Timothy F. Kirn

SAN FRANCISCO — Screening for the four common problems of old age that constitute geriatric syndrome—cognitive loss, falls, incontinence, and depression—offers a holistic way to meet the needs of elderly patients, William J. Hall, M.D., said at the annual meeting of the American College of Physicians.

These problems affect the patient's quality of life and compliance with treatment for other medical conditions, noted Dr. Hall, director of the Center for Healthy Aging at the University of Rochester (N.Y.).

“The fact is, when elderly people are depressed, they don't take their ACE inhibitors,” he said. “It's as simple as that.”

A good way to address geriatric syndrome during office visits, Dr. Hall said, is to focus on one of the following components at each visit:

▸ Cognitive loss. The Mini-Mental State Examination (MMSE) is a good screen for cognitive loss. But a new mental status exam that is even more practical appears to be highly sensitive. The exam includes a category fluency test (in 1 minute, the patient names as many things as possible in a category such as animals or cities) and a phonemic fluency test (in 1 minute, the patient names as many words as possible that start with a given letter).

When a cutoff of 15 words is used for the category fluency test, it appears to pick up about 90% of cases of dementia—even mild dementia (Neurology 2004;62:556–62).

The test may provide differential information, because patients with vascular dementia have more impairment in the phonemic test than the category test, Dr. Hall said.

Treatments for cognitive impairment seem to have “reached the end of the line” with the cholinesterase inhibitors and memantine, at least for now, he said.

Much of the initial enthusiasm about the cholinesterase inhibitors has turned to skepticism recently. Donepezil (Aricept) was shown in one influential study to double the time it took for patients to enter a nursing home, but that study has not yet been replicated. In general, there is a dearth of independent studies of cholinesterase inhibitors not sponsored by drug manufacturers.

Combined treatment with memantine and donepezil has become popular based on a study suggesting that it improved quality of life, but many experts looking at the data question whether the degree of improvement is worth the cost, Dr. Hall said.

That does not mean that the drugs are not beneficial, just that the complete data are not in, he added. “I would have a very hard time not trying Aricept in dementia,” he said. “There is so little hope otherwise.”

▸ Falls. European geriatricians studying the stance and movement of elderly people who have serious falls have identified a “psychomotor disadaptation syndrome.” The characteristic features include a stance with trunk bent forward, toes clenched, and knee flexion, or the presence of reactional hypertonia.

In the office setting, the “get-up-and-go” test offers a practical way to identify patients at risk of falling, Dr. Hall said. The patient is directed to rise from a chair, walk 10 feet, turn around, return to the chair, and sit down. The tester rates the patient's stability.

Muscle weakness appears to be the most important predictor of falls. “It trumps everything else by a substantial order of magnitude,” Dr. Hall said.

Even minimal strength training can yield benefits, and several exercises can be used that do not require expensive equipment or supervision. Wall squats done with small weights are helpful and pose little risk of falling, because the patient has his or her back to the wall, he said.

▸ Urinary incontinence. After age 65 years, 15%–30% of women have urinary incontinence, and 50% of all elderly patients living in institutions have it. Even though urinary incontinence can greatly limit their activities, fewer than half of patients seek medical help without prompting. When patients do seek help, the average time from the beginning of a serious problem to the appointment is 41 months. Thus physicians must be proactive in looking for the problem, Dr. Hall said.

The cough stress test is “really good” at picking up urinary incontinence. Leakage with a cough may signal either stress incontinence or overactive bladder. With stress incontinence, the leakage occurs immediately. With overactive bladder, it takes a few seconds, he explained.

Kegel exercises are highly effective for stress incontinence. A recent major review of the evidence suggested that women who did pelvic floor muscle training were 23 times more likely to have cure or improvement in their incontinence, without the need for other treatments.

▸ Depression. Few elderly people develop full-blown depression that would meet diagnostic criteria. Rather, they are prone to subclinical depression that can almost be described as a “failure to thrive,” he said.

According to a Cochrane Collaboration review that has not yet been published, effective screening for depression—even mild depression—can be done with two questions: “Have you been bothered in the past month by low interest in pleasure or doing things?” and “Have you been feeling down, depressed, or hopeless in the past month?”

Selective serotonin reuptake inhibitors can be effective. A recent study of sertraline found that an 8-week course of treatment produced good improvement in the elderly, Dr. Hall noted. But patients not assigned to drug therapy also showed a fairly pronounced improvement—a common finding in studies of depression in the elderly.

SAN FRANCISCO — Screening for the four common problems of old age that constitute geriatric syndrome—cognitive loss, falls, incontinence, and depression—offers a holistic way to meet the needs of elderly patients, William J. Hall, M.D., said at the annual meeting of the American College of Physicians.

These problems affect the patient's quality of life and compliance with treatment for other medical conditions, noted Dr. Hall, director of the Center for Healthy Aging at the University of Rochester (N.Y.).

“The fact is, when elderly people are depressed, they don't take their ACE inhibitors,” he said. “It's as simple as that.”

A good way to address geriatric syndrome during office visits, Dr. Hall said, is to focus on one of the following components at each visit:

▸ Cognitive loss. The Mini-Mental State Examination (MMSE) is a good screen for cognitive loss. But a new mental status exam that is even more practical appears to be highly sensitive. The exam includes a category fluency test (in 1 minute, the patient names as many things as possible in a category such as animals or cities) and a phonemic fluency test (in 1 minute, the patient names as many words as possible that start with a given letter).

When a cutoff of 15 words is used for the category fluency test, it appears to pick up about 90% of cases of dementia—even mild dementia (Neurology 2004;62:556–62).

The test may provide differential information, because patients with vascular dementia have more impairment in the phonemic test than the category test, Dr. Hall said.

Treatments for cognitive impairment seem to have “reached the end of the line” with the cholinesterase inhibitors and memantine, at least for now, he said.

Much of the initial enthusiasm about the cholinesterase inhibitors has turned to skepticism recently. Donepezil (Aricept) was shown in one influential study to double the time it took for patients to enter a nursing home, but that study has not yet been replicated. In general, there is a dearth of independent studies of cholinesterase inhibitors not sponsored by drug manufacturers.

Combined treatment with memantine and donepezil has become popular based on a study suggesting that it improved quality of life, but many experts looking at the data question whether the degree of improvement is worth the cost, Dr. Hall said.

That does not mean that the drugs are not beneficial, just that the complete data are not in, he added. “I would have a very hard time not trying Aricept in dementia,” he said. “There is so little hope otherwise.”

▸ Falls. European geriatricians studying the stance and movement of elderly people who have serious falls have identified a “psychomotor disadaptation syndrome.” The characteristic features include a stance with trunk bent forward, toes clenched, and knee flexion, or the presence of reactional hypertonia.

