Timothy F. Kirn

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.

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 are more effective when used in combination with other medications, Dr. Borenstein said.

In a telephone survey of patients with acute low back pain who were 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. They were 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.

Several studies using animal models suggest that back pain, and the radicular pain that frequently accompanies it, is not caused by direct compression so much as by processes occurring in the nucleus pulposus, perhaps mediated by tumor necrosis factor.

Yet to be published open-label trials of infliximab that were 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.

However, 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 commented.

Another trial is underway. “[We need to] find out who the appropriate patients are,” he said. “Then I suspect we will be able to show this is a good therapy.”

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 are more effective when used in combination with other medications, Dr. Borenstein said.

In a telephone survey of patients with acute low back pain who were 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. They were 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.

Several studies using animal models suggest that back pain, and the radicular pain that frequently accompanies it, is not caused by direct compression so much as by processes occurring in the nucleus pulposus, perhaps mediated by tumor necrosis factor.

Yet to be published open-label trials of infliximab that were 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.

However, 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 commented.

Another trial is underway. “[We need to] find out who the appropriate patients are,” he said. “Then I suspect we will be able to show this is a good therapy.”

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 are more effective when used in combination with other medications, Dr. Borenstein said.

In a telephone survey of patients with acute low back pain who were 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. They were 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.

Several studies using animal models suggest that back pain, and the radicular pain that frequently accompanies it, is not caused by direct compression so much as by processes occurring in the nucleus pulposus, perhaps mediated by tumor necrosis factor.

Yet to be published open-label trials of infliximab that were 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.

However, 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 commented.

Another trial is underway. “[We need to] find out who the appropriate patients are,” he said. “Then I suspect we will be able to show this is a good therapy.”

SAN ANTONIO — The next-generation selective estrogen receptor modulator, lasofoxifene, increased vertebral bone mineral density better than did raloxifene, according to the findings of a company-sponsored trial presented at the annual meeting of the American College of Rheumatology.

In the study, 410 postmenopausal women were randomly assigned to one of two doses of lasofoxifene, 0.25 mg or 1 mg daily; raloxifene at 60 mg daily; or a placebo. The half-life of lasofoxifene is about a week versus 28 hours for raloxifene, said Andy Lee, a director with Pfizer Global Research and Development, New London, Conn.

The lasofoxifene increased bone mineral density (BMD) at the lumbar spine by a mean of about 2% after 2 years of treatment. That compared with no mean improvement in spine BMD—but no density loss—in patients assigned to raloxifene, and a 2% density loss in the placebo group.

BMD at the total hip improved by a mean of 1% for patients taking either raloxifene or lasofoxifene; total hip BMD stayed the same in patients taking placebo.

Although responsiveness to lasofoxifene varied, overall more women responded to lasofoxifene than to raloxifene, Mr. Lee said. Spine density improved or was at least maintained in 90% and 93% of the patients in the low- and high-dose lasofoxifene groups, respectively. That compared with 77% of the patients who took raloxifene and 65% of the patients who took placebo.

Changes in bone turnover markers were also greater with lasofoxifene. N-telopeptide levels, for example, decreased by a mean 35% in the patients on lasofoxifene, versus 15% in the patients on raloxifene. And the new drug reduced LDL cholesterol levels by a mean of 20% versus 12% for raloxifene.

Future trials of lasofoxifene will use the 0.25-mg dose, Mr. Lee said.

Some women on lasofoxifene experienced hot flashes, leg cramps, and increased vaginal moisture, but overall the two drugs were tolerated similarly.

None of the lasofoxifene trials has shown an increase in endometrial hyperplasia or vaginal bleeding, Mr. Lee said. Likewise, there have been no reports of urogenital prolapse, a problem that has plagued earlier selective estrogen receptor modulators.

SAN ANTONIO — The next-generation selective estrogen receptor modulator, lasofoxifene, increased vertebral bone mineral density better than did raloxifene, according to the findings of a company-sponsored trial presented at the annual meeting of the American College of Rheumatology.

In the study, 410 postmenopausal women were randomly assigned to one of two doses of lasofoxifene, 0.25 mg or 1 mg daily; raloxifene at 60 mg daily; or a placebo. The half-life of lasofoxifene is about a week versus 28 hours for raloxifene, said Andy Lee, a director with Pfizer Global Research and Development, New London, Conn.

The lasofoxifene increased bone mineral density (BMD) at the lumbar spine by a mean of about 2% after 2 years of treatment. That compared with no mean improvement in spine BMD—but no density loss—in patients assigned to raloxifene, and a 2% density loss in the placebo group.

