Doug Brunk

SAN DIEGO – The prevalence of hepatitis B virus among children aged 6-19 years declined significantly between 1994 and 2004, Annemarie Wasley, Sc.D., reported during a poster session at the annual meeting of the Infectious Diseases Society of America.

“We have seen significant declines among kids, which is evidence that the impact of universal vaccination is becoming apparent,” Dr. Wasley, an epidemiologist with the division of viral hepatitis at the Centers for Disease Control and Prevention, Atlanta, said in an interview.

The finding comes from a comparison of the National Health and Nutrition Examination Surveys (NHANES) from 1988-1994 and 1999-2004. The researchers tested 22,435 serum samples from NHANES 1999-2004 for antibody to hepatitis B virus (HBV) core antigen, and if positive, HBV surface antigen. The prevalence estimates were weighted to represent the United States population and age-adjusted to allow comparison between participants of the two surveys.

The overall prevalence of HBV was 4.8% in NHANES 1988-1994 and 5.4% in NHANES 1999-2004, a difference that was not statistically significant. However, the prevalence of HBV among 6- to -19-year-olds declined significantly, from 1.9% in NHANES 1988-1994 to 0.5% in NHANES 1999-2004.

She also reported that the prevalence of HBV infection among foreign-born children aged 6-19 years declined significantly from 12.8% in NHANES 1988-1994 to 2.0% in NHANES 1999-2004.

“The prevalence among foreign-born children is still significantly higher than for U.S.-born children, who have a prevalence of 0.4%, but this difference is much smaller than in previous surveys,” she said. “Some implementation of routine vaccination has been occurring in a stepwise manner in different parts of the globe. To see the impact of that in our data was a surprise. Vaccination of kids is having an impact here and globally. That's great news.”

An analysis of all age groups found that the HBV prevalence was higher among black NHANES 1999-2004 participants (12.8%) than in white (3.0%) and Mexican American (2.8%) participants.

SAN DIEGO – The prevalence of hepatitis B virus among children aged 6-19 years declined significantly between 1994 and 2004, Annemarie Wasley, Sc.D., reported during a poster session at the annual meeting of the Infectious Diseases Society of America.

“We have seen significant declines among kids, which is evidence that the impact of universal vaccination is becoming apparent,” Dr. Wasley, an epidemiologist with the division of viral hepatitis at the Centers for Disease Control and Prevention, Atlanta, said in an interview.

The finding comes from a comparison of the National Health and Nutrition Examination Surveys (NHANES) from 1988-1994 and 1999-2004. The researchers tested 22,435 serum samples from NHANES 1999-2004 for antibody to hepatitis B virus (HBV) core antigen, and if positive, HBV surface antigen. The prevalence estimates were weighted to represent the United States population and age-adjusted to allow comparison between participants of the two surveys.

The overall prevalence of HBV was 4.8% in NHANES 1988-1994 and 5.4% in NHANES 1999-2004, a difference that was not statistically significant. However, the prevalence of HBV among 6- to -19-year-olds declined significantly, from 1.9% in NHANES 1988-1994 to 0.5% in NHANES 1999-2004.

She also reported that the prevalence of HBV infection among foreign-born children aged 6-19 years declined significantly from 12.8% in NHANES 1988-1994 to 2.0% in NHANES 1999-2004.

“The prevalence among foreign-born children is still significantly higher than for U.S.-born children, who have a prevalence of 0.4%, but this difference is much smaller than in previous surveys,” she said. “Some implementation of routine vaccination has been occurring in a stepwise manner in different parts of the globe. To see the impact of that in our data was a surprise. Vaccination of kids is having an impact here and globally. That's great news.”

An analysis of all age groups found that the HBV prevalence was higher among black NHANES 1999-2004 participants (12.8%) than in white (3.0%) and Mexican American (2.8%) participants.

SAN DIEGO – The prevalence of hepatitis B virus among children aged 6-19 years declined significantly between 1994 and 2004, Annemarie Wasley, Sc.D., reported during a poster session at the annual meeting of the Infectious Diseases Society of America.

“We have seen significant declines among kids, which is evidence that the impact of universal vaccination is becoming apparent,” Dr. Wasley, an epidemiologist with the division of viral hepatitis at the Centers for Disease Control and Prevention, Atlanta, said in an interview.

The finding comes from a comparison of the National Health and Nutrition Examination Surveys (NHANES) from 1988-1994 and 1999-2004. The researchers tested 22,435 serum samples from NHANES 1999-2004 for antibody to hepatitis B virus (HBV) core antigen, and if positive, HBV surface antigen. The prevalence estimates were weighted to represent the United States population and age-adjusted to allow comparison between participants of the two surveys.

The overall prevalence of HBV was 4.8% in NHANES 1988-1994 and 5.4% in NHANES 1999-2004, a difference that was not statistically significant. However, the prevalence of HBV among 6- to -19-year-olds declined significantly, from 1.9% in NHANES 1988-1994 to 0.5% in NHANES 1999-2004.

She also reported that the prevalence of HBV infection among foreign-born children aged 6-19 years declined significantly from 12.8% in NHANES 1988-1994 to 2.0% in NHANES 1999-2004.

“The prevalence among foreign-born children is still significantly higher than for U.S.-born children, who have a prevalence of 0.4%, but this difference is much smaller than in previous surveys,” she said. “Some implementation of routine vaccination has been occurring in a stepwise manner in different parts of the globe. To see the impact of that in our data was a surprise. Vaccination of kids is having an impact here and globally. That's great news.”

An analysis of all age groups found that the HBV prevalence was higher among black NHANES 1999-2004 participants (12.8%) than in white (3.0%) and Mexican American (2.8%) participants.

SAN DIEGO — When it comes to diagnosing endometriosis, visual inspection is not enough, Dr. Georgine Lamvu said at the annual meeting of the International Pelvic Pain Society.

“We need to be more careful to use excisional biopsies during laparoscopies and careful about the thorough evaluation of the pelvic structures, to record these so we can keep track of the infiltration, size, and distribution of the lesions,” said Dr. Lamvu of the department of obstetrics and gynecology at the Florida Hospital, Orlando.

She went on to note that not all endometriosis causes chronic pelvic pain. In one study of 15 patients with presumed endometriosis who went on to have conscious laparoscopic pain mapping, endometriotic lesions reproduced pain in 7 patients, all of whom had histologic confirmation of the diagnosis. Endometriotic lesions did not reproduce pain in eight cases.

“Seven of nine cases with histologically confirmed endometriosis mapped their pain to endometriotic lesions but none of the six cases in which the visual diagnosis of endometriosis was not histologically confirmed mapped their pain to 'endometriotic' lesions,” she said. “So although it's very important to confirm histology, we should not always assume that because you have pathology you'll have pain.”

Level A evidence suggests that endometriosis is associated with chronic pelvic pain in 50%–70% of patients. “This still does not answer the question: Is endometriosis the source of their pain?” Dr. Lamvu said. “Eighty percent of women with chronic pelvic pain also end up being diagnosed with endometriosis at some point. That does not mean that the endometriosis is the source of pain.”

Other potential causes of pelvic pain to rule out include urinary sources such as interstitial cystitis, gastrointestinal sources such as irritable bowel syndrome, and musculoskeletal trigger points.

“It's important to explain to patients with chronic pelvic pain that they may have symptomatic endometriosis or that they may have been misdiagnosed with endometriosis,” she said. “It's also important to explain to them that endometriosis can be inadequately treated and can exacerbate pain from other sources.”

The pathophysiology of endometriosis remains unclear but one concept developed in 1949 called the composite theory has gained the attention of researchers in recent years. This theory suggests that a variety of immunologic and genetic factors may mediate endometriosis, including direct extension into myometrium and adjacent organs, exfoliation of viable endometrial cells through tubes, and implantation of these cells into the peritoneum and adjacent organs.

“There [are] a lot of convincing data that retrograde menstruation and implantation of endometrial fragments are the primary mode of developing endometriosis in the peritoneal cavity, but it's definitely not the only process,” Dr. Lamvu said. “Research is now focusing on mechanisms that are involved in the attachment and the clearance of viable endometrium from the pelvic cavity. So the focus has come to alterations in the immune system.”

Current treatment for endometriosis associated with pelvic pain includes observation with palliative treatment with NSAIDs, hormonal suppression with continuous oral contraceptives, and gonadotropin-releasing hormone agonists (GnRH), excision, ablation, or cystectomy, and definitive extirpating surgery such as hysterectomy or bilateral salpingo-oophorectomy.

“A lot of us are now doing a combination of medical and surgical therapies,” Dr. Lamvu said.

Which surgical technique is best for managing endometriosis remains unclear. “There have been no comparison trials,” she said. “Some experts suspect that excision may be more effective for pain management in deep lesions, but for the general population of gynecologists superficial ablation with some type of medical therapy afterwards will be less risky.”

She added that pain improvement in the postoperative period “may be best for patients who have extensive disease. There may be some correlation between the extent of disease and response to treatment.”

Pain usually recurs within a year in 40% of patients who undergo surgical therapy and within 1–2 years in 30%–40% of patients who receive medical therapy. “This is a frustration for all of us,” said Dr. Lamvu, who is also assistant director of the Florida Hospital Family Practice Residency program. “There is no telling whether these numbers will [improve] now that we are incorporating so many different therapies for the management of pain.”

Future therapies include selective progesterone receptor modulators such as asoprisnil, which induce amenorrhea without side effects of hypoestrogenism and control uterine prostaglandins. Doses of 5, 10, or 25 mg per day may be effective in reducing pelvic pain.

'Endometriosis can be inadequately treated and can exacerbate pain from other sources.' DR. LAMVU

SAN DIEGO — When it comes to diagnosing endometriosis, visual inspection is not enough, Dr. Georgine Lamvu said at the annual meeting of the International Pelvic Pain Society.

“We need to be more careful to use excisional biopsies during laparoscopies and careful about the thorough evaluation of the pelvic structures, to record these so we can keep track of the infiltration, size, and distribution of the lesions,” said Dr. Lamvu of the department of obstetrics and gynecology at the Florida Hospital, Orlando.

She went on to note that not all endometriosis causes chronic pelvic pain. In one study of 15 patients with presumed endometriosis who went on to have conscious laparoscopic pain mapping, endometriotic lesions reproduced pain in 7 patients, all of whom had histologic confirmation of the diagnosis. Endometriotic lesions did not reproduce pain in eight cases.

“Seven of nine cases with histologically confirmed endometriosis mapped their pain to endometriotic lesions but none of the six cases in which the visual diagnosis of endometriosis was not histologically confirmed mapped their pain to 'endometriotic' lesions,” she said. “So although it's very important to confirm histology, we should not always assume that because you have pathology you'll have pain.”

Level A evidence suggests that endometriosis is associated with chronic pelvic pain in 50%–70% of patients. “This still does not answer the question: Is endometriosis the source of their pain?” Dr. Lamvu said. “Eighty percent of women with chronic pelvic pain also end up being diagnosed with endometriosis at some point. That does not mean that the endometriosis is the source of pain.”

Other potential causes of pelvic pain to rule out include urinary sources such as interstitial cystitis, gastrointestinal sources such as irritable bowel syndrome, and musculoskeletal trigger points.

“It's important to explain to patients with chronic pelvic pain that they may have symptomatic endometriosis or that they may have been misdiagnosed with endometriosis,” she said. “It's also important to explain to them that endometriosis can be inadequately treated and can exacerbate pain from other sources.”

The pathophysiology of endometriosis remains unclear but one concept developed in 1949 called the composite theory has gained the attention of researchers in recent years. This theory suggests that a variety of immunologic and genetic factors may mediate endometriosis, including direct extension into myometrium and adjacent organs, exfoliation of viable endometrial cells through tubes, and implantation of these cells into the peritoneum and adjacent organs.

“There [are] a lot of convincing data that retrograde menstruation and implantation of endometrial fragments are the primary mode of developing endometriosis in the peritoneal cavity, but it's definitely not the only process,” Dr. Lamvu said. “Research is now focusing on mechanisms that are involved in the attachment and the clearance of viable endometrium from the pelvic cavity. So the focus has come to alterations in the immune system.”

Current treatment for endometriosis associated with pelvic pain includes observation with palliative treatment with NSAIDs, hormonal suppression with continuous oral contraceptives, and gonadotropin-releasing hormone agonists (GnRH), excision, ablation, or cystectomy, and definitive extirpating surgery such as hysterectomy or bilateral salpingo-oophorectomy.

“A lot of us are now doing a combination of medical and surgical therapies,” Dr. Lamvu said.

