr. Lau said.

Dr. Lau's group has previously reported that omeprazole treatment of patients who underwent endoscopic treatment for an upper gastrointestinal bleed significantly decreased the rate of rebleeding within 30 days, from a rate of 22% in a placebo group to 7% in a treated group (N. Engl. J. Med. 2000;343:310–6).

CHICAGO — Early high-dose omeprazole infusion speeds resolution of upper gastrointestinal bleeding and reduces the need for endoscopic treatment, according to preliminary results of a prospective trial from Hong Kong.

“Preemptive use of high-dose omeprazole has a hemostatic effect. It hastens resolution of active bleeding, and, in fact, reduces the need for endoscopic therapy,” James Y. Lau, M.D., said at the annual Digestive Disease Week. “It potentially enables early discharge of patients and reduces hospital resource utilization.”

In Dr. Lau's randomized, controlled trial, only 15% of 179 patients treated with omeprazole needed endoscopic therapy, compared with 31% of 190 patients who received placebo.

The study was conducted between February 2004 and November 2004; 648 individuals with upper gastrointestinal bleeding were considered for enrollment in the study. Patients were excluded if they were chronic aspirin users, needed urgent endoscopic therapy, or were considered too unhealthy (such as those with cirrhosis), said Dr. Lau of Prince of Wales Hospital of the Chinese University of Hong Kong.

The treated patients received an 80-mg bolus of intravenous omeprazole, followed by an infusion of 8 mg per hour for 72 hours.

Endoscopy was conducted when it was scheduled in the endoscopy clinic, generally in the morning, after the drug or placebo was begun and the patient had been admitted to the hospital.

Endoscopic treatment was considered necessary when patients were found to still have actively bleeding ulcers or ulcers with nonbleeding but visible vessels, or when there was a clot found that could be lifted to treat an oozing vessel underneath. Treatment consisted of epinephrine injection followed by heater-probe coagulation.

Overall, 220 of the patients were found on endoscopy to have, or to have had, a bleeding gastric ulcer. In that group, 17% of 110 omeprazole-treated patients needed endoscopic treatment, versus 35% of 112 placebo-treated patients. Moreover, only 3 omeprazole-treated patients with a gastric ulcer had active bleeding at the time of endoscopy, compared with 18 of the placebo patients.

Omeprazole appears to help stop bleeding in gastric ulcers because a neutral pH facilitates platelet aggregation, Dr. Lau said.

Dr. Lau's group has previously reported that omeprazole treatment of patients who underwent endoscopic treatment for an upper gastrointestinal bleed significantly decreased the rate of rebleeding within 30 days, from a rate of 22% in a placebo group to 7% in a treated group (N. Engl. J. Med. 2000;343:310–6).

CHICAGO — Early high-dose omeprazole infusion speeds resolution of upper gastrointestinal bleeding and reduces the need for endoscopic treatment, according to preliminary results of a prospective trial from Hong Kong.

“Preemptive use of high-dose omeprazole has a hemostatic effect. It hastens resolution of active bleeding, and, in fact, reduces the need for endoscopic therapy,” James Y. Lau, M.D., said at the annual Digestive Disease Week. “It potentially enables early discharge of patients and reduces hospital resource utilization.”

In Dr. Lau's randomized, controlled trial, only 15% of 179 patients treated with omeprazole needed endoscopic therapy, compared with 31% of 190 patients who received placebo.

The study was conducted between February 2004 and November 2004; 648 individuals with upper gastrointestinal bleeding were considered for enrollment in the study. Patients were excluded if they were chronic aspirin users, needed urgent endoscopic therapy, or were considered too unhealthy (such as those with cirrhosis), said Dr. Lau of Prince of Wales Hospital of the Chinese University of Hong Kong.

The treated patients received an 80-mg bolus of intravenous omeprazole, followed by an infusion of 8 mg per hour for 72 hours.

Endoscopy was conducted when it was scheduled in the endoscopy clinic, generally in the morning, after the drug or placebo was begun and the patient had been admitted to the hospital.

Endoscopic treatment was considered necessary when patients were found to still have actively bleeding ulcers or ulcers with nonbleeding but visible vessels, or when there was a clot found that could be lifted to treat an oozing vessel underneath. Treatment consisted of epinephrine injection followed by heater-probe coagulation.

