Sherry Boschert

SEATTLE — There is no standard way to screen for sleep apnea in patients with heart failure, but there are several screening models to choose from, Dr. Steven M. Scharf said at the annual meeting of the Heart Failure Society of America.

Sleep apnea commonly accompanies heart failure, and can be treated, though there's little high-quality evidence that treatment alters mortality or quality of life. Still, “you certainly should screen all your heart failure patients,” said Dr. Scharf, professor of medicine and director of the sleep disorders lab at the University of Maryland, Baltimore.

One good clinical screening tool is the Berlin Questionnaire, which asks about symptoms in three categories: excessive sleepiness or sleepiness while driving; wild, disturbing snoring or gasping; and either obesity or heart failure (Ann. Intern. Med. 1999;131:485–91). Primary care patients with symptoms from two of the three categories have a high risk for obstructive sleep apnea, but the sensitivity and specificity of the Berlin Questionnaire in patients with heart failure is unknown, he said.

Other screening schemes stratify patients by neck circumference, with larger necks increasing the risk for sleep apnea (N. Engl. J. Med. 2002;347:498–91). Various other scoring systems combine clinical findings such as male gender, body mass index, a snoring index, and a choking index to rate the likelihood of sleep apnea. Many of these screening models may be useful, Dr. Scharf suggested.

If a heart failure patient seems to have a high probability of having sleep apnea (perhaps based on the Berlin Questionnaire and neck circumference), schedule a full polysomnograph evaluation, he advised.

Consider doing overnight pulse oximetry testing in heart failure patients who don't meet your threshold for high risk for apnea, he added. A recent meta-analysis of 79 studies that used pulse oximetry for screening suggests that if you have a strong clinical suspicion for obstructive sleep apnea and testing shows fewer than 15 desaturations per hour, diagnostic polysomnography may be warranted (Chest 2001;120:625–33). With more than 15 desaturations/hour, a full evaluation for sleep apnea or treatment with titrated continuous positive airway pressure may be reasonable.

Two articles suggest that an algorithm assessing heart rate variability might help screen for apnea in heart failure patients, but practice parameters don't exist and would need to be developed, he said (Eur. Respir. J. 2006;27:571–7).

One small study suggests the PAT100 Watch, which measures peripheral arterial tone, also might help screen for sleep apnea. Portable polysomnography (outside sleep labs) is not recommended by the American Thoracic Society and other organizations.

Dr. Scharf has no affiliation with companies that sell the tools he discussed.

Patients with symptoms from two of the three Berlin Questionnaire categories are at high risk for apnea. DR. SCHARF

SEATTLE — There is no standard way to screen for sleep apnea in patients with heart failure, but there are several screening models to choose from, Dr. Steven M. Scharf said at the annual meeting of the Heart Failure Society of America.

Sleep apnea commonly accompanies heart failure, and can be treated, though there's little high-quality evidence that treatment alters mortality or quality of life. Still, “you certainly should screen all your heart failure patients,” said Dr. Scharf, professor of medicine and director of the sleep disorders lab at the University of Maryland, Baltimore.

One good clinical screening tool is the Berlin Questionnaire, which asks about symptoms in three categories: excessive sleepiness or sleepiness while driving; wild, disturbing snoring or gasping; and either obesity or heart failure (Ann. Intern. Med. 1999;131:485–91). Primary care patients with symptoms from two of the three categories have a high risk for obstructive sleep apnea, but the sensitivity and specificity of the Berlin Questionnaire in patients with heart failure is unknown, he said.

Other screening schemes stratify patients by neck circumference, with larger necks increasing the risk for sleep apnea (N. Engl. J. Med. 2002;347:498–91). Various other scoring systems combine clinical findings such as male gender, body mass index, a snoring index, and a choking index to rate the likelihood of sleep apnea. Many of these screening models may be useful, Dr. Scharf suggested.

If a heart failure patient seems to have a high probability of having sleep apnea (perhaps based on the Berlin Questionnaire and neck circumference), schedule a full polysomnograph evaluation, he advised.

Consider doing overnight pulse oximetry testing in heart failure patients who don't meet your threshold for high risk for apnea, he added. A recent meta-analysis of 79 studies that used pulse oximetry for screening suggests that if you have a strong clinical suspicion for obstructive sleep apnea and testing shows fewer than 15 desaturations per hour, diagnostic polysomnography may be warranted (Chest 2001;120:625–33). With more than 15 desaturations/hour, a full evaluation for sleep apnea or treatment with titrated continuous positive airway pressure may be reasonable.

Two articles suggest that an algorithm assessing heart rate variability might help screen for apnea in heart failure patients, but practice parameters don't exist and would need to be developed, he said (Eur. Respir. J. 2006;27:571–7).

One small study suggests the PAT100 Watch, which measures peripheral arterial tone, also might help screen for sleep apnea. Portable polysomnography (outside sleep labs) is not recommended by the American Thoracic Society and other organizations.

Dr. Scharf has no affiliation with companies that sell the tools he discussed.

Patients with symptoms from two of the three Berlin Questionnaire categories are at high risk for apnea. DR. SCHARF

SEATTLE — There is no standard way to screen for sleep apnea in patients with heart failure, but there are several screening models to choose from, Dr. Steven M. Scharf said at the annual meeting of the Heart Failure Society of America.

Sleep apnea commonly accompanies heart failure, and can be treated, though there's little high-quality evidence that treatment alters mortality or quality of life. Still, “you certainly should screen all your heart failure patients,” said Dr. Scharf, professor of medicine and director of the sleep disorders lab at the University of Maryland, Baltimore.

One good clinical screening tool is the Berlin Questionnaire, which asks about symptoms in three categories: excessive sleepiness or sleepiness while driving; wild, disturbing snoring or gasping; and either obesity or heart failure (Ann. Intern. Med. 1999;131:485–91). Primary care patients with symptoms from two of the three categories have a high risk for obstructive sleep apnea, but the sensitivity and specificity of the Berlin Questionnaire in patients with heart failure is unknown, he said.

Other screening schemes stratify patients by neck circumference, with larger necks increasing the risk for sleep apnea (N. Engl. J. Med. 2002;347:498–91). Various other scoring systems combine clinical findings such as male gender, body mass index, a snoring index, and a choking index to rate the likelihood of sleep apnea. Many of these screening models may be useful, Dr. Scharf suggested.

If a heart failure patient seems to have a high probability of having sleep apnea (perhaps based on the Berlin Questionnaire and neck circumference), schedule a full polysomnograph evaluation, he advised.

Consider doing overnight pulse oximetry testing in heart failure patients who don't meet your threshold for high risk for apnea, he added. A recent meta-analysis of 79 studies that used pulse oximetry for screening suggests that if you have a strong clinical suspicion for obstructive sleep apnea and testing shows fewer than 15 desaturations per hour, diagnostic polysomnography may be warranted (Chest 2001;120:625–33). With more than 15 desaturations/hour, a full evaluation for sleep apnea or treatment with titrated continuous positive airway pressure may be reasonable.

Two articles suggest that an algorithm assessing heart rate variability might help screen for apnea in heart failure patients, but practice parameters don't exist and would need to be developed, he said (Eur. Respir. J. 2006;27:571–7).

One small study suggests the PAT100 Watch, which measures peripheral arterial tone, also might help screen for sleep apnea. Portable polysomnography (outside sleep labs) is not recommended by the American Thoracic Society and other organizations.

Dr. Scharf has no affiliation with companies that sell the tools he discussed.

Patients with symptoms from two of the three Berlin Questionnaire categories are at high risk for apnea. DR. SCHARF

SEATTLE — Patients with heart failure or hypertension who answered “Yes” to at least two of three questions had a high likelihood of having obstructive sleep apnea, Cheryl L. Bartone reported in a poster presentation at the annual meeting of the Heart Failure Society of America.

Ms. Bartone and her associates compared responses to the screening questionnaire with polysomnography results (the preferred method for diagnosing obstructive sleep apnea) in 70 outpatients with heart failure or hypertension seen a cardiology office. The three-question tool was 90% sensitive and 45% specific in detecting obstructive sleep apnea, said Ms. Bartone of the Ohio Heart and Vascular Center, Cincinnati. The tool had a positive predictive value of 67% and a negative predictive value of 78%. Patients were asked:

▸ Do you snore loudly?

▸ Do you wake up more than once a night?

▸ Do you have morning fatigue?

Polysomnograms showed that 67 patients had some degree of obstructive sleep apnea, defined as an apnea-hypopnea index of 5 or greater. The obstructive sleep apnea was considered significant in 39 patients who had moderate or severe obstructive sleep apnea, defined as an apnea-hypopnea index of 20 or greater.

Of the 52 patients who answered “Yes” to at least two questions, 32 had significant obstructive sleep apnea. Of the 18 who answered “Yes” to only one or none of the questions, 4 had significant obstructive sleep apnea. Patients with significant obstructive sleep apnea were more likely to be on β-blockers than were those without significant obstructive sleep apnea (82% vs. 74%) and were less likely to be on an ACE inhibitor or angiotensin receptor blocker (74% vs. 77%). The investigators have no financial conflicts of interest in the study.

SEATTLE — Patients with heart failure or hypertension who answered “Yes” to at least two of three questions had a high likelihood of having obstructive sleep apnea, Cheryl L. Bartone reported in a poster presentation at the annual meeting of the Heart Failure Society of America.

Ms. Bartone and her associates compared responses to the screening questionnaire with polysomnography results (the preferred method for diagnosing obstructive sleep apnea) in 70 outpatients with heart failure or hypertension seen a cardiology office. The three-question tool was 90% sensitive and 45% specific in detecting obstructive sleep apnea, said Ms. Bartone of the Ohio Heart and Vascular Center, Cincinnati. The tool had a positive predictive value of 67% and a negative predictive value of 78%. Patients were asked:

▸ Do you snore loudly?