Which surgical technique is best for managing endometriosis remains unclear. “There have been no comparison trials,” she said. “Some experts suspect that excision may be more effective for pain management in deep lesions, but for the general population of gynecologists superficial ablation with some type of medical therapy afterwards will be less risky.”

She added that pain improvement in the postoperative period “may be best for patients who have extensive disease. There may be some correlation between the extent of disease and response to treatment.”

Pain usually recurs within a year in 40% of patients who undergo surgical therapy and within 1–2 years in 30%–40% of patients who receive medical therapy. “This is a frustration for all of us,” said Dr. Lamvu, who is also assistant director of the Florida Hospital Family Practice Residency program. “There is no telling whether these numbers will [improve] now that we are incorporating so many different therapies for the management of pain.”

Future therapies include selective progesterone receptor modulators such as asoprisnil, which induce amenorrhea without side effects of hypoestrogenism and control uterine prostaglandins. Doses of 5, 10, or 25 mg per day may be effective in reducing pelvic pain.

'Endometriosis can be inadequately treated and can exacerbate pain from other sources.' DR. LAMVU

SAN DIEGO — When it comes to diagnosing endometriosis, visual inspection is not enough, Dr. Georgine Lamvu said at the annual meeting of the International Pelvic Pain Society.

“We need to be more careful to use excisional biopsies during laparoscopies and careful about the thorough evaluation of the pelvic structures, to record these so we can keep track of the infiltration, size, and distribution of the lesions,” said Dr. Lamvu of the department of obstetrics and gynecology at the Florida Hospital, Orlando.

She went on to note that not all endometriosis causes chronic pelvic pain. In one study of 15 patients with presumed endometriosis who went on to have conscious laparoscopic pain mapping, endometriotic lesions reproduced pain in 7 patients, all of whom had histologic confirmation of the diagnosis. Endometriotic lesions did not reproduce pain in eight cases.

“Seven of nine cases with histologically confirmed endometriosis mapped their pain to endometriotic lesions but none of the six cases in which the visual diagnosis of endometriosis was not histologically confirmed mapped their pain to 'endometriotic' lesions,” she said. “So although it's very important to confirm histology, we should not always assume that because you have pathology you'll have pain.”

Level A evidence suggests that endometriosis is associated with chronic pelvic pain in 50%–70% of patients. “This still does not answer the question: Is endometriosis the source of their pain?” Dr. Lamvu said. “Eighty percent of women with chronic pelvic pain also end up being diagnosed with endometriosis at some point. That does not mean that the endometriosis is the source of pain.”

Other potential causes of pelvic pain to rule out include urinary sources such as interstitial cystitis, gastrointestinal sources such as irritable bowel syndrome, and musculoskeletal trigger points.

“It's important to explain to patients with chronic pelvic pain that they may have symptomatic endometriosis or that they may have been misdiagnosed with endometriosis,” she said. “It's also important to explain to them that endometriosis can be inadequately treated and can exacerbate pain from other sources.”

The pathophysiology of endometriosis remains unclear but one concept developed in 1949 called the composite theory has gained the attention of researchers in recent years. This theory suggests that a variety of immunologic and genetic factors may mediate endometriosis, including direct extension into myometrium and adjacent organs, exfoliation of viable endometrial cells through tubes, and implantation of these cells into the peritoneum and adjacent organs.

“There [are] a lot of convincing data that retrograde menstruation and implantation of endometrial fragments are the primary mode of developing endometriosis in the peritoneal cavity, but it's definitely not the only process,” Dr. Lamvu said. “Research is now focusing on mechanisms that are involved in the attachment and the clearance of viable endometrium from the pelvic cavity. So the focus has come to alterations in the immune system.”

Current treatment for endometriosis associated with pelvic pain includes observation with palliative treatment with NSAIDs, hormonal suppression with continuous oral contraceptives, and gonadotropin-releasing hormone agonists (GnRH), excision, ablation, or cystectomy, and definitive extirpating surgery such as hysterectomy or bilateral salpingo-oophorectomy.

“A lot of us are now doing a combination of medical and surgical therapies,” Dr. Lamvu said.

Which surgical technique is best for managing endometriosis remains unclear. “There have been no comparison trials,” she said. “Some experts suspect that excision may be more effective for pain management in deep lesions, but for the general population of gynecologists superficial ablation with some type of medical therapy afterwards will be less risky.”

She added that pain improvement in the postoperative period “may be best for patients who have extensive disease. There may be some correlation between the extent of disease and response to treatment.”

Pain usually recurs within a year in 40% of patients who undergo surgical therapy and within 1–2 years in 30%–40% of patients who receive medical therapy. “This is a frustration for all of us,” said Dr. Lamvu, who is also assistant director of the Florida Hospital Family Practice Residency program. “There is no telling whether these numbers will [improve] now that we are incorporating so many different therapies for the management of pain.”

Future therapies include selective progesterone receptor modulators such as asoprisnil, which induce amenorrhea without side effects of hypoestrogenism and control uterine prostaglandins. Doses of 5, 10, or 25 mg per day may be effective in reducing pelvic pain.

'Endometriosis can be inadequately treated and can exacerbate pain from other sources.' DR. LAMVU

The way Dr. John A. Kitzhaber sees it, Americans can't afford to sit back and wait for the future of health care to unfold before them. Instead, they should assume an active role in shaping its future.

“If people are unable or unwilling to agree among themselves on a vision for the future, the political process cannot and will not do it for them–and we will be destined to continue to be shackled to the failed policies of the past,” he warned at the November 2007 annual meeting of the Society of Clinical Surgery in Portland, Ore. “By default, we will be allowing our future to become a matter of chance rather than a matter of choice. I think we are better than that.”

In January 2006, Dr. Kitzhaber, the former governor of Oregon, founded the Archimedes Movement, a grassroots organization that takes a “we can do better” approach to the governance and delivery of health care. The movement is “committed to providing a safe forum in which citizens and stakeholders alike can be brought together to create a shared vision of a new health care system, a space in which we can ask, 'If anything were possible, what would a better system look like?,' “he said.

The name refers to Archimedes, the Greek mathematician who invented the lever and is reputed to have said, “Give me a lever and a place to stand, and I can move the Earth.”

A key strategy of the effort is to agree on what a new health care system should look like, and to expose the contradictions and inequities of the current system and create a “tension” between the status quo and a vision for a new system.

Dr. Kitzhaber, an emergency physician who governed Oregon from 1995 to 2003, said he believes there should be a different standard for the part of health care that is financed by public resources and the portion that is financed by private resources. “We must demand that we get an actual health benefit for the public dollars we allocate for health care, a positive return on investment, [and] the effective and efficient use of public tax dollars. And, since these are public resources–resources held in common–we must demand that their allocation benefits all of our citizens, not just some of them; that it does not leave 47 million people behind.”

As an example, he said people who wish to buy an expensive brand name drug when a much cheaper generic is just as effective clinically, and just as safe, should be able to do so with their own personal resources. Public resources should not be used to subsidize the difference in cost. Similarly, he said, expectant parents who want an ultrasound to determine the sex of their unborn child when the procedure is not indicated clinically for a normal term pregnancy should be able to get that–but again, the cost should not be subsidized with public resources.

To date, the Archimedes Movement has conducted public forums and vision-sharing meetings with more than 3,000 Oregonians in 30 chapters, 13 hospital CEOs, 11 insurer and health plan executives, dozens of physicians and nurses, leaders of national state and labor organizations, and representatives of more than 50 non-health-related businesses in the state.

The resulting consensus led to the Oregon Better Health Act, which was introduced in the 2007 Oregon legislature as Senate Bill 27. It proposes that Oregonians have access to a “core benefit” of essential health services, and seeks to realign financial incentives to ensure fair and reasonable payment to providers, value-based cost sharing for consumers, and a transition to a more efficient delivery system.

Although SB 27 did not pass in the 2007 session, the enthusiasm it generated from citizens and stakeholders propelled the Archimedes Movement into the limelight. It also produced three documents that offer a conceptual framework for a new system in the state and that may serve as a foundation for bringing about national reform. The documents–a Statement of Intent, Principles, and a Framework–are available at www.wecandobetter.org

Nowadays, Dr. Kitzhaber and his associates are working to expand the movement to other states, especially Washington and Montana. This strategy stems from the fact that the committee that has jurisdiction over health care in the U.S. Senate is the Senate Finance Committee. Both of Oregon's senators (Democrat Ron Wyden and Republican Gordon Smith) are members of this committee, as is Sen. Maria Cantwell (D-Wash.). The committee is chaired by Sen. Max Baucus (D-Mont.).

Dr. Kitzhaber pointed out that the discourse on health care reform he has heard from the 2008 presidential candidates convinces him that the Archimedes Movement is peaking at the right time.

He said that although each of the 2008 presidential candidates has proposals for health care reform, they are all defining the challenge narrowly as just a financing problem related to insurance.

“No candidate of either party has stepped up to honestly acknowledge the reality of fiscal limits,” he said.

“The very fact that none of these issues are a central part of the national political debate is evidence of the underlying failure in our current governance structure, of the diminishing capacity of our political system to allocate and manage public resources in a way that serves the larger public interest.

“It is an affirmation of the fact that we cannot solve this crisis by relying solely on our current legislative institutions.”

'We must demand that we get an actual health benefit for the public dollars we allocate for care.' DR. KITZHABER

The way Dr. John A. Kitzhaber sees it, Americans can't afford to sit back and wait for the future of health care to unfold before them. Instead, they should assume an active role in shaping its future.

“If people are unable or unwilling to agree among themselves on a vision for the future, the political process cannot and will not do it for them–and we will be destined to continue to be shackled to the failed policies of the past,” he warned at the November 2007 annual meeting of the Society of Clinical Surgery in Portland, Ore. “By default, we will be allowing our future to become a matter of chance rather than a matter of choice. I think we are better than that.”

In January 2006, Dr. Kitzhaber, the former governor of Oregon, founded the Archimedes Movement, a grassroots organization that takes a “we can do better” approach to the governance and delivery of health care. The movement is “committed to providing a safe forum in which citizens and stakeholders alike can be brought together to create a shared vision of a new health care system, a space in which we can ask, 'If anything were possible, what would a better system look like?,' “he said.

The name refers to Archimedes, the Greek mathematician who invented the lever and is reputed to have said, “Give me a lever and a place to stand, and I can move the Earth.”

A key strategy of the effort is to agree on what a new health care system should look like, and to expose the contradictions and inequities of the current system and create a “tension” between the status quo and a vision for a new system.

Dr. Kitzhaber, an emergency physician who governed Oregon from 1995 to 2003, said he believes there should be a different standard for the part of health care that is financed by public resources and the portion that is financed by private resources. “We must demand that we get an actual health benefit for the public dollars we allocate for health care, a positive return on investment, [and] the effective and efficient use of public tax dollars. And, since these are public resources–resources held in common–we must demand that their allocation benefits all of our citizens, not just some of them; that it does not leave 47 million people behind.”

As an example, he said people who wish to buy an expensive brand name drug when a much cheaper generic is just as effective clinically, and just as safe, should be able to do so with their own personal resources. Public resources should not be used to subsidize the difference in cost. Similarly, he said, expectant parents who want an ultrasound to determine the sex of their unborn child when the procedure is not indicated clinically for a normal term pregnancy should be able to get that–but again, the cost should not be subsidized with public resources.

To date, the Archimedes Movement has conducted public forums and vision-sharing meetings with more than 3,000 Oregonians in 30 chapters, 13 hospital CEOs, 11 insurer and health plan executives, dozens of physicians and nurses, leaders of national state and labor organizations, and representatives of more than 50 non-health-related businesses in the state.

The resulting consensus led to the Oregon Better Health Act, which was introduced in the 2007 Oregon legislature as Senate Bill 27. It proposes that Oregonians have access to a “core benefit” of essential health services, and seeks to realign financial incentives to ensure fair and reasonable payment to providers, value-based cost sharing for consumers, and a transition to a more efficient delivery system.

Although SB 27 did not pass in the 2007 session, the enthusiasm it generated from citizens and stakeholders propelled the Archimedes Movement into the limelight. It also produced three documents that offer a conceptual framework for a new system in the state and that may serve as a foundation for bringing about national reform. The documents–a Statement of Intent, Principles, and a Framework–are available at www.wecandobetter.org

Nowadays, Dr. Kitzhaber and his associates are working to expand the movement to other states, especially Washington and Montana. This strategy stems from the fact that the committee that has jurisdiction over health care in the U.S. Senate is the Senate Finance Committee. Both of Oregon's senators (Democrat Ron Wyden and Republican Gordon Smith) are members of this committee, as is Sen. Maria Cantwell (D-Wash.). The committee is chaired by Sen. Max Baucus (D-Mont.).