In the office setting, the “get-up-and-go” test offers a practical way to identify patients at risk of falling, Dr. Hall said. The patient is directed to rise from a chair, walk 10 feet, turn around, return to the chair, and sit down. The tester rates the patient's stability.

Muscle weakness appears to be the most important predictor of falls. “It trumps everything else by a substantial order of magnitude,” Dr. Hall said.

Even minimal strength training can yield benefits, and several exercises can be used that do not require expensive equipment or supervision. Wall squats done with small weights are helpful and pose little risk of falling, because the patient has his or her back to the wall, he said.

▸ Urinary incontinence. After age 65 years, 15%–30% of women have urinary incontinence, and 50% of all elderly patients living in institutions have it. Even though urinary incontinence can greatly limit their activities, fewer than half of patients seek medical help without prompting. When patients do seek help, the average time from the beginning of a serious problem to the appointment is 41 months. Thus physicians must be proactive in looking for the problem, Dr. Hall said.

The cough stress test is “really good” at picking up urinary incontinence. Leakage with a cough may signal either stress incontinence or overactive bladder. With stress incontinence, the leakage occurs immediately. With overactive bladder, it takes a few seconds, he explained.

Kegel exercises are highly effective for stress incontinence. A recent major review of the evidence suggested that women who did pelvic floor muscle training were 23 times more likely to have cure or improvement in their incontinence, without the need for other treatments.

▸ Depression. Few elderly people develop full-blown depression that would meet diagnostic criteria. Rather, they are prone to subclinical depression that can almost be described as a “failure to thrive,” he said.

According to a Cochrane Collaboration review that has not yet been published, effective screening for depression—even mild depression—can be done with two questions: “Have you been bothered in the past month by low interest in pleasure or doing things?” and “Have you been feeling down, depressed, or hopeless in the past month?”

Selective serotonin reuptake inhibitors can be effective. A recent study of sertraline found that an 8-week course of treatment produced good improvement in the elderly, Dr. Hall noted. But patients not assigned to drug therapy also showed a fairly pronounced improvement—a common finding in studies of depression in the elderly.

SAN FRANCISCO — Screening for the four common problems of old age that constitute geriatric syndrome—cognitive loss, falls, incontinence, and depression—offers a holistic way to meet the needs of elderly patients, William J. Hall, M.D., said at the annual meeting of the American College of Physicians.

These problems affect the patient's quality of life and compliance with treatment for other medical conditions, noted Dr. Hall, director of the Center for Healthy Aging at the University of Rochester (N.Y.).

“The fact is, when elderly people are depressed, they don't take their ACE inhibitors,” he said. “It's as simple as that.”

A good way to address geriatric syndrome during office visits, Dr. Hall said, is to focus on one of the following components at each visit:

▸ Cognitive loss. The Mini-Mental State Examination (MMSE) is a good screen for cognitive loss. But a new mental status exam that is even more practical appears to be highly sensitive. The exam includes a category fluency test (in 1 minute, the patient names as many things as possible in a category such as animals or cities) and a phonemic fluency test (in 1 minute, the patient names as many words as possible that start with a given letter).

When a cutoff of 15 words is used for the category fluency test, it appears to pick up about 90% of cases of dementia—even mild dementia (Neurology 2004;62:556–62).

The test may provide differential information, because patients with vascular dementia have more impairment in the phonemic test than the category test, Dr. Hall said.

Treatments for cognitive impairment seem to have “reached the end of the line” with the cholinesterase inhibitors and memantine, at least for now, he said.

Much of the initial enthusiasm about the cholinesterase inhibitors has turned to skepticism recently. Donepezil (Aricept) was shown in one influential study to double the time it took for patients to enter a nursing home, but that study has not yet been replicated. In general, there is a dearth of independent studies of cholinesterase inhibitors not sponsored by drug manufacturers.

Combined treatment with memantine and donepezil has become popular based on a study suggesting that it improved quality of life, but many experts looking at the data question whether the degree of improvement is worth the cost, Dr. Hall said.

That does not mean that the drugs are not beneficial, just that the complete data are not in, he added. “I would have a very hard time not trying Aricept in dementia,” he said. “There is so little hope otherwise.”

▸ Falls. European geriatricians studying the stance and movement of elderly people who have serious falls have identified a “psychomotor disadaptation syndrome.” The characteristic features include a stance with trunk bent forward, toes clenched, and knee flexion, or the presence of reactional hypertonia.

In the office setting, the “get-up-and-go” test offers a practical way to identify patients at risk of falling, Dr. Hall said. The patient is directed to rise from a chair, walk 10 feet, turn around, return to the chair, and sit down. The tester rates the patient's stability.

Muscle weakness appears to be the most important predictor of falls. “It trumps everything else by a substantial order of magnitude,” Dr. Hall said.

Even minimal strength training can yield benefits, and several exercises can be used that do not require expensive equipment or supervision. Wall squats done with small weights are helpful and pose little risk of falling, because the patient has his or her back to the wall, he said.

▸ Urinary incontinence. After age 65 years, 15%–30% of women have urinary incontinence, and 50% of all elderly patients living in institutions have it. Even though urinary incontinence can greatly limit their activities, fewer than half of patients seek medical help without prompting. When patients do seek help, the average time from the beginning of a serious problem to the appointment is 41 months. Thus physicians must be proactive in looking for the problem, Dr. Hall said.

The cough stress test is “really good” at picking up urinary incontinence. Leakage with a cough may signal either stress incontinence or overactive bladder. With stress incontinence, the leakage occurs immediately. With overactive bladder, it takes a few seconds, he explained.

Kegel exercises are highly effective for stress incontinence. A recent major review of the evidence suggested that women who did pelvic floor muscle training were 23 times more likely to have cure or improvement in their incontinence, without the need for other treatments.

▸ Depression. Few elderly people develop full-blown depression that would meet diagnostic criteria. Rather, they are prone to subclinical depression that can almost be described as a “failure to thrive,” he said.

According to a Cochrane Collaboration review that has not yet been published, effective screening for depression—even mild depression—can be done with two questions: “Have you been bothered in the past month by low interest in pleasure or doing things?” and “Have you been feeling down, depressed, or hopeless in the past month?”

Selective serotonin reuptake inhibitors can be effective. A recent study of sertraline found that an 8-week course of treatment produced good improvement in the elderly, Dr. Hall noted. But patients not assigned to drug therapy also showed a fairly pronounced improvement—a common finding in studies of depression in the elderly.

HONOLULU — Four factors can help distinguish a girl who has an eating disorder from one who simply diets, Catherine M. Shisslak, Ph.D., said at the annual meeting of the American Psychological Association.

