Kate Johnson

MONTREAL — Several noninvasive tests used in combination may be a more sensitive method for monitoring celiac disease activity and patient compliance with the gluten-free diet than are current approaches.

At Canadian Digestive Diseases Week, Dr. Alaa Rostom said that the majority of his celiac disease patients make every effort to avoid gluten, but hidden sources of this protein—found in wheat, rye, and barley—are often responsible for persistent symptoms. Dr. Rostom, from the University of Calgary (Alta.), presented his research in a poster at the meeting.

“The gold standard for diagnosis is positive serology and a consistent biopsy. But once a gluten-free diet is started, it takes large dietary indiscretions to turn the serology positive again,” he said.

Dr. Rostom polled a celiac disease expert panel regarding the accuracy of various noninvasive tests for monitoring disease activity and dietary adherence. The experts were asked to rank their top six tests, and tests were included in a final list if they were ranked by more than 50% of panel members. Univariate analysis revealed that the use of serology, the lactulose/mannitol test for intestinal permeability, body mass index, triceps skinfold thickness, the gastrointestinal symptom rating score (GSRS), and a quality of life measure were all considered useful by panel members.

Dr. Rostom then calculated the sensitivity and specificity of the various tests based on a retrospective data set of about 200 patients. “Serology has important sensitivity, about 90%, but the specificity is less than 90%, which explains why it won't detect small amounts of gluten exposure,” he said. “On the other hand, the lactulose/mannitol test isn't very sensitive but it has a pretty high specificity.” Therefore, combining results from both of these tests proved more useful than relying on either one alone, and yielded both a sensitivity of 92% and a specificity of 92%, which is comparable to results obtained from intestinal biopsy, he explained.

By using these results, Dr. Rostom compiled the Celiac Disease Activity Scoring System (CeDARS), which is now being validated in two randomized controlled trials. “I think probably the best assessment will likely come from combining serology, plus the lactulose/mannitol test, plus GSRS,” he suggested, pointing out that the beauty of this particular combination of tests is that it can capture different stages of response to gluten exposure.

Dr. Rostom emphasized that the goal of CeDARS is not to replace, but rather to enhance annual serology, which is currently recommended for monitoring celiac disease patients.

MONTREAL — Several noninvasive tests used in combination may be a more sensitive method for monitoring celiac disease activity and patient compliance with the gluten-free diet than are current approaches.

At Canadian Digestive Diseases Week, Dr. Alaa Rostom said that the majority of his celiac disease patients make every effort to avoid gluten, but hidden sources of this protein—found in wheat, rye, and barley—are often responsible for persistent symptoms. Dr. Rostom, from the University of Calgary (Alta.), presented his research in a poster at the meeting.

“The gold standard for diagnosis is positive serology and a consistent biopsy. But once a gluten-free diet is started, it takes large dietary indiscretions to turn the serology positive again,” he said.

Dr. Rostom polled a celiac disease expert panel regarding the accuracy of various noninvasive tests for monitoring disease activity and dietary adherence. The experts were asked to rank their top six tests, and tests were included in a final list if they were ranked by more than 50% of panel members. Univariate analysis revealed that the use of serology, the lactulose/mannitol test for intestinal permeability, body mass index, triceps skinfold thickness, the gastrointestinal symptom rating score (GSRS), and a quality of life measure were all considered useful by panel members.

Dr. Rostom then calculated the sensitivity and specificity of the various tests based on a retrospective data set of about 200 patients. “Serology has important sensitivity, about 90%, but the specificity is less than 90%, which explains why it won't detect small amounts of gluten exposure,” he said. “On the other hand, the lactulose/mannitol test isn't very sensitive but it has a pretty high specificity.” Therefore, combining results from both of these tests proved more useful than relying on either one alone, and yielded both a sensitivity of 92% and a specificity of 92%, which is comparable to results obtained from intestinal biopsy, he explained.

By using these results, Dr. Rostom compiled the Celiac Disease Activity Scoring System (CeDARS), which is now being validated in two randomized controlled trials. “I think probably the best assessment will likely come from combining serology, plus the lactulose/mannitol test, plus GSRS,” he suggested, pointing out that the beauty of this particular combination of tests is that it can capture different stages of response to gluten exposure.

Dr. Rostom emphasized that the goal of CeDARS is not to replace, but rather to enhance annual serology, which is currently recommended for monitoring celiac disease patients.

MONTREAL — Several noninvasive tests used in combination may be a more sensitive method for monitoring celiac disease activity and patient compliance with the gluten-free diet than are current approaches.

At Canadian Digestive Diseases Week, Dr. Alaa Rostom said that the majority of his celiac disease patients make every effort to avoid gluten, but hidden sources of this protein—found in wheat, rye, and barley—are often responsible for persistent symptoms. Dr. Rostom, from the University of Calgary (Alta.), presented his research in a poster at the meeting.

“The gold standard for diagnosis is positive serology and a consistent biopsy. But once a gluten-free diet is started, it takes large dietary indiscretions to turn the serology positive again,” he said.

Dr. Rostom polled a celiac disease expert panel regarding the accuracy of various noninvasive tests for monitoring disease activity and dietary adherence. The experts were asked to rank their top six tests, and tests were included in a final list if they were ranked by more than 50% of panel members. Univariate analysis revealed that the use of serology, the lactulose/mannitol test for intestinal permeability, body mass index, triceps skinfold thickness, the gastrointestinal symptom rating score (GSRS), and a quality of life measure were all considered useful by panel members.

Dr. Rostom then calculated the sensitivity and specificity of the various tests based on a retrospective data set of about 200 patients. “Serology has important sensitivity, about 90%, but the specificity is less than 90%, which explains why it won't detect small amounts of gluten exposure,” he said. “On the other hand, the lactulose/mannitol test isn't very sensitive but it has a pretty high specificity.” Therefore, combining results from both of these tests proved more useful than relying on either one alone, and yielded both a sensitivity of 92% and a specificity of 92%, which is comparable to results obtained from intestinal biopsy, he explained.

By using these results, Dr. Rostom compiled the Celiac Disease Activity Scoring System (CeDARS), which is now being validated in two randomized controlled trials. “I think probably the best assessment will likely come from combining serology, plus the lactulose/mannitol test, plus GSRS,” he suggested, pointing out that the beauty of this particular combination of tests is that it can capture different stages of response to gluten exposure.

Dr. Rostom emphasized that the goal of CeDARS is not to replace, but rather to enhance annual serology, which is currently recommended for monitoring celiac disease patients.

MONTREAL — The incidence of adult and pediatric eosinophilic esophagitis appears to be increasing dramatically, and endoscopic investigation and treatment have low complication rates, according to the findings of the largest reported population-based study of the disorder.

Dr. Chad Williams and his colleagues from the University of Calgary (Alta.) found an incidence of 7.2 cases/100,000 person-years in 2006 in the Calgary Health Region (population 1.2 million), the highest incidence to date, they reported in a poster at the Canadian Digestive Diseases Week.

“The number of diagnoses per year is definitely rising,” Dr. Williams said in an interview. “Whether that reflects a true increase in incidence we're not sure. We may be just recognizing it more.”

Few studies have investigated the incidence of eosinophilic esophagitis in general, and none has addressed the incidence in the adult North American population in particular, he said. A European study reported an adult incidence of 6 cases/100,000 person-years (J. Allergy Clin. Immunol. 2005;115:418–9).

In their retrospective cohort study, Dr. Williams and his colleagues identified adult and pediatric biopsy-proven cases of eosinophilic esophagitis in the Calgary Health Region between 2002 and 2006. Overall, there were 2 cases identified in 2002, and no cases in 2003. However, the reported incidence rose dramatically from 1.83 cases/100,000 person-years in 2004 to 4.27 cases in 2005 and to 7.2 cases in 2006.

The incidence per 1,000 upper endoscopies rose from 2.16 cases in 2004 to 8.35 cases in 2006.The incidence seemed to increase in adults, while it dipped among children. The number of cases in adults went from 5 in 2004 to 75 in 2006, compared with 16 in 2004 to 6 in 2006 in children.

Among the total of 158 identified cases, 75% were adults and 84% were male. The median age of adult patients was 39 years, and the median pediatric age was 12 years.

“In the pediatric population, patients usually present with food aversion, gastroesophageal refluxlike symptoms and abdominal pain, but in the adult population, the two main symptoms are dysphagia and food bolus impaction,” said Dr. Williams at the conference, which was sponsored by the Canadian Association of Gastroenterology.

In a subanalysis of 144 of the eosinophilic esophagitis cases, the mean age of the patient population was 40 years (range 16 to 78 years), Dr. Williams' group reported in another poster.

Most (85%) of the patients were male, 74% presented with dysphagia, and 18% with food impaction. Allergies were noted in 27% of patients, asthma in 22%, gastroesophageal reflux disease in about 20%, and autoimmune disease in about 3%. All of the patients underwent endoscopic evaluation and biopsy, with 22% of patients also receiving concurrent therapeutic esophageal dilation.

Endoscopic complications were more common in patients undergoing dilation, with six mucosal tears documented, but no perforations, said Dr. Williams. In patients undergoing endoscopic biopsy alone, there was one mucosal tear resulting from the biopsy, and one resulting from trauma from the endoscope. Overall, this complication rate was low, compared with a previously reported rate of 30% (Clin. Gastroenterol. Hepatol. 2007;5:1149–53).

“Gastroscopy is a fairly safe procedure, although we did have one mucosal tear in our group, but I am not a proponent of dilation in this population,” he said, recommending medical treatment with fluticasone as the first-line therapy.

An endoscopic image shows the typical appearance of eosinophilic esophagitis. Courtesy Dr. Chad Williams

MONTREAL — The incidence of adult and pediatric eosinophilic esophagitis appears to be increasing dramatically, and endoscopic investigation and treatment have low complication rates, according to the findings of the largest reported population-based study of the disorder.

Dr. Chad Williams and his colleagues from the University of Calgary (Alta.) found an incidence of 7.2 cases/100,000 person-years in 2006 in the Calgary Health Region (population 1.2 million), the highest incidence to date, they reported in a poster at the Canadian Digestive Diseases Week.

“The number of diagnoses per year is definitely rising,” Dr. Williams said in an interview. “Whether that reflects a true increase in incidence we're not sure. We may be just recognizing it more.”

Few studies have investigated the incidence of eosinophilic esophagitis in general, and none has addressed the incidence in the adult North American population in particular, he said. A European study reported an adult incidence of 6 cases/100,000 person-years (J. Allergy Clin. Immunol. 2005;115:418–9).

In their retrospective cohort study, Dr. Williams and his colleagues identified adult and pediatric biopsy-proven cases of eosinophilic esophagitis in the Calgary Health Region between 2002 and 2006. Overall, there were 2 cases identified in 2002, and no cases in 2003. However, the reported incidence rose dramatically from 1.83 cases/100,000 person-years in 2004 to 4.27 cases in 2005 and to 7.2 cases in 2006.

The incidence per 1,000 upper endoscopies rose from 2.16 cases in 2004 to 8.35 cases in 2006.The incidence seemed to increase in adults, while it dipped among children. The number of cases in adults went from 5 in 2004 to 75 in 2006, compared with 16 in 2004 to 6 in 2006 in children.

Among the total of 158 identified cases, 75% were adults and 84% were male. The median age of adult patients was 39 years, and the median pediatric age was 12 years.

“In the pediatric population, patients usually present with food aversion, gastroesophageal refluxlike symptoms and abdominal pain, but in the adult population, the two main symptoms are dysphagia and food bolus impaction,” said Dr. Williams at the conference, which was sponsored by the Canadian Association of Gastroenterology.

In a subanalysis of 144 of the eosinophilic esophagitis cases, the mean age of the patient population was 40 years (range 16 to 78 years), Dr. Williams' group reported in another poster.

Most (85%) of the patients were male, 74% presented with dysphagia, and 18% with food impaction. Allergies were noted in 27% of patients, asthma in 22%, gastroesophageal reflux disease in about 20%, and autoimmune disease in about 3%. All of the patients underwent endoscopic evaluation and biopsy, with 22% of patients also receiving concurrent therapeutic esophageal dilation.

