Damian McNamara

White students attending more racially diverse medical schools consider themselves better prepared to care for patients of racial and ethnic minority groups than are students at less diverse medical schools, according to a study of more than 20,000 graduates.

Attitudes about providing equivalent access to health care for everyone also were stronger among students at more diverse schools. These students' responses were 50% more favorable toward equitable access to care, compared with their counterparts at the least diverse schools.

The associations were particularly strong at medical schools that foster positive interactions and sharing of opinions among students from different backgrounds, Dr. Somnath Saha and colleagues reported in a recent issue of JAMA (2008;300:1135–45).

The investigators also found a “threshold effect” regarding minority student enrollment. Specifically, diversity outcomes were positive among the 118 medical schools in the study if the proportion of underrepresented minority graduates (URMs) exceeded 10%, or the total nonwhite student population was more than 36%. The authors had no disclosures.

Policies and programs devised to achieve racial diversity in medical schools and to increase the numbers of underrepresented black, Hispanic, and Native American students “have come under increasing scrutiny as being unnecessary and discriminatory,” the authors wrote. Dr. Saha is an internist at the Portland VA Medical Center and Oregon Health and Science University.

Affirmative action and addressing prior injustices are the justification for most programs to increase URM student diversity, However, Dr. Olveen Carrasquillo and Dr. Elizabeth T. Lee-Rey wrote in an editorial in the same issue of JAMA, “the well-documented history of widespread racism within organized medicine and the American Medical Association's apology is a reminder of how pervasive and tolerated such practices were only a few decades ago” (2008;300:1203–4).

In the current study, Dr. Saha and colleagues assessed results of the online graduation questionnaires administered by the Association of American Medical Colleges in 2003 and 2004. They assessed anonymous responses from 20,112 individuals, representing 64% of all graduates during those 2 years.

Race and ethnicity were self-reported. The 9% of URM respondents included black, American Indian, Alaska Native, Mexican American/Chicano, mainland Puerto Rican, and Native Hawaiian students. Minorities not considered to be underrepresented in the physician workforce, primarily Asians and non-URM Hispanic or Latino students, comprised the 23% nonwhite/non-URM group. The remaining 68% were white students.

A total of 21% of the 13,764 graduates in 2003 and 22% of the 7,472 graduates in 2004 strongly agreed that “everyone is entitled to adequate care.” Also, 42% of the 2003 graduates and 44% of the 2004 graduates strongly agreed that “access to care is a major problem.”

A total of 59% of the 2003 cohort and 60% of the 2004 cohort indicated they felt prepared to serve diverse populations.

Interestingly, white students at more diverse medical schools did not indicate they were more likely to care for underserved populations. “This may reflect confounding by the urban versus rural location of schools,” the authors wrote. “Rural schools are likely to have both fewer nonwhite students and more students who plan to practice in rural, underserved locations.”

In contrast, a total of 49% of URMs planned to work with underserved patient populations, significantly more than both white (19%) and nonwhite/non-URM students (16%).

“The finding by Saha and colleagues in this issue of JAMA that… increased medical school diversity is associated with white students feeling better prepared to care for diverse patients is an important contribution to the medical literature,” Dr. Carrasquillo and Dr. Lee-Rey wrote. “Findings from this methodologically rigorous study can inform efforts to elicit continued support by the Supreme Court for admissions policies favorable to URM diversity.”

“As with all cross-sectional studies, there are important limitations, the most important of which is the inability to address causality,” Dr. Carrasquillo and Dr. Lee-Rey wrote.

Dr. Saha and colleagues noted that they had no measures of student attitude, experience, or plans to practice medicine prior to entering medical school. In addition, schools that actively recruit a diverse student body might be more committed to improving diversity-related outcomes, another possible confounder of the study.

“Acknowledging these limitations, we believe our findings have potential policy implications,” they wrote. “A diverse student body is likely to be necessary but not sufficient. Medical schools may need to actively foster positive interaction among individuals from different backgrounds to derive the benefits of diversity.”

Dr. Carrasquillo is the director of the Center for the Health of Urban Minorities at Columbia University Medical Center and Dr. Lee-Rey is the codirector of the Hispanic Center for Excellence, Albert Einstein College of Medicine, both in New York.

White students attending more racially diverse medical schools consider themselves better prepared to care for patients of racial and ethnic minority groups than are students at less diverse medical schools, according to a study of more than 20,000 graduates.

Attitudes about providing equivalent access to health care for everyone also were stronger among students at more diverse schools. These students' responses were 50% more favorable toward equitable access to care, compared with their counterparts at the least diverse schools.

The associations were particularly strong at medical schools that foster positive interactions and sharing of opinions among students from different backgrounds, Dr. Somnath Saha and colleagues reported in a recent issue of JAMA (2008;300:1135–45).

The investigators also found a “threshold effect” regarding minority student enrollment. Specifically, diversity outcomes were positive among the 118 medical schools in the study if the proportion of underrepresented minority graduates (URMs) exceeded 10%, or the total nonwhite student population was more than 36%. The authors had no disclosures.

Policies and programs devised to achieve racial diversity in medical schools and to increase the numbers of underrepresented black, Hispanic, and Native American students “have come under increasing scrutiny as being unnecessary and discriminatory,” the authors wrote. Dr. Saha is an internist at the Portland VA Medical Center and Oregon Health and Science University.

Affirmative action and addressing prior injustices are the justification for most programs to increase URM student diversity, However, Dr. Olveen Carrasquillo and Dr. Elizabeth T. Lee-Rey wrote in an editorial in the same issue of JAMA, “the well-documented history of widespread racism within organized medicine and the American Medical Association's apology is a reminder of how pervasive and tolerated such practices were only a few decades ago” (2008;300:1203–4).

In the current study, Dr. Saha and colleagues assessed results of the online graduation questionnaires administered by the Association of American Medical Colleges in 2003 and 2004. They assessed anonymous responses from 20,112 individuals, representing 64% of all graduates during those 2 years.

Race and ethnicity were self-reported. The 9% of URM respondents included black, American Indian, Alaska Native, Mexican American/Chicano, mainland Puerto Rican, and Native Hawaiian students. Minorities not considered to be underrepresented in the physician workforce, primarily Asians and non-URM Hispanic or Latino students, comprised the 23% nonwhite/non-URM group. The remaining 68% were white students.

A total of 21% of the 13,764 graduates in 2003 and 22% of the 7,472 graduates in 2004 strongly agreed that “everyone is entitled to adequate care.” Also, 42% of the 2003 graduates and 44% of the 2004 graduates strongly agreed that “access to care is a major problem.”

A total of 59% of the 2003 cohort and 60% of the 2004 cohort indicated they felt prepared to serve diverse populations.

Interestingly, white students at more diverse medical schools did not indicate they were more likely to care for underserved populations. “This may reflect confounding by the urban versus rural location of schools,” the authors wrote. “Rural schools are likely to have both fewer nonwhite students and more students who plan to practice in rural, underserved locations.”

In contrast, a total of 49% of URMs planned to work with underserved patient populations, significantly more than both white (19%) and nonwhite/non-URM students (16%).

“The finding by Saha and colleagues in this issue of JAMA that… increased medical school diversity is associated with white students feeling better prepared to care for diverse patients is an important contribution to the medical literature,” Dr. Carrasquillo and Dr. Lee-Rey wrote. “Findings from this methodologically rigorous study can inform efforts to elicit continued support by the Supreme Court for admissions policies favorable to URM diversity.”

“As with all cross-sectional studies, there are important limitations, the most important of which is the inability to address causality,” Dr. Carrasquillo and Dr. Lee-Rey wrote.

Dr. Saha and colleagues noted that they had no measures of student attitude, experience, or plans to practice medicine prior to entering medical school. In addition, schools that actively recruit a diverse student body might be more committed to improving diversity-related outcomes, another possible confounder of the study.

“Acknowledging these limitations, we believe our findings have potential policy implications,” they wrote. “A diverse student body is likely to be necessary but not sufficient. Medical schools may need to actively foster positive interaction among individuals from different backgrounds to derive the benefits of diversity.”

Dr. Carrasquillo is the director of the Center for the Health of Urban Minorities at Columbia University Medical Center and Dr. Lee-Rey is the codirector of the Hispanic Center for Excellence, Albert Einstein College of Medicine, both in New York.

White students attending more racially diverse medical schools consider themselves better prepared to care for patients of racial and ethnic minority groups than are students at less diverse medical schools, according to a study of more than 20,000 graduates.

Attitudes about providing equivalent access to health care for everyone also were stronger among students at more diverse schools. These students' responses were 50% more favorable toward equitable access to care, compared with their counterparts at the least diverse schools.

The associations were particularly strong at medical schools that foster positive interactions and sharing of opinions among students from different backgrounds, Dr. Somnath Saha and colleagues reported in a recent issue of JAMA (2008;300:1135–45).

The investigators also found a “threshold effect” regarding minority student enrollment. Specifically, diversity outcomes were positive among the 118 medical schools in the study if the proportion of underrepresented minority graduates (URMs) exceeded 10%, or the total nonwhite student population was more than 36%. The authors had no disclosures.

Policies and programs devised to achieve racial diversity in medical schools and to increase the numbers of underrepresented black, Hispanic, and Native American students “have come under increasing scrutiny as being unnecessary and discriminatory,” the authors wrote. Dr. Saha is an internist at the Portland VA Medical Center and Oregon Health and Science University.

Affirmative action and addressing prior injustices are the justification for most programs to increase URM student diversity, However, Dr. Olveen Carrasquillo and Dr. Elizabeth T. Lee-Rey wrote in an editorial in the same issue of JAMA, “the well-documented history of widespread racism within organized medicine and the American Medical Association's apology is a reminder of how pervasive and tolerated such practices were only a few decades ago” (2008;300:1203–4).

In the current study, Dr. Saha and colleagues assessed results of the online graduation questionnaires administered by the Association of American Medical Colleges in 2003 and 2004. They assessed anonymous responses from 20,112 individuals, representing 64% of all graduates during those 2 years.

Race and ethnicity were self-reported. The 9% of URM respondents included black, American Indian, Alaska Native, Mexican American/Chicano, mainland Puerto Rican, and Native Hawaiian students. Minorities not considered to be underrepresented in the physician workforce, primarily Asians and non-URM Hispanic or Latino students, comprised the 23% nonwhite/non-URM group. The remaining 68% were white students.

A total of 21% of the 13,764 graduates in 2003 and 22% of the 7,472 graduates in 2004 strongly agreed that “everyone is entitled to adequate care.” Also, 42% of the 2003 graduates and 44% of the 2004 graduates strongly agreed that “access to care is a major problem.”

A total of 59% of the 2003 cohort and 60% of the 2004 cohort indicated they felt prepared to serve diverse populations.

Interestingly, white students at more diverse medical schools did not indicate they were more likely to care for underserved populations. “This may reflect confounding by the urban versus rural location of schools,” the authors wrote. “Rural schools are likely to have both fewer nonwhite students and more students who plan to practice in rural, underserved locations.”

In contrast, a total of 49% of URMs planned to work with underserved patient populations, significantly more than both white (19%) and nonwhite/non-URM students (16%).

“The finding by Saha and colleagues in this issue of JAMA that… increased medical school diversity is associated with white students feeling better prepared to care for diverse patients is an important contribution to the medical literature,” Dr. Carrasquillo and Dr. Lee-Rey wrote. “Findings from this methodologically rigorous study can inform efforts to elicit continued support by the Supreme Court for admissions policies favorable to URM diversity.”

“As with all cross-sectional studies, there are important limitations, the most important of which is the inability to address causality,” Dr. Carrasquillo and Dr. Lee-Rey wrote.

Dr. Saha and colleagues noted that they had no measures of student attitude, experience, or plans to practice medicine prior to entering medical school. In addition, schools that actively recruit a diverse student body might be more committed to improving diversity-related outcomes, another possible confounder of the study.

“Acknowledging these limitations, we believe our findings have potential policy implications,” they wrote. “A diverse student body is likely to be necessary but not sufficient. Medical schools may need to actively foster positive interaction among individuals from different backgrounds to derive the benefits of diversity.”

Dr. Carrasquillo is the director of the Center for the Health of Urban Minorities at Columbia University Medical Center and Dr. Lee-Rey is the codirector of the Hispanic Center for Excellence, Albert Einstein College of Medicine, both in New York.

MIAMI — A “progressive discipline” system of warnings and suggestions for improvement before firing an underperforming employee maximizes chances of winning a wrongful termination lawsuit, according to a labor and employee attorney.

In addition, perform regular and honest performance evaluations and keep all employee documents under lock and key.

“I suggest to my clients that they do not fire someone until there is enough of a paper trail,” said Chad K. Lang, a labor and employee attorney practicing in Miami.