More than 50% of adolescent girls report dieting chronically, intermittently, or occasionally, according to the results of a longitudinal study of 1,170 girls for 4 years through high school.

Any girl who reports dieting in the past year and has these four risk factors—high body mass index, onset of menstruation by sixth grade, overly concerned with weight or shape, and teasing by peers—should be screened, Dr. Shisslak said in a poster presentation.

Those factors correctly identified 88% who reported they were chronic dieters. Eighty percent were chronic dieters who had an eating disorder at the start of the study or developed one in high school.

The unexpected finding was that peer teasing played such a prominent role in the disorders, Dr. Shisslak said. Other studies have noted how parents' comments about weight can be implicated, but this study suggests comments from peers can be even more devastating.

The results also suggest girls who do not report regular dieting but suddenly start a diet may be more likely to develop a disorder than those who occasionally but regularly diet. Eight percent of intermittent dieters had a disorder, compared with 2% who occasionally dieted.

Intermittent dieters were defined as those who reported dieting only 1 or 2 years during the 4 years of the study.

The investigators followed the girls using a 103-question survey, which they completed each year. They also measured height and weight annually to determine body mass index, and they conducted a semistructured interview designed to identify eating disorders.

HONOLULU — Four factors can help distinguish a girl who has an eating disorder from one who simply diets, Catherine M. Shisslak, Ph.D., said at the annual meeting of the American Psychological Association.

More than 50% of adolescent girls report dieting chronically, intermittently, or occasionally, according to the results of a longitudinal study of 1,170 girls for 4 years through high school.

Any girl who reports dieting in the past year and has these four risk factors—high body mass index, onset of menstruation by sixth grade, overly concerned with weight or shape, and teasing by peers—should be screened, Dr. Shisslak said in a poster presentation.

Those factors correctly identified 88% who reported they were chronic dieters. Eighty percent were chronic dieters who had an eating disorder at the start of the study or developed one in high school.

The unexpected finding was that peer teasing played such a prominent role in the disorders, Dr. Shisslak said. Other studies have noted how parents' comments about weight can be implicated, but this study suggests comments from peers can be even more devastating.

The results also suggest girls who do not report regular dieting but suddenly start a diet may be more likely to develop a disorder than those who occasionally but regularly diet. Eight percent of intermittent dieters had a disorder, compared with 2% who occasionally dieted.

Intermittent dieters were defined as those who reported dieting only 1 or 2 years during the 4 years of the study.

The investigators followed the girls using a 103-question survey, which they completed each year. They also measured height and weight annually to determine body mass index, and they conducted a semistructured interview designed to identify eating disorders.

HONOLULU — Four factors can help distinguish a girl who has an eating disorder from one who simply diets, Catherine M. Shisslak, Ph.D., said at the annual meeting of the American Psychological Association.

More than 50% of adolescent girls report dieting chronically, intermittently, or occasionally, according to the results of a longitudinal study of 1,170 girls for 4 years through high school.

Any girl who reports dieting in the past year and has these four risk factors—high body mass index, onset of menstruation by sixth grade, overly concerned with weight or shape, and teasing by peers—should be screened, Dr. Shisslak said in a poster presentation.

Those factors correctly identified 88% who reported they were chronic dieters. Eighty percent were chronic dieters who had an eating disorder at the start of the study or developed one in high school.

The unexpected finding was that peer teasing played such a prominent role in the disorders, Dr. Shisslak said. Other studies have noted how parents' comments about weight can be implicated, but this study suggests comments from peers can be even more devastating.

The results also suggest girls who do not report regular dieting but suddenly start a diet may be more likely to develop a disorder than those who occasionally but regularly diet. Eight percent of intermittent dieters had a disorder, compared with 2% who occasionally dieted.

Intermittent dieters were defined as those who reported dieting only 1 or 2 years during the 4 years of the study.

The investigators followed the girls using a 103-question survey, which they completed each year. They also measured height and weight annually to determine body mass index, and they conducted a semistructured interview designed to identify eating disorders.

LOS ANGELES — Physicians mostly fail to follow up with adolescent patients they treat for a chlamydia infection, as recommendations state they should, according to a study conducted with the records from five Northern California pediatric clinics.

Only 10% of 122 patients testing positive for a Chlamydia trachomatis infection at the clinics received appropriate retesting, and many also did not appear to have been counseled about safer sex, did not notify their partners, or were not tested for other STDs, Loris Hwang, M.D., and her colleagues said in a poster presentation at the annual meeting of the Society for Adolescent Medicine.

Antibiotic resistance is not considered a problem with chlamydia, so treatment generally is successful and a follow-up visit is not necessary to test for cure. Rather, the reason for follow-up is because those who get infected tend to return to the same “sexual networks” where they got the infection in the first place, said Dr. Hwang of the University of California, San Francisco.

Because the study was conducted at clinics that were all part of the Kaiser Permanente system, an HMO where return visits would presumably be fairly easy for patients, “the situation is probably worse in other clinics,” Dr. Hwang said in an interview.

Guidelines for chlamydia treatment from the Centers for Disease Control and Prevention recommend that patients have one follow-up visit for retesting at 3–4 months following a treatment visit, and then another within 12 months. Retesting at less than 3 weeks from treatment is specifically not recommended because nonculture tests can remain positive for that amount of time.

There were 122 individuals in the study, and 97% received appropriate antibiotics; of those, 22% were retested within 3 weeks of treatment. An additional 17% were retested after 3 weeks but before 3 months. And, 10% received retesting at some time after 3 months and before 12 months.

The remaining patients either had another visit but were not retested, were advised to return but did not, or had no records about a follow-up visit.

Regarding the other recommendations in the CDC guidelines, Dr. Hwang and her colleagues found that the physicians tended to do better with the female patients than the males.

Eighty-three percent of the study's 96 adolescent women were counseled on safer sex, compared with 62% of the study's 26 adolescent men. Thirty-eight percent of the women were screened for other sexually transmitted diseases, compared with 31% of the men. And, partners were notified or treated for 57% of the females, but only 31% of the men.

LOS ANGELES — Physicians mostly fail to follow up with adolescent patients they treat for a chlamydia infection, as recommendations state they should, according to a study conducted with the records from five Northern California pediatric clinics.

Only 10% of 122 patients testing positive for a Chlamydia trachomatis infection at the clinics received appropriate retesting, and many also did not appear to have been counseled about safer sex, did not notify their partners, or were not tested for other STDs, Loris Hwang, M.D., and her colleagues said in a poster presentation at the annual meeting of the Society for Adolescent Medicine.

