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Cervical cancer screening
To the Editor: In their excellent review of cervical cancer screening,1Jin and colleagues discussed the current screening guidelines advocated by various medical organizations. The authors wisely advised clinicians to modify these guidelines when the lifestyle of an individual patient differs from the expected behavior of the patient’s peer group. For example, they said “it is probably reasonable to continue screening in women age 70 and older who are sexually active with multiple partners and who have a history of abnormal Pap test results.”
To this I would add that it seems reasonable to continue screening a woman over 70 who is sexually active with multiple partners, even if she still has no history of abnormal Pap test results. Similar reasoning might be applied to the statement, “women age 30 and older who had negative results on both Pap and HPV testing should be screened no more often than every 3 years.” This makes sense on a population-wide basis, since women over 30 are more likely to be married and have fewer sexual partners. But why should women who continue to have multiple sex partners into their 30s be screened any less frequently than women in their 20s?
The high negative predictive value of HPV-plus-Pap testing is based on the risk characteristics of the population being screened, as well as on the technical characteristics of the tests. Rigid adherence to screening guidelines may be a disservice to individuals whose lifestyles place them at higher risk than the norm for their age cohort.
- Jin XW, Sikon A, Yen-Lieberman B. Cervical cancer screening: less testing, smarter testing. Cleve Clin J Med 2011; 78:737–747.
To the Editor: In their excellent review of cervical cancer screening,1Jin and colleagues discussed the current screening guidelines advocated by various medical organizations. The authors wisely advised clinicians to modify these guidelines when the lifestyle of an individual patient differs from the expected behavior of the patient’s peer group. For example, they said “it is probably reasonable to continue screening in women age 70 and older who are sexually active with multiple partners and who have a history of abnormal Pap test results.”
To this I would add that it seems reasonable to continue screening a woman over 70 who is sexually active with multiple partners, even if she still has no history of abnormal Pap test results. Similar reasoning might be applied to the statement, “women age 30 and older who had negative results on both Pap and HPV testing should be screened no more often than every 3 years.” This makes sense on a population-wide basis, since women over 30 are more likely to be married and have fewer sexual partners. But why should women who continue to have multiple sex partners into their 30s be screened any less frequently than women in their 20s?
The high negative predictive value of HPV-plus-Pap testing is based on the risk characteristics of the population being screened, as well as on the technical characteristics of the tests. Rigid adherence to screening guidelines may be a disservice to individuals whose lifestyles place them at higher risk than the norm for their age cohort.
To the Editor: In their excellent review of cervical cancer screening,1Jin and colleagues discussed the current screening guidelines advocated by various medical organizations. The authors wisely advised clinicians to modify these guidelines when the lifestyle of an individual patient differs from the expected behavior of the patient’s peer group. For example, they said “it is probably reasonable to continue screening in women age 70 and older who are sexually active with multiple partners and who have a history of abnormal Pap test results.”
To this I would add that it seems reasonable to continue screening a woman over 70 who is sexually active with multiple partners, even if she still has no history of abnormal Pap test results. Similar reasoning might be applied to the statement, “women age 30 and older who had negative results on both Pap and HPV testing should be screened no more often than every 3 years.” This makes sense on a population-wide basis, since women over 30 are more likely to be married and have fewer sexual partners. But why should women who continue to have multiple sex partners into their 30s be screened any less frequently than women in their 20s?
The high negative predictive value of HPV-plus-Pap testing is based on the risk characteristics of the population being screened, as well as on the technical characteristics of the tests. Rigid adherence to screening guidelines may be a disservice to individuals whose lifestyles place them at higher risk than the norm for their age cohort.
- Jin XW, Sikon A, Yen-Lieberman B. Cervical cancer screening: less testing, smarter testing. Cleve Clin J Med 2011; 78:737–747.
- Jin XW, Sikon A, Yen-Lieberman B. Cervical cancer screening: less testing, smarter testing. Cleve Clin J Med 2011; 78:737–747.