Dr. Kitzhaber pointed out that the discourse on health care reform he has heard from the 2008 presidential candidates convinces him that the Archimedes Movement is peaking at the right time.

He said that although each of the 2008 presidential candidates has proposals for health care reform, they are all defining the challenge narrowly as just a financing problem related to insurance.

“No candidate of either party has stepped up to honestly acknowledge the reality of fiscal limits,” he said.

“The very fact that none of these issues are a central part of the national political debate is evidence of the underlying failure in our current governance structure, of the diminishing capacity of our political system to allocate and manage public resources in a way that serves the larger public interest.

“It is an affirmation of the fact that we cannot solve this crisis by relying solely on our current legislative institutions.”

'We must demand that we get an actual health benefit for the public dollars we allocate for care.' DR. KITZHABER

The way Dr. John A. Kitzhaber sees it, Americans can't afford to sit back and wait for the future of health care to unfold before them. Instead, they should assume an active role in shaping its future.

“If people are unable or unwilling to agree among themselves on a vision for the future, the political process cannot and will not do it for them–and we will be destined to continue to be shackled to the failed policies of the past,” he warned at the November 2007 annual meeting of the Society of Clinical Surgery in Portland, Ore. “By default, we will be allowing our future to become a matter of chance rather than a matter of choice. I think we are better than that.”

In January 2006, Dr. Kitzhaber, the former governor of Oregon, founded the Archimedes Movement, a grassroots organization that takes a “we can do better” approach to the governance and delivery of health care. The movement is “committed to providing a safe forum in which citizens and stakeholders alike can be brought together to create a shared vision of a new health care system, a space in which we can ask, 'If anything were possible, what would a better system look like?,' “he said.

The name refers to Archimedes, the Greek mathematician who invented the lever and is reputed to have said, “Give me a lever and a place to stand, and I can move the Earth.”

A key strategy of the effort is to agree on what a new health care system should look like, and to expose the contradictions and inequities of the current system and create a “tension” between the status quo and a vision for a new system.

Dr. Kitzhaber, an emergency physician who governed Oregon from 1995 to 2003, said he believes there should be a different standard for the part of health care that is financed by public resources and the portion that is financed by private resources. “We must demand that we get an actual health benefit for the public dollars we allocate for health care, a positive return on investment, [and] the effective and efficient use of public tax dollars. And, since these are public resources–resources held in common–we must demand that their allocation benefits all of our citizens, not just some of them; that it does not leave 47 million people behind.”

As an example, he said people who wish to buy an expensive brand name drug when a much cheaper generic is just as effective clinically, and just as safe, should be able to do so with their own personal resources. Public resources should not be used to subsidize the difference in cost. Similarly, he said, expectant parents who want an ultrasound to determine the sex of their unborn child when the procedure is not indicated clinically for a normal term pregnancy should be able to get that–but again, the cost should not be subsidized with public resources.

To date, the Archimedes Movement has conducted public forums and vision-sharing meetings with more than 3,000 Oregonians in 30 chapters, 13 hospital CEOs, 11 insurer and health plan executives, dozens of physicians and nurses, leaders of national state and labor organizations, and representatives of more than 50 non-health-related businesses in the state.

The resulting consensus led to the Oregon Better Health Act, which was introduced in the 2007 Oregon legislature as Senate Bill 27. It proposes that Oregonians have access to a “core benefit” of essential health services, and seeks to realign financial incentives to ensure fair and reasonable payment to providers, value-based cost sharing for consumers, and a transition to a more efficient delivery system.

Although SB 27 did not pass in the 2007 session, the enthusiasm it generated from citizens and stakeholders propelled the Archimedes Movement into the limelight. It also produced three documents that offer a conceptual framework for a new system in the state and that may serve as a foundation for bringing about national reform. The documents–a Statement of Intent, Principles, and a Framework–are available at www.wecandobetter.org

Nowadays, Dr. Kitzhaber and his associates are working to expand the movement to other states, especially Washington and Montana. This strategy stems from the fact that the committee that has jurisdiction over health care in the U.S. Senate is the Senate Finance Committee. Both of Oregon's senators (Democrat Ron Wyden and Republican Gordon Smith) are members of this committee, as is Sen. Maria Cantwell (D-Wash.). The committee is chaired by Sen. Max Baucus (D-Mont.).

Dr. Kitzhaber pointed out that the discourse on health care reform he has heard from the 2008 presidential candidates convinces him that the Archimedes Movement is peaking at the right time.

He said that although each of the 2008 presidential candidates has proposals for health care reform, they are all defining the challenge narrowly as just a financing problem related to insurance.

“No candidate of either party has stepped up to honestly acknowledge the reality of fiscal limits,” he said.

“The very fact that none of these issues are a central part of the national political debate is evidence of the underlying failure in our current governance structure, of the diminishing capacity of our political system to allocate and manage public resources in a way that serves the larger public interest.

“It is an affirmation of the fact that we cannot solve this crisis by relying solely on our current legislative institutions.”

'We must demand that we get an actual health benefit for the public dollars we allocate for care.' DR. KITZHABER

SAN DIEGO – A good way to ensure a balanced approach to opioid prescribing is to follow the key principles of the Model Policy for the Use of Controlled Substances for the Treatment of Pain, Dr. Edward Michna advised at the annual meeting of the International Pelvic Pain Society.

Written by the Federation of State Medical Boards in 1998, the model policy was developed so the medical community would adopt consistent standards for prescribing controlled substances for pain (www.fsmb.org/grpol_policydocs.html

▸ Evaluate the patient. “You have to see the patient, you have to take a history and conduct a physical exam,” said Dr. Michna, an anesthesiologist who is director of pain trials at Brigham and Women's Hospital, Boston. “Certainly the condition that you're considering must be one of the things that are known to be responsive to opioid therapy.”

▸ Develop a treatment plan. Write down the result you expect from placing the patient on opioids and when you plan to evaluate the patient again. “The problem is, most doctors are not good about documentation,” he said.

Dr. Michna offered the “four A's” as a reminder of critical areas for optimal opioid management. The first A stands for analgesia. What is the pain level experienced by the patient? “You need to use some sort of measurement, whether it's a visual analog scale or a scale in which you ask them to rate their pain as good, bad, or fair.”

The second A stands for activity. What's the patient's activity like? How is their disease state impairing that activity? What do they want to do that they can't do? “I usually ask the patient, 'How do you spend your day?' If they say 'I'm sitting in front of the television with the clicker,' obviously we're not promoting daily living activity,” Dr. Michna said.

The third A stands for adverse events or side effects. “When you are taking opioids there are side effects,” he said. “You have to monitor them and document what the patient's experience is.”

The fourth A stands for aberrancy: “Aberrancy of use of medications and drug diversion, those kinds of things.”

▸ Establish written consent and agreement for treatment.

▸ Conduct periodic review. How often you see that patient “depends on how difficult that patient is or prior history,” said Dr. Michna, who is a former medical malpractice attorney. “You can't individualize care across the board.”

▸ Keep accurate medical records. This is the problem most physicians have, Dr. Michna said. “Even though we know we need to document, the pressures of day-to-day practice are such that you start getting sloppy. It's that sloppiness that can get you into trouble.”

▸ Stay in compliance with controlled substances legislation and federal laws. Dr. Michna recommended the new handbook “Responsible Opioid Prescribing: A Physician's Guide,” by pain specialist Dr. Scott M. Fishman. The Federation of State Medical Boards Research and Education Foundation will provide state medical boards with printed copies to distribute on a state-by-state basis as funds are raised.

Dr. Michna emphasized the importance of getting as much information as possible during the first visit with patients who are potential candidates for opioid therapy. He and his associates routinely call referring physicians to see if the patient has any history of opioid use or misuse. They also ask the patient if he or she has a history of addiction. “That might not prevent you from treating that patient, but you'd certainly want to know about it,” Dr. Michna said.

He and his associates also perform urine screens on the first and every subsequent office visit. Most clinicians use immunochemistry, but the better test is mass spectrometry, which can detect drug levels in nanograms. “The problem is cost,” he said. “Immunochemistry is cheaper than any other format.”

Patients who like their physicians rarely sue them. “When I was an attorney I never had a patient coming in saying to me that 'I feel bad. I really like my doctor. I don't really want to sue.' It was usually 'I want to get that S.O.B. He did this to me. He didn't answer my phone calls.' You need to care for your patients. You need to make proper referrals.”

SAN DIEGO – A good way to ensure a balanced approach to opioid prescribing is to follow the key principles of the Model Policy for the Use of Controlled Substances for the Treatment of Pain, Dr. Edward Michna advised at the annual meeting of the International Pelvic Pain Society.

Written by the Federation of State Medical Boards in 1998, the model policy was developed so the medical community would adopt consistent standards for prescribing controlled substances for pain (www.fsmb.org/grpol_policydocs.html

▸ Evaluate the patient. “You have to see the patient, you have to take a history and conduct a physical exam,” said Dr. Michna, an anesthesiologist who is director of pain trials at Brigham and Women's Hospital, Boston. “Certainly the condition that you're considering must be one of the things that are known to be responsive to opioid therapy.”

▸ Develop a treatment plan. Write down the result you expect from placing the patient on opioids and when you plan to evaluate the patient again. “The problem is, most doctors are not good about documentation,” he said.

Dr. Michna offered the “four A's” as a reminder of critical areas for optimal opioid management. The first A stands for analgesia. What is the pain level experienced by the patient? “You need to use some sort of measurement, whether it's a visual analog scale or a scale in which you ask them to rate their pain as good, bad, or fair.”

The second A stands for activity. What's the patient's activity like? How is their disease state impairing that activity? What do they want to do that they can't do? “I usually ask the patient, 'How do you spend your day?' If they say 'I'm sitting in front of the television with the clicker,' obviously we're not promoting daily living activity,” Dr. Michna said.

The third A stands for adverse events or side effects. “When you are taking opioids there are side effects,” he said. “You have to monitor them and document what the patient's experience is.”

The fourth A stands for aberrancy: “Aberrancy of use of medications and drug diversion, those kinds of things.”

▸ Establish written consent and agreement for treatment.

▸ Conduct periodic review. How often you see that patient “depends on how difficult that patient is or prior history,” said Dr. Michna, who is a former medical malpractice attorney. “You can't individualize care across the board.”

▸ Keep accurate medical records. This is the problem most physicians have, Dr. Michna said. “Even though we know we need to document, the pressures of day-to-day practice are such that you start getting sloppy. It's that sloppiness that can get you into trouble.”

▸ Stay in compliance with controlled substances legislation and federal laws. Dr. Michna recommended the new handbook “Responsible Opioid Prescribing: A Physician's Guide,” by pain specialist Dr. Scott M. Fishman. The Federation of State Medical Boards Research and Education Foundation will provide state medical boards with printed copies to distribute on a state-by-state basis as funds are raised.

Dr. Michna emphasized the importance of getting as much information as possible during the first visit with patients who are potential candidates for opioid therapy. He and his associates routinely call referring physicians to see if the patient has any history of opioid use or misuse. They also ask the patient if he or she has a history of addiction. “That might not prevent you from treating that patient, but you'd certainly want to know about it,” Dr. Michna said.

He and his associates also perform urine screens on the first and every subsequent office visit. Most clinicians use immunochemistry, but the better test is mass spectrometry, which can detect drug levels in nanograms. “The problem is cost,” he said. “Immunochemistry is cheaper than any other format.”

Patients who like their physicians rarely sue them. “When I was an attorney I never had a patient coming in saying to me that 'I feel bad. I really like my doctor. I don't really want to sue.' It was usually 'I want to get that S.O.B. He did this to me. He didn't answer my phone calls.' You need to care for your patients. You need to make proper referrals.”

SAN DIEGO – A good way to ensure a balanced approach to opioid prescribing is to follow the key principles of the Model Policy for the Use of Controlled Substances for the Treatment of Pain, Dr. Edward Michna advised at the annual meeting of the International Pelvic Pain Society.

Written by the Federation of State Medical Boards in 1998, the model policy was developed so the medical community would adopt consistent standards for prescribing controlled substances for pain (www.fsmb.org/grpol_policydocs.html

▸ Evaluate the patient. “You have to see the patient, you have to take a history and conduct a physical exam,” said Dr. Michna, an anesthesiologist who is director of pain trials at Brigham and Women's Hospital, Boston. “Certainly the condition that you're considering must be one of the things that are known to be responsive to opioid therapy.”

▸ Develop a treatment plan. Write down the result you expect from placing the patient on opioids and when you plan to evaluate the patient again. “The problem is, most doctors are not good about documentation,” he said.

