Betsy Bates

LOS ANGELES — Even the experts disagree about what tests should be ordered to rule out organic disease in patients presenting with symptoms of irritable bowel syndrome, according to survey results presented at the annual Digestive Disease Week.

Dr. Brennan M. Spiegel and associates at the University of California, Los Angeles, surveyed 27 recognized experts in irritable bowel syndrome (IBS), 53 randomly chosen gastroenterologists from the American Gastroenterological Association, 89 primary care physicians, and 102 nurse-practitioners to determine whether various health care professionals consider IBS to be a diagnosis of exclusion.

Their results suggest that many physicians and other health care professionals are not following practice guidelines issued in 2002 by the American College of Gastroenterology (ACG), which emphasize the importance of assessing IBS symptoms and discourage extensive work-ups for patients who do not have alarming symptoms or findings on physical examination.

Survey respondents were presented with a fictitious patient scenario and asked what tests they would order to establish a diagnosis of IBS. In the vignette, the patient was a 42-year-old woman with a history of loose stools for many years and up to six bowel movements a day. She described crampy, left lower quadrant pain that improved with stool passage. Neither her history nor her physical exam revealed any alarming symptoms.

On that description alone, two-thirds of IBS experts were willing to endorse a diagnosis of IBS, compared with 34% of primary care physicians, 43% of gastroenterologists, and 41% of nurse-practitioners.

IBS experts were in strong agreement that two tests would be warranted to rule out organic disease: a complete blood count and a test for antibodies to celiac sprue. They also agreed on one inappropriate test: a breath test for small-intestine bacterial overgrowth.

“Everything else was uncertain, even among experts, about what to do,” Dr. Spiegel said. Respondents showed “extreme variation” in the additional tests they said they would order, with some advocating a chemistry panel, erythrocyte sedimentation rate, thyroid stimulating hormone, stool white blood cell count, and other tests.

On average, the IBS experts said they would order a total of 2 tests, while gastroenterologists would order 3.9; primary care physicians, 4.1; and nurse-practitioners, 4.3.

The experts, chosen on the basis of their publications and selection for guidelines committees, were also far less likely than other health professionals to say they believed IBS was a diagnosis of exclusion; the rate was 8% of experts, compared with 42% of gastroenterologists and 72% of both primary care physicians and nurse-practitioners.

After adjustment was made for type of health professional, practice type, age, gender, and experience treating IBS patients, the belief that IBS is a diagnosis of exclusion predicted the desire to order 1.6 more tests and spend $364 more on diagnostic testing of the patient in the vignette.

“In general, this disconnect indicates that these guidelines, [which] have been much ballyhooed by the ACG and other groups, either are not being disseminated correctly or simply are not being followed or believed,” Dr. Spiegel said.

An audience member praised the study, saying the findings were “dead on.”

“I think we all realize that the diagnosis of IBS is probably imperfect and fraught with error,” Dr. Spiegel responded.

Interim results of an unrelated study presented at the meeting suggest that if one test is going to be ordered for patients meeting Rome II criteria for diarrhea-predominant or mixed IBS, a celiac disease panel is probably a good choice.

A study from the National Naval Medical Center in Bethesda, Md., Walter Reed Army Medical Center in Washington, and the University of Maryland, Baltimore, attempted to identify organic gastrointestinal findings among 323 patients with IBS who received an extensive array of tests: complete blood count, comprehensive metabolic panel, thyroid function test, erythrocyte sedimentation rate, C-reactive protein panel, inflammatory bowel disease panel, hypolactasia (lactase deficiency) genetic assay, celiac disease panel, and colonoscopy with rectosigmoid biopsies.

A total of 9 of 323 patients, or 2.8%, were diagnosed with organic gastrointestinal disease based on the exhaustive testing.

These included four, or 1.2%, with celiac disease; three with inflammatory bowel disease; one with malignancy; and one with sigmoid volvulus.

The only test that identified significantly more disease in IBS patients than in 241 controls was the celiac sprue test, reported Dr. Brooks D. Cash, director of clinical research and a gastroenterologist at the National Naval Medical Center.

LOS ANGELES — Even the experts disagree about what tests should be ordered to rule out organic disease in patients presenting with symptoms of irritable bowel syndrome, according to survey results presented at the annual Digestive Disease Week.

Dr. Brennan M. Spiegel and associates at the University of California, Los Angeles, surveyed 27 recognized experts in irritable bowel syndrome (IBS), 53 randomly chosen gastroenterologists from the American Gastroenterological Association, 89 primary care physicians, and 102 nurse-practitioners to determine whether various health care professionals consider IBS to be a diagnosis of exclusion.

Their results suggest that many physicians and other health care professionals are not following practice guidelines issued in 2002 by the American College of Gastroenterology (ACG), which emphasize the importance of assessing IBS symptoms and discourage extensive work-ups for patients who do not have alarming symptoms or findings on physical examination.

Survey respondents were presented with a fictitious patient scenario and asked what tests they would order to establish a diagnosis of IBS. In the vignette, the patient was a 42-year-old woman with a history of loose stools for many years and up to six bowel movements a day. She described crampy, left lower quadrant pain that improved with stool passage. Neither her history nor her physical exam revealed any alarming symptoms.

On that description alone, two-thirds of IBS experts were willing to endorse a diagnosis of IBS, compared with 34% of primary care physicians, 43% of gastroenterologists, and 41% of nurse-practitioners.

IBS experts were in strong agreement that two tests would be warranted to rule out organic disease: a complete blood count and a test for antibodies to celiac sprue. They also agreed on one inappropriate test: a breath test for small-intestine bacterial overgrowth.

“Everything else was uncertain, even among experts, about what to do,” Dr. Spiegel said. Respondents showed “extreme variation” in the additional tests they said they would order, with some advocating a chemistry panel, erythrocyte sedimentation rate, thyroid stimulating hormone, stool white blood cell count, and other tests.

On average, the IBS experts said they would order a total of 2 tests, while gastroenterologists would order 3.9; primary care physicians, 4.1; and nurse-practitioners, 4.3.

The experts, chosen on the basis of their publications and selection for guidelines committees, were also far less likely than other health professionals to say they believed IBS was a diagnosis of exclusion; the rate was 8% of experts, compared with 42% of gastroenterologists and 72% of both primary care physicians and nurse-practitioners.

After adjustment was made for type of health professional, practice type, age, gender, and experience treating IBS patients, the belief that IBS is a diagnosis of exclusion predicted the desire to order 1.6 more tests and spend $364 more on diagnostic testing of the patient in the vignette.

“In general, this disconnect indicates that these guidelines, [which] have been much ballyhooed by the ACG and other groups, either are not being disseminated correctly or simply are not being followed or believed,” Dr. Spiegel said.

An audience member praised the study, saying the findings were “dead on.”

“I think we all realize that the diagnosis of IBS is probably imperfect and fraught with error,” Dr. Spiegel responded.

Interim results of an unrelated study presented at the meeting suggest that if one test is going to be ordered for patients meeting Rome II criteria for diarrhea-predominant or mixed IBS, a celiac disease panel is probably a good choice.

A study from the National Naval Medical Center in Bethesda, Md., Walter Reed Army Medical Center in Washington, and the University of Maryland, Baltimore, attempted to identify organic gastrointestinal findings among 323 patients with IBS who received an extensive array of tests: complete blood count, comprehensive metabolic panel, thyroid function test, erythrocyte sedimentation rate, C-reactive protein panel, inflammatory bowel disease panel, hypolactasia (lactase deficiency) genetic assay, celiac disease panel, and colonoscopy with rectosigmoid biopsies.

A total of 9 of 323 patients, or 2.8%, were diagnosed with organic gastrointestinal disease based on the exhaustive testing.

These included four, or 1.2%, with celiac disease; three with inflammatory bowel disease; one with malignancy; and one with sigmoid volvulus.

The only test that identified significantly more disease in IBS patients than in 241 controls was the celiac sprue test, reported Dr. Brooks D. Cash, director of clinical research and a gastroenterologist at the National Naval Medical Center.

LOS ANGELES — Even the experts disagree about what tests should be ordered to rule out organic disease in patients presenting with symptoms of irritable bowel syndrome, according to survey results presented at the annual Digestive Disease Week.

Dr. Brennan M. Spiegel and associates at the University of California, Los Angeles, surveyed 27 recognized experts in irritable bowel syndrome (IBS), 53 randomly chosen gastroenterologists from the American Gastroenterological Association, 89 primary care physicians, and 102 nurse-practitioners to determine whether various health care professionals consider IBS to be a diagnosis of exclusion.

Their results suggest that many physicians and other health care professionals are not following practice guidelines issued in 2002 by the American College of Gastroenterology (ACG), which emphasize the importance of assessing IBS symptoms and discourage extensive work-ups for patients who do not have alarming symptoms or findings on physical examination.

Survey respondents were presented with a fictitious patient scenario and asked what tests they would order to establish a diagnosis of IBS. In the vignette, the patient was a 42-year-old woman with a history of loose stools for many years and up to six bowel movements a day. She described crampy, left lower quadrant pain that improved with stool passage. Neither her history nor her physical exam revealed any alarming symptoms.

On that description alone, two-thirds of IBS experts were willing to endorse a diagnosis of IBS, compared with 34% of primary care physicians, 43% of gastroenterologists, and 41% of nurse-practitioners.

IBS experts were in strong agreement that two tests would be warranted to rule out organic disease: a complete blood count and a test for antibodies to celiac sprue. They also agreed on one inappropriate test: a breath test for small-intestine bacterial overgrowth.

“Everything else was uncertain, even among experts, about what to do,” Dr. Spiegel said. Respondents showed “extreme variation” in the additional tests they said they would order, with some advocating a chemistry panel, erythrocyte sedimentation rate, thyroid stimulating hormone, stool white blood cell count, and other tests.

On average, the IBS experts said they would order a total of 2 tests, while gastroenterologists would order 3.9; primary care physicians, 4.1; and nurse-practitioners, 4.3.

The experts, chosen on the basis of their publications and selection for guidelines committees, were also far less likely than other health professionals to say they believed IBS was a diagnosis of exclusion; the rate was 8% of experts, compared with 42% of gastroenterologists and 72% of both primary care physicians and nurse-practitioners.

