John R. Bell

WASHINGTON — Patients with diverticular disease can most likely eat high-fiber foods like corn, nuts, and popcorn without fear of symptom aggravation, a large prospective study suggests. In fact, some of these foods were associated with a protective effect against such symptoms.

The findings contradict the widely held assumption that foods like these, “being somewhat rougher or less well digested than other foods, would be more likely to traumatize the colon wall,” study investigator Dr. Lisa L. Strate of the division of gastroenterology at the University of Washington, Seattle, said at a press briefing at the annual Digestive Disease Week.

Dr. Strate and her colleagues reported findings from more than 47,000 male participants in the Health Professionals Follow-Up Study, which began in 1986. The men were aged 40–75 years at baseline. The investigators analyzed data for participants who had reported newly diagnosed diverticulosis or diverticular complications at any of the intervening biennial follow-up points, through 2004.

They also examined data from questionnaires about diet, diagnosis, and treatment.

No multivariate associations existed between consumption of nuts, corn, popcorn, or all three and diverticular bleeding (383 incident cases) and diverticulitis (801 cases) over 18 years of follow-up, Dr. Strate reported at the briefing.

In addition, popcorn consumption appeared to confer a protective effect against these conditions. After adjustment for risk factors for diverticular complications, men with the highest level of popcorn consumption (at least twice a week), compared with men who ate the least popcorn (less than once per month), had a hazard ratio of 0.72 for diverticulitis.

Similarly, for men who ate nuts at least twice per week, the diverticulitis hazard ratio was 0.8.

Physicians have historically advised patients with diverticular disease to avoid eating foods that often are incompletely digested, Dr. Strate noted. “But, in reality, we don't understand much about the pathogenesis of these complications. … Nuts and seeds were particularly thought to result in these complications, because [it was thought] they might be more likely to lodge in or to injure the mucosa.”

Patients with diverticulosis no longer have to avoid corn, nuts, and popcorn. ©David Allen/FOTOLIA

WASHINGTON — Patients with diverticular disease can most likely eat high-fiber foods like corn, nuts, and popcorn without fear of symptom aggravation, a large prospective study suggests. In fact, some of these foods were associated with a protective effect against such symptoms.

The findings contradict the widely held assumption that foods like these, “being somewhat rougher or less well digested than other foods, would be more likely to traumatize the colon wall,” study investigator Dr. Lisa L. Strate of the division of gastroenterology at the University of Washington, Seattle, said at a press briefing at the annual Digestive Disease Week.

Dr. Strate and her colleagues reported findings from more than 47,000 male participants in the Health Professionals Follow-Up Study, which began in 1986. The men were aged 40–75 years at baseline. The investigators analyzed data for participants who had reported newly diagnosed diverticulosis or diverticular complications at any of the intervening biennial follow-up points, through 2004.

They also examined data from questionnaires about diet, diagnosis, and treatment.

No multivariate associations existed between consumption of nuts, corn, popcorn, or all three and diverticular bleeding (383 incident cases) and diverticulitis (801 cases) over 18 years of follow-up, Dr. Strate reported at the briefing.

In addition, popcorn consumption appeared to confer a protective effect against these conditions. After adjustment for risk factors for diverticular complications, men with the highest level of popcorn consumption (at least twice a week), compared with men who ate the least popcorn (less than once per month), had a hazard ratio of 0.72 for diverticulitis.

Similarly, for men who ate nuts at least twice per week, the diverticulitis hazard ratio was 0.8.

Physicians have historically advised patients with diverticular disease to avoid eating foods that often are incompletely digested, Dr. Strate noted. “But, in reality, we don't understand much about the pathogenesis of these complications. … Nuts and seeds were particularly thought to result in these complications, because [it was thought] they might be more likely to lodge in or to injure the mucosa.”

Patients with diverticulosis no longer have to avoid corn, nuts, and popcorn. ©David Allen/FOTOLIA

WASHINGTON — Patients with diverticular disease can most likely eat high-fiber foods like corn, nuts, and popcorn without fear of symptom aggravation, a large prospective study suggests. In fact, some of these foods were associated with a protective effect against such symptoms.

The findings contradict the widely held assumption that foods like these, “being somewhat rougher or less well digested than other foods, would be more likely to traumatize the colon wall,” study investigator Dr. Lisa L. Strate of the division of gastroenterology at the University of Washington, Seattle, said at a press briefing at the annual Digestive Disease Week.

Dr. Strate and her colleagues reported findings from more than 47,000 male participants in the Health Professionals Follow-Up Study, which began in 1986. The men were aged 40–75 years at baseline. The investigators analyzed data for participants who had reported newly diagnosed diverticulosis or diverticular complications at any of the intervening biennial follow-up points, through 2004.

They also examined data from questionnaires about diet, diagnosis, and treatment.

No multivariate associations existed between consumption of nuts, corn, popcorn, or all three and diverticular bleeding (383 incident cases) and diverticulitis (801 cases) over 18 years of follow-up, Dr. Strate reported at the briefing.

In addition, popcorn consumption appeared to confer a protective effect against these conditions. After adjustment for risk factors for diverticular complications, men with the highest level of popcorn consumption (at least twice a week), compared with men who ate the least popcorn (less than once per month), had a hazard ratio of 0.72 for diverticulitis.

Similarly, for men who ate nuts at least twice per week, the diverticulitis hazard ratio was 0.8.

Physicians have historically advised patients with diverticular disease to avoid eating foods that often are incompletely digested, Dr. Strate noted. “But, in reality, we don't understand much about the pathogenesis of these complications. … Nuts and seeds were particularly thought to result in these complications, because [it was thought] they might be more likely to lodge in or to injure the mucosa.”

Patients with diverticulosis no longer have to avoid corn, nuts, and popcorn. ©David Allen/FOTOLIA

LAS VEGAS — Patients who present with localized erythema near the site of a tick bite should not necessarily be referred for laboratory tests, Dr. Jana Hercogova said at a dermatology seminar sponsored by Skin Disease Education Foundation.

In fact, a tick bite followed by a local skin reaction should simply be examined in 1 week and, if the redness persists, treated with antibiotics, said Dr. Hercogova of Charles University, Prague.

Dr. Hercogova said that physicians treating pregnant women should consider the gestational age when choosing treatment. In the first trimester, she advised using penicillin G 20 million U/day for 2 days, with oral antibiotics as an option for the following 2 weeks. If infection is suspected to have begun in the second or third trimester, she said she uses only oral antibiotics—mainly penicillin derivatives.

Physicians should also be familiar with macular and annular erythema migrans, she noted, adding that patients with morphea should also be tested for Borrelia infection. However, she cautioned, “we should treat the patient without [serologic] evidence if we see a clinically clear case.”

If tests are done and come back positive for Lyme disease, she recommended treating the patient with doxycycline or penicillin, depending on whether Ehrlichia coinfection is present.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

LAS VEGAS — Patients who present with localized erythema near the site of a tick bite should not necessarily be referred for laboratory tests, Dr. Jana Hercogova said at a dermatology seminar sponsored by Skin Disease Education Foundation.

In fact, a tick bite followed by a local skin reaction should simply be examined in 1 week and, if the redness persists, treated with antibiotics, said Dr. Hercogova of Charles University, Prague.

Dr. Hercogova said that physicians treating pregnant women should consider the gestational age when choosing treatment. In the first trimester, she advised using penicillin G 20 million U/day for 2 days, with oral antibiotics as an option for the following 2 weeks. If infection is suspected to have begun in the second or third trimester, she said she uses only oral antibiotics—mainly penicillin derivatives.

Physicians should also be familiar with macular and annular erythema migrans, she noted, adding that patients with morphea should also be tested for Borrelia infection. However, she cautioned, “we should treat the patient without [serologic] evidence if we see a clinically clear case.”

If tests are done and come back positive for Lyme disease, she recommended treating the patient with doxycycline or penicillin, depending on whether Ehrlichia coinfection is present.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

LAS VEGAS — Patients who present with localized erythema near the site of a tick bite should not necessarily be referred for laboratory tests, Dr. Jana Hercogova said at a dermatology seminar sponsored by Skin Disease Education Foundation.

In fact, a tick bite followed by a local skin reaction should simply be examined in 1 week and, if the redness persists, treated with antibiotics, said Dr. Hercogova of Charles University, Prague.

Dr. Hercogova said that physicians treating pregnant women should consider the gestational age when choosing treatment. In the first trimester, she advised using penicillin G 20 million U/day for 2 days, with oral antibiotics as an option for the following 2 weeks. If infection is suspected to have begun in the second or third trimester, she said she uses only oral antibiotics—mainly penicillin derivatives.

Physicians should also be familiar with macular and annular erythema migrans, she noted, adding that patients with morphea should also be tested for Borrelia infection. However, she cautioned, “we should treat the patient without [serologic] evidence if we see a clinically clear case.”

If tests are done and come back positive for Lyme disease, she recommended treating the patient with doxycycline or penicillin, depending on whether Ehrlichia coinfection is present.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

AUSTIN, TEX. – Despite a generally low rate of participation in smoking-cessation programs among persons with psychotic disorders, cessation intervention is effective in this population, at least in the short term, Amanda Baker, Ph.D., said at the annual meeting of the Society for Research on Nicotine and Tobacco.

