Damian McNamara

ORLANDO — With an average cost just over $2,000, endoscopic mucosal resection of colorectal lesions can be an effective and less expensive alternative to surgery, according to a recent study.

Endoscopic mucosal resection (EMR) is a standard technique useful for resection of large sessile and flat lesions, Dr. Tonya Kaltenbach said. However, “despite efficacy data, [patients are] often referred for surgical resection.”

The “total cost of endoscopic mucosal resection of large colon lesions is approximately one-fifth the cost of surgical resection,” Dr. Kaltenbach said at the annual meeting of the American College of Gastroenterology.

Polyp size may make a difference in cost considerations, according to a previous study (Clin. Gastroenterol. Hepatol. 2007;5:1076–9). Researchers compared 184 consecutive patients with sessile colorectal polyps 2 cm or larger with another 184 consecutive controls with smaller sessile or pedunculated polyps. Longer colonoscopy time (mean 51 minutes vs. 20 minutes) and use of more equipment increased costs substantially among patients with larger polyps.

For the current study, Dr. Kaltenbach and her associates retrospectively studied 141 consecutive patients over 2 years; all were referred to an urban tertiary care center for endoscopic resection of a colon or rectal lesion. Gastroenterologists referred 118 cases, and surgeons referred the remaining 23 patients.

A single endoscopist at Interventional Endoscopy Services treated all the patients. A total of 91 patients (65%) were men, mean age was 67 years, and mean lesion size was 28 mm (range, 6–80 mm). Mean procedure time was 51 minutes.

Surgery was recommended to 27 patients (19%). Reasons included a nonlifting sign (12 patients), invasive cancer detected before EMR (9 patients), and a large lesion size (6 patients).

The endoscopist successfully removed 114 lesions (81%) using EMR. A total of 77 of these lesions (55%) were flat and 60% were located in the right colon. Just more than half, 55%, of the resected lesions had high-grade histopathology or villous features, said Dr. Kaltenbach, a gastroenterologist and interventional endoscopist at California Pacific Medical Center's Interventional Endoscopy Services in San Francisco.

Complications included one bleed and one hospitalization. There were no perforations.

“Endoscopic resection costs were slightly above $2,100,” Dr. Kaltenbach said. Specifically, total costs were $2,121 per case, which included $615 in indirect and $1,506 in direct costs. Supplies, use of the postanesthesia care unit, and endoscope charges accounted for 89% of the direct hospital costs.

The overall hospital revenue was positive. “On average, costs were lower than the generated revenue from the hospital perspective,” Dr. Kaltenbach said.

In her patient cohort, the hospital costs averaged $17,657 for patients who underwent a partial colectomy for large polyps that were not amenable to endoscopic resection because of cancer invasion or nonlifting properties.

The retrospective design of the study is a possible limitation, Dr. Kaltenbach said.

In addition, the generalizability of findings based on a single endoscopist's experience is unknown.

Assessment of long-term efficacy was a secondary aim of the study. About 40% (46) of the EMR patients had a follow-up examination. The majority of these, 80%, had only a scar at the resection site, and 20% had a minor residual lesion (mean size 4 mm).

Dr. Kaltenbach reported no relevant disclosures.

ORLANDO — With an average cost just over $2,000, endoscopic mucosal resection of colorectal lesions can be an effective and less expensive alternative to surgery, according to a recent study.

Endoscopic mucosal resection (EMR) is a standard technique useful for resection of large sessile and flat lesions, Dr. Tonya Kaltenbach said. However, “despite efficacy data, [patients are] often referred for surgical resection.”

The “total cost of endoscopic mucosal resection of large colon lesions is approximately one-fifth the cost of surgical resection,” Dr. Kaltenbach said at the annual meeting of the American College of Gastroenterology.

Polyp size may make a difference in cost considerations, according to a previous study (Clin. Gastroenterol. Hepatol. 2007;5:1076–9). Researchers compared 184 consecutive patients with sessile colorectal polyps 2 cm or larger with another 184 consecutive controls with smaller sessile or pedunculated polyps. Longer colonoscopy time (mean 51 minutes vs. 20 minutes) and use of more equipment increased costs substantially among patients with larger polyps.

For the current study, Dr. Kaltenbach and her associates retrospectively studied 141 consecutive patients over 2 years; all were referred to an urban tertiary care center for endoscopic resection of a colon or rectal lesion. Gastroenterologists referred 118 cases, and surgeons referred the remaining 23 patients.

A single endoscopist at Interventional Endoscopy Services treated all the patients. A total of 91 patients (65%) were men, mean age was 67 years, and mean lesion size was 28 mm (range, 6–80 mm). Mean procedure time was 51 minutes.

Surgery was recommended to 27 patients (19%). Reasons included a nonlifting sign (12 patients), invasive cancer detected before EMR (9 patients), and a large lesion size (6 patients).

The endoscopist successfully removed 114 lesions (81%) using EMR. A total of 77 of these lesions (55%) were flat and 60% were located in the right colon. Just more than half, 55%, of the resected lesions had high-grade histopathology or villous features, said Dr. Kaltenbach, a gastroenterologist and interventional endoscopist at California Pacific Medical Center's Interventional Endoscopy Services in San Francisco.

Complications included one bleed and one hospitalization. There were no perforations.

“Endoscopic resection costs were slightly above $2,100,” Dr. Kaltenbach said. Specifically, total costs were $2,121 per case, which included $615 in indirect and $1,506 in direct costs. Supplies, use of the postanesthesia care unit, and endoscope charges accounted for 89% of the direct hospital costs.

The overall hospital revenue was positive. “On average, costs were lower than the generated revenue from the hospital perspective,” Dr. Kaltenbach said.

In her patient cohort, the hospital costs averaged $17,657 for patients who underwent a partial colectomy for large polyps that were not amenable to endoscopic resection because of cancer invasion or nonlifting properties.

The retrospective design of the study is a possible limitation, Dr. Kaltenbach said.

In addition, the generalizability of findings based on a single endoscopist's experience is unknown.

Assessment of long-term efficacy was a secondary aim of the study. About 40% (46) of the EMR patients had a follow-up examination. The majority of these, 80%, had only a scar at the resection site, and 20% had a minor residual lesion (mean size 4 mm).

Dr. Kaltenbach reported no relevant disclosures.

ORLANDO — With an average cost just over $2,000, endoscopic mucosal resection of colorectal lesions can be an effective and less expensive alternative to surgery, according to a recent study.

Endoscopic mucosal resection (EMR) is a standard technique useful for resection of large sessile and flat lesions, Dr. Tonya Kaltenbach said. However, “despite efficacy data, [patients are] often referred for surgical resection.”

The “total cost of endoscopic mucosal resection of large colon lesions is approximately one-fifth the cost of surgical resection,” Dr. Kaltenbach said at the annual meeting of the American College of Gastroenterology.

Polyp size may make a difference in cost considerations, according to a previous study (Clin. Gastroenterol. Hepatol. 2007;5:1076–9). Researchers compared 184 consecutive patients with sessile colorectal polyps 2 cm or larger with another 184 consecutive controls with smaller sessile or pedunculated polyps. Longer colonoscopy time (mean 51 minutes vs. 20 minutes) and use of more equipment increased costs substantially among patients with larger polyps.

For the current study, Dr. Kaltenbach and her associates retrospectively studied 141 consecutive patients over 2 years; all were referred to an urban tertiary care center for endoscopic resection of a colon or rectal lesion. Gastroenterologists referred 118 cases, and surgeons referred the remaining 23 patients.

A single endoscopist at Interventional Endoscopy Services treated all the patients. A total of 91 patients (65%) were men, mean age was 67 years, and mean lesion size was 28 mm (range, 6–80 mm). Mean procedure time was 51 minutes.

Surgery was recommended to 27 patients (19%). Reasons included a nonlifting sign (12 patients), invasive cancer detected before EMR (9 patients), and a large lesion size (6 patients).

The endoscopist successfully removed 114 lesions (81%) using EMR. A total of 77 of these lesions (55%) were flat and 60% were located in the right colon. Just more than half, 55%, of the resected lesions had high-grade histopathology or villous features, said Dr. Kaltenbach, a gastroenterologist and interventional endoscopist at California Pacific Medical Center's Interventional Endoscopy Services in San Francisco.

Complications included one bleed and one hospitalization. There were no perforations.

“Endoscopic resection costs were slightly above $2,100,” Dr. Kaltenbach said. Specifically, total costs were $2,121 per case, which included $615 in indirect and $1,506 in direct costs. Supplies, use of the postanesthesia care unit, and endoscope charges accounted for 89% of the direct hospital costs.

The overall hospital revenue was positive. “On average, costs were lower than the generated revenue from the hospital perspective,” Dr. Kaltenbach said.

In her patient cohort, the hospital costs averaged $17,657 for patients who underwent a partial colectomy for large polyps that were not amenable to endoscopic resection because of cancer invasion or nonlifting properties.

The retrospective design of the study is a possible limitation, Dr. Kaltenbach said.

In addition, the generalizability of findings based on a single endoscopist's experience is unknown.

Assessment of long-term efficacy was a secondary aim of the study. About 40% (46) of the EMR patients had a follow-up examination. The majority of these, 80%, had only a scar at the resection site, and 20% had a minor residual lesion (mean size 4 mm).

Dr. Kaltenbach reported no relevant disclosures.

ORLANDO — The Framingham stroke risk score can predict a high-risk postmenopausal woman's likelihood of a future cerebrovascular event with raloxifene use.

Investigators in 26 countries enrolled 10,101 women at risk for a major coronary event in the Raloxifene for the Heart Study (RUTH). A total of 5,031 women had documented coronary heart disease and the remaining 5,070 had multiple coronary heart disease risk factors. Although overall stroke risk was not significantly different between women randomized to raloxifene versus placebo, a higher number of fatal stroke events occurred in the treatment group, 59, compared with 39 in the placebo group during a mean of 5.6 years follow-up.

To see how this increased risk associated with raloxifene (hazard ratio, 1.49; absolute risk increase, 0.7 per 1,000 woman-years) would apply to women stratified by baseline Framingham stroke scale score, David Cox, Ph.D., and colleague retrospectively calculated 10-year cumulative risk. They presented findings at the annual meeting of the North American Menopause Society. Eli Lilly & Co. supported the study, and Dr. Cox is a clinical research scientist for the company.

As expected, risks congregated in the third- and fourth-highest quartiles of Framingham score risk. However, there were no significant differences between treatment groups in either all strokes or nonfatal strokes, regardless of baseline Framingham score. Regarding fatal stroke, Dr. Cox said, “after 2 years, you start to see a split between placebo and raloxifene for risk of fatal stroke by Framingham stroke risk score in RUTH.” Specifically, women who scored a 13 or greater on the Framingham tool at baseline were at increased risk of stroke death.

ORLANDO — The Framingham stroke risk score can predict a high-risk postmenopausal woman's likelihood of a future cerebrovascular event with raloxifene use.

Investigators in 26 countries enrolled 10,101 women at risk for a major coronary event in the Raloxifene for the Heart Study (RUTH). A total of 5,031 women had documented coronary heart disease and the remaining 5,070 had multiple coronary heart disease risk factors. Although overall stroke risk was not significantly different between women randomized to raloxifene versus placebo, a higher number of fatal stroke events occurred in the treatment group, 59, compared with 39 in the placebo group during a mean of 5.6 years follow-up.