Endoscopic complications were more common in patients undergoing dilation, with six mucosal tears documented, but no perforations, said Dr. Williams. In patients undergoing endoscopic biopsy alone, there was one mucosal tear resulting from the biopsy, and one resulting from trauma from the endoscope. Overall, this complication rate was low, compared with a previously reported rate of 30% (Clin. Gastroenterol. Hepatol. 2007;5:1149–53).

“Gastroscopy is a fairly safe procedure, although we did have one mucosal tear in our group, but I am not a proponent of dilation in this population,” he said, recommending medical treatment with fluticasone as the first-line therapy.

An endoscopic image shows the typical appearance of eosinophilic esophagitis. Courtesy Dr. Chad Williams

MONTREAL — The incidence of adult and pediatric eosinophilic esophagitis appears to be increasing dramatically, and endoscopic investigation and treatment have low complication rates, according to the findings of the largest reported population-based study of the disorder.

Dr. Chad Williams and his colleagues from the University of Calgary (Alta.) found an incidence of 7.2 cases/100,000 person-years in 2006 in the Calgary Health Region (population 1.2 million), the highest incidence to date, they reported in a poster at the Canadian Digestive Diseases Week.

“The number of diagnoses per year is definitely rising,” Dr. Williams said in an interview. “Whether that reflects a true increase in incidence we're not sure. We may be just recognizing it more.”

Few studies have investigated the incidence of eosinophilic esophagitis in general, and none has addressed the incidence in the adult North American population in particular, he said. A European study reported an adult incidence of 6 cases/100,000 person-years (J. Allergy Clin. Immunol. 2005;115:418–9).

In their retrospective cohort study, Dr. Williams and his colleagues identified adult and pediatric biopsy-proven cases of eosinophilic esophagitis in the Calgary Health Region between 2002 and 2006. Overall, there were 2 cases identified in 2002, and no cases in 2003. However, the reported incidence rose dramatically from 1.83 cases/100,000 person-years in 2004 to 4.27 cases in 2005 and to 7.2 cases in 2006.

The incidence per 1,000 upper endoscopies rose from 2.16 cases in 2004 to 8.35 cases in 2006.The incidence seemed to increase in adults, while it dipped among children. The number of cases in adults went from 5 in 2004 to 75 in 2006, compared with 16 in 2004 to 6 in 2006 in children.

Among the total of 158 identified cases, 75% were adults and 84% were male. The median age of adult patients was 39 years, and the median pediatric age was 12 years.

“In the pediatric population, patients usually present with food aversion, gastroesophageal refluxlike symptoms and abdominal pain, but in the adult population, the two main symptoms are dysphagia and food bolus impaction,” said Dr. Williams at the conference, which was sponsored by the Canadian Association of Gastroenterology.

In a subanalysis of 144 of the eosinophilic esophagitis cases, the mean age of the patient population was 40 years (range 16 to 78 years), Dr. Williams' group reported in another poster.

Most (85%) of the patients were male, 74% presented with dysphagia, and 18% with food impaction. Allergies were noted in 27% of patients, asthma in 22%, gastroesophageal reflux disease in about 20%, and autoimmune disease in about 3%. All of the patients underwent endoscopic evaluation and biopsy, with 22% of patients also receiving concurrent therapeutic esophageal dilation.

Endoscopic complications were more common in patients undergoing dilation, with six mucosal tears documented, but no perforations, said Dr. Williams. In patients undergoing endoscopic biopsy alone, there was one mucosal tear resulting from the biopsy, and one resulting from trauma from the endoscope. Overall, this complication rate was low, compared with a previously reported rate of 30% (Clin. Gastroenterol. Hepatol. 2007;5:1149–53).

“Gastroscopy is a fairly safe procedure, although we did have one mucosal tear in our group, but I am not a proponent of dilation in this population,” he said, recommending medical treatment with fluticasone as the first-line therapy.

An endoscopic image shows the typical appearance of eosinophilic esophagitis. Courtesy Dr. Chad Williams

Emergency on-call coverage from specialist physicians, including dermatologists, is "unraveling" at hospitals across the country, resulting in delayed treatment, patient transfers, permanent injuries, and even death, according to a study from the Center for Studying Health System Change, a nonpartisan policy research group in Washington.

While the problem is predominantly an issue for hospital emergency departments, it also is becoming increasingly problematic for inpatients who need urgent specialty care, according to the report. The findings are based on 2007 data from 12 nationally representative communities: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; Northern New Jersey; Orange County, Calif; Phoenix; Seattle; and Syracuse, N.Y.

The picture is particularly grim given the fact that overall ED utilization rates have risen by 7% in the past decade, from 36.9 to 39.6 visits per 100 people, according to the report. While insured people account for the vast majority of ED visits, "the proportion of visits by uninsured people is rising at a relatively higher rate," the study's authors wrote.

Citing a 2006 paper from the American College of Emergency Physicians, the study reported that 73% of emergency departments in the United States report inadequate on-call coverage by specialist physicians. In particularly short supply are plastic surgeons, ophthalmologists, dermatologists, orthopedic surgeons, neurosurgeons, trauma surgeons, hand surgeons, obstetrician-gynecologists, and neurologists, While an actual shortage of such physicians may sometimes be to blame, "physician unwillingness to take call appears to be a more pressing issue for many hospitals," the study authors stated.

Although unwillingness to accept on-call duty is largely influenced by quality of life issues, the requirement to provide on-call coverage has traditionally been mandated by hospitals under the Emergency Medical Treatment and Labor Act. However, many specialists are now shifting their practices away from the hospital setting, and are no longer obligated by medical staff privileges, noted the report's authors.

Many physicians also believe payment for on-call care is inadequate, especially when they are caring for uninsured patients. Specialists are also concerned that providing emergency care may increase their exposure to medical liability and drive up the cost of their malpractice premiums, according to the report.

As a result, adverse patient outcomes are reported. One study found that 21% of patient deaths or permanent injuries related to ED treatment delays are attributed to lack of specialists' availability, noted the report. Complete lack of access to specialty care in some EDs is forcing either travel or transfer of patients. And for the physicians who continue to provide on-call coverage, increasing workload and decreasing morale may put patients further at risk.

Crisis May Drive Docs Away

"It's not a surprise that we're having this problem—it's a surprise to me that we have any on-call specialists at all," Dr. Todd Taylor, previously an emergency physician and speaker for the ACEP Council, said in an interview. Dr. Taylor left clinical medicine last summer to work in the computer industry, he said, because the risks of liability were more than he could justify.

For Dr. Taylor, it is these very liability risks that are at the root of the current on-call crisis. "The liability issue has become the overriding barrier to physicians being willing to put themselves at risk," he said. "Until and unless you solve the liability crisis in emergency care and health care in general, nothing else you do matters."

Most on-call specialists have a private practice outside of the emergency department—they don't need the ED—so it's not a big surprise they were the first to leave, he explained. "But now that core emergency physicians, who were trained to practice only emergency medicine, are making the same choices, that should be a wake-up call," Dr. Taylor said. "That's what's different now compared to 2 or 3 years ago."

On-Call Shortage Cripples Trauma Care

Lack of optimal on-call coverage is what will ultimately "cripple" trauma and emergency care, agreed Dr. L. D. Britt, professor of surgery at the Eastern Virginia Medical School in Norfolk. "Some of the specialists are asking for unbelievably exorbitant fees to provide coverage, and hospitals are being held hostage," he said in an interview.

While Dr. Britt sympathizes with physicians' struggles with payment and liability issues, he believes the true bottom line is simply that obligations are being overlooked. "It cannot be everyone saying, 'I can't do this.' Something has to give," Dr. Britt said. "Speaking for myself, I consider it my obligation to provide emergency coverage if I am on call. I know that's my responsibility—and I'm a chairman of a department. Some people can find ways out of it, but I'm saying we cannot have all those options out there."

In addition, high fees charged by specialists and paid by hospitals for on-call coverage are not justified based on the premise that on-call coverage increases a physician's liability exposure, he said. "Being on call doesn't give you more litigation than being in general surgery—that's well documented," he said.

Dr. Taylor disagreed. "The literature is very clear that emergency care is one of the highest liability environments in health care," he said. "You only have to look at what's happened to emergency physician malpractice premiums relative to others not involved in emergency care. Mine almost doubled the last 3 years I worked."

Emergency on-call coverage from specialist physicians, including dermatologists, is "unraveling" at hospitals across the country, resulting in delayed treatment, patient transfers, permanent injuries, and even death, according to a study from the Center for Studying Health System Change, a nonpartisan policy research group in Washington.

While the problem is predominantly an issue for hospital emergency departments, it also is becoming increasingly problematic for inpatients who need urgent specialty care, according to the report. The findings are based on 2007 data from 12 nationally representative communities: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; Northern New Jersey; Orange County, Calif; Phoenix; Seattle; and Syracuse, N.Y.

The picture is particularly grim given the fact that overall ED utilization rates have risen by 7% in the past decade, from 36.9 to 39.6 visits per 100 people, according to the report. While insured people account for the vast majority of ED visits, "the proportion of visits by uninsured people is rising at a relatively higher rate," the study's authors wrote.

Citing a 2006 paper from the American College of Emergency Physicians, the study reported that 73% of emergency departments in the United States report inadequate on-call coverage by specialist physicians. In particularly short supply are plastic surgeons, ophthalmologists, dermatologists, orthopedic surgeons, neurosurgeons, trauma surgeons, hand surgeons, obstetrician-gynecologists, and neurologists, While an actual shortage of such physicians may sometimes be to blame, "physician unwillingness to take call appears to be a more pressing issue for many hospitals," the study authors stated.

Although unwillingness to accept on-call duty is largely influenced by quality of life issues, the requirement to provide on-call coverage has traditionally been mandated by hospitals under the Emergency Medical Treatment and Labor Act. However, many specialists are now shifting their practices away from the hospital setting, and are no longer obligated by medical staff privileges, noted the report's authors.

Many physicians also believe payment for on-call care is inadequate, especially when they are caring for uninsured patients. Specialists are also concerned that providing emergency care may increase their exposure to medical liability and drive up the cost of their malpractice premiums, according to the report.

As a result, adverse patient outcomes are reported. One study found that 21% of patient deaths or permanent injuries related to ED treatment delays are attributed to lack of specialists' availability, noted the report. Complete lack of access to specialty care in some EDs is forcing either travel or transfer of patients. And for the physicians who continue to provide on-call coverage, increasing workload and decreasing morale may put patients further at risk.

Crisis May Drive Docs Away

"It's not a surprise that we're having this problem—it's a surprise to me that we have any on-call specialists at all," Dr. Todd Taylor, previously an emergency physician and speaker for the ACEP Council, said in an interview. Dr. Taylor left clinical medicine last summer to work in the computer industry, he said, because the risks of liability were more than he could justify.

For Dr. Taylor, it is these very liability risks that are at the root of the current on-call crisis. "The liability issue has become the overriding barrier to physicians being willing to put themselves at risk," he said. "Until and unless you solve the liability crisis in emergency care and health care in general, nothing else you do matters."

Most on-call specialists have a private practice outside of the emergency department—they don't need the ED—so it's not a big surprise they were the first to leave, he explained. "But now that core emergency physicians, who were trained to practice only emergency medicine, are making the same choices, that should be a wake-up call," Dr. Taylor said. "That's what's different now compared to 2 or 3 years ago."

On-Call Shortage Cripples Trauma Care

Lack of optimal on-call coverage is what will ultimately "cripple" trauma and emergency care, agreed Dr. L. D. Britt, professor of surgery at the Eastern Virginia Medical School in Norfolk. "Some of the specialists are asking for unbelievably exorbitant fees to provide coverage, and hospitals are being held hostage," he said in an interview.

While Dr. Britt sympathizes with physicians' struggles with payment and liability issues, he believes the true bottom line is simply that obligations are being overlooked. "It cannot be everyone saying, 'I can't do this.' Something has to give," Dr. Britt said. "Speaking for myself, I consider it my obligation to provide emergency coverage if I am on call. I know that's my responsibility—and I'm a chairman of a department. Some people can find ways out of it, but I'm saying we cannot have all those options out there."