Overall, 220 of the patients were found on endoscopy to have, or to have had, a bleeding gastric ulcer. In that group, 17% of 110 omeprazole-treated patients needed endoscopic treatment, versus 35% of 112 placebo-treated patients. Moreover, only 3 omeprazole-treated patients with a gastric ulcer had active bleeding at the time of endoscopy, compared with 18 of the placebo patients.

Omeprazole appears to help stop bleeding in gastric ulcers because a neutral pH facilitates platelet aggregation, Dr. Lau said.

Dr. Lau's group has previously reported that omeprazole treatment of patients who underwent endoscopic treatment for an upper gastrointestinal bleed significantly decreased the rate of rebleeding within 30 days, from a rate of 22% in a placebo group to 7% in a treated group (N. Engl. J. Med. 2000;343:310–6).

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 it 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 for the 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, Ms. Gelperin 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.

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 Web site records, the most frequently asked questions by males are about masturbation and penis size. The most frequently asked questions by females are about “can I get pregnant if …” and painful sex. Questions asked 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 pop 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.

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.

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 it 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 for the 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, Ms. Gelperin 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.

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 Web site records, the most frequently asked questions by males are about masturbation and penis size. The most frequently asked questions by females are about “can I get pregnant if …” and painful sex. Questions asked 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 pop 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.

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.

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 it 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 for the 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, Ms. Gelperin 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.

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 Web site records, the most frequently asked questions by males are about masturbation and penis size. The most frequently asked questions by females are about “can I get pregnant if …” and painful sex. Questions asked 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 pop 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.

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.

SAN FRANCISCO — The baby boomers might do more than bankrupt Medicare—they could break the entire medical system, members of a panel said at the annual meeting of the American College of Physicians.

With 76 million baby boomers starting to approach age 65, the elderly population will double by 2040, potentially bankrupting the Medicare trust fund by 2020 and Social Security by 2042.

But they may also overwhelm the health care system with chronic conditions.

The medical system is set up to assume that patients with a chronic condition have only one, but most of the elderly have more than one chronic condition, said Robert A. Berenson, M.D., a senior fellow in health policy at the Urban Institute in Washington.

Among persons who are older than 65 years, 84% have at least one chronic condition, 62% have two or more, and 20% have four or more.

People with chronic conditions see more physicians more often, which greatly increases the potential for inefficiency and confusion in their care, Dr. Berenson said. The average person with no chronic conditions sees 1.3 physicians a year and has two medical visits. In contrast, the average person who has five chronic conditions sees almost 14 physicians (including radiologists and anesthesiologists) per year and has a total of 37 visits, he said.

A Harris survey asking persons with a chronic condition about their care in the preceding 12 months found 54% had been told they were at risk for a harmful drug interaction because of what they were taking, 54% had duplicate tests or procedures, 52% had received different diagnoses from different physicians, and 45% had received contradictory medical information.

Fundamental problems in the medical system must be addressed to manage the influx of baby boomers with multiple needs. These problems include the shortage of geriatricians; training oriented toward hospital care, rather than prevention and management of chronic conditions; and even the reliance on guidelines for care.

Guidelines are generally written for one condition and tend to ignore comorbidities, Dr. Berenson said.

The growth of the elderly population is a problem compounded by the obesity epidemic and the sedentary lifestyle of many Americans, said David K. McCulloch, M.D., of GroupHealth Cooperative, Seattle.

To respond to this “triple whammy” crisis in health care, the medical system will have to reinvent itself to embrace more prevention and coordinated care, including adopting pay-for-performance strategies that offer providers incentives for keeping patients well, Dr. McCulloch said.

There is evidence that a chronic-illness model of care delivery that coordinates care and provides wellness services can reduce costs and hospitalizations and benefit patients. Many of the patients who can benefit from this approach are diabetic patients, he said.

At Dr. McCulloch's HMO, a 3-year pilot program for 18,000 diabetic patients decreased hospitalizations by 25% and overall costs by 11%, although pharmacy costs increased 16%. The program was credited with improving the patient group's average hemoglobin A_1c levels significantly.

An unpublished Rand study found evidence that this type of program can be implemented in private physicians' practices, and that when one practice in an area adopts such an approach, other practices in the area begin to copy it, Dr. McCulloch said.

Dr. Berenson commented that the relative value resource-based system of payment might have to be overhauled so that there is more incentive for good chronic-disease management.

SAN FRANCISCO — The baby boomers might do more than bankrupt Medicare—they could break the entire medical system, members of a panel said at the annual meeting of the American College of Physicians.