Dr. Michna offered the “four A's” as a reminder of critical areas for optimal opioid management. The first A stands for analgesia. What is the pain level experienced by the patient? “You need to use some sort of measurement, whether it's a visual analog scale or a scale in which you ask them to rate their pain as good, bad, or fair.”

The second A stands for activity. What's the patient's activity like? How is their disease state impairing that activity? What do they want to do that they can't do? “I usually ask the patient, 'How do you spend your day?' If they say 'I'm sitting in front of the television with the clicker,' obviously we're not promoting daily living activity,” Dr. Michna said.

The third A stands for adverse events or side effects. “When you are taking opioids there are side effects,” he said. “You have to monitor them and document what the patient's experience is.”

The fourth A stands for aberrancy: “Aberrancy of use of medications and drug diversion, those kinds of things.”

▸ Establish written consent and agreement for treatment.

▸ Conduct periodic review. How often you see that patient “depends on how difficult that patient is or prior history,” said Dr. Michna, who is a former medical malpractice attorney. “You can't individualize care across the board.”

▸ Keep accurate medical records. This is the problem most physicians have, Dr. Michna said. “Even though we know we need to document, the pressures of day-to-day practice are such that you start getting sloppy. It's that sloppiness that can get you into trouble.”

▸ Stay in compliance with controlled substances legislation and federal laws. Dr. Michna recommended the new handbook “Responsible Opioid Prescribing: A Physician's Guide,” by pain specialist Dr. Scott M. Fishman. The Federation of State Medical Boards Research and Education Foundation will provide state medical boards with printed copies to distribute on a state-by-state basis as funds are raised.

Dr. Michna emphasized the importance of getting as much information as possible during the first visit with patients who are potential candidates for opioid therapy. He and his associates routinely call referring physicians to see if the patient has any history of opioid use or misuse. They also ask the patient if he or she has a history of addiction. “That might not prevent you from treating that patient, but you'd certainly want to know about it,” Dr. Michna said.

He and his associates also perform urine screens on the first and every subsequent office visit. Most clinicians use immunochemistry, but the better test is mass spectrometry, which can detect drug levels in nanograms. “The problem is cost,” he said. “Immunochemistry is cheaper than any other format.”

Patients who like their physicians rarely sue them. “When I was an attorney I never had a patient coming in saying to me that 'I feel bad. I really like my doctor. I don't really want to sue.' It was usually 'I want to get that S.O.B. He did this to me. He didn't answer my phone calls.' You need to care for your patients. You need to make proper referrals.”

CORONADO, CALIF. – Tramadol may be effective primary medical treatment for opiate dependence, results from a small study demonstrate.

“I think it's safe to try for somebody who hasn't succeeded on Suboxone for some reason or for someone who can't afford Suboxone,” Dr. Thomas E. Radecki said in an interview during a poster session at the annual meeting of the American Academy of Addiction Psychiatry. “However, there is a great need at this point for randomized, controlled research to compare (tramadol) to Suboxone and drug-free treatments.”

In an open trial, 69 patients aged 18-50 years with a DSM-IV diagnosis of opiate dependence were initially administered 150 mg tramadol four times a day for the first 2-3 days of detoxification, and then encouraged to reduce the dosage to no more than 100 mg four times a day.

Office visits initially were once a week for two visits, then every 2 weeks until stable, and then every 3-4 weeks. Patients had random urine toxicology screens, said Dr. Radecki, a psychiatrist in Clarion, Pa.

Of the 69 patients, 65 (94%) kept at least one follow-up appointment and the median time of therapy to date is 21 weeks.

Enough clinical data were available to evaluate tramadol's effectiveness in 59 patients. Of these, 68% were still in treatment and opiate free. “This compares favorably to Suboxone,” he said. Three patients experienced seizures because of taking higher than recommended doses of tramadol.

Dr. Radecki pointed out that tramadol is somewhat less addictive than Suboxone.

He estimated that tramadol costs each patient $16 per month; Suboxone costs each patient $300 per month. In his practice, that translates into a savings of more than $174,000 per year.

Dr. Radecki had no relevant financial relationships to disclose.

CORONADO, CALIF. – Tramadol may be effective primary medical treatment for opiate dependence, results from a small study demonstrate.

“I think it's safe to try for somebody who hasn't succeeded on Suboxone for some reason or for someone who can't afford Suboxone,” Dr. Thomas E. Radecki said in an interview during a poster session at the annual meeting of the American Academy of Addiction Psychiatry. “However, there is a great need at this point for randomized, controlled research to compare (tramadol) to Suboxone and drug-free treatments.”

In an open trial, 69 patients aged 18-50 years with a DSM-IV diagnosis of opiate dependence were initially administered 150 mg tramadol four times a day for the first 2-3 days of detoxification, and then encouraged to reduce the dosage to no more than 100 mg four times a day.

Office visits initially were once a week for two visits, then every 2 weeks until stable, and then every 3-4 weeks. Patients had random urine toxicology screens, said Dr. Radecki, a psychiatrist in Clarion, Pa.

Of the 69 patients, 65 (94%) kept at least one follow-up appointment and the median time of therapy to date is 21 weeks.

Enough clinical data were available to evaluate tramadol's effectiveness in 59 patients. Of these, 68% were still in treatment and opiate free. “This compares favorably to Suboxone,” he said. Three patients experienced seizures because of taking higher than recommended doses of tramadol.

Dr. Radecki pointed out that tramadol is somewhat less addictive than Suboxone.

He estimated that tramadol costs each patient $16 per month; Suboxone costs each patient $300 per month. In his practice, that translates into a savings of more than $174,000 per year.

Dr. Radecki had no relevant financial relationships to disclose.

CORONADO, CALIF. – Tramadol may be effective primary medical treatment for opiate dependence, results from a small study demonstrate.

“I think it's safe to try for somebody who hasn't succeeded on Suboxone for some reason or for someone who can't afford Suboxone,” Dr. Thomas E. Radecki said in an interview during a poster session at the annual meeting of the American Academy of Addiction Psychiatry. “However, there is a great need at this point for randomized, controlled research to compare (tramadol) to Suboxone and drug-free treatments.”

In an open trial, 69 patients aged 18-50 years with a DSM-IV diagnosis of opiate dependence were initially administered 150 mg tramadol four times a day for the first 2-3 days of detoxification, and then encouraged to reduce the dosage to no more than 100 mg four times a day.

Office visits initially were once a week for two visits, then every 2 weeks until stable, and then every 3-4 weeks. Patients had random urine toxicology screens, said Dr. Radecki, a psychiatrist in Clarion, Pa.

Of the 69 patients, 65 (94%) kept at least one follow-up appointment and the median time of therapy to date is 21 weeks.

Enough clinical data were available to evaluate tramadol's effectiveness in 59 patients. Of these, 68% were still in treatment and opiate free. “This compares favorably to Suboxone,” he said. Three patients experienced seizures because of taking higher than recommended doses of tramadol.

Dr. Radecki pointed out that tramadol is somewhat less addictive than Suboxone.

He estimated that tramadol costs each patient $16 per month; Suboxone costs each patient $300 per month. In his practice, that translates into a savings of more than $174,000 per year.

Dr. Radecki had no relevant financial relationships to disclose.

CORONADO, CALIF. – One decisive factor that sets older adults who abuse alcohol apart from their younger counterparts is a generally lower level of tolerance for the substance.

“They may have problems with lower intake due to the increased sensitivity to the alcohol, and therefore have higher blood alcohol levels with less intake,” Dr. Louis A. Trevisan said at the annual meeting of the American Academy of Addiction Psychiatry.

According to the National Epidemiologic Survey on Alcohol and Related Conditions, a community survey conducted in 2001 and 2002 by the National Institute on Alcohol Abuse and Alcoholism, the prevalence of alcohol use disorder among people aged 65 years and older is 1.35%. Dr. Trevisan, a geriatric and addiction psychiatrist at Yale University, New Haven, Conn., said that elderly alcoholics fall into types: those who start drinking well before they reach age 50 (earlier elderly onset) and those who start drinking after age 50 (later elderly onset).

Earlier elderly onset alcoholics “make up the large majority of older problem drinkers,” he said. “They usually have chronic alcohol-related medical problems, a positive family history, serious psychiatric comorbidities.” In addition, he said, older problem drinkers usually are less socially adjusted, may have an intractable course and more legal problems, and usually need more medically focused intensive treatment for their addiction.

Later elderly onset alcoholics usually begin drinking after a stress-related event, such as death of a spouse, family member, or close friend, or the loss of a job or a home. “They're usually more emotionally stable, usually have a milder clinical picture, and in general they have greater life satisfaction,” Dr. Trevisan said.

They also tend to respond better to treatment, compared with earlier elderly onset alcoholics.

Other risk factors associated with the development of addiction in late life include a personal history of alcohol abuse or use in the past, chronic pain, predisposition to depression or anxiety disorders, and loss of social support or retirement.

Dr. Gregory Acampora, a substance abuse fellow at the Yale/VA Alcohol Research Center, advised clinicians to assess the mental status of older patients with suspected alcohol problems because the effects of alcohol only exacerbate underlying cognitive infirmities. This is important, because cognitive impairment is dose related acutely “and can cause persistent cognitive deficits.”

Moreover, dementia often is prevalent in this patient population and affects agnosia, aphasia, apraxia, or a disturbance in executive functioning. The 1% prevalence of dementia for people aged 60-69 doubles every 5 years to a prevalence of about 39% for people aged 90-95 (JAMA 2007; 297:2391-404).

Dr. Acampora also recommended assessing the fall risk in the work-up of any older patient with a suspected drinking problem, noting that gait directly affects long-term outcome.

“The slower you walk, the higher your risk of a fall and of a bad outcome,” he said.

In addition, research has demonstrated that a history of problem drinking is associated with a significantly greater risk of falls (J. Am. Geriatr. Soc. 2006;54:1649-57).

He went on to note that medication interaction “has to be considered” in the work-up of older adults with a suspected drinking problem, and that two “misadventures” can occur with patients who take several prescription medications.

“One is that they take all of them–and for each drug there is an increased risk of a drug-drug interaction,” Dr. Acampora said. “The other is that they don't take the drug. The disease state may worsen, and a clinician may end up trying to adjust against his belief that a patient is taking the medication” when in fact he or she is not.

Later elderly onset alcoholics usually begindrinking after a stress-related event. DR. TREVISAN

CORONADO, CALIF. – One decisive factor that sets older adults who abuse alcohol apart from their younger counterparts is a generally lower level of tolerance for the substance.

“They may have problems with lower intake due to the increased sensitivity to the alcohol, and therefore have higher blood alcohol levels with less intake,” Dr. Louis A. Trevisan said at the annual meeting of the American Academy of Addiction Psychiatry.

According to the National Epidemiologic Survey on Alcohol and Related Conditions, a community survey conducted in 2001 and 2002 by the National Institute on Alcohol Abuse and Alcoholism, the prevalence of alcohol use disorder among people aged 65 years and older is 1.35%. Dr. Trevisan, a geriatric and addiction psychiatrist at Yale University, New Haven, Conn., said that elderly alcoholics fall into types: those who start drinking well before they reach age 50 (earlier elderly onset) and those who start drinking after age 50 (later elderly onset).

Earlier elderly onset alcoholics “make up the large majority of older problem drinkers,” he said. “They usually have chronic alcohol-related medical problems, a positive family history, serious psychiatric comorbidities.” In addition, he said, older problem drinkers usually are less socially adjusted, may have an intractable course and more legal problems, and usually need more medically focused intensive treatment for their addiction.

Later elderly onset alcoholics usually begin drinking after a stress-related event, such as death of a spouse, family member, or close friend, or the loss of a job or a home. “They're usually more emotionally stable, usually have a milder clinical picture, and in general they have greater life satisfaction,” Dr. Trevisan said.

They also tend to respond better to treatment, compared with earlier elderly onset alcoholics.

Other risk factors associated with the development of addiction in late life include a personal history of alcohol abuse or use in the past, chronic pain, predisposition to depression or anxiety disorders, and loss of social support or retirement.

Dr. Gregory Acampora, a substance abuse fellow at the Yale/VA Alcohol Research Center, advised clinicians to assess the mental status of older patients with suspected alcohol problems because the effects of alcohol only exacerbate underlying cognitive infirmities. This is important, because cognitive impairment is dose related acutely “and can cause persistent cognitive deficits.”

Moreover, dementia often is prevalent in this patient population and affects agnosia, aphasia, apraxia, or a disturbance in executive functioning. The 1% prevalence of dementia for people aged 60-69 doubles every 5 years to a prevalence of about 39% for people aged 90-95 (JAMA 2007; 297:2391-404).