To see how this increased risk associated with raloxifene (hazard ratio, 1.49; absolute risk increase, 0.7 per 1,000 woman-years) would apply to women stratified by baseline Framingham stroke scale score, David Cox, Ph.D., and colleague retrospectively calculated 10-year cumulative risk. They presented findings at the annual meeting of the North American Menopause Society. Eli Lilly & Co. supported the study, and Dr. Cox is a clinical research scientist for the company.

As expected, risks congregated in the third- and fourth-highest quartiles of Framingham score risk. However, there were no significant differences between treatment groups in either all strokes or nonfatal strokes, regardless of baseline Framingham score. Regarding fatal stroke, Dr. Cox said, “after 2 years, you start to see a split between placebo and raloxifene for risk of fatal stroke by Framingham stroke risk score in RUTH.” Specifically, women who scored a 13 or greater on the Framingham tool at baseline were at increased risk of stroke death.

ORLANDO — The Framingham stroke risk score can predict a high-risk postmenopausal woman's likelihood of a future cerebrovascular event with raloxifene use.

Investigators in 26 countries enrolled 10,101 women at risk for a major coronary event in the Raloxifene for the Heart Study (RUTH). A total of 5,031 women had documented coronary heart disease and the remaining 5,070 had multiple coronary heart disease risk factors. Although overall stroke risk was not significantly different between women randomized to raloxifene versus placebo, a higher number of fatal stroke events occurred in the treatment group, 59, compared with 39 in the placebo group during a mean of 5.6 years follow-up.

To see how this increased risk associated with raloxifene (hazard ratio, 1.49; absolute risk increase, 0.7 per 1,000 woman-years) would apply to women stratified by baseline Framingham stroke scale score, David Cox, Ph.D., and colleague retrospectively calculated 10-year cumulative risk. They presented findings at the annual meeting of the North American Menopause Society. Eli Lilly & Co. supported the study, and Dr. Cox is a clinical research scientist for the company.

As expected, risks congregated in the third- and fourth-highest quartiles of Framingham score risk. However, there were no significant differences between treatment groups in either all strokes or nonfatal strokes, regardless of baseline Framingham score. Regarding fatal stroke, Dr. Cox said, “after 2 years, you start to see a split between placebo and raloxifene for risk of fatal stroke by Framingham stroke risk score in RUTH.” Specifically, women who scored a 13 or greater on the Framingham tool at baseline were at increased risk of stroke death.

Dx: Epidermolysis Bullosa Acquisita

The woman's bullous lesions previously improved with dapsone 50 mg daily, but treatment was discontinued after she developed a hypersensitivity syndrome. She then was prescribed azathioprine 75 mg daily, hydroxychloroquine 200 mg twice daily, and systemic corticosteroids in varying strengths. At time of presentation, she was taking 15 mg prednisone.

“Differential diagnoses included bullous systemic lupus erythematosus (BSLE), bullous pemphigoid, and epidermolysis bullosa acquisita,” Dr. Alia Sampson Brown said at the Caribbean Dermatology Symposium.

Physicians took punch biopsies to perform hematoxylin and eosin staining and direct immunofluorescence, as well as serum for an indirect immunofluorescence assay.

Histology showed a split at the dermal-epidermal junction where a blister cavity formed with paucicellular inflammation. Also, indirect immunofluorescence demonstrated dermal staining of IgG at the basement membrane zone, as well as presence of IgG bullous pemphigoid antibodies 180 and 230.

A diagnosis of epidermolysis bullosa acquisita was made. A major feature, subepidermal blistering, is caused by antibiodies to collagen type VII.

“Our patient had an underlying diagnosis of [systemic lupus erythematosus] and then developed epidermolysis bullosa acquisita,” said Dr. Brown, a dermatology resident at the University of Louisville (Ky.). Because of its rarity, there are no randomized studies of this disease, only case reports in the literature (Cutis 2002;70:31–4; Clin. Exp. Dermatol. 1993;18:378–80).

“Histology cannot distinguish epidermolysis bullosa acquisita from BSLE. There is, however, histological overlap,” Dr. Brown said in an interview. For example, BSLE and the inflammatory variant of epidermolysis bullosa acquisita each can feature neutrophils, but this finding is variable.

“What helps you most to distinguish between these entities is the presence or absence of certain clinical clues, as well as the course of the disease,” Dr. Brown said. BSLE in general does not occur over trauma-prone areas, nor does it heal with scarring, milia, or the development of calcinosis. Epidermolysis bullosa acquisita is difficult to treat, whereas patients with BSLE generally respond to dapsone therapy.

Even given this challenge, a differential diagnosis is important between these two diseases. “They have similar histology but act very differently,” Dr. Brown said.

While hospitalized, the patient continued to receive azathioprine 75 mg daily and prednisone 15 mg daily. She was discharged after 10 days. A short time later, the woman was admitted to an institution closer to her home with acute renal failure. She died from a pulmonary embolism.

Dr. Jeffrey P. Callen and Dr. Carol Kulp-Shorten, also of the University of Louisville, contributed to this case.

Histology showsa split at the dermal-epidermal junction with paucicellular inflammation within the blister cavity. Courtesy Dr. Janine Malone

Dx: Epidermolysis Bullosa Acquisita

The woman's bullous lesions previously improved with dapsone 50 mg daily, but treatment was discontinued after she developed a hypersensitivity syndrome. She then was prescribed azathioprine 75 mg daily, hydroxychloroquine 200 mg twice daily, and systemic corticosteroids in varying strengths. At time of presentation, she was taking 15 mg prednisone.

“Differential diagnoses included bullous systemic lupus erythematosus (BSLE), bullous pemphigoid, and epidermolysis bullosa acquisita,” Dr. Alia Sampson Brown said at the Caribbean Dermatology Symposium.

Physicians took punch biopsies to perform hematoxylin and eosin staining and direct immunofluorescence, as well as serum for an indirect immunofluorescence assay.

Histology showed a split at the dermal-epidermal junction where a blister cavity formed with paucicellular inflammation. Also, indirect immunofluorescence demonstrated dermal staining of IgG at the basement membrane zone, as well as presence of IgG bullous pemphigoid antibodies 180 and 230.

A diagnosis of epidermolysis bullosa acquisita was made. A major feature, subepidermal blistering, is caused by antibiodies to collagen type VII.

“Our patient had an underlying diagnosis of [systemic lupus erythematosus] and then developed epidermolysis bullosa acquisita,” said Dr. Brown, a dermatology resident at the University of Louisville (Ky.). Because of its rarity, there are no randomized studies of this disease, only case reports in the literature (Cutis 2002;70:31–4; Clin. Exp. Dermatol. 1993;18:378–80).

“Histology cannot distinguish epidermolysis bullosa acquisita from BSLE. There is, however, histological overlap,” Dr. Brown said in an interview. For example, BSLE and the inflammatory variant of epidermolysis bullosa acquisita each can feature neutrophils, but this finding is variable.

“What helps you most to distinguish between these entities is the presence or absence of certain clinical clues, as well as the course of the disease,” Dr. Brown said. BSLE in general does not occur over trauma-prone areas, nor does it heal with scarring, milia, or the development of calcinosis. Epidermolysis bullosa acquisita is difficult to treat, whereas patients with BSLE generally respond to dapsone therapy.

Even given this challenge, a differential diagnosis is important between these two diseases. “They have similar histology but act very differently,” Dr. Brown said.

While hospitalized, the patient continued to receive azathioprine 75 mg daily and prednisone 15 mg daily. She was discharged after 10 days. A short time later, the woman was admitted to an institution closer to her home with acute renal failure. She died from a pulmonary embolism.

Dr. Jeffrey P. Callen and Dr. Carol Kulp-Shorten, also of the University of Louisville, contributed to this case.

Histology showsa split at the dermal-epidermal junction with paucicellular inflammation within the blister cavity. Courtesy Dr. Janine Malone

Dx: Epidermolysis Bullosa Acquisita

The woman's bullous lesions previously improved with dapsone 50 mg daily, but treatment was discontinued after she developed a hypersensitivity syndrome. She then was prescribed azathioprine 75 mg daily, hydroxychloroquine 200 mg twice daily, and systemic corticosteroids in varying strengths. At time of presentation, she was taking 15 mg prednisone.

“Differential diagnoses included bullous systemic lupus erythematosus (BSLE), bullous pemphigoid, and epidermolysis bullosa acquisita,” Dr. Alia Sampson Brown said at the Caribbean Dermatology Symposium.

Physicians took punch biopsies to perform hematoxylin and eosin staining and direct immunofluorescence, as well as serum for an indirect immunofluorescence assay.

Histology showed a split at the dermal-epidermal junction where a blister cavity formed with paucicellular inflammation. Also, indirect immunofluorescence demonstrated dermal staining of IgG at the basement membrane zone, as well as presence of IgG bullous pemphigoid antibodies 180 and 230.

A diagnosis of epidermolysis bullosa acquisita was made. A major feature, subepidermal blistering, is caused by antibiodies to collagen type VII.

“Our patient had an underlying diagnosis of [systemic lupus erythematosus] and then developed epidermolysis bullosa acquisita,” said Dr. Brown, a dermatology resident at the University of Louisville (Ky.). Because of its rarity, there are no randomized studies of this disease, only case reports in the literature (Cutis 2002;70:31–4; Clin. Exp. Dermatol. 1993;18:378–80).

“Histology cannot distinguish epidermolysis bullosa acquisita from BSLE. There is, however, histological overlap,” Dr. Brown said in an interview. For example, BSLE and the inflammatory variant of epidermolysis bullosa acquisita each can feature neutrophils, but this finding is variable.

“What helps you most to distinguish between these entities is the presence or absence of certain clinical clues, as well as the course of the disease,” Dr. Brown said. BSLE in general does not occur over trauma-prone areas, nor does it heal with scarring, milia, or the development of calcinosis. Epidermolysis bullosa acquisita is difficult to treat, whereas patients with BSLE generally respond to dapsone therapy.

Even given this challenge, a differential diagnosis is important between these two diseases. “They have similar histology but act very differently,” Dr. Brown said.

While hospitalized, the patient continued to receive azathioprine 75 mg daily and prednisone 15 mg daily. She was discharged after 10 days. A short time later, the woman was admitted to an institution closer to her home with acute renal failure. She died from a pulmonary embolism.

Dr. Jeffrey P. Callen and Dr. Carol Kulp-Shorten, also of the University of Louisville, contributed to this case.

Histology showsa split at the dermal-epidermal junction with paucicellular inflammation within the blister cavity. Courtesy Dr. Janine Malone

SINT MAARTEN, NETHERLANDS ANTILLES — A combination of doxycycline and metronidazole cleared more inflammatory rosacea lesions and worked faster than metronidazole alone in a randomized controlled trial.

This combination should be considered a first-line treatment for rosacea, according to the efficacy and safety findings that were presented by Dr. Joseph F. Fowler Jr. at the Caribbean Dermatology Symposium.

Previous research suggested that agents with anti-inflammatory activity, including doxycycline or tetracycline and topical metronidazole, are effective for management of rosacea symptoms (Cutis 2004;73:15–18; Skinmed 2003;2:43–47).

