What Matters

Nephrolithiasis affects 1 in 11 people in the United States resulting in several million emergency department visits annually. The prevalence of nephrolithiasis is higher among men, obese individuals, and white non-Hispanics. The prevalence of kidney stones also appears to be increasing.

Our patients tell us that few things hurt worse than kidney stones. We may feel especially compelled to make a diagnosis given pain severity in otherwise healthy adults who have "never experienced this kind of pain before." Perhaps because of this, lots of patients are undergoing CT imaging for kidney stones ... in the United States. Interestingly, the European Urology Association recommends ultrasonography as the first-line test for urolithiasis.

Can we predict who has a kidney stone?

Moore and colleagues derived and validated a clinical prediction rule for uncomplicated ureteral stone. The derivation cohort was 1,040 patients undergoing noncontrast CT for suspected uncomplicated kidney stone. The validation cohort was 491 consecutively enrolled patients.

Data analysis revealed five factors that were significantly associated with the presence of a ureteral stone: male sex (2 points), duration of pain to presentation (greater than 24 hours: 0 points; 6-24 hours: 1 point; less than 6 hours: 3 points), nonblack race (3 points), presence of nausea or vomiting (nausea alone: 1 point; vomiting alone: 2 points), and microscopic hematuria (3 points). The points add up to low probability (0-5 points = 10% chance of stone), moderate probability (6-9 points = about 50% chance of stone), and high probability (10-13 points = about 90% chance of stone). Acutely important alternative causes were found in 1.6% of the high-probability group in the validation set. These causes were diverticulitis, appendicitis, mass, pyelonephritis, cholecystitis, pneumonia, bowel obstruction, colitis, aortic aneurysm, and pancreatitis.

This algorithm was derived and validated in the emergency setting so it will have different performance characteristics in the outpatient, ambulatory, phone-triage world. However, as the authors discuss, this algorithm could be used to help institutions make decisions about lowering radiation doses for "stone protocol" scans. Scales such as these should be incorporated into electronic medical record systems to improve care delivery.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no disclosures.

Nephrolithiasis affects 1 in 11 people in the United States resulting in several million emergency department visits annually. The prevalence of nephrolithiasis is higher among men, obese individuals, and white non-Hispanics. The prevalence of kidney stones also appears to be increasing.

Our patients tell us that few things hurt worse than kidney stones. We may feel especially compelled to make a diagnosis given pain severity in otherwise healthy adults who have "never experienced this kind of pain before." Perhaps because of this, lots of patients are undergoing CT imaging for kidney stones ... in the United States. Interestingly, the European Urology Association recommends ultrasonography as the first-line test for urolithiasis.

Can we predict who has a kidney stone?

Moore and colleagues derived and validated a clinical prediction rule for uncomplicated ureteral stone. The derivation cohort was 1,040 patients undergoing noncontrast CT for suspected uncomplicated kidney stone. The validation cohort was 491 consecutively enrolled patients.

Data analysis revealed five factors that were significantly associated with the presence of a ureteral stone: male sex (2 points), duration of pain to presentation (greater than 24 hours: 0 points; 6-24 hours: 1 point; less than 6 hours: 3 points), nonblack race (3 points), presence of nausea or vomiting (nausea alone: 1 point; vomiting alone: 2 points), and microscopic hematuria (3 points). The points add up to low probability (0-5 points = 10% chance of stone), moderate probability (6-9 points = about 50% chance of stone), and high probability (10-13 points = about 90% chance of stone). Acutely important alternative causes were found in 1.6% of the high-probability group in the validation set. These causes were diverticulitis, appendicitis, mass, pyelonephritis, cholecystitis, pneumonia, bowel obstruction, colitis, aortic aneurysm, and pancreatitis.

This algorithm was derived and validated in the emergency setting so it will have different performance characteristics in the outpatient, ambulatory, phone-triage world. However, as the authors discuss, this algorithm could be used to help institutions make decisions about lowering radiation doses for "stone protocol" scans. Scales such as these should be incorporated into electronic medical record systems to improve care delivery.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no disclosures.

Nephrolithiasis affects 1 in 11 people in the United States resulting in several million emergency department visits annually. The prevalence of nephrolithiasis is higher among men, obese individuals, and white non-Hispanics. The prevalence of kidney stones also appears to be increasing.

Our patients tell us that few things hurt worse than kidney stones. We may feel especially compelled to make a diagnosis given pain severity in otherwise healthy adults who have "never experienced this kind of pain before." Perhaps because of this, lots of patients are undergoing CT imaging for kidney stones ... in the United States. Interestingly, the European Urology Association recommends ultrasonography as the first-line test for urolithiasis.

Can we predict who has a kidney stone?

Moore and colleagues derived and validated a clinical prediction rule for uncomplicated ureteral stone. The derivation cohort was 1,040 patients undergoing noncontrast CT for suspected uncomplicated kidney stone. The validation cohort was 491 consecutively enrolled patients.

Data analysis revealed five factors that were significantly associated with the presence of a ureteral stone: male sex (2 points), duration of pain to presentation (greater than 24 hours: 0 points; 6-24 hours: 1 point; less than 6 hours: 3 points), nonblack race (3 points), presence of nausea or vomiting (nausea alone: 1 point; vomiting alone: 2 points), and microscopic hematuria (3 points). The points add up to low probability (0-5 points = 10% chance of stone), moderate probability (6-9 points = about 50% chance of stone), and high probability (10-13 points = about 90% chance of stone). Acutely important alternative causes were found in 1.6% of the high-probability group in the validation set. These causes were diverticulitis, appendicitis, mass, pyelonephritis, cholecystitis, pneumonia, bowel obstruction, colitis, aortic aneurysm, and pancreatitis.

This algorithm was derived and validated in the emergency setting so it will have different performance characteristics in the outpatient, ambulatory, phone-triage world. However, as the authors discuss, this algorithm could be used to help institutions make decisions about lowering radiation doses for "stone protocol" scans. Scales such as these should be incorporated into electronic medical record systems to improve care delivery.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no disclosures.