Dr. Acampora also recommended assessing the fall risk in the work-up of any older patient with a suspected drinking problem, noting that gait directly affects long-term outcome.

“The slower you walk, the higher your risk of a fall and of a bad outcome,” he said.

In addition, research has demonstrated that a history of problem drinking is associated with a significantly greater risk of falls (J. Am. Geriatr. Soc. 2006;54:1649-57).

He went on to note that medication interaction “has to be considered” in the work-up of older adults with a suspected drinking problem, and that two “misadventures” can occur with patients who take several prescription medications.

“One is that they take all of them–and for each drug there is an increased risk of a drug-drug interaction,” Dr. Acampora said. “The other is that they don't take the drug. The disease state may worsen, and a clinician may end up trying to adjust against his belief that a patient is taking the medication” when in fact he or she is not.

Later elderly onset alcoholics usually begindrinking after a stress-related event. DR. TREVISAN

CORONADO, CALIF. – One decisive factor that sets older adults who abuse alcohol apart from their younger counterparts is a generally lower level of tolerance for the substance.

“They may have problems with lower intake due to the increased sensitivity to the alcohol, and therefore have higher blood alcohol levels with less intake,” Dr. Louis A. Trevisan said at the annual meeting of the American Academy of Addiction Psychiatry.

According to the National Epidemiologic Survey on Alcohol and Related Conditions, a community survey conducted in 2001 and 2002 by the National Institute on Alcohol Abuse and Alcoholism, the prevalence of alcohol use disorder among people aged 65 years and older is 1.35%. Dr. Trevisan, a geriatric and addiction psychiatrist at Yale University, New Haven, Conn., said that elderly alcoholics fall into types: those who start drinking well before they reach age 50 (earlier elderly onset) and those who start drinking after age 50 (later elderly onset).

Earlier elderly onset alcoholics “make up the large majority of older problem drinkers,” he said. “They usually have chronic alcohol-related medical problems, a positive family history, serious psychiatric comorbidities.” In addition, he said, older problem drinkers usually are less socially adjusted, may have an intractable course and more legal problems, and usually need more medically focused intensive treatment for their addiction.

Later elderly onset alcoholics usually begin drinking after a stress-related event, such as death of a spouse, family member, or close friend, or the loss of a job or a home. “They're usually more emotionally stable, usually have a milder clinical picture, and in general they have greater life satisfaction,” Dr. Trevisan said.

They also tend to respond better to treatment, compared with earlier elderly onset alcoholics.

Other risk factors associated with the development of addiction in late life include a personal history of alcohol abuse or use in the past, chronic pain, predisposition to depression or anxiety disorders, and loss of social support or retirement.

Dr. Gregory Acampora, a substance abuse fellow at the Yale/VA Alcohol Research Center, advised clinicians to assess the mental status of older patients with suspected alcohol problems because the effects of alcohol only exacerbate underlying cognitive infirmities. This is important, because cognitive impairment is dose related acutely “and can cause persistent cognitive deficits.”

Moreover, dementia often is prevalent in this patient population and affects agnosia, aphasia, apraxia, or a disturbance in executive functioning. The 1% prevalence of dementia for people aged 60-69 doubles every 5 years to a prevalence of about 39% for people aged 90-95 (JAMA 2007; 297:2391-404).

Dr. Acampora also recommended assessing the fall risk in the work-up of any older patient with a suspected drinking problem, noting that gait directly affects long-term outcome.

“The slower you walk, the higher your risk of a fall and of a bad outcome,” he said.

In addition, research has demonstrated that a history of problem drinking is associated with a significantly greater risk of falls (J. Am. Geriatr. Soc. 2006;54:1649-57).

He went on to note that medication interaction “has to be considered” in the work-up of older adults with a suspected drinking problem, and that two “misadventures” can occur with patients who take several prescription medications.

“One is that they take all of them–and for each drug there is an increased risk of a drug-drug interaction,” Dr. Acampora said. “The other is that they don't take the drug. The disease state may worsen, and a clinician may end up trying to adjust against his belief that a patient is taking the medication” when in fact he or she is not.

Later elderly onset alcoholics usually begindrinking after a stress-related event. DR. TREVISAN

SAN DIEGO — The way Dr. Mark Novotny sees it, hospitalists are uniquely qualified to lead hospital-based quality improvement projects because they encounter inefficiencies on a daily basis such as missing lab specimens, lost chest x-rays, or a patient they've been asked to see who has been moved to another room.

“The inefficiency and waste of hospital processes are not just an observation on a spreadsheet, they're your day,” he said at the annual meeting of the Society of Hospital Medicine. “Those inefficiencies and waste in your day are multiplied by every other caregiver, and the patient. Most estimates are that 30% of health care dollars are completely wasted. That's a lot of money.”

A key factor to leading a quality improvement project is the willingness to accept accountability for managing resources, said Dr. Novotny, a hospitalist who is chief medical officer of Southwestern Vermont Health Care, a not-for-profit consortium of services based in Bennington, Vt. The goal of your project might be to align resources to accomplish performance improvement, reduce harm to patients, achieve reliable processes, or reduce waste of time and money. Whatever it is, “choose an issue about which you're passionate,” he advised. “Volunteer to lead a task force, understand the resources, and pick a measurable goal and time frame. Get the training you need to understand how to set a goal, measure, and improve.”

It also helps to “think like the administrators” in your practice setting and be able to articulate how the project will save money and improve quality. “The cost of poor quality is something that you can identify and take to the administrators for support of your project,” said Dr. Novotny, who became a physician leader after starting out as a general internist 26 years ago. “There are reimbursement issues that are now tied to quality measures. Find out what quality issues the administration is already worried about.”

He offered the following tips for leading quality improvement projects:

▸Use your clinical knowledge to bring forward system problems. “You know where the problems are out there,” he said, adding that efficient data capture and data management are common challenges in today's practice environment.

▸Acquire the performance improvement skills you need. Take the Society of Hospital Medicine's Quality Improvement Pre-Course, courses at the Institute for Healthcare Improvement or Intermountain Health Care, or learn the tools from your own quality department.

▸Find partners who will work with you and support your goal. These may include nursing leaders, the chief medical officer, the chief operating officer, or case managers. “They're out there, and they can advocate the goal that you have,” he said. “They don't have to work for you, but they can support your goal.”

▸Use the politics of your organization to help you. “To me politics means the informal organizational chart,” Dr. Novotny said. “It's knowing who has influence, and being able to anticipate who's going to get in your way at your next meeting. It's knowing how to move something through your organization using influential people.”

▸Get someone from finance on board with the project. “You can get a finance manager or the chief financial officer to look at your data or your proposal before you take the project to the next level,” he said.

▸Get somebody with experience in quality/safety issues to help you design the project. “I've only recently begun to understand how complicated this is, because most of the processes you work in are chaotic,” he said. “They need design to become standardized, and it's not easy.”

▸Learn to run a meeting efficiently. “When you do this well, people will come to your next meeting,” he said.

If your quality improvement project is successful, don't take sole credit for the success. “Always credit the team and be quiet,” Dr. Novotny said. “When you credit the team, they'll come back for more, and then you'll get something else done. If you credit yourself, your team feels devalued. That was your last group project.”

He acknowledged that the hardest part of spearheading a quality improvement project is balancing the amount of time you spend on it. Hospitalists “have so much energy and passion for this work that people are using their own personal time,” he said. “I don't think that's a sustainable model. People are going to burn out. Don't do this without resources. You need an administrative assistant or someone to help you. You need to negotiate” for those resources.

When starting a quality improvement project, 'choose an issue about which you're passionate.' DR. NOVOTNY

SAN DIEGO — The way Dr. Mark Novotny sees it, hospitalists are uniquely qualified to lead hospital-based quality improvement projects because they encounter inefficiencies on a daily basis such as missing lab specimens, lost chest x-rays, or a patient they've been asked to see who has been moved to another room.

“The inefficiency and waste of hospital processes are not just an observation on a spreadsheet, they're your day,” he said at the annual meeting of the Society of Hospital Medicine. “Those inefficiencies and waste in your day are multiplied by every other caregiver, and the patient. Most estimates are that 30% of health care dollars are completely wasted. That's a lot of money.”

A key factor to leading a quality improvement project is the willingness to accept accountability for managing resources, said Dr. Novotny, a hospitalist who is chief medical officer of Southwestern Vermont Health Care, a not-for-profit consortium of services based in Bennington, Vt. The goal of your project might be to align resources to accomplish performance improvement, reduce harm to patients, achieve reliable processes, or reduce waste of time and money. Whatever it is, “choose an issue about which you're passionate,” he advised. “Volunteer to lead a task force, understand the resources, and pick a measurable goal and time frame. Get the training you need to understand how to set a goal, measure, and improve.”

It also helps to “think like the administrators” in your practice setting and be able to articulate how the project will save money and improve quality. “The cost of poor quality is something that you can identify and take to the administrators for support of your project,” said Dr. Novotny, who became a physician leader after starting out as a general internist 26 years ago. “There are reimbursement issues that are now tied to quality measures. Find out what quality issues the administration is already worried about.”

He offered the following tips for leading quality improvement projects:

▸Use your clinical knowledge to bring forward system problems. “You know where the problems are out there,” he said, adding that efficient data capture and data management are common challenges in today's practice environment.

▸Acquire the performance improvement skills you need. Take the Society of Hospital Medicine's Quality Improvement Pre-Course, courses at the Institute for Healthcare Improvement or Intermountain Health Care, or learn the tools from your own quality department.

▸Find partners who will work with you and support your goal. These may include nursing leaders, the chief medical officer, the chief operating officer, or case managers. “They're out there, and they can advocate the goal that you have,” he said. “They don't have to work for you, but they can support your goal.”

▸Use the politics of your organization to help you. “To me politics means the informal organizational chart,” Dr. Novotny said. “It's knowing who has influence, and being able to anticipate who's going to get in your way at your next meeting. It's knowing how to move something through your organization using influential people.”

▸Get someone from finance on board with the project. “You can get a finance manager or the chief financial officer to look at your data or your proposal before you take the project to the next level,” he said.

▸Get somebody with experience in quality/safety issues to help you design the project. “I've only recently begun to understand how complicated this is, because most of the processes you work in are chaotic,” he said. “They need design to become standardized, and it's not easy.”

▸Learn to run a meeting efficiently. “When you do this well, people will come to your next meeting,” he said.

If your quality improvement project is successful, don't take sole credit for the success. “Always credit the team and be quiet,” Dr. Novotny said. “When you credit the team, they'll come back for more, and then you'll get something else done. If you credit yourself, your team feels devalued. That was your last group project.”

He acknowledged that the hardest part of spearheading a quality improvement project is balancing the amount of time you spend on it. Hospitalists “have so much energy and passion for this work that people are using their own personal time,” he said. “I don't think that's a sustainable model. People are going to burn out. Don't do this without resources. You need an administrative assistant or someone to help you. You need to negotiate” for those resources.

When starting a quality improvement project, 'choose an issue about which you're passionate.' DR. NOVOTNY

SAN DIEGO — The way Dr. Mark Novotny sees it, hospitalists are uniquely qualified to lead hospital-based quality improvement projects because they encounter inefficiencies on a daily basis such as missing lab specimens, lost chest x-rays, or a patient they've been asked to see who has been moved to another room.

“The inefficiency and waste of hospital processes are not just an observation on a spreadsheet, they're your day,” he said at the annual meeting of the Society of Hospital Medicine. “Those inefficiencies and waste in your day are multiplied by every other caregiver, and the patient. Most estimates are that 30% of health care dollars are completely wasted. That's a lot of money.”

A key factor to leading a quality improvement project is the willingness to accept accountability for managing resources, said Dr. Novotny, a hospitalist who is chief medical officer of Southwestern Vermont Health Care, a not-for-profit consortium of services based in Bennington, Vt. The goal of your project might be to align resources to accomplish performance improvement, reduce harm to patients, achieve reliable processes, or reduce waste of time and money. Whatever it is, “choose an issue about which you're passionate,” he advised. “Volunteer to lead a task force, understand the resources, and pick a measurable goal and time frame. Get the training you need to understand how to set a goal, measure, and improve.”

It also helps to “think like the administrators” in your practice setting and be able to articulate how the project will save money and improve quality. “The cost of poor quality is something that you can identify and take to the administrators for support of your project,” said Dr. Novotny, who became a physician leader after starting out as a general internist 26 years ago. “There are reimbursement issues that are now tied to quality measures. Find out what quality issues the administration is already worried about.”