BMD at the total hip improved by a mean of 1% for patients taking either raloxifene or lasofoxifene; total hip BMD stayed the same in patients taking placebo.

Although responsiveness to lasofoxifene varied, overall more women responded to lasofoxifene than to raloxifene, Mr. Lee said. Spine density improved or was at least maintained in 90% and 93% of the patients in the low- and high-dose lasofoxifene groups, respectively. That compared with 77% of the patients who took raloxifene and 65% of the patients who took placebo.

Changes in bone turnover markers were also greater with lasofoxifene. N-telopeptide levels, for example, decreased by a mean 35% in the patients on lasofoxifene, versus 15% in the patients on raloxifene. And the new drug reduced LDL cholesterol levels by a mean of 20% versus 12% for raloxifene.

Future trials of lasofoxifene will use the 0.25-mg dose, Mr. Lee said.

Some women on lasofoxifene experienced hot flashes, leg cramps, and increased vaginal moisture, but overall the two drugs were tolerated similarly.

None of the lasofoxifene trials has shown an increase in endometrial hyperplasia or vaginal bleeding, Mr. Lee said. Likewise, there have been no reports of urogenital prolapse, a problem that has plagued earlier selective estrogen receptor modulators.

SAN ANTONIO — The next-generation selective estrogen receptor modulator, lasofoxifene, increased vertebral bone mineral density better than did raloxifene, according to the findings of a company-sponsored trial presented at the annual meeting of the American College of Rheumatology.

In the study, 410 postmenopausal women were randomly assigned to one of two doses of lasofoxifene, 0.25 mg or 1 mg daily; raloxifene at 60 mg daily; or a placebo. The half-life of lasofoxifene is about a week versus 28 hours for raloxifene, said Andy Lee, a director with Pfizer Global Research and Development, New London, Conn.

The lasofoxifene increased bone mineral density (BMD) at the lumbar spine by a mean of about 2% after 2 years of treatment. That compared with no mean improvement in spine BMD—but no density loss—in patients assigned to raloxifene, and a 2% density loss in the placebo group.

BMD at the total hip improved by a mean of 1% for patients taking either raloxifene or lasofoxifene; total hip BMD stayed the same in patients taking placebo.

Although responsiveness to lasofoxifene varied, overall more women responded to lasofoxifene than to raloxifene, Mr. Lee said. Spine density improved or was at least maintained in 90% and 93% of the patients in the low- and high-dose lasofoxifene groups, respectively. That compared with 77% of the patients who took raloxifene and 65% of the patients who took placebo.

Changes in bone turnover markers were also greater with lasofoxifene. N-telopeptide levels, for example, decreased by a mean 35% in the patients on lasofoxifene, versus 15% in the patients on raloxifene. And the new drug reduced LDL cholesterol levels by a mean of 20% versus 12% for raloxifene.

Future trials of lasofoxifene will use the 0.25-mg dose, Mr. Lee said.

Some women on lasofoxifene experienced hot flashes, leg cramps, and increased vaginal moisture, but overall the two drugs were tolerated similarly.

None of the lasofoxifene trials has shown an increase in endometrial hyperplasia or vaginal bleeding, Mr. Lee said. Likewise, there have been no reports of urogenital prolapse, a problem that has plagued earlier selective estrogen receptor modulators.

INCLINE VILLAGE, NEV. – A 14-year-old intoxicated and confused girl is brought into the emergency department by her parents. She has nystagmus and is extremely ataxic. One of her friends reports that she may have taken some “skittles.”

What are “skittles”? How about “red hots”? “Triple C”?

All are street names for Coricidin, the dextromethorphan-containing cough and cold medication that has become one of the more frequent reasons for calls to poison control centers over the past few years, Steven R. Offerman, M.D., said at an annual emergency medicine meeting sponsored by the University of California, Davis.

“It is just rampant now,” said Dr. Offerman in the toxicology division of the department of emergency medicine at the University of California, Davis. “We're seeing this in poison control all the time.”

Between 2000 and 2003, the number of calls to poison control centers nationwide involving abuse or misuse of dextromethorphan by teenagers has roughly doubled, to 3,271 calls in 2003, according to the American Association of Poison Control Centers. Although there are several products that contain dextromethorphan, almost 90% of the calls involve Coricidin.

The reason that product is so popular has to do with the fact that it comes in gelatin tablets, Dr. Offerman said.

Dextromethorphan was first approved in 1958 and was introduced as a replacement for codeine in cough medications. The first product, Romilar, came in tablet form. Its abuse potential was quickly discovered, and in the 1970s Romilar tablets were taken out of the over-the-counter market. New products put dextromethorphan into cough syrups intentionally designed with a bad taste to discourage abuse.