Data from the Centers for Disease Control and Prevention’s National Ambulatory Medical Center Survey reveal benzodiazepine prescriptions grew by 12.5% per year between 2002 and 2009. Data from the National Health and Nutrition Examination Survey suggest that prescriptions for sleep aids (sedatives and hypnotics) tripled between 1998 and 2006. Four percent of U.S. adults age 20 years or older and 7% of adults age 80 years or older report using a prescription sleep aid in the past month.

Aside from the addictive potential and their limited long-term effectiveness, they may be associated with an increased risk of death.

Dr. Scott Weich and his colleagues at University of Warwick, Coventry, England, analyzed data from a retrospective matched cohort study involving 34,727 patients aged at least 16 years who received prescriptions for anxiolytics or hypnotics and 69,418 patients who did not (BMJ 2014;348:g1996). To reduce the likelihood that patients received a prescription that they did not fill, only patients receiving at least two prescriptions were included. The average follow-up period was 7.6 years. The most commonly prescribed drugs were diazepam (48%), temazepam (35%), zopiclone (34%), and zolpidem (8%).

Significantly higher ratios for mortality were observed with the use of these drugs. Adjusting for potential confounders, the hazard ratio for mortality during the whole follow-up period was significantly elevated for the group receiving any sedative or hypnotic in the first year of recruitment (hazard ratio, 3.32; 95% confidence interval: 3.19-3.45).

Dose responses were observed for study drugs. For example, the HR for patients receiving more than 90 doses during the first year was 4.51 (95% CI: 4.22-4.82). Patients who did not receive study drugs beyond 1 year were less likely to die than those who continued to take them. The authors point out that these data translate into four excess deaths linked to use of these drugs per 100 people over 7.6 years after the initial prescription.

The biggest challenge will be to figure out how best to incorporate this information into our counseling of patients without sounding like we are "fear-mongering." Fear-mongering doesn’t work – it just makes our patients more anxious, when what we really need to do is calm them down.

Cognitive-behavioral therapy works for insomnia, but patients report not having the time. I always start the discussion by telling patients to read the book "No More Sleepless Nights" and to start a sleep log. Amazing what we can learn from this. This as least gets the ball rolling.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. Dr. Ebbert does not receive royalties from the sale of "No More Sleepless Nights."

Data from the Centers for Disease Control and Prevention’s National Ambulatory Medical Center Survey reveal benzodiazepine prescriptions grew by 12.5% per year between 2002 and 2009. Data from the National Health and Nutrition Examination Survey suggest that prescriptions for sleep aids (sedatives and hypnotics) tripled between 1998 and 2006. Four percent of U.S. adults age 20 years or older and 7% of adults age 80 years or older report using a prescription sleep aid in the past month.

Aside from the addictive potential and their limited long-term effectiveness, they may be associated with an increased risk of death.

Dr. Scott Weich and his colleagues at University of Warwick, Coventry, England, analyzed data from a retrospective matched cohort study involving 34,727 patients aged at least 16 years who received prescriptions for anxiolytics or hypnotics and 69,418 patients who did not (BMJ 2014;348:g1996). To reduce the likelihood that patients received a prescription that they did not fill, only patients receiving at least two prescriptions were included. The average follow-up period was 7.6 years. The most commonly prescribed drugs were diazepam (48%), temazepam (35%), zopiclone (34%), and zolpidem (8%).

Significantly higher ratios for mortality were observed with the use of these drugs. Adjusting for potential confounders, the hazard ratio for mortality during the whole follow-up period was significantly elevated for the group receiving any sedative or hypnotic in the first year of recruitment (hazard ratio, 3.32; 95% confidence interval: 3.19-3.45).

Dose responses were observed for study drugs. For example, the HR for patients receiving more than 90 doses during the first year was 4.51 (95% CI: 4.22-4.82). Patients who did not receive study drugs beyond 1 year were less likely to die than those who continued to take them. The authors point out that these data translate into four excess deaths linked to use of these drugs per 100 people over 7.6 years after the initial prescription.

The biggest challenge will be to figure out how best to incorporate this information into our counseling of patients without sounding like we are "fear-mongering." Fear-mongering doesn’t work – it just makes our patients more anxious, when what we really need to do is calm them down.

Cognitive-behavioral therapy works for insomnia, but patients report not having the time. I always start the discussion by telling patients to read the book "No More Sleepless Nights" and to start a sleep log. Amazing what we can learn from this. This as least gets the ball rolling.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. Dr. Ebbert does not receive royalties from the sale of "No More Sleepless Nights."

Data from the Centers for Disease Control and Prevention’s National Ambulatory Medical Center Survey reveal benzodiazepine prescriptions grew by 12.5% per year between 2002 and 2009. Data from the National Health and Nutrition Examination Survey suggest that prescriptions for sleep aids (sedatives and hypnotics) tripled between 1998 and 2006. Four percent of U.S. adults age 20 years or older and 7% of adults age 80 years or older report using a prescription sleep aid in the past month.

Aside from the addictive potential and their limited long-term effectiveness, they may be associated with an increased risk of death.

Dr. Scott Weich and his colleagues at University of Warwick, Coventry, England, analyzed data from a retrospective matched cohort study involving 34,727 patients aged at least 16 years who received prescriptions for anxiolytics or hypnotics and 69,418 patients who did not (BMJ 2014;348:g1996). To reduce the likelihood that patients received a prescription that they did not fill, only patients receiving at least two prescriptions were included. The average follow-up period was 7.6 years. The most commonly prescribed drugs were diazepam (48%), temazepam (35%), zopiclone (34%), and zolpidem (8%).