Giant cell arteritis
To the Editor: As a practicing internist, I found Dr. Alexandra Villa-Forte’s review of giant-cell arteritis (Cleve Clin J Med 2011; 78:265–270) both interesting and useful, as usual for the Cleveland Clinic Journal of Medicine. However, she did not mention the recommendation by some experts that patients who have had temporal arteritis should receive annual chest x-rays, for a decade or longer, to screen for the development of thoracic aortic aneurysm. Does she agree with this precaution? Is it advisable, in addition, to screen for abdominal aortic aneurysm by means of abdominal ultrasonography? If so, at what time intervals should this be done?
To the Editor: As a practicing internist, I found Dr. Alexandra Villa-Forte’s review of giant-cell arteritis (Cleve Clin J Med 2011; 78:265–270) both interesting and useful, as usual for the Cleveland Clinic Journal of Medicine. However, she did not mention the recommendation by some experts that patients who have had temporal arteritis should receive annual chest x-rays, for a decade or longer, to screen for the development of thoracic aortic aneurysm. Does she agree with this precaution? Is it advisable, in addition, to screen for abdominal aortic aneurysm by means of abdominal ultrasonography? If so, at what time intervals should this be done?
To the Editor: As a practicing internist, I found Dr. Alexandra Villa-Forte’s review of giant-cell arteritis (Cleve Clin J Med 2011; 78:265–270) both interesting and useful, as usual for the Cleveland Clinic Journal of Medicine. However, she did not mention the recommendation by some experts that patients who have had temporal arteritis should receive annual chest x-rays, for a decade or longer, to screen for the development of thoracic aortic aneurysm. Does she agree with this precaution? Is it advisable, in addition, to screen for abdominal aortic aneurysm by means of abdominal ultrasonography? If so, at what time intervals should this be done?
Coadministration of clopidogrel and proton pump inhibitors
To the Editor: Thank you for the excellent review on proton pump inhibitors (PPIs) in the January 2011 issue.1 I would like to make the following comments about Dr. Madanick’s suggested algorithm (see Figure 2 in the article) for deciding whether to use a PPI in patients requiring clopidogrel:
A posting dated October 27, 2010, on the Web site of the US Food and Drug Administration (FDA) states the following: “With regard to the proton pump inhibitor (PPI) drug class, this recommendation [against the concomitant use of Plavix (clopidogrel) and omeprazole (Prilosec)] applies only to omeprazole and not to all PPIs. Not all PPIs have the same inhibitory effect on the enzyme [CYP2C19] that is crucial for conversion of Plavix into its active form. Pantoprazole (Protonix) may be an alternative PPI for consideration. It is a weak inhibitor of CYP2C19 and has less effect on the pharmacological activity of Plavix than omeprazole.”2 Thus, when it is deemed necessary to coadminister clopidogrel with a PPI, pantoprazole appears to be the preferred PPI.
If the patient is taking clopidogrel for stroke prophylaxis, one can consider switching to Aggrenox (aspirin plus extended-release dipyridamole), which has no warnings regarding coadministration with PPIs.
Patients taking aspirin plus clopidogrel may benefit by the addition of misoprostol (Cytotec), which is indicated for reducing the risk of aspirin-induced gastric ulcers in patients at high risk of complications from gastric ulcer.
- Madanick RD. Proton pump inhibitor side effects and drug interactions: much ado about nothing? Cleve Clin J Med 2011; 78:39–49.
- US Food and Drug Administration. FDA reminder to avoid concomitant use of Plavix (clopidogrel) and omeprazole. www.fda.gov/Drugs/DrugSafety/ucm231161.htm. Accessed March 23, 2011.
To the Editor: Thank you for the excellent review on proton pump inhibitors (PPIs) in the January 2011 issue.1 I would like to make the following comments about Dr. Madanick’s suggested algorithm (see Figure 2 in the article) for deciding whether to use a PPI in patients requiring clopidogrel:
A posting dated October 27, 2010, on the Web site of the US Food and Drug Administration (FDA) states the following: “With regard to the proton pump inhibitor (PPI) drug class, this recommendation [against the concomitant use of Plavix (clopidogrel) and omeprazole (Prilosec)] applies only to omeprazole and not to all PPIs. Not all PPIs have the same inhibitory effect on the enzyme [CYP2C19] that is crucial for conversion of Plavix into its active form. Pantoprazole (Protonix) may be an alternative PPI for consideration. It is a weak inhibitor of CYP2C19 and has less effect on the pharmacological activity of Plavix than omeprazole.”2 Thus, when it is deemed necessary to coadminister clopidogrel with a PPI, pantoprazole appears to be the preferred PPI.