In the 1990s, however, several products reintroduced it in tablet form, he said.

The high that teens get from dextromethorphan is described as an LSD-like, hallucinogenic high. Dextromethorphan is a prodrug converted to the d-isomer of levorphanol, a semisynthetic morphine derivative, which noncompetitively antagonizes N-methyl-D-aspartate (NMDA) receptors, and possibly also affects serotonin receptors.

Teens who are in the know talk about using specific dosages to reach different “plateaus”: the first, a mild stimulant effect (100–200 mg); the second, intoxication with mild hallucinations (200–400 mg); the third and most sought after, an “out of the body” experience (300–600 mg, or 14–16 Coricidin HBP Cough/Cold tablets, each of which contains 30 mg dextromethorphan hydrobromide).

At doses above 600 mg, individuals become fully dissociated, the fourth plateau.

Web sites contain recipes for making dextromethorphan cough syrups more palatable and provide instructions on how to extract it from Sucrets lozenges, Dr. Offerman said.

Treatment of an overdose requires supportive care, but it is also a good idea to consider decontamination with activated charcoal, Dr. Offerman advised. Many of the products also contain an antihistamine, which delays gastric emptying.

Dr. Offerman said he recommends giving charcoal all the way up to 6 hours after ingestion.

Emergency department physicians also need to be aware that many of the dextromethorphan-containing products may also contain large amounts of other active ingredients, particularly acetaminophen.

Drug toxicology screens do not specifically test for dextromethorphan, but the drug can cross-react with the test for phencyclidine (PCP).

Some reports have suggested that naloxone is effective in reversing dextromethorphan. But there have also been reports that naloxone does not work, Dr. Offerman said.

INCLINE VILLAGE, NEV. – A 14-year-old intoxicated and confused girl is brought into the emergency department by her parents. She has nystagmus and is extremely ataxic. One of her friends reports that she may have taken some “skittles.”

What are “skittles”? How about “red hots”? “Triple C”?

All are street names for Coricidin, the dextromethorphan-containing cough and cold medication that has become one of the more frequent reasons for calls to poison control centers over the past few years, Steven R. Offerman, M.D., said at an annual emergency medicine meeting sponsored by the University of California, Davis.

“It is just rampant now,” said Dr. Offerman in the toxicology division of the department of emergency medicine at the University of California, Davis. “We're seeing this in poison control all the time.”

Between 2000 and 2003, the number of calls to poison control centers nationwide involving abuse or misuse of dextromethorphan by teenagers has roughly doubled, to 3,271 calls in 2003, according to the American Association of Poison Control Centers. Although there are several products that contain dextromethorphan, almost 90% of the calls involve Coricidin.

The reason that product is so popular has to do with the fact that it comes in gelatin tablets, Dr. Offerman said.

Dextromethorphan was first approved in 1958 and was introduced as a replacement for codeine in cough medications. The first product, Romilar, came in tablet form. Its abuse potential was quickly discovered, and in the 1970s Romilar tablets were taken out of the over-the-counter market. New products put dextromethorphan into cough syrups intentionally designed with a bad taste to discourage abuse.

In the 1990s, however, several products reintroduced it in tablet form, he said.

The high that teens get from dextromethorphan is described as an LSD-like, hallucinogenic high. Dextromethorphan is a prodrug converted to the d-isomer of levorphanol, a semisynthetic morphine derivative, which noncompetitively antagonizes N-methyl-D-aspartate (NMDA) receptors, and possibly also affects serotonin receptors.

Teens who are in the know talk about using specific dosages to reach different “plateaus”: the first, a mild stimulant effect (100–200 mg); the second, intoxication with mild hallucinations (200–400 mg); the third and most sought after, an “out of the body” experience (300–600 mg, or 14–16 Coricidin HBP Cough/Cold tablets, each of which contains 30 mg dextromethorphan hydrobromide).

At doses above 600 mg, individuals become fully dissociated, the fourth plateau.

Web sites contain recipes for making dextromethorphan cough syrups more palatable and provide instructions on how to extract it from Sucrets lozenges, Dr. Offerman said.

Treatment of an overdose requires supportive care, but it is also a good idea to consider decontamination with activated charcoal, Dr. Offerman advised. Many of the products also contain an antihistamine, which delays gastric emptying.

Dr. Offerman said he recommends giving charcoal all the way up to 6 hours after ingestion.

Emergency department physicians also need to be aware that many of the dextromethorphan-containing products may also contain large amounts of other active ingredients, particularly acetaminophen.

Drug toxicology screens do not specifically test for dextromethorphan, but the drug can cross-react with the test for phencyclidine (PCP).