Significantly higher ratios for mortality were observed with the use of these drugs. Adjusting for potential confounders, the hazard ratio for mortality during the whole follow-up period was significantly elevated for the group receiving any sedative or hypnotic in the first year of recruitment (hazard ratio, 3.32; 95% confidence interval: 3.19-3.45).

Dose responses were observed for study drugs. For example, the HR for patients receiving more than 90 doses during the first year was 4.51 (95% CI: 4.22-4.82). Patients who did not receive study drugs beyond 1 year were less likely to die than those who continued to take them. The authors point out that these data translate into four excess deaths linked to use of these drugs per 100 people over 7.6 years after the initial prescription.

The biggest challenge will be to figure out how best to incorporate this information into our counseling of patients without sounding like we are "fear-mongering." Fear-mongering doesn’t work – it just makes our patients more anxious, when what we really need to do is calm them down.

Cognitive-behavioral therapy works for insomnia, but patients report not having the time. I always start the discussion by telling patients to read the book "No More Sleepless Nights" and to start a sleep log. Amazing what we can learn from this. This as least gets the ball rolling.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. Dr. Ebbert does not receive royalties from the sale of "No More Sleepless Nights."

While not a new phenomenon, antimicrobial resistance is an alarming and, arguably, still underappreciated public health problem. A mere 70 years after the introduction of antibiotics, we face the distinct possibility of a future without effective antibiotics for some infections. Such a reality will render select surgical operations, cancer chemotherapy, and organ transplants exceedingly dangerous.

The scarcity of new antimicrobial agents and the paucity of new agents in the drug development pipeline limit treatment options, particularly for patients with infections caused by multidrug-resistant organisms. Annually, multidrug resistant organisms cause an estimated 25,000 deaths in Europe and 12,000 deaths in the United States. In response to this threat, the Transatlantic Taskforce on Antimicrobial Resistance (TATFAR) was established and published their report with 17 recommendations.

Respiratory tract infections are one of the most common symptoms presenting to primary care. Overprescribing in this setting is rampant, driven largely by patient expectations and clinician need for expediency and desire to receive "high marks" for satisfaction. Available evidence has suggested that delayed antibiotic prescribing is effective. But what is the best method to delay antibiotic prescribing?

Researchers in the United Kingdom evaluated the comparative effectiveness of four different strategies of delayed antibiotic prescribing for patients not needing antibiotics right away:

• Recontact: Patients were asked to contact the office and leave a message for a clinician to prescribe an antibiotic.

• Postdated prescription: The prescription could be filled only after a certain date.

• Wait/Request: Patients were instructed to wait but could request an antibiotic from the front office.

• Delayed use: Patients received antibiotics but were asked to wait to use them.

A "no prescription" arm was added later in the trial. The primary outcome was symptom severity measured at the end of each day during days 2-4 of a two-week symptom diary. Secondary outcomes included antibiotic use and side effects.

No differences were observed between the four strategies with respect to symptom control. Antibiotic use did not differ significantly between strategies and the lowest use was reported in the no prescription arm. No significant differences were observed between groups in patient satisfaction. Complications were slightly higher in the no antibiotic group (2.5%), compared with the delayed groups (1.4%).

Delayed prescribing is associated with less than 40% of patients using an antibiotic. Given the current crisis with multidrug resistance, we should feel obligated to try one of the proposed strategies for delayed antibiotic prescription if patients do not need one right away.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no conflicts of interest.

While not a new phenomenon, antimicrobial resistance is an alarming and, arguably, still underappreciated public health problem. A mere 70 years after the introduction of antibiotics, we face the distinct possibility of a future without effective antibiotics for some infections. Such a reality will render select surgical operations, cancer chemotherapy, and organ transplants exceedingly dangerous.

The scarcity of new antimicrobial agents and the paucity of new agents in the drug development pipeline limit treatment options, particularly for patients with infections caused by multidrug-resistant organisms. Annually, multidrug resistant organisms cause an estimated 25,000 deaths in Europe and 12,000 deaths in the United States. In response to this threat, the Transatlantic Taskforce on Antimicrobial Resistance (TATFAR) was established and published their report with 17 recommendations.

Respiratory tract infections are one of the most common symptoms presenting to primary care. Overprescribing in this setting is rampant, driven largely by patient expectations and clinician need for expediency and desire to receive "high marks" for satisfaction. Available evidence has suggested that delayed antibiotic prescribing is effective. But what is the best method to delay antibiotic prescribing?

Researchers in the United Kingdom evaluated the comparative effectiveness of four different strategies of delayed antibiotic prescribing for patients not needing antibiotics right away:

• Recontact: Patients were asked to contact the office and leave a message for a clinician to prescribe an antibiotic.

• Postdated prescription: The prescription could be filled only after a certain date.

• Wait/Request: Patients were instructed to wait but could request an antibiotic from the front office.

• Delayed use: Patients received antibiotics but were asked to wait to use them.

A "no prescription" arm was added later in the trial. The primary outcome was symptom severity measured at the end of each day during days 2-4 of a two-week symptom diary. Secondary outcomes included antibiotic use and side effects.

No differences were observed between the four strategies with respect to symptom control. Antibiotic use did not differ significantly between strategies and the lowest use was reported in the no prescription arm. No significant differences were observed between groups in patient satisfaction. Complications were slightly higher in the no antibiotic group (2.5%), compared with the delayed groups (1.4%).

Delayed prescribing is associated with less than 40% of patients using an antibiotic. Given the current crisis with multidrug resistance, we should feel obligated to try one of the proposed strategies for delayed antibiotic prescription if patients do not need one right away.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no conflicts of interest.

While not a new phenomenon, antimicrobial resistance is an alarming and, arguably, still underappreciated public health problem. A mere 70 years after the introduction of antibiotics, we face the distinct possibility of a future without effective antibiotics for some infections. Such a reality will render select surgical operations, cancer chemotherapy, and organ transplants exceedingly dangerous.