If the patient is taking clopidogrel for stroke prophylaxis, one can consider switching to Aggrenox (aspirin plus extended-release dipyridamole), which has no warnings regarding coadministration with PPIs.
Patients taking aspirin plus clopidogrel may benefit by the addition of misoprostol (Cytotec), which is indicated for reducing the risk of aspirin-induced gastric ulcers in patients at high risk of complications from gastric ulcer.
To the Editor: Thank you for the excellent review on proton pump inhibitors (PPIs) in the January 2011 issue.1 I would like to make the following comments about Dr. Madanick’s suggested algorithm (see Figure 2 in the article) for deciding whether to use a PPI in patients requiring clopidogrel:
A posting dated October 27, 2010, on the Web site of the US Food and Drug Administration (FDA) states the following: “With regard to the proton pump inhibitor (PPI) drug class, this recommendation [against the concomitant use of Plavix (clopidogrel) and omeprazole (Prilosec)] applies only to omeprazole and not to all PPIs. Not all PPIs have the same inhibitory effect on the enzyme [CYP2C19] that is crucial for conversion of Plavix into its active form. Pantoprazole (Protonix) may be an alternative PPI for consideration. It is a weak inhibitor of CYP2C19 and has less effect on the pharmacological activity of Plavix than omeprazole.”2 Thus, when it is deemed necessary to coadminister clopidogrel with a PPI, pantoprazole appears to be the preferred PPI.
If the patient is taking clopidogrel for stroke prophylaxis, one can consider switching to Aggrenox (aspirin plus extended-release dipyridamole), which has no warnings regarding coadministration with PPIs.
Patients taking aspirin plus clopidogrel may benefit by the addition of misoprostol (Cytotec), which is indicated for reducing the risk of aspirin-induced gastric ulcers in patients at high risk of complications from gastric ulcer.
- Madanick RD. Proton pump inhibitor side effects and drug interactions: much ado about nothing? Cleve Clin J Med 2011; 78:39–49.
- US Food and Drug Administration. FDA reminder to avoid concomitant use of Plavix (clopidogrel) and omeprazole. www.fda.gov/Drugs/DrugSafety/ucm231161.htm. Accessed March 23, 2011.
- Madanick RD. Proton pump inhibitor side effects and drug interactions: much ado about nothing? Cleve Clin J Med 2011; 78:39–49.
- US Food and Drug Administration. FDA reminder to avoid concomitant use of Plavix (clopidogrel) and omeprazole. www.fda.gov/Drugs/DrugSafety/ucm231161.htm. Accessed March 23, 2011.
Gout and chronic kidney disease
To the Editor: Thank you for the thorough review of gout and chronic kidney disease in the December 2010 issue of Cleveland Clinic Journal of Medicine.
Table 2 displays results from the Febuxostat Versus Allopurinol Controlled Trial (FACT), in which we see that 76% of patients treated with febuxostat 80 mg per day achieved a serum uric acid level of less than 6 mg/dL at week 28. With a dose of febuxostat 240 mg per day, 94% of patients were able to reduce their serum uric acid below 6 mg/dL, the threshold needed to prevent precipitation of uric acid crystals. However, the maximum daily dose recommended in the product information for Uloric (febuxostat) is 80 mg, at which approximately 24% of patients failed to lower their serum uric acid levels to less than 6 mg/dL.
When encountering such patients in clinical practice, would the authors advise pushing the daily dose of febuxostat up to 240 mg, if needed? Alternatively, is there any role for combination therapy with both febuxostat and allopurinol for gout patients with severe resistant hyperuricemia?
To the Editor: Thank you for the thorough review of gout and chronic kidney disease in the December 2010 issue of Cleveland Clinic Journal of Medicine.