Some reports have suggested that naloxone is effective in reversing dextromethorphan. But there have also been reports that naloxone does not work, Dr. Offerman said.

INCLINE VILLAGE, NEV. – A 14-year-old intoxicated and confused girl is brought into the emergency department by her parents. She has nystagmus and is extremely ataxic. One of her friends reports that she may have taken some “skittles.”

What are “skittles”? How about “red hots”? “Triple C”?

All are street names for Coricidin, the dextromethorphan-containing cough and cold medication that has become one of the more frequent reasons for calls to poison control centers over the past few years, Steven R. Offerman, M.D., said at an annual emergency medicine meeting sponsored by the University of California, Davis.

“It is just rampant now,” said Dr. Offerman in the toxicology division of the department of emergency medicine at the University of California, Davis. “We're seeing this in poison control all the time.”

Between 2000 and 2003, the number of calls to poison control centers nationwide involving abuse or misuse of dextromethorphan by teenagers has roughly doubled, to 3,271 calls in 2003, according to the American Association of Poison Control Centers. Although there are several products that contain dextromethorphan, almost 90% of the calls involve Coricidin.

The reason that product is so popular has to do with the fact that it comes in gelatin tablets, Dr. Offerman said.

Dextromethorphan was first approved in 1958 and was introduced as a replacement for codeine in cough medications. The first product, Romilar, came in tablet form. Its abuse potential was quickly discovered, and in the 1970s Romilar tablets were taken out of the over-the-counter market. New products put dextromethorphan into cough syrups intentionally designed with a bad taste to discourage abuse.

In the 1990s, however, several products reintroduced it in tablet form, he said.

The high that teens get from dextromethorphan is described as an LSD-like, hallucinogenic high. Dextromethorphan is a prodrug converted to the d-isomer of levorphanol, a semisynthetic morphine derivative, which noncompetitively antagonizes N-methyl-D-aspartate (NMDA) receptors, and possibly also affects serotonin receptors.

Teens who are in the know talk about using specific dosages to reach different “plateaus”: the first, a mild stimulant effect (100–200 mg); the second, intoxication with mild hallucinations (200–400 mg); the third and most sought after, an “out of the body” experience (300–600 mg, or 14–16 Coricidin HBP Cough/Cold tablets, each of which contains 30 mg dextromethorphan hydrobromide).

At doses above 600 mg, individuals become fully dissociated, the fourth plateau.

Web sites contain recipes for making dextromethorphan cough syrups more palatable and provide instructions on how to extract it from Sucrets lozenges, Dr. Offerman said.

Treatment of an overdose requires supportive care, but it is also a good idea to consider decontamination with activated charcoal, Dr. Offerman advised. Many of the products also contain an antihistamine, which delays gastric emptying.

Dr. Offerman said he recommends giving charcoal all the way up to 6 hours after ingestion.

Emergency department physicians also need to be aware that many of the dextromethorphan-containing products may also contain large amounts of other active ingredients, particularly acetaminophen.

Drug toxicology screens do not specifically test for dextromethorphan, but the drug can cross-react with the test for phencyclidine (PCP).

Some reports have suggested that naloxone is effective in reversing dextromethorphan. But there have also been reports that naloxone does not work, Dr. Offerman said.

LOS ANGELES – Oral contraceptive pills do not cause mood swings or depression in most adolescents. On the contrary, overall, it appears that oral contraceptives increase positive mood and decrease negative mood, Mary A. Ott, M.D., said at the annual meeting of the Society for Adolescent Medicine.

“Our pill users in our study felt better,” said Dr. Ott of Indiana University, Indianapolis. “This is different from the adult data.”

Data from studies of adults on whether oral contraception impacts mood negatively have been somewhat conflicting, and results of prospective studies have varied from those of retrospective studies. Overall, however, there has been a suggestion in adults that oral contraception can increase depression or exacerbate mood lability, and it is well known that mood changes are a common reason women stop using the pill, Dr. Ott said in a poster presentation.

In her study of 226 adolescent females, oral contraception decreased reports of negative mood by 27% over time and increased positive mood by 32% over time, relative to reports from subjects not on oral contraception. The study involved having the 226 enrolled subjects keep daily mood diaries for two 12-week periods, twice each year, over 2 years. In the diaries, the participants were asked to rate the level of three negative moods they might have experienced during the day (irritable, angry, unhappy) and the level of three positive moods (cheerful, happy, friendly), each on a five-point scale reflecting a range from “not at all” to “all day.”

A diary in which the participant reported being on oral contraception both at the start and at the end of the period was considered an oral contraception diary.