Antibiotic resistance is not considered a problem with chlamydia, so treatment generally is successful and a follow-up visit is not necessary to test for cure. Rather, the reason for follow-up is because those who get infected tend to return to the same “sexual networks” where they got the infection in the first place, said Dr. Hwang of the University of California, San Francisco.

Because the study was conducted at clinics that were all part of the Kaiser Permanente system, an HMO where return visits would presumably be fairly easy for patients, “the situation is probably worse in other clinics,” Dr. Hwang said in an interview.

Guidelines for chlamydia treatment from the Centers for Disease Control and Prevention recommend that patients have one follow-up visit for retesting at 3–4 months following a treatment visit, and then another within 12 months. Retesting at less than 3 weeks from treatment is specifically not recommended because nonculture tests can remain positive for that amount of time.

There were 122 individuals in the study, and 97% received appropriate antibiotics; of those, 22% were retested within 3 weeks of treatment. An additional 17% were retested after 3 weeks but before 3 months. And, 10% received retesting at some time after 3 months and before 12 months.

The remaining patients either had another visit but were not retested, were advised to return but did not, or had no records about a follow-up visit.

Regarding the other recommendations in the CDC guidelines, Dr. Hwang and her colleagues found that the physicians tended to do better with the female patients than the males.

Eighty-three percent of the study's 96 adolescent women were counseled on safer sex, compared with 62% of the study's 26 adolescent men. Thirty-eight percent of the women were screened for other sexually transmitted diseases, compared with 31% of the men. And, partners were notified or treated for 57% of the females, but only 31% of the men.

LOS ANGELES — Physicians mostly fail to follow up with adolescent patients they treat for a chlamydia infection, as recommendations state they should, according to a study conducted with the records from five Northern California pediatric clinics.

Only 10% of 122 patients testing positive for a Chlamydia trachomatis infection at the clinics received appropriate retesting, and many also did not appear to have been counseled about safer sex, did not notify their partners, or were not tested for other STDs, Loris Hwang, M.D., and her colleagues said in a poster presentation at the annual meeting of the Society for Adolescent Medicine.

Antibiotic resistance is not considered a problem with chlamydia, so treatment generally is successful and a follow-up visit is not necessary to test for cure. Rather, the reason for follow-up is because those who get infected tend to return to the same “sexual networks” where they got the infection in the first place, said Dr. Hwang of the University of California, San Francisco.

Because the study was conducted at clinics that were all part of the Kaiser Permanente system, an HMO where return visits would presumably be fairly easy for patients, “the situation is probably worse in other clinics,” Dr. Hwang said in an interview.

Guidelines for chlamydia treatment from the Centers for Disease Control and Prevention recommend that patients have one follow-up visit for retesting at 3–4 months following a treatment visit, and then another within 12 months. Retesting at less than 3 weeks from treatment is specifically not recommended because nonculture tests can remain positive for that amount of time.

There were 122 individuals in the study, and 97% received appropriate antibiotics; of those, 22% were retested within 3 weeks of treatment. An additional 17% were retested after 3 weeks but before 3 months. And, 10% received retesting at some time after 3 months and before 12 months.

The remaining patients either had another visit but were not retested, were advised to return but did not, or had no records about a follow-up visit.

Regarding the other recommendations in the CDC guidelines, Dr. Hwang and her colleagues found that the physicians tended to do better with the female patients than the males.

Eighty-three percent of the study's 96 adolescent women were counseled on safer sex, compared with 62% of the study's 26 adolescent men. Thirty-eight percent of the women were screened for other sexually transmitted diseases, compared with 31% of the men. And, partners were notified or treated for 57% of the females, but only 31% of the men.

SNOWMASS, COLO. – Sciatica and low back pain respond best to low doses of medications used in combination as opposed to high-dose monotherapy, David G. Borenstein, M.D., said at a symposium sponsored by the American College of Rheumatology.

There are no magic bullets. Instead, “it's trial and error and seeing what works with a patient,” said Dr. Borenstein, a textbook author and researcher who practices in a rheumatology group in Washington.

According to prescribing patterns, it appears that muscle relaxants are among the most effective medications for back pain, but they're more effective when used in combination with other medications.

In a telephone survey of patients with acute low back pain contacted 1 week after an office visit, the best outcomes appeared to be associated with a combination treatment using a muscle relaxant and an NSAID together. Other respondents were taking no medication, or opioids, acetaminophen, and muscle relaxants alone (Spine 1998;23:607–14).

Dr. Borenstein said the survey findings are consistent with his own clinical experience using combination regimens, which he said can minimize side effects and have a synergistic effect. He added that providers could use a lot more guidance on how to use drugs in combination; more dose-finding studies are needed.

In a report on two combined studies involving 1,405 patients with low back or neck pain, participants were randomly assigned to take the muscle relaxant cyclobenzaprine or placebo. Dr. Borenstein noted that the cyclobenzaprine outperformed placebo in three primary, patient-rated end points: relief from pain at the start of the day, assessment of medication helpfulness, and clinical global impression of change.

Interestingly, when the researchers looked at three doses–2.5 mg, 5 mg, and 10 mg–each taken three times daily, they found that all the doses were more effective than placebo. The 5-mg dose was no less effective than the 10-mg dose and was less likely to cause sedation, Dr. Borenstein said (Clin. Ther. 2003;25:1056–73).

Future strategies for treating low back pain may involve biologics such as infliximab, Dr. Borenstein said.

Yet to be published open-label trials of infliximab, conducted in Finland, have shown significant efficacy within hours of patients' receiving a single injection, compared with controls that were given sham injections of saline.

Yet the only double-blinded, controlled trial reported to date found no benefit relative to placebo. The lack of efficacy seen in this unpublished trial may have been due to the high placebo response, Dr. Borenstein said. Another trial is underway.

SNOWMASS, COLO. – Sciatica and low back pain respond best to low doses of medications used in combination as opposed to high-dose monotherapy, David G. Borenstein, M.D., said at a symposium sponsored by the American College of Rheumatology.

There are no magic bullets. Instead, “it's trial and error and seeing what works with a patient,” said Dr. Borenstein, a textbook author and researcher who practices in a rheumatology group in Washington.

According to prescribing patterns, it appears that muscle relaxants are among the most effective medications for back pain, but they're more effective when used in combination with other medications.

In a telephone survey of patients with acute low back pain contacted 1 week after an office visit, the best outcomes appeared to be associated with a combination treatment using a muscle relaxant and an NSAID together. Other respondents were taking no medication, or opioids, acetaminophen, and muscle relaxants alone (Spine 1998;23:607–14).

Dr. Borenstein said the survey findings are consistent with his own clinical experience using combination regimens, which he said can minimize side effects and have a synergistic effect. He added that providers could use a lot more guidance on how to use drugs in combination; more dose-finding studies are needed.