Table 2 displays results from the Febuxostat Versus Allopurinol Controlled Trial (FACT), in which we see that 76% of patients treated with febuxostat 80 mg per day achieved a serum uric acid level of less than 6 mg/dL at week 28. With a dose of febuxostat 240 mg per day, 94% of patients were able to reduce their serum uric acid below 6 mg/dL, the threshold needed to prevent precipitation of uric acid crystals. However, the maximum daily dose recommended in the product information for Uloric (febuxostat) is 80 mg, at which approximately 24% of patients failed to lower their serum uric acid levels to less than 6 mg/dL.
When encountering such patients in clinical practice, would the authors advise pushing the daily dose of febuxostat up to 240 mg, if needed? Alternatively, is there any role for combination therapy with both febuxostat and allopurinol for gout patients with severe resistant hyperuricemia?
To the Editor: Thank you for the thorough review of gout and chronic kidney disease in the December 2010 issue of Cleveland Clinic Journal of Medicine.
Table 2 displays results from the Febuxostat Versus Allopurinol Controlled Trial (FACT), in which we see that 76% of patients treated with febuxostat 80 mg per day achieved a serum uric acid level of less than 6 mg/dL at week 28. With a dose of febuxostat 240 mg per day, 94% of patients were able to reduce their serum uric acid below 6 mg/dL, the threshold needed to prevent precipitation of uric acid crystals. However, the maximum daily dose recommended in the product information for Uloric (febuxostat) is 80 mg, at which approximately 24% of patients failed to lower their serum uric acid levels to less than 6 mg/dL.
When encountering such patients in clinical practice, would the authors advise pushing the daily dose of febuxostat up to 240 mg, if needed? Alternatively, is there any role for combination therapy with both febuxostat and allopurinol for gout patients with severe resistant hyperuricemia?
Kidney stones
To the Editor: Thanks for the excellent review articles on nephrolithiasis in your October 2009 issue.1,2
Dr. Hall1 cites studies in which patients given the alpha blocker tamsulosin (Flomax) or the calcium channel blocker nifedipine (Procardia) had improved rates of kidney stone passage compared with placebo. As a primary care physician, I am often confronted with the challenge of managing a patient who is waiting for a kidney stone to pass while taking tamsulosin. Is Dr. Hall aware of any clinical studies, or at least theoretical reasons, which would support adding nifedipine in such cases?
Secondly, Dr. Hall cites studies that demonstrated that a higher intake of dietary calcium is actually associated with fewer calcium stone events in both men and women. An unanswered question is whether patients taking calcium supplements for osteoporosis or osteopenia can safely continue to do so after a calcium stone event, or indeed, whether calcium supplementation might actually be helpful in preventing a recurrent calcum stone.
If there is an absence of randomized studies to answer these questions, Dr. Hall’s recommendations based on his expert experience would be most welcome.
- Hall PM. Nephrolithiasis: treatment, causes, and prevention. Cleve Clin J Med 2009; 76:583–591.
- Samplaski MK, Irwin BH, Desai M. Less-invasive ways to remove stones from the kidneys and ureters. Cleve Clin J Med 2009; 76:592–598.
To the Editor: Thanks for the excellent review articles on nephrolithiasis in your October 2009 issue.1,2
Dr. Hall1 cites studies in which patients given the alpha blocker tamsulosin (Flomax) or the calcium channel blocker nifedipine (Procardia) had improved rates of kidney stone passage compared with placebo. As a primary care physician, I am often confronted with the challenge of managing a patient who is waiting for a kidney stone to pass while taking tamsulosin. Is Dr. Hall aware of any clinical studies, or at least theoretical reasons, which would support adding nifedipine in such cases?
Secondly, Dr. Hall cites studies that demonstrated that a higher intake of dietary calcium is actually associated with fewer calcium stone events in both men and women. An unanswered question is whether patients taking calcium supplements for osteoporosis or osteopenia can safely continue to do so after a calcium stone event, or indeed, whether calcium supplementation might actually be helpful in preventing a recurrent calcum stone.
If there is an absence of randomized studies to answer these questions, Dr. Hall’s recommendations based on his expert experience would be most welcome.