When mean scores were graphed, negative mood scores in the nonusers stayed relatively stable over time. Scores for the users were lower initially, but by the end of the study scores among users had improved 27% relative to the nonusers.

Positive mood increased for both groups over time, but increased 32% more for the oral contraception users.

LOS ANGELES – Oral contraceptive pills do not cause mood swings or depression in most adolescents. On the contrary, overall, it appears that oral contraceptives increase positive mood and decrease negative mood, Mary A. Ott, M.D., said at the annual meeting of the Society for Adolescent Medicine.

“Our pill users in our study felt better,” said Dr. Ott of Indiana University, Indianapolis. “This is different from the adult data.”

Data from studies of adults on whether oral contraception impacts mood negatively have been somewhat conflicting, and results of prospective studies have varied from those of retrospective studies. Overall, however, there has been a suggestion in adults that oral contraception can increase depression or exacerbate mood lability, and it is well known that mood changes are a common reason women stop using the pill, Dr. Ott said in a poster presentation.

In her study of 226 adolescent females, oral contraception decreased reports of negative mood by 27% over time and increased positive mood by 32% over time, relative to reports from subjects not on oral contraception. The study involved having the 226 enrolled subjects keep daily mood diaries for two 12-week periods, twice each year, over 2 years. In the diaries, the participants were asked to rate the level of three negative moods they might have experienced during the day (irritable, angry, unhappy) and the level of three positive moods (cheerful, happy, friendly), each on a five-point scale reflecting a range from “not at all” to “all day.”

A diary in which the participant reported being on oral contraception both at the start and at the end of the period was considered an oral contraception diary.

When mean scores were graphed, negative mood scores in the nonusers stayed relatively stable over time. Scores for the users were lower initially, but by the end of the study scores among users had improved 27% relative to the nonusers.

Positive mood increased for both groups over time, but increased 32% more for the oral contraception users.

LOS ANGELES – Oral contraceptive pills do not cause mood swings or depression in most adolescents. On the contrary, overall, it appears that oral contraceptives increase positive mood and decrease negative mood, Mary A. Ott, M.D., said at the annual meeting of the Society for Adolescent Medicine.

“Our pill users in our study felt better,” said Dr. Ott of Indiana University, Indianapolis. “This is different from the adult data.”

Data from studies of adults on whether oral contraception impacts mood negatively have been somewhat conflicting, and results of prospective studies have varied from those of retrospective studies. Overall, however, there has been a suggestion in adults that oral contraception can increase depression or exacerbate mood lability, and it is well known that mood changes are a common reason women stop using the pill, Dr. Ott said in a poster presentation.

In her study of 226 adolescent females, oral contraception decreased reports of negative mood by 27% over time and increased positive mood by 32% over time, relative to reports from subjects not on oral contraception. The study involved having the 226 enrolled subjects keep daily mood diaries for two 12-week periods, twice each year, over 2 years. In the diaries, the participants were asked to rate the level of three negative moods they might have experienced during the day (irritable, angry, unhappy) and the level of three positive moods (cheerful, happy, friendly), each on a five-point scale reflecting a range from “not at all” to “all day.”

A diary in which the participant reported being on oral contraception both at the start and at the end of the period was considered an oral contraception diary.

When mean scores were graphed, negative mood scores in the nonusers stayed relatively stable over time. Scores for the users were lower initially, but by the end of the study scores among users had improved 27% relative to the nonusers.

Positive mood increased for both groups over time, but increased 32% more for the oral contraception users.

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 their multiple chronic health 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 that asked individuals with a chronic condition about their medical care in the preceding 12 months found that 54% had been told they were at risk for a harmful drug interaction because of what they were taking, and 54% had duplicate tests or procedures.

In addition, 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 their multiple chronic health 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 that asked individuals with a chronic condition about their medical care in the preceding 12 months found that 54% had been told they were at risk for a harmful drug interaction because of what they were taking, and 54% had duplicate tests or procedures.

In addition, 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 their multiple chronic health 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 that asked individuals with a chronic condition about their medical care in the preceding 12 months found that 54% had been told they were at risk for a harmful drug interaction because of what they were taking, and 54% had duplicate tests or procedures.

In addition, 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 said. 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.

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 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, Dr. Nelson 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,” he 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 said. 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.

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 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, Dr. Nelson 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,” he 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 said. 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.

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 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, Dr. Nelson 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,” he said.

SAN FRANCISCO — Linezolid is being used too often for staphylococcal infections when other options are available, William E. Dismukes, M.D., said at the annual meeting of the American College of Physicians.

For example, linezolid is being used increasingly often for treatment of methicillin-resistant Staphylococcus aureus (MRSA) pneumonia.