▸ Do you wake up more than once a night?

▸ Do you have morning fatigue?

Polysomnograms showed that 67 patients had some degree of obstructive sleep apnea, defined as an apnea-hypopnea index of 5 or greater. The obstructive sleep apnea was considered significant in 39 patients who had moderate or severe obstructive sleep apnea, defined as an apnea-hypopnea index of 20 or greater.

Of the 52 patients who answered “Yes” to at least two questions, 32 had significant obstructive sleep apnea. Of the 18 who answered “Yes” to only one or none of the questions, 4 had significant obstructive sleep apnea. Patients with significant obstructive sleep apnea were more likely to be on β-blockers than were those without significant obstructive sleep apnea (82% vs. 74%) and were less likely to be on an ACE inhibitor or angiotensin receptor blocker (74% vs. 77%). The investigators have no financial conflicts of interest in the study.

SEATTLE — Patients with heart failure or hypertension who answered “Yes” to at least two of three questions had a high likelihood of having obstructive sleep apnea, Cheryl L. Bartone reported in a poster presentation at the annual meeting of the Heart Failure Society of America.

Ms. Bartone and her associates compared responses to the screening questionnaire with polysomnography results (the preferred method for diagnosing obstructive sleep apnea) in 70 outpatients with heart failure or hypertension seen a cardiology office. The three-question tool was 90% sensitive and 45% specific in detecting obstructive sleep apnea, said Ms. Bartone of the Ohio Heart and Vascular Center, Cincinnati. The tool had a positive predictive value of 67% and a negative predictive value of 78%. Patients were asked:

▸ Do you snore loudly?

▸ Do you wake up more than once a night?

▸ Do you have morning fatigue?

Polysomnograms showed that 67 patients had some degree of obstructive sleep apnea, defined as an apnea-hypopnea index of 5 or greater. The obstructive sleep apnea was considered significant in 39 patients who had moderate or severe obstructive sleep apnea, defined as an apnea-hypopnea index of 20 or greater.

Of the 52 patients who answered “Yes” to at least two questions, 32 had significant obstructive sleep apnea. Of the 18 who answered “Yes” to only one or none of the questions, 4 had significant obstructive sleep apnea. Patients with significant obstructive sleep apnea were more likely to be on β-blockers than were those without significant obstructive sleep apnea (82% vs. 74%) and were less likely to be on an ACE inhibitor or angiotensin receptor blocker (74% vs. 77%). The investigators have no financial conflicts of interest in the study.

SAN FRANCISCO – A seven-bed care management unit in an emergency department reduced overcrowding by trimming the number of patients admitted to the hospital or waiting for telemetry beds, a pilot study of 1,325 patients found.

One factor in the national crisis of emergency department overcrowding is the slow transit of patients being admitted to the hospital. They often spend more than 24 hours in the emergency department, Dr. Varnada A. Karriem-Norwood said in a poster presentation at the annual meeting of the Society for Academic Emergency Medicine.

Dr. Karriem-Norwood and associates at Emory University, Atlanta, conducted a prospective study of patients admitted from the emergency department to a care management unit for asthma, chest pain, heart failure, or hyperglycemia between August 2003 and April 2004. Four case managers available in the unit 24 hours each day coordinated a care plan with a physician, educated patients, filled prescriptions, entered patient information into a database, arranged follow-up, and maintained phone contact with patients.

The care management unit successfully discharged about 87% of patients, admitted 13% to the hospital, and transferred three patients (less than 1%) back to the emergency department. The concept could be introduced at other hospitals, the investigators said.

SAN FRANCISCO – A seven-bed care management unit in an emergency department reduced overcrowding by trimming the number of patients admitted to the hospital or waiting for telemetry beds, a pilot study of 1,325 patients found.

One factor in the national crisis of emergency department overcrowding is the slow transit of patients being admitted to the hospital. They often spend more than 24 hours in the emergency department, Dr. Varnada A. Karriem-Norwood said in a poster presentation at the annual meeting of the Society for Academic Emergency Medicine.

Dr. Karriem-Norwood and associates at Emory University, Atlanta, conducted a prospective study of patients admitted from the emergency department to a care management unit for asthma, chest pain, heart failure, or hyperglycemia between August 2003 and April 2004. Four case managers available in the unit 24 hours each day coordinated a care plan with a physician, educated patients, filled prescriptions, entered patient information into a database, arranged follow-up, and maintained phone contact with patients.

The care management unit successfully discharged about 87% of patients, admitted 13% to the hospital, and transferred three patients (less than 1%) back to the emergency department. The concept could be introduced at other hospitals, the investigators said.

SAN FRANCISCO – A seven-bed care management unit in an emergency department reduced overcrowding by trimming the number of patients admitted to the hospital or waiting for telemetry beds, a pilot study of 1,325 patients found.

One factor in the national crisis of emergency department overcrowding is the slow transit of patients being admitted to the hospital. They often spend more than 24 hours in the emergency department, Dr. Varnada A. Karriem-Norwood said in a poster presentation at the annual meeting of the Society for Academic Emergency Medicine.

Dr. Karriem-Norwood and associates at Emory University, Atlanta, conducted a prospective study of patients admitted from the emergency department to a care management unit for asthma, chest pain, heart failure, or hyperglycemia between August 2003 and April 2004. Four case managers available in the unit 24 hours each day coordinated a care plan with a physician, educated patients, filled prescriptions, entered patient information into a database, arranged follow-up, and maintained phone contact with patients.

The care management unit successfully discharged about 87% of patients, admitted 13% to the hospital, and transferred three patients (less than 1%) back to the emergency department. The concept could be introduced at other hospitals, the investigators said.

SAN FRANCISCO — Tigecycline appeared to be comparable in efficacy and tolerability to levofloxacin in treating community-acquired pneumonia in two phase III studies of 891 hospitalized patients needing intravenous therapy, Dr. Gary Dukart reported in a poster presentation at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

If approved, tigecycline would be the first glycylcycline available to treat pneumonia, said Dr. Dukart of Wyeth Research, Collegeville, Pa., and his associates. Wyeth markets the drug, which is approved in 40 countries including the United States, for treating complicated intra-abdominal infections and complicated skin and skin structure infections. Tigecycline is a broad-spectrum antibiotic with in vitro activity against gram-positive, gram-negative, anaerobic, and atypical bacteria, including some resistant strains.

A separate study of tigecycline therapy for hospital-acquired pneumonia is ongoing. Once that is complete, the company plans to apply in 2007 for approval of tigecycline to treat community or hospital-acquired pneumonias, he said.

Patients in the multicenter, double-blind studies of community-acquired pneumonia were randomized to 7–10 days of intravenous tigecycline (100 mg initially, then 50 mg every 12 hours) or intravenous levofloxacin. Levofloxacin dosages differed in the two trials: In one, patients received 500 mg every 24 hours; in the other, they got 500 mg every 12 or 24 hours at the discretion of the physician and based on local practice. In one trial, patients who showed improvements could be switched after at least 3 days of intravenous therapy to oral levofloxacin for the duration of therapy.

The mean duration of treatment in both groups was 10 days. The mean hospital stay in both groups was 6 days.

Among 846 patients who received at least one dose of medication (a modified intent-to-treat population), 81% on tigecycline and 80% on levofloxacin were considered cured. Among 574 “evaluable” patients assessed for cure between 7 and 23 days after the last dose of medication, 90% in the tigecycline group and 86% in the levofloxacin group were cured. The differences between groups were not significant.

Among 40 patients with pneumonia due to documented Streptococcus pneumoniae infection, tigecycline cured 20 (91%) of 22 patients and levofloxacin cured 13 (72%) of 18.

The rate of drug discontinuation because of side effects did not differ significantly between groups—6% with tigecycline and 8% with levofloxacin. Serious adverse events occurred in 10% with tigecycline and 11% with levofloxacin. In each group, 3% of patients died, but the deaths were not considered related to the drugs.

Drug-related adverse events affected 48% on tigecycline and 37% on levofloxacin, a significant difference. A significantly greater proportion of patients in the tigecycline group experienced nausea or vomiting (24% and 16%, respectively), compared with the levofloxacin group (6% and 3%). Patients in the tigecycline group were significantly less likely to have elevated ALT or AST levels (3% and 2%), compared with the levofloxacin group (6% and 6%).

Other common side effects were comparable between groups and included diarrhea, phlebitis, or headache in 3%–8% of patients.

The studies excluded patients needing ICU care at the time of randomization, patients hospitalized in the previous 2 weeks, residents of long-term care facilities for longer than 2 weeks, and patients with known or suspected Pseudomonas aeruginosa infection, active tuberculosis, or Legionella pneumonia.

About 6 million Americans get community-acquired pneumonia each year, leading to 1 million hospitalizations annually. About 12% of patients hospitalized for the disease die.

The conference was sponsored by the American Society for Microbiology.

SAN FRANCISCO — Tigecycline appeared to be comparable in efficacy and tolerability to levofloxacin in treating community-acquired pneumonia in two phase III studies of 891 hospitalized patients needing intravenous therapy, Dr. Gary Dukart reported in a poster presentation at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

If approved, tigecycline would be the first glycylcycline available to treat pneumonia, said Dr. Dukart of Wyeth Research, Collegeville, Pa., and his associates. Wyeth markets the drug, which is approved in 40 countries including the United States, for treating complicated intra-abdominal infections and complicated skin and skin structure infections. Tigecycline is a broad-spectrum antibiotic with in vitro activity against gram-positive, gram-negative, anaerobic, and atypical bacteria, including some resistant strains.