To the Editor: Thanks for the excellent review articles on nephrolithiasis in your October 2009 issue.1,2
Dr. Hall1 cites studies in which patients given the alpha blocker tamsulosin (Flomax) or the calcium channel blocker nifedipine (Procardia) had improved rates of kidney stone passage compared with placebo. As a primary care physician, I am often confronted with the challenge of managing a patient who is waiting for a kidney stone to pass while taking tamsulosin. Is Dr. Hall aware of any clinical studies, or at least theoretical reasons, which would support adding nifedipine in such cases?
Secondly, Dr. Hall cites studies that demonstrated that a higher intake of dietary calcium is actually associated with fewer calcium stone events in both men and women. An unanswered question is whether patients taking calcium supplements for osteoporosis or osteopenia can safely continue to do so after a calcium stone event, or indeed, whether calcium supplementation might actually be helpful in preventing a recurrent calcum stone.
If there is an absence of randomized studies to answer these questions, Dr. Hall’s recommendations based on his expert experience would be most welcome.
- Hall PM. Nephrolithiasis: treatment, causes, and prevention. Cleve Clin J Med 2009; 76:583–591.
- Samplaski MK, Irwin BH, Desai M. Less-invasive ways to remove stones from the kidneys and ureters. Cleve Clin J Med 2009; 76:592–598.
- Hall PM. Nephrolithiasis: treatment, causes, and prevention. Cleve Clin J Med 2009; 76:583–591.
- Samplaski MK, Irwin BH, Desai M. Less-invasive ways to remove stones from the kidneys and ureters. Cleve Clin J Med 2009; 76:592–598.
Prostate cancer prevention
To the Editor: Thank you for the excellent review on prostate cancer screening and prevention by Eric A. Klein, MD, in your August 2009 issue.
Dr. Klein concludes that the results of the Prostate Cancer Prevention Trial (PCPT) and the Reduction by Dutasteride of Prostate Events (REDUCE) trial were “congruent” with respect to the magnitude of prostate cancer risk prevention, beneficial effects on benign prostatic hypertrophy, and toxicity. In other words, finasteride and dutasteride produced equivalent clinical results with respect to prostate health despite the fact that dutasteride inhibits 5-alpha-reductase types 1 and 2, while finasteride inhibits only type 2.
Over the years, many patients have been prescribed dutasteride rather than finasteride because of hopes that the former might be more effective for maintaining prostate health. In August 2009, the retail price on Drugstore.com of a 90-day supply of generic finasteride is $190, vs $321 for dutasteride (which is available only as branded Avodart). In my experience as a practicing primary care physician, most patients would prefer to save money by switching to the less expensive generic drug if it provides equivalent prostate health outcomes compared with the more expensive branded drug.
I would like to ask Dr. Klein’s opinion on allowing patients to switch from Avodart to generic finasteride in order to save money, and on the general issue of which agent to use first-line for prostate health concerns.
To the Editor: Thank you for the excellent review on prostate cancer screening and prevention by Eric A. Klein, MD, in your August 2009 issue.
Dr. Klein concludes that the results of the Prostate Cancer Prevention Trial (PCPT) and the Reduction by Dutasteride of Prostate Events (REDUCE) trial were “congruent” with respect to the magnitude of prostate cancer risk prevention, beneficial effects on benign prostatic hypertrophy, and toxicity. In other words, finasteride and dutasteride produced equivalent clinical results with respect to prostate health despite the fact that dutasteride inhibits 5-alpha-reductase types 1 and 2, while finasteride inhibits only type 2.
Over the years, many patients have been prescribed dutasteride rather than finasteride because of hopes that the former might be more effective for maintaining prostate health. In August 2009, the retail price on Drugstore.com of a 90-day supply of generic finasteride is $190, vs $321 for dutasteride (which is available only as branded Avodart). In my experience as a practicing primary care physician, most patients would prefer to save money by switching to the less expensive generic drug if it provides equivalent prostate health outcomes compared with the more expensive branded drug.
I would like to ask Dr. Klein’s opinion on allowing patients to switch from Avodart to generic finasteride in order to save money, and on the general issue of which agent to use first-line for prostate health concerns.