In addition, high fees charged by specialists and paid by hospitals for on-call coverage are not justified based on the premise that on-call coverage increases a physician's liability exposure, he said. "Being on call doesn't give you more litigation than being in general surgery—that's well documented," he said.

Dr. Taylor disagreed. "The literature is very clear that emergency care is one of the highest liability environments in health care," he said. "You only have to look at what's happened to emergency physician malpractice premiums relative to others not involved in emergency care. Mine almost doubled the last 3 years I worked."

Emergency on-call coverage from specialist physicians, including dermatologists, is "unraveling" at hospitals across the country, resulting in delayed treatment, patient transfers, permanent injuries, and even death, according to a study from the Center for Studying Health System Change, a nonpartisan policy research group in Washington.

While the problem is predominantly an issue for hospital emergency departments, it also is becoming increasingly problematic for inpatients who need urgent specialty care, according to the report. The findings are based on 2007 data from 12 nationally representative communities: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; Northern New Jersey; Orange County, Calif; Phoenix; Seattle; and Syracuse, N.Y.

The picture is particularly grim given the fact that overall ED utilization rates have risen by 7% in the past decade, from 36.9 to 39.6 visits per 100 people, according to the report. While insured people account for the vast majority of ED visits, "the proportion of visits by uninsured people is rising at a relatively higher rate," the study's authors wrote.

Citing a 2006 paper from the American College of Emergency Physicians, the study reported that 73% of emergency departments in the United States report inadequate on-call coverage by specialist physicians. In particularly short supply are plastic surgeons, ophthalmologists, dermatologists, orthopedic surgeons, neurosurgeons, trauma surgeons, hand surgeons, obstetrician-gynecologists, and neurologists, While an actual shortage of such physicians may sometimes be to blame, "physician unwillingness to take call appears to be a more pressing issue for many hospitals," the study authors stated.

Although unwillingness to accept on-call duty is largely influenced by quality of life issues, the requirement to provide on-call coverage has traditionally been mandated by hospitals under the Emergency Medical Treatment and Labor Act. However, many specialists are now shifting their practices away from the hospital setting, and are no longer obligated by medical staff privileges, noted the report's authors.

Many physicians also believe payment for on-call care is inadequate, especially when they are caring for uninsured patients. Specialists are also concerned that providing emergency care may increase their exposure to medical liability and drive up the cost of their malpractice premiums, according to the report.

As a result, adverse patient outcomes are reported. One study found that 21% of patient deaths or permanent injuries related to ED treatment delays are attributed to lack of specialists' availability, noted the report. Complete lack of access to specialty care in some EDs is forcing either travel or transfer of patients. And for the physicians who continue to provide on-call coverage, increasing workload and decreasing morale may put patients further at risk.

Crisis May Drive Docs Away

"It's not a surprise that we're having this problem—it's a surprise to me that we have any on-call specialists at all," Dr. Todd Taylor, previously an emergency physician and speaker for the ACEP Council, said in an interview. Dr. Taylor left clinical medicine last summer to work in the computer industry, he said, because the risks of liability were more than he could justify.

For Dr. Taylor, it is these very liability risks that are at the root of the current on-call crisis. "The liability issue has become the overriding barrier to physicians being willing to put themselves at risk," he said. "Until and unless you solve the liability crisis in emergency care and health care in general, nothing else you do matters."

Most on-call specialists have a private practice outside of the emergency department—they don't need the ED—so it's not a big surprise they were the first to leave, he explained. "But now that core emergency physicians, who were trained to practice only emergency medicine, are making the same choices, that should be a wake-up call," Dr. Taylor said. "That's what's different now compared to 2 or 3 years ago."

On-Call Shortage Cripples Trauma Care

Lack of optimal on-call coverage is what will ultimately "cripple" trauma and emergency care, agreed Dr. L. D. Britt, professor of surgery at the Eastern Virginia Medical School in Norfolk. "Some of the specialists are asking for unbelievably exorbitant fees to provide coverage, and hospitals are being held hostage," he said in an interview.

While Dr. Britt sympathizes with physicians' struggles with payment and liability issues, he believes the true bottom line is simply that obligations are being overlooked. "It cannot be everyone saying, 'I can't do this.' Something has to give," Dr. Britt said. "Speaking for myself, I consider it my obligation to provide emergency coverage if I am on call. I know that's my responsibility—and I'm a chairman of a department. Some people can find ways out of it, but I'm saying we cannot have all those options out there."

In addition, high fees charged by specialists and paid by hospitals for on-call coverage are not justified based on the premise that on-call coverage increases a physician's liability exposure, he said. "Being on call doesn't give you more litigation than being in general surgery—that's well documented," he said.

Dr. Taylor disagreed. "The literature is very clear that emergency care is one of the highest liability environments in health care," he said. "You only have to look at what's happened to emergency physician malpractice premiums relative to others not involved in emergency care. Mine almost doubled the last 3 years I worked."

ORLANDO — Despite a high prevalence of chronic pain in older adults, adherence to pain medications is low—fueled largely by patients' stoicism, beliefs about pain and aging, and concerns about safety and addiction, according to Dr. Stephen Thielke, a psychiatrist at the University of Washington, Seattle.

Chronic pain not only results in suffering but also is strongly associated with depression and declines in health status, he reported at the annual meeting of the American Association for Geriatric Psychiatry. Recent work by his group has demonstrated that people who report more pain are less likely to respond to integrated depression treatment, compared with those with less pain (Am. J. Geriatr. Psychiatry 2007;15:699-707).

Although 75% of seniors in Medicare surveys report having arthritis (the most common cause of pain in this population), only about 40% of them report actively treating it. In other samples, only about half of patients who report functional impairments from pain take any medication for it, Dr. Thielke noted, which differs from seniors' use of treatments for other chronic medical conditions.

“There is clearly something different about treating arthritis pain, compared [with] treating other medical problems,” he said.

Research about the experience of seniors who have arthritis pain has helped to identify some of the factors involved in seniors' use of medications. In a recent qualitative study of 19 older adults with arthritis pain, only 4 subjects (21%) were taking pain medications as directed; the remaining 79% “purposefully did not take their OA [osteoarthritis] medications as prescribed” (Arthritis Rheum. 2006;55:272-8).

Many of them “described treatment behaviors that we might consider irrational,” noted Dr. Thielke, such as filling prescriptions and then throwing the medication away, putting lower dose pills into a bottle with a higher dose on the label, and hiding their nonadherence from family members. Stoicism was a common theme, he said, with patients minimizing their pain and reporting high pain tolerance. Fear of addiction was reported by many patients as a key barrier to using stronger painkillers. At the same time, 18 of 19 of the participants (95%) were taking at least one herbal remedy and/or vitamin for their arthritis.

Further insights have come from focus groups of older patients with osteoarthritis, which revealed that many of them considered pain “a normal part of getting older,” felt that medications are potentially harmful, and saw medication as masking rather than curing their pain (Arthritis Rheum. 2006;55:905-12).

“Patients placed more emphasis on acceptance, rather than treatment, of pain, and safety, rather than effectiveness, of treatments, and they tended to see pain medications as high risk,” noted Dr. Thielke. He also reported other research findings that suggested the elderly have limited knowledge about arthritis medications, with few individuals being able to list potential side effects or to describe preventive use of medications (Rheumatology 2006;46:796-800).

He speculated that recent publicized safety concerns about NSAIDs and opioid analgesics further complicate patients' efforts to choose treatments that are safe and that patients might conclude that all pain-relieving medications are too risky to try.

Physicians may be complicit in fostering the expectation that pain should be accepted rather than treated by avoiding direct conversations with patients about the consequences of pain and their concerns about treatments for it, Dr. Thielke said. This can add to the patients' perception that they should tough it out. Patients may consider their need for pain medication as wasteful, rash, hedonistic, or selfish, and their ability to forgo analgesia as stoical, patient, thrifty, and selfless, he said.

Prescription directions that advise taking “as needed” also are interpreted differently by patients and physicians. “Many patients will interpret 'as needed' as 'when desperate' or 'when all else fails',” he said, while the provider intends it to mean 'to improve symptoms' or 'to enhance quality of life'. The goal is to make patients understand that their use of pain medication is not a statement about their character strength or toughness; rather, they are trying to improve their health, functioning, overall well-being, and safety. Focus on functioning, not just pain.”

ORLANDO — Despite a high prevalence of chronic pain in older adults, adherence to pain medications is low—fueled largely by patients' stoicism, beliefs about pain and aging, and concerns about safety and addiction, according to Dr. Stephen Thielke, a psychiatrist at the University of Washington, Seattle.

Chronic pain not only results in suffering but also is strongly associated with depression and declines in health status, he reported at the annual meeting of the American Association for Geriatric Psychiatry. Recent work by his group has demonstrated that people who report more pain are less likely to respond to integrated depression treatment, compared with those with less pain (Am. J. Geriatr. Psychiatry 2007;15:699-707).

Although 75% of seniors in Medicare surveys report having arthritis (the most common cause of pain in this population), only about 40% of them report actively treating it. In other samples, only about half of patients who report functional impairments from pain take any medication for it, Dr. Thielke noted, which differs from seniors' use of treatments for other chronic medical conditions.

“There is clearly something different about treating arthritis pain, compared [with] treating other medical problems,” he said.

Research about the experience of seniors who have arthritis pain has helped to identify some of the factors involved in seniors' use of medications. In a recent qualitative study of 19 older adults with arthritis pain, only 4 subjects (21%) were taking pain medications as directed; the remaining 79% “purposefully did not take their OA [osteoarthritis] medications as prescribed” (Arthritis Rheum. 2006;55:272-8).

Many of them “described treatment behaviors that we might consider irrational,” noted Dr. Thielke, such as filling prescriptions and then throwing the medication away, putting lower dose pills into a bottle with a higher dose on the label, and hiding their nonadherence from family members. Stoicism was a common theme, he said, with patients minimizing their pain and reporting high pain tolerance. Fear of addiction was reported by many patients as a key barrier to using stronger painkillers. At the same time, 18 of 19 of the participants (95%) were taking at least one herbal remedy and/or vitamin for their arthritis.

Further insights have come from focus groups of older patients with osteoarthritis, which revealed that many of them considered pain “a normal part of getting older,” felt that medications are potentially harmful, and saw medication as masking rather than curing their pain (Arthritis Rheum. 2006;55:905-12).

“Patients placed more emphasis on acceptance, rather than treatment, of pain, and safety, rather than effectiveness, of treatments, and they tended to see pain medications as high risk,” noted Dr. Thielke. He also reported other research findings that suggested the elderly have limited knowledge about arthritis medications, with few individuals being able to list potential side effects or to describe preventive use of medications (Rheumatology 2006;46:796-800).

He speculated that recent publicized safety concerns about NSAIDs and opioid analgesics further complicate patients' efforts to choose treatments that are safe and that patients might conclude that all pain-relieving medications are too risky to try.

Physicians may be complicit in fostering the expectation that pain should be accepted rather than treated by avoiding direct conversations with patients about the consequences of pain and their concerns about treatments for it, Dr. Thielke said. This can add to the patients' perception that they should tough it out. Patients may consider their need for pain medication as wasteful, rash, hedonistic, or selfish, and their ability to forgo analgesia as stoical, patient, thrifty, and selfless, he said.

Prescription directions that advise taking “as needed” also are interpreted differently by patients and physicians. “Many patients will interpret 'as needed' as 'when desperate' or 'when all else fails',” he said, while the provider intends it to mean 'to improve symptoms' or 'to enhance quality of life'. The goal is to make patients understand that their use of pain medication is not a statement about their character strength or toughness; rather, they are trying to improve their health, functioning, overall well-being, and safety. Focus on functioning, not just pain.”

ORLANDO — Despite a high prevalence of chronic pain in older adults, adherence to pain medications is low—fueled largely by patients' stoicism, beliefs about pain and aging, and concerns about safety and addiction, according to Dr. Stephen Thielke, a psychiatrist at the University of Washington, Seattle.