The drug is approved for the treatment of hospital-acquired MRSA pneumonia, and its use may be increasing largely in response to an article published in 2003 in the journal Chest, said Dr. Dismukes, director of the division of infectious diseases at the University of Alabama, Birmingham.

In the paper, the authors combined data from two separate studies in which vancomycin and linezolid were used. They concluded that survival and clinical cure rates were both better with linezolid.

The survival rate was reported to be 80% with linezolid versus 63% with vancomycin. The clinical cure rate, defined as resolution of signs and symptoms at the end of treatment with improvement or no change in x-rays, was 59% for linezolid and 35% for vancomycin (Chest 2003;124:1789–97).

But not everyone is convinced, including Dr. Dismukes. “This paper has generated all kinds of controversy,” he said.

In his opinion, the analysis is less than definitive because it included groups from two different trials, and there were only 160 MRSA patients. “You do get higher lung-tissue levels with linezolid,” Dr. Dismukes said. “But I am skeptical.”

Another use for linezolid that is becoming increasingly common is staphylococcal endocarditis. There are anecdotal reports of successful treatments, but no clinical trial data. In contrast, much experience and data are available on use of nafcillin and gentamicin, or vancomycin with or without gentamicin, Dr. Dismukes said.

“I think we use too much of this drug for indications such as this for which there [are] no data,” he said.

Linezolid is approved for complicated and uncomplicated soft tissue infections, both methicillin resistant and methicillin susceptible. But community-acquired MRSA infections are different from hospital-acquired MRSA, and so, for uncomplicated infections, cost is an issue.

Hospital-acquired Staphylococcus aureus that is methicillin resistant most often has a resistance pattern that includes resistance to other non-β-lactam antibiotics, because the gene that confers methicillin resistance most commonly comes as part of a cassette chromosome that contains other resistance determinants. But that is not generally true of community-acquired MRSA, which is usually susceptible to doxycycline, trimethoprim/sulfamethoxazole, and quinolones, Dr. Dismukes said.

A single course of linezolid can cost over $1,000, whereas in some of these cases trimethoprim/sulfamethoxazole would do, he said.

Moreover, adverse events do occur. Linezolid can cause bone marrow suppression, neuropathies with long-term use, and serotonin syndrome in patients on drugs such as selective serotonin reuptake inhibitors.

SAN FRANCISCO — Linezolid is being used too often for staphylococcal infections when other options are available, William E. Dismukes, M.D., said at the annual meeting of the American College of Physicians.

For example, linezolid is being used increasingly often for treatment of methicillin-resistant Staphylococcus aureus (MRSA) pneumonia.

The drug is approved for the treatment of hospital-acquired MRSA pneumonia, and its use may be increasing largely in response to an article published in 2003 in the journal Chest, said Dr. Dismukes, director of the division of infectious diseases at the University of Alabama, Birmingham.

In the paper, the authors combined data from two separate studies in which vancomycin and linezolid were used. They concluded that survival and clinical cure rates were both better with linezolid.

The survival rate was reported to be 80% with linezolid versus 63% with vancomycin. The clinical cure rate, defined as resolution of signs and symptoms at the end of treatment with improvement or no change in x-rays, was 59% for linezolid and 35% for vancomycin (Chest 2003;124:1789–97).

But not everyone is convinced, including Dr. Dismukes. “This paper has generated all kinds of controversy,” he said.

In his opinion, the analysis is less than definitive because it included groups from two different trials, and there were only 160 MRSA patients. “You do get higher lung-tissue levels with linezolid,” Dr. Dismukes said. “But I am skeptical.”

Another use for linezolid that is becoming increasingly common is staphylococcal endocarditis. There are anecdotal reports of successful treatments, but no clinical trial data. In contrast, much experience and data are available on use of nafcillin and gentamicin, or vancomycin with or without gentamicin, Dr. Dismukes said.

“I think we use too much of this drug for indications such as this for which there [are] no data,” he said.

Linezolid is approved for complicated and uncomplicated soft tissue infections, both methicillin resistant and methicillin susceptible. But community-acquired MRSA infections are different from hospital-acquired MRSA, and so, for uncomplicated infections, cost is an issue.

Hospital-acquired Staphylococcus aureus that is methicillin resistant most often has a resistance pattern that includes resistance to other non-β-lactam antibiotics, because the gene that confers methicillin resistance most commonly comes as part of a cassette chromosome that contains other resistance determinants. But that is not generally true of community-acquired MRSA, which is usually susceptible to doxycycline, trimethoprim/sulfamethoxazole, and quinolones, Dr. Dismukes said.

A single course of linezolid can cost over $1,000, whereas in some of these cases trimethoprim/sulfamethoxazole would do, he said.