“Progressive discipline … is about fairness. The No. 1 reason employees file lawsuits is they believe they were not treated fairly, regardless of how many warnings you gave them. They truly believe they are right,” Mr. Lang said. There is no legal requirement for progressive discipline, but it will look “very fair to a jury.” It will be perceived as, “We gave them benefit of the doubt, they chose not to listen, and we had to let them go.”

Avoid oral warnings about performance, Mr. Lang said. But if an initial warning is spoken, document it in writing afterward. E-mail is acceptable. For example, send an e-mail stating, “Thank you for meeting with me today. This is what we discussed.”

Subsequent warnings are more formal and always should be in writing, Mr. Lang said at a pediatric update sponsored by Miami Children's Hospital.

Have a witness in the room when presenting an employee with a written performance warning, Mr. Lang suggested. “A lot of people do these in a closed-door situation.” The presence of a manager or supervisor is recommended, preferably one of the same gender as the employee in question to avoid allegations of sexual harassment before termination.

Link the written warning to prior oral discussions and require the employee to sign and date it. “A lot of times, people remember the signature but forget to date it,” Mr. Lang said. “They might countersue and say they signed it at a different time.” If an employee refuses to sign the written warning, note this, sign and date it, and have the witness do the same. “The witness does not need to say a word. They are observers, so if it comes down to it, it does not become a 'he said, she said' situation.”

Employees also should sign an employee handbook acknowledgment form, Mr. Lang said. “An employee will most likely lie and say [he or she] never received it.”

A written company policy should state that these progressive steps are a guideline, and in some instances there will be immediate termination, Mr. Lang said. The employee handbook should include an “at-will” employee policy. This implies there is no contract for you to keep them.

Honest, written performance evaluations for all employees are another protection against a future lawsuit, Mr. Lang said. “A lukewarm evaluation will not help if you fire them for doing a poor job. If you are going to take the time to do these, tell the truth and be accurate.”

Many employers tie evaluation scores to salary and bonus pay. It will look inconsistent to a judge or jury, however, if an underperformer gets the same raise as another employee doing well. “If it goes to disposition, they will ask why you gave an underperformer a raise in the first place, and then why was it equal to someone you did not fire,” Mr. Lang said.

Praise and criticism are not mutually exclusive. Recognize tasks they are doing well in their performance evaluations, Mr. Lang said. Use objective criteria and standards when possible, and include an improvement plan for underperformers. It can state, for example, that within 30 days or 60 days they have 'X' and 'Y' to do. “Improvement plans are good and they are objective.”

In addition, “I highly recommend you keep the documents under lock and key,” Mr. Lang said. Often, employees know when their firing is coming, and a day or two beforehand their personnel files miraculously disappear.

A final piece of advice is to have a specific document retention strategy in your office policies, Mr. Lang said. “This is where lawsuits are won and lost nowadays.” It is advantageous, for example, to state that all e-mail messages are automatically deleted after 6 months or 1 year. Otherwise, a judge can deem failure to preserve electronic records “willful spoliation,” and the jury will be instructed to presume that the records were harmful to the defendant's case.

MIAMI — A “progressive discipline” system of warnings and suggestions for improvement before firing an underperforming employee maximizes chances of winning a wrongful termination lawsuit, according to a labor and employee attorney.

In addition, perform regular and honest performance evaluations and keep all employee documents under lock and key.

“I suggest to my clients that they do not fire someone until there is enough of a paper trail,” said Chad K. Lang, a labor and employee attorney practicing in Miami.

“Progressive discipline … is about fairness. The No. 1 reason employees file lawsuits is they believe they were not treated fairly, regardless of how many warnings you gave them. They truly believe they are right,” Mr. Lang said. There is no legal requirement for progressive discipline, but it will look “very fair to a jury.” It will be perceived as, “We gave them benefit of the doubt, they chose not to listen, and we had to let them go.”

Avoid oral warnings about performance, Mr. Lang said. But if an initial warning is spoken, document it in writing afterward. E-mail is acceptable. For example, send an e-mail stating, “Thank you for meeting with me today. This is what we discussed.”

Subsequent warnings are more formal and always should be in writing, Mr. Lang said at a pediatric update sponsored by Miami Children's Hospital.

Have a witness in the room when presenting an employee with a written performance warning, Mr. Lang suggested. “A lot of people do these in a closed-door situation.” The presence of a manager or supervisor is recommended, preferably one of the same gender as the employee in question to avoid allegations of sexual harassment before termination.

Link the written warning to prior oral discussions and require the employee to sign and date it. “A lot of times, people remember the signature but forget to date it,” Mr. Lang said. “They might countersue and say they signed it at a different time.” If an employee refuses to sign the written warning, note this, sign and date it, and have the witness do the same. “The witness does not need to say a word. They are observers, so if it comes down to it, it does not become a 'he said, she said' situation.”

Employees also should sign an employee handbook acknowledgment form, Mr. Lang said. “An employee will most likely lie and say [he or she] never received it.”

A written company policy should state that these progressive steps are a guideline, and in some instances there will be immediate termination, Mr. Lang said. The employee handbook should include an “at-will” employee policy. This implies there is no contract for you to keep them.

Honest, written performance evaluations for all employees are another protection against a future lawsuit, Mr. Lang said. “A lukewarm evaluation will not help if you fire them for doing a poor job. If you are going to take the time to do these, tell the truth and be accurate.”

Many employers tie evaluation scores to salary and bonus pay. It will look inconsistent to a judge or jury, however, if an underperformer gets the same raise as another employee doing well. “If it goes to disposition, they will ask why you gave an underperformer a raise in the first place, and then why was it equal to someone you did not fire,” Mr. Lang said.

Praise and criticism are not mutually exclusive. Recognize tasks they are doing well in their performance evaluations, Mr. Lang said. Use objective criteria and standards when possible, and include an improvement plan for underperformers. It can state, for example, that within 30 days or 60 days they have 'X' and 'Y' to do. “Improvement plans are good and they are objective.”

In addition, “I highly recommend you keep the documents under lock and key,” Mr. Lang said. Often, employees know when their firing is coming, and a day or two beforehand their personnel files miraculously disappear.

A final piece of advice is to have a specific document retention strategy in your office policies, Mr. Lang said. “This is where lawsuits are won and lost nowadays.” It is advantageous, for example, to state that all e-mail messages are automatically deleted after 6 months or 1 year. Otherwise, a judge can deem failure to preserve electronic records “willful spoliation,” and the jury will be instructed to presume that the records were harmful to the defendant's case.

MIAMI — A “progressive discipline” system of warnings and suggestions for improvement before firing an underperforming employee maximizes chances of winning a wrongful termination lawsuit, according to a labor and employee attorney.

In addition, perform regular and honest performance evaluations and keep all employee documents under lock and key.

“I suggest to my clients that they do not fire someone until there is enough of a paper trail,” said Chad K. Lang, a labor and employee attorney practicing in Miami.

“Progressive discipline … is about fairness. The No. 1 reason employees file lawsuits is they believe they were not treated fairly, regardless of how many warnings you gave them. They truly believe they are right,” Mr. Lang said. There is no legal requirement for progressive discipline, but it will look “very fair to a jury.” It will be perceived as, “We gave them benefit of the doubt, they chose not to listen, and we had to let them go.”

Avoid oral warnings about performance, Mr. Lang said. But if an initial warning is spoken, document it in writing afterward. E-mail is acceptable. For example, send an e-mail stating, “Thank you for meeting with me today. This is what we discussed.”

Subsequent warnings are more formal and always should be in writing, Mr. Lang said at a pediatric update sponsored by Miami Children's Hospital.

Have a witness in the room when presenting an employee with a written performance warning, Mr. Lang suggested. “A lot of people do these in a closed-door situation.” The presence of a manager or supervisor is recommended, preferably one of the same gender as the employee in question to avoid allegations of sexual harassment before termination.

Link the written warning to prior oral discussions and require the employee to sign and date it. “A lot of times, people remember the signature but forget to date it,” Mr. Lang said. “They might countersue and say they signed it at a different time.” If an employee refuses to sign the written warning, note this, sign and date it, and have the witness do the same. “The witness does not need to say a word. They are observers, so if it comes down to it, it does not become a 'he said, she said' situation.”

Employees also should sign an employee handbook acknowledgment form, Mr. Lang said. “An employee will most likely lie and say [he or she] never received it.”

A written company policy should state that these progressive steps are a guideline, and in some instances there will be immediate termination, Mr. Lang said. The employee handbook should include an “at-will” employee policy. This implies there is no contract for you to keep them.

Honest, written performance evaluations for all employees are another protection against a future lawsuit, Mr. Lang said. “A lukewarm evaluation will not help if you fire them for doing a poor job. If you are going to take the time to do these, tell the truth and be accurate.”

Many employers tie evaluation scores to salary and bonus pay. It will look inconsistent to a judge or jury, however, if an underperformer gets the same raise as another employee doing well. “If it goes to disposition, they will ask why you gave an underperformer a raise in the first place, and then why was it equal to someone you did not fire,” Mr. Lang said.

Praise and criticism are not mutually exclusive. Recognize tasks they are doing well in their performance evaluations, Mr. Lang said. Use objective criteria and standards when possible, and include an improvement plan for underperformers. It can state, for example, that within 30 days or 60 days they have 'X' and 'Y' to do. “Improvement plans are good and they are objective.”

In addition, “I highly recommend you keep the documents under lock and key,” Mr. Lang said. Often, employees know when their firing is coming, and a day or two beforehand their personnel files miraculously disappear.

A final piece of advice is to have a specific document retention strategy in your office policies, Mr. Lang said. “This is where lawsuits are won and lost nowadays.” It is advantageous, for example, to state that all e-mail messages are automatically deleted after 6 months or 1 year. Otherwise, a judge can deem failure to preserve electronic records “willful spoliation,” and the jury will be instructed to presume that the records were harmful to the defendant's case.

A transcript of the meeting is available at www.medpac.gov/transcripts/04090410medpac.final.pdf

The time for hospitalists to become involved with and essential to “medical home” systems of health care is now, while these programs are still in the design or pilot stage, according to experts interviewed for this article.

The “home” is not a physical location but rather a centralized and coordinated network of multidisciplinary providers. Having a primary care physician or specialist at the center of a medical home promotes enhanced and more efficient patient care. Patients enrolled in such a system experience better overall quality of care and lower health care expenditures, according to a review study (Pediatrics 2004;113[suppl. 5]:1493-8).

The Centers for Medicare and Medicaid Services (CMS) and private insurers are investigating the medical home approach because these plans likely will save money, for example, through fewer unnecessary diagnostic tests and less redundancy of services.

“Medical home initiatives are gaining attention of late. Some private payers are starting them, and some state Medicaid agencies, frankly, have been working with them for many years,” Cristina L. Boccuti, senior analyst for the Medicare Payment Advisory Commission (MedPAC), said at a public meeting held by MedPAC in Washington.

Although a medical home primarily provides chronic care management, hospitalists will have a role, Dr. Amir K. Jaffer, chief of the division of hospital medicine, University of Miami, said in an interview. “My own feeling is, hospitalists have a place here when patients with a chronic disease get sick and need to be admitted.”

The American College of Physicians (ACP), the American Academy of Family Physicians, and the American Academy of Pediatrics are promoting medical homes as a means to improve patient care and outcomes, Dr. Jaffer said. However, “a lot of these organizations talking about medical homes have not linked them to the hospitalist model of care.” Therefore, hospitalists need to be proactive.

The Society of Hospital Medicine (SHM) in Philadelphia “has no official policy on the medical home,” chief executive officer Dr. Laurence Wellikson said, when he was asked to comment. “SHM has worked with ACP and others on developing a consensus document on transition of care, and we have long supported efforts to bolster primary care.”

A link to the hospital is very important to these medical homes, Dr. Jaffer said. However, the hospitalists' role goes beyond communicating with a patient's primary physician during hospital admission. “The idea in the first place is to prevent the hospitalization, to prevent them from getting sick. You may be able to avoid these admissions.”

The medical home construct also aims to reduce fragmentation of care. “The medical home is about centralizing care versus everyone working in silos. It's a coordinated care model, and the hospitalists are really vital to this and should be in a position to champion this idea,” William J. DeMarco said in an interview. Mr. DeMarco is president and CEO of DeMarco & Associates Inc., a national, independent health care consulting firm in Rockford, Ill.

“Ideally, through better care coordination, medical homes could enhance communication among providers, thereby eliminating redundancy and improving quality,” Ms. Boccuti said during the meeting. “They may also improve patients' understanding of their conditions and treatment, and reduce the use of high-cost settings such as hospitals and [emergency departments].”