Chronic pain not only results in suffering but also is strongly associated with depression and declines in health status, he reported at the annual meeting of the American Association for Geriatric Psychiatry. Recent work by his group has demonstrated that people who report more pain are less likely to respond to integrated depression treatment, compared with those with less pain (Am. J. Geriatr. Psychiatry 2007;15:699-707).

Although 75% of seniors in Medicare surveys report having arthritis (the most common cause of pain in this population), only about 40% of them report actively treating it. In other samples, only about half of patients who report functional impairments from pain take any medication for it, Dr. Thielke noted, which differs from seniors' use of treatments for other chronic medical conditions.

“There is clearly something different about treating arthritis pain, compared [with] treating other medical problems,” he said.

Research about the experience of seniors who have arthritis pain has helped to identify some of the factors involved in seniors' use of medications. In a recent qualitative study of 19 older adults with arthritis pain, only 4 subjects (21%) were taking pain medications as directed; the remaining 79% “purposefully did not take their OA [osteoarthritis] medications as prescribed” (Arthritis Rheum. 2006;55:272-8).

Many of them “described treatment behaviors that we might consider irrational,” noted Dr. Thielke, such as filling prescriptions and then throwing the medication away, putting lower dose pills into a bottle with a higher dose on the label, and hiding their nonadherence from family members. Stoicism was a common theme, he said, with patients minimizing their pain and reporting high pain tolerance. Fear of addiction was reported by many patients as a key barrier to using stronger painkillers. At the same time, 18 of 19 of the participants (95%) were taking at least one herbal remedy and/or vitamin for their arthritis.

Further insights have come from focus groups of older patients with osteoarthritis, which revealed that many of them considered pain “a normal part of getting older,” felt that medications are potentially harmful, and saw medication as masking rather than curing their pain (Arthritis Rheum. 2006;55:905-12).

“Patients placed more emphasis on acceptance, rather than treatment, of pain, and safety, rather than effectiveness, of treatments, and they tended to see pain medications as high risk,” noted Dr. Thielke. He also reported other research findings that suggested the elderly have limited knowledge about arthritis medications, with few individuals being able to list potential side effects or to describe preventive use of medications (Rheumatology 2006;46:796-800).

He speculated that recent publicized safety concerns about NSAIDs and opioid analgesics further complicate patients' efforts to choose treatments that are safe and that patients might conclude that all pain-relieving medications are too risky to try.

Physicians may be complicit in fostering the expectation that pain should be accepted rather than treated by avoiding direct conversations with patients about the consequences of pain and their concerns about treatments for it, Dr. Thielke said. This can add to the patients' perception that they should tough it out. Patients may consider their need for pain medication as wasteful, rash, hedonistic, or selfish, and their ability to forgo analgesia as stoical, patient, thrifty, and selfless, he said.

Prescription directions that advise taking “as needed” also are interpreted differently by patients and physicians. “Many patients will interpret 'as needed' as 'when desperate' or 'when all else fails',” he said, while the provider intends it to mean 'to improve symptoms' or 'to enhance quality of life'. The goal is to make patients understand that their use of pain medication is not a statement about their character strength or toughness; rather, they are trying to improve their health, functioning, overall well-being, and safety. Focus on functioning, not just pain.”

MONTREAL — The extent of malnutrition is frequently underestimated in patients with chronic liver disease who are awaiting transplant, and would be better assessed with indirect calorimetry rather than traditional tools, Lynne MacArthur reported at the Canadian Digestive Diseases Week.

Presurgical malnutrition has a negative impact on survival and is associated with complications such as increased risk of systemic infection and encephalopathy, but the malnutrition is reversible when detected, noted Ms. MacArthur, a dietician at the London (Ont.) Health Sciences Centre.

Malnutrition has been found to be present in up to 90% of patients with advanced liver disease, so if the patients are listed for transplant, “they are likely malnourished,” she said at the meeting, which was sponsored by the Canadian Association of Gastroenterology.

Traditional tools for measuring malnutrition, such as the Harris Benedict Equation (HBE), are not useful in patients with liver disease “because markers like body weight and biochemistry don't quantify malnutrition and are not accurate” in these patients, Ms. MacArthur said.

Specifically, “a predictive equation like [the] Harris Benedict Equation is of limited use in chronic liver disease because it often underestimates the resting energy expenditure,” she explained.

Resting energy expenditure is the absolute minimum energy needed for survival, not including energy required for exercise, thermogenesis, or weight gain, she said.

Patients with liver disease are often hypermetabolic, which increases their resting energy expenditure.

In addition, the surgical stress factor, which is known to raise energy requirements by as much as 50% in other transplant patients, has not been quantified adequately in cirrhosis and chronic liver disease patients, she said.

Indirect calorimetry can measure actual resting energy expenditure in the individual patient by using inspired oxygen and expired carbon dioxide. Her study compared actual resting energy expenditure, measured by indirect calorimetry, to the predicted resting energy expenditure according to HBE in 19 patients with chronic liver disease awaiting transplant. For the indirect calorimetry measurement, patients lay supine for 15 minutes with a steady exchange of oxygen and carbon dioxide.

“HBE consistently underestimated metabolic needs in all but two patients,” Ms. MacArthur reported. “Patients' actual energy needs were much more impressive with measured energy expenditure, and predicted energy expenditure didn't capture the true intrapatient variability.”

In 69% of patients with hypermetabolism, defined as measured energy expenditure greater than 110% of that predicted by HBE, “the energy requirements were grossly underestimated,” she said. Measured energy expenditure was much higher than that predicted by HBE.

In addition, measured energy expenditure did not appear to correlate with disease severity, she noted.

The study estimated that when indirect calorimetry is not available, increasing nutritional intake by 27% over energy needs as predicted by HBE would adjust for the surgical stress factor and malnutrition in patients with chronic liver disease awaiting transplant.

Such adjustments at the London Health Sciences Centre have led to significant improvements in nutritional status among liver transplant candidates. “We've seen them gain weight and muscle, usually with enteral nutrition,” Ms. MacArthur said in an interview.

“We give outpatients tube feeds and have also seen improvement. When they feed themselves, typically they don't get to 100% of their needs. They're not hungry, they're full because of the ascites, and they may be encephalopathic—sleeping all day and not eating,” she added.

MONTREAL — The extent of malnutrition is frequently underestimated in patients with chronic liver disease who are awaiting transplant, and would be better assessed with indirect calorimetry rather than traditional tools, Lynne MacArthur reported at the Canadian Digestive Diseases Week.

Presurgical malnutrition has a negative impact on survival and is associated with complications such as increased risk of systemic infection and encephalopathy, but the malnutrition is reversible when detected, noted Ms. MacArthur, a dietician at the London (Ont.) Health Sciences Centre.

Malnutrition has been found to be present in up to 90% of patients with advanced liver disease, so if the patients are listed for transplant, “they are likely malnourished,” she said at the meeting, which was sponsored by the Canadian Association of Gastroenterology.

Traditional tools for measuring malnutrition, such as the Harris Benedict Equation (HBE), are not useful in patients with liver disease “because markers like body weight and biochemistry don't quantify malnutrition and are not accurate” in these patients, Ms. MacArthur said.

Specifically, “a predictive equation like [the] Harris Benedict Equation is of limited use in chronic liver disease because it often underestimates the resting energy expenditure,” she explained.

Resting energy expenditure is the absolute minimum energy needed for survival, not including energy required for exercise, thermogenesis, or weight gain, she said.

Patients with liver disease are often hypermetabolic, which increases their resting energy expenditure.

In addition, the surgical stress factor, which is known to raise energy requirements by as much as 50% in other transplant patients, has not been quantified adequately in cirrhosis and chronic liver disease patients, she said.

Indirect calorimetry can measure actual resting energy expenditure in the individual patient by using inspired oxygen and expired carbon dioxide. Her study compared actual resting energy expenditure, measured by indirect calorimetry, to the predicted resting energy expenditure according to HBE in 19 patients with chronic liver disease awaiting transplant. For the indirect calorimetry measurement, patients lay supine for 15 minutes with a steady exchange of oxygen and carbon dioxide.

“HBE consistently underestimated metabolic needs in all but two patients,” Ms. MacArthur reported. “Patients' actual energy needs were much more impressive with measured energy expenditure, and predicted energy expenditure didn't capture the true intrapatient variability.”

In 69% of patients with hypermetabolism, defined as measured energy expenditure greater than 110% of that predicted by HBE, “the energy requirements were grossly underestimated,” she said. Measured energy expenditure was much higher than that predicted by HBE.

In addition, measured energy expenditure did not appear to correlate with disease severity, she noted.

The study estimated that when indirect calorimetry is not available, increasing nutritional intake by 27% over energy needs as predicted by HBE would adjust for the surgical stress factor and malnutrition in patients with chronic liver disease awaiting transplant.

Such adjustments at the London Health Sciences Centre have led to significant improvements in nutritional status among liver transplant candidates. “We've seen them gain weight and muscle, usually with enteral nutrition,” Ms. MacArthur said in an interview.

“We give outpatients tube feeds and have also seen improvement. When they feed themselves, typically they don't get to 100% of their needs. They're not hungry, they're full because of the ascites, and they may be encephalopathic—sleeping all day and not eating,” she added.

MONTREAL — The extent of malnutrition is frequently underestimated in patients with chronic liver disease who are awaiting transplant, and would be better assessed with indirect calorimetry rather than traditional tools, Lynne MacArthur reported at the Canadian Digestive Diseases Week.

Presurgical malnutrition has a negative impact on survival and is associated with complications such as increased risk of systemic infection and encephalopathy, but the malnutrition is reversible when detected, noted Ms. MacArthur, a dietician at the London (Ont.) Health Sciences Centre.

Malnutrition has been found to be present in up to 90% of patients with advanced liver disease, so if the patients are listed for transplant, “they are likely malnourished,” she said at the meeting, which was sponsored by the Canadian Association of Gastroenterology.

Traditional tools for measuring malnutrition, such as the Harris Benedict Equation (HBE), are not useful in patients with liver disease “because markers like body weight and biochemistry don't quantify malnutrition and are not accurate” in these patients, Ms. MacArthur said.

Specifically, “a predictive equation like [the] Harris Benedict Equation is of limited use in chronic liver disease because it often underestimates the resting energy expenditure,” she explained.

Resting energy expenditure is the absolute minimum energy needed for survival, not including energy required for exercise, thermogenesis, or weight gain, she said.

Patients with liver disease are often hypermetabolic, which increases their resting energy expenditure.

In addition, the surgical stress factor, which is known to raise energy requirements by as much as 50% in other transplant patients, has not been quantified adequately in cirrhosis and chronic liver disease patients, she said.

Indirect calorimetry can measure actual resting energy expenditure in the individual patient by using inspired oxygen and expired carbon dioxide. Her study compared actual resting energy expenditure, measured by indirect calorimetry, to the predicted resting energy expenditure according to HBE in 19 patients with chronic liver disease awaiting transplant. For the indirect calorimetry measurement, patients lay supine for 15 minutes with a steady exchange of oxygen and carbon dioxide.

“HBE consistently underestimated metabolic needs in all but two patients,” Ms. MacArthur reported. “Patients' actual energy needs were much more impressive with measured energy expenditure, and predicted energy expenditure didn't capture the true intrapatient variability.”

In 69% of patients with hypermetabolism, defined as measured energy expenditure greater than 110% of that predicted by HBE, “the energy requirements were grossly underestimated,” she said. Measured energy expenditure was much higher than that predicted by HBE.

In addition, measured energy expenditure did not appear to correlate with disease severity, she noted.

The study estimated that when indirect calorimetry is not available, increasing nutritional intake by 27% over energy needs as predicted by HBE would adjust for the surgical stress factor and malnutrition in patients with chronic liver disease awaiting transplant.

Such adjustments at the London Health Sciences Centre have led to significant improvements in nutritional status among liver transplant candidates. “We've seen them gain weight and muscle, usually with enteral nutrition,” Ms. MacArthur said in an interview.

“We give outpatients tube feeds and have also seen improvement. When they feed themselves, typically they don't get to 100% of their needs. They're not hungry, they're full because of the ascites, and they may be encephalopathic—sleeping all day and not eating,” she added.