With 76 million baby boomers starting to approach age 65, the elderly population will double by 2040, potentially bankrupting the Medicare trust fund by 2020 and Social Security by 2042.

But they may also overwhelm the health care system with chronic conditions.

The medical system is set up to assume that patients with a chronic condition have only one, but most of the elderly have more than one chronic condition, said Robert A. Berenson, M.D., a senior fellow in health policy at the Urban Institute in Washington.

Among persons who are older than 65 years, 84% have at least one chronic condition, 62% have two or more, and 20% have four or more.

People with chronic conditions see more physicians more often, which greatly increases the potential for inefficiency and confusion in their care, Dr. Berenson said. The average person with no chronic conditions sees 1.3 physicians a year and has two medical visits. In contrast, the average person who has five chronic conditions sees almost 14 physicians (including radiologists and anesthesiologists) per year and has a total of 37 visits, he said.

A Harris survey asking persons with a chronic condition about their care in the preceding 12 months found 54% had been told they were at risk for a harmful drug interaction because of what they were taking, 54% had duplicate tests or procedures, 52% had received different diagnoses from different physicians, and 45% had received contradictory medical information.

Fundamental problems in the medical system must be addressed to manage the influx of baby boomers with multiple needs. These problems include the shortage of geriatricians; training oriented toward hospital care, rather than prevention and management of chronic conditions; and even the reliance on guidelines for care.

Guidelines are generally written for one condition and tend to ignore comorbidities, Dr. Berenson said.

The growth of the elderly population is a problem compounded by the obesity epidemic and the sedentary lifestyle of many Americans, said David K. McCulloch, M.D., of GroupHealth Cooperative, Seattle.

To respond to this “triple whammy” crisis in health care, the medical system will have to reinvent itself to embrace more prevention and coordinated care, including adopting pay-for-performance strategies that offer providers incentives for keeping patients well, Dr. McCulloch said.

There is evidence that a chronic-illness model of care delivery that coordinates care and provides wellness services can reduce costs and hospitalizations and benefit patients. Many of the patients who can benefit from this approach are diabetic patients, he said.

At Dr. McCulloch's HMO, a 3-year pilot program for 18,000 diabetic patients decreased hospitalizations by 25% and overall costs by 11%, although pharmacy costs increased 16%. The program was credited with improving the patient group's average hemoglobin A_1c levels significantly.

An unpublished Rand study found evidence that this type of program can be implemented in private physicians' practices, and that when one practice in an area adopts such an approach, other practices in the area begin to copy it, Dr. McCulloch said.

Dr. Berenson commented that the relative value resource-based system of payment might have to be overhauled so that there is more incentive for good chronic-disease management.

SAN FRANCISCO — The baby boomers might do more than bankrupt Medicare—they could break the entire medical system, members of a panel said at the annual meeting of the American College of Physicians.

With 76 million baby boomers starting to approach age 65, the elderly population will double by 2040, potentially bankrupting the Medicare trust fund by 2020 and Social Security by 2042.

But they may also overwhelm the health care system with chronic conditions.

The medical system is set up to assume that patients with a chronic condition have only one, but most of the elderly have more than one chronic condition, said Robert A. Berenson, M.D., a senior fellow in health policy at the Urban Institute in Washington.

Among persons who are older than 65 years, 84% have at least one chronic condition, 62% have two or more, and 20% have four or more.

People with chronic conditions see more physicians more often, which greatly increases the potential for inefficiency and confusion in their care, Dr. Berenson said. The average person with no chronic conditions sees 1.3 physicians a year and has two medical visits. In contrast, the average person who has five chronic conditions sees almost 14 physicians (including radiologists and anesthesiologists) per year and has a total of 37 visits, he said.

A Harris survey asking persons with a chronic condition about their care in the preceding 12 months found 54% had been told they were at risk for a harmful drug interaction because of what they were taking, 54% had duplicate tests or procedures, 52% had received different diagnoses from different physicians, and 45% had received contradictory medical information.

Fundamental problems in the medical system must be addressed to manage the influx of baby boomers with multiple needs. These problems include the shortage of geriatricians; training oriented toward hospital care, rather than prevention and management of chronic conditions; and even the reliance on guidelines for care.

Guidelines are generally written for one condition and tend to ignore comorbidities, Dr. Berenson said.