To the Editor: Thank you for the excellent review on prostate cancer screening and prevention by Eric A. Klein, MD, in your August 2009 issue.
Dr. Klein concludes that the results of the Prostate Cancer Prevention Trial (PCPT) and the Reduction by Dutasteride of Prostate Events (REDUCE) trial were “congruent” with respect to the magnitude of prostate cancer risk prevention, beneficial effects on benign prostatic hypertrophy, and toxicity. In other words, finasteride and dutasteride produced equivalent clinical results with respect to prostate health despite the fact that dutasteride inhibits 5-alpha-reductase types 1 and 2, while finasteride inhibits only type 2.
Over the years, many patients have been prescribed dutasteride rather than finasteride because of hopes that the former might be more effective for maintaining prostate health. In August 2009, the retail price on Drugstore.com of a 90-day supply of generic finasteride is $190, vs $321 for dutasteride (which is available only as branded Avodart). In my experience as a practicing primary care physician, most patients would prefer to save money by switching to the less expensive generic drug if it provides equivalent prostate health outcomes compared with the more expensive branded drug.
I would like to ask Dr. Klein’s opinion on allowing patients to switch from Avodart to generic finasteride in order to save money, and on the general issue of which agent to use first-line for prostate health concerns.
Radiologic workup of a palpable breast mass
To the Editor: Thank you for the excellent review, “The radiologic workup of a palpable breast mass” in your March 2009 issue.1
The authors stated that magnetic resonance imaging (MRI) of the breast “does not currently have a role in the workup of a palpable abnormality.” This may be true in general, because breast MRI is more expensive than mammography plus or minus ultrasonography. However, breast surgeons are currently ordering preoperative MRI to evaluate biopsy-proven breast cancer to help them plan the surgery. This is because MRI provides superior three-dimensional spatial resolution and image quality as compared with ultrasonography or mammography.
My question is whether breast MRI might be useful in the prebiopsy diagnostic workup of breast masses in special cases. For example, some women have very sensitive breasts and refuse to undergo mammography, which requires compression of the breast. Another special case is when the palpable mass is located in a portion of the breast which is not amenable to mammography, such as in the axillary tail of the breast. In these cases, MRI might be helpful if the palpable mass is not definitively imaged with ultrasonography. Would the authors care to comment?
- Stein L, Chellman-Jeffers M. Radiologic workup of a palpable breast mass. Cleve Clin J Med 2009; 76:175–180.
To the Editor: Thank you for the excellent review, “The radiologic workup of a palpable breast mass” in your March 2009 issue.1
The authors stated that magnetic resonance imaging (MRI) of the breast “does not currently have a role in the workup of a palpable abnormality.” This may be true in general, because breast MRI is more expensive than mammography plus or minus ultrasonography. However, breast surgeons are currently ordering preoperative MRI to evaluate biopsy-proven breast cancer to help them plan the surgery. This is because MRI provides superior three-dimensional spatial resolution and image quality as compared with ultrasonography or mammography.
My question is whether breast MRI might be useful in the prebiopsy diagnostic workup of breast masses in special cases. For example, some women have very sensitive breasts and refuse to undergo mammography, which requires compression of the breast. Another special case is when the palpable mass is located in a portion of the breast which is not amenable to mammography, such as in the axillary tail of the breast. In these cases, MRI might be helpful if the palpable mass is not definitively imaged with ultrasonography. Would the authors care to comment?
To the Editor: Thank you for the excellent review, “The radiologic workup of a palpable breast mass” in your March 2009 issue.1
The authors stated that magnetic resonance imaging (MRI) of the breast “does not currently have a role in the workup of a palpable abnormality.” This may be true in general, because breast MRI is more expensive than mammography plus or minus ultrasonography. However, breast surgeons are currently ordering preoperative MRI to evaluate biopsy-proven breast cancer to help them plan the surgery. This is because MRI provides superior three-dimensional spatial resolution and image quality as compared with ultrasonography or mammography.