He offered the following tips for leading quality improvement projects:

▸Use your clinical knowledge to bring forward system problems. “You know where the problems are out there,” he said, adding that efficient data capture and data management are common challenges in today's practice environment.

▸Acquire the performance improvement skills you need. Take the Society of Hospital Medicine's Quality Improvement Pre-Course, courses at the Institute for Healthcare Improvement or Intermountain Health Care, or learn the tools from your own quality department.

▸Find partners who will work with you and support your goal. These may include nursing leaders, the chief medical officer, the chief operating officer, or case managers. “They're out there, and they can advocate the goal that you have,” he said. “They don't have to work for you, but they can support your goal.”

▸Use the politics of your organization to help you. “To me politics means the informal organizational chart,” Dr. Novotny said. “It's knowing who has influence, and being able to anticipate who's going to get in your way at your next meeting. It's knowing how to move something through your organization using influential people.”

▸Get someone from finance on board with the project. “You can get a finance manager or the chief financial officer to look at your data or your proposal before you take the project to the next level,” he said.

▸Get somebody with experience in quality/safety issues to help you design the project. “I've only recently begun to understand how complicated this is, because most of the processes you work in are chaotic,” he said. “They need design to become standardized, and it's not easy.”

▸Learn to run a meeting efficiently. “When you do this well, people will come to your next meeting,” he said.

If your quality improvement project is successful, don't take sole credit for the success. “Always credit the team and be quiet,” Dr. Novotny said. “When you credit the team, they'll come back for more, and then you'll get something else done. If you credit yourself, your team feels devalued. That was your last group project.”

He acknowledged that the hardest part of spearheading a quality improvement project is balancing the amount of time you spend on it. Hospitalists “have so much energy and passion for this work that people are using their own personal time,” he said. “I don't think that's a sustainable model. People are going to burn out. Don't do this without resources. You need an administrative assistant or someone to help you. You need to negotiate” for those resources.

When starting a quality improvement project, 'choose an issue about which you're passionate.' DR. NOVOTNY

SAN DIEGO — As a hospitalist, the best approach to the comanagement of patients is to define your boundaries from the start and revisit those boundaries frequently.

Ask other members of the care team specific questions, such as: What parts of this patient's care are your responsibility? What parts of the care are mine? How are we going to decide who does what?

“If you don't know what you're doing when you're seeing the patients, if you don't have a coherent and mutually agreed upon vision for how you're going to make the care better, I'm not sure that you're actually doing anything other than showing up,” Dr. Eric M. Siegal said at the annual meeting of the Society of Hospital Medicine.

Comanagement relationships can be fraught with ambiguity, so he offered the following “existential questions” to ask in an effort to achieve clarity:

▸Why are we being asked to comanage this patient's care?

▸What are the “rules of engagement”? Do I make suggestions or decisions?

▸What responsibilities are mine vs. yours?

▸Where do our responsibilities overlap, and how do we manage those overlaps?

▸What happens if we disagree?

▸Who makes the final call?

“If you haven't at least thought these through and talked these over with the people with whom you're working, you're setting yourself up for a problem, a conflict at some point down the road,” Dr. Siegal warned.

In terms of protocol, “you absolutely have to insist on uniformity,” said Dr. Siegal, a hospitalist who is regional medical director of Cogent Healthcare, Nashville, Tenn. “You can't have orthopedist A doing it his way and orthopedist B doing it her way and hospitalist C doing it a third way. If this is how we're going to do it, then this is how everybody does it.” This applies to hospitalists as well, who need to be vigilant that they are all practicing consistently. Because board certification in hospital medicine is not yet available, hospitalists often have significantly different skill sets.

For example, if all of the members of your hospitalist program are adept at managing mechanical respiratory ventilation, that's great. But if only one member of your program can manage mechanical respiratory ventilation, “then you either have to pull that person out of the rotation to cover the vents, or nobody can manage the vents,” he said. Don't have a two-tiered system “because nothing drives specialists and nurses more crazy than to see one hospitalist come in and do one thing and then see the next hospitalist either unable to do it or do it radically differently.”

If you need help defining a reasonable role for a hospitalist, Dr. Siegal recommended reviewing the core competencies published in the January/February 2006 supplement of the Journal of Hospital Medicine (www3.interscience.wiley.com/journal/112396185/issue

Dr. Siegal recommends negotiating your expectations with other members of the comanagement team and developing guidelines when ambiguity exists. When he was director of the hospitalist program at Meriter Hospital, an affiliate of the University of Wisconsin, Madison, he sat down with cardiologists at the hospital and devised cardiology admission guidelines so everyone would be on the same page. They agreed that the cardiologist would admit patients with specific conditions that included ST-segment elevation, myocardial infarction, and advanced heart block requiring or potentially requiring emergency temporary pacing, while the hospitalist would admit patients with a different set of conditions that included chest pain of uncertain etiology and atrial arrhythmias.

“Does this cover every possible permutation? No,” Dr. Siegal said. “But the point was, we agreed on a basic set of rules up front. We disseminated them, put them in the emergency department, and it lowered the number of confusing calls and decreased the amount of angst. It's worked really nicely. As much as you can, cookbook this stuff up front so you know what the rules are.”

Revisiting the comanagement relationship after the first few months is a good idea, he noted, “because perspectives change, sometimes for the better, and sometimes for the worse.” As a case in point he described a surgeon he worked with who was initially skeptical of hospitalists. One day Dr. Siegal was called to stabilize one of the surgeon's patients who was crashing in the postanesthesia care unit. The surgeon was busy with a case at another hospital when this occurred.

“I took care of that patient and the next thing I knew, I could do no wrong,” Dr. Siegal recalled. “I'm not sure how I went from being marginally competent to very competent based on one case, but from his perspective I was and that was good enough. The point is, relationships change, but they may not always change for the better. One screw-up can radically change the relationship for the worse as well.”

He acknowledged that there will be people in comanagement relationships whom you won't get along with despite your best efforts. “So you have to be thoughtful about what you're getting yourself into in the first place,” he said.

'As much as you can, cookbook this stuff up front so you know what the rules are.' DR. SIEGAL

SAN DIEGO — As a hospitalist, the best approach to the comanagement of patients is to define your boundaries from the start and revisit those boundaries frequently.

Ask other members of the care team specific questions, such as: What parts of this patient's care are your responsibility? What parts of the care are mine? How are we going to decide who does what?

“If you don't know what you're doing when you're seeing the patients, if you don't have a coherent and mutually agreed upon vision for how you're going to make the care better, I'm not sure that you're actually doing anything other than showing up,” Dr. Eric M. Siegal said at the annual meeting of the Society of Hospital Medicine.

Comanagement relationships can be fraught with ambiguity, so he offered the following “existential questions” to ask in an effort to achieve clarity:

▸Why are we being asked to comanage this patient's care?

▸What are the “rules of engagement”? Do I make suggestions or decisions?

▸What responsibilities are mine vs. yours?

▸Where do our responsibilities overlap, and how do we manage those overlaps?

▸What happens if we disagree?

▸Who makes the final call?

“If you haven't at least thought these through and talked these over with the people with whom you're working, you're setting yourself up for a problem, a conflict at some point down the road,” Dr. Siegal warned.

In terms of protocol, “you absolutely have to insist on uniformity,” said Dr. Siegal, a hospitalist who is regional medical director of Cogent Healthcare, Nashville, Tenn. “You can't have orthopedist A doing it his way and orthopedist B doing it her way and hospitalist C doing it a third way. If this is how we're going to do it, then this is how everybody does it.” This applies to hospitalists as well, who need to be vigilant that they are all practicing consistently. Because board certification in hospital medicine is not yet available, hospitalists often have significantly different skill sets.

For example, if all of the members of your hospitalist program are adept at managing mechanical respiratory ventilation, that's great. But if only one member of your program can manage mechanical respiratory ventilation, “then you either have to pull that person out of the rotation to cover the vents, or nobody can manage the vents,” he said. Don't have a two-tiered system “because nothing drives specialists and nurses more crazy than to see one hospitalist come in and do one thing and then see the next hospitalist either unable to do it or do it radically differently.”

If you need help defining a reasonable role for a hospitalist, Dr. Siegal recommended reviewing the core competencies published in the January/February 2006 supplement of the Journal of Hospital Medicine (www3.interscience.wiley.com/journal/112396185/issue

Dr. Siegal recommends negotiating your expectations with other members of the comanagement team and developing guidelines when ambiguity exists. When he was director of the hospitalist program at Meriter Hospital, an affiliate of the University of Wisconsin, Madison, he sat down with cardiologists at the hospital and devised cardiology admission guidelines so everyone would be on the same page. They agreed that the cardiologist would admit patients with specific conditions that included ST-segment elevation, myocardial infarction, and advanced heart block requiring or potentially requiring emergency temporary pacing, while the hospitalist would admit patients with a different set of conditions that included chest pain of uncertain etiology and atrial arrhythmias.

“Does this cover every possible permutation? No,” Dr. Siegal said. “But the point was, we agreed on a basic set of rules up front. We disseminated them, put them in the emergency department, and it lowered the number of confusing calls and decreased the amount of angst. It's worked really nicely. As much as you can, cookbook this stuff up front so you know what the rules are.”

Revisiting the comanagement relationship after the first few months is a good idea, he noted, “because perspectives change, sometimes for the better, and sometimes for the worse.” As a case in point he described a surgeon he worked with who was initially skeptical of hospitalists. One day Dr. Siegal was called to stabilize one of the surgeon's patients who was crashing in the postanesthesia care unit. The surgeon was busy with a case at another hospital when this occurred.

“I took care of that patient and the next thing I knew, I could do no wrong,” Dr. Siegal recalled. “I'm not sure how I went from being marginally competent to very competent based on one case, but from his perspective I was and that was good enough. The point is, relationships change, but they may not always change for the better. One screw-up can radically change the relationship for the worse as well.”

He acknowledged that there will be people in comanagement relationships whom you won't get along with despite your best efforts. “So you have to be thoughtful about what you're getting yourself into in the first place,” he said.

'As much as you can, cookbook this stuff up front so you know what the rules are.' DR. SIEGAL

SAN DIEGO — As a hospitalist, the best approach to the comanagement of patients is to define your boundaries from the start and revisit those boundaries frequently.

Ask other members of the care team specific questions, such as: What parts of this patient's care are your responsibility? What parts of the care are mine? How are we going to decide who does what?

“If you don't know what you're doing when you're seeing the patients, if you don't have a coherent and mutually agreed upon vision for how you're going to make the care better, I'm not sure that you're actually doing anything other than showing up,” Dr. Eric M. Siegal said at the annual meeting of the Society of Hospital Medicine.

Comanagement relationships can be fraught with ambiguity, so he offered the following “existential questions” to ask in an effort to achieve clarity:

▸Why are we being asked to comanage this patient's care?

▸What are the “rules of engagement”? Do I make suggestions or decisions?

▸What responsibilities are mine vs. yours?

▸Where do our responsibilities overlap, and how do we manage those overlaps?

▸What happens if we disagree?

▸Who makes the final call?

“If you haven't at least thought these through and talked these over with the people with whom you're working, you're setting yourself up for a problem, a conflict at some point down the road,” Dr. Siegal warned.

In terms of protocol, “you absolutely have to insist on uniformity,” said Dr. Siegal, a hospitalist who is regional medical director of Cogent Healthcare, Nashville, Tenn. “You can't have orthopedist A doing it his way and orthopedist B doing it her way and hospitalist C doing it a third way. If this is how we're going to do it, then this is how everybody does it.” This applies to hospitalists as well, who need to be vigilant that they are all practicing consistently. Because board certification in hospital medicine is not yet available, hospitalists often have significantly different skill sets.

For example, if all of the members of your hospitalist program are adept at managing mechanical respiratory ventilation, that's great. But if only one member of your program can manage mechanical respiratory ventilation, “then you either have to pull that person out of the rotation to cover the vents, or nobody can manage the vents,” he said. Don't have a two-tiered system “because nothing drives specialists and nurses more crazy than to see one hospitalist come in and do one thing and then see the next hospitalist either unable to do it or do it radically differently.”

If you need help defining a reasonable role for a hospitalist, Dr. Siegal recommended reviewing the core competencies published in the January/February 2006 supplement of the Journal of Hospital Medicine (www3.interscience.wiley.com/journal/112396185/issue

Dr. Siegal recommends negotiating your expectations with other members of the comanagement team and developing guidelines when ambiguity exists. When he was director of the hospitalist program at Meriter Hospital, an affiliate of the University of Wisconsin, Madison, he sat down with cardiologists at the hospital and devised cardiology admission guidelines so everyone would be on the same page. They agreed that the cardiologist would admit patients with specific conditions that included ST-segment elevation, myocardial infarction, and advanced heart block requiring or potentially requiring emergency temporary pacing, while the hospitalist would admit patients with a different set of conditions that included chest pain of uncertain etiology and atrial arrhythmias.