A hospitalist can work with the primary care physician or specialist to get the patient out of the hospital earlier, Mr. DeMarco said. “Even if they can save 1–2 days of hospitalization per month, the hospitalist[s] would pay for themselves.”

“Hospitalists can and should play an essential role,” said Dr. David Bronson, chair of the Medicine Institute at the Cleveland Clinic. “No one physician can cover 24/7/365, and teamwork amongst physicians will be essential for success of the medical home model.”

The main roadblock for physicians regarding medical homes is reimbursement, Dr. Jaffer said. The CMS “will have to take into account this continuous interaction we have with patients … versus the episodic, fee-for-service, procedure-based system we have now.”

To date, there is no specifically defined, ideal model of reimbursement for the medical home, either for primary care, hospitalists, or specialty care, Dr. Bronson said. “The most likely model is a care coordination fee that rewards the medical home physician for ensuring appropriate coordination of care and care transitions.”

Mr. DeMarco agreed with this approach: “There should be a management fee in exchange for the extra time to coordinate care and document.”

Health information technology, including centralized electronic medical records (EMRs), is essential to the implementation of the medical home model, which focuses on chronic disease management and preventive services, Dr. Jaffer said.

A centralized record also can improve patient compliance with referrals and recommended services, Mr. DeMarco said. “The patient may say, 'I feel fine. I'm not going to go see this other doctor.' But their medical home doctor will know they did not go, and know to monitor their follow-up.”

“The medical home is the best hope for transformation of and reinvestment in primary care,” Dr. Bronson commented.

A transcript of the meeting is available at www.medpac.gov/transcripts/04090410medpac.final.pdf

The time for hospitalists to become involved with and essential to “medical home” systems of health care is now, while these programs are still in the design or pilot stage, according to experts interviewed for this article.

The “home” is not a physical location but rather a centralized and coordinated network of multidisciplinary providers. Having a primary care physician or specialist at the center of a medical home promotes enhanced and more efficient patient care. Patients enrolled in such a system experience better overall quality of care and lower health care expenditures, according to a review study (Pediatrics 2004;113[suppl. 5]:1493-8).

The Centers for Medicare and Medicaid Services (CMS) and private insurers are investigating the medical home approach because these plans likely will save money, for example, through fewer unnecessary diagnostic tests and less redundancy of services.

“Medical home initiatives are gaining attention of late. Some private payers are starting them, and some state Medicaid agencies, frankly, have been working with them for many years,” Cristina L. Boccuti, senior analyst for the Medicare Payment Advisory Commission (MedPAC), said at a public meeting held by MedPAC in Washington.

Although a medical home primarily provides chronic care management, hospitalists will have a role, Dr. Amir K. Jaffer, chief of the division of hospital medicine, University of Miami, said in an interview. “My own feeling is, hospitalists have a place here when patients with a chronic disease get sick and need to be admitted.”

The American College of Physicians (ACP), the American Academy of Family Physicians, and the American Academy of Pediatrics are promoting medical homes as a means to improve patient care and outcomes, Dr. Jaffer said. However, “a lot of these organizations talking about medical homes have not linked them to the hospitalist model of care.” Therefore, hospitalists need to be proactive.

The Society of Hospital Medicine (SHM) in Philadelphia “has no official policy on the medical home,” chief executive officer Dr. Laurence Wellikson said, when he was asked to comment. “SHM has worked with ACP and others on developing a consensus document on transition of care, and we have long supported efforts to bolster primary care.”

A link to the hospital is very important to these medical homes, Dr. Jaffer said. However, the hospitalists' role goes beyond communicating with a patient's primary physician during hospital admission. “The idea in the first place is to prevent the hospitalization, to prevent them from getting sick. You may be able to avoid these admissions.”

The medical home construct also aims to reduce fragmentation of care. “The medical home is about centralizing care versus everyone working in silos. It's a coordinated care model, and the hospitalists are really vital to this and should be in a position to champion this idea,” William J. DeMarco said in an interview. Mr. DeMarco is president and CEO of DeMarco & Associates Inc., a national, independent health care consulting firm in Rockford, Ill.

“Ideally, through better care coordination, medical homes could enhance communication among providers, thereby eliminating redundancy and improving quality,” Ms. Boccuti said during the meeting. “They may also improve patients' understanding of their conditions and treatment, and reduce the use of high-cost settings such as hospitals and [emergency departments].”

A hospitalist can work with the primary care physician or specialist to get the patient out of the hospital earlier, Mr. DeMarco said. “Even if they can save 1–2 days of hospitalization per month, the hospitalist[s] would pay for themselves.”

“Hospitalists can and should play an essential role,” said Dr. David Bronson, chair of the Medicine Institute at the Cleveland Clinic. “No one physician can cover 24/7/365, and teamwork amongst physicians will be essential for success of the medical home model.”

The main roadblock for physicians regarding medical homes is reimbursement, Dr. Jaffer said. The CMS “will have to take into account this continuous interaction we have with patients … versus the episodic, fee-for-service, procedure-based system we have now.”

To date, there is no specifically defined, ideal model of reimbursement for the medical home, either for primary care, hospitalists, or specialty care, Dr. Bronson said. “The most likely model is a care coordination fee that rewards the medical home physician for ensuring appropriate coordination of care and care transitions.”

Mr. DeMarco agreed with this approach: “There should be a management fee in exchange for the extra time to coordinate care and document.”

Health information technology, including centralized electronic medical records (EMRs), is essential to the implementation of the medical home model, which focuses on chronic disease management and preventive services, Dr. Jaffer said.

A centralized record also can improve patient compliance with referrals and recommended services, Mr. DeMarco said. “The patient may say, 'I feel fine. I'm not going to go see this other doctor.' But their medical home doctor will know they did not go, and know to monitor their follow-up.”

“The medical home is the best hope for transformation of and reinvestment in primary care,” Dr. Bronson commented.

A transcript of the meeting is available at www.medpac.gov/transcripts/04090410medpac.final.pdf

The time for hospitalists to become involved with and essential to “medical home” systems of health care is now, while these programs are still in the design or pilot stage, according to experts interviewed for this article.

The “home” is not a physical location but rather a centralized and coordinated network of multidisciplinary providers. Having a primary care physician or specialist at the center of a medical home promotes enhanced and more efficient patient care. Patients enrolled in such a system experience better overall quality of care and lower health care expenditures, according to a review study (Pediatrics 2004;113[suppl. 5]:1493-8).

The Centers for Medicare and Medicaid Services (CMS) and private insurers are investigating the medical home approach because these plans likely will save money, for example, through fewer unnecessary diagnostic tests and less redundancy of services.

“Medical home initiatives are gaining attention of late. Some private payers are starting them, and some state Medicaid agencies, frankly, have been working with them for many years,” Cristina L. Boccuti, senior analyst for the Medicare Payment Advisory Commission (MedPAC), said at a public meeting held by MedPAC in Washington.

Although a medical home primarily provides chronic care management, hospitalists will have a role, Dr. Amir K. Jaffer, chief of the division of hospital medicine, University of Miami, said in an interview. “My own feeling is, hospitalists have a place here when patients with a chronic disease get sick and need to be admitted.”

The American College of Physicians (ACP), the American Academy of Family Physicians, and the American Academy of Pediatrics are promoting medical homes as a means to improve patient care and outcomes, Dr. Jaffer said. However, “a lot of these organizations talking about medical homes have not linked them to the hospitalist model of care.” Therefore, hospitalists need to be proactive.

The Society of Hospital Medicine (SHM) in Philadelphia “has no official policy on the medical home,” chief executive officer Dr. Laurence Wellikson said, when he was asked to comment. “SHM has worked with ACP and others on developing a consensus document on transition of care, and we have long supported efforts to bolster primary care.”

A link to the hospital is very important to these medical homes, Dr. Jaffer said. However, the hospitalists' role goes beyond communicating with a patient's primary physician during hospital admission. “The idea in the first place is to prevent the hospitalization, to prevent them from getting sick. You may be able to avoid these admissions.”

The medical home construct also aims to reduce fragmentation of care. “The medical home is about centralizing care versus everyone working in silos. It's a coordinated care model, and the hospitalists are really vital to this and should be in a position to champion this idea,” William J. DeMarco said in an interview. Mr. DeMarco is president and CEO of DeMarco & Associates Inc., a national, independent health care consulting firm in Rockford, Ill.

“Ideally, through better care coordination, medical homes could enhance communication among providers, thereby eliminating redundancy and improving quality,” Ms. Boccuti said during the meeting. “They may also improve patients' understanding of their conditions and treatment, and reduce the use of high-cost settings such as hospitals and [emergency departments].”

A hospitalist can work with the primary care physician or specialist to get the patient out of the hospital earlier, Mr. DeMarco said. “Even if they can save 1–2 days of hospitalization per month, the hospitalist[s] would pay for themselves.”

“Hospitalists can and should play an essential role,” said Dr. David Bronson, chair of the Medicine Institute at the Cleveland Clinic. “No one physician can cover 24/7/365, and teamwork amongst physicians will be essential for success of the medical home model.”

The main roadblock for physicians regarding medical homes is reimbursement, Dr. Jaffer said. The CMS “will have to take into account this continuous interaction we have with patients … versus the episodic, fee-for-service, procedure-based system we have now.”

To date, there is no specifically defined, ideal model of reimbursement for the medical home, either for primary care, hospitalists, or specialty care, Dr. Bronson said. “The most likely model is a care coordination fee that rewards the medical home physician for ensuring appropriate coordination of care and care transitions.”

Mr. DeMarco agreed with this approach: “There should be a management fee in exchange for the extra time to coordinate care and document.”

Health information technology, including centralized electronic medical records (EMRs), is essential to the implementation of the medical home model, which focuses on chronic disease management and preventive services, Dr. Jaffer said.

A centralized record also can improve patient compliance with referrals and recommended services, Mr. DeMarco said. “The patient may say, 'I feel fine. I'm not going to go see this other doctor.' But their medical home doctor will know they did not go, and know to monitor their follow-up.”

“The medical home is the best hope for transformation of and reinvestment in primary care,” Dr. Bronson commented.

A new high-definition, wide-angle videoendoscope did not detect significantly more colorectal adenomas or polyps, compared with a conventional colonoscope in a randomized study.

The study's researchers noted that although it seemed logical that a higher resolution endoscope would yield better results, the nonacademic, real-world setting for the study could explain the nonsuperiority of the high-definition scope.

Dr. Maria Pellise said she and her colleagues chose to increase the clinical relevance of their results by enrolling nonselected, consecutive adult patients referred to Hospital Clinic de Barcelona, a community hospital in Spain.

After exclusions, 310 patients were randomly assigned to colonoscopy with a wide-angle (170-degree), high-definition videoendoscope (Olympus prototype XCF H160AY2L, Olympus Europe, Hamburg, Germany). This prototype is now available commercially. Another 310 patients were randomized to a standard-angle (140-degree), standard-resolution videocolonoscope (Olympus Q160).

A team of seven full-time, board-certified gastroenterologists who spend at least 50% of their time doing endoscopy evaluated both groups.

The participants did not constitute a selected or high-risk population for colorectal cancer, unlike those in other studies. Only 25% were referred for screening or surveillance reasons, only 15% had a personal history of colorectal cancer (including adenoma), and mean age was less than 60 years.

Both devices detected a similar number and type of lesions. In fact, there were no significant differences between the two scopes in several different measures of efficacy, including overall number of adenomas and polyps, the ratio of flat or small adenomas, or the number of patients with high-risk lesions.

A total of 418 of the 518 lesions (81%) detected in the entire study population yielded pathology results. Findings included 272 adenomas (65%), 109 hyperplastic polyps (26%), and 37 inflammatory lesions (9%).

There were no differences between groups in degree of dysplasia or the morphology of adenomas, although there was a trend toward increased detection of small adenomas with the high-definition device. Overall, the majority of adenomas, 235 (86%), were low-grade dysplasia. The remaining 14% were high-grade dysplasia or carcinoma. Just more than half of adenomas were smaller than 5 mm, and 68% were sessile or pedunculated (doi:10.1053/j.gastro.2008.06.090).

A total of 82 patients in the high-definition group and 79 in the standard group had at least one adenoma detected. Also, 42 patients in the high-definition group and 39 in the standard group had at least one hyperplastic polyp detected.

The number of high-risk patients in each group did not differ significantly. The number of patients with three or more adenomas was 10 in the high-definition group versus 16 in the standard group. Also, a high-grade adenoma was found in 14 patients in the high-definition group and in 13 in the standard group.

Dr. Pellise and her colleagues also recorded the time to reach the cecum. The standard scope was slightly faster than the high-definition scope (mean 8.2 minutes versus 8.9 minutes), but the difference was not statistically significant.