After adjustment was made for type of health professional, practice type, age, gender, and experience treating IBS patients, the belief that IBS is a diagnosis of exclusion predicted the desire to order 1.6 more tests and spend $364 more on diagnostic testing of the patient in the vignette.

“In general, this disconnect indicates that these guidelines, [which] have been much ballyhooed by the ACG and other groups, either are not being disseminated correctly or simply are not being followed or believed,” Dr. Spiegel said.

An audience member praised the study, saying the findings were “dead on.”

“I think we all realize that the diagnosis of IBS is probably imperfect and fraught with error,” Dr. Spiegel responded.

Interim results of an unrelated study presented at the meeting suggest that if one test is going to be ordered for patients meeting Rome II criteria for diarrhea-predominant or mixed IBS, a celiac disease panel is probably a good choice.

A study from the National Naval Medical Center in Bethesda, Md., Walter Reed Army Medical Center in Washington, and the University of Maryland, Baltimore, attempted to identify organic gastrointestinal findings among 323 patients with IBS who received an extensive array of tests: complete blood count, comprehensive metabolic panel, thyroid function test, erythrocyte sedimentation rate, C-reactive protein panel, inflammatory bowel disease panel, hypolactasia (lactase deficiency) genetic assay, celiac disease panel, and colonoscopy with rectosigmoid biopsies.

A total of 9 of 323 patients, or 2.8%, were diagnosed with organic gastrointestinal disease based on the exhaustive testing.

These included four, or 1.2%, with celiac disease; three with inflammatory bowel disease; one with malignancy; and one with sigmoid volvulus.

The only test that identified significantly more disease in IBS patients than in 241 controls was the celiac sprue test, reported Dr. Brooks D. Cash, director of clinical research and a gastroenterologist at the National Naval Medical Center.

LOS ANGELES — Virtual colonoscopy missed adenomatous lesions in 12% of patients, including 5% who had advanced lesions detected only on a follow-up optical colonoscopy, researchers reported at the annual Digestive Disease Week.

Investigators at the University of Wisconsin, Madison, studied records of 160 patients who first had virtual colonoscopy performed by primary 3-D read with 2-D resolution and were then sent for optical colonoscopy.

Patients had both tests if a significant portion of the colon was not visualized on virtual colonoscopy, if they had findings of a polyp or mass greater than 10 mm, if virtual colonoscopy detected polyps between 6 mm and 9 mm, or at the patient's discretion. Lesions less than 6 mm that were seen on virtual colonoscopy were not reported, and patients with these lesions were not referred for optical colonoscopy.

Invasive colonoscopy detected adenomatous lesions not seen on virtual colonoscopy in 19 of 160 patients. Eight of these patients had previously undetected advanced lesions, defined as any adenoma greater than 9 mm or a lesion less than 9 mm with villous pathology.

The second test also detected a false-positive rate of 5% with virtual colonoscopy.

In all, conventional colonoscopy detected 138 lesions, in 54 patients, that had not been seen on virtual colonoscopy, including 99 less than 6 mm, 27 between 6 mm and 9mm, and 12 greater than 9 mm. Most of the lesions were hyperplastic.

“These findings suggest that virtual colonoscopy identifies the majority of colorectal polyps with advanced pathology during routine screening examinations,” said Dr. Daniel Cornett of the section of gastroenterology and hepatology at the University of Wisconsin, Madison.

But he added that virtual colonoscopy poses a “small risk” of missing polyps with advanced pathology, “especially smaller polyps less than 9 mm in size with villous pathology and larger adenomas that are flat in nature or resemble a mucosal fold.”

Both Dr. Cornett and coauthor Dr. Courtney Barancin, a gastroenterology fellow, expressed concern that some protocols for virtual colonoscopy do not refer for optical colonoscopy patients with lesions less than 6 mm.

LOS ANGELES — Virtual colonoscopy missed adenomatous lesions in 12% of patients, including 5% who had advanced lesions detected only on a follow-up optical colonoscopy, researchers reported at the annual Digestive Disease Week.

Investigators at the University of Wisconsin, Madison, studied records of 160 patients who first had virtual colonoscopy performed by primary 3-D read with 2-D resolution and were then sent for optical colonoscopy.

Patients had both tests if a significant portion of the colon was not visualized on virtual colonoscopy, if they had findings of a polyp or mass greater than 10 mm, if virtual colonoscopy detected polyps between 6 mm and 9 mm, or at the patient's discretion. Lesions less than 6 mm that were seen on virtual colonoscopy were not reported, and patients with these lesions were not referred for optical colonoscopy.

Invasive colonoscopy detected adenomatous lesions not seen on virtual colonoscopy in 19 of 160 patients. Eight of these patients had previously undetected advanced lesions, defined as any adenoma greater than 9 mm or a lesion less than 9 mm with villous pathology.

The second test also detected a false-positive rate of 5% with virtual colonoscopy.

In all, conventional colonoscopy detected 138 lesions, in 54 patients, that had not been seen on virtual colonoscopy, including 99 less than 6 mm, 27 between 6 mm and 9mm, and 12 greater than 9 mm. Most of the lesions were hyperplastic.

“These findings suggest that virtual colonoscopy identifies the majority of colorectal polyps with advanced pathology during routine screening examinations,” said Dr. Daniel Cornett of the section of gastroenterology and hepatology at the University of Wisconsin, Madison.

But he added that virtual colonoscopy poses a “small risk” of missing polyps with advanced pathology, “especially smaller polyps less than 9 mm in size with villous pathology and larger adenomas that are flat in nature or resemble a mucosal fold.”

Both Dr. Cornett and coauthor Dr. Courtney Barancin, a gastroenterology fellow, expressed concern that some protocols for virtual colonoscopy do not refer for optical colonoscopy patients with lesions less than 6 mm.

LOS ANGELES — Virtual colonoscopy missed adenomatous lesions in 12% of patients, including 5% who had advanced lesions detected only on a follow-up optical colonoscopy, researchers reported at the annual Digestive Disease Week.

Investigators at the University of Wisconsin, Madison, studied records of 160 patients who first had virtual colonoscopy performed by primary 3-D read with 2-D resolution and were then sent for optical colonoscopy.

Patients had both tests if a significant portion of the colon was not visualized on virtual colonoscopy, if they had findings of a polyp or mass greater than 10 mm, if virtual colonoscopy detected polyps between 6 mm and 9 mm, or at the patient's discretion. Lesions less than 6 mm that were seen on virtual colonoscopy were not reported, and patients with these lesions were not referred for optical colonoscopy.

Invasive colonoscopy detected adenomatous lesions not seen on virtual colonoscopy in 19 of 160 patients. Eight of these patients had previously undetected advanced lesions, defined as any adenoma greater than 9 mm or a lesion less than 9 mm with villous pathology.

The second test also detected a false-positive rate of 5% with virtual colonoscopy.

In all, conventional colonoscopy detected 138 lesions, in 54 patients, that had not been seen on virtual colonoscopy, including 99 less than 6 mm, 27 between 6 mm and 9mm, and 12 greater than 9 mm. Most of the lesions were hyperplastic.

“These findings suggest that virtual colonoscopy identifies the majority of colorectal polyps with advanced pathology during routine screening examinations,” said Dr. Daniel Cornett of the section of gastroenterology and hepatology at the University of Wisconsin, Madison.

But he added that virtual colonoscopy poses a “small risk” of missing polyps with advanced pathology, “especially smaller polyps less than 9 mm in size with villous pathology and larger adenomas that are flat in nature or resemble a mucosal fold.”

Both Dr. Cornett and coauthor Dr. Courtney Barancin, a gastroenterology fellow, expressed concern that some protocols for virtual colonoscopy do not refer for optical colonoscopy patients with lesions less than 6 mm.

INDIAN WELLS, CALIF. — Successful pregnancies and deliveries have resulted from donated embryos that had been frozen for more than 10 years, raising questions about arbitrary deadlines for unused embryos to be destroyed.

Researchers at the Cooper Center for In-Vitro Fertilization in Marlton, N.J., studied the viability of frozen embryos anonymously donated to infertile couples to see whether long-term freezing had an impact on their quality or survival.

Results were presented in poster at the annual meeting of the Pacific Coast Reproductive Society. (See chart.)

“There did not appear to be any decrease in pregnancy or implantation rates with longer storage duration. In contrast, there seemed to be a trend for the older embryos to do slightly better, with a higher pregnancy rate and lower spontaneous abortion rate, although this was not significant,” noted Dr. Jerome H. Check, medical director of the center, and his associates.

In two cases, live births resulted from embryos that had been frozen for more than 10 years.

A twin pregnancy resulted from an embryo stored 11.8 years by a donor who was aged 38 years at the time of storage. A total of six embryos were available for transfer and all survived thawing. Among the three transferred embryos, all reached the eight-cell stage and were of good quality. The recipient was delivered of a healthy boy and girl at full term.

A second live birth resulted from an embryo stored for 10.8 years by a 27-year-old donor. Three of four embryos available for thawing survived and two were transferred. Both had good morphology and had reached the eight- and nine-cell stage, respectively, at the time of transfer. A pregnancy resulted in the birth of a healthy, full-term boy.

A literature search revealed that the longest time a multicell embryo has been frozen and then resulted in a delivery was 12 years, but an increasing number of reports suggests that healthy babies can result from embryos frozen indefinitely.

“These data are important, since legislation in some countries allows or requires embryos to be destroyed after 2–5 years of storage,” the poster noted.

“Unequivocally, cryopreserved embryos can produce viable pregnancies and deliveries far beyond this arbitrary cutoff time. When considered in combination with a voluntary embryo donation program, it seems wise to allow [in vitro fertilization] couples the option of cryopreserving supernumerary embryos and donating them when no longer needed,” no matter how long the time period, the authors said.

The Cooper center is part of Cooper University Hospital, where Dr. Check serves as professor of obstetrics and gynecology and director of reproductive endocrinology. It is the teaching hospital for the University of Medicine and Dentistry of New Jersey/Robert Wood Johnson Medical School-Camden.

ELSEVIER GLOBAL MEDICAL NEWS

INDIAN WELLS, CALIF. — Successful pregnancies and deliveries have resulted from donated embryos that had been frozen for more than 10 years, raising questions about arbitrary deadlines for unused embryos to be destroyed.

Researchers at the Cooper Center for In-Vitro Fertilization in Marlton, N.J., studied the viability of frozen embryos anonymously donated to infertile couples to see whether long-term freezing had an impact on their quality or survival.