Dr. Fowler assessed the safety and efficacy of using 40-mg delayed-release doxycycline capsules (Oracea, Galderma), which is the anti-inflammatory dose of the antibiotic, in combination with metronidazole topical gel 1%.

“I chose metronidazole 1% because it is one of the more established products. … I was able to show both drugs had an effect. But when combining the two, you get much faster and greater improvement,” said Dr. Fowler, clinical professor in the dermatology division, University of Louisville (Ky.).

A total of 36 patients were randomized to combination treatment, and another 36 to an oral placebo and metronidazole gel 1% (monotherapy group). Following baseline assessment, patients were evaluated at weeks 4, 8, and 12, at which time metronidazole therapy was stopped. Patients continued to take oral doxycycline or placebo for another 4 weeks.

The 56 women and 16 men enrolled in the study had a mean age of 48 years. Baseline mean total inflammatory lesion count (papules, pustules, and nodules) was similar between groups—21 in the combination group and 19 in the monotherapy group.

A total of 64 participants completed the study—30 in the combination group and 34 in the monotherapy arm. In all, 4 people withdrew because of adverse events (including 3 in the combination group), 2 people withdrew consent, 1 was removed for a protocol violation, and 1 was lost to follow-up.

The primary outcome, mean change in total inflammatory lesion count, was significantly improved in the combination group. For example, from baseline to week 4, the count decreased by 10 lesions among combination patients versus 3 among monotherapy patients. “The quick onset [of the oral drug] is a critical take-home message,” Dr. Fowler said.

By week 16, the mean reduction in total inflammatory lesions was 13 in the combination group, compared with 7 for the monotherapy group.

Patients in the combination therapy group had greater improvements on investigator global assessment at all time points, including significant differences at weeks 12 and 16.

Between weeks 12 and 16, patients who received doxycycline monotherapy maintained the benefits of decreased inflammatory lesion counts and improvements on global assessment.

Dr. Fowler was a consultant and clinical research investigator for CollaGenex Pharmaceuticals Inc. at the time of the study.

Galderma has since acquired CollaGenex, and Dr. Fowler receives research support from Galderma.

By week 4, lesion count decreased by 10 among combination patients and by 3 in those on monotherapy. DR. FOWLER

SINT MAARTEN, NETHERLANDS ANTILLES — A combination of doxycycline and metronidazole cleared more inflammatory rosacea lesions and worked faster than metronidazole alone in a randomized controlled trial.

This combination should be considered a first-line treatment for rosacea, according to the efficacy and safety findings that were presented by Dr. Joseph F. Fowler Jr. at the Caribbean Dermatology Symposium.

Previous research suggested that agents with anti-inflammatory activity, including doxycycline or tetracycline and topical metronidazole, are effective for management of rosacea symptoms (Cutis 2004;73:15–18; Skinmed 2003;2:43–47).

Dr. Fowler assessed the safety and efficacy of using 40-mg delayed-release doxycycline capsules (Oracea, Galderma), which is the anti-inflammatory dose of the antibiotic, in combination with metronidazole topical gel 1%.

“I chose metronidazole 1% because it is one of the more established products. … I was able to show both drugs had an effect. But when combining the two, you get much faster and greater improvement,” said Dr. Fowler, clinical professor in the dermatology division, University of Louisville (Ky.).

A total of 36 patients were randomized to combination treatment, and another 36 to an oral placebo and metronidazole gel 1% (monotherapy group). Following baseline assessment, patients were evaluated at weeks 4, 8, and 12, at which time metronidazole therapy was stopped. Patients continued to take oral doxycycline or placebo for another 4 weeks.

The 56 women and 16 men enrolled in the study had a mean age of 48 years. Baseline mean total inflammatory lesion count (papules, pustules, and nodules) was similar between groups—21 in the combination group and 19 in the monotherapy group.

A total of 64 participants completed the study—30 in the combination group and 34 in the monotherapy arm. In all, 4 people withdrew because of adverse events (including 3 in the combination group), 2 people withdrew consent, 1 was removed for a protocol violation, and 1 was lost to follow-up.

The primary outcome, mean change in total inflammatory lesion count, was significantly improved in the combination group. For example, from baseline to week 4, the count decreased by 10 lesions among combination patients versus 3 among monotherapy patients. “The quick onset [of the oral drug] is a critical take-home message,” Dr. Fowler said.

By week 16, the mean reduction in total inflammatory lesions was 13 in the combination group, compared with 7 for the monotherapy group.

Patients in the combination therapy group had greater improvements on investigator global assessment at all time points, including significant differences at weeks 12 and 16.

Between weeks 12 and 16, patients who received doxycycline monotherapy maintained the benefits of decreased inflammatory lesion counts and improvements on global assessment.

Dr. Fowler was a consultant and clinical research investigator for CollaGenex Pharmaceuticals Inc. at the time of the study.

Galderma has since acquired CollaGenex, and Dr. Fowler receives research support from Galderma.

By week 4, lesion count decreased by 10 among combination patients and by 3 in those on monotherapy. DR. FOWLER

SINT MAARTEN, NETHERLANDS ANTILLES — A combination of doxycycline and metronidazole cleared more inflammatory rosacea lesions and worked faster than metronidazole alone in a randomized controlled trial.

This combination should be considered a first-line treatment for rosacea, according to the efficacy and safety findings that were presented by Dr. Joseph F. Fowler Jr. at the Caribbean Dermatology Symposium.

Previous research suggested that agents with anti-inflammatory activity, including doxycycline or tetracycline and topical metronidazole, are effective for management of rosacea symptoms (Cutis 2004;73:15–18; Skinmed 2003;2:43–47).

Dr. Fowler assessed the safety and efficacy of using 40-mg delayed-release doxycycline capsules (Oracea, Galderma), which is the anti-inflammatory dose of the antibiotic, in combination with metronidazole topical gel 1%.

“I chose metronidazole 1% because it is one of the more established products. … I was able to show both drugs had an effect. But when combining the two, you get much faster and greater improvement,” said Dr. Fowler, clinical professor in the dermatology division, University of Louisville (Ky.).

A total of 36 patients were randomized to combination treatment, and another 36 to an oral placebo and metronidazole gel 1% (monotherapy group). Following baseline assessment, patients were evaluated at weeks 4, 8, and 12, at which time metronidazole therapy was stopped. Patients continued to take oral doxycycline or placebo for another 4 weeks.

The 56 women and 16 men enrolled in the study had a mean age of 48 years. Baseline mean total inflammatory lesion count (papules, pustules, and nodules) was similar between groups—21 in the combination group and 19 in the monotherapy group.

A total of 64 participants completed the study—30 in the combination group and 34 in the monotherapy arm. In all, 4 people withdrew because of adverse events (including 3 in the combination group), 2 people withdrew consent, 1 was removed for a protocol violation, and 1 was lost to follow-up.

The primary outcome, mean change in total inflammatory lesion count, was significantly improved in the combination group. For example, from baseline to week 4, the count decreased by 10 lesions among combination patients versus 3 among monotherapy patients. “The quick onset [of the oral drug] is a critical take-home message,” Dr. Fowler said.

By week 16, the mean reduction in total inflammatory lesions was 13 in the combination group, compared with 7 for the monotherapy group.

Patients in the combination therapy group had greater improvements on investigator global assessment at all time points, including significant differences at weeks 12 and 16.

Between weeks 12 and 16, patients who received doxycycline monotherapy maintained the benefits of decreased inflammatory lesion counts and improvements on global assessment.

Dr. Fowler was a consultant and clinical research investigator for CollaGenex Pharmaceuticals Inc. at the time of the study.

Galderma has since acquired CollaGenex, and Dr. Fowler receives research support from Galderma.

By week 4, lesion count decreased by 10 among combination patients and by 3 in those on monotherapy. DR. FOWLER

SINT MAARTEN, NETHERLANDS ANTILLES — Be on the lookout for Acinetobacter baumannii infections among wounded military personnel returning to the United States, an expert warned.

“This is a major problem with our soldiers returning from Iraq and Afghanistan,” according to Dr. Theodore Rosen, adding that the pathogen causes soft tissue and skin infections, osteomyelitis, and if left untreated, fatal bacteremia.

It is also a concern for their family members. “You have to ask them if a family member was fighting over in the Middle East and injured,” Dr. Rosen said. “You need to pay attention because this can save a life,” he said at the Caribbean Dermatology Symposium.

Primary care physicians and dermatologists may be the first to see the cutaneous manifestations of A. baumannii infection.

“We have people who are reservists, they come back, and they come in with a boil or cellulitis,” Dr. Rosen explained. “Culture them, consult ID fast, and get them in the hospital—they need intravenous drugs we don't normally give.”

Multidrug resistance and a delay of weeks or months before clinical symptoms appear are other causes for concern with this gram-negative pathogen. A. baumannii is only 100% sensitive to colistin, 80%-plus to imipenem, and 50% to amikacin, according to a 2004 report (MMWR 2004;53:1063–6).

In that report, the Centers for Disease Control and Prevention had noted an increasing number of A. baumannii bloodstream infections in patients at military medical facilities that treated service members injured in the Iraq/Kuwait region during Operation Iraqi Freedom and in Afghanistan during Operation Enduring Freedom. Officials identified 102 patients at military hospitals who met the CDC criteria for A. baumannii infection between January 2002 and August 2004.

A. baumannii is found in soil and water. Combat trauma is often the cause of initial infection, which was the case for a 55-year-old man injured by a grenade in Iraq. The explosion caused material to enter his anterior thigh and created a large posterolateral hip exit wound and an open left subtrochanteric femur fracture. He was successfully treated with debridement and antibiotic therapy, according to the case report (Emerg. Infec. Dis. 2008;14:512–4).

Infection also can be nosocomial. A. baumannii was implicated in the deaths of five noncombat patients at Walter Reed Army Medical Center in Washington (Clin. Infect. Dis. 2006;43:1045). All of these patients were infected by returning soldiers.

The pathogen causes soft tissue and skin infections, osteomyelitis, and if left untreated, fatal bacteremia. DR. ROSEN

SINT MAARTEN, NETHERLANDS ANTILLES — Be on the lookout for Acinetobacter baumannii infections among wounded military personnel returning to the United States, an expert warned.

“This is a major problem with our soldiers returning from Iraq and Afghanistan,” according to Dr. Theodore Rosen, adding that the pathogen causes soft tissue and skin infections, osteomyelitis, and if left untreated, fatal bacteremia.

It is also a concern for their family members. “You have to ask them if a family member was fighting over in the Middle East and injured,” Dr. Rosen said. “You need to pay attention because this can save a life,” he said at the Caribbean Dermatology Symposium.

Primary care physicians and dermatologists may be the first to see the cutaneous manifestations of A. baumannii infection.

“We have people who are reservists, they come back, and they come in with a boil or cellulitis,” Dr. Rosen explained. “Culture them, consult ID fast, and get them in the hospital—they need intravenous drugs we don't normally give.”

Multidrug resistance and a delay of weeks or months before clinical symptoms appear are other causes for concern with this gram-negative pathogen. A. baumannii is only 100% sensitive to colistin, 80%-plus to imipenem, and 50% to amikacin, according to a 2004 report (MMWR 2004;53:1063–6).