A separate study of tigecycline therapy for hospital-acquired pneumonia is ongoing. Once that is complete, the company plans to apply in 2007 for approval of tigecycline to treat community or hospital-acquired pneumonias, he said.

Patients in the multicenter, double-blind studies of community-acquired pneumonia were randomized to 7–10 days of intravenous tigecycline (100 mg initially, then 50 mg every 12 hours) or intravenous levofloxacin. Levofloxacin dosages differed in the two trials: In one, patients received 500 mg every 24 hours; in the other, they got 500 mg every 12 or 24 hours at the discretion of the physician and based on local practice. In one trial, patients who showed improvements could be switched after at least 3 days of intravenous therapy to oral levofloxacin for the duration of therapy.

The mean duration of treatment in both groups was 10 days. The mean hospital stay in both groups was 6 days.

Among 846 patients who received at least one dose of medication (a modified intent-to-treat population), 81% on tigecycline and 80% on levofloxacin were considered cured. Among 574 “evaluable” patients assessed for cure between 7 and 23 days after the last dose of medication, 90% in the tigecycline group and 86% in the levofloxacin group were cured. The differences between groups were not significant.

Among 40 patients with pneumonia due to documented Streptococcus pneumoniae infection, tigecycline cured 20 (91%) of 22 patients and levofloxacin cured 13 (72%) of 18.

The rate of drug discontinuation because of side effects did not differ significantly between groups—6% with tigecycline and 8% with levofloxacin. Serious adverse events occurred in 10% with tigecycline and 11% with levofloxacin. In each group, 3% of patients died, but the deaths were not considered related to the drugs.

Drug-related adverse events affected 48% on tigecycline and 37% on levofloxacin, a significant difference. A significantly greater proportion of patients in the tigecycline group experienced nausea or vomiting (24% and 16%, respectively), compared with the levofloxacin group (6% and 3%). Patients in the tigecycline group were significantly less likely to have elevated ALT or AST levels (3% and 2%), compared with the levofloxacin group (6% and 6%).

Other common side effects were comparable between groups and included diarrhea, phlebitis, or headache in 3%–8% of patients.

The studies excluded patients needing ICU care at the time of randomization, patients hospitalized in the previous 2 weeks, residents of long-term care facilities for longer than 2 weeks, and patients with known or suspected Pseudomonas aeruginosa infection, active tuberculosis, or Legionella pneumonia.

About 6 million Americans get community-acquired pneumonia each year, leading to 1 million hospitalizations annually. About 12% of patients hospitalized for the disease die.

The conference was sponsored by the American Society for Microbiology.

SAN FRANCISCO — Tigecycline appeared to be comparable in efficacy and tolerability to levofloxacin in treating community-acquired pneumonia in two phase III studies of 891 hospitalized patients needing intravenous therapy, Dr. Gary Dukart reported in a poster presentation at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

If approved, tigecycline would be the first glycylcycline available to treat pneumonia, said Dr. Dukart of Wyeth Research, Collegeville, Pa., and his associates. Wyeth markets the drug, which is approved in 40 countries including the United States, for treating complicated intra-abdominal infections and complicated skin and skin structure infections. Tigecycline is a broad-spectrum antibiotic with in vitro activity against gram-positive, gram-negative, anaerobic, and atypical bacteria, including some resistant strains.

A separate study of tigecycline therapy for hospital-acquired pneumonia is ongoing. Once that is complete, the company plans to apply in 2007 for approval of tigecycline to treat community or hospital-acquired pneumonias, he said.

Patients in the multicenter, double-blind studies of community-acquired pneumonia were randomized to 7–10 days of intravenous tigecycline (100 mg initially, then 50 mg every 12 hours) or intravenous levofloxacin. Levofloxacin dosages differed in the two trials: In one, patients received 500 mg every 24 hours; in the other, they got 500 mg every 12 or 24 hours at the discretion of the physician and based on local practice. In one trial, patients who showed improvements could be switched after at least 3 days of intravenous therapy to oral levofloxacin for the duration of therapy.

The mean duration of treatment in both groups was 10 days. The mean hospital stay in both groups was 6 days.

Among 846 patients who received at least one dose of medication (a modified intent-to-treat population), 81% on tigecycline and 80% on levofloxacin were considered cured. Among 574 “evaluable” patients assessed for cure between 7 and 23 days after the last dose of medication, 90% in the tigecycline group and 86% in the levofloxacin group were cured. The differences between groups were not significant.

Among 40 patients with pneumonia due to documented Streptococcus pneumoniae infection, tigecycline cured 20 (91%) of 22 patients and levofloxacin cured 13 (72%) of 18.

The rate of drug discontinuation because of side effects did not differ significantly between groups—6% with tigecycline and 8% with levofloxacin. Serious adverse events occurred in 10% with tigecycline and 11% with levofloxacin. In each group, 3% of patients died, but the deaths were not considered related to the drugs.

Drug-related adverse events affected 48% on tigecycline and 37% on levofloxacin, a significant difference. A significantly greater proportion of patients in the tigecycline group experienced nausea or vomiting (24% and 16%, respectively), compared with the levofloxacin group (6% and 3%). Patients in the tigecycline group were significantly less likely to have elevated ALT or AST levels (3% and 2%), compared with the levofloxacin group (6% and 6%).

Other common side effects were comparable between groups and included diarrhea, phlebitis, or headache in 3%–8% of patients.

The studies excluded patients needing ICU care at the time of randomization, patients hospitalized in the previous 2 weeks, residents of long-term care facilities for longer than 2 weeks, and patients with known or suspected Pseudomonas aeruginosa infection, active tuberculosis, or Legionella pneumonia.

About 6 million Americans get community-acquired pneumonia each year, leading to 1 million hospitalizations annually. About 12% of patients hospitalized for the disease die.

The conference was sponsored by the American Society for Microbiology.

WINNIPEG, MAN. — Some residency programs have increased efforts to teach ethics to young dermatologists.

At Brown University in Providence, R.I., and the University of Cincinnati, the increased focus on ethics grew out of the personal interests of leaders at both institutions.

The American College of Graduate Medical Education (ACGME) states that residents must meet six general requirements, one of which is professionalism. The ACGME has no specific didactic course work requirements or verification procedures related to professionalism, however, and few dermatology residencies offer much formal training in bioethics or professionalism, said Dr. Lionel Bercovitch of Brown University.

"Those of us in practice, and residents and trainees, encounter ethical issues from the minute we walk into the office to the time we leave," he noted at the annual conference of the Canadian Dermatology Association.

Dr. Bercovitch and his associates, seeking to go beyond issues of industry gifts to physicians, instituted a curriculum in biomedical ethics and professionalism in 2001 that sought to cover a broader range of topics in ethics. (See box.)

They designed it specifically for dermatology trainees, skipping some topics that apply more directly to other specialties—such as end-of-life care or euthanasia—and including topics like cosmeceutical dispensing that might not be addressed in conventional medical ethics courses.

Once or twice a month, dermatology residents are required to attend a dinner, funded by the university, to discuss a topic in ethics after reviewing as many as 30 papers or articles related to the topic that are chosen in advance by the course leader and a resident assistant.

"These are not bull sessions. Residents are expected to come and be prepared to defend their views after a review of the literature," Dr. Bercovitch said.

The topic of cosmetic dermatology generated so much interest and debate that it was extended to two sessions.

The lively discussions are key to the seminar's success, said Dr. Katherine Brown, a resident at the university, in a phone interview. "Since you're among close colleagues and friends, you can say what's on your mind and ask questions that, in another forum, you would not feel comfortable to ask," she noted. "It needs to be a discussion, not a lecture. Make sure all of the voices are heard and no one person takes over."

Dr. Priya Zeikus, formerly a resident at Brown and now a Mohs surgery fellow at the Lahey Clinic in Boston, said that—although the busy, exhausted residents did not like having to plow through the required reading and attend the ethics sessions after a long workday—it did add to their education by addressing ethical issues not covered in medical school, such as cosmeceutical dispensing.

"Looking back on it, it certainly did raise issues that I didn't think of as ethical issues previously," she said in a phone interview.

Dermatology residents traditionally get a good deal of ethics training, but it does not necessarily occur in a conventional class setting, said Dr. Jorge Garcia-Zuazaga, chair of the American Academy of Dermatology's Residents and Fellows Committee and a resident at Case Western Reserve University Hospital, Cleveland.

At his institution, all dermatology residents are required to complete a 6-hour computer-based lecture series that includes medical ethics, professionalism, and professional conduct.

Also, residents learn the ethics of the profession through the day-to-day role modeling of faculty members; feedback from nurses and clinical support staff; regular evaluations; grand rounds discussions; and journal clubs, he said in a phone interview.

The AAD posts several policies on ethics on its Web site and has compiled principles of professional conduct, Dr. Garcia-Zuazaga added.

Without a more focused effort to discuss ethics, however, many dermatology residents mistakenly assume that, because they are good people, their actions are ethical, said Dr. Diya F. Mutasim, professor and chair of dermatology at the University of Cincinnati.

A discussion at one of his department's annual retreats with its residents moved him to increase teaching around ethics. Residents at the retreat believed one could simply tell who is an ethical person.

"They don't realize ethics is not an either/or thing. It's more complex," he said. "It's something fluid" that relates to situations, not just the person.

He now leads discussions on ethics, professionalism, humanities, and other topics about once a month during the Thursday morning grand rounds time slot. Residents and faculty attend and are asked to have read two or three papers and articles on the topic beforehand.

The residents have taken to it enthusiastically. "Because they're not graded on it, and it's not on board exams, they sit and relax," Dr. Mutasim said.