Results were presented in poster at the annual meeting of the Pacific Coast Reproductive Society. (See chart.)

“There did not appear to be any decrease in pregnancy or implantation rates with longer storage duration. In contrast, there seemed to be a trend for the older embryos to do slightly better, with a higher pregnancy rate and lower spontaneous abortion rate, although this was not significant,” noted Dr. Jerome H. Check, medical director of the center, and his associates.

In two cases, live births resulted from embryos that had been frozen for more than 10 years.

A twin pregnancy resulted from an embryo stored 11.8 years by a donor who was aged 38 years at the time of storage. A total of six embryos were available for transfer and all survived thawing. Among the three transferred embryos, all reached the eight-cell stage and were of good quality. The recipient was delivered of a healthy boy and girl at full term.

A second live birth resulted from an embryo stored for 10.8 years by a 27-year-old donor. Three of four embryos available for thawing survived and two were transferred. Both had good morphology and had reached the eight- and nine-cell stage, respectively, at the time of transfer. A pregnancy resulted in the birth of a healthy, full-term boy.

A literature search revealed that the longest time a multicell embryo has been frozen and then resulted in a delivery was 12 years, but an increasing number of reports suggests that healthy babies can result from embryos frozen indefinitely.

“These data are important, since legislation in some countries allows or requires embryos to be destroyed after 2–5 years of storage,” the poster noted.

“Unequivocally, cryopreserved embryos can produce viable pregnancies and deliveries far beyond this arbitrary cutoff time. When considered in combination with a voluntary embryo donation program, it seems wise to allow [in vitro fertilization] couples the option of cryopreserving supernumerary embryos and donating them when no longer needed,” no matter how long the time period, the authors said.

The Cooper center is part of Cooper University Hospital, where Dr. Check serves as professor of obstetrics and gynecology and director of reproductive endocrinology. It is the teaching hospital for the University of Medicine and Dentistry of New Jersey/Robert Wood Johnson Medical School-Camden.

ELSEVIER GLOBAL MEDICAL NEWS

INDIAN WELLS, CALIF. — Successful pregnancies and deliveries have resulted from donated embryos that had been frozen for more than 10 years, raising questions about arbitrary deadlines for unused embryos to be destroyed.

Researchers at the Cooper Center for In-Vitro Fertilization in Marlton, N.J., studied the viability of frozen embryos anonymously donated to infertile couples to see whether long-term freezing had an impact on their quality or survival.

Results were presented in poster at the annual meeting of the Pacific Coast Reproductive Society. (See chart.)

“There did not appear to be any decrease in pregnancy or implantation rates with longer storage duration. In contrast, there seemed to be a trend for the older embryos to do slightly better, with a higher pregnancy rate and lower spontaneous abortion rate, although this was not significant,” noted Dr. Jerome H. Check, medical director of the center, and his associates.

In two cases, live births resulted from embryos that had been frozen for more than 10 years.

A twin pregnancy resulted from an embryo stored 11.8 years by a donor who was aged 38 years at the time of storage. A total of six embryos were available for transfer and all survived thawing. Among the three transferred embryos, all reached the eight-cell stage and were of good quality. The recipient was delivered of a healthy boy and girl at full term.

A second live birth resulted from an embryo stored for 10.8 years by a 27-year-old donor. Three of four embryos available for thawing survived and two were transferred. Both had good morphology and had reached the eight- and nine-cell stage, respectively, at the time of transfer. A pregnancy resulted in the birth of a healthy, full-term boy.

A literature search revealed that the longest time a multicell embryo has been frozen and then resulted in a delivery was 12 years, but an increasing number of reports suggests that healthy babies can result from embryos frozen indefinitely.

“These data are important, since legislation in some countries allows or requires embryos to be destroyed after 2–5 years of storage,” the poster noted.

“Unequivocally, cryopreserved embryos can produce viable pregnancies and deliveries far beyond this arbitrary cutoff time. When considered in combination with a voluntary embryo donation program, it seems wise to allow [in vitro fertilization] couples the option of cryopreserving supernumerary embryos and donating them when no longer needed,” no matter how long the time period, the authors said.

The Cooper center is part of Cooper University Hospital, where Dr. Check serves as professor of obstetrics and gynecology and director of reproductive endocrinology. It is the teaching hospital for the University of Medicine and Dentistry of New Jersey/Robert Wood Johnson Medical School-Camden.

ELSEVIER GLOBAL MEDICAL NEWS

LOS ANGELES — Low literacy was by far the most common independent predictor of poor bowel preparation and incomplete colonoscopy in a study presented at the annual Digestive Disease Week.

Among 195 patients who underwent colonoscopy at an inner city hospital, John H. Stroger Jr. Hospital of Cook County, 30% had poor bowel preparation, requiring a repeat examination.

Another 22% had only “fair” bowel preparation, meaning small or flat lesions could be missed, reported Dr. Rony Ghaoui, a fellow in gastroenterology at Rush Medical College, Chicago.

Fully one-quarter of the colonoscopies were incomplete, 90% of them because of poor bowel preparation.

The patients included in the study ranged in age from 18 to 82 years (mean age 54). Most (64%) were women, and 49% were African American, 32% were Hispanic, and 11% were non-Hispanic white.

Written instructions given to patients at the time the colonoscopies were scheduled were available in either English or Spanish.

A 7-minute literacy test administered to patients on the morning of their examinations determined that 40% had low literacy, about 20% had marginal literacy, and about 40% had adequate literacy.

Among those with low literacy, 63% had poor bowel preparation, compared with 12% of those patients with marginal or adequate literacy.

Importantly, however, more than 80% of patients with low literacy said they had adhered to the bowel preparation instructions.

Just 5 of 78 patients with low literacy said they had difficulty reading in general, and only 8 said they had difficulty reading the bowel preparation instructions.

“[This] was, for me, an eye-opener as to how difficult it is for us as physicians to really detect the literacy problem,” Dr. Ghaoui said. Although 40 million Americans—an estimated 26% of the population—have difficulty reading, “It's taboo. People don't talk about it,” he said. In one study, nearly 70% of illiterate adults had not confided that fact to a spouse or child.

The issue of literacy is critically important in current protocols for colonoscopy preparation, which rely on written instructions. When colonoscopies cannot be completed or must be repeated because of poor bowel preparation, there is “a long list of consequences,” he stressed, including patient inconvenience and time away from work, scheduling burdens at busy facilities, a waste of resources, and potentially delayed or missed diagnoses of colorectal cancer.

The odds ratios for predicting poor bowel preparation (after adjusting for age, gender, ethnic group, and language) were 12 for low literacy, 6 for eating dinner the night before the examination, and 5 for not taking bisacodyl.

Other important predictors included eating lunch the previous day, and not finishing the polyethelene glycol solution. Receiving additional instructions about the preparation process from a physician or a nurse was somewhat protective, with an odds ratio of 0.5.

Using the best predictive model in a logistic regression analysis, the odds ratio for low literacy was even higher, at 22, Dr. Ghaoui said.

He called for more research into how low literacy translates into poor preparation—whether the instructions themselves are misunderstood, or whether patients with low literacy do not understand the importance of the test itself or of adherence to the instructions.

Because patients do not volunteer the fact that they have low literacy, brief tools to measure literacy might be helpful for physicians to use in their practices, he added.

Finally, better methods of explaining colonoscopy preparation must be developed and tested, Dr. Ghaoui said.

LOS ANGELES — Low literacy was by far the most common independent predictor of poor bowel preparation and incomplete colonoscopy in a study presented at the annual Digestive Disease Week.

Among 195 patients who underwent colonoscopy at an inner city hospital, John H. Stroger Jr. Hospital of Cook County, 30% had poor bowel preparation, requiring a repeat examination.

Another 22% had only “fair” bowel preparation, meaning small or flat lesions could be missed, reported Dr. Rony Ghaoui, a fellow in gastroenterology at Rush Medical College, Chicago.

Fully one-quarter of the colonoscopies were incomplete, 90% of them because of poor bowel preparation.

The patients included in the study ranged in age from 18 to 82 years (mean age 54). Most (64%) were women, and 49% were African American, 32% were Hispanic, and 11% were non-Hispanic white.

Written instructions given to patients at the time the colonoscopies were scheduled were available in either English or Spanish.

A 7-minute literacy test administered to patients on the morning of their examinations determined that 40% had low literacy, about 20% had marginal literacy, and about 40% had adequate literacy.

Among those with low literacy, 63% had poor bowel preparation, compared with 12% of those patients with marginal or adequate literacy.

Importantly, however, more than 80% of patients with low literacy said they had adhered to the bowel preparation instructions.

Just 5 of 78 patients with low literacy said they had difficulty reading in general, and only 8 said they had difficulty reading the bowel preparation instructions.

“[This] was, for me, an eye-opener as to how difficult it is for us as physicians to really detect the literacy problem,” Dr. Ghaoui said. Although 40 million Americans—an estimated 26% of the population—have difficulty reading, “It's taboo. People don't talk about it,” he said. In one study, nearly 70% of illiterate adults had not confided that fact to a spouse or child.

The issue of literacy is critically important in current protocols for colonoscopy preparation, which rely on written instructions. When colonoscopies cannot be completed or must be repeated because of poor bowel preparation, there is “a long list of consequences,” he stressed, including patient inconvenience and time away from work, scheduling burdens at busy facilities, a waste of resources, and potentially delayed or missed diagnoses of colorectal cancer.

The odds ratios for predicting poor bowel preparation (after adjusting for age, gender, ethnic group, and language) were 12 for low literacy, 6 for eating dinner the night before the examination, and 5 for not taking bisacodyl.

Other important predictors included eating lunch the previous day, and not finishing the polyethelene glycol solution. Receiving additional instructions about the preparation process from a physician or a nurse was somewhat protective, with an odds ratio of 0.5.

Using the best predictive model in a logistic regression analysis, the odds ratio for low literacy was even higher, at 22, Dr. Ghaoui said.

He called for more research into how low literacy translates into poor preparation—whether the instructions themselves are misunderstood, or whether patients with low literacy do not understand the importance of the test itself or of adherence to the instructions.

Because patients do not volunteer the fact that they have low literacy, brief tools to measure literacy might be helpful for physicians to use in their practices, he added.