For the randomized, double-blind trial, Dr. Baker of the University of Newcastle (Australia) and colleagues enrolled 298 regular smokers with a nonacute psychotic disorder (including but not limited to schizophrenia) who lived in the community.

Participants were assigned to routine care (151 persons) or usual treatment plus a smoking cessation intervention (147 persons). There were eight sessions in the intervention, and they included nicotine replacement therapy, motivational interviewing, and cognitive-behavioral therapy. There were six weekly 1-hour sessions and two more biweekly sessions. The investigators observed a statistically significant dose-response relationship between treatment session attendance and smoking cessation at 1 year but not at 3 years. At 12 months, 18% of control participants had quit smoking, vs. 31% of treatment participants (11% for fewer than five sessions, 21% for five to seven sessions, and 47% for all eight sessions).

At 3 years, 19% of controls and 19% of all treatment participants had achieved cessation (6% of those attending fewer than five sessions, 12% who attended five to seven sessions, and 30% who participated in all eight sessions). The 3-year results did not reach statistical significance, however, and Dr. Baker noted that the investigators were able to contact only slightly more than half the participants at 3 years' follow-up. The portion of each group completing all intervention sessions was similar between the two arms: 56% of the intervention group and 54% of the control group.

The investigators noted that 12-month smoking reduction by at least 50% was significantly predictive of abstinence at 3 years. Point-prevalence abstinence at 36 months was 34% among those who had reduced their smoking by half at 12 months, vs. 11% for those who had not, Dr. Baker reported. There was no worsening of psychotic symptoms among any of those patients.

The 3-year results mean that “maintenance of treatment gains… really remains a major challenge” in patients with psychotic disorder, she said. A forthcoming study will modify the intervention to include longer sessions and address overall lifestyle of the smokers.

Participants were a mean of 37 years old, and 56% were male. Most were receiving disability benefits, and 72% were single. At baseline, they smoked a mean of 30 cigarettes per day and reported two previous quit attempts. They were residents of the greater Sydney area or of the Newcastle area, 2 hours north of Sydney.

Most of the participants cited going “cold turkey” as their most effective prior method of smoking cessation. Their main self-reported reasons for smoking were “craving” or “addiction,” Dr. Baker said.

The nicotine replacement patches used in the study were provided by GlaxoSmithKline Inc.

AUSTIN, TEX. – Despite a generally low rate of participation in smoking-cessation programs among persons with psychotic disorders, cessation intervention is effective in this population, at least in the short term, Amanda Baker, Ph.D., said at the annual meeting of the Society for Research on Nicotine and Tobacco.

For the randomized, double-blind trial, Dr. Baker of the University of Newcastle (Australia) and colleagues enrolled 298 regular smokers with a nonacute psychotic disorder (including but not limited to schizophrenia) who lived in the community.

Participants were assigned to routine care (151 persons) or usual treatment plus a smoking cessation intervention (147 persons). There were eight sessions in the intervention, and they included nicotine replacement therapy, motivational interviewing, and cognitive-behavioral therapy. There were six weekly 1-hour sessions and two more biweekly sessions. The investigators observed a statistically significant dose-response relationship between treatment session attendance and smoking cessation at 1 year but not at 3 years. At 12 months, 18% of control participants had quit smoking, vs. 31% of treatment participants (11% for fewer than five sessions, 21% for five to seven sessions, and 47% for all eight sessions).

At 3 years, 19% of controls and 19% of all treatment participants had achieved cessation (6% of those attending fewer than five sessions, 12% who attended five to seven sessions, and 30% who participated in all eight sessions). The 3-year results did not reach statistical significance, however, and Dr. Baker noted that the investigators were able to contact only slightly more than half the participants at 3 years' follow-up. The portion of each group completing all intervention sessions was similar between the two arms: 56% of the intervention group and 54% of the control group.

The investigators noted that 12-month smoking reduction by at least 50% was significantly predictive of abstinence at 3 years. Point-prevalence abstinence at 36 months was 34% among those who had reduced their smoking by half at 12 months, vs. 11% for those who had not, Dr. Baker reported. There was no worsening of psychotic symptoms among any of those patients.

The 3-year results mean that “maintenance of treatment gains… really remains a major challenge” in patients with psychotic disorder, she said. A forthcoming study will modify the intervention to include longer sessions and address overall lifestyle of the smokers.

Participants were a mean of 37 years old, and 56% were male. Most were receiving disability benefits, and 72% were single. At baseline, they smoked a mean of 30 cigarettes per day and reported two previous quit attempts. They were residents of the greater Sydney area or of the Newcastle area, 2 hours north of Sydney.

Most of the participants cited going “cold turkey” as their most effective prior method of smoking cessation. Their main self-reported reasons for smoking were “craving” or “addiction,” Dr. Baker said.

The nicotine replacement patches used in the study were provided by GlaxoSmithKline Inc.

AUSTIN, TEX. – Despite a generally low rate of participation in smoking-cessation programs among persons with psychotic disorders, cessation intervention is effective in this population, at least in the short term, Amanda Baker, Ph.D., said at the annual meeting of the Society for Research on Nicotine and Tobacco.

For the randomized, double-blind trial, Dr. Baker of the University of Newcastle (Australia) and colleagues enrolled 298 regular smokers with a nonacute psychotic disorder (including but not limited to schizophrenia) who lived in the community.

Participants were assigned to routine care (151 persons) or usual treatment plus a smoking cessation intervention (147 persons). There were eight sessions in the intervention, and they included nicotine replacement therapy, motivational interviewing, and cognitive-behavioral therapy. There were six weekly 1-hour sessions and two more biweekly sessions. The investigators observed a statistically significant dose-response relationship between treatment session attendance and smoking cessation at 1 year but not at 3 years. At 12 months, 18% of control participants had quit smoking, vs. 31% of treatment participants (11% for fewer than five sessions, 21% for five to seven sessions, and 47% for all eight sessions).

At 3 years, 19% of controls and 19% of all treatment participants had achieved cessation (6% of those attending fewer than five sessions, 12% who attended five to seven sessions, and 30% who participated in all eight sessions). The 3-year results did not reach statistical significance, however, and Dr. Baker noted that the investigators were able to contact only slightly more than half the participants at 3 years' follow-up. The portion of each group completing all intervention sessions was similar between the two arms: 56% of the intervention group and 54% of the control group.

The investigators noted that 12-month smoking reduction by at least 50% was significantly predictive of abstinence at 3 years. Point-prevalence abstinence at 36 months was 34% among those who had reduced their smoking by half at 12 months, vs. 11% for those who had not, Dr. Baker reported. There was no worsening of psychotic symptoms among any of those patients.

The 3-year results mean that “maintenance of treatment gains… really remains a major challenge” in patients with psychotic disorder, she said. A forthcoming study will modify the intervention to include longer sessions and address overall lifestyle of the smokers.

Participants were a mean of 37 years old, and 56% were male. Most were receiving disability benefits, and 72% were single. At baseline, they smoked a mean of 30 cigarettes per day and reported two previous quit attempts. They were residents of the greater Sydney area or of the Newcastle area, 2 hours north of Sydney.

Most of the participants cited going “cold turkey” as their most effective prior method of smoking cessation. Their main self-reported reasons for smoking were “craving” or “addiction,” Dr. Baker said.

The nicotine replacement patches used in the study were provided by GlaxoSmithKline Inc.

AUSTIN, TEX. – Adolescents who smoke infrequently or occasionally are prime candidates for smoking cessation counseling, Kathleen A. Kealey said in a poster presentation at the annual meeting of the Society for Research on Nicotine and Tobacco.

She and her colleagues at Fred Hutchinson Cancer Research Center, Seattle, administered a classroom-based survey to 93% of all juniors (mean age 17 years) enrolled in 50 high schools in Washington state, and followed each survey with a phone interview to classify them as nonsmokers, infrequent smokers (defined as having smoked at least one cigarette on 1–4 days of the last 30 days), occasional smokers (5–19 smoking days), or regular smokers (20 or more smoking days).

Smoking and nonsmoking students in 25 schools were then randomized to telephone motivational interviewing (at least one call); students in the other 25 schools were assigned to the control arm. Nonsmokers were given reinforcement counseling, in part to avoid stigmatizing the smoking students during enrollment by singling them out among their peers.

The investigators found that fewer infrequent (21%) and occasional (33%) smokers had tried to quit smoking in the last 12 months than had the regular smokers (49%).

However, students in the two lighter-smoking groups were more likely to say that they planned to quit smoking in the next month (30% and 21% vs. 11%) and that they had a strong desire to quit (37% and 32% vs. 26%). All differences were statistically significant.

Regular smokers were less likely to complete the full intervention (62%) than were the infrequent smokers (81%) or occasional smokers (64%), so it appears that adolescent light smokers not only have traits favorable to smoking cessation, they are also amenable to cessation intervention and predisposed to completing such interventions once they begin them.

The study is part of a larger randomized controlled trial that will compare cessation rates among the entire cohort of 2,151 high school seniors.