MONTREAL — Primary care physicians referring patients for routine colorectal cancer screening may see better adherence, particularly among men, if they consider patient preference regarding screening modality, reported Maida Sewitch, Ph.D., from McGill University, Montreal. However, the picture is less clear for women.

In a study of 203 primary care patients referred for colorectal cancer screening (40% male, mean age 64 years), overall adherence was 52%, Dr. Sewitch reported in a poster at Canadian Digestive Diseases Week.

For both genders combined, the strongest predictor of adherence was a physician's referral that matched a patient's preferred screening modality (adjusted odds ratio 3.64), she said. However, the results looked quite different when analyzed according to patient gender.

“What we found was that the people for whom matched modality was important were the men—and that men who were matched on modality were 3.5 times more likely to adhere to screening referral than men who were not matched. But women didn't care about modality. We didn't expect that at all,” Dr. Sewitch said in an interview.

The four choices of screening modality offered in the study were colonoscopy, double contrast barium enema, flexible sigmoidoscopy, and fecal occult blood testing (FOBT). The most commonly requested modality was FOBT, she said.

Although matching the referral modality to patient preference increased the odds of screening adherence in men (AOR 3.49), it only had a slight impact in women (AOR 1.24), she said. Instead, the predictor of female adherence to screening was past history of screening (AOR 2.1), she reported.

Women may “have more trust in their physician's recommendation, and a past history of screening may demystify the experience, whereas men want what they want,” Dr. Sewitch said. “It might have a lot to do with control.

“Physicians should be speaking with patients about what they want. If they're going to recommend some kind of colorectal cancer screening, they can ask their patients what they want to do and give their referral based on that,” she said.

A second poster presented at the meeting described an investigation of patient preference regarding the timing of a precolonoscopy consult with a gastroenterologist. A total of 125 average-risk patients (66% male, mean age 60 years) participated in the study, with 21% receiving a gastroenterology consult on a different day (DD) previous to their colonoscopy, and 79% receiving the consult on the same day (SD), just before their colonoscopy.

Patients were asked to complete a questionnaire after their colonoscopy regarding their preference for a DD or SD consult, reported Dr. Liliana Oliveira from the University of Ottawa. The study found that patient preferences appeared to be affected only by prior consultation experience. Among patients who had an SD consult, 86% indicated a preference for this practice, and among those who had a DD consult, 61.5% preferred this practice; these findings were significant.

She stressed that SD consultation is only intended for average-risk patients. Although SD consultation is common, she said it remains somewhat controversial.

MONTREAL — Primary care physicians referring patients for routine colorectal cancer screening may see better adherence, particularly among men, if they consider patient preference regarding screening modality, reported Maida Sewitch, Ph.D., from McGill University, Montreal. However, the picture is less clear for women.

In a study of 203 primary care patients referred for colorectal cancer screening (40% male, mean age 64 years), overall adherence was 52%, Dr. Sewitch reported in a poster at Canadian Digestive Diseases Week.

For both genders combined, the strongest predictor of adherence was a physician's referral that matched a patient's preferred screening modality (adjusted odds ratio 3.64), she said. However, the results looked quite different when analyzed according to patient gender.

“What we found was that the people for whom matched modality was important were the men—and that men who were matched on modality were 3.5 times more likely to adhere to screening referral than men who were not matched. But women didn't care about modality. We didn't expect that at all,” Dr. Sewitch said in an interview.

The four choices of screening modality offered in the study were colonoscopy, double contrast barium enema, flexible sigmoidoscopy, and fecal occult blood testing (FOBT). The most commonly requested modality was FOBT, she said.

Although matching the referral modality to patient preference increased the odds of screening adherence in men (AOR 3.49), it only had a slight impact in women (AOR 1.24), she said. Instead, the predictor of female adherence to screening was past history of screening (AOR 2.1), she reported.

Women may “have more trust in their physician's recommendation, and a past history of screening may demystify the experience, whereas men want what they want,” Dr. Sewitch said. “It might have a lot to do with control.

“Physicians should be speaking with patients about what they want. If they're going to recommend some kind of colorectal cancer screening, they can ask their patients what they want to do and give their referral based on that,” she said.

A second poster presented at the meeting described an investigation of patient preference regarding the timing of a precolonoscopy consult with a gastroenterologist. A total of 125 average-risk patients (66% male, mean age 60 years) participated in the study, with 21% receiving a gastroenterology consult on a different day (DD) previous to their colonoscopy, and 79% receiving the consult on the same day (SD), just before their colonoscopy.

Patients were asked to complete a questionnaire after their colonoscopy regarding their preference for a DD or SD consult, reported Dr. Liliana Oliveira from the University of Ottawa. The study found that patient preferences appeared to be affected only by prior consultation experience. Among patients who had an SD consult, 86% indicated a preference for this practice, and among those who had a DD consult, 61.5% preferred this practice; these findings were significant.

She stressed that SD consultation is only intended for average-risk patients. Although SD consultation is common, she said it remains somewhat controversial.

MONTREAL — Primary care physicians referring patients for routine colorectal cancer screening may see better adherence, particularly among men, if they consider patient preference regarding screening modality, reported Maida Sewitch, Ph.D., from McGill University, Montreal. However, the picture is less clear for women.

In a study of 203 primary care patients referred for colorectal cancer screening (40% male, mean age 64 years), overall adherence was 52%, Dr. Sewitch reported in a poster at Canadian Digestive Diseases Week.

For both genders combined, the strongest predictor of adherence was a physician's referral that matched a patient's preferred screening modality (adjusted odds ratio 3.64), she said. However, the results looked quite different when analyzed according to patient gender.

“What we found was that the people for whom matched modality was important were the men—and that men who were matched on modality were 3.5 times more likely to adhere to screening referral than men who were not matched. But women didn't care about modality. We didn't expect that at all,” Dr. Sewitch said in an interview.

The four choices of screening modality offered in the study were colonoscopy, double contrast barium enema, flexible sigmoidoscopy, and fecal occult blood testing (FOBT). The most commonly requested modality was FOBT, she said.

Although matching the referral modality to patient preference increased the odds of screening adherence in men (AOR 3.49), it only had a slight impact in women (AOR 1.24), she said. Instead, the predictor of female adherence to screening was past history of screening (AOR 2.1), she reported.

Women may “have more trust in their physician's recommendation, and a past history of screening may demystify the experience, whereas men want what they want,” Dr. Sewitch said. “It might have a lot to do with control.

“Physicians should be speaking with patients about what they want. If they're going to recommend some kind of colorectal cancer screening, they can ask their patients what they want to do and give their referral based on that,” she said.

A second poster presented at the meeting described an investigation of patient preference regarding the timing of a precolonoscopy consult with a gastroenterologist. A total of 125 average-risk patients (66% male, mean age 60 years) participated in the study, with 21% receiving a gastroenterology consult on a different day (DD) previous to their colonoscopy, and 79% receiving the consult on the same day (SD), just before their colonoscopy.

Patients were asked to complete a questionnaire after their colonoscopy regarding their preference for a DD or SD consult, reported Dr. Liliana Oliveira from the University of Ottawa. The study found that patient preferences appeared to be affected only by prior consultation experience. Among patients who had an SD consult, 86% indicated a preference for this practice, and among those who had a DD consult, 61.5% preferred this practice; these findings were significant.

She stressed that SD consultation is only intended for average-risk patients. Although SD consultation is common, she said it remains somewhat controversial.

Methotrexate significantly improved health-related quality of life in juvenile idiopathic arthritis.

Although information on the efficacy and safety of second-line agents is “abundant,” little is known about the effect of current treatments on the health-related quality of life (HRQOL) of patients with JIA, reported Dr. A. Céspedes-Cruz from the Pediatric Rheumatology International Trials Organization in Genoa (Italy) and associates.

In their analysis of 521 children with the disorder, methotrexate (MTX) treatment “produced a significant improvement across a wide range of HRQOL components, especially in the physical domain,” they reported. “Although similar studies in adults with rheumatoid arthritis have been reported, to the best of our knowledge this is the first time that HRQOL has been examined in JIA, demonstrating that effective therapies such as MTX can reverse the impairments of HRQOL and substantially improve a patient's life.”

The 521 children (mean age, 8 years) were selected from a larger randomized trial aimed at evaluating the safety and efficacy of various doses of MTX. All subjects had polyarticular-course JIA (systemic, polyarthritis, or extended oligoarthritis categories), and were newly treated with a standard dosage of MTX (10 mg/m

Patients were included in the analysis if they had completed at least 6 months of treatment with MTX and had an HRQOL assessment at baseline and/or at 6 months. The Child Health Questionnaire (CHQ), designed to capture the physical, emotional, and social components of health status, was used to assess HRQOL in patients and controls.

In general, patients in the study had relatively short disease duration (mean, 2.8 years) and high disease severity and disability at baseline. Their HRQOL was poor at baseline, particularly in the physical domains, with many health concepts being 2 standard deviations (SD) below the mean for healthy children, noted the authors. “Bodily pain/discomfort was the most impaired CHQ health concept, with values that were 60% below the threshold of absence of pain,” they wrote. “Also at baseline, patients showed other health concepts related to physical well-being that were below 2 SD of the mean of healthy controls, such as perceiving themselves as having less opportunity or energy to participate in physical and social activities because of their impaired global health.” Patients' psychosocial domains were also significantly lower than those of healthy controls, though not as impaired as the physical domains.

After 6 months of treatment with standard-dose MTX, a total of 403 (77%) of the 521 patients had significant symptom improvement. A further 39 and 36 patients, respectively, were eligible for randomization to 6 subsequent months of intermediate- or high-dose treatment, noted the authors. Significant improvement in HRQOL was noted after 6 months in all CHQ health concept scores for the initial responders, “indicating that the physical and psychosocial consequences of the disease are partly reversible as a result of medical intervention,” they wrote. This improvement in HRQOL was also seen after the nonresponders were treated with higher MTX doses, they added. “It is notable that almost all the health concepts that at baseline were less than 2 SD of the mean of healthy control reached mean values above this level, except physical health, which, despite improvements, remained closer to the cut-off of 2 SD of healthy children,” they wrote. “This finding suggests that a major functional impairment remains in these patients despite the observed improvement in disease activity measures.”

The study also sought to identify the determinants of sustained poor physical and psychosocial well-being after MTX treatment. It found that a greater baseline disability was the strongest determinant of persistently poor physical well-being (odds ratio, 5.2), with weaker determinants being erythrocyte sedimentation rate, parents' assessment of child's pain, and antinuclear antibody-negative status. These findings “may allow doctors to identify children at greater risk of retaining poor physical health despite treatment with MTX,” they wrote. “These children would require additional medical and/or physical/psychological interventions to decrease this risk.”

The strongest determinant for persistently poor psychosocial well-being was the number of limited joints (OR 6), followed by the parents' assessment of child well-being, and to a lesser extent, the doctor's global assessment of disease activity and an antinuclear antibody-negative status. The authors noted the unexpected and conflicting finding that, while the parents' assessment of increased baseline disability and child well-being was associated with persistence of poor psychosocial well-being, the doctors' assessments of fewer joints with limited range and a lower level of disease activity were also associated with persistently poor psychosocial scores. “This highlights the discrepancy in the evaluation of the child between the parent and the doctor, with the former being more concerned about psychosocial well-being and the latter being more influenced by physical measures of the child's health,” they wrote (Ann. Rheum. Dis. 2008;67:309–14).

Future studies in JIA need to evaluate the effect of other medication, particularly biological agents, on HRQOL, the researchers concluded.

Methotrexate significantly improved health-related quality of life in juvenile idiopathic arthritis.

Although information on the efficacy and safety of second-line agents is “abundant,” little is known about the effect of current treatments on the health-related quality of life (HRQOL) of patients with JIA, reported Dr. A. Céspedes-Cruz from the Pediatric Rheumatology International Trials Organization in Genoa (Italy) and associates.