In that report, the Centers for Disease Control and Prevention had noted an increasing number of A. baumannii bloodstream infections in patients at military medical facilities that treated service members injured in the Iraq/Kuwait region during Operation Iraqi Freedom and in Afghanistan during Operation Enduring Freedom. Officials identified 102 patients at military hospitals who met the CDC criteria for A. baumannii infection between January 2002 and August 2004.

A. baumannii is found in soil and water. Combat trauma is often the cause of initial infection, which was the case for a 55-year-old man injured by a grenade in Iraq. The explosion caused material to enter his anterior thigh and created a large posterolateral hip exit wound and an open left subtrochanteric femur fracture. He was successfully treated with debridement and antibiotic therapy, according to the case report (Emerg. Infec. Dis. 2008;14:512–4).

Infection also can be nosocomial. A. baumannii was implicated in the deaths of five noncombat patients at Walter Reed Army Medical Center in Washington (Clin. Infect. Dis. 2006;43:1045). All of these patients were infected by returning soldiers.

The pathogen causes soft tissue and skin infections, osteomyelitis, and if left untreated, fatal bacteremia. DR. ROSEN

SINT MAARTEN, NETHERLANDS ANTILLES — Be on the lookout for Acinetobacter baumannii infections among wounded military personnel returning to the United States, an expert warned.

“This is a major problem with our soldiers returning from Iraq and Afghanistan,” according to Dr. Theodore Rosen, adding that the pathogen causes soft tissue and skin infections, osteomyelitis, and if left untreated, fatal bacteremia.

It is also a concern for their family members. “You have to ask them if a family member was fighting over in the Middle East and injured,” Dr. Rosen said. “You need to pay attention because this can save a life,” he said at the Caribbean Dermatology Symposium.

Primary care physicians and dermatologists may be the first to see the cutaneous manifestations of A. baumannii infection.

“We have people who are reservists, they come back, and they come in with a boil or cellulitis,” Dr. Rosen explained. “Culture them, consult ID fast, and get them in the hospital—they need intravenous drugs we don't normally give.”

Multidrug resistance and a delay of weeks or months before clinical symptoms appear are other causes for concern with this gram-negative pathogen. A. baumannii is only 100% sensitive to colistin, 80%-plus to imipenem, and 50% to amikacin, according to a 2004 report (MMWR 2004;53:1063–6).

In that report, the Centers for Disease Control and Prevention had noted an increasing number of A. baumannii bloodstream infections in patients at military medical facilities that treated service members injured in the Iraq/Kuwait region during Operation Iraqi Freedom and in Afghanistan during Operation Enduring Freedom. Officials identified 102 patients at military hospitals who met the CDC criteria for A. baumannii infection between January 2002 and August 2004.

A. baumannii is found in soil and water. Combat trauma is often the cause of initial infection, which was the case for a 55-year-old man injured by a grenade in Iraq. The explosion caused material to enter his anterior thigh and created a large posterolateral hip exit wound and an open left subtrochanteric femur fracture. He was successfully treated with debridement and antibiotic therapy, according to the case report (Emerg. Infec. Dis. 2008;14:512–4).

Infection also can be nosocomial. A. baumannii was implicated in the deaths of five noncombat patients at Walter Reed Army Medical Center in Washington (Clin. Infect. Dis. 2006;43:1045). All of these patients were infected by returning soldiers.

The pathogen causes soft tissue and skin infections, osteomyelitis, and if left untreated, fatal bacteremia. DR. ROSEN

MIAMI BEACH — Using physiologic insulin replacement strategies, physicians can manage glycemia throughout the perioperative period and optimize patient outcomes.

“We have a number of options to improve glycemic control … and a number of strategies for transitioning the patient after surgery,” Dr. Luigi F. Meneghini said during a meeting on perioperative medicine sponsored by the University of Miami. He explained how to use basal insulin, supplemental scale boluses, and/or prandial insulin during the preoperative, intraoperative, and postoperative periods.

Even surgical patients not diagnosed with diabetes can experience hyperglycemia and associated perioperative and postoperative risks, said Dr. Meneghini, director of clinical operations, division of endocrinology, diabetes and metabolism at the University of Miami.

Why is the perioperative period such a risky time for people with diabetes? Surgery and anesthesia can increase levels of stress hormones, epinephrine, cortisol, growth hormones, and inflammatory cytokines such as interleukin-6 and tumor necrosis factor-alpha. Also, general anesthesia, bypass surgery, sepsis, parenteral nutrition, and use of steroids can alter insulin resistance, decrease insulin secretion, and cause lipolysis and protein catabolism. “This all makes perioperative management of diabetes so much more difficult,” he said.

Perioperative glycemic control can be achieved through implementation of the following strategies before, during, or after surgery:

▸ Preoperatively. The goal is to stabilize glycemia, in many cases with subcutaneous insulin. However, if the patient has type 1 diabetes, continue basal insulin, “no questions asked,” Dr. Meneghini said.

Discontinue all oral agents prior to surgery, perform a finger-stick glucose test every 4-6 hours, and use a supplemental scale for additional insulin if blood glucose levels exceed target values.

“You will need some basal insulin replacement. Insulin needs are still there when you are fasting; you can give [basal insulin] to anyone whether they are NPO [nothing by mouth] or not,” Dr. Meneghini said.

The American Diabetes Association recommends a glycemic target of about 110 mg/dL to less than 140 mg/dL for critically ill patients. For patients who are not critically ill, fasting blood glucose levels of less than 126 mg/dL or random blood glucose levels less than 180-200 mg/dL are recommended (Diabetes Care 2008;31[suppl. 1]:S12-54).

Several preoperative factors should be checked, but at least do an ECG, basic metabolic panel (BMP), and hemoglobin A1c assay, Dr. Meneghini said. “The [Hb]A1c before surgery may be useful for assessing risk and to determine if preoperative glycemic control is adequate.”

▸ Intraoperatively. Intraoperative management depends on the length of the procedure, Dr. Meneghini said. “For a 1- to 2-hour surgery, you can probably continue preoperative glucose management orders.” However, for a longer or more complex surgery, switch to intravenous drip insulin, ideally before surgery in order to stabilize glucose. Physicians can use the Modified Markovitz Protocol (Endocr. Pract. 2002;8:10-8) to calculate glycemic control intraoperatively.

Intravenous regular insulin has a half-life of 7 minutes, and by half an hour there is no more on board, “which can be very handy,” Dr. Meneghini said. “This is why we usually go to [intravenous] regular insulin for the perioperative period or critical care.”

▸ Postoperatively. After surgery, transition patients from intravenous to subcutaneous insulin management, Dr. Meneghini advised. “And that is a tricky passage in many cases. … We need to deal with inconsistent PO intake, stress, infection, and increased insulin resistance.”

Ensure adequate basal insulin levels during the transition to subcutaneous insulin, especially in type 1 diabetes patients. Basal insulin replacement can start at any time, Dr. Meneghini said. “I recommend you start 24 hours prior to discontinuation of the [intravenous] insulin drip. This ensures adequate basal coverage during the transition.”

Replace insulin according to physiologic needs. Match the basal replacement to hepatic glucose output, for example. Also match the prandial glucose to carbohydrate intake, and correct hyperglycemia as needed using a supplemental scale.

Postoperative nutrition should be taken into account. For example, if a patient is receiving total parenteral nutrition, start 1 U of regular insulin subcutaneously per 10-15 g of dextrose in the bag, Dr. Meneghini said. If the patient is on continuous enteral feeding, administer regular insulin every 6 hours or a rapid-acting insulin analog every 4 hours. Also, start 1 U of subcutaneous insulin to cover every 10-15 g of carbohydrates. If the enteral feed is a bolus, start 1 U of insulin subcutaneous per 10-15 g of carbohydrates and inject 15-20 minutes prior to the bolus.

If the patient is eating, use regular insulin or an insulin analog (preferred to minimize stacking) to cover meals, Dr. Meneghini said. Start 1 U of insulin subcutaneously to cover 10-15 g of carbohydrates and use what he calls the “Miami 4/12 Rule,” whereby the basal insulin replacement dose is calculated by taking the patient's weight in kilograms and dividing it by 4 and the prandial coverage is calculated by dividing the patient's weight in kilograms by 12.

MIAMI BEACH — Using physiologic insulin replacement strategies, physicians can manage glycemia throughout the perioperative period and optimize patient outcomes.

“We have a number of options to improve glycemic control … and a number of strategies for transitioning the patient after surgery,” Dr. Luigi F. Meneghini said during a meeting on perioperative medicine sponsored by the University of Miami. He explained how to use basal insulin, supplemental scale boluses, and/or prandial insulin during the preoperative, intraoperative, and postoperative periods.

Even surgical patients not diagnosed with diabetes can experience hyperglycemia and associated perioperative and postoperative risks, said Dr. Meneghini, director of clinical operations, division of endocrinology, diabetes and metabolism at the University of Miami.

Why is the perioperative period such a risky time for people with diabetes? Surgery and anesthesia can increase levels of stress hormones, epinephrine, cortisol, growth hormones, and inflammatory cytokines such as interleukin-6 and tumor necrosis factor-alpha. Also, general anesthesia, bypass surgery, sepsis, parenteral nutrition, and use of steroids can alter insulin resistance, decrease insulin secretion, and cause lipolysis and protein catabolism. “This all makes perioperative management of diabetes so much more difficult,” he said.

Perioperative glycemic control can be achieved through implementation of the following strategies before, during, or after surgery:

▸ Preoperatively. The goal is to stabilize glycemia, in many cases with subcutaneous insulin. However, if the patient has type 1 diabetes, continue basal insulin, “no questions asked,” Dr. Meneghini said.

Discontinue all oral agents prior to surgery, perform a finger-stick glucose test every 4-6 hours, and use a supplemental scale for additional insulin if blood glucose levels exceed target values.

“You will need some basal insulin replacement. Insulin needs are still there when you are fasting; you can give [basal insulin] to anyone whether they are NPO [nothing by mouth] or not,” Dr. Meneghini said.

The American Diabetes Association recommends a glycemic target of about 110 mg/dL to less than 140 mg/dL for critically ill patients. For patients who are not critically ill, fasting blood glucose levels of less than 126 mg/dL or random blood glucose levels less than 180-200 mg/dL are recommended (Diabetes Care 2008;31[suppl. 1]:S12-54).

Several preoperative factors should be checked, but at least do an ECG, basic metabolic panel (BMP), and hemoglobin A1c assay, Dr. Meneghini said. “The [Hb]A1c before surgery may be useful for assessing risk and to determine if preoperative glycemic control is adequate.”

▸ Intraoperatively. Intraoperative management depends on the length of the procedure, Dr. Meneghini said. “For a 1- to 2-hour surgery, you can probably continue preoperative glucose management orders.” However, for a longer or more complex surgery, switch to intravenous drip insulin, ideally before surgery in order to stabilize glucose. Physicians can use the Modified Markovitz Protocol (Endocr. Pract. 2002;8:10-8) to calculate glycemic control intraoperatively.

Intravenous regular insulin has a half-life of 7 minutes, and by half an hour there is no more on board, “which can be very handy,” Dr. Meneghini said. “This is why we usually go to [intravenous] regular insulin for the perioperative period or critical care.”

▸ Postoperatively. After surgery, transition patients from intravenous to subcutaneous insulin management, Dr. Meneghini advised. “And that is a tricky passage in many cases. … We need to deal with inconsistent PO intake, stress, infection, and increased insulin resistance.”