“Does this cover every possible permutation? No,” Dr. Siegal said. “But the point was, we agreed on a basic set of rules up front. We disseminated them, put them in the emergency department, and it lowered the number of confusing calls and decreased the amount of angst. It's worked really nicely. As much as you can, cookbook this stuff up front so you know what the rules are.”

Revisiting the comanagement relationship after the first few months is a good idea, he noted, “because perspectives change, sometimes for the better, and sometimes for the worse.” As a case in point he described a surgeon he worked with who was initially skeptical of hospitalists. One day Dr. Siegal was called to stabilize one of the surgeon's patients who was crashing in the postanesthesia care unit. The surgeon was busy with a case at another hospital when this occurred.

“I took care of that patient and the next thing I knew, I could do no wrong,” Dr. Siegal recalled. “I'm not sure how I went from being marginally competent to very competent based on one case, but from his perspective I was and that was good enough. The point is, relationships change, but they may not always change for the better. One screw-up can radically change the relationship for the worse as well.”

He acknowledged that there will be people in comanagement relationships whom you won't get along with despite your best efforts. “So you have to be thoughtful about what you're getting yourself into in the first place,” he said.

'As much as you can, cookbook this stuff up front so you know what the rules are.' DR. SIEGAL

CORONADO, CALIF. — Of 104 physicians in New York state who were admitted to substance abuse treatment programs between 2003 and 2004 and were monitored for a mean of 41 months by the state's Committee for Physicians' Health, only 9 (9%) were discharged because of noncompliance with program expectations.

That might spell success at first glance, but at the annual meeting of the American Academy of Addiction Psychiatry, Dr. Marc Galanter emphasized the need for more research to optimize treatment outcomes for physicians in recovery.

“There are still a number of issues to be considered,” said Dr. Galanter, professor of psychiatry and director of the division of alcoholism and drug abuse in the department of psychiatry at New York University, New York. “One is the need for prospective study—following the treatment contemporaneously—which we have yet to see,” he said. “Another is to better understand the role of medication.”

Buprenorphine inevitably will be used more widely; however, the question of whether physicians should be allowed to practice while taking opioid maintenance therapy is likely to become a political issue at the state level, he said.

He also recommended that a more active role for cognitive-behavioral therapy “be studied because this is a modality that is currently regarded as essential to effective treatment.”

Dr. Galanter based his remarks on results from a study he led that sought to provide an independent evaluation of the oversight and rehabilitation of 104 substance-abusing physicians who had completed their monitoring period by the New York State Committee for Physicians' Health (CPH). About 30% of physicians who enroll in the CPH program receive at least 28 days of inpatient treatment. Components of ambulatory management include workplace monitoring, 12-step program attendance, and random urine toxicologies.

The researchers, who were not affiliated with CPH, selected the 104 records at random (Am. J. Addict. 2007;16:117–23). The mean age of the study participants was 42 years, most (96) were male, about half (51) were married, and 66 were employed as physicians at the time of admission.

More than half (59) had a history of substance abuse treatment, and 38 had attended 12-step meetings before program admission. In addition, 33 were in psychotherapy of some sort prior to admission, and 27 were taking psychiatric medications, primarily antidepressants.

The most common primary substance of abuse was alcohol (38), followed by prescription opiates (35), said Dr. Galanter, who is also the editor of the journal Substance Abuse.

The top five medical specialties represented were anesthesia (22 physicians), internal medicine (11), family medicine (10), obstetrics and gynecology (9), and pediatrics (8). “Anesthesia is overrepresented among impaired physicians because of access to addictive agents, and because in some cases people go into anesthesia attracted to the idea of handling and having access to opioids,” Dr. Galanter said.

The overall period of treatment and monitoring averaged 41 months; 30 participants required inpatient hospitalization.

Fifteen physicians did not want to attend 12-step meetings but were pressed by counselors to do so. Of those, nine later went. “The outcome of those pressed to go was not significantly different from that of the other patients,” he said. “So apparently the coercive nature of the treatment in that regard was not compromising to the outcome.”

Of the 104 patients, 38 relapsed as confirmed by urine toxicology or by confirmation from an informed source. Even under good circumstances, some relapse is inevitable before the patient is stabilized, Dr. Galanter said. However, one complication is that physician impairment programs are responsible for serving large numbers of physicians.

“The pressure of the needs of public health that they experience puts them in a difficult position,” Dr. Galanter said. “My impression is that it's remarkable how effective they are in balancing the physician needs against the demands of the general public.”

Predictors of relapse included past use of cocaine, unemployment at the time of program admission, a greater mean number of urines tested, and a longer length of program involvement.

Nine patients were discharged for noncompliance with program expectations. “They essentially lost the option of practicing medicine,” he said. “Relatively speaking, this gives you an idea of a very good outcome, considering that full compliance is essential to success in this program.”

Dr. Galanter said he considers the 12-step component of the CPH program essential to overall success. Given the need for full abstinence before returning to practice, he pointed out, these spiritually oriented 12-step programs are uniquely valuable in ensuring an optimal outcome.

“It's really remarkable what transformation many of these physicians experienced over the course of rehabilitation,” he said. “What we don't know is how we can compare recovery of this kind to recovery based on opioid replacement or on the variety of medications that we're going to be using. It's an issue of tremendous importance in terms of our investigation of future psychosocial modalities.”

Even under good circumstances, some relapse is inevitable before the patient is stabilized. DR. GALANTER

CORONADO, CALIF. — Of 104 physicians in New York state who were admitted to substance abuse treatment programs between 2003 and 2004 and were monitored for a mean of 41 months by the state's Committee for Physicians' Health, only 9 (9%) were discharged because of noncompliance with program expectations.

That might spell success at first glance, but at the annual meeting of the American Academy of Addiction Psychiatry, Dr. Marc Galanter emphasized the need for more research to optimize treatment outcomes for physicians in recovery.

“There are still a number of issues to be considered,” said Dr. Galanter, professor of psychiatry and director of the division of alcoholism and drug abuse in the department of psychiatry at New York University, New York. “One is the need for prospective study—following the treatment contemporaneously—which we have yet to see,” he said. “Another is to better understand the role of medication.”

Buprenorphine inevitably will be used more widely; however, the question of whether physicians should be allowed to practice while taking opioid maintenance therapy is likely to become a political issue at the state level, he said.

He also recommended that a more active role for cognitive-behavioral therapy “be studied because this is a modality that is currently regarded as essential to effective treatment.”

Dr. Galanter based his remarks on results from a study he led that sought to provide an independent evaluation of the oversight and rehabilitation of 104 substance-abusing physicians who had completed their monitoring period by the New York State Committee for Physicians' Health (CPH). About 30% of physicians who enroll in the CPH program receive at least 28 days of inpatient treatment. Components of ambulatory management include workplace monitoring, 12-step program attendance, and random urine toxicologies.

The researchers, who were not affiliated with CPH, selected the 104 records at random (Am. J. Addict. 2007;16:117–23). The mean age of the study participants was 42 years, most (96) were male, about half (51) were married, and 66 were employed as physicians at the time of admission.

More than half (59) had a history of substance abuse treatment, and 38 had attended 12-step meetings before program admission. In addition, 33 were in psychotherapy of some sort prior to admission, and 27 were taking psychiatric medications, primarily antidepressants.

The most common primary substance of abuse was alcohol (38), followed by prescription opiates (35), said Dr. Galanter, who is also the editor of the journal Substance Abuse.

The top five medical specialties represented were anesthesia (22 physicians), internal medicine (11), family medicine (10), obstetrics and gynecology (9), and pediatrics (8). “Anesthesia is overrepresented among impaired physicians because of access to addictive agents, and because in some cases people go into anesthesia attracted to the idea of handling and having access to opioids,” Dr. Galanter said.

The overall period of treatment and monitoring averaged 41 months; 30 participants required inpatient hospitalization.

Fifteen physicians did not want to attend 12-step meetings but were pressed by counselors to do so. Of those, nine later went. “The outcome of those pressed to go was not significantly different from that of the other patients,” he said. “So apparently the coercive nature of the treatment in that regard was not compromising to the outcome.”

Of the 104 patients, 38 relapsed as confirmed by urine toxicology or by confirmation from an informed source. Even under good circumstances, some relapse is inevitable before the patient is stabilized, Dr. Galanter said. However, one complication is that physician impairment programs are responsible for serving large numbers of physicians.

“The pressure of the needs of public health that they experience puts them in a difficult position,” Dr. Galanter said. “My impression is that it's remarkable how effective they are in balancing the physician needs against the demands of the general public.”

Predictors of relapse included past use of cocaine, unemployment at the time of program admission, a greater mean number of urines tested, and a longer length of program involvement.

Nine patients were discharged for noncompliance with program expectations. “They essentially lost the option of practicing medicine,” he said. “Relatively speaking, this gives you an idea of a very good outcome, considering that full compliance is essential to success in this program.”

Dr. Galanter said he considers the 12-step component of the CPH program essential to overall success. Given the need for full abstinence before returning to practice, he pointed out, these spiritually oriented 12-step programs are uniquely valuable in ensuring an optimal outcome.

“It's really remarkable what transformation many of these physicians experienced over the course of rehabilitation,” he said. “What we don't know is how we can compare recovery of this kind to recovery based on opioid replacement or on the variety of medications that we're going to be using. It's an issue of tremendous importance in terms of our investigation of future psychosocial modalities.”

Even under good circumstances, some relapse is inevitable before the patient is stabilized. DR. GALANTER

CORONADO, CALIF. — Of 104 physicians in New York state who were admitted to substance abuse treatment programs between 2003 and 2004 and were monitored for a mean of 41 months by the state's Committee for Physicians' Health, only 9 (9%) were discharged because of noncompliance with program expectations.

That might spell success at first glance, but at the annual meeting of the American Academy of Addiction Psychiatry, Dr. Marc Galanter emphasized the need for more research to optimize treatment outcomes for physicians in recovery.

“There are still a number of issues to be considered,” said Dr. Galanter, professor of psychiatry and director of the division of alcoholism and drug abuse in the department of psychiatry at New York University, New York. “One is the need for prospective study—following the treatment contemporaneously—which we have yet to see,” he said. “Another is to better understand the role of medication.”

Buprenorphine inevitably will be used more widely; however, the question of whether physicians should be allowed to practice while taking opioid maintenance therapy is likely to become a political issue at the state level, he said.

He also recommended that a more active role for cognitive-behavioral therapy “be studied because this is a modality that is currently regarded as essential to effective treatment.”

Dr. Galanter based his remarks on results from a study he led that sought to provide an independent evaluation of the oversight and rehabilitation of 104 substance-abusing physicians who had completed their monitoring period by the New York State Committee for Physicians' Health (CPH). About 30% of physicians who enroll in the CPH program receive at least 28 days of inpatient treatment. Components of ambulatory management include workplace monitoring, 12-step program attendance, and random urine toxicologies.

The researchers, who were not affiliated with CPH, selected the 104 records at random (Am. J. Addict. 2007;16:117–23). The mean age of the study participants was 42 years, most (96) were male, about half (51) were married, and 66 were employed as physicians at the time of admission.

More than half (59) had a history of substance abuse treatment, and 38 had attended 12-step meetings before program admission. In addition, 33 were in psychotherapy of some sort prior to admission, and 27 were taking psychiatric medications, primarily antidepressants.

The most common primary substance of abuse was alcohol (38), followed by prescription opiates (35), said Dr. Galanter, who is also the editor of the journal Substance Abuse.

The top five medical specialties represented were anesthesia (22 physicians), internal medicine (11), family medicine (10), obstetrics and gynecology (9), and pediatrics (8). “Anesthesia is overrepresented among impaired physicians because of access to addictive agents, and because in some cases people go into anesthesia attracted to the idea of handling and having access to opioids,” Dr. Galanter said.

The overall period of treatment and monitoring averaged 41 months; 30 participants required inpatient hospitalization.

Fifteen physicians did not want to attend 12-step meetings but were pressed by counselors to do so. Of those, nine later went. “The outcome of those pressed to go was not significantly different from that of the other patients,” he said. “So apparently the coercive nature of the treatment in that regard was not compromising to the outcome.”

Of the 104 patients, 38 relapsed as confirmed by urine toxicology or by confirmation from an informed source. Even under good circumstances, some relapse is inevitable before the patient is stabilized, Dr. Galanter said. However, one complication is that physician impairment programs are responsible for serving large numbers of physicians.