In their analysis of 521 children with the disorder, methotrexate (MTX) treatment “produced a significant improvement across a wide range of HRQOL components, especially in the physical domain,” they reported. “Although similar studies in adults with rheumatoid arthritis have been reported, to the best of our knowledge this is the first time that HRQOL has been examined in JIA, demonstrating that effective therapies such as MTX can reverse the impairments of HRQOL and substantially improve a patient's life.”

The 521 children (mean age, 8 years) were selected from a larger randomized trial aimed at evaluating the safety and efficacy of various doses of MTX. All subjects had polyarticular-course JIA (systemic, polyarthritis, or extended oligoarthritis categories), and were newly treated with a standard dosage of MTX (10 mg/m

Patients were included in the analysis if they had completed at least 6 months of treatment with MTX and had an HRQOL assessment at baseline and/or at 6 months. The Child Health Questionnaire (CHQ), designed to capture the physical, emotional, and social components of health status, was used to assess HRQOL in patients and controls.

In general, patients in the study had relatively short disease duration (mean, 2.8 years) and high disease severity and disability at baseline. Their HRQOL was poor at baseline, particularly in the physical domains, with many health concepts being 2 standard deviations (SD) below the mean for healthy children, noted the authors. “Bodily pain/discomfort was the most impaired CHQ health concept, with values that were 60% below the threshold of absence of pain,” they wrote. “Also at baseline, patients showed other health concepts related to physical well-being that were below 2 SD of the mean of healthy controls, such as perceiving themselves as having less opportunity or energy to participate in physical and social activities because of their impaired global health.” Patients' psychosocial domains were also significantly lower than those of healthy controls, though not as impaired as the physical domains.

After 6 months of treatment with standard-dose MTX, a total of 403 (77%) of the 521 patients had significant symptom improvement. A further 39 and 36 patients, respectively, were eligible for randomization to 6 subsequent months of intermediate- or high-dose treatment, noted the authors. Significant improvement in HRQOL was noted after 6 months in all CHQ health concept scores for the initial responders, “indicating that the physical and psychosocial consequences of the disease are partly reversible as a result of medical intervention,” they wrote. This improvement in HRQOL was also seen after the nonresponders were treated with higher MTX doses, they added. “It is notable that almost all the health concepts that at baseline were less than 2 SD of the mean of healthy control reached mean values above this level, except physical health, which, despite improvements, remained closer to the cut-off of 2 SD of healthy children,” they wrote. “This finding suggests that a major functional impairment remains in these patients despite the observed improvement in disease activity measures.”

The study also sought to identify the determinants of sustained poor physical and psychosocial well-being after MTX treatment. It found that a greater baseline disability was the strongest determinant of persistently poor physical well-being (odds ratio, 5.2), with weaker determinants being erythrocyte sedimentation rate, parents' assessment of child's pain, and antinuclear antibody-negative status. These findings “may allow doctors to identify children at greater risk of retaining poor physical health despite treatment with MTX,” they wrote. “These children would require additional medical and/or physical/psychological interventions to decrease this risk.”

The strongest determinant for persistently poor psychosocial well-being was the number of limited joints (OR 6), followed by the parents' assessment of child well-being, and to a lesser extent, the doctor's global assessment of disease activity and an antinuclear antibody-negative status. The authors noted the unexpected and conflicting finding that, while the parents' assessment of increased baseline disability and child well-being was associated with persistence of poor psychosocial well-being, the doctors' assessments of fewer joints with limited range and a lower level of disease activity were also associated with persistently poor psychosocial scores. “This highlights the discrepancy in the evaluation of the child between the parent and the doctor, with the former being more concerned about psychosocial well-being and the latter being more influenced by physical measures of the child's health,” they wrote (Ann. Rheum. Dis. 2008;67:309–14).

Future studies in JIA need to evaluate the effect of other medication, particularly biological agents, on HRQOL, the researchers concluded.

Methotrexate significantly improved health-related quality of life in juvenile idiopathic arthritis.

Although information on the efficacy and safety of second-line agents is “abundant,” little is known about the effect of current treatments on the health-related quality of life (HRQOL) of patients with JIA, reported Dr. A. Céspedes-Cruz from the Pediatric Rheumatology International Trials Organization in Genoa (Italy) and associates.

In their analysis of 521 children with the disorder, methotrexate (MTX) treatment “produced a significant improvement across a wide range of HRQOL components, especially in the physical domain,” they reported. “Although similar studies in adults with rheumatoid arthritis have been reported, to the best of our knowledge this is the first time that HRQOL has been examined in JIA, demonstrating that effective therapies such as MTX can reverse the impairments of HRQOL and substantially improve a patient's life.”

The 521 children (mean age, 8 years) were selected from a larger randomized trial aimed at evaluating the safety and efficacy of various doses of MTX. All subjects had polyarticular-course JIA (systemic, polyarthritis, or extended oligoarthritis categories), and were newly treated with a standard dosage of MTX (10 mg/m

Patients were included in the analysis if they had completed at least 6 months of treatment with MTX and had an HRQOL assessment at baseline and/or at 6 months. The Child Health Questionnaire (CHQ), designed to capture the physical, emotional, and social components of health status, was used to assess HRQOL in patients and controls.

In general, patients in the study had relatively short disease duration (mean, 2.8 years) and high disease severity and disability at baseline. Their HRQOL was poor at baseline, particularly in the physical domains, with many health concepts being 2 standard deviations (SD) below the mean for healthy children, noted the authors. “Bodily pain/discomfort was the most impaired CHQ health concept, with values that were 60% below the threshold of absence of pain,” they wrote. “Also at baseline, patients showed other health concepts related to physical well-being that were below 2 SD of the mean of healthy controls, such as perceiving themselves as having less opportunity or energy to participate in physical and social activities because of their impaired global health.” Patients' psychosocial domains were also significantly lower than those of healthy controls, though not as impaired as the physical domains.

After 6 months of treatment with standard-dose MTX, a total of 403 (77%) of the 521 patients had significant symptom improvement. A further 39 and 36 patients, respectively, were eligible for randomization to 6 subsequent months of intermediate- or high-dose treatment, noted the authors. Significant improvement in HRQOL was noted after 6 months in all CHQ health concept scores for the initial responders, “indicating that the physical and psychosocial consequences of the disease are partly reversible as a result of medical intervention,” they wrote. This improvement in HRQOL was also seen after the nonresponders were treated with higher MTX doses, they added. “It is notable that almost all the health concepts that at baseline were less than 2 SD of the mean of healthy control reached mean values above this level, except physical health, which, despite improvements, remained closer to the cut-off of 2 SD of healthy children,” they wrote. “This finding suggests that a major functional impairment remains in these patients despite the observed improvement in disease activity measures.”

The study also sought to identify the determinants of sustained poor physical and psychosocial well-being after MTX treatment. It found that a greater baseline disability was the strongest determinant of persistently poor physical well-being (odds ratio, 5.2), with weaker determinants being erythrocyte sedimentation rate, parents' assessment of child's pain, and antinuclear antibody-negative status. These findings “may allow doctors to identify children at greater risk of retaining poor physical health despite treatment with MTX,” they wrote. “These children would require additional medical and/or physical/psychological interventions to decrease this risk.”

The strongest determinant for persistently poor psychosocial well-being was the number of limited joints (OR 6), followed by the parents' assessment of child well-being, and to a lesser extent, the doctor's global assessment of disease activity and an antinuclear antibody-negative status. The authors noted the unexpected and conflicting finding that, while the parents' assessment of increased baseline disability and child well-being was associated with persistence of poor psychosocial well-being, the doctors' assessments of fewer joints with limited range and a lower level of disease activity were also associated with persistently poor psychosocial scores. “This highlights the discrepancy in the evaluation of the child between the parent and the doctor, with the former being more concerned about psychosocial well-being and the latter being more influenced by physical measures of the child's health,” they wrote (Ann. Rheum. Dis. 2008;67:309–14).

Future studies in JIA need to evaluate the effect of other medication, particularly biological agents, on HRQOL, the researchers concluded.

ORLANDO — Pain is a comorbid condition too often overlooked in the setting of geriatric psychiatry, despite the potential for better mental health outcomes when it is treated, Dr. Jordan F. Karp said at the annual meeting of the American Association for Geriatric Psychiatry.

“I don't think enough attention is paid to assessing, diagnosing, and managing pain by many psychiatrists and other physicians who treat older adults,” he said in an interview. “I highly doubt that clinicians are aware of the effects of pain on cognition.”

Because pain has reached “epidemic” proportions among the elderly and can significantly worsen cognition and depression, it should be assessed and treated routinely as part of the psychiatric management of this population, said Dr. Karp, medical director of geriatric psychiatry at one of the referral pain clinics at the University of Pittsburgh Medical Center.

Studies suggest that up to 50% of community-dwelling seniors experience pain that interferes with normal functioning, and up to 80% of nursing home patients live with undertreated pain—the source of which can be musculoskeletal, neuropathic, visceral, metabolic, or other. (See box.)

It is well known that persistent pain limits mobility, increases the risk of falls, and can lead to social isolation, but it is not always appreciated that pain can also increase anxiety, depression, and cognitive impairment, said Dr. Karp, who has a clinical and research focus on both pain and affective disorders in older adults. He disclosed his advisory role with Eli Lilly & Co. and Myriad Genetics Inc.

In a recent survey of 56 patients in an older adult pain management program, he showed that higher pain severity was associated with poorer performance on a test of number/letter switching (Pain Med. 2006;7:444–52).

In another study of older adults (mean age 73 years), different investigators demonstrated lower neuropsychological function among 163 subjects with chronic low back pain (CLBP), compared with 163 who were pain free (Pain Med. 2006;7:60–70). Recent preliminary evidence also suggests reduced brain volume among eight seniors with CLBP, compared with eight who were pain free (Pain Med. 2008;9:240–8).

The comorbidity of pain and depression is a vicious circle, Dr. Thomas Meeks of the University of California, San Diego, said in a separate presentation at the meeting.

A link between depression and immune system dysfunction has been described, and both pain and weakened immunity have been associated with an increase in inflammatory cytokines. Inflammatory cytokines are also associated with anorexia, sleep disturbance, and fatigue and have been shown to negatively affect brain chemicals such as serotonin and norepinephrine, suggesting “there may be a role of inflammatory cytokines in late-life depression,” he said.

Since the rise in inflammatory cytokines seen with acute pain can persist long after the source of the pain has been corrected, prompt diagnosis and treatment of pain is important to reduce the risk of persistent pain and chronic depression, Dr. Meeks said.

“We need to keep pain in mind and ask our patients about it,” said Dr. Karp. In addition to various visual or verbal rating scales that can be used to inquire about pain, he said, certain direct questions might be helpful:

▸ Are you in pain now, or if not now, do you hurt more often than not?

▸ Where do you hurt?

▸ How has pain interfered with your life?

▸ Does pain interfere with your sleep?

“Insomnia is ubiquitous in this group,” he said. “It has been associated with a decreased pain threshold, and it decreases patients' ability to actively cope with their pain problem.”

Preliminary analysis from some of his pilot work has shown that insomnia and fatigue among older patients are associated with passive rather than active coping skills. “Passive skills are less effective and involve things like catastrophizing, praying, or hoping the pain will stop, whereas more active coping involves increasing behavioral activities and using coping self-statements like 'I will get through this,' 'the pain will pass,' or 'the pain will not kill me,'” he said.

When direct questioning is not useful or patients are nonverbal, behavioral observation can reveal a great deal about the pain an individual may be experiencing. “They may be grimacing or sighing; they may be irritable, disruptive, or verbally abusive; their body position may be rigid or guarded; or they might show their discomfort by fidgeting,” said Dr. Karp.

The recently validated Elderly Pain Caring Assessment 2 provides further insight into nonverbal cues (Pain 2007;133:87–98). “It's unlikely that we are going to be able to introduce another assessment into our nursing homes, but informing staff about some of these probes may be useful,” he said.

Regardless of whether patients live in the community or in a nursing home, treating their pain with opioids can raise concerns about sedation and cognitive impairment. The decision should involve an individualized risk-benefit analysis. “While opioids do increase the risk of sedation, confusion, falls, and constipation, for some people the analgesia that results outweighs these potential risks—and cognition actually seems to improve,” he said. “Perhaps they are less distracted by pain and are better able to focus and concentrate.”