AUSTIN, TEX. – Adolescents who smoke infrequently or occasionally are prime candidates for smoking cessation counseling, Kathleen A. Kealey said in a poster presentation at the annual meeting of the Society for Research on Nicotine and Tobacco.

She and her colleagues at Fred Hutchinson Cancer Research Center, Seattle, administered a classroom-based survey to 93% of all juniors (mean age 17 years) enrolled in 50 high schools in Washington state, and followed each survey with a phone interview to classify them as nonsmokers, infrequent smokers (defined as having smoked at least one cigarette on 1–4 days of the last 30 days), occasional smokers (5–19 smoking days), or regular smokers (20 or more smoking days).

Smoking and nonsmoking students in 25 schools were then randomized to telephone motivational interviewing (at least one call); students in the other 25 schools were assigned to the control arm. Nonsmokers were given reinforcement counseling, in part to avoid stigmatizing the smoking students during enrollment by singling them out among their peers.

The investigators found that fewer infrequent (21%) and occasional (33%) smokers had tried to quit smoking in the last 12 months than had the regular smokers (49%).

However, students in the two lighter-smoking groups were more likely to say that they planned to quit smoking in the next month (30% and 21% vs. 11%) and that they had a strong desire to quit (37% and 32% vs. 26%). All differences were statistically significant.

Regular smokers were less likely to complete the full intervention (62%) than were the infrequent smokers (81%) or occasional smokers (64%), so it appears that adolescent light smokers not only have traits favorable to smoking cessation, they are also amenable to cessation intervention and predisposed to completing such interventions once they begin them.

The study is part of a larger randomized controlled trial that will compare cessation rates among the entire cohort of 2,151 high school seniors.

AUSTIN, TEX. – Adolescents who smoke infrequently or occasionally are prime candidates for smoking cessation counseling, Kathleen A. Kealey said in a poster presentation at the annual meeting of the Society for Research on Nicotine and Tobacco.

She and her colleagues at Fred Hutchinson Cancer Research Center, Seattle, administered a classroom-based survey to 93% of all juniors (mean age 17 years) enrolled in 50 high schools in Washington state, and followed each survey with a phone interview to classify them as nonsmokers, infrequent smokers (defined as having smoked at least one cigarette on 1–4 days of the last 30 days), occasional smokers (5–19 smoking days), or regular smokers (20 or more smoking days).

Smoking and nonsmoking students in 25 schools were then randomized to telephone motivational interviewing (at least one call); students in the other 25 schools were assigned to the control arm. Nonsmokers were given reinforcement counseling, in part to avoid stigmatizing the smoking students during enrollment by singling them out among their peers.

The investigators found that fewer infrequent (21%) and occasional (33%) smokers had tried to quit smoking in the last 12 months than had the regular smokers (49%).

However, students in the two lighter-smoking groups were more likely to say that they planned to quit smoking in the next month (30% and 21% vs. 11%) and that they had a strong desire to quit (37% and 32% vs. 26%). All differences were statistically significant.

Regular smokers were less likely to complete the full intervention (62%) than were the infrequent smokers (81%) or occasional smokers (64%), so it appears that adolescent light smokers not only have traits favorable to smoking cessation, they are also amenable to cessation intervention and predisposed to completing such interventions once they begin them.

The study is part of a larger randomized controlled trial that will compare cessation rates among the entire cohort of 2,151 high school seniors.

WASHINGTON — Findings from the largest study of the standard treatment for hepatitis C infection, peginterferon and ribavirin, indicate that nearly all patients achieved a durable sustained virologic response—a cure, in the words of Dr. Mark G. Swain, who announced the results at the annual Digestive Disease Week.

The ongoing study, funded by Roche Pharmaceuticals, which manufactures both drugs, includes 997 patients from nine randomized multicenter phase III trials published since 2000. Patients from those trials were eligible for inclusion if they had achieved a sustained virologic response (SVR), defined as undetectable hepatitis C virus (HCV) RNA (fewer than 50 IU/mL) at 24 weeks' follow-up. The patients have been tested yearly for the presence of serum HCV RNA.

Of the total patient population, 163 were infected only with HCV and were treated with peginterferon alfa-2a monotherapy. Another 741 monoinfected patients were given both peginterferon alfa-2a and ribavirin, and 93 patients who were coinfected with HIV and HCV were treated with either monotherapy or combination therapy.

At a mean follow-up of 4.1 years (range 0.4–7.0 years), 989 of the 997 patients (99.2%) were free of HCV RNA. The other eight patients (0.8%) later became HCV RNA positive at a mean of 2 years after cessation of therapy. However, it is not known whether these patients (four men and four women) were reinfected during follow-up or experienced virologic relapse.

“There appear to be no risk factors associated with detectability of HCV RNA during follow-up,” Dr. Swain noted. None of these eight patients had underlying cirrhosis, and “interestingly, only one patient actually received what we would now consider an adequate course of therapy, defined by current treatment paradigms,” said Dr. Swain, professor of medicine, at the University of Calgary, Alta.

“These data suggest that clinical relapse is extremely rare in patients who achieve an SVR with peginterferon alfa-2a plus or minus ribavirin. And therefore, we suggest that patients who achieve an SVR may be deemed clinically cured of chronic hepatitis C,” he concluded.

Dr. Jay Hoofnagle, director of the liver disease branch at the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) in Bethesda, Md., as an audience member questioned whether the eight patients who became positive for HCV RNA during follow-up were truly positive. He said that in his experience, polymerase chain reaction (PCR) testing can yield a false-positive rate of up to 1%, due to technical errors in the laboratory or other causes. “I think you need to bring those people back and make sure they have an infection,” he suggested.

Dr. Swain acknowledged that although false-positive results were possible, “0.8% is well within the numbers that people would normally report for reinfection, I think, in a population this size.” He noted that one of these eight patients has been retested and is still positive for HCV RNA, and genotypic testing for this patient suggested that reinfection had occurred.

A false-positive rate of 1% would be considered high in commercial testing facilities such as the one used in his and his colleagues' study, Dr. Swain said in an interview. Moreover, “false positives would have to be a result of faulty technique—which would be unlikely to give just one false-positive result in a group of batched samples run at the same time—or contamination,” he said. “I am very comfortable that these patients were not false positives,” he said.

Prior studies have reported SVR rates of up to 66% in patients monoinfected with HCV, Dr. Swain noted, and in 40% of HIV coinfected patients.

“This is not the first study, but this is definitely the most compelling and the largest,” Dr. John Vierling, professor of medicine and surgery at Baylor University, Houston, said in an interview. He noted that the first hint that an SVR might be possible with this treatment came in 1981, when one of the current study's component trials, led by Dr. Hoofnagle, ended up with normalization of the patients' liver tests. More recently, those patients were retested via PCR and liver biopsy, “and there was no evidence of virus in the liver cells … and those who had had some scarring reactions before they were treated some 20-some years ago—the scar was no longer present. The fibrosis that existed was now gone.”

More recently, a European study found a high rate of SVR at the end of therapy and after 6 months' follow-up, which was eventually extended to 17 years. “What they found was that 98% of this large number of people had no detectable virus” in blood, white blood cells, or in the liver.

Dr. Vierling noted that the confluence of modern technology and a large study population account for the credence of Dr. Swain's and his colleagues' study.

“The beauty of this type of study is that these were studies in which we know everything about the patients. … They were able, [using] this mechanism, for the first time, to give us these 997 people that we're absolutely sure had a sustained virologic response,” defined by blood testing. Unlike older studies that predated PCR testing, “you don't have the question of whether any of them got into that group who may have harbored virus, but nobody knew it.”

Patients who achieve a sustained virologic response may be deemed clinically cured of chronic hepatitis C. DR. SWAIN

ELSEVIER GLOBAL MEDICAL NEWS

WASHINGTON — Findings from the largest study of the standard treatment for hepatitis C infection, peginterferon and ribavirin, indicate that nearly all patients achieved a durable sustained virologic response—a cure, in the words of Dr. Mark G. Swain, who announced the results at the annual Digestive Disease Week.

The ongoing study, funded by Roche Pharmaceuticals, which manufactures both drugs, includes 997 patients from nine randomized multicenter phase III trials published since 2000. Patients from those trials were eligible for inclusion if they had achieved a sustained virologic response (SVR), defined as undetectable hepatitis C virus (HCV) RNA (fewer than 50 IU/mL) at 24 weeks' follow-up. The patients have been tested yearly for the presence of serum HCV RNA.

Of the total patient population, 163 were infected only with HCV and were treated with peginterferon alfa-2a monotherapy. Another 741 monoinfected patients were given both peginterferon alfa-2a and ribavirin, and 93 patients who were coinfected with HIV and HCV were treated with either monotherapy or combination therapy.

At a mean follow-up of 4.1 years (range 0.4–7.0 years), 989 of the 997 patients (99.2%) were free of HCV RNA. The other eight patients (0.8%) later became HCV RNA positive at a mean of 2 years after cessation of therapy. However, it is not known whether these patients (four men and four women) were reinfected during follow-up or experienced virologic relapse.