“The pressure of the needs of public health that they experience puts them in a difficult position,” Dr. Galanter said. “My impression is that it's remarkable how effective they are in balancing the physician needs against the demands of the general public.”

Predictors of relapse included past use of cocaine, unemployment at the time of program admission, a greater mean number of urines tested, and a longer length of program involvement.

Nine patients were discharged for noncompliance with program expectations. “They essentially lost the option of practicing medicine,” he said. “Relatively speaking, this gives you an idea of a very good outcome, considering that full compliance is essential to success in this program.”

Dr. Galanter said he considers the 12-step component of the CPH program essential to overall success. Given the need for full abstinence before returning to practice, he pointed out, these spiritually oriented 12-step programs are uniquely valuable in ensuring an optimal outcome.

“It's really remarkable what transformation many of these physicians experienced over the course of rehabilitation,” he said. “What we don't know is how we can compare recovery of this kind to recovery based on opioid replacement or on the variety of medications that we're going to be using. It's an issue of tremendous importance in terms of our investigation of future psychosocial modalities.”

Even under good circumstances, some relapse is inevitable before the patient is stabilized. DR. GALANTER

In the not-so-distant past, endoscopists always sought the input of pathologists when diagnosing gastrointestinal cancers.

Now, thanks to the maturation of image-enhanced endoscopy, endoscopists are sometimes able to make a diagnosis on the spot.

“The time for endoscopic diagnosis has come of age because now we have increased accuracy—sensitivity and specificity—in terms of diagnosing diseases, especially for the early tumors,” Dr. Roy Soetikno, chief of the gastroenterology section at Veterans Affairs Palo Alto (Calif.) Health Care System, said in an interview.

“This technology is now hand in hand with the much-improved optics of the endoscopes. This allows more things to be done during endoscopic assessment, such as cutting tumors at time of assessment rather than going back in, so it's increasing efficiency and reducing costs.”

In an effort to assist clinicians in the appropriate use of such technology, Dr. Soetikno and his associates assembled the guidelines, “Technology Assessment on Image-Enhanced Endoscopy,” based on a Medline search performed through June 2007. The guidelines are the first of their kind (Gastroenterology 2008;134:327–40).

One reason that the researchers assembled these guidelines is to promote the use of image-enhanced endoscopy (IEE) outside of specialized academic centers, where it has been used almost exclusively. For many clinicians, using dye for image enhancement was a cumbersome process, requiring preparation of the solution, spraying it on, and interpretation.

“It added more time,” Dr. Soetikno explained. “It was not just 'turn the key,' so to speak. Today, though, by changing the properties of the lights that go through the endoscope, we can mimic what could have been achieved by the dye. Either the endoscopy lights have changed, or we're using some kind of computer software to process the image, so in the end you highlight the gland or the abnormality, and you get a better diagnosis.”

According to the guidelines, available data support the use of IEE in the detection and treatment of early squamous cell carcinoma of the esophagus, early gastric cancer, and superficial colorectal lesions.

The guidelines also state that the use of Lugol's solution “may improve the endoscopic visualization of high-grade dysplasia and early squamous cell carcinoma of the esophagus, and thus may be considered [for use] in high-risk patient populations.”

Diluted indigo carmine solution can be helpful in the diagnosis and treatment of early gastric cancer because it “pools at the border of the lesion and thus enhances visualization of these lesions, which are most often nonpolypoid. By pooling into the depression or ulceration of the lesion, the solution aids in the classification of the morphology, which in turn is important in the medical decision making of treatment strategy.”

Equipment-based advances in endoscopic imaging continue to evolve and enhance visualization, including devices that use manipulations of the light source or captured light.

Other approaches being studied include narrow-band imaging, which uses a narrow light source to enhance visualization of the surface microvessels; spectral estimation technologies, which use computerized processing to convert standard RGB (red, green, blue) signals from the endoscope's charged-coupled device; and autofluorescence imaging, which uses changes in concentrations of endogenous fluorophores.

The researchers also noted that high-resolution or high-definition endoscopes provide “a more detailed image of gastrointestinal mucosa, and high-magnification endoscopy enlarges the image up to 100×,” compared with 30× in standard endoscopy, which uses a 20-inch monitor. “At higher magnification with IEE, the visualized surface patterns of the gastrointestinal mucosa have been suggested to correlate well with the underlying histology.

“Proposed uses for high magnification used in conjunction with IEE include distinguishing neoplastic and nonneoplastic lesions, assessing depth of invasion in early colorectal carcinoma, and detecting minute tumor residue after endoscopic mucosal resection,” the authors said.

Potential barriers to the dissemination of IEE “include perceptions of its inefficiency and [high] cost, inadequate mechanism for reimbursement, lack of standardized training in techniques, and deficiency of high-quality comparison studies,” the researchers wrote.

Dr. Soetikno said that neither he nor his associates have any relevant financial relationships to disclose.

A brownish polypoid adenoma is clearly visualized with narrow-band imaging. ©American Society for Gastrointestinal Endoscopy

In the not-so-distant past, endoscopists always sought the input of pathologists when diagnosing gastrointestinal cancers.

Now, thanks to the maturation of image-enhanced endoscopy, endoscopists are sometimes able to make a diagnosis on the spot.

“The time for endoscopic diagnosis has come of age because now we have increased accuracy—sensitivity and specificity—in terms of diagnosing diseases, especially for the early tumors,” Dr. Roy Soetikno, chief of the gastroenterology section at Veterans Affairs Palo Alto (Calif.) Health Care System, said in an interview.

“This technology is now hand in hand with the much-improved optics of the endoscopes. This allows more things to be done during endoscopic assessment, such as cutting tumors at time of assessment rather than going back in, so it's increasing efficiency and reducing costs.”

In an effort to assist clinicians in the appropriate use of such technology, Dr. Soetikno and his associates assembled the guidelines, “Technology Assessment on Image-Enhanced Endoscopy,” based on a Medline search performed through June 2007. The guidelines are the first of their kind (Gastroenterology 2008;134:327–40).

One reason that the researchers assembled these guidelines is to promote the use of image-enhanced endoscopy (IEE) outside of specialized academic centers, where it has been used almost exclusively. For many clinicians, using dye for image enhancement was a cumbersome process, requiring preparation of the solution, spraying it on, and interpretation.

“It added more time,” Dr. Soetikno explained. “It was not just 'turn the key,' so to speak. Today, though, by changing the properties of the lights that go through the endoscope, we can mimic what could have been achieved by the dye. Either the endoscopy lights have changed, or we're using some kind of computer software to process the image, so in the end you highlight the gland or the abnormality, and you get a better diagnosis.”

According to the guidelines, available data support the use of IEE in the detection and treatment of early squamous cell carcinoma of the esophagus, early gastric cancer, and superficial colorectal lesions.

The guidelines also state that the use of Lugol's solution “may improve the endoscopic visualization of high-grade dysplasia and early squamous cell carcinoma of the esophagus, and thus may be considered [for use] in high-risk patient populations.”

Diluted indigo carmine solution can be helpful in the diagnosis and treatment of early gastric cancer because it “pools at the border of the lesion and thus enhances visualization of these lesions, which are most often nonpolypoid. By pooling into the depression or ulceration of the lesion, the solution aids in the classification of the morphology, which in turn is important in the medical decision making of treatment strategy.”

Equipment-based advances in endoscopic imaging continue to evolve and enhance visualization, including devices that use manipulations of the light source or captured light.

Other approaches being studied include narrow-band imaging, which uses a narrow light source to enhance visualization of the surface microvessels; spectral estimation technologies, which use computerized processing to convert standard RGB (red, green, blue) signals from the endoscope's charged-coupled device; and autofluorescence imaging, which uses changes in concentrations of endogenous fluorophores.

The researchers also noted that high-resolution or high-definition endoscopes provide “a more detailed image of gastrointestinal mucosa, and high-magnification endoscopy enlarges the image up to 100×,” compared with 30× in standard endoscopy, which uses a 20-inch monitor. “At higher magnification with IEE, the visualized surface patterns of the gastrointestinal mucosa have been suggested to correlate well with the underlying histology.

“Proposed uses for high magnification used in conjunction with IEE include distinguishing neoplastic and nonneoplastic lesions, assessing depth of invasion in early colorectal carcinoma, and detecting minute tumor residue after endoscopic mucosal resection,” the authors said.

Potential barriers to the dissemination of IEE “include perceptions of its inefficiency and [high] cost, inadequate mechanism for reimbursement, lack of standardized training in techniques, and deficiency of high-quality comparison studies,” the researchers wrote.

Dr. Soetikno said that neither he nor his associates have any relevant financial relationships to disclose.

A brownish polypoid adenoma is clearly visualized with narrow-band imaging. ©American Society for Gastrointestinal Endoscopy

In the not-so-distant past, endoscopists always sought the input of pathologists when diagnosing gastrointestinal cancers.

Now, thanks to the maturation of image-enhanced endoscopy, endoscopists are sometimes able to make a diagnosis on the spot.

“The time for endoscopic diagnosis has come of age because now we have increased accuracy—sensitivity and specificity—in terms of diagnosing diseases, especially for the early tumors,” Dr. Roy Soetikno, chief of the gastroenterology section at Veterans Affairs Palo Alto (Calif.) Health Care System, said in an interview.

“This technology is now hand in hand with the much-improved optics of the endoscopes. This allows more things to be done during endoscopic assessment, such as cutting tumors at time of assessment rather than going back in, so it's increasing efficiency and reducing costs.”

In an effort to assist clinicians in the appropriate use of such technology, Dr. Soetikno and his associates assembled the guidelines, “Technology Assessment on Image-Enhanced Endoscopy,” based on a Medline search performed through June 2007. The guidelines are the first of their kind (Gastroenterology 2008;134:327–40).

One reason that the researchers assembled these guidelines is to promote the use of image-enhanced endoscopy (IEE) outside of specialized academic centers, where it has been used almost exclusively. For many clinicians, using dye for image enhancement was a cumbersome process, requiring preparation of the solution, spraying it on, and interpretation.

“It added more time,” Dr. Soetikno explained. “It was not just 'turn the key,' so to speak. Today, though, by changing the properties of the lights that go through the endoscope, we can mimic what could have been achieved by the dye. Either the endoscopy lights have changed, or we're using some kind of computer software to process the image, so in the end you highlight the gland or the abnormality, and you get a better diagnosis.”

According to the guidelines, available data support the use of IEE in the detection and treatment of early squamous cell carcinoma of the esophagus, early gastric cancer, and superficial colorectal lesions.

The guidelines also state that the use of Lugol's solution “may improve the endoscopic visualization of high-grade dysplasia and early squamous cell carcinoma of the esophagus, and thus may be considered [for use] in high-risk patient populations.”

Diluted indigo carmine solution can be helpful in the diagnosis and treatment of early gastric cancer because it “pools at the border of the lesion and thus enhances visualization of these lesions, which are most often nonpolypoid. By pooling into the depression or ulceration of the lesion, the solution aids in the classification of the morphology, which in turn is important in the medical decision making of treatment strategy.”

Equipment-based advances in endoscopic imaging continue to evolve and enhance visualization, including devices that use manipulations of the light source or captured light.

Other approaches being studied include narrow-band imaging, which uses a narrow light source to enhance visualization of the surface microvessels; spectral estimation technologies, which use computerized processing to convert standard RGB (red, green, blue) signals from the endoscope's charged-coupled device; and autofluorescence imaging, which uses changes in concentrations of endogenous fluorophores.

The researchers also noted that high-resolution or high-definition endoscopes provide “a more detailed image of gastrointestinal mucosa, and high-magnification endoscopy enlarges the image up to 100×,” compared with 30× in standard endoscopy, which uses a 20-inch monitor. “At higher magnification with IEE, the visualized surface patterns of the gastrointestinal mucosa have been suggested to correlate well with the underlying histology.

“Proposed uses for high magnification used in conjunction with IEE include distinguishing neoplastic and nonneoplastic lesions, assessing depth of invasion in early colorectal carcinoma, and detecting minute tumor residue after endoscopic mucosal resection,” the authors said.

Potential barriers to the dissemination of IEE “include perceptions of its inefficiency and [high] cost, inadequate mechanism for reimbursement, lack of standardized training in techniques, and deficiency of high-quality comparison studies,” the researchers wrote.

Dr. Soetikno said that neither he nor his associates have any relevant financial relationships to disclose.

A brownish polypoid adenoma is clearly visualized with narrow-band imaging. ©American Society for Gastrointestinal Endoscopy