In a report on two combined studies involving 1,405 patients with low back or neck pain, participants were randomly assigned to take the muscle relaxant cyclobenzaprine or placebo. Dr. Borenstein noted that the cyclobenzaprine outperformed placebo in three primary, patient-rated end points: relief from pain at the start of the day, assessment of medication helpfulness, and clinical global impression of change.

Interestingly, when the researchers looked at three doses–2.5 mg, 5 mg, and 10 mg–each taken three times daily, they found that all the doses were more effective than placebo. The 5-mg dose was no less effective than the 10-mg dose and was less likely to cause sedation, Dr. Borenstein said (Clin. Ther. 2003;25:1056–73).

Future strategies for treating low back pain may involve biologics such as infliximab, Dr. Borenstein said.

Yet to be published open-label trials of infliximab, conducted in Finland, have shown significant efficacy within hours of patients' receiving a single injection, compared with controls that were given sham injections of saline.

Yet the only double-blinded, controlled trial reported to date found no benefit relative to placebo. The lack of efficacy seen in this unpublished trial may have been due to the high placebo response, Dr. Borenstein said. Another trial is underway.

SNOWMASS, COLO. – Sciatica and low back pain respond best to low doses of medications used in combination as opposed to high-dose monotherapy, David G. Borenstein, M.D., said at a symposium sponsored by the American College of Rheumatology.

There are no magic bullets. Instead, “it's trial and error and seeing what works with a patient,” said Dr. Borenstein, a textbook author and researcher who practices in a rheumatology group in Washington.

According to prescribing patterns, it appears that muscle relaxants are among the most effective medications for back pain, but they're more effective when used in combination with other medications.

In a telephone survey of patients with acute low back pain contacted 1 week after an office visit, the best outcomes appeared to be associated with a combination treatment using a muscle relaxant and an NSAID together. Other respondents were taking no medication, or opioids, acetaminophen, and muscle relaxants alone (Spine 1998;23:607–14).

Dr. Borenstein said the survey findings are consistent with his own clinical experience using combination regimens, which he said can minimize side effects and have a synergistic effect. He added that providers could use a lot more guidance on how to use drugs in combination; more dose-finding studies are needed.

In a report on two combined studies involving 1,405 patients with low back or neck pain, participants were randomly assigned to take the muscle relaxant cyclobenzaprine or placebo. Dr. Borenstein noted that the cyclobenzaprine outperformed placebo in three primary, patient-rated end points: relief from pain at the start of the day, assessment of medication helpfulness, and clinical global impression of change.

Interestingly, when the researchers looked at three doses–2.5 mg, 5 mg, and 10 mg–each taken three times daily, they found that all the doses were more effective than placebo. The 5-mg dose was no less effective than the 10-mg dose and was less likely to cause sedation, Dr. Borenstein said (Clin. Ther. 2003;25:1056–73).

Future strategies for treating low back pain may involve biologics such as infliximab, Dr. Borenstein said.

Yet to be published open-label trials of infliximab, conducted in Finland, have shown significant efficacy within hours of patients' receiving a single injection, compared with controls that were given sham injections of saline.

Yet the only double-blinded, controlled trial reported to date found no benefit relative to placebo. The lack of efficacy seen in this unpublished trial may have been due to the high placebo response, Dr. Borenstein said. Another trial is underway.

CHICAGO — Levofloxacin-based therapy is superior to the other commonly used antibiotic combinations for Helicobacter pylori eradication, both as first and as second-line treatment, according to presentations at the annual Digestive Disease Week.

Levofloxacin-based therapy is becoming popular as salvage therapy after initial antibiotic therapy has failed, as occurs in perhaps 25% of initial treatments, said Richard J. Saad, M.D., of the division of gastroenterology at the University of Michigan, Ann Arbor. But reports on its efficacy rate have varied, and it has not been clear how triple therapy using levofloxacin compares with the more standard quadruple therapy used for patients who have failed eradication.

So Dr. Saad and colleagues performed a metaanalysis of trials reported since 2002.

Their analysis showed that triple treatment with levofloxacin (Levaquin), amoxicillin, and a proton-pump inhibitor for 10 days was 40% more likely to result in H. pylori eradication than quadruple therapy with bismuth subsalicylate, tetracycline, metronidazole, and a proton-pump inhibitor.

The analysis indicated that the levofloxacin-based therapy has a success rate of 87%, compared with a rate of 60% for standard quadruple therapy, Dr. Saad said.

Patients who used a levofloxacin also were 52% less likely to have side effects, and 70% less likely to discontinue therapy due to side effects.

In addition, the analysis showed that 10 days treatment with the levofloxacin-based therapy was significantly superior to 7 days (an eradication rate of 87%, vs. 68%), and that twice daily dosing of the levofloxacin (250 mg) was somewhat better than once daily dosing (500 mg), but only marginally so. Dr. Saad reported no conflicts of interest concerning the medications studied.

In a separate presentation, levofloxacin-based initial therapy had a higher eradication rate than two other commonly used combinations, Antonio Gasbarrini, M.D., said at the meeting.

His group found that a 7-day course of treatment with levofloxacin (500 mg, once daily), clarithromycin (500 mg, twice daily), and esomeprazole (20 mg, twice daily) resulted in eradication of H. pylori in 87 out of 100 patients, said Dr. Gasbarrini, of Gemelli Hospital, Catholic University of the Sacred Heart, Rome.

In comparison, a 7-day course of treatment with clarithromycin (500 mg, twice daily), amoxicillin (1 g, twice daily), and esomeprazole (20 mg, twice daily) resulted in eradication in 75 out of 100 patients, and a 7-day course of clarithromycin (500 mg, twice daily), metronidazole (500 mg, twice daily), and esomeprazole (20 mg, twice daily) resulted in eradication in 72 out of 100 patients.

Antibiotic resistance is the main reason initial treatment of H. pylori fails, and the known resistance rates in Italy (10%–30%) probably justify using the levofloxacin-based regimen as the first-line therapy, said Dr. Gasbarrini, who reported no conflicts of interest.

CHICAGO — Levofloxacin-based therapy is superior to the other commonly used antibiotic combinations for Helicobacter pylori eradication, both as first and as second-line treatment, according to presentations at the annual Digestive Disease Week.

Levofloxacin-based therapy is becoming popular as salvage therapy after initial antibiotic therapy has failed, as occurs in perhaps 25% of initial treatments, said Richard J. Saad, M.D., of the division of gastroenterology at the University of Michigan, Ann Arbor. But reports on its efficacy rate have varied, and it has not been clear how triple therapy using levofloxacin compares with the more standard quadruple therapy used for patients who have failed eradication.