“There appear to be no risk factors associated with detectability of HCV RNA during follow-up,” Dr. Swain noted. None of these eight patients had underlying cirrhosis, and “interestingly, only one patient actually received what we would now consider an adequate course of therapy, defined by current treatment paradigms,” said Dr. Swain, professor of medicine, at the University of Calgary, Alta.

“These data suggest that clinical relapse is extremely rare in patients who achieve an SVR with peginterferon alfa-2a plus or minus ribavirin. And therefore, we suggest that patients who achieve an SVR may be deemed clinically cured of chronic hepatitis C,” he concluded.

Dr. Jay Hoofnagle, director of the liver disease branch at the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) in Bethesda, Md., as an audience member questioned whether the eight patients who became positive for HCV RNA during follow-up were truly positive. He said that in his experience, polymerase chain reaction (PCR) testing can yield a false-positive rate of up to 1%, due to technical errors in the laboratory or other causes. “I think you need to bring those people back and make sure they have an infection,” he suggested.

Dr. Swain acknowledged that although false-positive results were possible, “0.8% is well within the numbers that people would normally report for reinfection, I think, in a population this size.” He noted that one of these eight patients has been retested and is still positive for HCV RNA, and genotypic testing for this patient suggested that reinfection had occurred.

A false-positive rate of 1% would be considered high in commercial testing facilities such as the one used in his and his colleagues' study, Dr. Swain said in an interview. Moreover, “false positives would have to be a result of faulty technique—which would be unlikely to give just one false-positive result in a group of batched samples run at the same time—or contamination,” he said. “I am very comfortable that these patients were not false positives,” he said.

Prior studies have reported SVR rates of up to 66% in patients monoinfected with HCV, Dr. Swain noted, and in 40% of HIV coinfected patients.

“This is not the first study, but this is definitely the most compelling and the largest,” Dr. John Vierling, professor of medicine and surgery at Baylor University, Houston, said in an interview. He noted that the first hint that an SVR might be possible with this treatment came in 1981, when one of the current study's component trials, led by Dr. Hoofnagle, ended up with normalization of the patients' liver tests. More recently, those patients were retested via PCR and liver biopsy, “and there was no evidence of virus in the liver cells … and those who had had some scarring reactions before they were treated some 20-some years ago—the scar was no longer present. The fibrosis that existed was now gone.”

More recently, a European study found a high rate of SVR at the end of therapy and after 6 months' follow-up, which was eventually extended to 17 years. “What they found was that 98% of this large number of people had no detectable virus” in blood, white blood cells, or in the liver.

Dr. Vierling noted that the confluence of modern technology and a large study population account for the credence of Dr. Swain's and his colleagues' study.

“The beauty of this type of study is that these were studies in which we know everything about the patients. … They were able, [using] this mechanism, for the first time, to give us these 997 people that we're absolutely sure had a sustained virologic response,” defined by blood testing. Unlike older studies that predated PCR testing, “you don't have the question of whether any of them got into that group who may have harbored virus, but nobody knew it.”

Patients who achieve a sustained virologic response may be deemed clinically cured of chronic hepatitis C. DR. SWAIN

ELSEVIER GLOBAL MEDICAL NEWS

WASHINGTON — Findings from the largest study of the standard treatment for hepatitis C infection, peginterferon and ribavirin, indicate that nearly all patients achieved a durable sustained virologic response—a cure, in the words of Dr. Mark G. Swain, who announced the results at the annual Digestive Disease Week.

The ongoing study, funded by Roche Pharmaceuticals, which manufactures both drugs, includes 997 patients from nine randomized multicenter phase III trials published since 2000. Patients from those trials were eligible for inclusion if they had achieved a sustained virologic response (SVR), defined as undetectable hepatitis C virus (HCV) RNA (fewer than 50 IU/mL) at 24 weeks' follow-up. The patients have been tested yearly for the presence of serum HCV RNA.

Of the total patient population, 163 were infected only with HCV and were treated with peginterferon alfa-2a monotherapy. Another 741 monoinfected patients were given both peginterferon alfa-2a and ribavirin, and 93 patients who were coinfected with HIV and HCV were treated with either monotherapy or combination therapy.

At a mean follow-up of 4.1 years (range 0.4–7.0 years), 989 of the 997 patients (99.2%) were free of HCV RNA. The other eight patients (0.8%) later became HCV RNA positive at a mean of 2 years after cessation of therapy. However, it is not known whether these patients (four men and four women) were reinfected during follow-up or experienced virologic relapse.

“There appear to be no risk factors associated with detectability of HCV RNA during follow-up,” Dr. Swain noted. None of these eight patients had underlying cirrhosis, and “interestingly, only one patient actually received what we would now consider an adequate course of therapy, defined by current treatment paradigms,” said Dr. Swain, professor of medicine, at the University of Calgary, Alta.

“These data suggest that clinical relapse is extremely rare in patients who achieve an SVR with peginterferon alfa-2a plus or minus ribavirin. And therefore, we suggest that patients who achieve an SVR may be deemed clinically cured of chronic hepatitis C,” he concluded.

Dr. Jay Hoofnagle, director of the liver disease branch at the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) in Bethesda, Md., as an audience member questioned whether the eight patients who became positive for HCV RNA during follow-up were truly positive. He said that in his experience, polymerase chain reaction (PCR) testing can yield a false-positive rate of up to 1%, due to technical errors in the laboratory or other causes. “I think you need to bring those people back and make sure they have an infection,” he suggested.

Dr. Swain acknowledged that although false-positive results were possible, “0.8% is well within the numbers that people would normally report for reinfection, I think, in a population this size.” He noted that one of these eight patients has been retested and is still positive for HCV RNA, and genotypic testing for this patient suggested that reinfection had occurred.

A false-positive rate of 1% would be considered high in commercial testing facilities such as the one used in his and his colleagues' study, Dr. Swain said in an interview. Moreover, “false positives would have to be a result of faulty technique—which would be unlikely to give just one false-positive result in a group of batched samples run at the same time—or contamination,” he said. “I am very comfortable that these patients were not false positives,” he said.

Prior studies have reported SVR rates of up to 66% in patients monoinfected with HCV, Dr. Swain noted, and in 40% of HIV coinfected patients.

“This is not the first study, but this is definitely the most compelling and the largest,” Dr. John Vierling, professor of medicine and surgery at Baylor University, Houston, said in an interview. He noted that the first hint that an SVR might be possible with this treatment came in 1981, when one of the current study's component trials, led by Dr. Hoofnagle, ended up with normalization of the patients' liver tests. More recently, those patients were retested via PCR and liver biopsy, “and there was no evidence of virus in the liver cells … and those who had had some scarring reactions before they were treated some 20-some years ago—the scar was no longer present. The fibrosis that existed was now gone.”

More recently, a European study found a high rate of SVR at the end of therapy and after 6 months' follow-up, which was eventually extended to 17 years. “What they found was that 98% of this large number of people had no detectable virus” in blood, white blood cells, or in the liver.

Dr. Vierling noted that the confluence of modern technology and a large study population account for the credence of Dr. Swain's and his colleagues' study.

“The beauty of this type of study is that these were studies in which we know everything about the patients. … They were able, [using] this mechanism, for the first time, to give us these 997 people that we're absolutely sure had a sustained virologic response,” defined by blood testing. Unlike older studies that predated PCR testing, “you don't have the question of whether any of them got into that group who may have harbored virus, but nobody knew it.”

Patients who achieve a sustained virologic response may be deemed clinically cured of chronic hepatitis C. DR. SWAIN

ELSEVIER GLOBAL MEDICAL NEWS

DENVER — Although few dispute the value of screening adolescents for depression in the primary care setting, there remains debate as to how often it happens.

Not much, according to Elizabeth Ozer, Ph.D., of the University of California, San Francisco. She and her colleagues analyzed data from the 2003 California Health Interview Survey, the largest state survey in the United States, and reported their findings during a poster presentation at the annual meeting of the Society for Adolescent Medicine.

Of 899 adolescents aged 13–17 years who made a clinic well visit 3 months prior to taking the survey, only one-third reported answering “Yes” to the question, “When you had your last routine physical exam, did you and a doctor or other health provider talk about your emotions or moods?” Screening was more prevalent in girls (37%) than in boys (26%), with an odds ratio of 1.7. “We don't know if it's because clinicians are more tuned in to the fact that we have higher rates of depression among adolescent girls … or if the girls are more likely to say something than the [boys] are,” Dr. Ozer said in an interview.

There were also different rates of screening by ethnicity, with a greater prevalence in whites and Hispanics (33% each) than in Asian Americans (25%) or African Americans (22%). The differences did not reach statistical significance.

The researchers also administered the Epidemiologic Studies Depression Scale, in which a score of 7 or greater indicates emotional distress. Distress was reported by 32% of the girls and 23% of the boys. In distressed girls, 60% said their physician had not asked them about their emotional health. “Given the rates of depression … we need higher rates of screening than that,” he said.

DENVER — Although few dispute the value of screening adolescents for depression in the primary care setting, there remains debate as to how often it happens.