Health care professionals should regard persistent pain in the elderly as treatable, with the potential for improvement in many patients. “We need to get the word out that the management of pain should be moved up the priority list, because we can get these patients feeling and functioning better,” Dr. Karp said.

Common Sources Of Geriatric Pain

Musculoskeletal

Degenerative joint disease

Spinal stenosis

Fractures

Improper positioning

Contractures

Visceral

Coronary artery disease

Urinary retention

Constipation

Neuropathic

Postherpetic neuralgia

Radiculopathy

Poststroke syndrome

Diabetic neuropathic pain

Metabolic

Vitamin D deficiency

Paget's disease

Other

Cancer

Fibromyalgia

Oral/dental disorder

Peripheral vascular disease

Polymyalgia rheumatica

ORLANDO — Pain is a comorbid condition too often overlooked in the setting of geriatric psychiatry, despite the potential for better mental health outcomes when it is treated, Dr. Jordan F. Karp said at the annual meeting of the American Association for Geriatric Psychiatry.

“I don't think enough attention is paid to assessing, diagnosing, and managing pain by many psychiatrists and other physicians who treat older adults,” he said in an interview. “I highly doubt that clinicians are aware of the effects of pain on cognition.”

Because pain has reached “epidemic” proportions among the elderly and can significantly worsen cognition and depression, it should be assessed and treated routinely as part of the psychiatric management of this population, said Dr. Karp, medical director of geriatric psychiatry at one of the referral pain clinics at the University of Pittsburgh Medical Center.

Studies suggest that up to 50% of community-dwelling seniors experience pain that interferes with normal functioning, and up to 80% of nursing home patients live with undertreated pain—the source of which can be musculoskeletal, neuropathic, visceral, metabolic, or other. (See box.)

It is well known that persistent pain limits mobility, increases the risk of falls, and can lead to social isolation, but it is not always appreciated that pain can also increase anxiety, depression, and cognitive impairment, said Dr. Karp, who has a clinical and research focus on both pain and affective disorders in older adults. He disclosed his advisory role with Eli Lilly & Co. and Myriad Genetics Inc.

In a recent survey of 56 patients in an older adult pain management program, he showed that higher pain severity was associated with poorer performance on a test of number/letter switching (Pain Med. 2006;7:444–52).

In another study of older adults (mean age 73 years), different investigators demonstrated lower neuropsychological function among 163 subjects with chronic low back pain (CLBP), compared with 163 who were pain free (Pain Med. 2006;7:60–70). Recent preliminary evidence also suggests reduced brain volume among eight seniors with CLBP, compared with eight who were pain free (Pain Med. 2008;9:240–8).

The comorbidity of pain and depression is a vicious circle, Dr. Thomas Meeks of the University of California, San Diego, said in a separate presentation at the meeting.

A link between depression and immune system dysfunction has been described, and both pain and weakened immunity have been associated with an increase in inflammatory cytokines. Inflammatory cytokines are also associated with anorexia, sleep disturbance, and fatigue and have been shown to negatively affect brain chemicals such as serotonin and norepinephrine, suggesting “there may be a role of inflammatory cytokines in late-life depression,” he said.

Since the rise in inflammatory cytokines seen with acute pain can persist long after the source of the pain has been corrected, prompt diagnosis and treatment of pain is important to reduce the risk of persistent pain and chronic depression, Dr. Meeks said.

“We need to keep pain in mind and ask our patients about it,” said Dr. Karp. In addition to various visual or verbal rating scales that can be used to inquire about pain, he said, certain direct questions might be helpful:

▸ Are you in pain now, or if not now, do you hurt more often than not?

▸ Where do you hurt?

▸ How has pain interfered with your life?

▸ Does pain interfere with your sleep?

“Insomnia is ubiquitous in this group,” he said. “It has been associated with a decreased pain threshold, and it decreases patients' ability to actively cope with their pain problem.”

Preliminary analysis from some of his pilot work has shown that insomnia and fatigue among older patients are associated with passive rather than active coping skills. “Passive skills are less effective and involve things like catastrophizing, praying, or hoping the pain will stop, whereas more active coping involves increasing behavioral activities and using coping self-statements like 'I will get through this,' 'the pain will pass,' or 'the pain will not kill me,'” he said.

When direct questioning is not useful or patients are nonverbal, behavioral observation can reveal a great deal about the pain an individual may be experiencing. “They may be grimacing or sighing; they may be irritable, disruptive, or verbally abusive; their body position may be rigid or guarded; or they might show their discomfort by fidgeting,” said Dr. Karp.

The recently validated Elderly Pain Caring Assessment 2 provides further insight into nonverbal cues (Pain 2007;133:87–98). “It's unlikely that we are going to be able to introduce another assessment into our nursing homes, but informing staff about some of these probes may be useful,” he said.

Regardless of whether patients live in the community or in a nursing home, treating their pain with opioids can raise concerns about sedation and cognitive impairment. The decision should involve an individualized risk-benefit analysis. “While opioids do increase the risk of sedation, confusion, falls, and constipation, for some people the analgesia that results outweighs these potential risks—and cognition actually seems to improve,” he said. “Perhaps they are less distracted by pain and are better able to focus and concentrate.”

Health care professionals should regard persistent pain in the elderly as treatable, with the potential for improvement in many patients. “We need to get the word out that the management of pain should be moved up the priority list, because we can get these patients feeling and functioning better,” Dr. Karp said.

Common Sources Of Geriatric Pain

Musculoskeletal

Degenerative joint disease

Spinal stenosis

Fractures

Improper positioning

Contractures

Visceral

Coronary artery disease

Urinary retention

Constipation

Neuropathic

Postherpetic neuralgia

Radiculopathy

Poststroke syndrome

Diabetic neuropathic pain

Metabolic

Vitamin D deficiency

Paget's disease

Other

Cancer

Fibromyalgia

Oral/dental disorder

Peripheral vascular disease

Polymyalgia rheumatica

ORLANDO — Pain is a comorbid condition too often overlooked in the setting of geriatric psychiatry, despite the potential for better mental health outcomes when it is treated, Dr. Jordan F. Karp said at the annual meeting of the American Association for Geriatric Psychiatry.

“I don't think enough attention is paid to assessing, diagnosing, and managing pain by many psychiatrists and other physicians who treat older adults,” he said in an interview. “I highly doubt that clinicians are aware of the effects of pain on cognition.”

Because pain has reached “epidemic” proportions among the elderly and can significantly worsen cognition and depression, it should be assessed and treated routinely as part of the psychiatric management of this population, said Dr. Karp, medical director of geriatric psychiatry at one of the referral pain clinics at the University of Pittsburgh Medical Center.

Studies suggest that up to 50% of community-dwelling seniors experience pain that interferes with normal functioning, and up to 80% of nursing home patients live with undertreated pain—the source of which can be musculoskeletal, neuropathic, visceral, metabolic, or other. (See box.)

It is well known that persistent pain limits mobility, increases the risk of falls, and can lead to social isolation, but it is not always appreciated that pain can also increase anxiety, depression, and cognitive impairment, said Dr. Karp, who has a clinical and research focus on both pain and affective disorders in older adults. He disclosed his advisory role with Eli Lilly & Co. and Myriad Genetics Inc.

In a recent survey of 56 patients in an older adult pain management program, he showed that higher pain severity was associated with poorer performance on a test of number/letter switching (Pain Med. 2006;7:444–52).

In another study of older adults (mean age 73 years), different investigators demonstrated lower neuropsychological function among 163 subjects with chronic low back pain (CLBP), compared with 163 who were pain free (Pain Med. 2006;7:60–70). Recent preliminary evidence also suggests reduced brain volume among eight seniors with CLBP, compared with eight who were pain free (Pain Med. 2008;9:240–8).

The comorbidity of pain and depression is a vicious circle, Dr. Thomas Meeks of the University of California, San Diego, said in a separate presentation at the meeting.

A link between depression and immune system dysfunction has been described, and both pain and weakened immunity have been associated with an increase in inflammatory cytokines. Inflammatory cytokines are also associated with anorexia, sleep disturbance, and fatigue and have been shown to negatively affect brain chemicals such as serotonin and norepinephrine, suggesting “there may be a role of inflammatory cytokines in late-life depression,” he said.

Since the rise in inflammatory cytokines seen with acute pain can persist long after the source of the pain has been corrected, prompt diagnosis and treatment of pain is important to reduce the risk of persistent pain and chronic depression, Dr. Meeks said.

“We need to keep pain in mind and ask our patients about it,” said Dr. Karp. In addition to various visual or verbal rating scales that can be used to inquire about pain, he said, certain direct questions might be helpful:

▸ Are you in pain now, or if not now, do you hurt more often than not?

▸ Where do you hurt?

▸ How has pain interfered with your life?

▸ Does pain interfere with your sleep?

“Insomnia is ubiquitous in this group,” he said. “It has been associated with a decreased pain threshold, and it decreases patients' ability to actively cope with their pain problem.”

Preliminary analysis from some of his pilot work has shown that insomnia and fatigue among older patients are associated with passive rather than active coping skills. “Passive skills are less effective and involve things like catastrophizing, praying, or hoping the pain will stop, whereas more active coping involves increasing behavioral activities and using coping self-statements like 'I will get through this,' 'the pain will pass,' or 'the pain will not kill me,'” he said.

When direct questioning is not useful or patients are nonverbal, behavioral observation can reveal a great deal about the pain an individual may be experiencing. “They may be grimacing or sighing; they may be irritable, disruptive, or verbally abusive; their body position may be rigid or guarded; or they might show their discomfort by fidgeting,” said Dr. Karp.

The recently validated Elderly Pain Caring Assessment 2 provides further insight into nonverbal cues (Pain 2007;133:87–98). “It's unlikely that we are going to be able to introduce another assessment into our nursing homes, but informing staff about some of these probes may be useful,” he said.

Regardless of whether patients live in the community or in a nursing home, treating their pain with opioids can raise concerns about sedation and cognitive impairment. The decision should involve an individualized risk-benefit analysis. “While opioids do increase the risk of sedation, confusion, falls, and constipation, for some people the analgesia that results outweighs these potential risks—and cognition actually seems to improve,” he said. “Perhaps they are less distracted by pain and are better able to focus and concentrate.”

Health care professionals should regard persistent pain in the elderly as treatable, with the potential for improvement in many patients. “We need to get the word out that the management of pain should be moved up the priority list, because we can get these patients feeling and functioning better,” Dr. Karp said.

Common Sources Of Geriatric Pain

Musculoskeletal

Degenerative joint disease

Spinal stenosis

Fractures

Improper positioning

Contractures

Visceral

Coronary artery disease

Urinary retention

Constipation

Neuropathic

Postherpetic neuralgia

Radiculopathy

Poststroke syndrome

Diabetic neuropathic pain

Metabolic

Vitamin D deficiency

Paget's disease

Other

Cancer

Fibromyalgia

Oral/dental disorder

Peripheral vascular disease

Polymyalgia rheumatica

Patients with irritable bowel syndrome have altered brain responses to the anticipation of pain and to pain itself, which might make them more sensitive to painful stimuli, reported Dr. Steven M. Berman and his colleagues from the Center for the Neurobiology of Stress at the University of California, Los Angeles.

During expectation of pain, irritable bowel syndrome patients generate higher levels of tonic noradrenergic activity, producing a bias toward interpretation of network activity as pain, and are inefficient at reducing such activity when discrimination of nonpainful stimulation should be maximized, they said (J. Neurosci. 2008;28:349–59).

Functional magnetic resonance imaging (fMRI) was used to measure the blood oxygen level-dependent response to anticipated and delivered rectal distention in 14 female IBS patients and 12 healthy controls (mean age 36 years). When controls were anticipating a painful stimulus, brain activity decreased in several regions, but there was less of this anticipatory deactivation in the IBS patients.