At a session on balancing professional and personal lives, residents opened up about their own difficulties. "Usually I discuss this when I meet with them for evaluations, but that's sort of threatening for them," he noted.

At a recent session on sexual harassment in medical school, the discussion became "extremely heated, almost like a psychotherapy session," he added.

All but 2 of the 11 women in the residency program, and one male resident, said they had been treated differently in medical school because of their sex, either in the form of bias or inappropriate behavior.

A discussion about the effect of pharmaceutical representatives on physician practice ultimately led to a new policy being implemented at the University of Cincinnati that limits contact between drug reps and residents.

Brown University also limits contacts and gifts from drug reps, but the same policies do not apply to attending physicians and doctors associated with the institution, Dr. Bercovitch noted, and "the residents rightly feel this is a double standard."

Examining the contradictions and ethical gray areas of medical practice fosters the critical thinking needed for ethical medical practice, Dr. Mutasim emphasized.

Ethical Concerns' Widening Reach

The first thing that comes to mind for many people when they think of ethical issues in medicine tends to be physicians' interaction with the pharmaceutical industry—particularly the acceptance of gifts or funding, and the disclosure of these relationships.

There are many more ethical issues that practicing physicians, residents, and medical students face on a daily basis that make good topics for teaching, Dr. Bercovitch said. These include:

▸ Informed consent.

▸ Patient autonomy.

▸ The dispensing of drug samples.

▸ Cosmetic dermatology.

▸ The dispensing of cosmeceuticals.

▸ Advertising.

▸ Coding and billing issues.

▸ Management of children and other vulnerable populations.

▸ Privacy and confidentiality of medical records.

▸ Physician mental health and substance abuse.

▸ Management of medical errors.

▸ Treatment of sexually transmitted diseases.

▸ Management of emancipated minors.

▸ The trainee's role with superiors and subordinates.

▸ Ethics of the residency match system.

▸ Research ethics.

▸ Publication issues for writers, reviewers, and editors.

▸ Gene testing and gene therapy.

WINNIPEG, MAN. — Some residency programs have increased efforts to teach ethics to young dermatologists.

At Brown University in Providence, R.I., and the University of Cincinnati, the increased focus on ethics grew out of the personal interests of leaders at both institutions.

The American College of Graduate Medical Education (ACGME) states that residents must meet six general requirements, one of which is professionalism. The ACGME has no specific didactic course work requirements or verification procedures related to professionalism, however, and few dermatology residencies offer much formal training in bioethics or professionalism, said Dr. Lionel Bercovitch of Brown University.

"Those of us in practice, and residents and trainees, encounter ethical issues from the minute we walk into the office to the time we leave," he noted at the annual conference of the Canadian Dermatology Association.

Dr. Bercovitch and his associates, seeking to go beyond issues of industry gifts to physicians, instituted a curriculum in biomedical ethics and professionalism in 2001 that sought to cover a broader range of topics in ethics. (See box.)

They designed it specifically for dermatology trainees, skipping some topics that apply more directly to other specialties—such as end-of-life care or euthanasia—and including topics like cosmeceutical dispensing that might not be addressed in conventional medical ethics courses.

Once or twice a month, dermatology residents are required to attend a dinner, funded by the university, to discuss a topic in ethics after reviewing as many as 30 papers or articles related to the topic that are chosen in advance by the course leader and a resident assistant.

"These are not bull sessions. Residents are expected to come and be prepared to defend their views after a review of the literature," Dr. Bercovitch said.

The topic of cosmetic dermatology generated so much interest and debate that it was extended to two sessions.

The lively discussions are key to the seminar's success, said Dr. Katherine Brown, a resident at the university, in a phone interview. "Since you're among close colleagues and friends, you can say what's on your mind and ask questions that, in another forum, you would not feel comfortable to ask," she noted. "It needs to be a discussion, not a lecture. Make sure all of the voices are heard and no one person takes over."

Dr. Priya Zeikus, formerly a resident at Brown and now a Mohs surgery fellow at the Lahey Clinic in Boston, said that—although the busy, exhausted residents did not like having to plow through the required reading and attend the ethics sessions after a long workday—it did add to their education by addressing ethical issues not covered in medical school, such as cosmeceutical dispensing.

"Looking back on it, it certainly did raise issues that I didn't think of as ethical issues previously," she said in a phone interview.

Dermatology residents traditionally get a good deal of ethics training, but it does not necessarily occur in a conventional class setting, said Dr. Jorge Garcia-Zuazaga, chair of the American Academy of Dermatology's Residents and Fellows Committee and a resident at Case Western Reserve University Hospital, Cleveland.

At his institution, all dermatology residents are required to complete a 6-hour computer-based lecture series that includes medical ethics, professionalism, and professional conduct.

Also, residents learn the ethics of the profession through the day-to-day role modeling of faculty members; feedback from nurses and clinical support staff; regular evaluations; grand rounds discussions; and journal clubs, he said in a phone interview.

The AAD posts several policies on ethics on its Web site and has compiled principles of professional conduct, Dr. Garcia-Zuazaga added.

Without a more focused effort to discuss ethics, however, many dermatology residents mistakenly assume that, because they are good people, their actions are ethical, said Dr. Diya F. Mutasim, professor and chair of dermatology at the University of Cincinnati.

A discussion at one of his department's annual retreats with its residents moved him to increase teaching around ethics. Residents at the retreat believed one could simply tell who is an ethical person.

"They don't realize ethics is not an either/or thing. It's more complex," he said. "It's something fluid" that relates to situations, not just the person.

He now leads discussions on ethics, professionalism, humanities, and other topics about once a month during the Thursday morning grand rounds time slot. Residents and faculty attend and are asked to have read two or three papers and articles on the topic beforehand.

The residents have taken to it enthusiastically. "Because they're not graded on it, and it's not on board exams, they sit and relax," Dr. Mutasim said.

At a session on balancing professional and personal lives, residents opened up about their own difficulties. "Usually I discuss this when I meet with them for evaluations, but that's sort of threatening for them," he noted.

At a recent session on sexual harassment in medical school, the discussion became "extremely heated, almost like a psychotherapy session," he added.

All but 2 of the 11 women in the residency program, and one male resident, said they had been treated differently in medical school because of their sex, either in the form of bias or inappropriate behavior.

A discussion about the effect of pharmaceutical representatives on physician practice ultimately led to a new policy being implemented at the University of Cincinnati that limits contact between drug reps and residents.

Brown University also limits contacts and gifts from drug reps, but the same policies do not apply to attending physicians and doctors associated with the institution, Dr. Bercovitch noted, and "the residents rightly feel this is a double standard."

Examining the contradictions and ethical gray areas of medical practice fosters the critical thinking needed for ethical medical practice, Dr. Mutasim emphasized.

Ethical Concerns' Widening Reach

The first thing that comes to mind for many people when they think of ethical issues in medicine tends to be physicians' interaction with the pharmaceutical industry—particularly the acceptance of gifts or funding, and the disclosure of these relationships.

There are many more ethical issues that practicing physicians, residents, and medical students face on a daily basis that make good topics for teaching, Dr. Bercovitch said. These include:

▸ Informed consent.

▸ Patient autonomy.

▸ The dispensing of drug samples.

▸ Cosmetic dermatology.

▸ The dispensing of cosmeceuticals.

▸ Advertising.

▸ Coding and billing issues.

▸ Management of children and other vulnerable populations.

▸ Privacy and confidentiality of medical records.

▸ Physician mental health and substance abuse.

▸ Management of medical errors.

▸ Treatment of sexually transmitted diseases.

▸ Management of emancipated minors.

▸ The trainee's role with superiors and subordinates.

▸ Ethics of the residency match system.

▸ Research ethics.

▸ Publication issues for writers, reviewers, and editors.

▸ Gene testing and gene therapy.

WINNIPEG, MAN. — Some residency programs have increased efforts to teach ethics to young dermatologists.

At Brown University in Providence, R.I., and the University of Cincinnati, the increased focus on ethics grew out of the personal interests of leaders at both institutions.

The American College of Graduate Medical Education (ACGME) states that residents must meet six general requirements, one of which is professionalism. The ACGME has no specific didactic course work requirements or verification procedures related to professionalism, however, and few dermatology residencies offer much formal training in bioethics or professionalism, said Dr. Lionel Bercovitch of Brown University.

"Those of us in practice, and residents and trainees, encounter ethical issues from the minute we walk into the office to the time we leave," he noted at the annual conference of the Canadian Dermatology Association.

Dr. Bercovitch and his associates, seeking to go beyond issues of industry gifts to physicians, instituted a curriculum in biomedical ethics and professionalism in 2001 that sought to cover a broader range of topics in ethics. (See box.)

They designed it specifically for dermatology trainees, skipping some topics that apply more directly to other specialties—such as end-of-life care or euthanasia—and including topics like cosmeceutical dispensing that might not be addressed in conventional medical ethics courses.

Once or twice a month, dermatology residents are required to attend a dinner, funded by the university, to discuss a topic in ethics after reviewing as many as 30 papers or articles related to the topic that are chosen in advance by the course leader and a resident assistant.

"These are not bull sessions. Residents are expected to come and be prepared to defend their views after a review of the literature," Dr. Bercovitch said.

The topic of cosmetic dermatology generated so much interest and debate that it was extended to two sessions.

The lively discussions are key to the seminar's success, said Dr. Katherine Brown, a resident at the university, in a phone interview. "Since you're among close colleagues and friends, you can say what's on your mind and ask questions that, in another forum, you would not feel comfortable to ask," she noted. "It needs to be a discussion, not a lecture. Make sure all of the voices are heard and no one person takes over."