Not much, according to Elizabeth Ozer, Ph.D., of the University of California, San Francisco. She and her colleagues analyzed data from the 2003 California Health Interview Survey, the largest state survey in the United States, and reported their findings during a poster presentation at the annual meeting of the Society for Adolescent Medicine.

Of 899 adolescents aged 13–17 years who made a clinic well visit 3 months prior to taking the survey, only one-third reported answering “Yes” to the question, “When you had your last routine physical exam, did you and a doctor or other health provider talk about your emotions or moods?” Screening was more prevalent in girls (37%) than in boys (26%), with an odds ratio of 1.7. “We don't know if it's because clinicians are more tuned in to the fact that we have higher rates of depression among adolescent girls … or if the girls are more likely to say something than the [boys] are,” Dr. Ozer said in an interview.

There were also different rates of screening by ethnicity, with a greater prevalence in whites and Hispanics (33% each) than in Asian Americans (25%) or African Americans (22%). The differences did not reach statistical significance.

The researchers also administered the Epidemiologic Studies Depression Scale, in which a score of 7 or greater indicates emotional distress. Distress was reported by 32% of the girls and 23% of the boys. In distressed girls, 60% said their physician had not asked them about their emotional health. “Given the rates of depression … we need higher rates of screening than that,” he said.

DENVER — Although few dispute the value of screening adolescents for depression in the primary care setting, there remains debate as to how often it happens.

Not much, according to Elizabeth Ozer, Ph.D., of the University of California, San Francisco. She and her colleagues analyzed data from the 2003 California Health Interview Survey, the largest state survey in the United States, and reported their findings during a poster presentation at the annual meeting of the Society for Adolescent Medicine.

Of 899 adolescents aged 13–17 years who made a clinic well visit 3 months prior to taking the survey, only one-third reported answering “Yes” to the question, “When you had your last routine physical exam, did you and a doctor or other health provider talk about your emotions or moods?” Screening was more prevalent in girls (37%) than in boys (26%), with an odds ratio of 1.7. “We don't know if it's because clinicians are more tuned in to the fact that we have higher rates of depression among adolescent girls … or if the girls are more likely to say something than the [boys] are,” Dr. Ozer said in an interview.

There were also different rates of screening by ethnicity, with a greater prevalence in whites and Hispanics (33% each) than in Asian Americans (25%) or African Americans (22%). The differences did not reach statistical significance.

The researchers also administered the Epidemiologic Studies Depression Scale, in which a score of 7 or greater indicates emotional distress. Distress was reported by 32% of the girls and 23% of the boys. In distressed girls, 60% said their physician had not asked them about their emotional health. “Given the rates of depression … we need higher rates of screening than that,” he said.

AUSTIN, TEX. – Adding a brief alcohol intervention to treatment for smoking cessation can improve patients' odds of quitting smoking, Christopher Kahler, Ph.D., reported at the annual meeting of the Society for Research on Nicotine and Tobacco.

Dr. Kahler and his colleagues at Brown University, Providence, R.I., conducted a randomized controlled trial of 176 smokers who drank heavily but who were not alcohol dependent. The investigators defined drinking heavily as drinking five or more drinks per occasion on 5 or more days in the past 30 days.

Participants were assigned to either standard cessation treatment alone (ST) or to standard cessation treatment plus a brief alcohol intervention (ST-BI), Dr. Kahler reported.

Both groups received four individual counseling sessions and 8 weeks of nicotine replacement therapy using a nicotine patch. Initially, a modestly increased tendency toward smoking abstinence was seen in the ST-BI group, but it did not reach statistical significance. However, when the 28 participants who drank the most heavily (four or more drinks per day for men and three or more drinks per day for women) were eliminated, ST-BI showed a statistically significant effect on smoking abstinence in the heavy drinkers.

These results suggest that “more intensive alcohol-focused intervention may be needed to achieve greater changes in drinking and to help the heaviest drinkers successfully quit smoking,” the investigators concluded.

After treatment, 58% of subjects in the ST-BI group said they intended to avoid alcohol as much as possible, compared with 35% of those in the ST group.

It is well documented that smokers drink more heavily than nonsmokers do, Dr. Kahler said. He also noted that 20% of current smokers consume more than four drinks at a time at least monthly, compared with 7% of nonsmokers. In addition, “it appears that alcohol use may increase the odds that temptations lead to lapses.”

No protocols have been established for addressing alcohol abuse during smoking cessation treatment.

ELSEVIER GLOBAL MEDICAL NEWS

AUSTIN, TEX. – Adding a brief alcohol intervention to treatment for smoking cessation can improve patients' odds of quitting smoking, Christopher Kahler, Ph.D., reported at the annual meeting of the Society for Research on Nicotine and Tobacco.

Dr. Kahler and his colleagues at Brown University, Providence, R.I., conducted a randomized controlled trial of 176 smokers who drank heavily but who were not alcohol dependent. The investigators defined drinking heavily as drinking five or more drinks per occasion on 5 or more days in the past 30 days.

Participants were assigned to either standard cessation treatment alone (ST) or to standard cessation treatment plus a brief alcohol intervention (ST-BI), Dr. Kahler reported.

Both groups received four individual counseling sessions and 8 weeks of nicotine replacement therapy using a nicotine patch. Initially, a modestly increased tendency toward smoking abstinence was seen in the ST-BI group, but it did not reach statistical significance. However, when the 28 participants who drank the most heavily (four or more drinks per day for men and three or more drinks per day for women) were eliminated, ST-BI showed a statistically significant effect on smoking abstinence in the heavy drinkers.

These results suggest that “more intensive alcohol-focused intervention may be needed to achieve greater changes in drinking and to help the heaviest drinkers successfully quit smoking,” the investigators concluded.

After treatment, 58% of subjects in the ST-BI group said they intended to avoid alcohol as much as possible, compared with 35% of those in the ST group.

It is well documented that smokers drink more heavily than nonsmokers do, Dr. Kahler said. He also noted that 20% of current smokers consume more than four drinks at a time at least monthly, compared with 7% of nonsmokers. In addition, “it appears that alcohol use may increase the odds that temptations lead to lapses.”

No protocols have been established for addressing alcohol abuse during smoking cessation treatment.

ELSEVIER GLOBAL MEDICAL NEWS

AUSTIN, TEX. – Adding a brief alcohol intervention to treatment for smoking cessation can improve patients' odds of quitting smoking, Christopher Kahler, Ph.D., reported at the annual meeting of the Society for Research on Nicotine and Tobacco.

Dr. Kahler and his colleagues at Brown University, Providence, R.I., conducted a randomized controlled trial of 176 smokers who drank heavily but who were not alcohol dependent. The investigators defined drinking heavily as drinking five or more drinks per occasion on 5 or more days in the past 30 days.

Participants were assigned to either standard cessation treatment alone (ST) or to standard cessation treatment plus a brief alcohol intervention (ST-BI), Dr. Kahler reported.

Both groups received four individual counseling sessions and 8 weeks of nicotine replacement therapy using a nicotine patch. Initially, a modestly increased tendency toward smoking abstinence was seen in the ST-BI group, but it did not reach statistical significance. However, when the 28 participants who drank the most heavily (four or more drinks per day for men and three or more drinks per day for women) were eliminated, ST-BI showed a statistically significant effect on smoking abstinence in the heavy drinkers.

These results suggest that “more intensive alcohol-focused intervention may be needed to achieve greater changes in drinking and to help the heaviest drinkers successfully quit smoking,” the investigators concluded.

After treatment, 58% of subjects in the ST-BI group said they intended to avoid alcohol as much as possible, compared with 35% of those in the ST group.

It is well documented that smokers drink more heavily than nonsmokers do, Dr. Kahler said. He also noted that 20% of current smokers consume more than four drinks at a time at least monthly, compared with 7% of nonsmokers. In addition, “it appears that alcohol use may increase the odds that temptations lead to lapses.”

No protocols have been established for addressing alcohol abuse during smoking cessation treatment.

ELSEVIER GLOBAL MEDICAL NEWS

DENVER — Screening for metabolic syndrome may identify patients at increased risk for comorbidities of obesity, according to researchers at the University of Colorado, Denver.

Dr. Kathy Love-Osborne presented a study of 83 obese teens with a family history of type 2 diabetes during a poster session at the annual meeting of the Society for Adolescent Medicine. To classify them as having metabolic syndrome (MS), modified Cook criteria were used, with patients having any three of the following considered to have MS: body mass index (BMI) or waist circumference above 95% for age and sex; blood pressure above 90% for age, sex, and height; triglycerides more than 110 mg/dL; HDL cholesterol level less than 40 mg/dL; and impaired fasting glucose (IFG), which was defined as fasting glucose levels above 100 mg/dL or impaired glucose tolerance (IGT), defined as levels above 140 mg/dL on a glucose tolerance test.

Of the 83 teens, 47 (57%) met three or more MS criteria, including all 10 of the teens with IGT. In addition, of the 33 participants with BMI more than 40 kg/m

Ultrasound results correlated with MS. Of 49 teens on whom any ultrasound was performed, results were abnormal in 24 participants; in the 37 subjects for whom a steatosis score was derived, this score also was significantly associated with MS criteria. Patients with one to two MS criteria had a mean score of 0.93, and those with three or more MS criteria had a mean score of 2.2.