Finally, better methods of explaining colonoscopy preparation must be developed and tested, Dr. Ghaoui said.

LOS ANGELES — Low literacy was by far the most common independent predictor of poor bowel preparation and incomplete colonoscopy in a study presented at the annual Digestive Disease Week.

Among 195 patients who underwent colonoscopy at an inner city hospital, John H. Stroger Jr. Hospital of Cook County, 30% had poor bowel preparation, requiring a repeat examination.

Another 22% had only “fair” bowel preparation, meaning small or flat lesions could be missed, reported Dr. Rony Ghaoui, a fellow in gastroenterology at Rush Medical College, Chicago.

Fully one-quarter of the colonoscopies were incomplete, 90% of them because of poor bowel preparation.

The patients included in the study ranged in age from 18 to 82 years (mean age 54). Most (64%) were women, and 49% were African American, 32% were Hispanic, and 11% were non-Hispanic white.

Written instructions given to patients at the time the colonoscopies were scheduled were available in either English or Spanish.

A 7-minute literacy test administered to patients on the morning of their examinations determined that 40% had low literacy, about 20% had marginal literacy, and about 40% had adequate literacy.

Among those with low literacy, 63% had poor bowel preparation, compared with 12% of those patients with marginal or adequate literacy.

Importantly, however, more than 80% of patients with low literacy said they had adhered to the bowel preparation instructions.

Just 5 of 78 patients with low literacy said they had difficulty reading in general, and only 8 said they had difficulty reading the bowel preparation instructions.

“[This] was, for me, an eye-opener as to how difficult it is for us as physicians to really detect the literacy problem,” Dr. Ghaoui said. Although 40 million Americans—an estimated 26% of the population—have difficulty reading, “It's taboo. People don't talk about it,” he said. In one study, nearly 70% of illiterate adults had not confided that fact to a spouse or child.

The issue of literacy is critically important in current protocols for colonoscopy preparation, which rely on written instructions. When colonoscopies cannot be completed or must be repeated because of poor bowel preparation, there is “a long list of consequences,” he stressed, including patient inconvenience and time away from work, scheduling burdens at busy facilities, a waste of resources, and potentially delayed or missed diagnoses of colorectal cancer.

The odds ratios for predicting poor bowel preparation (after adjusting for age, gender, ethnic group, and language) were 12 for low literacy, 6 for eating dinner the night before the examination, and 5 for not taking bisacodyl.

Other important predictors included eating lunch the previous day, and not finishing the polyethelene glycol solution. Receiving additional instructions about the preparation process from a physician or a nurse was somewhat protective, with an odds ratio of 0.5.

Using the best predictive model in a logistic regression analysis, the odds ratio for low literacy was even higher, at 22, Dr. Ghaoui said.

He called for more research into how low literacy translates into poor preparation—whether the instructions themselves are misunderstood, or whether patients with low literacy do not understand the importance of the test itself or of adherence to the instructions.

Because patients do not volunteer the fact that they have low literacy, brief tools to measure literacy might be helpful for physicians to use in their practices, he added.

Finally, better methods of explaining colonoscopy preparation must be developed and tested, Dr. Ghaoui said.

LOS ANGELES — A number of clinical, laboratory, and serologic “red flags” may distinguish patients with ulcerative colitis who will progress to a diagnosis of Crohn's disease, researchers reported at the annual Digestive Disease Week.

Dr. Gil Y. Melmed and his associates at the Inflammatory Bowel Disease Center at Cedars-Sinai Medical Center and the University of California, Los Angeles, designed a nested case-control study to compare 21 patients whose diagnosis evolved into Crohn's disease with two groups of age-matched controls: 52 patients with simple ulcerative colitis and 56 patients with Crohn's disease.

Patients whose disease progressed were more likely than other ulcerative colitis patients to have extensive colonic involvement at diagnosis and a positive C Bir1 serology. In addition, they had an increased likelihood of having two or more red flags at initial presentation, including:

▸ Weight loss of more than 10% of body weight.

▸ Nonbloody diarrhea.

▸ Family history of Crohn's disease in at least one first-degree relative.

▸ Oral ulceration.

▸ Active smoking.

▸ Upper GI symptoms.

▸ History of blood transfusion.

▸ Perianal disease.

▸ Non-H. pylori gastritis.

▸ Thrombocytosis.

▸ Elevated C-reactive protein level.

▸ Hypoalbuminemia.

Other red flags included Crohn's disease-associated serologies, including ASCA IgA, ASCA IgG, anti-0mp-C, and anti-12.

A multivariate logistic regression analysis found three red flags that independently raised the odds of an ulcerative colitis patient progressing to the more serious diagnosis of Crohn's disease. These were nonbloody diarrhea at presentation (odds ratio, 23.5), weight loss (odds ratio, 12.4), and a positive C Bir1 serology (odds ratio, 6).

Nearly half of the patients who went on to develop Crohn's disease had pancolitis at initial colonoscopy, and two had an inflammatory condition of the ileum, “backwash ileus.”

None of the control patients with ulcerative colitis had total colonic involvement, and just 9 of 52 had pancolitis. The majority had left-sided involvement or proctitis.

Although “red flags” were present in all patients who went on to develop Crohn's disease, the length of time to a change in diagnosis was variable, ranging from 6 months to 17 years, with a mean of 4 years, Dr. Melmed noted in his poster presentation.

In an interview after the meeting, he said members of his group were surprised by the strength of the associations they identified, despite the small sample size.

“Something about the initial disease presentation seems to be very indicative in our cohort of a change in diagnosis, and we are beginning to learn about the role serology has to play in these patients as well,” he said.

He advocated a further work-up of patients with ulcerative colitis who have these features, particularly if they are not responding to conventional therapy, considering surgery, or being considered for enrollment in a clinical trial.

An appropriate work-up would include colonoscopy with ileoscopy (if not previously performed), a small bowel series with barium, or CT, MR enterography, capsule endoscopy, or upper endoscopy.

“Another issue that came up in our study was that many people with ulcerative colitis had been diagnosed on the basis of a flexible sigmoidoscopy rather than a complete colonoscopy, which could potentially identify Crohn's disease. We had to exclude these patients, who may have been misdiagnosed from the outset of their disease course,” Dr. Melmed said.

The study was sponsored by the International Organization for the Study of Inflammatory Bowel Disease and a grant from the National Institutes of Health.

LOS ANGELES — A number of clinical, laboratory, and serologic “red flags” may distinguish patients with ulcerative colitis who will progress to a diagnosis of Crohn's disease, researchers reported at the annual Digestive Disease Week.

Dr. Gil Y. Melmed and his associates at the Inflammatory Bowel Disease Center at Cedars-Sinai Medical Center and the University of California, Los Angeles, designed a nested case-control study to compare 21 patients whose diagnosis evolved into Crohn's disease with two groups of age-matched controls: 52 patients with simple ulcerative colitis and 56 patients with Crohn's disease.

Patients whose disease progressed were more likely than other ulcerative colitis patients to have extensive colonic involvement at diagnosis and a positive C Bir1 serology. In addition, they had an increased likelihood of having two or more red flags at initial presentation, including:

▸ Weight loss of more than 10% of body weight.

▸ Nonbloody diarrhea.

▸ Family history of Crohn's disease in at least one first-degree relative.

▸ Oral ulceration.

▸ Active smoking.

▸ Upper GI symptoms.

▸ History of blood transfusion.

▸ Perianal disease.

▸ Non-H. pylori gastritis.

▸ Thrombocytosis.

▸ Elevated C-reactive protein level.

▸ Hypoalbuminemia.

Other red flags included Crohn's disease-associated serologies, including ASCA IgA, ASCA IgG, anti-0mp-C, and anti-12.

A multivariate logistic regression analysis found three red flags that independently raised the odds of an ulcerative colitis patient progressing to the more serious diagnosis of Crohn's disease. These were nonbloody diarrhea at presentation (odds ratio, 23.5), weight loss (odds ratio, 12.4), and a positive C Bir1 serology (odds ratio, 6).

Nearly half of the patients who went on to develop Crohn's disease had pancolitis at initial colonoscopy, and two had an inflammatory condition of the ileum, “backwash ileus.”

None of the control patients with ulcerative colitis had total colonic involvement, and just 9 of 52 had pancolitis. The majority had left-sided involvement or proctitis.

Although “red flags” were present in all patients who went on to develop Crohn's disease, the length of time to a change in diagnosis was variable, ranging from 6 months to 17 years, with a mean of 4 years, Dr. Melmed noted in his poster presentation.

In an interview after the meeting, he said members of his group were surprised by the strength of the associations they identified, despite the small sample size.

“Something about the initial disease presentation seems to be very indicative in our cohort of a change in diagnosis, and we are beginning to learn about the role serology has to play in these patients as well,” he said.

He advocated a further work-up of patients with ulcerative colitis who have these features, particularly if they are not responding to conventional therapy, considering surgery, or being considered for enrollment in a clinical trial.

An appropriate work-up would include colonoscopy with ileoscopy (if not previously performed), a small bowel series with barium, or CT, MR enterography, capsule endoscopy, or upper endoscopy.

“Another issue that came up in our study was that many people with ulcerative colitis had been diagnosed on the basis of a flexible sigmoidoscopy rather than a complete colonoscopy, which could potentially identify Crohn's disease. We had to exclude these patients, who may have been misdiagnosed from the outset of their disease course,” Dr. Melmed said.

The study was sponsored by the International Organization for the Study of Inflammatory Bowel Disease and a grant from the National Institutes of Health.

LOS ANGELES — A number of clinical, laboratory, and serologic “red flags” may distinguish patients with ulcerative colitis who will progress to a diagnosis of Crohn's disease, researchers reported at the annual Digestive Disease Week.

Dr. Gil Y. Melmed and his associates at the Inflammatory Bowel Disease Center at Cedars-Sinai Medical Center and the University of California, Los Angeles, designed a nested case-control study to compare 21 patients whose diagnosis evolved into Crohn's disease with two groups of age-matched controls: 52 patients with simple ulcerative colitis and 56 patients with Crohn's disease.

Patients whose disease progressed were more likely than other ulcerative colitis patients to have extensive colonic involvement at diagnosis and a positive C Bir1 serology. In addition, they had an increased likelihood of having two or more red flags at initial presentation, including:

▸ Weight loss of more than 10% of body weight.

▸ Nonbloody diarrhea.