Dr. Priya Zeikus, formerly a resident at Brown and now a Mohs surgery fellow at the Lahey Clinic in Boston, said that—although the busy, exhausted residents did not like having to plow through the required reading and attend the ethics sessions after a long workday—it did add to their education by addressing ethical issues not covered in medical school, such as cosmeceutical dispensing.

"Looking back on it, it certainly did raise issues that I didn't think of as ethical issues previously," she said in a phone interview.

Dermatology residents traditionally get a good deal of ethics training, but it does not necessarily occur in a conventional class setting, said Dr. Jorge Garcia-Zuazaga, chair of the American Academy of Dermatology's Residents and Fellows Committee and a resident at Case Western Reserve University Hospital, Cleveland.

At his institution, all dermatology residents are required to complete a 6-hour computer-based lecture series that includes medical ethics, professionalism, and professional conduct.

Also, residents learn the ethics of the profession through the day-to-day role modeling of faculty members; feedback from nurses and clinical support staff; regular evaluations; grand rounds discussions; and journal clubs, he said in a phone interview.

The AAD posts several policies on ethics on its Web site and has compiled principles of professional conduct, Dr. Garcia-Zuazaga added.

Without a more focused effort to discuss ethics, however, many dermatology residents mistakenly assume that, because they are good people, their actions are ethical, said Dr. Diya F. Mutasim, professor and chair of dermatology at the University of Cincinnati.

A discussion at one of his department's annual retreats with its residents moved him to increase teaching around ethics. Residents at the retreat believed one could simply tell who is an ethical person.

"They don't realize ethics is not an either/or thing. It's more complex," he said. "It's something fluid" that relates to situations, not just the person.

He now leads discussions on ethics, professionalism, humanities, and other topics about once a month during the Thursday morning grand rounds time slot. Residents and faculty attend and are asked to have read two or three papers and articles on the topic beforehand.

The residents have taken to it enthusiastically. "Because they're not graded on it, and it's not on board exams, they sit and relax," Dr. Mutasim said.

At a session on balancing professional and personal lives, residents opened up about their own difficulties. "Usually I discuss this when I meet with them for evaluations, but that's sort of threatening for them," he noted.

At a recent session on sexual harassment in medical school, the discussion became "extremely heated, almost like a psychotherapy session," he added.

All but 2 of the 11 women in the residency program, and one male resident, said they had been treated differently in medical school because of their sex, either in the form of bias or inappropriate behavior.

A discussion about the effect of pharmaceutical representatives on physician practice ultimately led to a new policy being implemented at the University of Cincinnati that limits contact between drug reps and residents.

Brown University also limits contacts and gifts from drug reps, but the same policies do not apply to attending physicians and doctors associated with the institution, Dr. Bercovitch noted, and "the residents rightly feel this is a double standard."

Examining the contradictions and ethical gray areas of medical practice fosters the critical thinking needed for ethical medical practice, Dr. Mutasim emphasized.

Ethical Concerns' Widening Reach

The first thing that comes to mind for many people when they think of ethical issues in medicine tends to be physicians' interaction with the pharmaceutical industry—particularly the acceptance of gifts or funding, and the disclosure of these relationships.

There are many more ethical issues that practicing physicians, residents, and medical students face on a daily basis that make good topics for teaching, Dr. Bercovitch said. These include:

▸ Informed consent.

▸ Patient autonomy.

▸ The dispensing of drug samples.

▸ Cosmetic dermatology.

▸ The dispensing of cosmeceuticals.

▸ Advertising.

▸ Coding and billing issues.

▸ Management of children and other vulnerable populations.

▸ Privacy and confidentiality of medical records.

▸ Physician mental health and substance abuse.

▸ Management of medical errors.

▸ Treatment of sexually transmitted diseases.

▸ Management of emancipated minors.

▸ The trainee's role with superiors and subordinates.

▸ Ethics of the residency match system.

▸ Research ethics.

▸ Publication issues for writers, reviewers, and editors.

▸ Gene testing and gene therapy.

MONTEREY, CALIF. — Development of new treatments for Crohn's disease or ulcerative colitis has generally focused on immunomodulators, cytokine therapy, and other biotechnology, but lower-technology options are being tried as well, Dr. Joshua R. Korzenik said.

Probiotics, parasites, and fecal transplants each have shown some positive results, although none are ready for prime time, Dr. Korzenik said at an update in gastroenterology and hepatology sponsored by the University of California, Davis.

▸ Probiotics. Most study findings on the use of beneficial bacteria to treat inflammatory bowel disease have not supported this strategy, but one study of treating pouchitis produced positive results.

The study included 40 patients who were treated for ulcerative colitis with colectomy and an ileoanal anastomosis (or J-pouch) operation and who subsequently developed a chronic inflammatory process, a problem occuring in about 15% of J-pouches. Antibiotics can control the pouchitis, but long term they are not ideal.

The researchers brought the patients' pouchitis into remission with antibiotics, then discontinued the antibiotic therapy and randomized 20 patients to a potent probiotic called VSL#3 and assigned another 20 patients to placebo. The pouchitis returned in all of the patients on placebo by 5 months later, but 17 patients in the probiotic group remained in remission 9 months after starting therapy (Gastroenterology 2000;119:305).

Typical probiotics found in health food stores contain between 1 and 20 billion bacteria per gram. VSL#3, which is sold over the Internet, contains about 1.6 trillion bacteria per gram, and patients in the study took three capsules a day. “You're still talking about relatively small potatoes,” compared with the 100 billion to 1 trillion bacteria in each gram of stool, said Dr. Korzenik, codirector of the Crohn's and Colitis Center at Massachusetts General Hospital, Boston, noted.

The VSL#3 treatment regimen costs about $12–$15 per day and is not covered by insurance.

▸ Parasites. Some researchers have speculated that the modern zeal for cleanliness eliminated helminth ova (infectious parasite eggs) from humans, and that this contributes to the development of Crohn's disease and ulcerative colitis. Reintroducing these to the body might help treat these diseases, Dr. Korzenik.

In one open-label study, 29 patients with active Crohn's disease took 2,500 Trichuris suis (pig whipworm) ova every 3 weeks for 24 weeks (Gut 2005;54:87–90). The disease responded to the treatment in 79% of the patients, and 72% of them achieved remission. “The results are almost too good to be true, but it's promising,” he said.

A separate placebo-controlled trial in patients with ulcerative colitis showed marginal benefit.

The ova are sold from Europe over the Internet as an expensive product called TSO. “I suggested it be called Ova the Counter,” he joked. The Food and Drug Administration is considering whether sales should be regulated.

▸ Fecal transplants. This treatment, also called “human probiotics” because the implanted bacteria come from donor stool, is modeled after fecal enemas used to treat some patients with refractory Clostridium difficile infection to reestablish normal flora.

In an open-label study of six patients with long-standing ulcerative colitis who received daily infusions for 1 week, all had improvement in symptoms (J. Clin. Gastroenterol. 2003;37:42–7).

MONTEREY, CALIF. — Development of new treatments for Crohn's disease or ulcerative colitis has generally focused on immunomodulators, cytokine therapy, and other biotechnology, but lower-technology options are being tried as well, Dr. Joshua R. Korzenik said.

Probiotics, parasites, and fecal transplants each have shown some positive results, although none are ready for prime time, Dr. Korzenik said at an update in gastroenterology and hepatology sponsored by the University of California, Davis.

▸ Probiotics. Most study findings on the use of beneficial bacteria to treat inflammatory bowel disease have not supported this strategy, but one study of treating pouchitis produced positive results.

The study included 40 patients who were treated for ulcerative colitis with colectomy and an ileoanal anastomosis (or J-pouch) operation and who subsequently developed a chronic inflammatory process, a problem occuring in about 15% of J-pouches. Antibiotics can control the pouchitis, but long term they are not ideal.

The researchers brought the patients' pouchitis into remission with antibiotics, then discontinued the antibiotic therapy and randomized 20 patients to a potent probiotic called VSL#3 and assigned another 20 patients to placebo. The pouchitis returned in all of the patients on placebo by 5 months later, but 17 patients in the probiotic group remained in remission 9 months after starting therapy (Gastroenterology 2000;119:305).

Typical probiotics found in health food stores contain between 1 and 20 billion bacteria per gram. VSL#3, which is sold over the Internet, contains about 1.6 trillion bacteria per gram, and patients in the study took three capsules a day. “You're still talking about relatively small potatoes,” compared with the 100 billion to 1 trillion bacteria in each gram of stool, said Dr. Korzenik, codirector of the Crohn's and Colitis Center at Massachusetts General Hospital, Boston, noted.

The VSL#3 treatment regimen costs about $12–$15 per day and is not covered by insurance.

▸ Parasites. Some researchers have speculated that the modern zeal for cleanliness eliminated helminth ova (infectious parasite eggs) from humans, and that this contributes to the development of Crohn's disease and ulcerative colitis. Reintroducing these to the body might help treat these diseases, Dr. Korzenik.

In one open-label study, 29 patients with active Crohn's disease took 2,500 Trichuris suis (pig whipworm) ova every 3 weeks for 24 weeks (Gut 2005;54:87–90). The disease responded to the treatment in 79% of the patients, and 72% of them achieved remission. “The results are almost too good to be true, but it's promising,” he said.

A separate placebo-controlled trial in patients with ulcerative colitis showed marginal benefit.

The ova are sold from Europe over the Internet as an expensive product called TSO. “I suggested it be called Ova the Counter,” he joked. The Food and Drug Administration is considering whether sales should be regulated.

▸ Fecal transplants. This treatment, also called “human probiotics” because the implanted bacteria come from donor stool, is modeled after fecal enemas used to treat some patients with refractory Clostridium difficile infection to reestablish normal flora.