DENVER — Screening for metabolic syndrome may identify patients at increased risk for comorbidities of obesity, according to researchers at the University of Colorado, Denver.

Dr. Kathy Love-Osborne presented a study of 83 obese teens with a family history of type 2 diabetes during a poster session at the annual meeting of the Society for Adolescent Medicine. To classify them as having metabolic syndrome (MS), modified Cook criteria were used, with patients having any three of the following considered to have MS: body mass index (BMI) or waist circumference above 95% for age and sex; blood pressure above 90% for age, sex, and height; triglycerides more than 110 mg/dL; HDL cholesterol level less than 40 mg/dL; and impaired fasting glucose (IFG), which was defined as fasting glucose levels above 100 mg/dL or impaired glucose tolerance (IGT), defined as levels above 140 mg/dL on a glucose tolerance test.

Of the 83 teens, 47 (57%) met three or more MS criteria, including all 10 of the teens with IGT. In addition, of the 33 participants with BMI more than 40 kg/m

Ultrasound results correlated with MS. Of 49 teens on whom any ultrasound was performed, results were abnormal in 24 participants; in the 37 subjects for whom a steatosis score was derived, this score also was significantly associated with MS criteria. Patients with one to two MS criteria had a mean score of 0.93, and those with three or more MS criteria had a mean score of 2.2.

DENVER — Screening for metabolic syndrome may identify patients at increased risk for comorbidities of obesity, according to researchers at the University of Colorado, Denver.

Dr. Kathy Love-Osborne presented a study of 83 obese teens with a family history of type 2 diabetes during a poster session at the annual meeting of the Society for Adolescent Medicine. To classify them as having metabolic syndrome (MS), modified Cook criteria were used, with patients having any three of the following considered to have MS: body mass index (BMI) or waist circumference above 95% for age and sex; blood pressure above 90% for age, sex, and height; triglycerides more than 110 mg/dL; HDL cholesterol level less than 40 mg/dL; and impaired fasting glucose (IFG), which was defined as fasting glucose levels above 100 mg/dL or impaired glucose tolerance (IGT), defined as levels above 140 mg/dL on a glucose tolerance test.

Of the 83 teens, 47 (57%) met three or more MS criteria, including all 10 of the teens with IGT. In addition, of the 33 participants with BMI more than 40 kg/m

Ultrasound results correlated with MS. Of 49 teens on whom any ultrasound was performed, results were abnormal in 24 participants; in the 37 subjects for whom a steatosis score was derived, this score also was significantly associated with MS criteria. Patients with one to two MS criteria had a mean score of 0.93, and those with three or more MS criteria had a mean score of 2.2.

Patients with gastroesophageal reflux disease may ask about the effect of dietary acids or medications on their disease, and despite the availability of “low acid” versions of coffee and orange juice, experts have different opinions on the impact of lifestyle factors in GERD.

Dr. Roy Orlando believes that high-acid foods can contribute to existing problems, because his patients have consistently reported worsening of symptoms after consuming them. “There are many things that can be irritants, but it's not all the time, and it's not in every person,” said Dr. Orlando, professor of medicine and section chief, gastroenterology and hepatology, at Tulane University Medical Center, New Orleans.

As far as causation, however, “coffee in and of itself is not likely to be the cause of a disease—the disease being reflux disease,” he said. “But if you have, or you develop, reflux disease, coffee could then be an irritant. The same thing is true if you have an ulcer of your stomach, or you have an irritation to the lining of your stomach from something entirely independent from the coffee you drank.”

Thus, even though coffee and other beverages are not proved to cause gastritis, heartburn, GERD, or ulcers, such foods “can certainly irritate the lining of the stomach” in people who already have one such condition, according to Dr. Orlando.

However, Dr. Donald O. Castell attributed less importance to dietary acids in these diseases. “There are many things that people eat or drink every day which have an acid pH level,” noted Dr. Castell, professor of medicine and director of the esophageal disorders program at the Medical University of South Carolina, Charleston, in an interview. “The most acidic are carbonated beverages, followed by citrus products, fruits, wine, coffee, and tea. By and large, these do not have any real effect on GERD except they may cause a transient burning symptom in the patient with esophagitis.”

He cautioned that pH testing can be influenced by these products. “During testing with a pH sensor, the ingestion of any of these may produce an artificial lowering of the pH that mimics reflux,” Dr. Castell said.

Dr. Orlando emphasized that manufacturers of “stomach friendly” products seem to be confusing GERD with the symptoms of heartburn, along with stomach distress. This may help to sell coffee and orange juice, he said, but physicians should ensure patients understand the differences between these ailments.

“The first thing one needs to be alert to is the fact that when [patients] talk about 'stomach problems,'… [these] are not esophagus problems,” nor vice versa, he said in an interview. “So one needs to be sure one is accurate when talking about stomach-friendly products. If indeed the concern of the person who was drinking a coffee was that the region just … below the breastbone hurt or was sore or vaguely uncomfortable, that wouldn't be reflux, and that isn't heartburn.”

Dr. Stuart Spechler noted that there is a paucity of research about the effects of dietary acids on GI and esophageal problems. “The data on the effects of coffee on heartburn have been contradictory at best, and it just doesn't seem to be a major player,” said Dr. Spechler, the Berta M. and Cecil O. Patterson chair in gastroenterology at the University of Texas Southwestern Medical Center, and chief of gastroenterology at the Veterans Affairs Medical Center, both in Dallas.

His advice to patients, like Dr. Orlando's, is to avoid foods that aggravate symptoms. “What we usually tell our patients is, if you identify foods that give you trouble, then by all means avoid those. But I don't specifically prohibit coffee or orange juice. And the idea that making orange juice a little bit less acidic in terms of heartburn—I find this a little difficult to believe.”

To qualify for a diagnosis of heartburn, the patient must report substernal discomfort that migrates in a superior direction, Dr. Orlando noted. Stomach problems, such as gastritis or gastric ulcers, include “a whole host of additional signs and symptoms,” he said.

Aspirin in particular is a common contributor to GERD, he said, given that so many people now take it daily to protect the heart. And because patients often experience irritation only after weeks or months, they mistakenly attribute their symptoms to a beverage or food, rather than the medication.

It would be rare to find a patient whose current GI complaint was caused by something he was drinking in the absence of medication or underlying disease, Dr. Orlando said, acknowledging that it could happen if a patient is experiencing unusual stress, such as a student studying for an important examination who drinks many cups of coffee in order to stay awake.

Dr. Spechler noted that the latest medical treatments “are so good at stopping stomach acid that, by and large, what we used to call lifestyle modifications have really assumed a very secondary or even tertiary role. … Most of the [old] prohibitions—the dietary restrictions and things like that—were based more on ideas than on proof.” Thus for patients who have no worsening of symptoms after eating high-acid foods, “I'm very lenient on diet for patients with reflux disease.”

He added that physicians at his institution also advise patients to avoid eating meals close to bedtime and to avoid lying down immediately after eating.

Regarding the role of NSAIDs in heartburn or GERD, Dr. Spechler said that most studies have not shown NSAIDs to exacerbate these conditions but cautioned that that at least one has shown that these drugs may increase reflux. Thus “there are some concerns” about allowing patients with reflux to continue on NSAIDs.

“If the pills get stuck in the esophagus, they can be caustic; they can actually cause burns in the esophagus,” he explained. Moreover, “there has been an association of strictures with use of NSAIDs. But in general, we don't see major problems anymore. We're seeing fewer strictures. The medical treatments are so good that restricting [NSAIDs] has become a very secondary feature of care for the patient with reflux disease.”

He said that his institution will soon publish a study examining the effects of ibuprofen on reflux, in which the drug was associated with an increase in reflux among some patients.

“It did not show an enormous increase in acid reflux, but it did show a significant increase,” he said. However, “we don't know if that's ibuprofen specific or if that's [caused by] all NSAIDs.”

Dr. Orlando, however, indicated that he believes lifestyle modification is an integral part of long-term treatment. After putting the patient on an H₂ antagonist or a proton pump inhibitor for 4–8 weeks, the problem usually subsides.

However, “if the patient hasn't adjusted their lifestyle, then I'll guarantee that those symptoms will come back again. So, in my mind, the medications are a crutch or a handle to capture the disease more efficiently, to get whatever damage may have been done to the lining of the stomach and the lining of the esophagus under control, and to remove what may be provocative things within the lifestyle—including diet—that may have contributed to the symptoms that you can control.”

Patients with gastroesophageal reflux disease may ask about the effect of dietary acids or medications on their disease, and despite the availability of “low acid” versions of coffee and orange juice, experts have different opinions on the impact of lifestyle factors in GERD.

Dr. Roy Orlando believes that high-acid foods can contribute to existing problems, because his patients have consistently reported worsening of symptoms after consuming them. “There are many things that can be irritants, but it's not all the time, and it's not in every person,” said Dr. Orlando, professor of medicine and section chief, gastroenterology and hepatology, at Tulane University Medical Center, New Orleans.