The findings support those of two previous studies that found no difference in adenoma miss rates with a wide-angle prototype endoscope similar to the one used in the current study, the authors noted (Am. J. Gastroenterol. 2004;99:2138–42; Am. J. Gastroenterol. 2003;98:2000–5).

The study was underpowered to find differences between groups in adenoma detection less than 30%, a potential limitation. In addition, the researchers only employed chromoendoscopy to increase detection after a suspicious lesion was identified.

Nevertheless, there still may be advantages to the high-definition device. “The wide-angle facility has [been] demonstrated to shorten endoscopic time without decreasing the diagnostic efficiency … and the high-definition screen provides a high-quality and clear image that is restful for the endoscopist's eyes.”

One of the study coauthors is a research nurse supported by Olympus Medical Systems, Europe. The company also supplied the prototype high-definition system for the study. There were no other disclosures.

A new high-definition, wide-angle videoendoscope did not detect significantly more colorectal adenomas or polyps, compared with a conventional colonoscope in a randomized study.

The study's researchers noted that although it seemed logical that a higher resolution endoscope would yield better results, the nonacademic, real-world setting for the study could explain the nonsuperiority of the high-definition scope.

Dr. Maria Pellise said she and her colleagues chose to increase the clinical relevance of their results by enrolling nonselected, consecutive adult patients referred to Hospital Clinic de Barcelona, a community hospital in Spain.

After exclusions, 310 patients were randomly assigned to colonoscopy with a wide-angle (170-degree), high-definition videoendoscope (Olympus prototype XCF H160AY2L, Olympus Europe, Hamburg, Germany). This prototype is now available commercially. Another 310 patients were randomized to a standard-angle (140-degree), standard-resolution videocolonoscope (Olympus Q160).

A team of seven full-time, board-certified gastroenterologists who spend at least 50% of their time doing endoscopy evaluated both groups.

The participants did not constitute a selected or high-risk population for colorectal cancer, unlike those in other studies. Only 25% were referred for screening or surveillance reasons, only 15% had a personal history of colorectal cancer (including adenoma), and mean age was less than 60 years.

Both devices detected a similar number and type of lesions. In fact, there were no significant differences between the two scopes in several different measures of efficacy, including overall number of adenomas and polyps, the ratio of flat or small adenomas, or the number of patients with high-risk lesions.

A total of 418 of the 518 lesions (81%) detected in the entire study population yielded pathology results. Findings included 272 adenomas (65%), 109 hyperplastic polyps (26%), and 37 inflammatory lesions (9%).

There were no differences between groups in degree of dysplasia or the morphology of adenomas, although there was a trend toward increased detection of small adenomas with the high-definition device. Overall, the majority of adenomas, 235 (86%), were low-grade dysplasia. The remaining 14% were high-grade dysplasia or carcinoma. Just more than half of adenomas were smaller than 5 mm, and 68% were sessile or pedunculated (doi:10.1053/j.gastro.2008.06.090).

A total of 82 patients in the high-definition group and 79 in the standard group had at least one adenoma detected. Also, 42 patients in the high-definition group and 39 in the standard group had at least one hyperplastic polyp detected.

The number of high-risk patients in each group did not differ significantly. The number of patients with three or more adenomas was 10 in the high-definition group versus 16 in the standard group. Also, a high-grade adenoma was found in 14 patients in the high-definition group and in 13 in the standard group.

Dr. Pellise and her colleagues also recorded the time to reach the cecum. The standard scope was slightly faster than the high-definition scope (mean 8.2 minutes versus 8.9 minutes), but the difference was not statistically significant.

The findings support those of two previous studies that found no difference in adenoma miss rates with a wide-angle prototype endoscope similar to the one used in the current study, the authors noted (Am. J. Gastroenterol. 2004;99:2138–42; Am. J. Gastroenterol. 2003;98:2000–5).

The study was underpowered to find differences between groups in adenoma detection less than 30%, a potential limitation. In addition, the researchers only employed chromoendoscopy to increase detection after a suspicious lesion was identified.

Nevertheless, there still may be advantages to the high-definition device. “The wide-angle facility has [been] demonstrated to shorten endoscopic time without decreasing the diagnostic efficiency … and the high-definition screen provides a high-quality and clear image that is restful for the endoscopist's eyes.”

One of the study coauthors is a research nurse supported by Olympus Medical Systems, Europe. The company also supplied the prototype high-definition system for the study. There were no other disclosures.

A new high-definition, wide-angle videoendoscope did not detect significantly more colorectal adenomas or polyps, compared with a conventional colonoscope in a randomized study.

The study's researchers noted that although it seemed logical that a higher resolution endoscope would yield better results, the nonacademic, real-world setting for the study could explain the nonsuperiority of the high-definition scope.

Dr. Maria Pellise said she and her colleagues chose to increase the clinical relevance of their results by enrolling nonselected, consecutive adult patients referred to Hospital Clinic de Barcelona, a community hospital in Spain.

After exclusions, 310 patients were randomly assigned to colonoscopy with a wide-angle (170-degree), high-definition videoendoscope (Olympus prototype XCF H160AY2L, Olympus Europe, Hamburg, Germany). This prototype is now available commercially. Another 310 patients were randomized to a standard-angle (140-degree), standard-resolution videocolonoscope (Olympus Q160).

A team of seven full-time, board-certified gastroenterologists who spend at least 50% of their time doing endoscopy evaluated both groups.

The participants did not constitute a selected or high-risk population for colorectal cancer, unlike those in other studies. Only 25% were referred for screening or surveillance reasons, only 15% had a personal history of colorectal cancer (including adenoma), and mean age was less than 60 years.

Both devices detected a similar number and type of lesions. In fact, there were no significant differences between the two scopes in several different measures of efficacy, including overall number of adenomas and polyps, the ratio of flat or small adenomas, or the number of patients with high-risk lesions.

A total of 418 of the 518 lesions (81%) detected in the entire study population yielded pathology results. Findings included 272 adenomas (65%), 109 hyperplastic polyps (26%), and 37 inflammatory lesions (9%).

There were no differences between groups in degree of dysplasia or the morphology of adenomas, although there was a trend toward increased detection of small adenomas with the high-definition device. Overall, the majority of adenomas, 235 (86%), were low-grade dysplasia. The remaining 14% were high-grade dysplasia or carcinoma. Just more than half of adenomas were smaller than 5 mm, and 68% were sessile or pedunculated (doi:10.1053/j.gastro.2008.06.090).

A total of 82 patients in the high-definition group and 79 in the standard group had at least one adenoma detected. Also, 42 patients in the high-definition group and 39 in the standard group had at least one hyperplastic polyp detected.

The number of high-risk patients in each group did not differ significantly. The number of patients with three or more adenomas was 10 in the high-definition group versus 16 in the standard group. Also, a high-grade adenoma was found in 14 patients in the high-definition group and in 13 in the standard group.

Dr. Pellise and her colleagues also recorded the time to reach the cecum. The standard scope was slightly faster than the high-definition scope (mean 8.2 minutes versus 8.9 minutes), but the difference was not statistically significant.

The findings support those of two previous studies that found no difference in adenoma miss rates with a wide-angle prototype endoscope similar to the one used in the current study, the authors noted (Am. J. Gastroenterol. 2004;99:2138–42; Am. J. Gastroenterol. 2003;98:2000–5).

The study was underpowered to find differences between groups in adenoma detection less than 30%, a potential limitation. In addition, the researchers only employed chromoendoscopy to increase detection after a suspicious lesion was identified.

Nevertheless, there still may be advantages to the high-definition device. “The wide-angle facility has [been] demonstrated to shorten endoscopic time without decreasing the diagnostic efficiency … and the high-definition screen provides a high-quality and clear image that is restful for the endoscopist's eyes.”

One of the study coauthors is a research nurse supported by Olympus Medical Systems, Europe. The company also supplied the prototype high-definition system for the study. There were no other disclosures.

Patients with minimal hepatic encephalopathy typically rate themselves as good drivers, but they have significantly worse performance and more accidents on a driving simulator.

The poor driving skills of these patients were corroborated by friends and family members in a study, wrote Dr. Jasmohan Singh Bajaj and colleagues.

Minimal hepatic encephalopathy (MHE) is a significant neurocognitive consequence of cirrhosis. Findings from previous studies suggest people with MHE experience poor quality of life and increased risk of progression to overt hepatic encephalopathy (Dig. Dis. Sci. 2003;48:1622; Nat. Clin. Pract. Gastroenterol. Hepatol. 2007;4:677–85).

Patients with MHE typically have no specific symptoms, and might be unaware of their driving deficits. Impaired reaction times, poor visual motor coordination, and navigation problems might explain the higher number of traffic accidents and violations reported in real life studies of people with MHE and in previous simulator studies (Am. J. Gastroenterol. 2007;102:1903–9). Previous researchers have noted driving impairments, but the degree to which people with MHE are aware of these deficits remains unknown.

Dr. Bajaj and associates at the Medical College of Wisconsin, Milwaukee, collected data on simulated driving test results, psychometric testing, and third-party ratings of driving skills, comparing two groups: 47 nonalcoholic patients with cirrhosis and 40 controls without cirrhosis. Mean age was 56 years in the cirrhosis group and 54 years in the controls. The number of collisions and improper turns were recorded while patients drove a fixed path and consulted a map on the simulator (STISIM Simulator, Systems Technology Inc.). There were no conflicts of interest.

A total of 36 patients with cirrhosis had MHE and the remaining 11 did not, based on psychometric testing (Clin. Gastroenterol. Hepatol. 2008 October, In Press).

A diagnosis of MHE was made if, on at least two tests, there were more than 2 standard deviations, compared with age- and education-matched community control.

The MHE-positive group had significantly worse psychometric test performance. For example, these patients took a mean of 32 seconds to complete the number connection test-A, compared with 27 seconds in the MHE-negative group and 22 seconds in the controls. MHE- positive patients also had a higher mean number of collisions (3) compared with 1.2 in the MHE-negative cirrhosis patients and 1.7 in controls. Similarly, the mean number of illegal turns was higher in the MHE-positive group (1.2 vs. 0.3 in the MHE-negative patients and 0.1 in controls).

In addition, patients and their spouse, family member, or friend completed the 26-item Driving Behavior Survey. There were no significant differences between MHE-positive, MHE-negative, and control groups in self-assessment of driving abilities.

However, observers rated the MHE-positive patients significantly lower on driving skills, compared with their self-assessment, suggesting poor self-knowledge in patients with MHE. “Insight into or self-awareness of driving impairment is essential for patients to seek intervention,” the authors wrote.

The MHE-negative and control groups did not differ significantly on psychometric test results or number of collisions or improper turns on the driving simulator. In addition, there were no significant differences in observer ratings of driving skills between these two groups.

Allowing the participants to elect an observer of their choice (most often, a spouse) was a possible limitation of the study. However, although they may have chosen a person more likely to rate their driving skills positively, the observers for the group with MHE still rated their driving skills significantly lower than did observers in the other groups.

Patients with cirrhosis should be educated about MHE and the potential for impaired driving skills, the researchers said.

Patients with minimal hepatic encephalopathy typically rate themselves as good drivers, but they have significantly worse performance and more accidents on a driving simulator.

The poor driving skills of these patients were corroborated by friends and family members in a study, wrote Dr. Jasmohan Singh Bajaj and colleagues.

Minimal hepatic encephalopathy (MHE) is a significant neurocognitive consequence of cirrhosis. Findings from previous studies suggest people with MHE experience poor quality of life and increased risk of progression to overt hepatic encephalopathy (Dig. Dis. Sci. 2003;48:1622; Nat. Clin. Pract. Gastroenterol. Hepatol. 2007;4:677–85).

Patients with MHE typically have no specific symptoms, and might be unaware of their driving deficits. Impaired reaction times, poor visual motor coordination, and navigation problems might explain the higher number of traffic accidents and violations reported in real life studies of people with MHE and in previous simulator studies (Am. J. Gastroenterol. 2007;102:1903–9). Previous researchers have noted driving impairments, but the degree to which people with MHE are aware of these deficits remains unknown.

Dr. Bajaj and associates at the Medical College of Wisconsin, Milwaukee, collected data on simulated driving test results, psychometric testing, and third-party ratings of driving skills, comparing two groups: 47 nonalcoholic patients with cirrhosis and 40 controls without cirrhosis. Mean age was 56 years in the cirrhosis group and 54 years in the controls. The number of collisions and improper turns were recorded while patients drove a fixed path and consulted a map on the simulator (STISIM Simulator, Systems Technology Inc.). There were no conflicts of interest.