In an open-label study of six patients with long-standing ulcerative colitis who received daily infusions for 1 week, all had improvement in symptoms (J. Clin. Gastroenterol. 2003;37:42–7).

MONTEREY, CALIF. — Development of new treatments for Crohn's disease or ulcerative colitis has generally focused on immunomodulators, cytokine therapy, and other biotechnology, but lower-technology options are being tried as well, Dr. Joshua R. Korzenik said.

Probiotics, parasites, and fecal transplants each have shown some positive results, although none are ready for prime time, Dr. Korzenik said at an update in gastroenterology and hepatology sponsored by the University of California, Davis.

▸ Probiotics. Most study findings on the use of beneficial bacteria to treat inflammatory bowel disease have not supported this strategy, but one study of treating pouchitis produced positive results.

The study included 40 patients who were treated for ulcerative colitis with colectomy and an ileoanal anastomosis (or J-pouch) operation and who subsequently developed a chronic inflammatory process, a problem occuring in about 15% of J-pouches. Antibiotics can control the pouchitis, but long term they are not ideal.

The researchers brought the patients' pouchitis into remission with antibiotics, then discontinued the antibiotic therapy and randomized 20 patients to a potent probiotic called VSL#3 and assigned another 20 patients to placebo. The pouchitis returned in all of the patients on placebo by 5 months later, but 17 patients in the probiotic group remained in remission 9 months after starting therapy (Gastroenterology 2000;119:305).

Typical probiotics found in health food stores contain between 1 and 20 billion bacteria per gram. VSL#3, which is sold over the Internet, contains about 1.6 trillion bacteria per gram, and patients in the study took three capsules a day. “You're still talking about relatively small potatoes,” compared with the 100 billion to 1 trillion bacteria in each gram of stool, said Dr. Korzenik, codirector of the Crohn's and Colitis Center at Massachusetts General Hospital, Boston, noted.

The VSL#3 treatment regimen costs about $12–$15 per day and is not covered by insurance.

▸ Parasites. Some researchers have speculated that the modern zeal for cleanliness eliminated helminth ova (infectious parasite eggs) from humans, and that this contributes to the development of Crohn's disease and ulcerative colitis. Reintroducing these to the body might help treat these diseases, Dr. Korzenik.

In one open-label study, 29 patients with active Crohn's disease took 2,500 Trichuris suis (pig whipworm) ova every 3 weeks for 24 weeks (Gut 2005;54:87–90). The disease responded to the treatment in 79% of the patients, and 72% of them achieved remission. “The results are almost too good to be true, but it's promising,” he said.

A separate placebo-controlled trial in patients with ulcerative colitis showed marginal benefit.

The ova are sold from Europe over the Internet as an expensive product called TSO. “I suggested it be called Ova the Counter,” he joked. The Food and Drug Administration is considering whether sales should be regulated.

▸ Fecal transplants. This treatment, also called “human probiotics” because the implanted bacteria come from donor stool, is modeled after fecal enemas used to treat some patients with refractory Clostridium difficile infection to reestablish normal flora.

In an open-label study of six patients with long-standing ulcerative colitis who received daily infusions for 1 week, all had improvement in symptoms (J. Clin. Gastroenterol. 2003;37:42–7).

SAN FRANCISCO — Several factors can help guide empiric therapy for acute otitis media by flagging patients at higher risk for infection with multiple organisms or resistant organisms, Dr. Mendel E. Singer said in a poster presentation at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Patients with bilateral infection, those with a history of acute otitis media, or patients infected in the fourth quarter of the year may warrant high-dose aminopenicillin therapy rather than low doses, said Dr. Singer, an epidemiologist at Case Western Reserve University, Cleveland.

He and associates retrospectively analyzed pooled data from 14 studies of patients aged 3–36 months treated at Soroka University Medical Center, Beer Sheva, Israel, for acute otitis media from 1994 to 2004. In 967 patients, 23% were infected with multiple pathogens. Of the 63% of patients with bilateral ear infections, 53% were more likely to have multiple pathogens than were those with unilateral infections, he said at the meeting, sponsored by the American Society for Microbiology.

Analysis of drug resistance in a subset of 333 patients infected with Streptococcus pneumoniae found that 33% had organisms resistant to the treatment drug. Data showed high rates of resistance to trimethoprim-sulfamethoxazole (in 67% of patients treated with these drugs) and to the cephalosporins cefdinir, cefaclor, or cefuroxime (in 59% of patients treated with these). There was moderate resistance to azithromycin (in 23%) and to low-dose regimens of the aminopenicillins amoxicillin or amoxicillin clavulanate (in 16% of patients given these drugs). Only 1% of isolates treated with high-dose aminopenicillins were resistant to therapy.

S. pneumoniae was 32% more likely to be drug-resistant in girls than in boys. A history of prior acute otitis media nearly tripled the risk for resistant S. pneumoniae. Infection in the fourth quarter of the year doubled the risk for resistance.

The data suggest that patients with any of these risk factors might best be treated empirically with high-dose amoxicillin or amoxicillin-clavulanate, Dr. Singer said. Patients without these characteristics may respond sufficiently to low doses of these drugs or to treatment with the other medications used in the study. Dr. Singer has no affiliations with the companies that market the drugs discussed.

SAN FRANCISCO — Several factors can help guide empiric therapy for acute otitis media by flagging patients at higher risk for infection with multiple organisms or resistant organisms, Dr. Mendel E. Singer said in a poster presentation at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Patients with bilateral infection, those with a history of acute otitis media, or patients infected in the fourth quarter of the year may warrant high-dose aminopenicillin therapy rather than low doses, said Dr. Singer, an epidemiologist at Case Western Reserve University, Cleveland.

He and associates retrospectively analyzed pooled data from 14 studies of patients aged 3–36 months treated at Soroka University Medical Center, Beer Sheva, Israel, for acute otitis media from 1994 to 2004. In 967 patients, 23% were infected with multiple pathogens. Of the 63% of patients with bilateral ear infections, 53% were more likely to have multiple pathogens than were those with unilateral infections, he said at the meeting, sponsored by the American Society for Microbiology.

Analysis of drug resistance in a subset of 333 patients infected with Streptococcus pneumoniae found that 33% had organisms resistant to the treatment drug. Data showed high rates of resistance to trimethoprim-sulfamethoxazole (in 67% of patients treated with these drugs) and to the cephalosporins cefdinir, cefaclor, or cefuroxime (in 59% of patients treated with these). There was moderate resistance to azithromycin (in 23%) and to low-dose regimens of the aminopenicillins amoxicillin or amoxicillin clavulanate (in 16% of patients given these drugs). Only 1% of isolates treated with high-dose aminopenicillins were resistant to therapy.

S. pneumoniae was 32% more likely to be drug-resistant in girls than in boys. A history of prior acute otitis media nearly tripled the risk for resistant S. pneumoniae. Infection in the fourth quarter of the year doubled the risk for resistance.

The data suggest that patients with any of these risk factors might best be treated empirically with high-dose amoxicillin or amoxicillin-clavulanate, Dr. Singer said. Patients without these characteristics may respond sufficiently to low doses of these drugs or to treatment with the other medications used in the study. Dr. Singer has no affiliations with the companies that market the drugs discussed.

SAN FRANCISCO — Several factors can help guide empiric therapy for acute otitis media by flagging patients at higher risk for infection with multiple organisms or resistant organisms, Dr. Mendel E. Singer said in a poster presentation at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Patients with bilateral infection, those with a history of acute otitis media, or patients infected in the fourth quarter of the year may warrant high-dose aminopenicillin therapy rather than low doses, said Dr. Singer, an epidemiologist at Case Western Reserve University, Cleveland.

He and associates retrospectively analyzed pooled data from 14 studies of patients aged 3–36 months treated at Soroka University Medical Center, Beer Sheva, Israel, for acute otitis media from 1994 to 2004. In 967 patients, 23% were infected with multiple pathogens. Of the 63% of patients with bilateral ear infections, 53% were more likely to have multiple pathogens than were those with unilateral infections, he said at the meeting, sponsored by the American Society for Microbiology.

Analysis of drug resistance in a subset of 333 patients infected with Streptococcus pneumoniae found that 33% had organisms resistant to the treatment drug. Data showed high rates of resistance to trimethoprim-sulfamethoxazole (in 67% of patients treated with these drugs) and to the cephalosporins cefdinir, cefaclor, or cefuroxime (in 59% of patients treated with these). There was moderate resistance to azithromycin (in 23%) and to low-dose regimens of the aminopenicillins amoxicillin or amoxicillin clavulanate (in 16% of patients given these drugs). Only 1% of isolates treated with high-dose aminopenicillins were resistant to therapy.

S. pneumoniae was 32% more likely to be drug-resistant in girls than in boys. A history of prior acute otitis media nearly tripled the risk for resistant S. pneumoniae. Infection in the fourth quarter of the year doubled the risk for resistance.

The data suggest that patients with any of these risk factors might best be treated empirically with high-dose amoxicillin or amoxicillin-clavulanate, Dr. Singer said. Patients without these characteristics may respond sufficiently to low doses of these drugs or to treatment with the other medications used in the study. Dr. Singer has no affiliations with the companies that market the drugs discussed.

LAKE TAHOE, CALIF. — Several new technologies aim to make colon cancer screening easier to perform, Dr. John M. Inadomi said at a meeting on gastroenterology and hepatology sponsored by the University of California, Davis.

“The only test that works is the one you can get your patients to do,” said Dr. Inadomi, chief of clinical gastroenterology at San Francisco General Hospital and chair of gastrointestinal medicine at the University of California, San Francisco.

Two of the newer methods (virtual colonoscopy and NeoGuide) are available, and two more are investigational.