The growth of the elderly population is a problem compounded by the obesity epidemic and the sedentary lifestyle of many Americans, said David K. McCulloch, M.D., of GroupHealth Cooperative, Seattle.

To respond to this “triple whammy” crisis in health care, the medical system will have to reinvent itself to embrace more prevention and coordinated care, including adopting pay-for-performance strategies that offer providers incentives for keeping patients well, Dr. McCulloch said.

There is evidence that a chronic-illness model of care delivery that coordinates care and provides wellness services can reduce costs and hospitalizations and benefit patients. Many of the patients who can benefit from this approach are diabetic patients, he said.

At Dr. McCulloch's HMO, a 3-year pilot program for 18,000 diabetic patients decreased hospitalizations by 25% and overall costs by 11%, although pharmacy costs increased 16%. The program was credited with improving the patient group's average hemoglobin A_1c levels significantly.

An unpublished Rand study found evidence that this type of program can be implemented in private physicians' practices, and that when one practice in an area adopts such an approach, other practices in the area begin to copy it, Dr. McCulloch said.

Dr. Berenson commented that the relative value resource-based system of payment might have to be overhauled so that there is more incentive for good chronic-disease management.

SAN FRANCISCO — Hospitalist practice is evolving rapidly into its own specialty, distinct from its largely internal medicine roots.

That process of evolution is bringing up questions and challenges, some of which may have implications for not just the hospitalists themselves but for hospitals and other physicians as well, John R. Nelson, M.D., said at the annual meeting of the American College of Physicians.

Hospitalist practice already meets many of the criteria often used to define a distinct specialty, said Dr. Nelson, a past president of the Society of Hospital Medicine.

In addition to having their own society, hospitalists now have their own continuing medical education courses, a handful of residency tracks, and fellowship programs.

Hospitalists are developing some distinct competencies, and plans for a hospitalist journal are in the works.

“We nearly meet all these requirements now, and the ones that we don't meet are coming soon,” Dr. Nelson said.

Current estimates suggest that 10,000–12,000 hospitalists are now practicing, up from a few hundred in the 1990s. And there continue to be more hospitalist positions opening than there are applicants to fill them.

A conservative estimate about the future is that there may be 25,000 hospitalists by as soon as 2010, and that the need will plateau with that number, he said.

“I feel that hospital medicine is growing according to Moore's law—the guy who said computers double their power and speed every 18 months,” said Dr. Nelson, director of hospitalist practice at Overlake Hospital Medical Center, Bellevue, Wash.

But this rapid expansion of hospital practice is liable to bring some economic issues to the fore, Dr. Nelson noted.

A concern has been raised that insurance companies will discover that hospitalists have greater liability exposure than office-based physicians.

Perhaps more importantly at this time, many hospitalists are subsidized by a health plan or the hospital where they work because their patient mix tends to include a high proportion of uninsured people.

According to a survey conducted by the Society of Hospital Medicine in 2003, the average hospitalist generates fees of $178,471 a year and receives $74,000 in hospital support, for a total that produces an average income of $158,493 plus $28,776 in benefits, after subtraction of costs and overhead.

As the ranks of hospitalists grow, hospitals may need to wean them off of this support, as happened with emergency department physicians as their specialty developed.

The difference, however, was that emergency physicians were able to have their fees raised and corrected in the era before the imposition of rigid fee caps, Dr. Nelson commented. That is not possible anymore.

Another economic challenge is that medicine is adopting global fee structures and pay-for-performance strategies.

That may put hospitalists in a particular bind, if hospitals turn to the hospitalists to achieve cost savings while the hospitalists are dependent on the hospitals for their practices, he said.

Also, as the field evolves, hospitalists are going to be pushed to specialize more, or at least to take on responsibilities that they do not often have now.

This is occurring already, and one example is the admission of patients with hypertensive intracerebral hemorrhage, Dr. Nelson said.

In some places, neurosurgeons are looking at hospitalists and wondering why they have to admit these patients, when in the vast majority of cases, the management will be medical in the hospital, followed by referral elsewhere.

Moreover, patient deaths are more common in the hospital than in outside practice, which probably means that hospitalists should develop more end-of-life expertise.

The vast majority of hospitalists still come from the ranks of internal medicine, but some institutions already have psychiatry, obstetrics, and cardiology hospitalists, Dr. Nelson said. He also noted that in countries such as Germany, hospital and office practice are already largely differentiated.