Moreover, adverse events do occur. Linezolid can cause bone marrow suppression, neuropathies with long-term use, and serotonin syndrome in patients on drugs such as selective serotonin reuptake inhibitors.

SAN FRANCISCO — Linezolid is being used too often for staphylococcal infections when other options are available, William E. Dismukes, M.D., said at the annual meeting of the American College of Physicians.

For example, linezolid is being used increasingly often for treatment of methicillin-resistant Staphylococcus aureus (MRSA) pneumonia.

The drug is approved for the treatment of hospital-acquired MRSA pneumonia, and its use may be increasing largely in response to an article published in 2003 in the journal Chest, said Dr. Dismukes, director of the division of infectious diseases at the University of Alabama, Birmingham.

In the paper, the authors combined data from two separate studies in which vancomycin and linezolid were used. They concluded that survival and clinical cure rates were both better with linezolid.

The survival rate was reported to be 80% with linezolid versus 63% with vancomycin. The clinical cure rate, defined as resolution of signs and symptoms at the end of treatment with improvement or no change in x-rays, was 59% for linezolid and 35% for vancomycin (Chest 2003;124:1789–97).

But not everyone is convinced, including Dr. Dismukes. “This paper has generated all kinds of controversy,” he said.

In his opinion, the analysis is less than definitive because it included groups from two different trials, and there were only 160 MRSA patients. “You do get higher lung-tissue levels with linezolid,” Dr. Dismukes said. “But I am skeptical.”

Another use for linezolid that is becoming increasingly common is staphylococcal endocarditis. There are anecdotal reports of successful treatments, but no clinical trial data. In contrast, much experience and data are available on use of nafcillin and gentamicin, or vancomycin with or without gentamicin, Dr. Dismukes said.

“I think we use too much of this drug for indications such as this for which there [are] no data,” he said.

Linezolid is approved for complicated and uncomplicated soft tissue infections, both methicillin resistant and methicillin susceptible. But community-acquired MRSA infections are different from hospital-acquired MRSA, and so, for uncomplicated infections, cost is an issue.

Hospital-acquired Staphylococcus aureus that is methicillin resistant most often has a resistance pattern that includes resistance to other non-β-lactam antibiotics, because the gene that confers methicillin resistance most commonly comes as part of a cassette chromosome that contains other resistance determinants. But that is not generally true of community-acquired MRSA, which is usually susceptible to doxycycline, trimethoprim/sulfamethoxazole, and quinolones, Dr. Dismukes said.

A single course of linezolid can cost over $1,000, whereas in some of these cases trimethoprim/sulfamethoxazole would do, he said.

Moreover, adverse events do occur. Linezolid can cause bone marrow suppression, neuropathies with long-term use, and serotonin syndrome in patients on drugs such as selective serotonin reuptake inhibitors.

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 study, which followed the adolescents for an average of 2.2 years, found 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, 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, 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 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 associated with longer duration 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 of the possibilities that might explain why condom use results in shorter infections include the fact 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 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 study, which followed the adolescents for an average of 2.2 years, found 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, 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, 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 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 associated with longer duration 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 of the possibilities that might explain why condom use results in shorter infections include the fact 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 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 study, which followed the adolescents for an average of 2.2 years, found 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, 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, 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 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 associated with longer duration 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 of the possibilities that might explain why condom use results in shorter infections include the fact 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 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 — Mycoplasma genitalium infection had an incidence of 11% in the first study to investigate the epidemiology of this newly recognized sexually transmitted disease in female adolescents, Aneesh K. Tosh, M.D., said at the annual meeting of the Society for Adolescent Medicine.

The study involved 233 female adolescents who were each followed for 27 months, with vaginal samples collected and sexual history interviews conducted every 3 months. Of the study subjects, 85% were sexually active—with an average age of first sexual intercourse of 14 years—and 85% were African American. All lived in an urban area.

During the study, 26 of the 233 subjects tested positive for a M. genitalium infection, said Dr. Tosh of the department of pediatrics at Indiana University. Only one of those infections was present at the start of the study. Nine of those who tested positive also tested positive on repeated occasions.

None of the participants who was sexually inactive ever tested positive.

Factors that were identified as being associated with infection were a greater number of sexual partners in the prior 3 months and concurrent chlamydia infection. Condom use, or the lack thereof, and concurrent gonorrhea or trichomonas infection were not associated with M. genitalium. There were few non-African Americans in the study, but there was no difference in incidence of M. genitalium infection by race, Dr. Tosh said.