A total of 36 patients with cirrhosis had MHE and the remaining 11 did not, based on psychometric testing (Clin. Gastroenterol. Hepatol. 2008 October, In Press).

A diagnosis of MHE was made if, on at least two tests, there were more than 2 standard deviations, compared with age- and education-matched community control.

The MHE-positive group had significantly worse psychometric test performance. For example, these patients took a mean of 32 seconds to complete the number connection test-A, compared with 27 seconds in the MHE-negative group and 22 seconds in the controls. MHE- positive patients also had a higher mean number of collisions (3) compared with 1.2 in the MHE-negative cirrhosis patients and 1.7 in controls. Similarly, the mean number of illegal turns was higher in the MHE-positive group (1.2 vs. 0.3 in the MHE-negative patients and 0.1 in controls).

In addition, patients and their spouse, family member, or friend completed the 26-item Driving Behavior Survey. There were no significant differences between MHE-positive, MHE-negative, and control groups in self-assessment of driving abilities.

However, observers rated the MHE-positive patients significantly lower on driving skills, compared with their self-assessment, suggesting poor self-knowledge in patients with MHE. “Insight into or self-awareness of driving impairment is essential for patients to seek intervention,” the authors wrote.

The MHE-negative and control groups did not differ significantly on psychometric test results or number of collisions or improper turns on the driving simulator. In addition, there were no significant differences in observer ratings of driving skills between these two groups.

Allowing the participants to elect an observer of their choice (most often, a spouse) was a possible limitation of the study. However, although they may have chosen a person more likely to rate their driving skills positively, the observers for the group with MHE still rated their driving skills significantly lower than did observers in the other groups.

Patients with cirrhosis should be educated about MHE and the potential for impaired driving skills, the researchers said.

Patients with minimal hepatic encephalopathy typically rate themselves as good drivers, but they have significantly worse performance and more accidents on a driving simulator.

The poor driving skills of these patients were corroborated by friends and family members in a study, wrote Dr. Jasmohan Singh Bajaj and colleagues.

Minimal hepatic encephalopathy (MHE) is a significant neurocognitive consequence of cirrhosis. Findings from previous studies suggest people with MHE experience poor quality of life and increased risk of progression to overt hepatic encephalopathy (Dig. Dis. Sci. 2003;48:1622; Nat. Clin. Pract. Gastroenterol. Hepatol. 2007;4:677–85).

Patients with MHE typically have no specific symptoms, and might be unaware of their driving deficits. Impaired reaction times, poor visual motor coordination, and navigation problems might explain the higher number of traffic accidents and violations reported in real life studies of people with MHE and in previous simulator studies (Am. J. Gastroenterol. 2007;102:1903–9). Previous researchers have noted driving impairments, but the degree to which people with MHE are aware of these deficits remains unknown.

Dr. Bajaj and associates at the Medical College of Wisconsin, Milwaukee, collected data on simulated driving test results, psychometric testing, and third-party ratings of driving skills, comparing two groups: 47 nonalcoholic patients with cirrhosis and 40 controls without cirrhosis. Mean age was 56 years in the cirrhosis group and 54 years in the controls. The number of collisions and improper turns were recorded while patients drove a fixed path and consulted a map on the simulator (STISIM Simulator, Systems Technology Inc.). There were no conflicts of interest.

A total of 36 patients with cirrhosis had MHE and the remaining 11 did not, based on psychometric testing (Clin. Gastroenterol. Hepatol. 2008 October, In Press).

A diagnosis of MHE was made if, on at least two tests, there were more than 2 standard deviations, compared with age- and education-matched community control.

The MHE-positive group had significantly worse psychometric test performance. For example, these patients took a mean of 32 seconds to complete the number connection test-A, compared with 27 seconds in the MHE-negative group and 22 seconds in the controls. MHE- positive patients also had a higher mean number of collisions (3) compared with 1.2 in the MHE-negative cirrhosis patients and 1.7 in controls. Similarly, the mean number of illegal turns was higher in the MHE-positive group (1.2 vs. 0.3 in the MHE-negative patients and 0.1 in controls).

In addition, patients and their spouse, family member, or friend completed the 26-item Driving Behavior Survey. There were no significant differences between MHE-positive, MHE-negative, and control groups in self-assessment of driving abilities.

However, observers rated the MHE-positive patients significantly lower on driving skills, compared with their self-assessment, suggesting poor self-knowledge in patients with MHE. “Insight into or self-awareness of driving impairment is essential for patients to seek intervention,” the authors wrote.

The MHE-negative and control groups did not differ significantly on psychometric test results or number of collisions or improper turns on the driving simulator. In addition, there were no significant differences in observer ratings of driving skills between these two groups.

Allowing the participants to elect an observer of their choice (most often, a spouse) was a possible limitation of the study. However, although they may have chosen a person more likely to rate their driving skills positively, the observers for the group with MHE still rated their driving skills significantly lower than did observers in the other groups.

Patients with cirrhosis should be educated about MHE and the potential for impaired driving skills, the researchers said.

Primary care physicians are more likely to adjust medications for patients with diabetes who are given interactive, online access to their personal health records before an appointment, compared with a control group, according to a randomized trial. However, clinical outcomes at 1 year—including glycemic control, LDL cholesterol levels, and blood pressure—did not differ significantly between the groups.

Dr. Richard W. Grant and his associates randomized 11 primary care practices to different degrees of online access to personal health information for their patients. They hypothesized that patients who take a greater role in managing their diabetes would experience better outcomes.

A total of four practices offered patients interactive access to their personal health record while patients from seven other practices made up the active control group. The practices' 126 patients who had interactive access could edit a list of their prescribed medications, report adverse effects, and answer brief questions about adherence. They also could see previous hemoglobin A_1c, blood pressure, and LDL cholesterol lab findings through a link to a centralized electronic medical record system (Arch. Intern. Med. 2008;168:1776–83).

In contrast, the practice's 118 active control patients were permitted only to review and update their family medical history online, as well as view cancer screening and other non-diabetes-related preventive services.

The study was conducted at Partners HealthCare System Inc. practices in eastern Massachusetts. The hospital- and community-based settings had 230 primary care physicians on staff.

Participants in each group had similar health care use and comparable baseline control of HbA_1c, blood pressure, and LDL cholesterol. Also, both groups demonstrated similar, moderate improvements in these outcomes during the study. For example, HbA_1c levels dropped a mean 0.16% in the interactive group vs. 0.26% in the active control group. A total of 73% of the interactive patients and 68% of the control patients achieved their HbA_1c goal at 1 year.

A total of 82 patients in the interactive group and 41 in the control group kept a medication journal. A subanalysis using this information showed that 53% of the interactive group had diabetes-related medication changes during subsequent visits, compared with 15% of control patients. “Our intervention may have worked to improve the process of diabetes mellitus care by reducing barriers to medication change at the clinic visit,” the authors wrote.

Less than 15% of patients at any of the practices opted to register for online access, which may partially explain the lack of significant difference in clinical outcomes at 12 months, the researchers noted. Lack of Internet access was not a significant factor—a separate internal survey of type 2 diabetes patients revealed that 52% routinely access general information online.

“Although the low rates of enrollment limit the interpretation of the 'real world' effect of our intervention, our results do clearly demonstrate that many patients with DM chose not to sign up for these services when presented the opportunity to engage in online access to their [primary care physicians],” the authors wrote. “Understanding this lack of enthusiasm becomes a crucial question that must be answered if we are to fully achieve the potential benefit of online patient health records.”

There were notable demographic differences between patients who opted to enroll in the study and those who did not. Participants were younger than nonparticipants (mean age, 56 vs. 60 years). A greater proportion were white (89% vs. 67%), had commercial insurance (72% vs. 47%), and were at or below their HbA_1c goal (54% vs. 47%). This is “evidence that the digital divide remains an important barrier to the adoption of new health information technologies,” the authors wrote.

Patients with poor metabolic control were less likely to enroll, another possible limitation of the study.

Future studies should assess greater numbers of patients, the authors noted. They added that outcomes also might improve if the current clinical practice design were changed to promote the engagement of physicians and patients more effectively in nontraditional health care interactions.

None of the study authors reported any conflicts of interest.

Primary care physicians are more likely to adjust medications for patients with diabetes who are given interactive, online access to their personal health records before an appointment, compared with a control group, according to a randomized trial. However, clinical outcomes at 1 year—including glycemic control, LDL cholesterol levels, and blood pressure—did not differ significantly between the groups.

Dr. Richard W. Grant and his associates randomized 11 primary care practices to different degrees of online access to personal health information for their patients. They hypothesized that patients who take a greater role in managing their diabetes would experience better outcomes.

A total of four practices offered patients interactive access to their personal health record while patients from seven other practices made up the active control group. The practices' 126 patients who had interactive access could edit a list of their prescribed medications, report adverse effects, and answer brief questions about adherence. They also could see previous hemoglobin A_1c, blood pressure, and LDL cholesterol lab findings through a link to a centralized electronic medical record system (Arch. Intern. Med. 2008;168:1776–83).

In contrast, the practice's 118 active control patients were permitted only to review and update their family medical history online, as well as view cancer screening and other non-diabetes-related preventive services.

The study was conducted at Partners HealthCare System Inc. practices in eastern Massachusetts. The hospital- and community-based settings had 230 primary care physicians on staff.

Participants in each group had similar health care use and comparable baseline control of HbA_1c, blood pressure, and LDL cholesterol. Also, both groups demonstrated similar, moderate improvements in these outcomes during the study. For example, HbA_1c levels dropped a mean 0.16% in the interactive group vs. 0.26% in the active control group. A total of 73% of the interactive patients and 68% of the control patients achieved their HbA_1c goal at 1 year.

A total of 82 patients in the interactive group and 41 in the control group kept a medication journal. A subanalysis using this information showed that 53% of the interactive group had diabetes-related medication changes during subsequent visits, compared with 15% of control patients. “Our intervention may have worked to improve the process of diabetes mellitus care by reducing barriers to medication change at the clinic visit,” the authors wrote.

Less than 15% of patients at any of the practices opted to register for online access, which may partially explain the lack of significant difference in clinical outcomes at 12 months, the researchers noted. Lack of Internet access was not a significant factor—a separate internal survey of type 2 diabetes patients revealed that 52% routinely access general information online.

“Although the low rates of enrollment limit the interpretation of the 'real world' effect of our intervention, our results do clearly demonstrate that many patients with DM chose not to sign up for these services when presented the opportunity to engage in online access to their [primary care physicians],” the authors wrote. “Understanding this lack of enthusiasm becomes a crucial question that must be answered if we are to fully achieve the potential benefit of online patient health records.”

There were notable demographic differences between patients who opted to enroll in the study and those who did not. Participants were younger than nonparticipants (mean age, 56 vs. 60 years). A greater proportion were white (89% vs. 67%), had commercial insurance (72% vs. 47%), and were at or below their HbA_1c goal (54% vs. 47%). This is “evidence that the digital divide remains an important barrier to the adoption of new health information technologies,” the authors wrote.

Patients with poor metabolic control were less likely to enroll, another possible limitation of the study.

Future studies should assess greater numbers of patients, the authors noted. They added that outcomes also might improve if the current clinical practice design were changed to promote the engagement of physicians and patients more effectively in nontraditional health care interactions.

None of the study authors reported any conflicts of interest.

Primary care physicians are more likely to adjust medications for patients with diabetes who are given interactive, online access to their personal health records before an appointment, compared with a control group, according to a randomized trial. However, clinical outcomes at 1 year—including glycemic control, LDL cholesterol levels, and blood pressure—did not differ significantly between the groups.

Dr. Richard W. Grant and his associates randomized 11 primary care practices to different degrees of online access to personal health information for their patients. They hypothesized that patients who take a greater role in managing their diabetes would experience better outcomes.

A total of four practices offered patients interactive access to their personal health record while patients from seven other practices made up the active control group. The practices' 126 patients who had interactive access could edit a list of their prescribed medications, report adverse effects, and answer brief questions about adherence. They also could see previous hemoglobin A_1c, blood pressure, and LDL cholesterol lab findings through a link to a centralized electronic medical record system (Arch. Intern. Med. 2008;168:1776–83).

In contrast, the practice's 118 active control patients were permitted only to review and update their family medical history online, as well as view cancer screening and other non-diabetes-related preventive services.

The study was conducted at Partners HealthCare System Inc. practices in eastern Massachusetts. The hospital- and community-based settings had 230 primary care physicians on staff.

Participants in each group had similar health care use and comparable baseline control of HbA_1c, blood pressure, and LDL cholesterol. Also, both groups demonstrated similar, moderate improvements in these outcomes during the study. For example, HbA_1c levels dropped a mean 0.16% in the interactive group vs. 0.26% in the active control group. A total of 73% of the interactive patients and 68% of the control patients achieved their HbA_1c goal at 1 year.