The specialization of hospitalists is already raising the question of credentialing, Dr. Nelson noted. At this time, hospitalists can and should just be credentialed in their own specialty, he said.

The bigger issue, he added, is what to do about hospital credentials for physicians who never go to the hospital anymore.

In his opinion, office-based practitioners can and should still continue to have hospital credentials because knowledge and expertise are not like the technical proficiency needed to perform a particular procedure, for which it has been shown that regular repetition is necessary for competency.

It is a question that hospitals are already asking, he said. They are also worried about how they will keep doctors loyal to their particular institution, when the doctors no longer go there.

“A lot of people are thinking about ways to keep doctors loyal to a hospital,” Dr. Nelson said.

SAN FRANCISCO — Hospitalist practice is evolving rapidly into its own specialty, distinct from its largely internal medicine roots.

That process of evolution is bringing up questions and challenges, some of which may have implications for not just the hospitalists themselves but for hospitals and other physicians as well, John R. Nelson, M.D., said at the annual meeting of the American College of Physicians.

Hospitalist practice already meets many of the criteria often used to define a distinct specialty, said Dr. Nelson, a past president of the Society of Hospital Medicine.

In addition to having their own society, hospitalists now have their own continuing medical education courses, a handful of residency tracks, and fellowship programs.

Hospitalists are developing some distinct competencies, and plans for a hospitalist journal are in the works.

“We nearly meet all these requirements now, and the ones that we don't meet are coming soon,” Dr. Nelson said.

Current estimates suggest that 10,000–12,000 hospitalists are now practicing, up from a few hundred in the 1990s. And there continue to be more hospitalist positions opening than there are applicants to fill them.

A conservative estimate about the future is that there may be 25,000 hospitalists by as soon as 2010, and that the need will plateau with that number, he said.

“I feel that hospital medicine is growing according to Moore's law—the guy who said computers double their power and speed every 18 months,” said Dr. Nelson, director of hospitalist practice at Overlake Hospital Medical Center, Bellevue, Wash.

But this rapid expansion of hospital practice is liable to bring some economic issues to the fore, Dr. Nelson noted.

A concern has been raised that insurance companies will discover that hospitalists have greater liability exposure than office-based physicians.

Perhaps more importantly at this time, many hospitalists are subsidized by a health plan or the hospital where they work because their patient mix tends to include a high proportion of uninsured people.

According to a survey conducted by the Society of Hospital Medicine in 2003, the average hospitalist generates fees of $178,471 a year and receives $74,000 in hospital support, for a total that produces an average income of $158,493 plus $28,776 in benefits, after subtraction of costs and overhead.

As the ranks of hospitalists grow, hospitals may need to wean them off of this support, as happened with emergency department physicians as their specialty developed.

The difference, however, was that emergency physicians were able to have their fees raised and corrected in the era before the imposition of rigid fee caps, Dr. Nelson commented. That is not possible anymore.

Another economic challenge is that medicine is adopting global fee structures and pay-for-performance strategies.

That may put hospitalists in a particular bind, if hospitals turn to the hospitalists to achieve cost savings while the hospitalists are dependent on the hospitals for their practices, he said.

Also, as the field evolves, hospitalists are going to be pushed to specialize more, or at least to take on responsibilities that they do not often have now.

This is occurring already, and one example is the admission of patients with hypertensive intracerebral hemorrhage, Dr. Nelson said.

In some places, neurosurgeons are looking at hospitalists and wondering why they have to admit these patients, when in the vast majority of cases, the management will be medical in the hospital, followed by referral elsewhere.

Moreover, patient deaths are more common in the hospital than in outside practice, which probably means that hospitalists should develop more end-of-life expertise.

The vast majority of hospitalists still come from the ranks of internal medicine, but some institutions already have psychiatry, obstetrics, and cardiology hospitalists, Dr. Nelson said. He also noted that in countries such as Germany, hospital and office practice are already largely differentiated.

The specialization of hospitalists is already raising the question of credentialing, Dr. Nelson noted. At this time, hospitalists can and should just be credentialed in their own specialty, he said.

The bigger issue, he added, is what to do about hospital credentials for physicians who never go to the hospital anymore.

In his opinion, office-based practitioners can and should still continue to have hospital credentials because knowledge and expertise are not like the technical proficiency needed to perform a particular procedure, for which it has been shown that regular repetition is necessary for competency.

It is a question that hospitals are already asking, he said. They are also worried about how they will keep doctors loyal to their particular institution, when the doctors no longer go there.