▸ Family history of Crohn's disease in at least one first-degree relative.

▸ Oral ulceration.

▸ Active smoking.

▸ Upper GI symptoms.

▸ History of blood transfusion.

▸ Perianal disease.

▸ Non-H. pylori gastritis.

▸ Thrombocytosis.

▸ Elevated C-reactive protein level.

▸ Hypoalbuminemia.

Other red flags included Crohn's disease-associated serologies, including ASCA IgA, ASCA IgG, anti-0mp-C, and anti-12.

A multivariate logistic regression analysis found three red flags that independently raised the odds of an ulcerative colitis patient progressing to the more serious diagnosis of Crohn's disease. These were nonbloody diarrhea at presentation (odds ratio, 23.5), weight loss (odds ratio, 12.4), and a positive C Bir1 serology (odds ratio, 6).

Nearly half of the patients who went on to develop Crohn's disease had pancolitis at initial colonoscopy, and two had an inflammatory condition of the ileum, “backwash ileus.”

None of the control patients with ulcerative colitis had total colonic involvement, and just 9 of 52 had pancolitis. The majority had left-sided involvement or proctitis.

Although “red flags” were present in all patients who went on to develop Crohn's disease, the length of time to a change in diagnosis was variable, ranging from 6 months to 17 years, with a mean of 4 years, Dr. Melmed noted in his poster presentation.

In an interview after the meeting, he said members of his group were surprised by the strength of the associations they identified, despite the small sample size.

“Something about the initial disease presentation seems to be very indicative in our cohort of a change in diagnosis, and we are beginning to learn about the role serology has to play in these patients as well,” he said.

He advocated a further work-up of patients with ulcerative colitis who have these features, particularly if they are not responding to conventional therapy, considering surgery, or being considered for enrollment in a clinical trial.

An appropriate work-up would include colonoscopy with ileoscopy (if not previously performed), a small bowel series with barium, or CT, MR enterography, capsule endoscopy, or upper endoscopy.

“Another issue that came up in our study was that many people with ulcerative colitis had been diagnosed on the basis of a flexible sigmoidoscopy rather than a complete colonoscopy, which could potentially identify Crohn's disease. We had to exclude these patients, who may have been misdiagnosed from the outset of their disease course,” Dr. Melmed said.

The study was sponsored by the International Organization for the Study of Inflammatory Bowel Disease and a grant from the National Institutes of Health.

LOS ANGELES — A combination of rifaximin and loperamide, taken at the first sign of traveler's diarrhea, is the optimal way to treat an illness that affects 10 million American tourists a year, Dr. Herbert L. DuPont said at the annual Digestive Disease Week.

Rifaximin, a gut-selective antibiotic, and loperamide, an antimotility agent, were tested alone and in combination in a randomized trial of 315 U.S. college students who developed acute diarrhea and at least one symptom of an enteric infection while studying in Mexico.

“The Imodium [loperamide] immediately stopped the diarrhea and the antibiotic cured the disease,” Dr. DuPont said in an interview during the meeting.

“If they took Imodium alone, they got immediate improvement, but then they continued to be sick. Rifaximin by itself was slow to get going, but it cured the disease after 24–30 hours,” he said.

“The combination zapped the thing rapidly and cured it, so we think it's probably the optimal way to manage traveler's diarrhea,” said Dr. DuPont, professor of medicine and epidemiology at the University of Texas, Houston, and chief of internal medicine at St. Luke's Episcopal Hospital, also in Houston.

The participants were assigned to receive either 200 mg of rifaximin three times daily for 3 days; 4 mg of loperamide initially, followed by 2 mg after each unformed stool, not to exceed 8 mg/day for 48 hours; or both of these regimens simultaneously.

During the 5-day study period, more than 75% of the students receiving rifaximin or the drug combination achieved a clinical cure, compared with 58% of those receiving loperamide alone.

The time from initiation of treatment to the passage of the last unformed stool was also shorter in patients taking the drug combination (27.3 hours) or rifaximin alone (32.5 hours) than with loperamide alone (69 hours), he reported.

Loperamide and the drug combination resulted in significantly fewer stools passed in the first 24 hours, but in the case of loperamide alone, the effect was transient.

Abdominal cramps were less frequent in patients taking the rifaximin-loperamide combination.

Finally, the participants' assessment of “complete wellness” was higher with rifaximin and the rifaximin-loperamide combination. All of the treatments were well tolerated.

In the poster presentation, Dr. DuPont concluded that the drug combination “provides clinically relevant benefits vs. either agent alone, providing more rapid symptom relief and clinical cure… [possibly representing] a new standard of care.”

Loperamide is available over the counter, and rifaximin is FDA approved for traveler's diarrhea. Salix Pharmaceuticals Inc., maker of rifaximin, provided funding for the study.

LOS ANGELES — A combination of rifaximin and loperamide, taken at the first sign of traveler's diarrhea, is the optimal way to treat an illness that affects 10 million American tourists a year, Dr. Herbert L. DuPont said at the annual Digestive Disease Week.

Rifaximin, a gut-selective antibiotic, and loperamide, an antimotility agent, were tested alone and in combination in a randomized trial of 315 U.S. college students who developed acute diarrhea and at least one symptom of an enteric infection while studying in Mexico.

“The Imodium [loperamide] immediately stopped the diarrhea and the antibiotic cured the disease,” Dr. DuPont said in an interview during the meeting.

“If they took Imodium alone, they got immediate improvement, but then they continued to be sick. Rifaximin by itself was slow to get going, but it cured the disease after 24–30 hours,” he said.

“The combination zapped the thing rapidly and cured it, so we think it's probably the optimal way to manage traveler's diarrhea,” said Dr. DuPont, professor of medicine and epidemiology at the University of Texas, Houston, and chief of internal medicine at St. Luke's Episcopal Hospital, also in Houston.

The participants were assigned to receive either 200 mg of rifaximin three times daily for 3 days; 4 mg of loperamide initially, followed by 2 mg after each unformed stool, not to exceed 8 mg/day for 48 hours; or both of these regimens simultaneously.

During the 5-day study period, more than 75% of the students receiving rifaximin or the drug combination achieved a clinical cure, compared with 58% of those receiving loperamide alone.

The time from initiation of treatment to the passage of the last unformed stool was also shorter in patients taking the drug combination (27.3 hours) or rifaximin alone (32.5 hours) than with loperamide alone (69 hours), he reported.

Loperamide and the drug combination resulted in significantly fewer stools passed in the first 24 hours, but in the case of loperamide alone, the effect was transient.

Abdominal cramps were less frequent in patients taking the rifaximin-loperamide combination.

Finally, the participants' assessment of “complete wellness” was higher with rifaximin and the rifaximin-loperamide combination. All of the treatments were well tolerated.

In the poster presentation, Dr. DuPont concluded that the drug combination “provides clinically relevant benefits vs. either agent alone, providing more rapid symptom relief and clinical cure… [possibly representing] a new standard of care.”

Loperamide is available over the counter, and rifaximin is FDA approved for traveler's diarrhea. Salix Pharmaceuticals Inc., maker of rifaximin, provided funding for the study.

LOS ANGELES — A combination of rifaximin and loperamide, taken at the first sign of traveler's diarrhea, is the optimal way to treat an illness that affects 10 million American tourists a year, Dr. Herbert L. DuPont said at the annual Digestive Disease Week.

Rifaximin, a gut-selective antibiotic, and loperamide, an antimotility agent, were tested alone and in combination in a randomized trial of 315 U.S. college students who developed acute diarrhea and at least one symptom of an enteric infection while studying in Mexico.

“The Imodium [loperamide] immediately stopped the diarrhea and the antibiotic cured the disease,” Dr. DuPont said in an interview during the meeting.

“If they took Imodium alone, they got immediate improvement, but then they continued to be sick. Rifaximin by itself was slow to get going, but it cured the disease after 24–30 hours,” he said.

“The combination zapped the thing rapidly and cured it, so we think it's probably the optimal way to manage traveler's diarrhea,” said Dr. DuPont, professor of medicine and epidemiology at the University of Texas, Houston, and chief of internal medicine at St. Luke's Episcopal Hospital, also in Houston.

The participants were assigned to receive either 200 mg of rifaximin three times daily for 3 days; 4 mg of loperamide initially, followed by 2 mg after each unformed stool, not to exceed 8 mg/day for 48 hours; or both of these regimens simultaneously.

During the 5-day study period, more than 75% of the students receiving rifaximin or the drug combination achieved a clinical cure, compared with 58% of those receiving loperamide alone.

The time from initiation of treatment to the passage of the last unformed stool was also shorter in patients taking the drug combination (27.3 hours) or rifaximin alone (32.5 hours) than with loperamide alone (69 hours), he reported.

Loperamide and the drug combination resulted in significantly fewer stools passed in the first 24 hours, but in the case of loperamide alone, the effect was transient.

Abdominal cramps were less frequent in patients taking the rifaximin-loperamide combination.

Finally, the participants' assessment of “complete wellness” was higher with rifaximin and the rifaximin-loperamide combination. All of the treatments were well tolerated.

In the poster presentation, Dr. DuPont concluded that the drug combination “provides clinically relevant benefits vs. either agent alone, providing more rapid symptom relief and clinical cure… [possibly representing] a new standard of care.”

Loperamide is available over the counter, and rifaximin is FDA approved for traveler's diarrhea. Salix Pharmaceuticals Inc., maker of rifaximin, provided funding for the study.

SANTA BARBARA, CALIF. – The children of older mothers who drank during pregnancy were shorter and had smaller head circumferences at the ages of 7 and 14 years than other children at those ages, it was reported at the annual meeting of the Research Society on Alcoholism.

Children of mothers who were 30 or older at delivery were affected above a threshold of moderate alcohol consumption, defined as about one alcoholic drink a day at the time of conception. Many women reduced their drinking during pregnancy, but the heaviest drinkers reduced their drinking less.

“Even if women reduce their drinking during pregnancy, their early drinking before they realize they are pregnant may have an impact on the infant,” said Sandra W. Jacobson, Ph.D., professor of psychiatry and behavioral neurosciences at Wayne State University in Detroit, a senior author on the study.

“We see effects in infants whose mothers drink as little as one drink/day, on average.”

Dr. Jacobson stressed that “average” drinks per day did not reflect the actual drinking patterns among women in the study. Just 1 woman of the 480 in the Detroit Longitudinal Prenatal Alcohol Exposure study actually drank every day.