▸ Virtual colonoscopy. Using CT or MRI to produce 2- or 3-D images of the colon is less invasive than inserting a scope, but has disadvantages.

The overall sensitivity was 75% and the specificity was 81% in a metaanalysis of 39 studies comparing CT or MR colonography for colonic polyps or cancer with colonoscopy, Dr. Inadomi noted. That means that colonic polyps or cancer are missed in 25% of patients who have them, and 19% of patients designated as having polyps or cancer do not have them.

When comparing the incremental cost per year of life saved, virtual colonoscopy would not be preferred over colonoscopy until the former's cost drops to less than $100 per screen, about a fifth of its cost now.

▸ NeoGuide. This computer-assisted colonoscope avoids pushing on the lumen of the colon, which can cause pain and complications.

In a conventional colonoscopy, a flexible endoscope inserted into the colon is advanced by pressure, pushing against the sides where the bowel turns in order to turn the scope. This force can displace the colon and stretch the surrounding tissue, a process called looping. “We bump into a lot of areas,” Dr. Inadomi said.

The NeoGuide's sensor detects the depth of insertion of the scope, helps it turn without relying on force and pressure, and records the angle of the scope tip, creating a 3-D map of the path that the tip travels through the colon. Multiple steerable segments in the scope allow it to bend into appropriate angles at the right locations to avoid pressure. “It's an active rather than a passive scope,” he said.

Pilot studies led to approval of the device in February. It has the potential to reduce pain, complications, and the time needed to perform colonoscopy, but no data confirm this yet. Colonoscopy using the NeoGuide could potentially be performed without sedation, which could be a major advantage if true.

▸ Aer-O-Scope. An investigational pneumatic “self-guiding” endoscope uses an air compressor to advance a scanning balloon carrying a camera for imaging. A rectal balloon prevents air from escaping from the colon.

Pilot data in 12 healthy volunteers found that the scope reached the cecum in 10 patients. Four patients reported sweating and bloating during the procedure, and two requested analgesia. No perforations or infections were seen. The procedure averaged 23 minutes, perhaps one-fifth the amount of time needed for a conventional colonoscopy.

The Aer-O-Scope could be used by technicians. It's strictly a diagnostic screening tool, since it does not allow biopsies to be removed.

▸ Colon capsule. The maker of the PillCam Capsule that can be swallowed and performs endoscopy is developing a similar capsule that would tumble through a fluid-filled colon, snapping pictures for screening.

Dr. Inadomi is working with the company, Given Imaging Ltd., to improve the colon capsule, which is not yet approved for use. He has no affiliations with companies that make the other devices he discussed.

This diagnostic test is fairly painless, requires colonic irrigation, and could be performed by nonphysicians with results read by physicians. Orientation in the colon remains a challenge. “The question is, how much of the surface area of the colon can be seen?” he said.

LAKE TAHOE, CALIF. — Several new technologies aim to make colon cancer screening easier to perform, Dr. John M. Inadomi said at a meeting on gastroenterology and hepatology sponsored by the University of California, Davis.

“The only test that works is the one you can get your patients to do,” said Dr. Inadomi, chief of clinical gastroenterology at San Francisco General Hospital and chair of gastrointestinal medicine at the University of California, San Francisco.

Two of the newer methods (virtual colonoscopy and NeoGuide) are available, and two more are investigational.

▸ Virtual colonoscopy. Using CT or MRI to produce 2- or 3-D images of the colon is less invasive than inserting a scope, but has disadvantages.

The overall sensitivity was 75% and the specificity was 81% in a metaanalysis of 39 studies comparing CT or MR colonography for colonic polyps or cancer with colonoscopy, Dr. Inadomi noted. That means that colonic polyps or cancer are missed in 25% of patients who have them, and 19% of patients designated as having polyps or cancer do not have them.

When comparing the incremental cost per year of life saved, virtual colonoscopy would not be preferred over colonoscopy until the former's cost drops to less than $100 per screen, about a fifth of its cost now.

▸ NeoGuide. This computer-assisted colonoscope avoids pushing on the lumen of the colon, which can cause pain and complications.

In a conventional colonoscopy, a flexible endoscope inserted into the colon is advanced by pressure, pushing against the sides where the bowel turns in order to turn the scope. This force can displace the colon and stretch the surrounding tissue, a process called looping. “We bump into a lot of areas,” Dr. Inadomi said.

The NeoGuide's sensor detects the depth of insertion of the scope, helps it turn without relying on force and pressure, and records the angle of the scope tip, creating a 3-D map of the path that the tip travels through the colon. Multiple steerable segments in the scope allow it to bend into appropriate angles at the right locations to avoid pressure. “It's an active rather than a passive scope,” he said.

Pilot studies led to approval of the device in February. It has the potential to reduce pain, complications, and the time needed to perform colonoscopy, but no data confirm this yet. Colonoscopy using the NeoGuide could potentially be performed without sedation, which could be a major advantage if true.

▸ Aer-O-Scope. An investigational pneumatic “self-guiding” endoscope uses an air compressor to advance a scanning balloon carrying a camera for imaging. A rectal balloon prevents air from escaping from the colon.

Pilot data in 12 healthy volunteers found that the scope reached the cecum in 10 patients. Four patients reported sweating and bloating during the procedure, and two requested analgesia. No perforations or infections were seen. The procedure averaged 23 minutes, perhaps one-fifth the amount of time needed for a conventional colonoscopy.

The Aer-O-Scope could be used by technicians. It's strictly a diagnostic screening tool, since it does not allow biopsies to be removed.

▸ Colon capsule. The maker of the PillCam Capsule that can be swallowed and performs endoscopy is developing a similar capsule that would tumble through a fluid-filled colon, snapping pictures for screening.

Dr. Inadomi is working with the company, Given Imaging Ltd., to improve the colon capsule, which is not yet approved for use. He has no affiliations with companies that make the other devices he discussed.

This diagnostic test is fairly painless, requires colonic irrigation, and could be performed by nonphysicians with results read by physicians. Orientation in the colon remains a challenge. “The question is, how much of the surface area of the colon can be seen?” he said.

LAKE TAHOE, CALIF. — Several new technologies aim to make colon cancer screening easier to perform, Dr. John M. Inadomi said at a meeting on gastroenterology and hepatology sponsored by the University of California, Davis.

“The only test that works is the one you can get your patients to do,” said Dr. Inadomi, chief of clinical gastroenterology at San Francisco General Hospital and chair of gastrointestinal medicine at the University of California, San Francisco.

Two of the newer methods (virtual colonoscopy and NeoGuide) are available, and two more are investigational.

▸ Virtual colonoscopy. Using CT or MRI to produce 2- or 3-D images of the colon is less invasive than inserting a scope, but has disadvantages.

The overall sensitivity was 75% and the specificity was 81% in a metaanalysis of 39 studies comparing CT or MR colonography for colonic polyps or cancer with colonoscopy, Dr. Inadomi noted. That means that colonic polyps or cancer are missed in 25% of patients who have them, and 19% of patients designated as having polyps or cancer do not have them.

When comparing the incremental cost per year of life saved, virtual colonoscopy would not be preferred over colonoscopy until the former's cost drops to less than $100 per screen, about a fifth of its cost now.

▸ NeoGuide. This computer-assisted colonoscope avoids pushing on the lumen of the colon, which can cause pain and complications.

In a conventional colonoscopy, a flexible endoscope inserted into the colon is advanced by pressure, pushing against the sides where the bowel turns in order to turn the scope. This force can displace the colon and stretch the surrounding tissue, a process called looping. “We bump into a lot of areas,” Dr. Inadomi said.

The NeoGuide's sensor detects the depth of insertion of the scope, helps it turn without relying on force and pressure, and records the angle of the scope tip, creating a 3-D map of the path that the tip travels through the colon. Multiple steerable segments in the scope allow it to bend into appropriate angles at the right locations to avoid pressure. “It's an active rather than a passive scope,” he said.

Pilot studies led to approval of the device in February. It has the potential to reduce pain, complications, and the time needed to perform colonoscopy, but no data confirm this yet. Colonoscopy using the NeoGuide could potentially be performed without sedation, which could be a major advantage if true.

▸ Aer-O-Scope. An investigational pneumatic “self-guiding” endoscope uses an air compressor to advance a scanning balloon carrying a camera for imaging. A rectal balloon prevents air from escaping from the colon.

Pilot data in 12 healthy volunteers found that the scope reached the cecum in 10 patients. Four patients reported sweating and bloating during the procedure, and two requested analgesia. No perforations or infections were seen. The procedure averaged 23 minutes, perhaps one-fifth the amount of time needed for a conventional colonoscopy.

The Aer-O-Scope could be used by technicians. It's strictly a diagnostic screening tool, since it does not allow biopsies to be removed.

▸ Colon capsule. The maker of the PillCam Capsule that can be swallowed and performs endoscopy is developing a similar capsule that would tumble through a fluid-filled colon, snapping pictures for screening.

Dr. Inadomi is working with the company, Given Imaging Ltd., to improve the colon capsule, which is not yet approved for use. He has no affiliations with companies that make the other devices he discussed.

This diagnostic test is fairly painless, requires colonic irrigation, and could be performed by nonphysicians with results read by physicians. Orientation in the colon remains a challenge. “The question is, how much of the surface area of the colon can be seen?” he said.

LAKE TAHOE, CALIF. — The frequency of colonoscopies to screen for cancer in patients with Crohn's disease colitis or ulcerative colitis should be based on how long they've had colitis, Dr. Joshua R. Korzenik said at a meeting on gastroenterology and hepatology sponsored by the University of California, Davis.

But if a colonoscopy can answer an important clinical question facing the patient today, it should be done now regardless of the colitis duration, said Dr. Korzenik, codirector of the Crohn's and Colitis Center at Massachusetts General Hospital, Boston.