The scarcity of new antimicrobial agents and the paucity of new agents in the drug development pipeline limit treatment options, particularly for patients with infections caused by multidrug-resistant organisms. Annually, multidrug resistant organisms cause an estimated 25,000 deaths in Europe and 12,000 deaths in the United States. In response to this threat, the Transatlantic Taskforce on Antimicrobial Resistance (TATFAR) was established and published their report with 17 recommendations.

Respiratory tract infections are one of the most common symptoms presenting to primary care. Overprescribing in this setting is rampant, driven largely by patient expectations and clinician need for expediency and desire to receive "high marks" for satisfaction. Available evidence has suggested that delayed antibiotic prescribing is effective. But what is the best method to delay antibiotic prescribing?

Researchers in the United Kingdom evaluated the comparative effectiveness of four different strategies of delayed antibiotic prescribing for patients not needing antibiotics right away:

• Recontact: Patients were asked to contact the office and leave a message for a clinician to prescribe an antibiotic.

• Postdated prescription: The prescription could be filled only after a certain date.

• Wait/Request: Patients were instructed to wait but could request an antibiotic from the front office.

• Delayed use: Patients received antibiotics but were asked to wait to use them.

A "no prescription" arm was added later in the trial. The primary outcome was symptom severity measured at the end of each day during days 2-4 of a two-week symptom diary. Secondary outcomes included antibiotic use and side effects.

No differences were observed between the four strategies with respect to symptom control. Antibiotic use did not differ significantly between strategies and the lowest use was reported in the no prescription arm. No significant differences were observed between groups in patient satisfaction. Complications were slightly higher in the no antibiotic group (2.5%), compared with the delayed groups (1.4%).

Delayed prescribing is associated with less than 40% of patients using an antibiotic. Given the current crisis with multidrug resistance, we should feel obligated to try one of the proposed strategies for delayed antibiotic prescription if patients do not need one right away.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no conflicts of interest.

Caffeine in the form of tea and coffee is the most widely consumed, socially acceptable stimulant around the globe. More than 150 million people in the United States drink coffee daily, with an average intake of 2 cups (which contains about 280 mg of caffeine).

Caffeine results in the release of excitatory neurotransmitters. Caffeine may increase energy expenditure and has been associated with reduced body mass. Studies have observed lower body mass index (BMI) in coffee consumers, compared with individuals who don’t consume coffee. Coffee may reduce appetite and dietary intake.

Greek researchers at Harokopio University, Athens, conducted a cross-over study to evaluate the effects of caffeinated coffee on appetite and dietary intake (Obesity 2013;21:1127-32). Sixteen normal-weight and 17 overweight/obese habitual coffee consumers (at least 1 cup of coffee/day) were enrolled. Each participant took part in three trials at least 1 week apart. Participants were required to abstain from caffeine for 24 hours and then reported to the lab to consume a breakfast and 200 mL of one of three experimental beverages: instant coffee with 3 mg caffeine/kg body weight (Coffee 3); instant coffee with 6 mg caffeine/kg (Coffee 6); or water. Participants had to consume the breakfast and the beverage within 5 minutes.

During a 3-hour period following beverage consumption, appetite feelings and participants’ dietary intake the day before the experiment were assessed. After this 3-hour period, participants were offered an ad libitum lunch buffet. The following day, participants reported by telephone their food and fluid intake for the rest of the experiment day.

Normal-weight participants consumed comparable energy in the ad libitum meal and in their total daily intake in the three interventions. However, among overweight/obese individuals, Coffee 6 resulted in significantly reduced energy intake during the ad libitum meal, compared with Coffee 3, and in significantly reduced total day energy intake, compared with both water and Coffee 3.

Doses used in this study for participants were somewhat staggering. The average caffeine content of the beverage in the Coffee 6 group was 526 mg. This is the caffeine content of roughly four 8-ounce cups of brewed coffee. The authors acknowledged that the Coffee 6 beverage was not easily consumed by "most of the volunteers."

We need to be cautious about the use of this dosing in the clinical setting. But as part of comprehensive weight-management strategy, caffeinated coffee may be helpful for reducing energy intake.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no conflicts of interest.

Caffeine in the form of tea and coffee is the most widely consumed, socially acceptable stimulant around the globe. More than 150 million people in the United States drink coffee daily, with an average intake of 2 cups (which contains about 280 mg of caffeine).

Caffeine results in the release of excitatory neurotransmitters. Caffeine may increase energy expenditure and has been associated with reduced body mass. Studies have observed lower body mass index (BMI) in coffee consumers, compared with individuals who don’t consume coffee. Coffee may reduce appetite and dietary intake.

Greek researchers at Harokopio University, Athens, conducted a cross-over study to evaluate the effects of caffeinated coffee on appetite and dietary intake (Obesity 2013;21:1127-32). Sixteen normal-weight and 17 overweight/obese habitual coffee consumers (at least 1 cup of coffee/day) were enrolled. Each participant took part in three trials at least 1 week apart. Participants were required to abstain from caffeine for 24 hours and then reported to the lab to consume a breakfast and 200 mL of one of three experimental beverages: instant coffee with 3 mg caffeine/kg body weight (Coffee 3); instant coffee with 6 mg caffeine/kg (Coffee 6); or water. Participants had to consume the breakfast and the beverage within 5 minutes.

During a 3-hour period following beverage consumption, appetite feelings and participants’ dietary intake the day before the experiment were assessed. After this 3-hour period, participants were offered an ad libitum lunch buffet. The following day, participants reported by telephone their food and fluid intake for the rest of the experiment day.

Normal-weight participants consumed comparable energy in the ad libitum meal and in their total daily intake in the three interventions. However, among overweight/obese individuals, Coffee 6 resulted in significantly reduced energy intake during the ad libitum meal, compared with Coffee 3, and in significantly reduced total day energy intake, compared with both water and Coffee 3.