Many of the others concentrated their drinking on 1 or 2 days a week, in some cases drinking three to four drinks at each session, she explained following the meeting.

Mean alcohol consumption at conception was about two drinks per day in the study of economically disadvantaged African American women and their children.

Mean alcohol intake dropped during pregnancy to a little more than two drinks per week.

Prenatal alcohol exposure was associated with lower birthweight and length in the entire sample of women, even after researchers controlled for smoking and other possible confounders, Dr. Jacobson said.

For mothers over 30 years of age at conception, the repercussions were long lasting.

With a cutoff point of 0.5 ounces of alcohol per day at conception, older mothers' children were 1.2 cm, 3.1 cm, and 3.7 cm shorter at birth, 7.5 years, and 14 years, respectively, than children of mothers with minimal alcohol exposure, she reported.

Their mean head circumference was smaller by 4.6 mm, 7.3 mm, and 14.5 mm at birth, 7.5 years, and 14 years.

“Prenatal alcohol exposure was not related to weight or body mass index at 7.5 or 14 years, suggesting that the effects on height and head circumference were not attributable to poor maternal nutrition,” the researchers reported in their poster presentation.

Smoking during pregnancy resulted in lower birthweight and reduced length and head circumference at birth, but had no discernible impact on children's growth over time.

In contrast, prenatal alcohol exposure's impact on size was evident at birth and became magnified as the study continued.

Although the study suggests that the children of older mothers are most vulnerable to prenatal alcohol exposure, all women who are considering pregnancy should be urged to stop drinking or to cut down as much as possible.

“At this time, no drinking is considered safe,” said Dr. Jacobson.

The study was supported by grants from the National Institute on Alcohol Abuse and Alcoholism and the Joseph Young, Sr., Fund of Michigan.

Douglas Fuller, a research assistant in the Wayne State University department of psychiatry and behavioral neurosciences, contributed to the study.

ELSEVIER GLOBAL MEDICAL NEWS

SANTA BARBARA, CALIF. – The children of older mothers who drank during pregnancy were shorter and had smaller head circumferences at the ages of 7 and 14 years than other children at those ages, it was reported at the annual meeting of the Research Society on Alcoholism.

Children of mothers who were 30 or older at delivery were affected above a threshold of moderate alcohol consumption, defined as about one alcoholic drink a day at the time of conception. Many women reduced their drinking during pregnancy, but the heaviest drinkers reduced their drinking less.

“Even if women reduce their drinking during pregnancy, their early drinking before they realize they are pregnant may have an impact on the infant,” said Sandra W. Jacobson, Ph.D., professor of psychiatry and behavioral neurosciences at Wayne State University in Detroit, a senior author on the study.

“We see effects in infants whose mothers drink as little as one drink/day, on average.”

Dr. Jacobson stressed that “average” drinks per day did not reflect the actual drinking patterns among women in the study. Just 1 woman of the 480 in the Detroit Longitudinal Prenatal Alcohol Exposure study actually drank every day.

Many of the others concentrated their drinking on 1 or 2 days a week, in some cases drinking three to four drinks at each session, she explained following the meeting.

Mean alcohol consumption at conception was about two drinks per day in the study of economically disadvantaged African American women and their children.

Mean alcohol intake dropped during pregnancy to a little more than two drinks per week.

Prenatal alcohol exposure was associated with lower birthweight and length in the entire sample of women, even after researchers controlled for smoking and other possible confounders, Dr. Jacobson said.

For mothers over 30 years of age at conception, the repercussions were long lasting.

With a cutoff point of 0.5 ounces of alcohol per day at conception, older mothers' children were 1.2 cm, 3.1 cm, and 3.7 cm shorter at birth, 7.5 years, and 14 years, respectively, than children of mothers with minimal alcohol exposure, she reported.

Their mean head circumference was smaller by 4.6 mm, 7.3 mm, and 14.5 mm at birth, 7.5 years, and 14 years.

“Prenatal alcohol exposure was not related to weight or body mass index at 7.5 or 14 years, suggesting that the effects on height and head circumference were not attributable to poor maternal nutrition,” the researchers reported in their poster presentation.

Smoking during pregnancy resulted in lower birthweight and reduced length and head circumference at birth, but had no discernible impact on children's growth over time.

In contrast, prenatal alcohol exposure's impact on size was evident at birth and became magnified as the study continued.

Although the study suggests that the children of older mothers are most vulnerable to prenatal alcohol exposure, all women who are considering pregnancy should be urged to stop drinking or to cut down as much as possible.

“At this time, no drinking is considered safe,” said Dr. Jacobson.

The study was supported by grants from the National Institute on Alcohol Abuse and Alcoholism and the Joseph Young, Sr., Fund of Michigan.

Douglas Fuller, a research assistant in the Wayne State University department of psychiatry and behavioral neurosciences, contributed to the study.

ELSEVIER GLOBAL MEDICAL NEWS

SANTA BARBARA, CALIF. – The children of older mothers who drank during pregnancy were shorter and had smaller head circumferences at the ages of 7 and 14 years than other children at those ages, it was reported at the annual meeting of the Research Society on Alcoholism.

Children of mothers who were 30 or older at delivery were affected above a threshold of moderate alcohol consumption, defined as about one alcoholic drink a day at the time of conception. Many women reduced their drinking during pregnancy, but the heaviest drinkers reduced their drinking less.

“Even if women reduce their drinking during pregnancy, their early drinking before they realize they are pregnant may have an impact on the infant,” said Sandra W. Jacobson, Ph.D., professor of psychiatry and behavioral neurosciences at Wayne State University in Detroit, a senior author on the study.

“We see effects in infants whose mothers drink as little as one drink/day, on average.”

Dr. Jacobson stressed that “average” drinks per day did not reflect the actual drinking patterns among women in the study. Just 1 woman of the 480 in the Detroit Longitudinal Prenatal Alcohol Exposure study actually drank every day.

Many of the others concentrated their drinking on 1 or 2 days a week, in some cases drinking three to four drinks at each session, she explained following the meeting.

Mean alcohol consumption at conception was about two drinks per day in the study of economically disadvantaged African American women and their children.

Mean alcohol intake dropped during pregnancy to a little more than two drinks per week.

Prenatal alcohol exposure was associated with lower birthweight and length in the entire sample of women, even after researchers controlled for smoking and other possible confounders, Dr. Jacobson said.

For mothers over 30 years of age at conception, the repercussions were long lasting.

With a cutoff point of 0.5 ounces of alcohol per day at conception, older mothers' children were 1.2 cm, 3.1 cm, and 3.7 cm shorter at birth, 7.5 years, and 14 years, respectively, than children of mothers with minimal alcohol exposure, she reported.

Their mean head circumference was smaller by 4.6 mm, 7.3 mm, and 14.5 mm at birth, 7.5 years, and 14 years.

“Prenatal alcohol exposure was not related to weight or body mass index at 7.5 or 14 years, suggesting that the effects on height and head circumference were not attributable to poor maternal nutrition,” the researchers reported in their poster presentation.

Smoking during pregnancy resulted in lower birthweight and reduced length and head circumference at birth, but had no discernible impact on children's growth over time.

In contrast, prenatal alcohol exposure's impact on size was evident at birth and became magnified as the study continued.

Although the study suggests that the children of older mothers are most vulnerable to prenatal alcohol exposure, all women who are considering pregnancy should be urged to stop drinking or to cut down as much as possible.

“At this time, no drinking is considered safe,” said Dr. Jacobson.

The study was supported by grants from the National Institute on Alcohol Abuse and Alcoholism and the Joseph Young, Sr., Fund of Michigan.

Douglas Fuller, a research assistant in the Wayne State University department of psychiatry and behavioral neurosciences, contributed to the study.

ELSEVIER GLOBAL MEDICAL NEWS

LOS ANGELES — A number of clinical, laboratory, and serologic “red flags” may distinguish patients with ulcerative colitis who will progress to a diagnosis of Crohn's disease, researchers reported at the annual Digestive Disease Week.

Dr. Gil Y. Melmed and his associates at the Inflammatory Bowel Disease Center at Cedars-Sinai Medical Center and the University of California, Los Angeles, designed a nested case-control study to compare 21 patients whose diagnosis evolved into Crohn's disease with two groups of age-matched controls: 52 patients with simple ulcerative colitis and 56 patients with Crohn's disease.

Patients whose disease progressed were more likely than other ulcerative colitis patients to have extensive colonic involvement at diagnosis and a positive C Bir1 serology. In addition, they had an increased likelihood of having two or more red flags at initial presentation, including:

▸ Weight loss of more than 10% of body weight.

▸ Nonbloody diarrhea.

▸ Family history of Crohn's disease in at least one first-degree relative.

▸ Oral ulceration.

▸ Active smoking.

▸ Upper GI symptoms.

▸ History of blood transfusion.

▸ Perianal disease.

▸ Non-Helicobacter pylori gastritis.

▸ Thrombocytosis.

▸ Elevated C-reactive protein level.

▸ Hypoalbuminemia.

Other red flags included Crohn's disease-associated serologies, including ASCA IgA, ASCA IgG, anti-0mp-C, and anti-12.

A multivariate logistic regression analysis found three red flags that independently raised the odds of an ulcerative colitis patient progressing to the more serious diagnosis of Crohn's disease. These were nonbloody diarrhea at presentation (odds ratio, 23.5), weight loss (odds ratio, 12.4), and a positive C Bir1 serology (odds ratio, 6).

Nearly half of the patients who went on to develop Crohn's disease had pancolitis at initial colonoscopy, and two had an inflammatory condition of the ileum, “backwash ileus.”

None of the control patients with ulcerative colitis had total colonic involvement, and just 9 of 52 had pancolitis. The majority had left-sided involvement or proctitis.

Although red flags were present in all patients who went on to develop Crohn's disease, the length of time to a change in diagnosis was variable, ranging from 6 months to 17 years, with a mean of 4 years, Dr. Melmed noted in his poster presentation.

In an interview after the meeting, he said members of his group were surprised by the strength of the associations they identified, despite the small sample size.

“Something about the initial disease presentation seems to be very indicative in our cohort of a change in diagnosis, and we are beginning to learn about the role serology has to play in these patients as well,” he said.