A total of 82 patients in the interactive group and 41 in the control group kept a medication journal. A subanalysis using this information showed that 53% of the interactive group had diabetes-related medication changes during subsequent visits, compared with 15% of control patients. “Our intervention may have worked to improve the process of diabetes mellitus care by reducing barriers to medication change at the clinic visit,” the authors wrote.

Less than 15% of patients at any of the practices opted to register for online access, which may partially explain the lack of significant difference in clinical outcomes at 12 months, the researchers noted. Lack of Internet access was not a significant factor—a separate internal survey of type 2 diabetes patients revealed that 52% routinely access general information online.

“Although the low rates of enrollment limit the interpretation of the 'real world' effect of our intervention, our results do clearly demonstrate that many patients with DM chose not to sign up for these services when presented the opportunity to engage in online access to their [primary care physicians],” the authors wrote. “Understanding this lack of enthusiasm becomes a crucial question that must be answered if we are to fully achieve the potential benefit of online patient health records.”

There were notable demographic differences between patients who opted to enroll in the study and those who did not. Participants were younger than nonparticipants (mean age, 56 vs. 60 years). A greater proportion were white (89% vs. 67%), had commercial insurance (72% vs. 47%), and were at or below their HbA_1c goal (54% vs. 47%). This is “evidence that the digital divide remains an important barrier to the adoption of new health information technologies,” the authors wrote.

Patients with poor metabolic control were less likely to enroll, another possible limitation of the study.

Future studies should assess greater numbers of patients, the authors noted. They added that outcomes also might improve if the current clinical practice design were changed to promote the engagement of physicians and patients more effectively in nontraditional health care interactions.

None of the study authors reported any conflicts of interest.

White students attending more racially diverse medical schools consider themselves better prepared to care for patients of racial and ethnic minority group, according to a study of more than 20,000 graduates.

Attitudes about providing equivalent access to health care for everyone also were stronger among students at more diverse schools. These students' responses were 50% more favorable toward equitable access to care, compared with their counterparts at the least diverse schools.

The associations were particularly strong at medical schools that foster positive interactions and sharing of opinions among students from different backgrounds, Dr. Somnath Saha and colleagues reported (JAMA 2008;300:1135–45). The investigators also found a "threshold effect" regarding minority student enrollment. Specifically, diversity outcomes were positive among the 118 medical schools in the study if the proportion of underrepresented minority graduates (URMs) exceeded 10%, or the total nonwhite student population was more than 36%. The authors had no disclosures.

Policies and programs devised to achieve racial diversity in medical schools and to increase the numbers of underrepresented black, Hispanic, and Native American students "have come under increasing scrutiny as being unnecessary and discriminatory," the authors wrote. Dr. Saha is an internist at the Portland VA Medical Center and Oregon Health and Science University.

Affirmative action and addressing prior injustices are the justification for most programs to increase URM student diversity.

However, Dr. Olveen Carrasquillo and Dr. Elizabeth T. Lee-Rey wrote in an editorial, "the well-documented history of widespread racism within organized medicine and the American Medical Association's apology is a reminder of how pervasive and tolerated such practices were only a few decades ago" (JAMA2008;300:1203–4).

Dr. Saha and colleagues assessed results of the online graduation questionnaires administered by the Association of American Medical Colleges in 2003 and 2004. They assessed anonymous responses from 20,112 individuals, representing 64% of all graduates during those 2 years.

Race and ethnicity were self-reported. The 9% of URM respondents included black, American Indian, Alaska Native, Mexican American/Chicano, mainland Puerto Rican, and Native Hawaiian students. Minorities not considered to be underrepresented in the physician workforce, primarily Asians and non-URM Hispanic or Latino students, comprised the 23% nonwhite/non-URM group. The remaining 68% were white students.

A total of 21% of the 13,764 graduates in 2003 and 22% of the 7,472 graduates in 2004 strongly agreed that "everyone is entitled to adequate care." Also, 42% of the 2003 graduates and 44% of the 2004 graduates strongly agreed that "access to care is a major problem." A total of 59% of the 2003 cohort and 60% of the 2004 cohort indicated they felt prepared to serve diverse populations.

Interestingly, white students at more diverse medical schools did not indicate they were more likely to care for underserved populations. "This may reflect confounding by the urban versus rural location of schools," the authors wrote. "Rural schools are likely to have both fewer nonwhite students and more students who plan to practice in rural, underserved locations."

In contrast, a total of 49% of URMs planned to work with underserved patient populations, significantly more than both white (19%) and nonwhite/non-URM students (16%).

"The finding by Saha and colleagues in this issue of JAMA that… increased medical school diversity is associated with white students feeling better prepared to care for diverse patients is an important contribution to the medical literature," Dr. Carrasquillo and Dr. Lee-Rey wrote. "Findings from this methodologically rigorous study can inform efforts to elicit continued support by the Supreme Court for admissions policies favorable to URM diversity." Dr. Carrasquillo is director of the Center for the Health of Urban Minorities at Columbia University Medical Center and Dr. Lee-Rey is codirector of the Hispanic Center for Excellence, Albert Einstein College of Medicine, both in New York.

White students attending more racially diverse medical schools consider themselves better prepared to care for patients of racial and ethnic minority group, according to a study of more than 20,000 graduates.

Attitudes about providing equivalent access to health care for everyone also were stronger among students at more diverse schools. These students' responses were 50% more favorable toward equitable access to care, compared with their counterparts at the least diverse schools.

The associations were particularly strong at medical schools that foster positive interactions and sharing of opinions among students from different backgrounds, Dr. Somnath Saha and colleagues reported (JAMA 2008;300:1135–45). The investigators also found a "threshold effect" regarding minority student enrollment. Specifically, diversity outcomes were positive among the 118 medical schools in the study if the proportion of underrepresented minority graduates (URMs) exceeded 10%, or the total nonwhite student population was more than 36%. The authors had no disclosures.

Policies and programs devised to achieve racial diversity in medical schools and to increase the numbers of underrepresented black, Hispanic, and Native American students "have come under increasing scrutiny as being unnecessary and discriminatory," the authors wrote. Dr. Saha is an internist at the Portland VA Medical Center and Oregon Health and Science University.

Affirmative action and addressing prior injustices are the justification for most programs to increase URM student diversity.

However, Dr. Olveen Carrasquillo and Dr. Elizabeth T. Lee-Rey wrote in an editorial, "the well-documented history of widespread racism within organized medicine and the American Medical Association's apology is a reminder of how pervasive and tolerated such practices were only a few decades ago" (JAMA2008;300:1203–4).

Dr. Saha and colleagues assessed results of the online graduation questionnaires administered by the Association of American Medical Colleges in 2003 and 2004. They assessed anonymous responses from 20,112 individuals, representing 64% of all graduates during those 2 years.

Race and ethnicity were self-reported. The 9% of URM respondents included black, American Indian, Alaska Native, Mexican American/Chicano, mainland Puerto Rican, and Native Hawaiian students. Minorities not considered to be underrepresented in the physician workforce, primarily Asians and non-URM Hispanic or Latino students, comprised the 23% nonwhite/non-URM group. The remaining 68% were white students.

A total of 21% of the 13,764 graduates in 2003 and 22% of the 7,472 graduates in 2004 strongly agreed that "everyone is entitled to adequate care." Also, 42% of the 2003 graduates and 44% of the 2004 graduates strongly agreed that "access to care is a major problem." A total of 59% of the 2003 cohort and 60% of the 2004 cohort indicated they felt prepared to serve diverse populations.

Interestingly, white students at more diverse medical schools did not indicate they were more likely to care for underserved populations. "This may reflect confounding by the urban versus rural location of schools," the authors wrote. "Rural schools are likely to have both fewer nonwhite students and more students who plan to practice in rural, underserved locations."

In contrast, a total of 49% of URMs planned to work with underserved patient populations, significantly more than both white (19%) and nonwhite/non-URM students (16%).

"The finding by Saha and colleagues in this issue of JAMA that… increased medical school diversity is associated with white students feeling better prepared to care for diverse patients is an important contribution to the medical literature," Dr. Carrasquillo and Dr. Lee-Rey wrote. "Findings from this methodologically rigorous study can inform efforts to elicit continued support by the Supreme Court for admissions policies favorable to URM diversity." Dr. Carrasquillo is director of the Center for the Health of Urban Minorities at Columbia University Medical Center and Dr. Lee-Rey is codirector of the Hispanic Center for Excellence, Albert Einstein College of Medicine, both in New York.

White students attending more racially diverse medical schools consider themselves better prepared to care for patients of racial and ethnic minority group, according to a study of more than 20,000 graduates.

Attitudes about providing equivalent access to health care for everyone also were stronger among students at more diverse schools. These students' responses were 50% more favorable toward equitable access to care, compared with their counterparts at the least diverse schools.

The associations were particularly strong at medical schools that foster positive interactions and sharing of opinions among students from different backgrounds, Dr. Somnath Saha and colleagues reported (JAMA 2008;300:1135–45). The investigators also found a "threshold effect" regarding minority student enrollment. Specifically, diversity outcomes were positive among the 118 medical schools in the study if the proportion of underrepresented minority graduates (URMs) exceeded 10%, or the total nonwhite student population was more than 36%. The authors had no disclosures.

Policies and programs devised to achieve racial diversity in medical schools and to increase the numbers of underrepresented black, Hispanic, and Native American students "have come under increasing scrutiny as being unnecessary and discriminatory," the authors wrote. Dr. Saha is an internist at the Portland VA Medical Center and Oregon Health and Science University.

Affirmative action and addressing prior injustices are the justification for most programs to increase URM student diversity.

However, Dr. Olveen Carrasquillo and Dr. Elizabeth T. Lee-Rey wrote in an editorial, "the well-documented history of widespread racism within organized medicine and the American Medical Association's apology is a reminder of how pervasive and tolerated such practices were only a few decades ago" (JAMA2008;300:1203–4).

Dr. Saha and colleagues assessed results of the online graduation questionnaires administered by the Association of American Medical Colleges in 2003 and 2004. They assessed anonymous responses from 20,112 individuals, representing 64% of all graduates during those 2 years.

Race and ethnicity were self-reported. The 9% of URM respondents included black, American Indian, Alaska Native, Mexican American/Chicano, mainland Puerto Rican, and Native Hawaiian students. Minorities not considered to be underrepresented in the physician workforce, primarily Asians and non-URM Hispanic or Latino students, comprised the 23% nonwhite/non-URM group. The remaining 68% were white students.

A total of 21% of the 13,764 graduates in 2003 and 22% of the 7,472 graduates in 2004 strongly agreed that "everyone is entitled to adequate care." Also, 42% of the 2003 graduates and 44% of the 2004 graduates strongly agreed that "access to care is a major problem." A total of 59% of the 2003 cohort and 60% of the 2004 cohort indicated they felt prepared to serve diverse populations.

Interestingly, white students at more diverse medical schools did not indicate they were more likely to care for underserved populations. "This may reflect confounding by the urban versus rural location of schools," the authors wrote. "Rural schools are likely to have both fewer nonwhite students and more students who plan to practice in rural, underserved locations."

In contrast, a total of 49% of URMs planned to work with underserved patient populations, significantly more than both white (19%) and nonwhite/non-URM students (16%).

"The finding by Saha and colleagues in this issue of JAMA that… increased medical school diversity is associated with white students feeling better prepared to care for diverse patients is an important contribution to the medical literature," Dr. Carrasquillo and Dr. Lee-Rey wrote. "Findings from this methodologically rigorous study can inform efforts to elicit continued support by the Supreme Court for admissions policies favorable to URM diversity." Dr. Carrasquillo is director of the Center for the Health of Urban Minorities at Columbia University Medical Center and Dr. Lee-Rey is codirector of the Hispanic Center for Excellence, Albert Einstein College of Medicine, both in New York.

Imagine detecting skin cancer at a very early stage merely by using a sensor with an alarm that sounds when it detects abnormal variations in volatile chemical odors in the patient's skin.

Although still in the prototype stage, researchers proved the technology works with basal cell carcinoma, and plan to soon assess efficacy for early detection of melanoma and squamous cell cancers as well.

"It's very promising. There are volatiles present that are indicative of cancer. They are present in normal and cancerous skin, but levels change in a quantitative manner," said George Preti, Ph.D.

Using gas chromatography and mass spectrometry, Dr. Preti and his associates demonstrated that basal cell carcinoma lesions in 11 people emitted different levels of volatile organic skin chemicals, compared with noncancerous skin, in 11 controls. They found many of the chemicals to be odorous. Coauthor Michelle Gallagher, Ph.D., presented their findings at the annual meeting of the American Chemical Society. Specific chemical identities have not been released.