Doses used in this study for participants were somewhat staggering. The average caffeine content of the beverage in the Coffee 6 group was 526 mg. This is the caffeine content of roughly four 8-ounce cups of brewed coffee. The authors acknowledged that the Coffee 6 beverage was not easily consumed by "most of the volunteers."

We need to be cautious about the use of this dosing in the clinical setting. But as part of comprehensive weight-management strategy, caffeinated coffee may be helpful for reducing energy intake.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no conflicts of interest.

Caffeine in the form of tea and coffee is the most widely consumed, socially acceptable stimulant around the globe. More than 150 million people in the United States drink coffee daily, with an average intake of 2 cups (which contains about 280 mg of caffeine).

Caffeine results in the release of excitatory neurotransmitters. Caffeine may increase energy expenditure and has been associated with reduced body mass. Studies have observed lower body mass index (BMI) in coffee consumers, compared with individuals who don’t consume coffee. Coffee may reduce appetite and dietary intake.

Greek researchers at Harokopio University, Athens, conducted a cross-over study to evaluate the effects of caffeinated coffee on appetite and dietary intake (Obesity 2013;21:1127-32). Sixteen normal-weight and 17 overweight/obese habitual coffee consumers (at least 1 cup of coffee/day) were enrolled. Each participant took part in three trials at least 1 week apart. Participants were required to abstain from caffeine for 24 hours and then reported to the lab to consume a breakfast and 200 mL of one of three experimental beverages: instant coffee with 3 mg caffeine/kg body weight (Coffee 3); instant coffee with 6 mg caffeine/kg (Coffee 6); or water. Participants had to consume the breakfast and the beverage within 5 minutes.

During a 3-hour period following beverage consumption, appetite feelings and participants’ dietary intake the day before the experiment were assessed. After this 3-hour period, participants were offered an ad libitum lunch buffet. The following day, participants reported by telephone their food and fluid intake for the rest of the experiment day.

Normal-weight participants consumed comparable energy in the ad libitum meal and in their total daily intake in the three interventions. However, among overweight/obese individuals, Coffee 6 resulted in significantly reduced energy intake during the ad libitum meal, compared with Coffee 3, and in significantly reduced total day energy intake, compared with both water and Coffee 3.

Doses used in this study for participants were somewhat staggering. The average caffeine content of the beverage in the Coffee 6 group was 526 mg. This is the caffeine content of roughly four 8-ounce cups of brewed coffee. The authors acknowledged that the Coffee 6 beverage was not easily consumed by "most of the volunteers."

We need to be cautious about the use of this dosing in the clinical setting. But as part of comprehensive weight-management strategy, caffeinated coffee may be helpful for reducing energy intake.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no conflicts of interest.

Two-thirds of U.S. adults currently consume alcohol, according to the National Health Interview Survey. While most are infrequent or light drinkers, 8% are problem drinkers (more than 14 drinks per week for men and more than 7 drinks per week for women).

Alcohol consumption is the second-leading cause of preventable death and disability in the United States. Annually, excessive alcohol consumption costs us almost a quarter of a trillion dollars in lost productivity, health care, law enforcement, and motor vehicle collisions.

Alcoholism is a relapsing and remitting disease characterized by psychosocial impairment and drug craving and withdrawal. Challenged by access inequalities to formal treatment services, few alcoholics, when interacting with the medical setting for other reasons, are offered or receive treatment. Some patients may be open to receiving treatment by primary care providers, but few drugs are available (naltrexone, acamprosate, and disulfiram). Clinicians may be unconvinced of their efficacy or uncomfortable with their use.

Gabapentin is an antiepileptic used commonly in primary care settings, mostly for neuropathic pain. Gabapentin is well tolerated, with a favorable pharmacokinetic profile and a broad therapeutic index. Preclinical data suggest that gabapentin normalizes stress-induced GABA (gamma-aminobutyric acid) activation associated with alcohol use disorder. Human data suggest that gabapentin reduces alcohol craving and alcohol-associated sleep and mood problems.

Mason and colleagues published the results from a randomized controlled clinical trial evaluating the efficacy and safety of different doses of gabapentin for increasing alcohol abstinence and reducing heavy drinking, insomnia, dysphoria, and craving. Potential participants were eligible for enrollment if they were aged 18 years or older, met criteria for alcohol dependence, and were recently abstinent from alcohol (at least 3 days). Participants were randomized to gabapentin 900 mg/day, gabapentin 1,800 mg/day, or placebo. Treatment was received for 12 weeks with titration and tapering (JAMA Intern. Med. 2014;174:70-7).

A total of 150 patients were randomized, and the groups were similar at baseline. Abstinence rates were 17%, 11.1%, and 4.1% in the 1,800-mg, 900-mg, and placebo groups (P = .04 for linear dose effect), respectively. The no-heavy-drinking rates were 44.7%, 29.6%, and 22.5% (P = .02 for linear dose effect). A dose effect was also observed for reductions in mood disturbance, sleep problems, and craving. No serious adverse events were reported.

We need to try to meet patients where they are. Patients should be directed to alcohol treatment services if they are willing to go. In my experience, many of them are not. In these cases, recommending an Alcoholics Anonymous group, trying gabapentin, and following them up in a clinic is a harm-reduction strategy worth trying.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no conflicts of interest.

Two-thirds of U.S. adults currently consume alcohol, according to the National Health Interview Survey. While most are infrequent or light drinkers, 8% are problem drinkers (more than 14 drinks per week for men and more than 7 drinks per week for women).

Alcohol consumption is the second-leading cause of preventable death and disability in the United States. Annually, excessive alcohol consumption costs us almost a quarter of a trillion dollars in lost productivity, health care, law enforcement, and motor vehicle collisions.

Alcoholism is a relapsing and remitting disease characterized by psychosocial impairment and drug craving and withdrawal. Challenged by access inequalities to formal treatment services, few alcoholics, when interacting with the medical setting for other reasons, are offered or receive treatment. Some patients may be open to receiving treatment by primary care providers, but few drugs are available (naltrexone, acamprosate, and disulfiram). Clinicians may be unconvinced of their efficacy or uncomfortable with their use.