He advocated a further work-up of patients with ulcerative colitis who have these features, particularly if they are not responding to conventional therapy, considering surgery, or being considered for enrollment in a clinical trial.

An appropriate work-up would include colonoscopy with ileoscopy (if not previously performed), a small bowel series with barium, or CT, MR enterography, capsule endoscopy, or upper endoscopy.

“Another issue that came up in our study was that many people with ulcerative colitis had been diagnosed on the basis of a flexible sigmoidoscopy rather than a complete colonoscopy, which could potentially identify Crohn's disease. We had to exclude these patients, who may have been misdiagnosed from the outset of their disease course,” Dr. Melmed said.

The study was sponsored by the International Organization for the Study of Inflammatory Bowel Disease and a grant from the National Institutes of Health.

LOS ANGELES — A number of clinical, laboratory, and serologic “red flags” may distinguish patients with ulcerative colitis who will progress to a diagnosis of Crohn's disease, researchers reported at the annual Digestive Disease Week.

Dr. Gil Y. Melmed and his associates at the Inflammatory Bowel Disease Center at Cedars-Sinai Medical Center and the University of California, Los Angeles, designed a nested case-control study to compare 21 patients whose diagnosis evolved into Crohn's disease with two groups of age-matched controls: 52 patients with simple ulcerative colitis and 56 patients with Crohn's disease.

Patients whose disease progressed were more likely than other ulcerative colitis patients to have extensive colonic involvement at diagnosis and a positive C Bir1 serology. In addition, they had an increased likelihood of having two or more red flags at initial presentation, including:

▸ Weight loss of more than 10% of body weight.

▸ Nonbloody diarrhea.

▸ Family history of Crohn's disease in at least one first-degree relative.

▸ Oral ulceration.

▸ Active smoking.

▸ Upper GI symptoms.

▸ History of blood transfusion.

▸ Perianal disease.

▸ Non-Helicobacter pylori gastritis.

▸ Thrombocytosis.

▸ Elevated C-reactive protein level.

▸ Hypoalbuminemia.

Other red flags included Crohn's disease-associated serologies, including ASCA IgA, ASCA IgG, anti-0mp-C, and anti-12.

A multivariate logistic regression analysis found three red flags that independently raised the odds of an ulcerative colitis patient progressing to the more serious diagnosis of Crohn's disease. These were nonbloody diarrhea at presentation (odds ratio, 23.5), weight loss (odds ratio, 12.4), and a positive C Bir1 serology (odds ratio, 6).

Nearly half of the patients who went on to develop Crohn's disease had pancolitis at initial colonoscopy, and two had an inflammatory condition of the ileum, “backwash ileus.”

None of the control patients with ulcerative colitis had total colonic involvement, and just 9 of 52 had pancolitis. The majority had left-sided involvement or proctitis.

Although red flags were present in all patients who went on to develop Crohn's disease, the length of time to a change in diagnosis was variable, ranging from 6 months to 17 years, with a mean of 4 years, Dr. Melmed noted in his poster presentation.

In an interview after the meeting, he said members of his group were surprised by the strength of the associations they identified, despite the small sample size.

“Something about the initial disease presentation seems to be very indicative in our cohort of a change in diagnosis, and we are beginning to learn about the role serology has to play in these patients as well,” he said.

He advocated a further work-up of patients with ulcerative colitis who have these features, particularly if they are not responding to conventional therapy, considering surgery, or being considered for enrollment in a clinical trial.

An appropriate work-up would include colonoscopy with ileoscopy (if not previously performed), a small bowel series with barium, or CT, MR enterography, capsule endoscopy, or upper endoscopy.

“Another issue that came up in our study was that many people with ulcerative colitis had been diagnosed on the basis of a flexible sigmoidoscopy rather than a complete colonoscopy, which could potentially identify Crohn's disease. We had to exclude these patients, who may have been misdiagnosed from the outset of their disease course,” Dr. Melmed said.

The study was sponsored by the International Organization for the Study of Inflammatory Bowel Disease and a grant from the National Institutes of Health.

LOS ANGELES — A number of clinical, laboratory, and serologic “red flags” may distinguish patients with ulcerative colitis who will progress to a diagnosis of Crohn's disease, researchers reported at the annual Digestive Disease Week.

Dr. Gil Y. Melmed and his associates at the Inflammatory Bowel Disease Center at Cedars-Sinai Medical Center and the University of California, Los Angeles, designed a nested case-control study to compare 21 patients whose diagnosis evolved into Crohn's disease with two groups of age-matched controls: 52 patients with simple ulcerative colitis and 56 patients with Crohn's disease.

Patients whose disease progressed were more likely than other ulcerative colitis patients to have extensive colonic involvement at diagnosis and a positive C Bir1 serology. In addition, they had an increased likelihood of having two or more red flags at initial presentation, including:

▸ Weight loss of more than 10% of body weight.

▸ Nonbloody diarrhea.

▸ Family history of Crohn's disease in at least one first-degree relative.

▸ Oral ulceration.

▸ Active smoking.

▸ Upper GI symptoms.

▸ History of blood transfusion.

▸ Perianal disease.

▸ Non-Helicobacter pylori gastritis.

▸ Thrombocytosis.

▸ Elevated C-reactive protein level.

▸ Hypoalbuminemia.

Other red flags included Crohn's disease-associated serologies, including ASCA IgA, ASCA IgG, anti-0mp-C, and anti-12.

A multivariate logistic regression analysis found three red flags that independently raised the odds of an ulcerative colitis patient progressing to the more serious diagnosis of Crohn's disease. These were nonbloody diarrhea at presentation (odds ratio, 23.5), weight loss (odds ratio, 12.4), and a positive C Bir1 serology (odds ratio, 6).

Nearly half of the patients who went on to develop Crohn's disease had pancolitis at initial colonoscopy, and two had an inflammatory condition of the ileum, “backwash ileus.”

None of the control patients with ulcerative colitis had total colonic involvement, and just 9 of 52 had pancolitis. The majority had left-sided involvement or proctitis.

Although red flags were present in all patients who went on to develop Crohn's disease, the length of time to a change in diagnosis was variable, ranging from 6 months to 17 years, with a mean of 4 years, Dr. Melmed noted in his poster presentation.

In an interview after the meeting, he said members of his group were surprised by the strength of the associations they identified, despite the small sample size.

“Something about the initial disease presentation seems to be very indicative in our cohort of a change in diagnosis, and we are beginning to learn about the role serology has to play in these patients as well,” he said.

He advocated a further work-up of patients with ulcerative colitis who have these features, particularly if they are not responding to conventional therapy, considering surgery, or being considered for enrollment in a clinical trial.

An appropriate work-up would include colonoscopy with ileoscopy (if not previously performed), a small bowel series with barium, or CT, MR enterography, capsule endoscopy, or upper endoscopy.

“Another issue that came up in our study was that many people with ulcerative colitis had been diagnosed on the basis of a flexible sigmoidoscopy rather than a complete colonoscopy, which could potentially identify Crohn's disease. We had to exclude these patients, who may have been misdiagnosed from the outset of their disease course,” Dr. Melmed said.

The study was sponsored by the International Organization for the Study of Inflammatory Bowel Disease and a grant from the National Institutes of Health.

LOS ANGELES — Low literacy was by far the most common independent predictor of poor bowel preparation and incomplete colonoscopy in a study presented at the annual Digestive Disease Week.

Among 195 patients who underwent colonoscopy at an inner city hospital, John H. Stroger Jr. Hospital of Cook County, 30% had poor bowel preparation, requiring a repeat examination. Another 22% had only “fair” bowel preparation, meaning small or flat lesions could be missed, reported Dr. Rony Ghaoui, a fellow in gastroenterology at Rush Medical College, Chicago.

Fully one-quarter of the colonoscopies were incomplete, 90% of them because of poor bowel preparation. The patients included in the study ranged in age from 18 to 82 years (mean age 54). Most (64%) were women, and 49% were African American, 32% were Hispanic, and 11% were non-Hispanic white.

Written instructions given to patients at the time the colonoscopies were scheduled were available in either English or Spanish. A 7-minute literacy test administered to patients on the morning of their examinations determined that 40% had low literacy, about 20% had marginal literacy, and about 40% had adequate literacy.

Among those with low literacy, 63% had poor bowel preparation, compared with 12% of those patients with marginal or adequate literacy. Importantly, however, more than 80% of patients with low literacy said they had adhered to the bowel preparation instructions.

Just 5 of 78 patients with low literacy said they had difficulty reading in general, and only 8 said they had difficulty reading the bowel preparation instructions. “[This] was, for me, an eye-opener as to how difficult it is for us as physicians to really detect the literacy problem,” Dr. Ghaoui said.

Although 40 million Americans—an estimated 26% of the population—have difficulty reading, “It's taboo. People don't talk about it,” he said. In one study, nearly 70% of illiterate adults had not confided that fact to a spouse or child.

The issue of literacy is critically important in current protocols for colonoscopy preparation, which rely on written instructions. When colonoscopies cannot be completed or must be repeated because of poor bowel preparation, there is “a long list of consequences,” he stressed, including patient inconvenience and time away from work, scheduling burdens at busy facilities, a waste of resources, and potentially delayed or missed diagnoses of colorectal cancer.

The odds ratios for predicting poor bowel preparation (after adjusting for age, gender, ethnic group, and language) were 12 for low literacy, 6 for eating dinner the night before the examination, and 5 for not taking bisacodyl. Other important predictors included eating lunch the previous day, and not finishing the polyethelene glycol solution. Receiving additional instructions about the preparation process from a physician or a nurse was somewhat protective, with an odds ratio of 0.5.

With use of the best predictive model in a logistic regression analysis, the odds ratio for low literacy was even higher, at 22, Dr. Ghaoui said.

He called for more research into how low literacy translates into poor preparation—whether the instructions themselves are misunderstood, or whether patients with low literacy do not understand the importance of the test itself or of adherence to the instructions.

Because patients do not volunteer the fact that they have low literacy, brief tools to measure literacy might be helpful for physicians to use in their practices, he added.

Finally, better methods of explaining colonoscopy preparation must be developed and tested, Dr. Ghaoui said.

LOS ANGELES — Low literacy was by far the most common independent predictor of poor bowel preparation and incomplete colonoscopy in a study presented at the annual Digestive Disease Week.