As far as causation, however, “coffee in and of itself is not likely to be the cause of a disease—the disease being reflux disease,” he said. “But if you have, or you develop, reflux disease, coffee could then be an irritant. The same thing is true if you have an ulcer of your stomach, or you have an irritation to the lining of your stomach from something entirely independent from the coffee you drank.”

Thus, even though coffee and other beverages are not proved to cause gastritis, heartburn, GERD, or ulcers, such foods “can certainly irritate the lining of the stomach” in people who already have one such condition, according to Dr. Orlando.

However, Dr. Donald O. Castell attributed less importance to dietary acids in these diseases. “There are many things that people eat or drink every day which have an acid pH level,” noted Dr. Castell, professor of medicine and director of the esophageal disorders program at the Medical University of South Carolina, Charleston, in an interview. “The most acidic are carbonated beverages, followed by citrus products, fruits, wine, coffee, and tea. By and large, these do not have any real effect on GERD except they may cause a transient burning symptom in the patient with esophagitis.”

He cautioned that pH testing can be influenced by these products. “During testing with a pH sensor, the ingestion of any of these may produce an artificial lowering of the pH that mimics reflux,” Dr. Castell said.

Dr. Orlando emphasized that manufacturers of “stomach friendly” products seem to be confusing GERD with the symptoms of heartburn, along with stomach distress. This may help to sell coffee and orange juice, he said, but physicians should ensure patients understand the differences between these ailments.

“The first thing one needs to be alert to is the fact that when [patients] talk about 'stomach problems,'… [these] are not esophagus problems,” nor vice versa, he said in an interview. “So one needs to be sure one is accurate when talking about stomach-friendly products. If indeed the concern of the person who was drinking a coffee was that the region just … below the breastbone hurt or was sore or vaguely uncomfortable, that wouldn't be reflux, and that isn't heartburn.”

Dr. Stuart Spechler noted that there is a paucity of research about the effects of dietary acids on GI and esophageal problems. “The data on the effects of coffee on heartburn have been contradictory at best, and it just doesn't seem to be a major player,” said Dr. Spechler, the Berta M. and Cecil O. Patterson chair in gastroenterology at the University of Texas Southwestern Medical Center, and chief of gastroenterology at the Veterans Affairs Medical Center, both in Dallas.

His advice to patients, like Dr. Orlando's, is to avoid foods that aggravate symptoms. “What we usually tell our patients is, if you identify foods that give you trouble, then by all means avoid those. But I don't specifically prohibit coffee or orange juice. And the idea that making orange juice a little bit less acidic in terms of heartburn—I find this a little difficult to believe.”

To qualify for a diagnosis of heartburn, the patient must report substernal discomfort that migrates in a superior direction, Dr. Orlando noted. Stomach problems, such as gastritis or gastric ulcers, include “a whole host of additional signs and symptoms,” he said.

Aspirin in particular is a common contributor to GERD, he said, given that so many people now take it daily to protect the heart. And because patients often experience irritation only after weeks or months, they mistakenly attribute their symptoms to a beverage or food, rather than the medication.

It would be rare to find a patient whose current GI complaint was caused by something he was drinking in the absence of medication or underlying disease, Dr. Orlando said, acknowledging that it could happen if a patient is experiencing unusual stress, such as a student studying for an important examination who drinks many cups of coffee in order to stay awake.

Dr. Spechler noted that the latest medical treatments “are so good at stopping stomach acid that, by and large, what we used to call lifestyle modifications have really assumed a very secondary or even tertiary role. … Most of the [old] prohibitions—the dietary restrictions and things like that—were based more on ideas than on proof.” Thus for patients who have no worsening of symptoms after eating high-acid foods, “I'm very lenient on diet for patients with reflux disease.”

He added that physicians at his institution also advise patients to avoid eating meals close to bedtime and to avoid lying down immediately after eating.

Regarding the role of NSAIDs in heartburn or GERD, Dr. Spechler said that most studies have not shown NSAIDs to exacerbate these conditions but cautioned that that at least one has shown that these drugs may increase reflux. Thus “there are some concerns” about allowing patients with reflux to continue on NSAIDs.

“If the pills get stuck in the esophagus, they can be caustic; they can actually cause burns in the esophagus,” he explained. Moreover, “there has been an association of strictures with use of NSAIDs. But in general, we don't see major problems anymore. We're seeing fewer strictures. The medical treatments are so good that restricting [NSAIDs] has become a very secondary feature of care for the patient with reflux disease.”

He said that his institution will soon publish a study examining the effects of ibuprofen on reflux, in which the drug was associated with an increase in reflux among some patients.

“It did not show an enormous increase in acid reflux, but it did show a significant increase,” he said. However, “we don't know if that's ibuprofen specific or if that's [caused by] all NSAIDs.”

Dr. Orlando, however, indicated that he believes lifestyle modification is an integral part of long-term treatment. After putting the patient on an H₂ antagonist or a proton pump inhibitor for 4–8 weeks, the problem usually subsides.

However, “if the patient hasn't adjusted their lifestyle, then I'll guarantee that those symptoms will come back again. So, in my mind, the medications are a crutch or a handle to capture the disease more efficiently, to get whatever damage may have been done to the lining of the stomach and the lining of the esophagus under control, and to remove what may be provocative things within the lifestyle—including diet—that may have contributed to the symptoms that you can control.”

Patients with gastroesophageal reflux disease may ask about the effect of dietary acids or medications on their disease, and despite the availability of “low acid” versions of coffee and orange juice, experts have different opinions on the impact of lifestyle factors in GERD.

Dr. Roy Orlando believes that high-acid foods can contribute to existing problems, because his patients have consistently reported worsening of symptoms after consuming them. “There are many things that can be irritants, but it's not all the time, and it's not in every person,” said Dr. Orlando, professor of medicine and section chief, gastroenterology and hepatology, at Tulane University Medical Center, New Orleans.

As far as causation, however, “coffee in and of itself is not likely to be the cause of a disease—the disease being reflux disease,” he said. “But if you have, or you develop, reflux disease, coffee could then be an irritant. The same thing is true if you have an ulcer of your stomach, or you have an irritation to the lining of your stomach from something entirely independent from the coffee you drank.”

Thus, even though coffee and other beverages are not proved to cause gastritis, heartburn, GERD, or ulcers, such foods “can certainly irritate the lining of the stomach” in people who already have one such condition, according to Dr. Orlando.

However, Dr. Donald O. Castell attributed less importance to dietary acids in these diseases. “There are many things that people eat or drink every day which have an acid pH level,” noted Dr. Castell, professor of medicine and director of the esophageal disorders program at the Medical University of South Carolina, Charleston, in an interview. “The most acidic are carbonated beverages, followed by citrus products, fruits, wine, coffee, and tea. By and large, these do not have any real effect on GERD except they may cause a transient burning symptom in the patient with esophagitis.”

He cautioned that pH testing can be influenced by these products. “During testing with a pH sensor, the ingestion of any of these may produce an artificial lowering of the pH that mimics reflux,” Dr. Castell said.

Dr. Orlando emphasized that manufacturers of “stomach friendly” products seem to be confusing GERD with the symptoms of heartburn, along with stomach distress. This may help to sell coffee and orange juice, he said, but physicians should ensure patients understand the differences between these ailments.

“The first thing one needs to be alert to is the fact that when [patients] talk about 'stomach problems,'… [these] are not esophagus problems,” nor vice versa, he said in an interview. “So one needs to be sure one is accurate when talking about stomach-friendly products. If indeed the concern of the person who was drinking a coffee was that the region just … below the breastbone hurt or was sore or vaguely uncomfortable, that wouldn't be reflux, and that isn't heartburn.”

Dr. Stuart Spechler noted that there is a paucity of research about the effects of dietary acids on GI and esophageal problems. “The data on the effects of coffee on heartburn have been contradictory at best, and it just doesn't seem to be a major player,” said Dr. Spechler, the Berta M. and Cecil O. Patterson chair in gastroenterology at the University of Texas Southwestern Medical Center, and chief of gastroenterology at the Veterans Affairs Medical Center, both in Dallas.

His advice to patients, like Dr. Orlando's, is to avoid foods that aggravate symptoms. “What we usually tell our patients is, if you identify foods that give you trouble, then by all means avoid those. But I don't specifically prohibit coffee or orange juice. And the idea that making orange juice a little bit less acidic in terms of heartburn—I find this a little difficult to believe.”

To qualify for a diagnosis of heartburn, the patient must report substernal discomfort that migrates in a superior direction, Dr. Orlando noted. Stomach problems, such as gastritis or gastric ulcers, include “a whole host of additional signs and symptoms,” he said.

Aspirin in particular is a common contributor to GERD, he said, given that so many people now take it daily to protect the heart. And because patients often experience irritation only after weeks or months, they mistakenly attribute their symptoms to a beverage or food, rather than the medication.

It would be rare to find a patient whose current GI complaint was caused by something he was drinking in the absence of medication or underlying disease, Dr. Orlando said, acknowledging that it could happen if a patient is experiencing unusual stress, such as a student studying for an important examination who drinks many cups of coffee in order to stay awake.