“A lot of people are thinking about ways to keep doctors loyal to a hospital,” Dr. Nelson said.

SAN FRANCISCO — Hospitalist practice is evolving rapidly into its own specialty, distinct from its largely internal medicine roots.

That process of evolution is bringing up questions and challenges, some of which may have implications for not just the hospitalists themselves but for hospitals and other physicians as well, John R. Nelson, M.D., said at the annual meeting of the American College of Physicians.

Hospitalist practice already meets many of the criteria often used to define a distinct specialty, said Dr. Nelson, a past president of the Society of Hospital Medicine.

In addition to having their own society, hospitalists now have their own continuing medical education courses, a handful of residency tracks, and fellowship programs.

Hospitalists are developing some distinct competencies, and plans for a hospitalist journal are in the works.

“We nearly meet all these requirements now, and the ones that we don't meet are coming soon,” Dr. Nelson said.

Current estimates suggest that 10,000–12,000 hospitalists are now practicing, up from a few hundred in the 1990s. And there continue to be more hospitalist positions opening than there are applicants to fill them.

A conservative estimate about the future is that there may be 25,000 hospitalists by as soon as 2010, and that the need will plateau with that number, he said.

“I feel that hospital medicine is growing according to Moore's law—the guy who said computers double their power and speed every 18 months,” said Dr. Nelson, director of hospitalist practice at Overlake Hospital Medical Center, Bellevue, Wash.

But this rapid expansion of hospital practice is liable to bring some economic issues to the fore, Dr. Nelson noted.

A concern has been raised that insurance companies will discover that hospitalists have greater liability exposure than office-based physicians.

Perhaps more importantly at this time, many hospitalists are subsidized by a health plan or the hospital where they work because their patient mix tends to include a high proportion of uninsured people.

According to a survey conducted by the Society of Hospital Medicine in 2003, the average hospitalist generates fees of $178,471 a year and receives $74,000 in hospital support, for a total that produces an average income of $158,493 plus $28,776 in benefits, after subtraction of costs and overhead.

As the ranks of hospitalists grow, hospitals may need to wean them off of this support, as happened with emergency department physicians as their specialty developed.

The difference, however, was that emergency physicians were able to have their fees raised and corrected in the era before the imposition of rigid fee caps, Dr. Nelson commented. That is not possible anymore.

Another economic challenge is that medicine is adopting global fee structures and pay-for-performance strategies.

That may put hospitalists in a particular bind, if hospitals turn to the hospitalists to achieve cost savings while the hospitalists are dependent on the hospitals for their practices, he said.

Also, as the field evolves, hospitalists are going to be pushed to specialize more, or at least to take on responsibilities that they do not often have now.

This is occurring already, and one example is the admission of patients with hypertensive intracerebral hemorrhage, Dr. Nelson said.

In some places, neurosurgeons are looking at hospitalists and wondering why they have to admit these patients, when in the vast majority of cases, the management will be medical in the hospital, followed by referral elsewhere.

Moreover, patient deaths are more common in the hospital than in outside practice, which probably means that hospitalists should develop more end-of-life expertise.

The vast majority of hospitalists still come from the ranks of internal medicine, but some institutions already have psychiatry, obstetrics, and cardiology hospitalists, Dr. Nelson said. He also noted that in countries such as Germany, hospital and office practice are already largely differentiated.

The specialization of hospitalists is already raising the question of credentialing, Dr. Nelson noted. At this time, hospitalists can and should just be credentialed in their own specialty, he said.

The bigger issue, he added, is what to do about hospital credentials for physicians who never go to the hospital anymore.

In his opinion, office-based practitioners can and should still continue to have hospital credentials because knowledge and expertise are not like the technical proficiency needed to perform a particular procedure, for which it has been shown that regular repetition is necessary for competency.

It is a question that hospitals are already asking, he said. They are also worried about how they will keep doctors loyal to their particular institution, when the doctors no longer go there.

“A lot of people are thinking about ways to keep doctors loyal to a hospital,” Dr. Nelson said.

INDIAN WELLS, CALIF. — Educated women of high socioeconomic status do not appear to get enough daily calcium, Andrea Stein, M.D., said at the annual meeting of the Pacific Coast Reproductive Society.

In a survey of 180 middle-aged patients seen in her gynecology practice, in a wealthy area of the Los Angeles region, more than 50% apparently consumed less than 1,000–1,500 mg of calcium per day, Dr. Stein said.