So Dr. Saad and colleagues performed a metaanalysis of trials reported since 2002.

Their analysis showed that triple treatment with levofloxacin (Levaquin), amoxicillin, and a proton-pump inhibitor for 10 days was 40% more likely to result in H. pylori eradication than quadruple therapy with bismuth subsalicylate, tetracycline, metronidazole, and a proton-pump inhibitor.

The analysis indicated that the levofloxacin-based therapy has a success rate of 87%, compared with a rate of 60% for standard quadruple therapy, Dr. Saad said.

Patients who used a levofloxacin also were 52% less likely to have side effects, and 70% less likely to discontinue therapy due to side effects.

In addition, the analysis showed that 10 days treatment with the levofloxacin-based therapy was significantly superior to 7 days (an eradication rate of 87%, vs. 68%), and that twice daily dosing of the levofloxacin (250 mg) was somewhat better than once daily dosing (500 mg), but only marginally so. Dr. Saad reported no conflicts of interest concerning the medications studied.

In a separate presentation, levofloxacin-based initial therapy had a higher eradication rate than two other commonly used combinations, Antonio Gasbarrini, M.D., said at the meeting.

His group found that a 7-day course of treatment with levofloxacin (500 mg, once daily), clarithromycin (500 mg, twice daily), and esomeprazole (20 mg, twice daily) resulted in eradication of H. pylori in 87 out of 100 patients, said Dr. Gasbarrini, of Gemelli Hospital, Catholic University of the Sacred Heart, Rome.

In comparison, a 7-day course of treatment with clarithromycin (500 mg, twice daily), amoxicillin (1 g, twice daily), and esomeprazole (20 mg, twice daily) resulted in eradication in 75 out of 100 patients, and a 7-day course of clarithromycin (500 mg, twice daily), metronidazole (500 mg, twice daily), and esomeprazole (20 mg, twice daily) resulted in eradication in 72 out of 100 patients.

Antibiotic resistance is the main reason initial treatment of H. pylori fails, and the known resistance rates in Italy (10%–30%) probably justify using the levofloxacin-based regimen as the first-line therapy, said Dr. Gasbarrini, who reported no conflicts of interest.

CHICAGO — Levofloxacin-based therapy is superior to the other commonly used antibiotic combinations for Helicobacter pylori eradication, both as first and as second-line treatment, according to presentations at the annual Digestive Disease Week.

Levofloxacin-based therapy is becoming popular as salvage therapy after initial antibiotic therapy has failed, as occurs in perhaps 25% of initial treatments, said Richard J. Saad, M.D., of the division of gastroenterology at the University of Michigan, Ann Arbor. But reports on its efficacy rate have varied, and it has not been clear how triple therapy using levofloxacin compares with the more standard quadruple therapy used for patients who have failed eradication.

So Dr. Saad and colleagues performed a metaanalysis of trials reported since 2002.

Their analysis showed that triple treatment with levofloxacin (Levaquin), amoxicillin, and a proton-pump inhibitor for 10 days was 40% more likely to result in H. pylori eradication than quadruple therapy with bismuth subsalicylate, tetracycline, metronidazole, and a proton-pump inhibitor.

The analysis indicated that the levofloxacin-based therapy has a success rate of 87%, compared with a rate of 60% for standard quadruple therapy, Dr. Saad said.

Patients who used a levofloxacin also were 52% less likely to have side effects, and 70% less likely to discontinue therapy due to side effects.

In addition, the analysis showed that 10 days treatment with the levofloxacin-based therapy was significantly superior to 7 days (an eradication rate of 87%, vs. 68%), and that twice daily dosing of the levofloxacin (250 mg) was somewhat better than once daily dosing (500 mg), but only marginally so. Dr. Saad reported no conflicts of interest concerning the medications studied.

In a separate presentation, levofloxacin-based initial therapy had a higher eradication rate than two other commonly used combinations, Antonio Gasbarrini, M.D., said at the meeting.

His group found that a 7-day course of treatment with levofloxacin (500 mg, once daily), clarithromycin (500 mg, twice daily), and esomeprazole (20 mg, twice daily) resulted in eradication of H. pylori in 87 out of 100 patients, said Dr. Gasbarrini, of Gemelli Hospital, Catholic University of the Sacred Heart, Rome.

In comparison, a 7-day course of treatment with clarithromycin (500 mg, twice daily), amoxicillin (1 g, twice daily), and esomeprazole (20 mg, twice daily) resulted in eradication in 75 out of 100 patients, and a 7-day course of clarithromycin (500 mg, twice daily), metronidazole (500 mg, twice daily), and esomeprazole (20 mg, twice daily) resulted in eradication in 72 out of 100 patients.

Antibiotic resistance is the main reason initial treatment of H. pylori fails, and the known resistance rates in Italy (10%–30%) probably justify using the levofloxacin-based regimen as the first-line therapy, said Dr. Gasbarrini, who reported no conflicts of interest.

CHICAGO — How is Helicobacter pylori transmitted in industrial countries with adequate sanitation?

Exposure to an infected person who is vomiting may be one way, according to findings from a large, 4-year study of California families with an index case of gastroenteritis.

The study found that the chance of acquiring H. pylori was 2.2 times higher when a person was exposed to a person with H. pylori infection who also had a case of infectious gastroenteritis than it was when a person lived with an H. pylori-infected individual who did not have infectious gastroenteritis.

The chance rose to 2.6 times if the H. pylori-infected person had vomiting with the gastroenteritis. Diarrhea also increased the risk, but only 2.0-fold, Sharon Perry, M.D., said at the annual Digestive Disease Week.

Figuring out how H. pylori is transmitted has been a “Holy Grail” of epidemiology for 20 years, said Dr. Perry, an epidemiologist at the Parsonnet Laboratory of the Division of Geographic Medicine and Infectious Diseases at Stanford University.

“This is not the Holy Grail study, but we may have visited the scene of the crime,” she said.

The study was conducted by contacting families in which an individual was seen for an episode of infectious gastroenteritis at any one of 15 clinics in the San Francisco Bay area. Of all the cases seen, 909 families agreed to participate in the study and were visited twice—first around the time of the gastroenteritis and again 3 months later. The family members were questioned, and stool and serology samples were collected.

Most of the families were Hispanic and lived in fairly crowded circumstances, Dr. Perry said.

Among 1,792 household contacts of a person with gastroenteritis, the study found 30 cases of individuals who were not infected with H. pylori at the first visit but were 3 months later, for an overall annualized rate of infection of 7%.

Seven of those new cases occurred in households without a person already infected with H. pylori, for an annualized rate of 4% for those households.