My question is whether breast MRI might be useful in the prebiopsy diagnostic workup of breast masses in special cases. For example, some women have very sensitive breasts and refuse to undergo mammography, which requires compression of the breast. Another special case is when the palpable mass is located in a portion of the breast which is not amenable to mammography, such as in the axillary tail of the breast. In these cases, MRI might be helpful if the palpable mass is not definitively imaged with ultrasonography. Would the authors care to comment?
- Stein L, Chellman-Jeffers M. Radiologic workup of a palpable breast mass. Cleve Clin J Med 2009; 76:175–180.
- Stein L, Chellman-Jeffers M. Radiologic workup of a palpable breast mass. Cleve Clin J Med 2009; 76:175–180.
Barium esophagography
To the Editor: I would like to comment on the excellent review article on barium esophagography by Drs. Allen, Baker, and Falk in your February 2009 issue. In their opening clinical vignette, they describe a 55-year-old female patient with gastroesophageal reflux disease (GERD) and slowly worsening dysphagia for solids. The patient was sent for barium esophagography, which disclosed an obstructing mucosal ring in the distal esophagus. The patient was then sent for endoscopy so that the ring could be treated with dilation. The authors present this case as an example of the type of patient who could obtain benefit from barium esophagography as the initial study. I disagree. In this patient’s case, the barium procedure accomplished nothing, but it did unnecessarily cost the patient money, time, and radiation exposure. The patient would have been better served by being sent directly for endoscopy at the start of her workup, so that her condition could be diagnosed and treated with a single procedure. In her case, this would have spared her any need for the barium procedure. I believe that patients with dysphagia and GERD are best served by initial endoscopy, since GERD is associated with esophageal strictures, dysplasia, and cancer. Barium esophagography can be reserved for those who have had a normal or nondiagnostic endoscopy. For example, a patient with dysphagia and a normal endoscopy might then be sent for esophagography to diagnose a motility disorder.
To the Editor: I would like to comment on the excellent review article on barium esophagography by Drs. Allen, Baker, and Falk in your February 2009 issue. In their opening clinical vignette, they describe a 55-year-old female patient with gastroesophageal reflux disease (GERD) and slowly worsening dysphagia for solids. The patient was sent for barium esophagography, which disclosed an obstructing mucosal ring in the distal esophagus. The patient was then sent for endoscopy so that the ring could be treated with dilation. The authors present this case as an example of the type of patient who could obtain benefit from barium esophagography as the initial study. I disagree. In this patient’s case, the barium procedure accomplished nothing, but it did unnecessarily cost the patient money, time, and radiation exposure. The patient would have been better served by being sent directly for endoscopy at the start of her workup, so that her condition could be diagnosed and treated with a single procedure. In her case, this would have spared her any need for the barium procedure. I believe that patients with dysphagia and GERD are best served by initial endoscopy, since GERD is associated with esophageal strictures, dysplasia, and cancer. Barium esophagography can be reserved for those who have had a normal or nondiagnostic endoscopy. For example, a patient with dysphagia and a normal endoscopy might then be sent for esophagography to diagnose a motility disorder.
To the Editor: I would like to comment on the excellent review article on barium esophagography by Drs. Allen, Baker, and Falk in your February 2009 issue. In their opening clinical vignette, they describe a 55-year-old female patient with gastroesophageal reflux disease (GERD) and slowly worsening dysphagia for solids. The patient was sent for barium esophagography, which disclosed an obstructing mucosal ring in the distal esophagus. The patient was then sent for endoscopy so that the ring could be treated with dilation. The authors present this case as an example of the type of patient who could obtain benefit from barium esophagography as the initial study. I disagree. In this patient’s case, the barium procedure accomplished nothing, but it did unnecessarily cost the patient money, time, and radiation exposure. The patient would have been better served by being sent directly for endoscopy at the start of her workup, so that her condition could be diagnosed and treated with a single procedure. In her case, this would have spared her any need for the barium procedure. I believe that patients with dysphagia and GERD are best served by initial endoscopy, since GERD is associated with esophageal strictures, dysplasia, and cancer. Barium esophagography can be reserved for those who have had a normal or nondiagnostic endoscopy. For example, a patient with dysphagia and a normal endoscopy might then be sent for esophagography to diagnose a motility disorder.