Ensure adequate basal insulin levels during the transition to subcutaneous insulin, especially in type 1 diabetes patients. Basal insulin replacement can start at any time, Dr. Meneghini said. “I recommend you start 24 hours prior to discontinuation of the [intravenous] insulin drip. This ensures adequate basal coverage during the transition.”

Replace insulin according to physiologic needs. Match the basal replacement to hepatic glucose output, for example. Also match the prandial glucose to carbohydrate intake, and correct hyperglycemia as needed using a supplemental scale.

Postoperative nutrition should be taken into account. For example, if a patient is receiving total parenteral nutrition, start 1 U of regular insulin subcutaneously per 10-15 g of dextrose in the bag, Dr. Meneghini said. If the patient is on continuous enteral feeding, administer regular insulin every 6 hours or a rapid-acting insulin analog every 4 hours. Also, start 1 U of subcutaneous insulin to cover every 10-15 g of carbohydrates. If the enteral feed is a bolus, start 1 U of insulin subcutaneous per 10-15 g of carbohydrates and inject 15-20 minutes prior to the bolus.

If the patient is eating, use regular insulin or an insulin analog (preferred to minimize stacking) to cover meals, Dr. Meneghini said. Start 1 U of insulin subcutaneously to cover 10-15 g of carbohydrates and use what he calls the “Miami 4/12 Rule,” whereby the basal insulin replacement dose is calculated by taking the patient's weight in kilograms and dividing it by 4 and the prandial coverage is calculated by dividing the patient's weight in kilograms by 12.

MIAMI BEACH — Using physiologic insulin replacement strategies, physicians can manage glycemia throughout the perioperative period and optimize patient outcomes.

“We have a number of options to improve glycemic control … and a number of strategies for transitioning the patient after surgery,” Dr. Luigi F. Meneghini said during a meeting on perioperative medicine sponsored by the University of Miami. He explained how to use basal insulin, supplemental scale boluses, and/or prandial insulin during the preoperative, intraoperative, and postoperative periods.

Even surgical patients not diagnosed with diabetes can experience hyperglycemia and associated perioperative and postoperative risks, said Dr. Meneghini, director of clinical operations, division of endocrinology, diabetes and metabolism at the University of Miami.

Why is the perioperative period such a risky time for people with diabetes? Surgery and anesthesia can increase levels of stress hormones, epinephrine, cortisol, growth hormones, and inflammatory cytokines such as interleukin-6 and tumor necrosis factor-alpha. Also, general anesthesia, bypass surgery, sepsis, parenteral nutrition, and use of steroids can alter insulin resistance, decrease insulin secretion, and cause lipolysis and protein catabolism. “This all makes perioperative management of diabetes so much more difficult,” he said.

Perioperative glycemic control can be achieved through implementation of the following strategies before, during, or after surgery:

▸ Preoperatively. The goal is to stabilize glycemia, in many cases with subcutaneous insulin. However, if the patient has type 1 diabetes, continue basal insulin, “no questions asked,” Dr. Meneghini said.

Discontinue all oral agents prior to surgery, perform a finger-stick glucose test every 4-6 hours, and use a supplemental scale for additional insulin if blood glucose levels exceed target values.

“You will need some basal insulin replacement. Insulin needs are still there when you are fasting; you can give [basal insulin] to anyone whether they are NPO [nothing by mouth] or not,” Dr. Meneghini said.

The American Diabetes Association recommends a glycemic target of about 110 mg/dL to less than 140 mg/dL for critically ill patients. For patients who are not critically ill, fasting blood glucose levels of less than 126 mg/dL or random blood glucose levels less than 180-200 mg/dL are recommended (Diabetes Care 2008;31[suppl. 1]:S12-54).

Several preoperative factors should be checked, but at least do an ECG, basic metabolic panel (BMP), and hemoglobin A1c assay, Dr. Meneghini said. “The [Hb]A1c before surgery may be useful for assessing risk and to determine if preoperative glycemic control is adequate.”

▸ Intraoperatively. Intraoperative management depends on the length of the procedure, Dr. Meneghini said. “For a 1- to 2-hour surgery, you can probably continue preoperative glucose management orders.” However, for a longer or more complex surgery, switch to intravenous drip insulin, ideally before surgery in order to stabilize glucose. Physicians can use the Modified Markovitz Protocol (Endocr. Pract. 2002;8:10-8) to calculate glycemic control intraoperatively.

Intravenous regular insulin has a half-life of 7 minutes, and by half an hour there is no more on board, “which can be very handy,” Dr. Meneghini said. “This is why we usually go to [intravenous] regular insulin for the perioperative period or critical care.”

▸ Postoperatively. After surgery, transition patients from intravenous to subcutaneous insulin management, Dr. Meneghini advised. “And that is a tricky passage in many cases. … We need to deal with inconsistent PO intake, stress, infection, and increased insulin resistance.”

Ensure adequate basal insulin levels during the transition to subcutaneous insulin, especially in type 1 diabetes patients. Basal insulin replacement can start at any time, Dr. Meneghini said. “I recommend you start 24 hours prior to discontinuation of the [intravenous] insulin drip. This ensures adequate basal coverage during the transition.”

Replace insulin according to physiologic needs. Match the basal replacement to hepatic glucose output, for example. Also match the prandial glucose to carbohydrate intake, and correct hyperglycemia as needed using a supplemental scale.

Postoperative nutrition should be taken into account. For example, if a patient is receiving total parenteral nutrition, start 1 U of regular insulin subcutaneously per 10-15 g of dextrose in the bag, Dr. Meneghini said. If the patient is on continuous enteral feeding, administer regular insulin every 6 hours or a rapid-acting insulin analog every 4 hours. Also, start 1 U of subcutaneous insulin to cover every 10-15 g of carbohydrates. If the enteral feed is a bolus, start 1 U of insulin subcutaneous per 10-15 g of carbohydrates and inject 15-20 minutes prior to the bolus.

If the patient is eating, use regular insulin or an insulin analog (preferred to minimize stacking) to cover meals, Dr. Meneghini said. Start 1 U of insulin subcutaneously to cover 10-15 g of carbohydrates and use what he calls the “Miami 4/12 Rule,” whereby the basal insulin replacement dose is calculated by taking the patient's weight in kilograms and dividing it by 4 and the prandial coverage is calculated by dividing the patient's weight in kilograms by 12.

MIAMI BEACH — Preoperative percent body fat is an independent predictor of surgical site infection risk and is a more accurate way to define obesity than is body mass index, according to preliminary results of a prospective, ongoing trial.

Surgical site infections (SSIs) develop in an estimated 290,000 of the 27 million procedures performed annually in the United States, data from the Centers for Disease Control and Prevention indicate. Previous research has linked obesity—as well as type of procedure, patient comorbidity, immunosuppression, and cigarette smoking—to an increased risk of such infections (Dis. Colon Rectum 2007;50:2223-37; J. Cardiovasc. Surg. 2007;48:641-6).

In the initial cohort of 194 patients in this study, Harvard medical student Emily Waisbren and her associates in the departments of anesthesiology and surgery at Brigham and Women's Hospital in Boston measured percent body fat using bioelectrical impedance analysis and body mass index (BMI) using the standard height and weight formula.

Patients ranged in age from 18 years to 64 years (mean age, 49), and 66% were women. The mean BMI was 29.5 kg/m

A total of 130 patients (67%) were obese according to the body fat criterion, compared with 74 (38%) using the BMI definition.

Participants were assessed before, during, and 30 days after elective surgery (primarily general, orthopedic, and obstetric procedures) on the basis of medical records, questionnaires, and follow-up telephone interviews. A total of 31% of the patients were taking antihypertensive medication, and 18% were current smokers. Most patients had an American Society of Anesthesiologists (ASA) score of 2, “so they were relatively healthy,” Ms. Waisbren said.

SSIs developed in 27 patients (14%). According to the percent body fat cutoffs, infections occurred in 4.7% of nonobese patients and in 18.5% of obese patients. In contrast, when the BMI cutoff was used, 14.2% of the nonobese and 13.5% of obese patients developed SSIs.

As percent body fat increased, there was a statistically significant increase in SSIs. For example, patients with percent body fat greater than 37% were two times more likely to develop an SSI, Ms. Waisbren said. “An association with increased SSI risk was seen with BMI also, but it was not statistically significant.”

Although there were no deaths related to these infections, Ms. Waisbren said that patients with an SSI experienced more adverse outcomes, including wound dehiscence, seroma, and hematoma, than did those without infections.

A meeting attendee asked if patients were possibly overlabeled as obese because two-thirds met the percent body fat definition. “There have been very little data to define the cutoff point,” Ms. Waisbren said. “But you raise the point of how appropriate the American Council on Exercise definition is.”

When a meeting attendee asked why the hip-to-waist ratio was not assessed, Ms. Waisbren said the investigators believed BMI was more accurate than hip-to-waist ratio.

However, she said, “BMI misses an important difference in body composition.” For example, a male body builder and an overweight woman with the same height and weight would have the same BMI, but very different body fat percentages.

Percent body fat was an independent predictor of SSI, according to a univariate analysis. Pedal edema, recent surgery, higher National Nosocomial Infection Surveillance score, and class 2 (clean-contaminated) or higher wound ratings were other predictors.

A multivariate assessment is planned as part of the ongoing study, Ms. Waisbren said.

This study was awarded the best research abstract at the meeting. Data collected for a total of 436 patients in this ongoing study concur with the initial cohort findings, Ms. Waisbren said.

She added that the plan is to enroll 600 elective surgery patients in the final assessment.

MIAMI BEACH — Preoperative percent body fat is an independent predictor of surgical site infection risk and is a more accurate way to define obesity than is body mass index, according to preliminary results of a prospective, ongoing trial.

Surgical site infections (SSIs) develop in an estimated 290,000 of the 27 million procedures performed annually in the United States, data from the Centers for Disease Control and Prevention indicate. Previous research has linked obesity—as well as type of procedure, patient comorbidity, immunosuppression, and cigarette smoking—to an increased risk of such infections (Dis. Colon Rectum 2007;50:2223-37; J. Cardiovasc. Surg. 2007;48:641-6).

In the initial cohort of 194 patients in this study, Harvard medical student Emily Waisbren and her associates in the departments of anesthesiology and surgery at Brigham and Women's Hospital in Boston measured percent body fat using bioelectrical impedance analysis and body mass index (BMI) using the standard height and weight formula.

Patients ranged in age from 18 years to 64 years (mean age, 49), and 66% were women. The mean BMI was 29.5 kg/m

A total of 130 patients (67%) were obese according to the body fat criterion, compared with 74 (38%) using the BMI definition.

Participants were assessed before, during, and 30 days after elective surgery (primarily general, orthopedic, and obstetric procedures) on the basis of medical records, questionnaires, and follow-up telephone interviews. A total of 31% of the patients were taking antihypertensive medication, and 18% were current smokers. Most patients had an American Society of Anesthesiologists (ASA) score of 2, “so they were relatively healthy,” Ms. Waisbren said.

SSIs developed in 27 patients (14%). According to the percent body fat cutoffs, infections occurred in 4.7% of nonobese patients and in 18.5% of obese patients. In contrast, when the BMI cutoff was used, 14.2% of the nonobese and 13.5% of obese patients developed SSIs.