Gabapentin is an antiepileptic used commonly in primary care settings, mostly for neuropathic pain. Gabapentin is well tolerated, with a favorable pharmacokinetic profile and a broad therapeutic index. Preclinical data suggest that gabapentin normalizes stress-induced GABA (gamma-aminobutyric acid) activation associated with alcohol use disorder. Human data suggest that gabapentin reduces alcohol craving and alcohol-associated sleep and mood problems.

Mason and colleagues published the results from a randomized controlled clinical trial evaluating the efficacy and safety of different doses of gabapentin for increasing alcohol abstinence and reducing heavy drinking, insomnia, dysphoria, and craving. Potential participants were eligible for enrollment if they were aged 18 years or older, met criteria for alcohol dependence, and were recently abstinent from alcohol (at least 3 days). Participants were randomized to gabapentin 900 mg/day, gabapentin 1,800 mg/day, or placebo. Treatment was received for 12 weeks with titration and tapering (JAMA Intern. Med. 2014;174:70-7).

A total of 150 patients were randomized, and the groups were similar at baseline. Abstinence rates were 17%, 11.1%, and 4.1% in the 1,800-mg, 900-mg, and placebo groups (P = .04 for linear dose effect), respectively. The no-heavy-drinking rates were 44.7%, 29.6%, and 22.5% (P = .02 for linear dose effect). A dose effect was also observed for reductions in mood disturbance, sleep problems, and craving. No serious adverse events were reported.

We need to try to meet patients where they are. Patients should be directed to alcohol treatment services if they are willing to go. In my experience, many of them are not. In these cases, recommending an Alcoholics Anonymous group, trying gabapentin, and following them up in a clinic is a harm-reduction strategy worth trying.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no conflicts of interest.

Two-thirds of U.S. adults currently consume alcohol, according to the National Health Interview Survey. While most are infrequent or light drinkers, 8% are problem drinkers (more than 14 drinks per week for men and more than 7 drinks per week for women).

Alcohol consumption is the second-leading cause of preventable death and disability in the United States. Annually, excessive alcohol consumption costs us almost a quarter of a trillion dollars in lost productivity, health care, law enforcement, and motor vehicle collisions.

Alcoholism is a relapsing and remitting disease characterized by psychosocial impairment and drug craving and withdrawal. Challenged by access inequalities to formal treatment services, few alcoholics, when interacting with the medical setting for other reasons, are offered or receive treatment. Some patients may be open to receiving treatment by primary care providers, but few drugs are available (naltrexone, acamprosate, and disulfiram). Clinicians may be unconvinced of their efficacy or uncomfortable with their use.

Gabapentin is an antiepileptic used commonly in primary care settings, mostly for neuropathic pain. Gabapentin is well tolerated, with a favorable pharmacokinetic profile and a broad therapeutic index. Preclinical data suggest that gabapentin normalizes stress-induced GABA (gamma-aminobutyric acid) activation associated with alcohol use disorder. Human data suggest that gabapentin reduces alcohol craving and alcohol-associated sleep and mood problems.

Mason and colleagues published the results from a randomized controlled clinical trial evaluating the efficacy and safety of different doses of gabapentin for increasing alcohol abstinence and reducing heavy drinking, insomnia, dysphoria, and craving. Potential participants were eligible for enrollment if they were aged 18 years or older, met criteria for alcohol dependence, and were recently abstinent from alcohol (at least 3 days). Participants were randomized to gabapentin 900 mg/day, gabapentin 1,800 mg/day, or placebo. Treatment was received for 12 weeks with titration and tapering (JAMA Intern. Med. 2014;174:70-7).

A total of 150 patients were randomized, and the groups were similar at baseline. Abstinence rates were 17%, 11.1%, and 4.1% in the 1,800-mg, 900-mg, and placebo groups (P = .04 for linear dose effect), respectively. The no-heavy-drinking rates were 44.7%, 29.6%, and 22.5% (P = .02 for linear dose effect). A dose effect was also observed for reductions in mood disturbance, sleep problems, and craving. No serious adverse events were reported.

We need to try to meet patients where they are. Patients should be directed to alcohol treatment services if they are willing to go. In my experience, many of them are not. In these cases, recommending an Alcoholics Anonymous group, trying gabapentin, and following them up in a clinic is a harm-reduction strategy worth trying.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no conflicts of interest.

Female pattern hair loss, which affects over 21 million women in the United States, is a nonscarring hair loss primarily involving the frontal and vertex scalp. FPHS causes women significant emotional and psychological distress. We see, and will continue to see, a lot of these cases in primary care. If left untreated or unaddressed, FPHL results in a slow, progressive decline in the density of scalp hair.

FPHL is characterized by the production of shorter and finer hairs and shortening of the growth phase of hair follicles. One may find it important to rule out secondary causes of hair loss, such as hyperandrogenism. So after excluding secondary causes, what are the best treatment options for treatment?

Researchers conducted a systematic review (Cochrane Database Syst. Rev. 2012 May, CD007628 [doi:10.1002/14651858.CD007628.pub3]) assessing the effectiveness of interventions for female pattern hair loss. Studies were included if they compared any type of monotherapy or combination therapy to treat FPHL. Studies evaluating treatments in women with increased circulating androgens (such as polycystic ovarian syndrome) were included. Primary outcomes included self-reported hair regrowth, quality of life, and adverse effects.

The Cochrane review included 22 studies that enrolled a total of 2,349 subjects. Ten studies evaluated minoxidil, four evaluated finasteride, two cyproterone acetate, and two flutamide. A variety of other exotic interventions was evaluated, including topical melatonin-alcohol solution, adenosine lotion, and pulsed electrostatic field.