Overall, 86% of the patients had a college degree, and 36% had an advanced degree, she noted. All were 45 years old or older.

Of the 99 patients taking no medications, 75% took a calcium supplement only once a day or less, and 48% had a milk product once a day or less. Of the 60 patients on hormone therapy, 68% took a calcium supplement once a day or less, and 43% had a milk product once or less a day.

For the 21 patients taking a bisphosphonate, raloxifene, or calcitonin, the percentages were 48% and 33%.

A single calcium supplement or a single serving will not provide the recommended amount of calcium for a woman aged 50 years or older, which is 1,200–1,500 mg/day, noted Dr. Stein, whose practice is in Santa Monica, Calif.

Calcium supplements contain only 500–600 mg elemental calcium per tablet, because that is the maximum an individual can absorb at any one time. A single serving size of skim milk, yogurt, or cheese contains only about 300 mg or less of calcium.

The survey findings suggest that women of high socioeconomic status are somewhat better at getting adequate calcium than those of low socioeconomic status, but only marginally so, Dr. Stein said in an interview. According to data from the 1999–2000 National Health and Nutrition Examination Survey, 80% of low-income women do not get adequate daily calcium.

INDIAN WELLS, CALIF. — Educated women of high socioeconomic status do not appear to get enough daily calcium, Andrea Stein, M.D., said at the annual meeting of the Pacific Coast Reproductive Society.

In a survey of 180 middle-aged patients seen in her gynecology practice, in a wealthy area of the Los Angeles region, more than 50% apparently consumed less than 1,000–1,500 mg of calcium per day, Dr. Stein said.

Overall, 86% of the patients had a college degree, and 36% had an advanced degree, she noted. All were 45 years old or older.

Of the 99 patients taking no medications, 75% took a calcium supplement only once a day or less, and 48% had a milk product once a day or less. Of the 60 patients on hormone therapy, 68% took a calcium supplement once a day or less, and 43% had a milk product once or less a day.

For the 21 patients taking a bisphosphonate, raloxifene, or calcitonin, the percentages were 48% and 33%.

A single calcium supplement or a single serving will not provide the recommended amount of calcium for a woman aged 50 years or older, which is 1,200–1,500 mg/day, noted Dr. Stein, whose practice is in Santa Monica, Calif.

Calcium supplements contain only 500–600 mg elemental calcium per tablet, because that is the maximum an individual can absorb at any one time. A single serving size of skim milk, yogurt, or cheese contains only about 300 mg or less of calcium.

The survey findings suggest that women of high socioeconomic status are somewhat better at getting adequate calcium than those of low socioeconomic status, but only marginally so, Dr. Stein said in an interview. According to data from the 1999–2000 National Health and Nutrition Examination Survey, 80% of low-income women do not get adequate daily calcium.

INDIAN WELLS, CALIF. — Educated women of high socioeconomic status do not appear to get enough daily calcium, Andrea Stein, M.D., said at the annual meeting of the Pacific Coast Reproductive Society.

In a survey of 180 middle-aged patients seen in her gynecology practice, in a wealthy area of the Los Angeles region, more than 50% apparently consumed less than 1,000–1,500 mg of calcium per day, Dr. Stein said.

Overall, 86% of the patients had a college degree, and 36% had an advanced degree, she noted. All were 45 years old or older.

Of the 99 patients taking no medications, 75% took a calcium supplement only once a day or less, and 48% had a milk product once a day or less. Of the 60 patients on hormone therapy, 68% took a calcium supplement once a day or less, and 43% had a milk product once or less a day.

For the 21 patients taking a bisphosphonate, raloxifene, or calcitonin, the percentages were 48% and 33%.

A single calcium supplement or a single serving will not provide the recommended amount of calcium for a woman aged 50 years or older, which is 1,200–1,500 mg/day, noted Dr. Stein, whose practice is in Santa Monica, Calif.

Calcium supplements contain only 500–600 mg elemental calcium per tablet, because that is the maximum an individual can absorb at any one time. A single serving size of skim milk, yogurt, or cheese contains only about 300 mg or less of calcium.

The survey findings suggest that women of high socioeconomic status are somewhat better at getting adequate calcium than those of low socioeconomic status, but only marginally so, Dr. Stein said in an interview. According to data from the 1999–2000 National Health and Nutrition Examination Survey, 80% of low-income women do not get adequate daily calcium.