Among 195 patients who underwent colonoscopy at an inner city hospital, John H. Stroger Jr. Hospital of Cook County, 30% had poor bowel preparation, requiring a repeat examination. Another 22% had only “fair” bowel preparation, meaning small or flat lesions could be missed, reported Dr. Rony Ghaoui, a fellow in gastroenterology at Rush Medical College, Chicago.

Fully one-quarter of the colonoscopies were incomplete, 90% of them because of poor bowel preparation. The patients included in the study ranged in age from 18 to 82 years (mean age 54). Most (64%) were women, and 49% were African American, 32% were Hispanic, and 11% were non-Hispanic white.

Written instructions given to patients at the time the colonoscopies were scheduled were available in either English or Spanish. A 7-minute literacy test administered to patients on the morning of their examinations determined that 40% had low literacy, about 20% had marginal literacy, and about 40% had adequate literacy.

Among those with low literacy, 63% had poor bowel preparation, compared with 12% of those patients with marginal or adequate literacy. Importantly, however, more than 80% of patients with low literacy said they had adhered to the bowel preparation instructions.

Just 5 of 78 patients with low literacy said they had difficulty reading in general, and only 8 said they had difficulty reading the bowel preparation instructions. “[This] was, for me, an eye-opener as to how difficult it is for us as physicians to really detect the literacy problem,” Dr. Ghaoui said.

Although 40 million Americans—an estimated 26% of the population—have difficulty reading, “It's taboo. People don't talk about it,” he said. In one study, nearly 70% of illiterate adults had not confided that fact to a spouse or child.

The issue of literacy is critically important in current protocols for colonoscopy preparation, which rely on written instructions. When colonoscopies cannot be completed or must be repeated because of poor bowel preparation, there is “a long list of consequences,” he stressed, including patient inconvenience and time away from work, scheduling burdens at busy facilities, a waste of resources, and potentially delayed or missed diagnoses of colorectal cancer.

The odds ratios for predicting poor bowel preparation (after adjusting for age, gender, ethnic group, and language) were 12 for low literacy, 6 for eating dinner the night before the examination, and 5 for not taking bisacodyl. Other important predictors included eating lunch the previous day, and not finishing the polyethelene glycol solution. Receiving additional instructions about the preparation process from a physician or a nurse was somewhat protective, with an odds ratio of 0.5.

With use of the best predictive model in a logistic regression analysis, the odds ratio for low literacy was even higher, at 22, Dr. Ghaoui said.

He called for more research into how low literacy translates into poor preparation—whether the instructions themselves are misunderstood, or whether patients with low literacy do not understand the importance of the test itself or of adherence to the instructions.

Because patients do not volunteer the fact that they have low literacy, brief tools to measure literacy might be helpful for physicians to use in their practices, he added.

Finally, better methods of explaining colonoscopy preparation must be developed and tested, Dr. Ghaoui said.

LOS ANGELES — Low literacy was by far the most common independent predictor of poor bowel preparation and incomplete colonoscopy in a study presented at the annual Digestive Disease Week.

Among 195 patients who underwent colonoscopy at an inner city hospital, John H. Stroger Jr. Hospital of Cook County, 30% had poor bowel preparation, requiring a repeat examination. Another 22% had only “fair” bowel preparation, meaning small or flat lesions could be missed, reported Dr. Rony Ghaoui, a fellow in gastroenterology at Rush Medical College, Chicago.

Fully one-quarter of the colonoscopies were incomplete, 90% of them because of poor bowel preparation. The patients included in the study ranged in age from 18 to 82 years (mean age 54). Most (64%) were women, and 49% were African American, 32% were Hispanic, and 11% were non-Hispanic white.

Written instructions given to patients at the time the colonoscopies were scheduled were available in either English or Spanish. A 7-minute literacy test administered to patients on the morning of their examinations determined that 40% had low literacy, about 20% had marginal literacy, and about 40% had adequate literacy.

Among those with low literacy, 63% had poor bowel preparation, compared with 12% of those patients with marginal or adequate literacy. Importantly, however, more than 80% of patients with low literacy said they had adhered to the bowel preparation instructions.

Just 5 of 78 patients with low literacy said they had difficulty reading in general, and only 8 said they had difficulty reading the bowel preparation instructions. “[This] was, for me, an eye-opener as to how difficult it is for us as physicians to really detect the literacy problem,” Dr. Ghaoui said.

Although 40 million Americans—an estimated 26% of the population—have difficulty reading, “It's taboo. People don't talk about it,” he said. In one study, nearly 70% of illiterate adults had not confided that fact to a spouse or child.

The issue of literacy is critically important in current protocols for colonoscopy preparation, which rely on written instructions. When colonoscopies cannot be completed or must be repeated because of poor bowel preparation, there is “a long list of consequences,” he stressed, including patient inconvenience and time away from work, scheduling burdens at busy facilities, a waste of resources, and potentially delayed or missed diagnoses of colorectal cancer.

The odds ratios for predicting poor bowel preparation (after adjusting for age, gender, ethnic group, and language) were 12 for low literacy, 6 for eating dinner the night before the examination, and 5 for not taking bisacodyl. Other important predictors included eating lunch the previous day, and not finishing the polyethelene glycol solution. Receiving additional instructions about the preparation process from a physician or a nurse was somewhat protective, with an odds ratio of 0.5.

With use of the best predictive model in a logistic regression analysis, the odds ratio for low literacy was even higher, at 22, Dr. Ghaoui said.

He called for more research into how low literacy translates into poor preparation—whether the instructions themselves are misunderstood, or whether patients with low literacy do not understand the importance of the test itself or of adherence to the instructions.

Because patients do not volunteer the fact that they have low literacy, brief tools to measure literacy might be helpful for physicians to use in their practices, he added.

Finally, better methods of explaining colonoscopy preparation must be developed and tested, Dr. Ghaoui said.

TUCSON, ARIZ. — The rate of anal sphincter laceration during vaginal delivery has sharply declined in recent years, paralleling modifications in obstetric practice, a University of Southern California study revealed.

Anal sphincter laceration occurred in 11.2% of vaginal deliveries at the colossal Los Angeles County/USC Medical Center in 1996, compared with 7.9% in 2004, with about a 6% reduction in risk every year after 1996, reported Dr. Steven Minaglia at the annual meeting of the Society of Gynecologic Surgeons.

During the time period studied, episiotomies declined from 9% to 8% of vaginal deliveries, vacuum deliveries from 5.1% to 2.9%, and forceps deliveries from 1.7% to 0%.

“Of note, the C-section rate went from 18.2% to 32.3%,” he said.

The retrospective study assessed characteristics in 1,703 patients who had an anal sphincter laceration and 14,964 who did not have such an injury, for a total of 16,667 singleton vaginal deliveries at greater than 20 weeks of gestation.

Younger age, lower parity, and higher birth weight all were associated with a higher likelihood of an anal sphincter laceration. Other important risk factors independently associated with a laceration included vacuum delivery (odds ratio 3.19), forceps delivery (OR 2.79), episiotomy (OR 1.36), shoulder dystocia (OR 2.03), and gestational age (OR 1.03, about a 4% increased risk for each week of gestation).

Dr. Minaglia, of the division of female pelvic medicine and reconstructive surgery, encouraged a further minimization of modifiable risk factors such as episiotomy and operative delivery to minimize long-term harm associated with sphincter laceration.

TUCSON, ARIZ. — The rate of anal sphincter laceration during vaginal delivery has sharply declined in recent years, paralleling modifications in obstetric practice, a University of Southern California study revealed.

Anal sphincter laceration occurred in 11.2% of vaginal deliveries at the colossal Los Angeles County/USC Medical Center in 1996, compared with 7.9% in 2004, with about a 6% reduction in risk every year after 1996, reported Dr. Steven Minaglia at the annual meeting of the Society of Gynecologic Surgeons.

During the time period studied, episiotomies declined from 9% to 8% of vaginal deliveries, vacuum deliveries from 5.1% to 2.9%, and forceps deliveries from 1.7% to 0%.

“Of note, the C-section rate went from 18.2% to 32.3%,” he said.

The retrospective study assessed characteristics in 1,703 patients who had an anal sphincter laceration and 14,964 who did not have such an injury, for a total of 16,667 singleton vaginal deliveries at greater than 20 weeks of gestation.

Younger age, lower parity, and higher birth weight all were associated with a higher likelihood of an anal sphincter laceration. Other important risk factors independently associated with a laceration included vacuum delivery (odds ratio 3.19), forceps delivery (OR 2.79), episiotomy (OR 1.36), shoulder dystocia (OR 2.03), and gestational age (OR 1.03, about a 4% increased risk for each week of gestation).

Dr. Minaglia, of the division of female pelvic medicine and reconstructive surgery, encouraged a further minimization of modifiable risk factors such as episiotomy and operative delivery to minimize long-term harm associated with sphincter laceration.

TUCSON, ARIZ. — The rate of anal sphincter laceration during vaginal delivery has sharply declined in recent years, paralleling modifications in obstetric practice, a University of Southern California study revealed.

Anal sphincter laceration occurred in 11.2% of vaginal deliveries at the colossal Los Angeles County/USC Medical Center in 1996, compared with 7.9% in 2004, with about a 6% reduction in risk every year after 1996, reported Dr. Steven Minaglia at the annual meeting of the Society of Gynecologic Surgeons.

During the time period studied, episiotomies declined from 9% to 8% of vaginal deliveries, vacuum deliveries from 5.1% to 2.9%, and forceps deliveries from 1.7% to 0%.

“Of note, the C-section rate went from 18.2% to 32.3%,” he said.

The retrospective study assessed characteristics in 1,703 patients who had an anal sphincter laceration and 14,964 who did not have such an injury, for a total of 16,667 singleton vaginal deliveries at greater than 20 weeks of gestation.

Younger age, lower parity, and higher birth weight all were associated with a higher likelihood of an anal sphincter laceration. Other important risk factors independently associated with a laceration included vacuum delivery (odds ratio 3.19), forceps delivery (OR 2.79), episiotomy (OR 1.36), shoulder dystocia (OR 2.03), and gestational age (OR 1.03, about a 4% increased risk for each week of gestation).

Dr. Minaglia, of the division of female pelvic medicine and reconstructive surgery, encouraged a further minimization of modifiable risk factors such as episiotomy and operative delivery to minimize long-term harm associated with sphincter laceration.