The current study builds on previous research done by Dr. Gallagher and her associates.

In a report, they identified nearly 100 different chemical compounds normally emitted by the forearm and upper back of 25 healthy volunteers (Brit. J. Derm. 2008 July 12; [doi: 10.1111/j.1365–2133.2008. 08748.x]). The study included patients aged 19–79 years and found some changes in skin emissions with age.

Other reports are anecdotal or only evaluate skin odor differences at the underarm (J. Chem. Ecol. 2005;31:1607–19; Chem. Biodivers. 2004;1:2042–50). The researchers began assessing skin emissions after studies showed that dogs were able to identify people with early-stage cancers using their heightened sense of smell (Integr. Cancer. Ther. 2006;5:30–9; BMJ 2004;329:712).

This was a proof-of-principle study, said Dr. Preti, who estimated clinical availability could take 7–10 years. He and his colleagues used a volatile organic chemical sensor designed for industrial and other applications, and next plan to design a probe specific to human skin.

Dr. Preti is a member of the Monell Chemical Senses Center, a nonprofit institute in Philadelphia. Dr. Gallagher was a postdoctorate fellow in Dr. Preti's lab at the time of the study; she is now at Rohm and Haas in Spring House, Pa. The authors of the study had no relevant financial disclosures.

Imagine detecting skin cancer at a very early stage merely by using a sensor with an alarm that sounds when it detects abnormal variations in volatile chemical odors in the patient's skin.

Although still in the prototype stage, researchers proved the technology works with basal cell carcinoma, and plan to soon assess efficacy for early detection of melanoma and squamous cell cancers as well.

"It's very promising. There are volatiles present that are indicative of cancer. They are present in normal and cancerous skin, but levels change in a quantitative manner," said George Preti, Ph.D.

Using gas chromatography and mass spectrometry, Dr. Preti and his associates demonstrated that basal cell carcinoma lesions in 11 people emitted different levels of volatile organic skin chemicals, compared with noncancerous skin, in 11 controls. They found many of the chemicals to be odorous. Coauthor Michelle Gallagher, Ph.D., presented their findings at the annual meeting of the American Chemical Society. Specific chemical identities have not been released.

The current study builds on previous research done by Dr. Gallagher and her associates.

In a report, they identified nearly 100 different chemical compounds normally emitted by the forearm and upper back of 25 healthy volunteers (Brit. J. Derm. 2008 July 12; [doi: 10.1111/j.1365–2133.2008. 08748.x]). The study included patients aged 19–79 years and found some changes in skin emissions with age.

Other reports are anecdotal or only evaluate skin odor differences at the underarm (J. Chem. Ecol. 2005;31:1607–19; Chem. Biodivers. 2004;1:2042–50). The researchers began assessing skin emissions after studies showed that dogs were able to identify people with early-stage cancers using their heightened sense of smell (Integr. Cancer. Ther. 2006;5:30–9; BMJ 2004;329:712).

This was a proof-of-principle study, said Dr. Preti, who estimated clinical availability could take 7–10 years. He and his colleagues used a volatile organic chemical sensor designed for industrial and other applications, and next plan to design a probe specific to human skin.

Dr. Preti is a member of the Monell Chemical Senses Center, a nonprofit institute in Philadelphia. Dr. Gallagher was a postdoctorate fellow in Dr. Preti's lab at the time of the study; she is now at Rohm and Haas in Spring House, Pa. The authors of the study had no relevant financial disclosures.

Imagine detecting skin cancer at a very early stage merely by using a sensor with an alarm that sounds when it detects abnormal variations in volatile chemical odors in the patient's skin.

Although still in the prototype stage, researchers proved the technology works with basal cell carcinoma, and plan to soon assess efficacy for early detection of melanoma and squamous cell cancers as well.

"It's very promising. There are volatiles present that are indicative of cancer. They are present in normal and cancerous skin, but levels change in a quantitative manner," said George Preti, Ph.D.

Using gas chromatography and mass spectrometry, Dr. Preti and his associates demonstrated that basal cell carcinoma lesions in 11 people emitted different levels of volatile organic skin chemicals, compared with noncancerous skin, in 11 controls. They found many of the chemicals to be odorous. Coauthor Michelle Gallagher, Ph.D., presented their findings at the annual meeting of the American Chemical Society. Specific chemical identities have not been released.

The current study builds on previous research done by Dr. Gallagher and her associates.

In a report, they identified nearly 100 different chemical compounds normally emitted by the forearm and upper back of 25 healthy volunteers (Brit. J. Derm. 2008 July 12; [doi: 10.1111/j.1365–2133.2008. 08748.x]). The study included patients aged 19–79 years and found some changes in skin emissions with age.

Other reports are anecdotal or only evaluate skin odor differences at the underarm (J. Chem. Ecol. 2005;31:1607–19; Chem. Biodivers. 2004;1:2042–50). The researchers began assessing skin emissions after studies showed that dogs were able to identify people with early-stage cancers using their heightened sense of smell (Integr. Cancer. Ther. 2006;5:30–9; BMJ 2004;329:712).

This was a proof-of-principle study, said Dr. Preti, who estimated clinical availability could take 7–10 years. He and his colleagues used a volatile organic chemical sensor designed for industrial and other applications, and next plan to design a probe specific to human skin.

Dr. Preti is a member of the Monell Chemical Senses Center, a nonprofit institute in Philadelphia. Dr. Gallagher was a postdoctorate fellow in Dr. Preti's lab at the time of the study; she is now at Rohm and Haas in Spring House, Pa. The authors of the study had no relevant financial disclosures.

One year of combination hormone replacement therapy significantly improves some menopausal symptoms and health-related quality of life for women, compared with placebo, according to the large, randomized, Women's International Study of Long Duration Oestrogen after the Menopause.

“In light of the WISDOM findings on quality of life, consideration should be given to revisiting HRT guidelines,” according to Dr. Alastair H. MacLennan of the University of Adelaide (Australia) and his colleagues on the WISDOM team.

In the study, a total of 1,043 women aged 50–69 years with follow-up data were randomised to daily oral combination hormone therapy (HT).

They took conjugated equine estrogen 0.625 mg plus medroxyprogesterone acetate 2.5/5.0 mg (Prempro, Wyeth Ayerst).

Their symptoms, quality of life, and other outcomes were compared with 1,087 women who took a once-daily oral placebo. Participants were enrolled in the United Kingdom, Australia, and New Zealand.

Fewer hot flushes (9% vs. 25% of the placebo group) and a lower rate of night sweats (14% vs. 23%) were among the significant benefits of combination HT at 1 year. In addition, fewer participants in the combination HT group reported aching joints and muscles (57% vs. 63%), insomnia (35% vs. 41%), or vaginal dryness (14% vs. 19%).

At the same time, women in the treatment group reported significantly more breast tenderness (16% vs. 7%) and vaginal discharge (14% vs. 5%) than did women in the placebo group (BMJ 2008; 337:a1190 [doi:10.1136/bmj.a1190

“This study shows just how effective hormone therapy can be in alleviating hot flushes and sleep disturbances and in generally improving other components of quality of life and well-being,” Dr. Amos Pines of the department of medicine at Ichilov Medical Center, Tel Aviv, said in a written statement.

Dr. Pines is not affiliated with the study and commented on behalf of the International Menopause Society.

“This is a significant study, which supports our views on HT,” Dr. David W. Sturdee, IMS president, said in the same statement. “It shows that HRT can offer real benefits to most women experiencing menopausal symptoms. This study reinforces the benefits of appropriate use [of HT].” Dr. Sturdee is in the department of obstetrics and gynaecology, Solihull (U.K.) Hospital.

“Taking everything into account, latest data [show] that hormone therapy in healthy women during the early postmenopausal period is really pretty safe,” Dr. Pines said.

Consider these benefits in individualised decisions about use of combined HT, the study authors wrote. And weigh them against short- and long-term risks of therapy, including potential increased cardiac events, venous thromboembolism, and breast cancer,

Other menopausal symptoms, depression, and overall quality of life were not significantly different between groups. The WISDOM outcome measures included a modified version of the Women's Health Questionnaire, a 28-item meno-pause symptom questionnaire, the European quality of life instrument, a generic overall quality of life visual analog scale, and a 20-item Center for Epidemiologic Studies Depression Scale.

The positive outcomes of the WISDOM study are consistent with vasomotor symptoms, sleep, and bodily pain improvements reported in the Women's Health Initiative (WHI) study (JAMA 2002;288:321–33). Similar health-related quality of life improvements were demonstrated in another study (N. Engl. J. Med. 2003;348:1839–54), but WISDOM is the first to use instruments specific to menopause.

WISDOM was initially launched in 1999 as a 10-year study to assess many possible effects of combined HRT. However, it was halted early after safety concerns of the WHI study were announced. Nevertheless, the WISDOM authors collected enough quality of life and symptom data from the women to perform the current analysis. A loss to follow-up and considerable discontinuation of study medication may have introduced selection bias and are potential limitations of the study, the authors noted.

The authors had no relevant financial disclosures.

One year of combination hormone replacement therapy significantly improves some menopausal symptoms and health-related quality of life for women, compared with placebo, according to the large, randomized, Women's International Study of Long Duration Oestrogen after the Menopause.

“In light of the WISDOM findings on quality of life, consideration should be given to revisiting HRT guidelines,” according to Dr. Alastair H. MacLennan of the University of Adelaide (Australia) and his colleagues on the WISDOM team.

In the study, a total of 1,043 women aged 50–69 years with follow-up data were randomised to daily oral combination hormone therapy (HT).

They took conjugated equine estrogen 0.625 mg plus medroxyprogesterone acetate 2.5/5.0 mg (Prempro, Wyeth Ayerst).

Their symptoms, quality of life, and other outcomes were compared with 1,087 women who took a once-daily oral placebo. Participants were enrolled in the United Kingdom, Australia, and New Zealand.

Fewer hot flushes (9% vs. 25% of the placebo group) and a lower rate of night sweats (14% vs. 23%) were among the significant benefits of combination HT at 1 year. In addition, fewer participants in the combination HT group reported aching joints and muscles (57% vs. 63%), insomnia (35% vs. 41%), or vaginal dryness (14% vs. 19%).

At the same time, women in the treatment group reported significantly more breast tenderness (16% vs. 7%) and vaginal discharge (14% vs. 5%) than did women in the placebo group (BMJ 2008; 337:a1190 [doi:10.1136/bmj.a1190

“This study shows just how effective hormone therapy can be in alleviating hot flushes and sleep disturbances and in generally improving other components of quality of life and well-being,” Dr. Amos Pines of the department of medicine at Ichilov Medical Center, Tel Aviv, said in a written statement.

Dr. Pines is not affiliated with the study and commented on behalf of the International Menopause Society.

“This is a significant study, which supports our views on HT,” Dr. David W. Sturdee, IMS president, said in the same statement. “It shows that HRT can offer real benefits to most women experiencing menopausal symptoms. This study reinforces the benefits of appropriate use [of HT].” Dr. Sturdee is in the department of obstetrics and gynaecology, Solihull (U.K.) Hospital.

“Taking everything into account, latest data [show] that hormone therapy in healthy women during the early postmenopausal period is really pretty safe,” Dr. Pines said.

Consider these benefits in individualised decisions about use of combined HT, the study authors wrote. And weigh them against short- and long-term risks of therapy, including potential increased cardiac events, venous thromboembolism, and breast cancer,

Other menopausal symptoms, depression, and overall quality of life were not significantly different between groups. The WISDOM outcome measures included a modified version of the Women's Health Questionnaire, a 28-item meno-pause symptom questionnaire, the European quality of life instrument, a generic overall quality of life visual analog scale, and a 20-item Center for Epidemiologic Studies Depression Scale.

The positive outcomes of the WISDOM study are consistent with vasomotor symptoms, sleep, and bodily pain improvements reported in the Women's Health Initiative (WHI) study (JAMA 2002;288:321–33). Similar health-related quality of life improvements were demonstrated in another study (N. Engl. J. Med. 2003;348:1839–54), but WISDOM is the first to use instruments specific to menopause.

WISDOM was initially launched in 1999 as a 10-year study to assess many possible effects of combined HRT. However, it was halted early after safety concerns of the WHI study were announced. Nevertheless, the WISDOM authors collected enough quality of life and symptom data from the women to perform the current analysis. A loss to follow-up and considerable discontinuation of study medication may have introduced selection bias and are potential limitations of the study, the authors noted.

The authors had no relevant financial disclosures.

One year of combination hormone replacement therapy significantly improves some menopausal symptoms and health-related quality of life for women, compared with placebo, according to the large, randomized, Women's International Study of Long Duration Oestrogen after the Menopause.