The best data continue to exist for minoxidil. "Pooled data from 4 studies indicated that a greater proportion of participants (121/488) treated with minoxidil reported a moderate increase in their hair regrowth when compared with placebo (64/476) (risk ratio, 1.86; 95% confidence interval [CI], 1.42 to 2.43). In 7 studies, there was an important increase of 13.28 in total hair count per cm² in the minoxidil group compared to the placebo group (95% CI, 10.89 to 15.68). There was no difference in the number of adverse events in the twice daily minoxidil and placebo intervention groups, with the exception of a reported increase of adverse events (additional hair growth on areas other than the scalp) with minoxidil (5%) twice daily," according to the Cochrane report.

Other promising agents might be octyl nicotinate (0.5%), myristyl nicotinate (5%), and flutamide. Fulvestrant, adenosine, pulsed electrostatic field, and estradiol valerate are ineffective.

Minoxidil it is. It may be important to remind patients that 2% twice daily may be as effective and safe as 5% once a day.

Dr. Ebbert is professor of medicine and a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no conflicts of interest.

Female pattern hair loss, which affects over 21 million women in the United States, is a nonscarring hair loss primarily involving the frontal and vertex scalp. FPHS causes women significant emotional and psychological distress. We see, and will continue to see, a lot of these cases in primary care. If left untreated or unaddressed, FPHL results in a slow, progressive decline in the density of scalp hair.

FPHL is characterized by the production of shorter and finer hairs and shortening of the growth phase of hair follicles. One may find it important to rule out secondary causes of hair loss, such as hyperandrogenism. So after excluding secondary causes, what are the best treatment options for treatment?

Researchers conducted a systematic review (Cochrane Database Syst. Rev. 2012 May, CD007628 [doi:10.1002/14651858.CD007628.pub3]) assessing the effectiveness of interventions for female pattern hair loss. Studies were included if they compared any type of monotherapy or combination therapy to treat FPHL. Studies evaluating treatments in women with increased circulating androgens (such as polycystic ovarian syndrome) were included. Primary outcomes included self-reported hair regrowth, quality of life, and adverse effects.

The Cochrane review included 22 studies that enrolled a total of 2,349 subjects. Ten studies evaluated minoxidil, four evaluated finasteride, two cyproterone acetate, and two flutamide. A variety of other exotic interventions was evaluated, including topical melatonin-alcohol solution, adenosine lotion, and pulsed electrostatic field.

The best data continue to exist for minoxidil. "Pooled data from 4 studies indicated that a greater proportion of participants (121/488) treated with minoxidil reported a moderate increase in their hair regrowth when compared with placebo (64/476) (risk ratio, 1.86; 95% confidence interval [CI], 1.42 to 2.43). In 7 studies, there was an important increase of 13.28 in total hair count per cm² in the minoxidil group compared to the placebo group (95% CI, 10.89 to 15.68). There was no difference in the number of adverse events in the twice daily minoxidil and placebo intervention groups, with the exception of a reported increase of adverse events (additional hair growth on areas other than the scalp) with minoxidil (5%) twice daily," according to the Cochrane report.

Other promising agents might be octyl nicotinate (0.5%), myristyl nicotinate (5%), and flutamide. Fulvestrant, adenosine, pulsed electrostatic field, and estradiol valerate are ineffective.

Minoxidil it is. It may be important to remind patients that 2% twice daily may be as effective and safe as 5% once a day.

Dr. Ebbert is professor of medicine and a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no conflicts of interest.

Female pattern hair loss, which affects over 21 million women in the United States, is a nonscarring hair loss primarily involving the frontal and vertex scalp. FPHS causes women significant emotional and psychological distress. We see, and will continue to see, a lot of these cases in primary care. If left untreated or unaddressed, FPHL results in a slow, progressive decline in the density of scalp hair.

FPHL is characterized by the production of shorter and finer hairs and shortening of the growth phase of hair follicles. One may find it important to rule out secondary causes of hair loss, such as hyperandrogenism. So after excluding secondary causes, what are the best treatment options for treatment?

Researchers conducted a systematic review (Cochrane Database Syst. Rev. 2012 May, CD007628 [doi:10.1002/14651858.CD007628.pub3]) assessing the effectiveness of interventions for female pattern hair loss. Studies were included if they compared any type of monotherapy or combination therapy to treat FPHL. Studies evaluating treatments in women with increased circulating androgens (such as polycystic ovarian syndrome) were included. Primary outcomes included self-reported hair regrowth, quality of life, and adverse effects.

The Cochrane review included 22 studies that enrolled a total of 2,349 subjects. Ten studies evaluated minoxidil, four evaluated finasteride, two cyproterone acetate, and two flutamide. A variety of other exotic interventions was evaluated, including topical melatonin-alcohol solution, adenosine lotion, and pulsed electrostatic field.

The best data continue to exist for minoxidil. "Pooled data from 4 studies indicated that a greater proportion of participants (121/488) treated with minoxidil reported a moderate increase in their hair regrowth when compared with placebo (64/476) (risk ratio, 1.86; 95% confidence interval [CI], 1.42 to 2.43). In 7 studies, there was an important increase of 13.28 in total hair count per cm² in the minoxidil group compared to the placebo group (95% CI, 10.89 to 15.68). There was no difference in the number of adverse events in the twice daily minoxidil and placebo intervention groups, with the exception of a reported increase of adverse events (additional hair growth on areas other than the scalp) with minoxidil (5%) twice daily," according to the Cochrane report.

Other promising agents might be octyl nicotinate (0.5%), myristyl nicotinate (5%), and flutamide. Fulvestrant, adenosine, pulsed electrostatic field, and estradiol valerate are ineffective.

Minoxidil it is. It may be important to remind patients that 2% twice daily may be as effective and safe as 5% once a day.

Dr. Ebbert is professor of medicine and a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no conflicts of interest.