As percent body fat increased, there was a statistically significant increase in SSIs. For example, patients with percent body fat greater than 37% were two times more likely to develop an SSI, Ms. Waisbren said. “An association with increased SSI risk was seen with BMI also, but it was not statistically significant.”

Although there were no deaths related to these infections, Ms. Waisbren said that patients with an SSI experienced more adverse outcomes, including wound dehiscence, seroma, and hematoma, than did those without infections.

A meeting attendee asked if patients were possibly overlabeled as obese because two-thirds met the percent body fat definition. “There have been very little data to define the cutoff point,” Ms. Waisbren said. “But you raise the point of how appropriate the American Council on Exercise definition is.”

When a meeting attendee asked why the hip-to-waist ratio was not assessed, Ms. Waisbren said the investigators believed BMI was more accurate than hip-to-waist ratio.

However, she said, “BMI misses an important difference in body composition.” For example, a male body builder and an overweight woman with the same height and weight would have the same BMI, but very different body fat percentages.

Percent body fat was an independent predictor of SSI, according to a univariate analysis. Pedal edema, recent surgery, higher National Nosocomial Infection Surveillance score, and class 2 (clean-contaminated) or higher wound ratings were other predictors.

A multivariate assessment is planned as part of the ongoing study, Ms. Waisbren said.

This study was awarded the best research abstract at the meeting. Data collected for a total of 436 patients in this ongoing study concur with the initial cohort findings, Ms. Waisbren said.

She added that the plan is to enroll 600 elective surgery patients in the final assessment.

MIAMI BEACH — Preoperative percent body fat is an independent predictor of surgical site infection risk and is a more accurate way to define obesity than is body mass index, according to preliminary results of a prospective, ongoing trial.

Surgical site infections (SSIs) develop in an estimated 290,000 of the 27 million procedures performed annually in the United States, data from the Centers for Disease Control and Prevention indicate. Previous research has linked obesity—as well as type of procedure, patient comorbidity, immunosuppression, and cigarette smoking—to an increased risk of such infections (Dis. Colon Rectum 2007;50:2223-37; J. Cardiovasc. Surg. 2007;48:641-6).

In the initial cohort of 194 patients in this study, Harvard medical student Emily Waisbren and her associates in the departments of anesthesiology and surgery at Brigham and Women's Hospital in Boston measured percent body fat using bioelectrical impedance analysis and body mass index (BMI) using the standard height and weight formula.

Patients ranged in age from 18 years to 64 years (mean age, 49), and 66% were women. The mean BMI was 29.5 kg/m

A total of 130 patients (67%) were obese according to the body fat criterion, compared with 74 (38%) using the BMI definition.

Participants were assessed before, during, and 30 days after elective surgery (primarily general, orthopedic, and obstetric procedures) on the basis of medical records, questionnaires, and follow-up telephone interviews. A total of 31% of the patients were taking antihypertensive medication, and 18% were current smokers. Most patients had an American Society of Anesthesiologists (ASA) score of 2, “so they were relatively healthy,” Ms. Waisbren said.

SSIs developed in 27 patients (14%). According to the percent body fat cutoffs, infections occurred in 4.7% of nonobese patients and in 18.5% of obese patients. In contrast, when the BMI cutoff was used, 14.2% of the nonobese and 13.5% of obese patients developed SSIs.

As percent body fat increased, there was a statistically significant increase in SSIs. For example, patients with percent body fat greater than 37% were two times more likely to develop an SSI, Ms. Waisbren said. “An association with increased SSI risk was seen with BMI also, but it was not statistically significant.”

Although there were no deaths related to these infections, Ms. Waisbren said that patients with an SSI experienced more adverse outcomes, including wound dehiscence, seroma, and hematoma, than did those without infections.

A meeting attendee asked if patients were possibly overlabeled as obese because two-thirds met the percent body fat definition. “There have been very little data to define the cutoff point,” Ms. Waisbren said. “But you raise the point of how appropriate the American Council on Exercise definition is.”

When a meeting attendee asked why the hip-to-waist ratio was not assessed, Ms. Waisbren said the investigators believed BMI was more accurate than hip-to-waist ratio.

However, she said, “BMI misses an important difference in body composition.” For example, a male body builder and an overweight woman with the same height and weight would have the same BMI, but very different body fat percentages.

Percent body fat was an independent predictor of SSI, according to a univariate analysis. Pedal edema, recent surgery, higher National Nosocomial Infection Surveillance score, and class 2 (clean-contaminated) or higher wound ratings were other predictors.

A multivariate assessment is planned as part of the ongoing study, Ms. Waisbren said.

This study was awarded the best research abstract at the meeting. Data collected for a total of 436 patients in this ongoing study concur with the initial cohort findings, Ms. Waisbren said.

She added that the plan is to enroll 600 elective surgery patients in the final assessment.

MIAMI BEACH — Patients taking most antihypertensive medications the morning of surgery are not at higher risk for hypotension or more vasopressor use during the perioperative period, according to a retrospective study.

However, significantly more patients taking an angiotensin-converting enzyme inhibitor experienced these events, and there was a higher incidence among those taking an angiotensin-receptor blocker as well.

“We think they should withhold ACE inhibitors and angiotensin-receptor blockers [ARBs]” on the morning of surgery, Dr. Matthieu Touchette said in an interview.

Dr. Touchette and his colleagues compared 371 patients with a diagnosis of hypertension evaluated in the preoperative clinic within the department of medicine at the University of Sherbrooke Central Hospital in Quebec.

All patients had elective surgery and a hospital length of stay longer than 1 day between November 2005 and November 2006. The researchers compared 91 patients who did not take their antihypertensive medication on the morning of surgery with 280 patients who did.

Their aim was to compare hypotensive episodes and use of vasopressors during the perioperative period between these groups. Results were presented in a poster at a meeting on perioperative medicine sponsored by the University of Miami.

Although the guidelines from the American College of Cardiology and the American Heart Association on antihypertensive medications suggest withholding ACE inhibitors and ARBs on the morning of surgery (Circulation 2007;116:e418-99), “we wanted to check if all hypertensive medications make a difference—do they really change” the perioperative course? said Dr. Touchette, an internist at the University of Sherbrooke Central Hospital.

The mean age of the patients was 67 years in the medicine group (43% men) and 69 years in the no-medicine group (54% men). There was more hypertension during preoperative evaluation in the medicine group (91%) than in the no-medicine group (81%). A lower proportion of patients in the medicine group had cardiovascular disease (24% vs. 46%), dyslipidemia (51% vs. 71%), and atrial fibrillation/flutter (7% vs. 21%).

The type of medication that patients were taking at the time of the preoperative clinical evaluation, not surprisingly, corresponded with these diagnoses. For example, more patients in the medicine group were taking diuretics (56% vs. 43%). In contrast, a higher proportion of patients who did not take hypertensives before surgery were on beta-blockers (54% vs. 23%), calcium channel blockers (48% vs. 25%), and nitroglycerin (9% vs. 2%).

“We found, and it's very interesting, that whether we give pills or not, many people have hypotension during surgery,” Dr. Touchette said.

Hypotension, defined as systolic blood pressure less than 90 mm Hg, occurred in 58% of the medicine group and 46% of the no-medicine group. “We were surprised how many of our patients have hypotensive episodes during surgery. I am an internist—so I am not usually in the OR.”

Despite a high incidence of perioperative hypotension, Dr. Touchette and his colleagues found no significant difference between groups. “There was no overall difference if we look at all the medications as one big bag,” he said.

They also found no significant difference in perioperative use of vasopressors between those who took their antihypertensive the morning of surgery (71%) and those who did not (79%).

However, “when we looked at individual drugs, the ACE inhibitors and ARBs were associated with more hypotensive episodes in the perioperative period,” Dr. Touchette said. Among the patients taking medication on the morning of surgery, there was a statistically significant increased association between perioperative hypotension or vasopressor use if they took an ACE inhibitor (adjusted odds ratio, 2.36), compared with those who did not take this type of medication.

Similarly, patients taking an ARB just before surgery had an increased risk for these two factors, although it was not statistically different (adjusted OR, 2.38).

In contrast, there was a lower risk among patients taking a calcium channel blocker on the morning of surgery (adjusted OR, 0.73), a diuretic (OR, 0.83), or a beta-blocker (OR, 0.89).

Dr. Touchette said that in the future they “would like to try to reproduce the study in a prospective manner.”

'ACE inhibitors and ARBs were associated with more hypotensive episodes in the perioperative period.' DR. TOUCHETTE

MIAMI BEACH — Patients taking most antihypertensive medications the morning of surgery are not at higher risk for hypotension or more vasopressor use during the perioperative period, according to a retrospective study.

However, significantly more patients taking an angiotensin-converting enzyme inhibitor experienced these events, and there was a higher incidence among those taking an angiotensin-receptor blocker as well.

“We think they should withhold ACE inhibitors and angiotensin-receptor blockers [ARBs]” on the morning of surgery, Dr. Matthieu Touchette said in an interview.

Dr. Touchette and his colleagues compared 371 patients with a diagnosis of hypertension evaluated in the preoperative clinic within the department of medicine at the University of Sherbrooke Central Hospital in Quebec.

All patients had elective surgery and a hospital length of stay longer than 1 day between November 2005 and November 2006. The researchers compared 91 patients who did not take their antihypertensive medication on the morning of surgery with 280 patients who did.

Their aim was to compare hypotensive episodes and use of vasopressors during the perioperative period between these groups. Results were presented in a poster at a meeting on perioperative medicine sponsored by the University of Miami.

Although the guidelines from the American College of Cardiology and the American Heart Association on antihypertensive medications suggest withholding ACE inhibitors and ARBs on the morning of surgery (Circulation 2007;116:e418-99), “we wanted to check if all hypertensive medications make a difference—do they really change” the perioperative course? said Dr. Touchette, an internist at the University of Sherbrooke Central Hospital.

The mean age of the patients was 67 years in the medicine group (43% men) and 69 years in the no-medicine group (54% men). There was more hypertension during preoperative evaluation in the medicine group (91%) than in the no-medicine group (81%). A lower proportion of patients in the medicine group had cardiovascular disease (24% vs. 46%), dyslipidemia (51% vs. 71%), and atrial fibrillation/flutter (7% vs. 21%).

The type of medication that patients were taking at the time of the preoperative clinical evaluation, not surprisingly, corresponded with these diagnoses. For example, more patients in the medicine group were taking diuretics (56% vs. 43%). In contrast, a higher proportion of patients who did not take hypertensives before surgery were on beta-blockers (54% vs. 23%), calcium channel blockers (48% vs. 25%), and nitroglycerin (9% vs. 2%).

“We found, and it's very interesting, that whether we give pills or not, many people have hypotension during surgery,” Dr. Touchette said.

Hypotension, defined as systolic blood pressure less than 90 mm Hg, occurred in 58% of the medicine group and 46% of the no-medicine group. “We were surprised how many of our patients have hypotensive episodes during surgery. I am an internist—so I am not usually in the OR.”

Despite a high incidence of perioperative hypotension, Dr. Touchette and his colleagues found no significant difference between groups. “There was no overall difference if we look at all the medications as one big bag,” he said.

They also found no significant difference in perioperative use of vasopressors between those who took their antihypertensive the morning of surgery (71%) and those who did not (79%).