Without that pressing motivation, a screening colonoscopy typically would be appropriate every 3–4 years during the first decade of a patient's Crohn's or ulcerative colitis. Because these patients can develop cancer not only from polyps but from flat, normal-appearing mucosa, multiple biopsies are needed. A minimum of 33 biopsies should be taken, spaced about every 4–10 cm throughout the colon.

“That has about a 90% likelihood of picking up dysplasia,” he said.

For patients with a disease duration of 10–20 years, colonoscopy should be performed every other year. For those with a disease duration longer than 20 years, annual colonoscopy is preferred.

“We're beginning to move toward chromoendoscopy, where we spray the colon with a contrast material that picks up dysplasia a little bit better,” he added.

If the colonoscopy detects high-grade dysplasia, the patient should undergo a colectomy, Dr. Korzenik advised.

LAKE TAHOE, CALIF. — The frequency of colonoscopies to screen for cancer in patients with Crohn's disease colitis or ulcerative colitis should be based on how long they've had colitis, Dr. Joshua R. Korzenik said at a meeting on gastroenterology and hepatology sponsored by the University of California, Davis.

But if a colonoscopy can answer an important clinical question facing the patient today, it should be done now regardless of the colitis duration, said Dr. Korzenik, codirector of the Crohn's and Colitis Center at Massachusetts General Hospital, Boston.

Without that pressing motivation, a screening colonoscopy typically would be appropriate every 3–4 years during the first decade of a patient's Crohn's or ulcerative colitis. Because these patients can develop cancer not only from polyps but from flat, normal-appearing mucosa, multiple biopsies are needed. A minimum of 33 biopsies should be taken, spaced about every 4–10 cm throughout the colon.

“That has about a 90% likelihood of picking up dysplasia,” he said.

For patients with a disease duration of 10–20 years, colonoscopy should be performed every other year. For those with a disease duration longer than 20 years, annual colonoscopy is preferred.

“We're beginning to move toward chromoendoscopy, where we spray the colon with a contrast material that picks up dysplasia a little bit better,” he added.

If the colonoscopy detects high-grade dysplasia, the patient should undergo a colectomy, Dr. Korzenik advised.

LAKE TAHOE, CALIF. — The frequency of colonoscopies to screen for cancer in patients with Crohn's disease colitis or ulcerative colitis should be based on how long they've had colitis, Dr. Joshua R. Korzenik said at a meeting on gastroenterology and hepatology sponsored by the University of California, Davis.

But if a colonoscopy can answer an important clinical question facing the patient today, it should be done now regardless of the colitis duration, said Dr. Korzenik, codirector of the Crohn's and Colitis Center at Massachusetts General Hospital, Boston.

Without that pressing motivation, a screening colonoscopy typically would be appropriate every 3–4 years during the first decade of a patient's Crohn's or ulcerative colitis. Because these patients can develop cancer not only from polyps but from flat, normal-appearing mucosa, multiple biopsies are needed. A minimum of 33 biopsies should be taken, spaced about every 4–10 cm throughout the colon.

“That has about a 90% likelihood of picking up dysplasia,” he said.

For patients with a disease duration of 10–20 years, colonoscopy should be performed every other year. For those with a disease duration longer than 20 years, annual colonoscopy is preferred.

“We're beginning to move toward chromoendoscopy, where we spray the colon with a contrast material that picks up dysplasia a little bit better,” he added.

If the colonoscopy detects high-grade dysplasia, the patient should undergo a colectomy, Dr. Korzenik advised.

LAKE TAHOE, CALIF. — Patients may be more likely to be screened for colon cancer if physicians schedule colonoscopies and tell the patients to show up rather than giving them a choice of screening options, Dr. John M. Inadomi said at a meeting on gastroenterology and hepatology sponsored by the University of California, Davis.

That's what he and associates at the University of California, San Francisco, found in a small pilot study, and they plan to study this further in a much larger trial, he said.

In the pilot study, they randomized 41 subjects and followed them for 6 months to see how many completed the colon cancer screening tests. None of the patients who either chose or were told to get three fecal occult blood tests (FOBTs) plus flexible sigmoidoscopy completed both. “So first of all, if you're trying to get people to do both FOBT and flex sig, forget it,” said Dr. Inadomi, chief of clinical gastroenterology at San Francisco General Hospital and director of GI Outcomes and Health Services Research at the university.

Patients who were told to get a colonoscopy were twice as likely to get one as patients who were counseled about screening options and who chose to get a colonoscopy, he added.

Fifteen patients in the “choice” arm of the study were counseled by a nurse-specialist who recited a scripted message designed to help patients choose between getting a colonoscopy or getting three FOBTs plus a flexible sigmoidoscopy. If the FOBTs or the flexible sigmoidoscopy was positive, the patient was to get a colonoscopy.

Nine patients chose colonoscopy, and three of them (33%) got the test. Of the six patients who chose FOBTs plus flexible sigmoidoscopy, two completed the FOBTs and two underwent flexible sigmoidoscopy but none completed both tests.

Among 26 patients in the “no choice” arm, 13 were told to show up for a colonos-copy and 9 patients (69%) did so. Of the 13 patients who were told to get FOBTs plus flexible sigmoidoscopy, 1 patient completed the FOBTs and 4 patients underwent the sigmoidoscopy, but none got both tests.

Newer screening options have joined these mainstays and further confuse patients when given a choice, Dr. Inadomi noted. The lack of a clearly defined preference leads people to defer a decision when given a choice. “The main thing to improve adherence with screening guidelines is to schedule patients for the test that they will complete,” he said.

LAKE TAHOE, CALIF. — Patients may be more likely to be screened for colon cancer if physicians schedule colonoscopies and tell the patients to show up rather than giving them a choice of screening options, Dr. John M. Inadomi said at a meeting on gastroenterology and hepatology sponsored by the University of California, Davis.

That's what he and associates at the University of California, San Francisco, found in a small pilot study, and they plan to study this further in a much larger trial, he said.

In the pilot study, they randomized 41 subjects and followed them for 6 months to see how many completed the colon cancer screening tests. None of the patients who either chose or were told to get three fecal occult blood tests (FOBTs) plus flexible sigmoidoscopy completed both. “So first of all, if you're trying to get people to do both FOBT and flex sig, forget it,” said Dr. Inadomi, chief of clinical gastroenterology at San Francisco General Hospital and director of GI Outcomes and Health Services Research at the university.

Patients who were told to get a colonoscopy were twice as likely to get one as patients who were counseled about screening options and who chose to get a colonoscopy, he added.

Fifteen patients in the “choice” arm of the study were counseled by a nurse-specialist who recited a scripted message designed to help patients choose between getting a colonoscopy or getting three FOBTs plus a flexible sigmoidoscopy. If the FOBTs or the flexible sigmoidoscopy was positive, the patient was to get a colonoscopy.

Nine patients chose colonoscopy, and three of them (33%) got the test. Of the six patients who chose FOBTs plus flexible sigmoidoscopy, two completed the FOBTs and two underwent flexible sigmoidoscopy but none completed both tests.

Among 26 patients in the “no choice” arm, 13 were told to show up for a colonos-copy and 9 patients (69%) did so. Of the 13 patients who were told to get FOBTs plus flexible sigmoidoscopy, 1 patient completed the FOBTs and 4 patients underwent the sigmoidoscopy, but none got both tests.

Newer screening options have joined these mainstays and further confuse patients when given a choice, Dr. Inadomi noted. The lack of a clearly defined preference leads people to defer a decision when given a choice. “The main thing to improve adherence with screening guidelines is to schedule patients for the test that they will complete,” he said.

LAKE TAHOE, CALIF. — Patients may be more likely to be screened for colon cancer if physicians schedule colonoscopies and tell the patients to show up rather than giving them a choice of screening options, Dr. John M. Inadomi said at a meeting on gastroenterology and hepatology sponsored by the University of California, Davis.

That's what he and associates at the University of California, San Francisco, found in a small pilot study, and they plan to study this further in a much larger trial, he said.

In the pilot study, they randomized 41 subjects and followed them for 6 months to see how many completed the colon cancer screening tests. None of the patients who either chose or were told to get three fecal occult blood tests (FOBTs) plus flexible sigmoidoscopy completed both. “So first of all, if you're trying to get people to do both FOBT and flex sig, forget it,” said Dr. Inadomi, chief of clinical gastroenterology at San Francisco General Hospital and director of GI Outcomes and Health Services Research at the university.

Patients who were told to get a colonoscopy were twice as likely to get one as patients who were counseled about screening options and who chose to get a colonoscopy, he added.

Fifteen patients in the “choice” arm of the study were counseled by a nurse-specialist who recited a scripted message designed to help patients choose between getting a colonoscopy or getting three FOBTs plus a flexible sigmoidoscopy. If the FOBTs or the flexible sigmoidoscopy was positive, the patient was to get a colonoscopy.

Nine patients chose colonoscopy, and three of them (33%) got the test. Of the six patients who chose FOBTs plus flexible sigmoidoscopy, two completed the FOBTs and two underwent flexible sigmoidoscopy but none completed both tests.

Among 26 patients in the “no choice” arm, 13 were told to show up for a colonos-copy and 9 patients (69%) did so. Of the 13 patients who were told to get FOBTs plus flexible sigmoidoscopy, 1 patient completed the FOBTs and 4 patients underwent the sigmoidoscopy, but none got both tests.

Newer screening options have joined these mainstays and further confuse patients when given a choice, Dr. Inadomi noted. The lack of a clearly defined preference leads people to defer a decision when given a choice. “The main thing to improve adherence with screening guidelines is to schedule patients for the test that they will complete,” he said.