Dr. Spechler noted that the latest medical treatments “are so good at stopping stomach acid that, by and large, what we used to call lifestyle modifications have really assumed a very secondary or even tertiary role. … Most of the [old] prohibitions—the dietary restrictions and things like that—were based more on ideas than on proof.” Thus for patients who have no worsening of symptoms after eating high-acid foods, “I'm very lenient on diet for patients with reflux disease.”

He added that physicians at his institution also advise patients to avoid eating meals close to bedtime and to avoid lying down immediately after eating.

Regarding the role of NSAIDs in heartburn or GERD, Dr. Spechler said that most studies have not shown NSAIDs to exacerbate these conditions but cautioned that that at least one has shown that these drugs may increase reflux. Thus “there are some concerns” about allowing patients with reflux to continue on NSAIDs.

“If the pills get stuck in the esophagus, they can be caustic; they can actually cause burns in the esophagus,” he explained. Moreover, “there has been an association of strictures with use of NSAIDs. But in general, we don't see major problems anymore. We're seeing fewer strictures. The medical treatments are so good that restricting [NSAIDs] has become a very secondary feature of care for the patient with reflux disease.”

He said that his institution will soon publish a study examining the effects of ibuprofen on reflux, in which the drug was associated with an increase in reflux among some patients.

“It did not show an enormous increase in acid reflux, but it did show a significant increase,” he said. However, “we don't know if that's ibuprofen specific or if that's [caused by] all NSAIDs.”

Dr. Orlando, however, indicated that he believes lifestyle modification is an integral part of long-term treatment. After putting the patient on an H₂ antagonist or a proton pump inhibitor for 4–8 weeks, the problem usually subsides.

However, “if the patient hasn't adjusted their lifestyle, then I'll guarantee that those symptoms will come back again. So, in my mind, the medications are a crutch or a handle to capture the disease more efficiently, to get whatever damage may have been done to the lining of the stomach and the lining of the esophagus under control, and to remove what may be provocative things within the lifestyle—including diet—that may have contributed to the symptoms that you can control.”

DENVER — Starting adolescent girls immediately on oral contraceptives without waiting until the next menstrual period improves continuation to the second pack of pills and beyond, Dr. Sharon M. Edwards said in a poster presentation at the annual meeting of the Society for Adolescent Medicine.

Dr. Edwards, a pediatrician at Mount Sinai School of Medicine, New York, and her colleagues enrolled 539 girls (mean age 16 years) in a prospective nonblinded randomized controlled trial to determine if starting OCs during the initial clinic visit in girls who test negative for pregnancy, regardless of menstrual cycle, would increase adherence and reduce pregnancies. The girls had presented to two large inner-city clinics requesting OCs.

A total of 267 patients were assigned to OCs with a conventional start (CS) and 272 to the “quick-start” (QS) method. In the CS group, 89% had a past unplanned pregnancy, as had 90% of the QS group.

The investigators assessed each group at 3 and 6 months after baseline with an 87% follow-up rate. The QS method was associated with second-pack OC continuation, with an odds ratio of 1.6.

Moreover, the QS method “simplifies the whole instruction method,” Dr. Edwards said in an interview. “If their period is 2 weeks later, it requires them to really wait a long time. Maybe she'll forget to start, or maybe in that interim, she'll get pregnant, because she's not on any method.” She added that the two clinics in the study could dispense the pills immediately, rather than giving a prescription to be filled.

She conceded the pregnancy rates between groups were not different at either follow-up.

The efficacy of the QS method was echoed by Dr. Margaret Blythe, professor of pediatrics at Riley Hospital for Children in Indianapolis. “We find that kids come into the clinic and get education about it, and often it will be very confusing to them as to really when to start it,” she said in an interview. “Or they'll walk out and think, 'Well, I don't really have to get the prescription, because my next period doesn't start for another couple of weeks.' But on the other hand, if you start them that day, there's an immediacy and a need to go ahead and get the prescription filled.”

Dr. Blythe said she often gives the first pack. The patient then takes the first pill on site.

“We do the same thing with Depo-Provera, in terms of making sure when their last period was, when their last unprotected sex was—and also, whether they're in need of emergency contraception,” she added.

As to why the QS method isn't standard, “I think one of the biggest issues was fear—having an unknown pregnancy and starting a hormone method with unknown effects,” Dr. Blythe said. “But the data really support [the idea] that these hormones are safe, even if someone is pregnant.”

DENVER — Starting adolescent girls immediately on oral contraceptives without waiting until the next menstrual period improves continuation to the second pack of pills and beyond, Dr. Sharon M. Edwards said in a poster presentation at the annual meeting of the Society for Adolescent Medicine.

Dr. Edwards, a pediatrician at Mount Sinai School of Medicine, New York, and her colleagues enrolled 539 girls (mean age 16 years) in a prospective nonblinded randomized controlled trial to determine if starting OCs during the initial clinic visit in girls who test negative for pregnancy, regardless of menstrual cycle, would increase adherence and reduce pregnancies. The girls had presented to two large inner-city clinics requesting OCs.

A total of 267 patients were assigned to OCs with a conventional start (CS) and 272 to the “quick-start” (QS) method. In the CS group, 89% had a past unplanned pregnancy, as had 90% of the QS group.

The investigators assessed each group at 3 and 6 months after baseline with an 87% follow-up rate. The QS method was associated with second-pack OC continuation, with an odds ratio of 1.6.

Moreover, the QS method “simplifies the whole instruction method,” Dr. Edwards said in an interview. “If their period is 2 weeks later, it requires them to really wait a long time. Maybe she'll forget to start, or maybe in that interim, she'll get pregnant, because she's not on any method.” She added that the two clinics in the study could dispense the pills immediately, rather than giving a prescription to be filled.

She conceded the pregnancy rates between groups were not different at either follow-up.

The efficacy of the QS method was echoed by Dr. Margaret Blythe, professor of pediatrics at Riley Hospital for Children in Indianapolis. “We find that kids come into the clinic and get education about it, and often it will be very confusing to them as to really when to start it,” she said in an interview. “Or they'll walk out and think, 'Well, I don't really have to get the prescription, because my next period doesn't start for another couple of weeks.' But on the other hand, if you start them that day, there's an immediacy and a need to go ahead and get the prescription filled.”

Dr. Blythe said she often gives the first pack. The patient then takes the first pill on site.

“We do the same thing with Depo-Provera, in terms of making sure when their last period was, when their last unprotected sex was—and also, whether they're in need of emergency contraception,” she added.

As to why the QS method isn't standard, “I think one of the biggest issues was fear—having an unknown pregnancy and starting a hormone method with unknown effects,” Dr. Blythe said. “But the data really support [the idea] that these hormones are safe, even if someone is pregnant.”

DENVER — Starting adolescent girls immediately on oral contraceptives without waiting until the next menstrual period improves continuation to the second pack of pills and beyond, Dr. Sharon M. Edwards said in a poster presentation at the annual meeting of the Society for Adolescent Medicine.

Dr. Edwards, a pediatrician at Mount Sinai School of Medicine, New York, and her colleagues enrolled 539 girls (mean age 16 years) in a prospective nonblinded randomized controlled trial to determine if starting OCs during the initial clinic visit in girls who test negative for pregnancy, regardless of menstrual cycle, would increase adherence and reduce pregnancies. The girls had presented to two large inner-city clinics requesting OCs.

A total of 267 patients were assigned to OCs with a conventional start (CS) and 272 to the “quick-start” (QS) method. In the CS group, 89% had a past unplanned pregnancy, as had 90% of the QS group.

The investigators assessed each group at 3 and 6 months after baseline with an 87% follow-up rate. The QS method was associated with second-pack OC continuation, with an odds ratio of 1.6.

Moreover, the QS method “simplifies the whole instruction method,” Dr. Edwards said in an interview. “If their period is 2 weeks later, it requires them to really wait a long time. Maybe she'll forget to start, or maybe in that interim, she'll get pregnant, because she's not on any method.” She added that the two clinics in the study could dispense the pills immediately, rather than giving a prescription to be filled.

She conceded the pregnancy rates between groups were not different at either follow-up.

The efficacy of the QS method was echoed by Dr. Margaret Blythe, professor of pediatrics at Riley Hospital for Children in Indianapolis. “We find that kids come into the clinic and get education about it, and often it will be very confusing to them as to really when to start it,” she said in an interview. “Or they'll walk out and think, 'Well, I don't really have to get the prescription, because my next period doesn't start for another couple of weeks.' But on the other hand, if you start them that day, there's an immediacy and a need to go ahead and get the prescription filled.”

Dr. Blythe said she often gives the first pack. The patient then takes the first pill on site.

“We do the same thing with Depo-Provera, in terms of making sure when their last period was, when their last unprotected sex was—and also, whether they're in need of emergency contraception,” she added.

As to why the QS method isn't standard, “I think one of the biggest issues was fear—having an unknown pregnancy and starting a hormone method with unknown effects,” Dr. Blythe said. “But the data really support [the idea] that these hormones are safe, even if someone is pregnant.”