Actinic keratosis, or solar keratosis, results from the proliferation of atypical epidermal keratinocytes. When we can take the time to do a skin examination, we all see a lot of them especially among our older and middle-aged sun worshippers and sunscreen agnostics. My traditional approach, for better or for worse, has been to acquire the liquid nitrogen bottle on the floor and go to work. But my recent review of guidelines prepared on behalf of the British Association of Dermatologists and published several years ago have prompted me to open my eyes a bit more to other possible approaches.

Reassuringly, the likelihood of progression of an AK to squamous cell carcinoma (SCC) is low. Estimates from a large U.S. cohort revealed a rate of transformation to invasive or in situ SCC of 0.6% after 1 year and 2.6 % after 4 years. But we have to remember that although the progression rate is low, 60% of SCC arise from AKs.

The AK guideline authors synthesized and graded published evidence. Topical therapies receiving an "A grade" (i.e., good evidence) included no therapy or emollients for mild AKs and 5-fluorouracil. Therapies with a "B grade" (i.e., fair evidence) include diclofenac gel and imiquimod.

Other treatments include cryosurgery (A grade) and photodynamic therapy (B grade). We do a lot of cryotherapy in our practice but patients need to be informed of the scarring and possible hyper- or hypopigmentation that can occur with treatment. Photodynamic therapy will, in most cases, be administered by dermatologists.

According to a recent paper in the Drugs and Therapeutic Bulletin, patients should be referred to a dermatologist if there is diagnostic uncertainty, concerns about malignancy, treatment failure or management concerns, or if the patient is at high risk (e.g., organ transplant recipients, multiple large lesions, or previous SCC).

The guideline authors suggest that most patients can be evaluated and treated in the primary care setting. They go on to say that there is inadequate evidence to justify treatment of all AKs in an attempt to prevent malignant transformation. While reassuring, this requires us to consider all possible treatment approaches. One liquid nitrogen bottle does not fit all.

Dr. Ebbert is professor of medicine and general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no conflicts of interest.

Actinic keratosis, or solar keratosis, results from the proliferation of atypical epidermal keratinocytes. When we can take the time to do a skin examination, we all see a lot of them especially among our older and middle-aged sun worshippers and sunscreen agnostics. My traditional approach, for better or for worse, has been to acquire the liquid nitrogen bottle on the floor and go to work. But my recent review of guidelines prepared on behalf of the British Association of Dermatologists and published several years ago have prompted me to open my eyes a bit more to other possible approaches.

Reassuringly, the likelihood of progression of an AK to squamous cell carcinoma (SCC) is low. Estimates from a large U.S. cohort revealed a rate of transformation to invasive or in situ SCC of 0.6% after 1 year and 2.6 % after 4 years. But we have to remember that although the progression rate is low, 60% of SCC arise from AKs.

The AK guideline authors synthesized and graded published evidence. Topical therapies receiving an "A grade" (i.e., good evidence) included no therapy or emollients for mild AKs and 5-fluorouracil. Therapies with a "B grade" (i.e., fair evidence) include diclofenac gel and imiquimod.

Other treatments include cryosurgery (A grade) and photodynamic therapy (B grade). We do a lot of cryotherapy in our practice but patients need to be informed of the scarring and possible hyper- or hypopigmentation that can occur with treatment. Photodynamic therapy will, in most cases, be administered by dermatologists.

According to a recent paper in the Drugs and Therapeutic Bulletin, patients should be referred to a dermatologist if there is diagnostic uncertainty, concerns about malignancy, treatment failure or management concerns, or if the patient is at high risk (e.g., organ transplant recipients, multiple large lesions, or previous SCC).

The guideline authors suggest that most patients can be evaluated and treated in the primary care setting. They go on to say that there is inadequate evidence to justify treatment of all AKs in an attempt to prevent malignant transformation. While reassuring, this requires us to consider all possible treatment approaches. One liquid nitrogen bottle does not fit all.

Dr. Ebbert is professor of medicine and general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no conflicts of interest.

Actinic keratosis, or solar keratosis, results from the proliferation of atypical epidermal keratinocytes. When we can take the time to do a skin examination, we all see a lot of them especially among our older and middle-aged sun worshippers and sunscreen agnostics. My traditional approach, for better or for worse, has been to acquire the liquid nitrogen bottle on the floor and go to work. But my recent review of guidelines prepared on behalf of the British Association of Dermatologists and published several years ago have prompted me to open my eyes a bit more to other possible approaches.

Reassuringly, the likelihood of progression of an AK to squamous cell carcinoma (SCC) is low. Estimates from a large U.S. cohort revealed a rate of transformation to invasive or in situ SCC of 0.6% after 1 year and 2.6 % after 4 years. But we have to remember that although the progression rate is low, 60% of SCC arise from AKs.

The AK guideline authors synthesized and graded published evidence. Topical therapies receiving an "A grade" (i.e., good evidence) included no therapy or emollients for mild AKs and 5-fluorouracil. Therapies with a "B grade" (i.e., fair evidence) include diclofenac gel and imiquimod.

Other treatments include cryosurgery (A grade) and photodynamic therapy (B grade). We do a lot of cryotherapy in our practice but patients need to be informed of the scarring and possible hyper- or hypopigmentation that can occur with treatment. Photodynamic therapy will, in most cases, be administered by dermatologists.

According to a recent paper in the Drugs and Therapeutic Bulletin, patients should be referred to a dermatologist if there is diagnostic uncertainty, concerns about malignancy, treatment failure or management concerns, or if the patient is at high risk (e.g., organ transplant recipients, multiple large lesions, or previous SCC).

The guideline authors suggest that most patients can be evaluated and treated in the primary care setting. They go on to say that there is inadequate evidence to justify treatment of all AKs in an attempt to prevent malignant transformation. While reassuring, this requires us to consider all possible treatment approaches. One liquid nitrogen bottle does not fit all.

Dr. Ebbert is professor of medicine and general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no conflicts of interest.