Thirteen new cases occurred in households were there was a person infected with H. pylori already, but that person was not the one who had infectious gastroenteritis, for an annualized infection rate of 7%. And 10 new cases occurred in households were a person infected with H. pylori initially was the same one who had infectious gastroenteritis, for an annualized infection rate of 11%, Dr. Perry said.

Half the new cases occurred in children less than 2 years of age.

CHICAGO — How is Helicobacter pylori transmitted in industrial countries with adequate sanitation?

Exposure to an infected person who is vomiting may be one way, according to findings from a large, 4-year study of California families with an index case of gastroenteritis.

The study found that the chance of acquiring H. pylori was 2.2 times higher when a person was exposed to a person with H. pylori infection who also had a case of infectious gastroenteritis than it was when a person lived with an H. pylori-infected individual who did not have infectious gastroenteritis.

The chance rose to 2.6 times if the H. pylori-infected person had vomiting with the gastroenteritis. Diarrhea also increased the risk, but only 2.0-fold, Sharon Perry, M.D., said at the annual Digestive Disease Week.

Figuring out how H. pylori is transmitted has been a “Holy Grail” of epidemiology for 20 years, said Dr. Perry, an epidemiologist at the Parsonnet Laboratory of the Division of Geographic Medicine and Infectious Diseases at Stanford University.

“This is not the Holy Grail study, but we may have visited the scene of the crime,” she said.

The study was conducted by contacting families in which an individual was seen for an episode of infectious gastroenteritis at any one of 15 clinics in the San Francisco Bay area. Of all the cases seen, 909 families agreed to participate in the study and were visited twice—first around the time of the gastroenteritis and again 3 months later. The family members were questioned, and stool and serology samples were collected.

Most of the families were Hispanic and lived in fairly crowded circumstances, Dr. Perry said.

Among 1,792 household contacts of a person with gastroenteritis, the study found 30 cases of individuals who were not infected with H. pylori at the first visit but were 3 months later, for an overall annualized rate of infection of 7%.

Seven of those new cases occurred in households without a person already infected with H. pylori, for an annualized rate of 4% for those households.

Thirteen new cases occurred in households were there was a person infected with H. pylori already, but that person was not the one who had infectious gastroenteritis, for an annualized infection rate of 7%. And 10 new cases occurred in households were a person infected with H. pylori initially was the same one who had infectious gastroenteritis, for an annualized infection rate of 11%, Dr. Perry said.

Half the new cases occurred in children less than 2 years of age.

CHICAGO — How is Helicobacter pylori transmitted in industrial countries with adequate sanitation?

Exposure to an infected person who is vomiting may be one way, according to findings from a large, 4-year study of California families with an index case of gastroenteritis.

The study found that the chance of acquiring H. pylori was 2.2 times higher when a person was exposed to a person with H. pylori infection who also had a case of infectious gastroenteritis than it was when a person lived with an H. pylori-infected individual who did not have infectious gastroenteritis.

The chance rose to 2.6 times if the H. pylori-infected person had vomiting with the gastroenteritis. Diarrhea also increased the risk, but only 2.0-fold, Sharon Perry, M.D., said at the annual Digestive Disease Week.

Figuring out how H. pylori is transmitted has been a “Holy Grail” of epidemiology for 20 years, said Dr. Perry, an epidemiologist at the Parsonnet Laboratory of the Division of Geographic Medicine and Infectious Diseases at Stanford University.

“This is not the Holy Grail study, but we may have visited the scene of the crime,” she said.

The study was conducted by contacting families in which an individual was seen for an episode of infectious gastroenteritis at any one of 15 clinics in the San Francisco Bay area. Of all the cases seen, 909 families agreed to participate in the study and were visited twice—first around the time of the gastroenteritis and again 3 months later. The family members were questioned, and stool and serology samples were collected.

Most of the families were Hispanic and lived in fairly crowded circumstances, Dr. Perry said.

Among 1,792 household contacts of a person with gastroenteritis, the study found 30 cases of individuals who were not infected with H. pylori at the first visit but were 3 months later, for an overall annualized rate of infection of 7%.

Seven of those new cases occurred in households without a person already infected with H. pylori, for an annualized rate of 4% for those households.

Thirteen new cases occurred in households were there was a person infected with H. pylori already, but that person was not the one who had infectious gastroenteritis, for an annualized infection rate of 7%. And 10 new cases occurred in households were a person infected with H. pylori initially was the same one who had infectious gastroenteritis, for an annualized infection rate of 11%, Dr. Perry said.

Half the new cases occurred in children less than 2 years of age.

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

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

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

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

Of nine sources of fiber studied, rice was the only one that was independently correlated with the prevalence of Crohn's disease. When changes in the consumption of animal fat were included in the analysis, rice remained the only independent factor.

Breakfast is the meal that has changed the most in Japan and is probably the most responsible for the decline in rice consumption, Dr. Shoda said in an interview. Many people in Japan now eat bread rather than rice with breakfast.

Dr. Shoda declined to speculate on what might explain the association. “This is just statistics,” he told this newspaper. “No one knows about this for certain. There must be other factors.”

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

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

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

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

Of nine sources of fiber studied, rice was the only one that was independently correlated with the prevalence of Crohn's disease. When changes in the consumption of animal fat were included in the analysis, rice remained the only independent factor.

Breakfast is the meal that has changed the most in Japan and is probably the most responsible for the decline in rice consumption, Dr. Shoda said in an interview. Many people in Japan now eat bread rather than rice with breakfast.

Dr. Shoda declined to speculate on what might explain the association. “This is just statistics,” he told this newspaper. “No one knows about this for certain. There must be other factors.”

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

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

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

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

Of nine sources of fiber studied, rice was the only one that was independently correlated with the prevalence of Crohn's disease. When changes in the consumption of animal fat were included in the analysis, rice remained the only independent factor.

Breakfast is the meal that has changed the most in Japan and is probably the most responsible for the decline in rice consumption, Dr. Shoda said in an interview. Many people in Japan now eat bread rather than rice with breakfast.

Dr. Shoda declined to speculate on what might explain the association. “This is just statistics,” he told this newspaper. “No one knows about this for certain. There must be other factors.”

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 that 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 that 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 that 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.

LOS ANGELES — Condom use does matter in human papillomavirus infections, because it is associated with a shorter persistence of infection in females, according to a study of 57 sexually active female adolescents.

The investigators followed the adolescents for an average 2.2 years, included periods during which the subjects collected vaginal swabs weekly. The results showed that in those who reported the least-frequent condom use, the mean duration of an HPV infection was 251 days, compared with a mean duration of 138 days for those reporting the most condom use, Marcia L. Shew, M.D., said at the annual meeting of the Society for Adolescent Medicine.