“In light of the WISDOM findings on quality of life, consideration should be given to revisiting HRT guidelines,” according to Dr. Alastair H. MacLennan of the University of Adelaide (Australia) and his colleagues on the WISDOM team.

In the study, a total of 1,043 women aged 50–69 years with follow-up data were randomised to daily oral combination hormone therapy (HT).

They took conjugated equine estrogen 0.625 mg plus medroxyprogesterone acetate 2.5/5.0 mg (Prempro, Wyeth Ayerst).

Their symptoms, quality of life, and other outcomes were compared with 1,087 women who took a once-daily oral placebo. Participants were enrolled in the United Kingdom, Australia, and New Zealand.

Fewer hot flushes (9% vs. 25% of the placebo group) and a lower rate of night sweats (14% vs. 23%) were among the significant benefits of combination HT at 1 year. In addition, fewer participants in the combination HT group reported aching joints and muscles (57% vs. 63%), insomnia (35% vs. 41%), or vaginal dryness (14% vs. 19%).

At the same time, women in the treatment group reported significantly more breast tenderness (16% vs. 7%) and vaginal discharge (14% vs. 5%) than did women in the placebo group (BMJ 2008; 337:a1190 [doi:10.1136/bmj.a1190

“This study shows just how effective hormone therapy can be in alleviating hot flushes and sleep disturbances and in generally improving other components of quality of life and well-being,” Dr. Amos Pines of the department of medicine at Ichilov Medical Center, Tel Aviv, said in a written statement.

Dr. Pines is not affiliated with the study and commented on behalf of the International Menopause Society.

“This is a significant study, which supports our views on HT,” Dr. David W. Sturdee, IMS president, said in the same statement. “It shows that HRT can offer real benefits to most women experiencing menopausal symptoms. This study reinforces the benefits of appropriate use [of HT].” Dr. Sturdee is in the department of obstetrics and gynaecology, Solihull (U.K.) Hospital.

“Taking everything into account, latest data [show] that hormone therapy in healthy women during the early postmenopausal period is really pretty safe,” Dr. Pines said.

Consider these benefits in individualised decisions about use of combined HT, the study authors wrote. And weigh them against short- and long-term risks of therapy, including potential increased cardiac events, venous thromboembolism, and breast cancer,

Other menopausal symptoms, depression, and overall quality of life were not significantly different between groups. The WISDOM outcome measures included a modified version of the Women's Health Questionnaire, a 28-item meno-pause symptom questionnaire, the European quality of life instrument, a generic overall quality of life visual analog scale, and a 20-item Center for Epidemiologic Studies Depression Scale.

The positive outcomes of the WISDOM study are consistent with vasomotor symptoms, sleep, and bodily pain improvements reported in the Women's Health Initiative (WHI) study (JAMA 2002;288:321–33). Similar health-related quality of life improvements were demonstrated in another study (N. Engl. J. Med. 2003;348:1839–54), but WISDOM is the first to use instruments specific to menopause.

WISDOM was initially launched in 1999 as a 10-year study to assess many possible effects of combined HRT. However, it was halted early after safety concerns of the WHI study were announced. Nevertheless, the WISDOM authors collected enough quality of life and symptom data from the women to perform the current analysis. A loss to follow-up and considerable discontinuation of study medication may have introduced selection bias and are potential limitations of the study, the authors noted.

The authors had no relevant financial disclosures.

MONTREAL — Clobetasol propionate and tacrolimus ointments offer similar efficacy for treatment of pediatric vitiligo, according to a prospective, randomized, double-blind clinical trial.

Both topicals were superior to placebo in this study of 100 pediatric patients.

In addition, facial vitiligo lesions responded quicker than did nonfacial ones to either active treatment in the 6-month study, Dr. Nhung Ho said at the annual conference of the Canadian Dermatology Association.

Fifty boys and 50 girls were randomized to one of three groups.

Thirty-three applied clobetasol propionate 0.05% ointment (available as a generic) for 2 months, then placebo ointment for 2 months, followed by clobetasol again for 2 months.

The on-and-off cycle design was used to minimize safety concerns, said Dr. Ho, a pediatric dermatologist at the Hospital for Sick Children in Toronto.

The second group, of 34 patients, applied tacrolimus 0.1% ointment (Protopic, Astellas Pharma US Inc.) for 6 months, and the remaining 33 patients applied a placebo for 6 months.

Participants were aged 2–16 years and vitiligo affected less than 20% of their body surface area at baseline.

They were enrolled at either a dermatology outpatient clinic or a private office between June 2005 and December 2007. A research grant from Astellas Pharmaceuticals funded the study.

Three assessors reviewed standardized photos at baseline, 2, 4, and 6 months.

Successful response was defined as more than 50% repigmentation of the vitiligo lesions.

There were 45 participants with facial vitiligo and 55 others with nonfacial lesions.

In the facial group, 58% responded to clobetasol propionate and 58% responded to tacrolimus.

The effect was lower for those with nonfacial lesions: Thirty-nine percent responded to clobetasol propionate and 23% to tacrolimus, Dr. Ho said.

Both active treatments were significantly better than placebo. A total of 24% of the placebo patients—7 of 29 who completed the study—responded, 5 responded partially and 2 responded with greater than 50% repigmentation, the pediatric dermatologist said.

There were no significant adverse events reported. Some patients experienced transient erythema but no atrophy occurred.

Possible limitations of the study include its short duration and "a humble number of patients," Dr. Ho said.

Vitiligo affects an estimated 1%–4% of the world's population. It presents in children of all races, with predominance in girls, and approximately 50% of lesions develop before age 20 years.

The pathogenesis of childhood vitiligo is still unknown, the pediatric dermatologist noted.

Evidence supports the use of topical therapies for localized pediatric vitiligo lesions.

For example, moderate- to high-potency topical corticosteroids caused repigmentation of vitiligo lesions for 45 of 70 children (64%) treated in one retrospective study (J. Am. Acad. Dermatol. 2007;56:236–41).

Another 24% (17 children) showed no change in their lesions, and 11% (8 children) had their vitiligo worsen.

Systemic absorption (29% of participants had abnormally high cortisol levels) was a caveat in this study.

In another retrospective study of 57 pediatric patients, tacrolimus ointment caused at least a partial response in 89% of facial vitiligo lesions (J. Am. Acad. Dermatol. 2004:51:760–66).

Response to the topical tacrolimus ointment was lower for vitiligo lesions on the trunk and extremities, with at least a partial response reported by 63% of the pediatric patients.

MONTREAL — Clobetasol propionate and tacrolimus ointments offer similar efficacy for treatment of pediatric vitiligo, according to a prospective, randomized, double-blind clinical trial.

Both topicals were superior to placebo in this study of 100 pediatric patients.

In addition, facial vitiligo lesions responded quicker than did nonfacial ones to either active treatment in the 6-month study, Dr. Nhung Ho said at the annual conference of the Canadian Dermatology Association.

Fifty boys and 50 girls were randomized to one of three groups.

Thirty-three applied clobetasol propionate 0.05% ointment (available as a generic) for 2 months, then placebo ointment for 2 months, followed by clobetasol again for 2 months.

The on-and-off cycle design was used to minimize safety concerns, said Dr. Ho, a pediatric dermatologist at the Hospital for Sick Children in Toronto.

The second group, of 34 patients, applied tacrolimus 0.1% ointment (Protopic, Astellas Pharma US Inc.) for 6 months, and the remaining 33 patients applied a placebo for 6 months.

Participants were aged 2–16 years and vitiligo affected less than 20% of their body surface area at baseline.

They were enrolled at either a dermatology outpatient clinic or a private office between June 2005 and December 2007. A research grant from Astellas Pharmaceuticals funded the study.

Three assessors reviewed standardized photos at baseline, 2, 4, and 6 months.

Successful response was defined as more than 50% repigmentation of the vitiligo lesions.

There were 45 participants with facial vitiligo and 55 others with nonfacial lesions.

In the facial group, 58% responded to clobetasol propionate and 58% responded to tacrolimus.

The effect was lower for those with nonfacial lesions: Thirty-nine percent responded to clobetasol propionate and 23% to tacrolimus, Dr. Ho said.

Both active treatments were significantly better than placebo. A total of 24% of the placebo patients—7 of 29 who completed the study—responded, 5 responded partially and 2 responded with greater than 50% repigmentation, the pediatric dermatologist said.

There were no significant adverse events reported. Some patients experienced transient erythema but no atrophy occurred.

Possible limitations of the study include its short duration and "a humble number of patients," Dr. Ho said.

Vitiligo affects an estimated 1%–4% of the world's population. It presents in children of all races, with predominance in girls, and approximately 50% of lesions develop before age 20 years.

The pathogenesis of childhood vitiligo is still unknown, the pediatric dermatologist noted.

Evidence supports the use of topical therapies for localized pediatric vitiligo lesions.

For example, moderate- to high-potency topical corticosteroids caused repigmentation of vitiligo lesions for 45 of 70 children (64%) treated in one retrospective study (J. Am. Acad. Dermatol. 2007;56:236–41).

Another 24% (17 children) showed no change in their lesions, and 11% (8 children) had their vitiligo worsen.

Systemic absorption (29% of participants had abnormally high cortisol levels) was a caveat in this study.

In another retrospective study of 57 pediatric patients, tacrolimus ointment caused at least a partial response in 89% of facial vitiligo lesions (J. Am. Acad. Dermatol. 2004:51:760–66).

Response to the topical tacrolimus ointment was lower for vitiligo lesions on the trunk and extremities, with at least a partial response reported by 63% of the pediatric patients.

MONTREAL — Clobetasol propionate and tacrolimus ointments offer similar efficacy for treatment of pediatric vitiligo, according to a prospective, randomized, double-blind clinical trial.

Both topicals were superior to placebo in this study of 100 pediatric patients.

In addition, facial vitiligo lesions responded quicker than did nonfacial ones to either active treatment in the 6-month study, Dr. Nhung Ho said at the annual conference of the Canadian Dermatology Association.

Fifty boys and 50 girls were randomized to one of three groups.

Thirty-three applied clobetasol propionate 0.05% ointment (available as a generic) for 2 months, then placebo ointment for 2 months, followed by clobetasol again for 2 months.

The on-and-off cycle design was used to minimize safety concerns, said Dr. Ho, a pediatric dermatologist at the Hospital for Sick Children in Toronto.

The second group, of 34 patients, applied tacrolimus 0.1% ointment (Protopic, Astellas Pharma US Inc.) for 6 months, and the remaining 33 patients applied a placebo for 6 months.

Participants were aged 2–16 years and vitiligo affected less than 20% of their body surface area at baseline.

They were enrolled at either a dermatology outpatient clinic or a private office between June 2005 and December 2007. A research grant from Astellas Pharmaceuticals funded the study.

Three assessors reviewed standardized photos at baseline, 2, 4, and 6 months.

Successful response was defined as more than 50% repigmentation of the vitiligo lesions.

There were 45 participants with facial vitiligo and 55 others with nonfacial lesions.

In the facial group, 58% responded to clobetasol propionate and 58% responded to tacrolimus.

The effect was lower for those with nonfacial lesions: Thirty-nine percent responded to clobetasol propionate and 23% to tacrolimus, Dr. Ho said.

Both active treatments were significantly better than placebo. A total of 24% of the placebo patients—7 of 29 who completed the study—responded, 5 responded partially and 2 responded with greater than 50% repigmentation, the pediatric dermatologist said.

There were no significant adverse events reported. Some patients experienced transient erythema but no atrophy occurred.

Possible limitations of the study include its short duration and "a humble number of patients," Dr. Ho said.

Vitiligo affects an estimated 1%–4% of the world's population. It presents in children of all races, with predominance in girls, and approximately 50% of lesions develop before age 20 years.

The pathogenesis of childhood vitiligo is still unknown, the pediatric dermatologist noted.

Evidence supports the use of topical therapies for localized pediatric vitiligo lesions.

For example, moderate- to high-potency topical corticosteroids caused repigmentation of vitiligo lesions for 45 of 70 children (64%) treated in one retrospective study (J. Am. Acad. Dermatol. 2007;56:236–41).

Another 24% (17 children) showed no change in their lesions, and 11% (8 children) had their vitiligo worsen.

Systemic absorption (29% of participants had abnormally high cortisol levels) was a caveat in this study.

In another retrospective study of 57 pediatric patients, tacrolimus ointment caused at least a partial response in 89% of facial vitiligo lesions (J. Am. Acad. Dermatol. 2004:51:760–66).

Response to the topical tacrolimus ointment was lower for vitiligo lesions on the trunk and extremities, with at least a partial response reported by 63% of the pediatric patients.