However, “when we looked at individual drugs, the ACE inhibitors and ARBs were associated with more hypotensive episodes in the perioperative period,” Dr. Touchette said. Among the patients taking medication on the morning of surgery, there was a statistically significant increased association between perioperative hypotension or vasopressor use if they took an ACE inhibitor (adjusted odds ratio, 2.36), compared with those who did not take this type of medication.

Similarly, patients taking an ARB just before surgery had an increased risk for these two factors, although it was not statistically different (adjusted OR, 2.38).

In contrast, there was a lower risk among patients taking a calcium channel blocker on the morning of surgery (adjusted OR, 0.73), a diuretic (OR, 0.83), or a beta-blocker (OR, 0.89).

Dr. Touchette said that in the future they “would like to try to reproduce the study in a prospective manner.”

'ACE inhibitors and ARBs were associated with more hypotensive episodes in the perioperative period.' DR. TOUCHETTE

MIAMI BEACH — Patients taking most antihypertensive medications the morning of surgery are not at higher risk for hypotension or more vasopressor use during the perioperative period, according to a retrospective study.

However, significantly more patients taking an angiotensin-converting enzyme inhibitor experienced these events, and there was a higher incidence among those taking an angiotensin-receptor blocker as well.

“We think they should withhold ACE inhibitors and angiotensin-receptor blockers [ARBs]” on the morning of surgery, Dr. Matthieu Touchette said in an interview.

Dr. Touchette and his colleagues compared 371 patients with a diagnosis of hypertension evaluated in the preoperative clinic within the department of medicine at the University of Sherbrooke Central Hospital in Quebec.

All patients had elective surgery and a hospital length of stay longer than 1 day between November 2005 and November 2006. The researchers compared 91 patients who did not take their antihypertensive medication on the morning of surgery with 280 patients who did.

Their aim was to compare hypotensive episodes and use of vasopressors during the perioperative period between these groups. Results were presented in a poster at a meeting on perioperative medicine sponsored by the University of Miami.

Although the guidelines from the American College of Cardiology and the American Heart Association on antihypertensive medications suggest withholding ACE inhibitors and ARBs on the morning of surgery (Circulation 2007;116:e418-99), “we wanted to check if all hypertensive medications make a difference—do they really change” the perioperative course? said Dr. Touchette, an internist at the University of Sherbrooke Central Hospital.

The mean age of the patients was 67 years in the medicine group (43% men) and 69 years in the no-medicine group (54% men). There was more hypertension during preoperative evaluation in the medicine group (91%) than in the no-medicine group (81%). A lower proportion of patients in the medicine group had cardiovascular disease (24% vs. 46%), dyslipidemia (51% vs. 71%), and atrial fibrillation/flutter (7% vs. 21%).

The type of medication that patients were taking at the time of the preoperative clinical evaluation, not surprisingly, corresponded with these diagnoses. For example, more patients in the medicine group were taking diuretics (56% vs. 43%). In contrast, a higher proportion of patients who did not take hypertensives before surgery were on beta-blockers (54% vs. 23%), calcium channel blockers (48% vs. 25%), and nitroglycerin (9% vs. 2%).

“We found, and it's very interesting, that whether we give pills or not, many people have hypotension during surgery,” Dr. Touchette said.

Hypotension, defined as systolic blood pressure less than 90 mm Hg, occurred in 58% of the medicine group and 46% of the no-medicine group. “We were surprised how many of our patients have hypotensive episodes during surgery. I am an internist—so I am not usually in the OR.”

Despite a high incidence of perioperative hypotension, Dr. Touchette and his colleagues found no significant difference between groups. “There was no overall difference if we look at all the medications as one big bag,” he said.

They also found no significant difference in perioperative use of vasopressors between those who took their antihypertensive the morning of surgery (71%) and those who did not (79%).

However, “when we looked at individual drugs, the ACE inhibitors and ARBs were associated with more hypotensive episodes in the perioperative period,” Dr. Touchette said. Among the patients taking medication on the morning of surgery, there was a statistically significant increased association between perioperative hypotension or vasopressor use if they took an ACE inhibitor (adjusted odds ratio, 2.36), compared with those who did not take this type of medication.

Similarly, patients taking an ARB just before surgery had an increased risk for these two factors, although it was not statistically different (adjusted OR, 2.38).

In contrast, there was a lower risk among patients taking a calcium channel blocker on the morning of surgery (adjusted OR, 0.73), a diuretic (OR, 0.83), or a beta-blocker (OR, 0.89).

Dr. Touchette said that in the future they “would like to try to reproduce the study in a prospective manner.”

'ACE inhibitors and ARBs were associated with more hypotensive episodes in the perioperative period.' DR. TOUCHETTE

ORLANDO — Provider specialty and procedure volume influence polyp detection, biopsy rates, and other measures of colonoscopy quality, according to a study of routine clinical practice.

“Over 14 million colonoscopies are performed in the U.S. These are performed by providers with different levels of training and in diverse practice settings,” Dr. Cynthia Ko said at the annual meeting of the American College of Gastroenterology.

Gastroenterologists performed 73% of 328,167 outpatient colonoscopies in a study based on Medicare claims. General surgeons performed 13% of colonoscopies, colorectal surgeons did 6%, internists did 5%, family physicians did 2%, and other specialists the remaining 1%.

Dr. Ko and her colleagues compared detection of colorectal polyps, complications within 30 days after colonoscopy, and biopsy rates by physician specialty and volume. They crossed 20% of relevant Medicare claims data from 2003 with physician information from the American Medical Association Physician Masterfile.

Overall, 38% of the colonoscopies revealed colorectal polyps, and 27% of colonoscopies involved biopsies, she said.

Gastroenterologists had a 45% polyp detection rate, compared with 35%–43% for the other physicians. Expressed in terms of odds ratios using the gastroenterologists as a reference (OR, 1.0), other physicians detected fewer polyps: General surgeons had an OR of 0.75, colorectal surgeons had an OR of 0.92, for internists the OR was 0.92, and for family physicians the OR was 0.85.

Gastroenterologists were more likely to perform polypectomy, with a 27% rate versus a range of 18%–23% among the other types of physicians.

A total of 5% of patients had an emergency department visit, and 6% were hospitalized within 30 days of colonoscopy. Older patients were more likely to experience these events.

The risk of hospitalization varied by physician specialty. Compared with the reference group of gastroenterologists, the patients of general surgeons were more likely to be hospitalized (OR, 1.06). In contrast, the patients of other specialists had a lower likelihood as follows: colorectal surgeons (OR, 0.69), internists (OR, 0.99), and family physicians (OR, 0.92).

A meeting attendee asked if a different type of patient typically presents to colorectal surgeons versus primary care providers. “Comorbidity is slightly higher for those who go to a gastroenterologist versus an internist or family physician,” said Dr. Ko of the medicine faculty, division of gastroenterology, University of Washington, Seattle.

Compared with patients of gastroenterologists, those patients who had colonoscopies done by general surgeons had a greater likelihood of additional examinations (OR, 1.04). Patients treated by internists or family physicians also were more likely to have repeat colonoscopies (OR of 1.08 and 1.15, respectively). In contrast, patients treated by colorectal surgeons had a lower likelihood (OR, 0.83).

A meeting attendee asked what proportion of polyps were adenomas. Dr. Ko replied that Medicare coding indicates only whether or not a polyp was detected and provides no histology information, a potential limitation of the study.

It may seem counterintuitive, but polyp detection and polypectomy rates were inversely related to physician volumes. Using the lowest volume quartile as a reference (OR, 1.00), physicians in the second-lowest quartile detected 9% more polyps (OR, 1.09), the third quartile detected 8% more (OR, 1.08), and those in the highest-volume quartile found 2% more (OR, 1.02). Biopsy rates also decreased with increasing volume: first quartile (OR, 1.00), second quartile (0.95), third quartile (0.90), and highest-volume quartile (0.83).

When asked to explain these findings, Dr. Ko said, “Polyp detection rates are linked to withdrawal times. I think physicians in very-high-volume centers may be going faster. I can't prove it with these data; it's just my hypothesis.”

ORLANDO — Provider specialty and procedure volume influence polyp detection, biopsy rates, and other measures of colonoscopy quality, according to a study of routine clinical practice.

“Over 14 million colonoscopies are performed in the U.S. These are performed by providers with different levels of training and in diverse practice settings,” Dr. Cynthia Ko said at the annual meeting of the American College of Gastroenterology.

Gastroenterologists performed 73% of 328,167 outpatient colonoscopies in a study based on Medicare claims. General surgeons performed 13% of colonoscopies, colorectal surgeons did 6%, internists did 5%, family physicians did 2%, and other specialists the remaining 1%.

Dr. Ko and her colleagues compared detection of colorectal polyps, complications within 30 days after colonoscopy, and biopsy rates by physician specialty and volume. They crossed 20% of relevant Medicare claims data from 2003 with physician information from the American Medical Association Physician Masterfile.

Overall, 38% of the colonoscopies revealed colorectal polyps, and 27% of colonoscopies involved biopsies, she said.

Gastroenterologists had a 45% polyp detection rate, compared with 35%–43% for the other physicians. Expressed in terms of odds ratios using the gastroenterologists as a reference (OR, 1.0), other physicians detected fewer polyps: General surgeons had an OR of 0.75, colorectal surgeons had an OR of 0.92, for internists the OR was 0.92, and for family physicians the OR was 0.85.

Gastroenterologists were more likely to perform polypectomy, with a 27% rate versus a range of 18%–23% among the other types of physicians.

A total of 5% of patients had an emergency department visit, and 6% were hospitalized within 30 days of colonoscopy. Older patients were more likely to experience these events.

The risk of hospitalization varied by physician specialty. Compared with the reference group of gastroenterologists, the patients of general surgeons were more likely to be hospitalized (OR, 1.06). In contrast, the patients of other specialists had a lower likelihood as follows: colorectal surgeons (OR, 0.69), internists (OR, 0.99), and family physicians (OR, 0.92).

A meeting attendee asked if a different type of patient typically presents to colorectal surgeons versus primary care providers. “Comorbidity is slightly higher for those who go to a gastroenterologist versus an internist or family physician,” said Dr. Ko of the medicine faculty, division of gastroenterology, University of Washington, Seattle.

Compared with patients of gastroenterologists, those patients who had colonoscopies done by general surgeons had a greater likelihood of additional examinations (OR, 1.04). Patients treated by internists or family physicians also were more likely to have repeat colonoscopies (OR of 1.08 and 1.15, respectively). In contrast, patients treated by colorectal surgeons had a lower likelihood (OR, 0.83).

A meeting attendee asked what proportion of polyps were adenomas. Dr. Ko replied that Medicare coding indicates only whether or not a polyp was detected and provides no histology information, a potential limitation of the study.

It may seem counterintuitive, but polyp detection and polypectomy rates were inversely related to physician volumes. Using the lowest volume quartile as a reference (OR, 1.00), physicians in the second-lowest quartile detected 9% more polyps (OR, 1.09), the third quartile detected 8% more (OR, 1.08), and those in the highest-volume quartile found 2% more (OR, 1.02). Biopsy rates also decreased with increasing volume: first quartile (OR, 1.00), second quartile (0.95), third quartile (0.90), and highest-volume quartile (0.83).