Noting that a recent National Institutes of Health report concluded that previous studies have not provided good enough evidence to know whether condom use prevents or influences HPV infection and transmission, Dr. Shew said, “We were so excited when we found out that condoms had a role, and it makes sense because condom use has clearly been shown to be associated with more frequent regression in cervical intraepithelial neoplasia.”

The study, which, in addition to the weekly vaginal swabs collected by the subjects themselves, looked at cervical swabs collected by the investigators every 3 months, found that 49 of the 57 subjects got at least one infection during the average 2.2 years, for a cumulative incidence of 86%, said Dr. Shew of Indiana University, Indianapolis.

Among them, there were 241 individual infections, or an average of about 5 per individual. Of those infections, 168 were of a high-risk, oncogenic type of papillomavirus, and 73 were of a low-risk type. The types most frequently detected were 52 and 16, both high-risk types, and 66, a low-risk type.

Factors the study found to be associated with longer duration of infection included oncogenic type, coinfection with chlamydia, a greater number of sexual partners, and less condom use.

Analysis indicated that the mean duration of infection with an oncogenic type papillomavirus was 226 days vs. a mean 159 days for the infections with nononcogenic types. Mean duration of infection in those cases that occurred with a concurrent chlamydia infection was 333 days vs. 96 days. And the average duration of an infection in an individual with multiple sexual partners was 436 days, vs. 96 days in those individuals who had only one or no partners during the infection.

Some possible explanations for why condom use results in shorter infections include that someone who is having repeated sex with an infected individual might be exposed to a higher viral load, or even that semen is proinflammatory, and that this somehow contributes, Dr. Shew said.

“We feel these findings have substantial clinical and public health significance, and clearly may help to reduce viral transmission,” she added.

LOS ANGELES — Condom use does matter in human papillomavirus infections, because it is associated with a shorter persistence of infection in females, according to a study of 57 sexually active female adolescents.

The investigators followed the adolescents for an average 2.2 years, included periods during which the subjects collected vaginal swabs weekly. The results showed that in those who reported the least-frequent condom use, the mean duration of an HPV infection was 251 days, compared with a mean duration of 138 days for those reporting the most condom use, Marcia L. Shew, M.D., said at the annual meeting of the Society for Adolescent Medicine.

Noting that a recent National Institutes of Health report concluded that previous studies have not provided good enough evidence to know whether condom use prevents or influences HPV infection and transmission, Dr. Shew said, “We were so excited when we found out that condoms had a role, and it makes sense because condom use has clearly been shown to be associated with more frequent regression in cervical intraepithelial neoplasia.”

The study, which, in addition to the weekly vaginal swabs collected by the subjects themselves, looked at cervical swabs collected by the investigators every 3 months, found that 49 of the 57 subjects got at least one infection during the average 2.2 years, for a cumulative incidence of 86%, said Dr. Shew of Indiana University, Indianapolis.

Among them, there were 241 individual infections, or an average of about 5 per individual. Of those infections, 168 were of a high-risk, oncogenic type of papillomavirus, and 73 were of a low-risk type. The types most frequently detected were 52 and 16, both high-risk types, and 66, a low-risk type.

Factors the study found to be associated with longer duration of infection included oncogenic type, coinfection with chlamydia, a greater number of sexual partners, and less condom use.

Analysis indicated that the mean duration of infection with an oncogenic type papillomavirus was 226 days vs. a mean 159 days for the infections with nononcogenic types. Mean duration of infection in those cases that occurred with a concurrent chlamydia infection was 333 days vs. 96 days. And the average duration of an infection in an individual with multiple sexual partners was 436 days, vs. 96 days in those individuals who had only one or no partners during the infection.

Some possible explanations for why condom use results in shorter infections include that someone who is having repeated sex with an infected individual might be exposed to a higher viral load, or even that semen is proinflammatory, and that this somehow contributes, Dr. Shew said.

“We feel these findings have substantial clinical and public health significance, and clearly may help to reduce viral transmission,” she added.

LOS ANGELES — Condom use does matter in human papillomavirus infections, because it is associated with a shorter persistence of infection in females, according to a study of 57 sexually active female adolescents.

The investigators followed the adolescents for an average 2.2 years, included periods during which the subjects collected vaginal swabs weekly. The results showed that in those who reported the least-frequent condom use, the mean duration of an HPV infection was 251 days, compared with a mean duration of 138 days for those reporting the most condom use, Marcia L. Shew, M.D., said at the annual meeting of the Society for Adolescent Medicine.

Noting that a recent National Institutes of Health report concluded that previous studies have not provided good enough evidence to know whether condom use prevents or influences HPV infection and transmission, Dr. Shew said, “We were so excited when we found out that condoms had a role, and it makes sense because condom use has clearly been shown to be associated with more frequent regression in cervical intraepithelial neoplasia.”

The study, which, in addition to the weekly vaginal swabs collected by the subjects themselves, looked at cervical swabs collected by the investigators every 3 months, found that 49 of the 57 subjects got at least one infection during the average 2.2 years, for a cumulative incidence of 86%, said Dr. Shew of Indiana University, Indianapolis.

Among them, there were 241 individual infections, or an average of about 5 per individual. Of those infections, 168 were of a high-risk, oncogenic type of papillomavirus, and 73 were of a low-risk type. The types most frequently detected were 52 and 16, both high-risk types, and 66, a low-risk type.

Factors the study found to be associated with longer duration of infection included oncogenic type, coinfection with chlamydia, a greater number of sexual partners, and less condom use.

Analysis indicated that the mean duration of infection with an oncogenic type papillomavirus was 226 days vs. a mean 159 days for the infections with nononcogenic types. Mean duration of infection in those cases that occurred with a concurrent chlamydia infection was 333 days vs. 96 days. And the average duration of an infection in an individual with multiple sexual partners was 436 days, vs. 96 days in those individuals who had only one or no partners during the infection.

Some possible explanations for why condom use results in shorter infections include that someone who is having repeated sex with an infected individual might be exposed to a higher viral load, or even that semen is proinflammatory, and that this somehow contributes, Dr. Shew said.

“We feel these findings have substantial clinical and public health significance, and clearly may help to reduce viral transmission,” she added.

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.

Of persons 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 with five chronic conditions sees almost 14 physicians (including radiologists and anesthesiologists) per year and has a total of 37 visits, Dr. Berenson 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, he 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.

Of persons 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 with five chronic conditions sees almost 14 physicians (including radiologists and anesthesiologists) per year and has a total of 37 visits, Dr. Berenson 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, he 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.

Of persons 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 with five chronic conditions sees almost 14 physicians (including radiologists and anesthesiologists) per year and has a total of 37 visits, Dr. Berenson 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, he 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.