Visceral distention of the rectum was then performed using a computer-driven pump and rectal balloon. Four to six sessions of 16 inflations were performed. Each inflation was preceded by an anticipatory cue. During rectal distention, increases in activity in the insula, dorsal anterior cingulate cortex, and dorsal brainstem were more extensive in IBS patients than in controls.

The results show that during expectation of experimental abdominal/pelvic discomfort, female IBS patients are more anxious and less able than healthy controls to downregulate activity within the CNS network activated by potentially aversive stimuli, the authors noted.

Patients with irritable bowel syndrome have altered brain responses to the anticipation of pain and to pain itself, which might make them more sensitive to painful stimuli, reported Dr. Steven M. Berman and his colleagues from the Center for the Neurobiology of Stress at the University of California, Los Angeles.

During expectation of pain, irritable bowel syndrome patients generate higher levels of tonic noradrenergic activity, producing a bias toward interpretation of network activity as pain, and are inefficient at reducing such activity when discrimination of nonpainful stimulation should be maximized, they said (J. Neurosci. 2008;28:349–59).

Functional magnetic resonance imaging (fMRI) was used to measure the blood oxygen level-dependent response to anticipated and delivered rectal distention in 14 female IBS patients and 12 healthy controls (mean age 36 years). When controls were anticipating a painful stimulus, brain activity decreased in several regions, but there was less of this anticipatory deactivation in the IBS patients.

Visceral distention of the rectum was then performed using a computer-driven pump and rectal balloon. Four to six sessions of 16 inflations were performed. Each inflation was preceded by an anticipatory cue. During rectal distention, increases in activity in the insula, dorsal anterior cingulate cortex, and dorsal brainstem were more extensive in IBS patients than in controls.

The results show that during expectation of experimental abdominal/pelvic discomfort, female IBS patients are more anxious and less able than healthy controls to downregulate activity within the CNS network activated by potentially aversive stimuli, the authors noted.

Patients with irritable bowel syndrome have altered brain responses to the anticipation of pain and to pain itself, which might make them more sensitive to painful stimuli, reported Dr. Steven M. Berman and his colleagues from the Center for the Neurobiology of Stress at the University of California, Los Angeles.

During expectation of pain, irritable bowel syndrome patients generate higher levels of tonic noradrenergic activity, producing a bias toward interpretation of network activity as pain, and are inefficient at reducing such activity when discrimination of nonpainful stimulation should be maximized, they said (J. Neurosci. 2008;28:349–59).

Functional magnetic resonance imaging (fMRI) was used to measure the blood oxygen level-dependent response to anticipated and delivered rectal distention in 14 female IBS patients and 12 healthy controls (mean age 36 years). When controls were anticipating a painful stimulus, brain activity decreased in several regions, but there was less of this anticipatory deactivation in the IBS patients.

Visceral distention of the rectum was then performed using a computer-driven pump and rectal balloon. Four to six sessions of 16 inflations were performed. Each inflation was preceded by an anticipatory cue. During rectal distention, increases in activity in the insula, dorsal anterior cingulate cortex, and dorsal brainstem were more extensive in IBS patients than in controls.

The results show that during expectation of experimental abdominal/pelvic discomfort, female IBS patients are more anxious and less able than healthy controls to downregulate activity within the CNS network activated by potentially aversive stimuli, the authors noted.

MONTREAL — Prophylactic administration of allopurinol before endoscopic retrograde cholangiopancreatography does not reduce the risk of postprocedure pancreatitis, compared with placebo, in average-risk patients, but the therapy may be beneficial in a high-risk subgroup, reported Dr. Joseph Romagnuolo of the Medical University of South Carolina, Charleston.

“I think it's probably not worth doing this in average-risk patients and may even be harmful. But we still don't have a whole lot of information about high-risk groups and so I think there's still an unanswered question as to whether it's beneficial in this group,” he said in an interview at the Canadian Digestive Diseases Week.

His randomized, multicenter, placebo-controlled trial found that there was not a significant difference in the rate of postprocedural pancreatitis between 293 patients who received allopurinol 300 mg and 293 patients who received placebo approximately 1 hour before ERCP.

Pancreatitis was defined as pancreatic-type pain requiring medical attention within 24 hours of the ERCP and lasting for more than 24 hours, he said.

The overall rate of pancreatitis was 5.5% in the allopurinol-treated group (mean age 54 years), compared with 4.1% in those receiving placebo (mean age 55.5 years), he noted. About 10% of the study subjects were classified as high-risk patients, and within this subgroup, allopurinol was associated with lower rates of pancreatitis, compared with placebo (6.3% vs. 23.5%).

In contrast, among average-risk patients only, the therapy was associated with higher rates of pancreatitis, compared with placebo (5.4% vs. 1.5%), suggesting “nonsignificant trends toward possible benefit in the high-risk group, and possible harm for the remaining subjects,” according to Dr. Romagnuolo. “In our trial, high risk was defined as suspected sphincter of Oddi dysfunction or if pancreatic therapy was anticipated as a reason for the procedure,” he explained. “So if there were plans to take out a pancreatic stone or stent a stricture, those were all considered high-risk patients.”

Three previous trials have shown discrepant results with allopurinol and post-ERCP pancreatitis, resulting in “clinical equipoise” regarding this intervention, Dr. Romagnuolo explained at the meeting sponsored by the Canadian Association of Gastroenterology. But his study is the first to stratify patients by risk, revealing an important consideration for future trials, he said.

It remains unclear why the therapy might have potential benefit in high-risk patients while being potentially harmful in average-risk patients, but one theory focuses on its impact on ischemic injury, he said. Allopurinol is a xanthine oxidase inhibitor and an antioxidant with antiapoptotic effects. “It can mediate capillary endothelial injury, which may be an early step in the pathogenesis of pancreatitis, especially ischemic pancreatitis. There may be more inflammation and capillary injury in high-risk patients that the allopurinol could help. But allopurinol has some propancreatitis factors that we don't know about, which, in average patients, may be enough to increase their risk.”

Pancreatitis is the most common complication of ERCP, with an overall incidence of 2%–15% and a related mortality of 0.1%–0.5%, Dr. Romagnuolo said. High-risk patients can have post-ERCP pancreatitis rates as high as 20%, underlining the importance of future investigation into the potential benefits of allopurinol prophylaxis in this population, he concluded.

MONTREAL — Prophylactic administration of allopurinol before endoscopic retrograde cholangiopancreatography does not reduce the risk of postprocedure pancreatitis, compared with placebo, in average-risk patients, but the therapy may be beneficial in a high-risk subgroup, reported Dr. Joseph Romagnuolo of the Medical University of South Carolina, Charleston.

“I think it's probably not worth doing this in average-risk patients and may even be harmful. But we still don't have a whole lot of information about high-risk groups and so I think there's still an unanswered question as to whether it's beneficial in this group,” he said in an interview at the Canadian Digestive Diseases Week.

His randomized, multicenter, placebo-controlled trial found that there was not a significant difference in the rate of postprocedural pancreatitis between 293 patients who received allopurinol 300 mg and 293 patients who received placebo approximately 1 hour before ERCP.

Pancreatitis was defined as pancreatic-type pain requiring medical attention within 24 hours of the ERCP and lasting for more than 24 hours, he said.

The overall rate of pancreatitis was 5.5% in the allopurinol-treated group (mean age 54 years), compared with 4.1% in those receiving placebo (mean age 55.5 years), he noted. About 10% of the study subjects were classified as high-risk patients, and within this subgroup, allopurinol was associated with lower rates of pancreatitis, compared with placebo (6.3% vs. 23.5%).

In contrast, among average-risk patients only, the therapy was associated with higher rates of pancreatitis, compared with placebo (5.4% vs. 1.5%), suggesting “nonsignificant trends toward possible benefit in the high-risk group, and possible harm for the remaining subjects,” according to Dr. Romagnuolo. “In our trial, high risk was defined as suspected sphincter of Oddi dysfunction or if pancreatic therapy was anticipated as a reason for the procedure,” he explained. “So if there were plans to take out a pancreatic stone or stent a stricture, those were all considered high-risk patients.”

Three previous trials have shown discrepant results with allopurinol and post-ERCP pancreatitis, resulting in “clinical equipoise” regarding this intervention, Dr. Romagnuolo explained at the meeting sponsored by the Canadian Association of Gastroenterology. But his study is the first to stratify patients by risk, revealing an important consideration for future trials, he said.

It remains unclear why the therapy might have potential benefit in high-risk patients while being potentially harmful in average-risk patients, but one theory focuses on its impact on ischemic injury, he said. Allopurinol is a xanthine oxidase inhibitor and an antioxidant with antiapoptotic effects. “It can mediate capillary endothelial injury, which may be an early step in the pathogenesis of pancreatitis, especially ischemic pancreatitis. There may be more inflammation and capillary injury in high-risk patients that the allopurinol could help. But allopurinol has some propancreatitis factors that we don't know about, which, in average patients, may be enough to increase their risk.”

Pancreatitis is the most common complication of ERCP, with an overall incidence of 2%–15% and a related mortality of 0.1%–0.5%, Dr. Romagnuolo said. High-risk patients can have post-ERCP pancreatitis rates as high as 20%, underlining the importance of future investigation into the potential benefits of allopurinol prophylaxis in this population, he concluded.

MONTREAL — Prophylactic administration of allopurinol before endoscopic retrograde cholangiopancreatography does not reduce the risk of postprocedure pancreatitis, compared with placebo, in average-risk patients, but the therapy may be beneficial in a high-risk subgroup, reported Dr. Joseph Romagnuolo of the Medical University of South Carolina, Charleston.

“I think it's probably not worth doing this in average-risk patients and may even be harmful. But we still don't have a whole lot of information about high-risk groups and so I think there's still an unanswered question as to whether it's beneficial in this group,” he said in an interview at the Canadian Digestive Diseases Week.

His randomized, multicenter, placebo-controlled trial found that there was not a significant difference in the rate of postprocedural pancreatitis between 293 patients who received allopurinol 300 mg and 293 patients who received placebo approximately 1 hour before ERCP.

Pancreatitis was defined as pancreatic-type pain requiring medical attention within 24 hours of the ERCP and lasting for more than 24 hours, he said.

The overall rate of pancreatitis was 5.5% in the allopurinol-treated group (mean age 54 years), compared with 4.1% in those receiving placebo (mean age 55.5 years), he noted. About 10% of the study subjects were classified as high-risk patients, and within this subgroup, allopurinol was associated with lower rates of pancreatitis, compared with placebo (6.3% vs. 23.5%).

In contrast, among average-risk patients only, the therapy was associated with higher rates of pancreatitis, compared with placebo (5.4% vs. 1.5%), suggesting “nonsignificant trends toward possible benefit in the high-risk group, and possible harm for the remaining subjects,” according to Dr. Romagnuolo. “In our trial, high risk was defined as suspected sphincter of Oddi dysfunction or if pancreatic therapy was anticipated as a reason for the procedure,” he explained. “So if there were plans to take out a pancreatic stone or stent a stricture, those were all considered high-risk patients.”

Three previous trials have shown discrepant results with allopurinol and post-ERCP pancreatitis, resulting in “clinical equipoise” regarding this intervention, Dr. Romagnuolo explained at the meeting sponsored by the Canadian Association of Gastroenterology. But his study is the first to stratify patients by risk, revealing an important consideration for future trials, he said.

It remains unclear why the therapy might have potential benefit in high-risk patients while being potentially harmful in average-risk patients, but one theory focuses on its impact on ischemic injury, he said. Allopurinol is a xanthine oxidase inhibitor and an antioxidant with antiapoptotic effects. “It can mediate capillary endothelial injury, which may be an early step in the pathogenesis of pancreatitis, especially ischemic pancreatitis. There may be more inflammation and capillary injury in high-risk patients that the allopurinol could help. But allopurinol has some propancreatitis factors that we don't know about, which, in average patients, may be enough to increase their risk.”

Pancreatitis is the most common complication of ERCP, with an overall incidence of 2%–15% and a related mortality of 0.1%–0.5%, Dr. Romagnuolo said. High-risk patients can have post-ERCP pancreatitis rates as high as 20%, underlining the importance of future investigation into the potential benefits of allopurinol prophylaxis in this population, he concluded.