When asked to explain these findings, Dr. Ko said, “Polyp detection rates are linked to withdrawal times. I think physicians in very-high-volume centers may be going faster. I can't prove it with these data; it's just my hypothesis.”

ORLANDO — Provider specialty and procedure volume influence polyp detection, biopsy rates, and other measures of colonoscopy quality, according to a study of routine clinical practice.

“Over 14 million colonoscopies are performed in the U.S. These are performed by providers with different levels of training and in diverse practice settings,” Dr. Cynthia Ko said at the annual meeting of the American College of Gastroenterology.

Gastroenterologists performed 73% of 328,167 outpatient colonoscopies in a study based on Medicare claims. General surgeons performed 13% of colonoscopies, colorectal surgeons did 6%, internists did 5%, family physicians did 2%, and other specialists the remaining 1%.

Dr. Ko and her colleagues compared detection of colorectal polyps, complications within 30 days after colonoscopy, and biopsy rates by physician specialty and volume. They crossed 20% of relevant Medicare claims data from 2003 with physician information from the American Medical Association Physician Masterfile.

Overall, 38% of the colonoscopies revealed colorectal polyps, and 27% of colonoscopies involved biopsies, she said.

Gastroenterologists had a 45% polyp detection rate, compared with 35%–43% for the other physicians. Expressed in terms of odds ratios using the gastroenterologists as a reference (OR, 1.0), other physicians detected fewer polyps: General surgeons had an OR of 0.75, colorectal surgeons had an OR of 0.92, for internists the OR was 0.92, and for family physicians the OR was 0.85.

Gastroenterologists were more likely to perform polypectomy, with a 27% rate versus a range of 18%–23% among the other types of physicians.

A total of 5% of patients had an emergency department visit, and 6% were hospitalized within 30 days of colonoscopy. Older patients were more likely to experience these events.

The risk of hospitalization varied by physician specialty. Compared with the reference group of gastroenterologists, the patients of general surgeons were more likely to be hospitalized (OR, 1.06). In contrast, the patients of other specialists had a lower likelihood as follows: colorectal surgeons (OR, 0.69), internists (OR, 0.99), and family physicians (OR, 0.92).

A meeting attendee asked if a different type of patient typically presents to colorectal surgeons versus primary care providers. “Comorbidity is slightly higher for those who go to a gastroenterologist versus an internist or family physician,” said Dr. Ko of the medicine faculty, division of gastroenterology, University of Washington, Seattle.

Compared with patients of gastroenterologists, those patients who had colonoscopies done by general surgeons had a greater likelihood of additional examinations (OR, 1.04). Patients treated by internists or family physicians also were more likely to have repeat colonoscopies (OR of 1.08 and 1.15, respectively). In contrast, patients treated by colorectal surgeons had a lower likelihood (OR, 0.83).

A meeting attendee asked what proportion of polyps were adenomas. Dr. Ko replied that Medicare coding indicates only whether or not a polyp was detected and provides no histology information, a potential limitation of the study.

It may seem counterintuitive, but polyp detection and polypectomy rates were inversely related to physician volumes. Using the lowest volume quartile as a reference (OR, 1.00), physicians in the second-lowest quartile detected 9% more polyps (OR, 1.09), the third quartile detected 8% more (OR, 1.08), and those in the highest-volume quartile found 2% more (OR, 1.02). Biopsy rates also decreased with increasing volume: first quartile (OR, 1.00), second quartile (0.95), third quartile (0.90), and highest-volume quartile (0.83).

When asked to explain these findings, Dr. Ko said, “Polyp detection rates are linked to withdrawal times. I think physicians in very-high-volume centers may be going faster. I can't prove it with these data; it's just my hypothesis.”

SINT MAARTEN, NETHERLANDS ANTILLES — Be on the lookout for Acinetobacter baumannii infections among wounded military personnel returning to the United States, an expert warned.

"This is a major problem with our soldiers returning from Iraq and Afghanistan," according to Dr. Theodore Rosen, adding that the pathogen causes soft tissue and skin infections, osteomyelitis, and if left untreated, fatal bacteremia.

It is also a concern for their family members. "You have to ask them if a family member was fighting over in the Middle East and injured," Dr. Rosen said. "You need to pay attention because this can save a life," he said at the Caribbean Dermatology Symposium.

Primary care physicians and dermatologists may be the first to see the cutaneous manifestations of A. baumannii infection. "We have people who are reservists, they come back, and they come in with a boil or cellulitis," Dr. Rosen said. "Culture them, consult ID fast, and get them in the hospital—they need intravenous drugs we don't normally give."

Multidrug resistance and a delay of weeks or months before clinical symptoms appear are other causes for concern with this gram-negative pathogen. A. baumannii is 100% sensitive only to colistin, 80%-plus to imipenem, and 50% to amikacin, according to a 2004 report (MMWR 2004;53:1063–6).

In that report, the Centers for Disease Control and Prevention had noted an increasing number of A. baumannii bloodstream infections in patients at military medical facilities treating service members injured in the Iraq/Kuwait region during Operation Iraqi Freedom and in Afghanistan during Operation Enduring Freedom. Officials identified 102 patients at military hospitals who met CDC criteria for A. baumannii infection between January 2002 and August 2004.

A. baumannii is found in soil and water. Combat trauma is often the cause of initial infection, which was the case for a 55-year-old man injured by a grenade in Iraq. The explosion caused material to enter his anterior thigh and created a large posterolateral hip exit wound and an open left subtrochanteric femur fracture. He was successfully treated with debridement and antibiotic therapy, according to the case report (Emerg. Infec. Dis. 2008;14:512–4).

Infection also can be nosocomial. A. baumannii was implicated in the deaths of five noncombat patients at Walter Reed Army Medical Center in Washington, all of whom were infected by returning soldiers (Clin. Infect. Dis. 2006;43:1045).

"Now it is [also] felt to be acquired in military medical facilities," said Dr. Rosen, professor of dermatology and chief, VA Dermatology Clinic, Baylor College of Medicine, Houston.

The gram-negative, nonmotile A. baumannii bacteria (magnified 27,600x) is 100% sensitive only to colistin, 80%-plus to imipenem, and 50% to amikacin. CDC/MATTHEW J. ARDUINO, DRPH/JANICE CARR/JANA SWENSON

SINT MAARTEN, NETHERLANDS ANTILLES — Be on the lookout for Acinetobacter baumannii infections among wounded military personnel returning to the United States, an expert warned.

"This is a major problem with our soldiers returning from Iraq and Afghanistan," according to Dr. Theodore Rosen, adding that the pathogen causes soft tissue and skin infections, osteomyelitis, and if left untreated, fatal bacteremia.

It is also a concern for their family members. "You have to ask them if a family member was fighting over in the Middle East and injured," Dr. Rosen said. "You need to pay attention because this can save a life," he said at the Caribbean Dermatology Symposium.

Primary care physicians and dermatologists may be the first to see the cutaneous manifestations of A. baumannii infection. "We have people who are reservists, they come back, and they come in with a boil or cellulitis," Dr. Rosen said. "Culture them, consult ID fast, and get them in the hospital—they need intravenous drugs we don't normally give."

Multidrug resistance and a delay of weeks or months before clinical symptoms appear are other causes for concern with this gram-negative pathogen. A. baumannii is 100% sensitive only to colistin, 80%-plus to imipenem, and 50% to amikacin, according to a 2004 report (MMWR 2004;53:1063–6).

In that report, the Centers for Disease Control and Prevention had noted an increasing number of A. baumannii bloodstream infections in patients at military medical facilities treating service members injured in the Iraq/Kuwait region during Operation Iraqi Freedom and in Afghanistan during Operation Enduring Freedom. Officials identified 102 patients at military hospitals who met CDC criteria for A. baumannii infection between January 2002 and August 2004.

A. baumannii is found in soil and water. Combat trauma is often the cause of initial infection, which was the case for a 55-year-old man injured by a grenade in Iraq. The explosion caused material to enter his anterior thigh and created a large posterolateral hip exit wound and an open left subtrochanteric femur fracture. He was successfully treated with debridement and antibiotic therapy, according to the case report (Emerg. Infec. Dis. 2008;14:512–4).

Infection also can be nosocomial. A. baumannii was implicated in the deaths of five noncombat patients at Walter Reed Army Medical Center in Washington, all of whom were infected by returning soldiers (Clin. Infect. Dis. 2006;43:1045).

"Now it is [also] felt to be acquired in military medical facilities," said Dr. Rosen, professor of dermatology and chief, VA Dermatology Clinic, Baylor College of Medicine, Houston.

The gram-negative, nonmotile A. baumannii bacteria (magnified 27,600x) is 100% sensitive only to colistin, 80%-plus to imipenem, and 50% to amikacin. CDC/MATTHEW J. ARDUINO, DRPH/JANICE CARR/JANA SWENSON

SINT MAARTEN, NETHERLANDS ANTILLES — Be on the lookout for Acinetobacter baumannii infections among wounded military personnel returning to the United States, an expert warned.

"This is a major problem with our soldiers returning from Iraq and Afghanistan," according to Dr. Theodore Rosen, adding that the pathogen causes soft tissue and skin infections, osteomyelitis, and if left untreated, fatal bacteremia.

It is also a concern for their family members. "You have to ask them if a family member was fighting over in the Middle East and injured," Dr. Rosen said. "You need to pay attention because this can save a life," he said at the Caribbean Dermatology Symposium.

Primary care physicians and dermatologists may be the first to see the cutaneous manifestations of A. baumannii infection. "We have people who are reservists, they come back, and they come in with a boil or cellulitis," Dr. Rosen said. "Culture them, consult ID fast, and get them in the hospital—they need intravenous drugs we don't normally give."

Multidrug resistance and a delay of weeks or months before clinical symptoms appear are other causes for concern with this gram-negative pathogen. A. baumannii is 100% sensitive only to colistin, 80%-plus to imipenem, and 50% to amikacin, according to a 2004 report (MMWR 2004;53:1063–6).

In that report, the Centers for Disease Control and Prevention had noted an increasing number of A. baumannii bloodstream infections in patients at military medical facilities treating service members injured in the Iraq/Kuwait region during Operation Iraqi Freedom and in Afghanistan during Operation Enduring Freedom. Officials identified 102 patients at military hospitals who met CDC criteria for A. baumannii infection between January 2002 and August 2004.

A. baumannii is found in soil and water. Combat trauma is often the cause of initial infection, which was the case for a 55-year-old man injured by a grenade in Iraq. The explosion caused material to enter his anterior thigh and created a large posterolateral hip exit wound and an open left subtrochanteric femur fracture. He was successfully treated with debridement and antibiotic therapy, according to the case report (Emerg. Infec. Dis. 2008;14:512–4).

Infection also can be nosocomial. A. baumannii was implicated in the deaths of five noncombat patients at Walter Reed Army Medical Center in Washington, all of whom were infected by returning soldiers (Clin. Infect. Dis. 2006;43:1045).

"Now it is [also] felt to be acquired in military medical facilities," said Dr. Rosen, professor of dermatology and chief, VA Dermatology Clinic, Baylor College of Medicine, Houston.

The gram-negative, nonmotile A. baumannii bacteria (magnified 27,600x) is 100% sensitive only to colistin, 80%-plus to imipenem, and 50% to amikacin. CDC/MATTHEW J. ARDUINO, DRPH/JANICE CARR/JANA SWENSON