Male sexual partners of the subjects were invited to participate in the study, and 94 partners were enrolled. Four of 17 partners of those females who tested positive for infection also tested positive at some time (25%), and two of 77 partners of uninfected females tested positive (3%).

M. genitalium was first isolated in 1980, Dr. Tosh said. Because it is a small organism that is difficult to culture, reliable testing was not available until the advent of laboratory polymerase chain reaction techniques. Until this study, most studies have been conducted with males and in STD clinics, though infection in females has been implicated in urethritis, cervicitis, salpingitis, and endometritis.

Currently there are no recommendations for treatment, because there is no approved clinical assay, though many believe guidelines of some sort [are likely to become available] soon, Dr. Tosh said.

None of the subjects in the study was treated, because the samples were collected a few years before the subjects were tested for M. genitalium.

LOS ANGELES — Mycoplasma genitalium infection had an incidence of 11% in the first study to investigate the epidemiology of this newly recognized sexually transmitted disease in female adolescents, Aneesh K. Tosh, M.D., said at the annual meeting of the Society for Adolescent Medicine.

The study involved 233 female adolescents who were each followed for 27 months, with vaginal samples collected and sexual history interviews conducted every 3 months. Of the study subjects, 85% were sexually active—with an average age of first sexual intercourse of 14 years—and 85% were African American. All lived in an urban area.

During the study, 26 of the 233 subjects tested positive for a M. genitalium infection, said Dr. Tosh of the department of pediatrics at Indiana University. Only one of those infections was present at the start of the study. Nine of those who tested positive also tested positive on repeated occasions.

None of the participants who was sexually inactive ever tested positive.

Factors that were identified as being associated with infection were a greater number of sexual partners in the prior 3 months and concurrent chlamydia infection. Condom use, or the lack thereof, and concurrent gonorrhea or trichomonas infection were not associated with M. genitalium. There were few non-African Americans in the study, but there was no difference in incidence of M. genitalium infection by race, Dr. Tosh said.

Male sexual partners of the subjects were invited to participate in the study, and 94 partners were enrolled. Four of 17 partners of those females who tested positive for infection also tested positive at some time (25%), and two of 77 partners of uninfected females tested positive (3%).

M. genitalium was first isolated in 1980, Dr. Tosh said. Because it is a small organism that is difficult to culture, reliable testing was not available until the advent of laboratory polymerase chain reaction techniques. Until this study, most studies have been conducted with males and in STD clinics, though infection in females has been implicated in urethritis, cervicitis, salpingitis, and endometritis.

Currently there are no recommendations for treatment, because there is no approved clinical assay, though many believe guidelines of some sort [are likely to become available] soon, Dr. Tosh said.

None of the subjects in the study was treated, because the samples were collected a few years before the subjects were tested for M. genitalium.

LOS ANGELES — Mycoplasma genitalium infection had an incidence of 11% in the first study to investigate the epidemiology of this newly recognized sexually transmitted disease in female adolescents, Aneesh K. Tosh, M.D., said at the annual meeting of the Society for Adolescent Medicine.

The study involved 233 female adolescents who were each followed for 27 months, with vaginal samples collected and sexual history interviews conducted every 3 months. Of the study subjects, 85% were sexually active—with an average age of first sexual intercourse of 14 years—and 85% were African American. All lived in an urban area.

During the study, 26 of the 233 subjects tested positive for a M. genitalium infection, said Dr. Tosh of the department of pediatrics at Indiana University. Only one of those infections was present at the start of the study. Nine of those who tested positive also tested positive on repeated occasions.

None of the participants who was sexually inactive ever tested positive.

Factors that were identified as being associated with infection were a greater number of sexual partners in the prior 3 months and concurrent chlamydia infection. Condom use, or the lack thereof, and concurrent gonorrhea or trichomonas infection were not associated with M. genitalium. There were few non-African Americans in the study, but there was no difference in incidence of M. genitalium infection by race, Dr. Tosh said.

Male sexual partners of the subjects were invited to participate in the study, and 94 partners were enrolled. Four of 17 partners of those females who tested positive for infection also tested positive at some time (25%), and two of 77 partners of uninfected females tested positive (3%).

M. genitalium was first isolated in 1980, Dr. Tosh said. Because it is a small organism that is difficult to culture, reliable testing was not available until the advent of laboratory polymerase chain reaction techniques. Until this study, most studies have been conducted with males and in STD clinics, though infection in females has been implicated in urethritis, cervicitis, salpingitis, and endometritis.

Currently there are no recommendations for treatment, because there is no approved clinical assay, though many believe guidelines of some sort [are likely to become available] soon, Dr. Tosh said.

None of the subjects in the study was treated, because the samples were collected a few years before the subjects were tested for M. genitalium.