Kate Johnson

COPENHAGEN — Diabetologists should pay particular attention to prediabetes when considering their patients' cardiovascular health, according to joint guidelines on diabetes and cardiovascular disease unveiled at the annual meeting of the European Association for the Study of Diabetes.

“The negative impact of dysglycemia is apparent before the onset of diabetes,” said Dr. Eberhard Standl of the International Diabetes Research Unit, Munich, and vice president of the association (EASD). “There are signs of diastolic dysfunction with impaired glucose tolerance before the development of overt diabetes.”

An executive summary of the joint guidelines, “Diabetes, Prediabetes, and Cardiovascular Disease,” which was drafted by the EASD and the European Society of Cardiology (ESC), is expected to be published simultaneously in the official journals of both organizations—the European Heart Journal and Diabetologia—in November. The full 200-page text of the guidelines, which includes 72 recommendations, will appear in the European Journal of Cardiovascular Prevention and Rehabilitation, as well as on the Web sites of both the EASD and the ESC, Dr. Standl said at a press conference that was held during the EASD meeting. Pocket guidelines also are being prepared.

The guidelines reflect a growing recognition within both fields of the common co-occurrence of diabetes and cardiovascular disease. “Every diabetologist sees cardiovascular disease, and every cardiologist sees diabetes,” Dr. Standl said.

“Between two-thirds and three-quarters of people with diabetes eventually die of a cardiovascular complication, and approximately two-thirds of patients seen for cardiac problems have diabetes, known or unknown,” added Dr. Ele Ferrannini, of the University of Pisa, Italy, and the president of EASD.

An algorithm included in the document recommends that diabetologists assess cardiovascular health in all their patients with known or unknown cardiovascular disease, using electrocardiography, echocardiography, and exercise testing. Patients with positive findings should be referred to a cardiologist for follow-up.

Similarly, cardiologists are advised to assess diabetic status in their patients using the oral glucose tolerance test (OGTT). While testing is not recommended in all cardiology patients, the decision about which cardiology patients to test can be made using the Finnish Diabetes Risk Score (FINDRISC), said Dr. Standl.

According to the EASD/ESC document, the oral glucose tolerance test is “the best method to diagnose previously unknown diabetes or prediabetes,” compared with fasting glucose measurements. However, a spokesman with the American Diabetes Association (ADA) said although the OGTT recommendation will mean greater identification of diabetes cases, it raises the risk of noncompliance. “The test is somewhat cumbersome and adds to the burden of so many things that need to be done with these patients,” Dr. Vivian Fonseca said in an interview. Dr. Fonseca, professor of medicine at Tulane University, New Orleans, is drafting similar joint guidelines on behalf of the ADA in cooperation with the American Heart Association.

Approximately two-thirds of patients seen for cardiac problems have diabetes, known or unknown. DR. FERRANNINI

COPENHAGEN — Diabetologists should pay particular attention to prediabetes when considering their patients' cardiovascular health, according to joint guidelines on diabetes and cardiovascular disease unveiled at the annual meeting of the European Association for the Study of Diabetes.

“The negative impact of dysglycemia is apparent before the onset of diabetes,” said Dr. Eberhard Standl of the International Diabetes Research Unit, Munich, and vice president of the association (EASD). “There are signs of diastolic dysfunction with impaired glucose tolerance before the development of overt diabetes.”

An executive summary of the joint guidelines, “Diabetes, Prediabetes, and Cardiovascular Disease,” which was drafted by the EASD and the European Society of Cardiology (ESC), is expected to be published simultaneously in the official journals of both organizations—the European Heart Journal and Diabetologia—in November. The full 200-page text of the guidelines, which includes 72 recommendations, will appear in the European Journal of Cardiovascular Prevention and Rehabilitation, as well as on the Web sites of both the EASD and the ESC, Dr. Standl said at a press conference that was held during the EASD meeting. Pocket guidelines also are being prepared.

The guidelines reflect a growing recognition within both fields of the common co-occurrence of diabetes and cardiovascular disease. “Every diabetologist sees cardiovascular disease, and every cardiologist sees diabetes,” Dr. Standl said.

“Between two-thirds and three-quarters of people with diabetes eventually die of a cardiovascular complication, and approximately two-thirds of patients seen for cardiac problems have diabetes, known or unknown,” added Dr. Ele Ferrannini, of the University of Pisa, Italy, and the president of EASD.

An algorithm included in the document recommends that diabetologists assess cardiovascular health in all their patients with known or unknown cardiovascular disease, using electrocardiography, echocardiography, and exercise testing. Patients with positive findings should be referred to a cardiologist for follow-up.

Similarly, cardiologists are advised to assess diabetic status in their patients using the oral glucose tolerance test (OGTT). While testing is not recommended in all cardiology patients, the decision about which cardiology patients to test can be made using the Finnish Diabetes Risk Score (FINDRISC), said Dr. Standl.

According to the EASD/ESC document, the oral glucose tolerance test is “the best method to diagnose previously unknown diabetes or prediabetes,” compared with fasting glucose measurements. However, a spokesman with the American Diabetes Association (ADA) said although the OGTT recommendation will mean greater identification of diabetes cases, it raises the risk of noncompliance. “The test is somewhat cumbersome and adds to the burden of so many things that need to be done with these patients,” Dr. Vivian Fonseca said in an interview. Dr. Fonseca, professor of medicine at Tulane University, New Orleans, is drafting similar joint guidelines on behalf of the ADA in cooperation with the American Heart Association.

Approximately two-thirds of patients seen for cardiac problems have diabetes, known or unknown. DR. FERRANNINI

COPENHAGEN — Diabetologists should pay particular attention to prediabetes when considering their patients' cardiovascular health, according to joint guidelines on diabetes and cardiovascular disease unveiled at the annual meeting of the European Association for the Study of Diabetes.

“The negative impact of dysglycemia is apparent before the onset of diabetes,” said Dr. Eberhard Standl of the International Diabetes Research Unit, Munich, and vice president of the association (EASD). “There are signs of diastolic dysfunction with impaired glucose tolerance before the development of overt diabetes.”

An executive summary of the joint guidelines, “Diabetes, Prediabetes, and Cardiovascular Disease,” which was drafted by the EASD and the European Society of Cardiology (ESC), is expected to be published simultaneously in the official journals of both organizations—the European Heart Journal and Diabetologia—in November. The full 200-page text of the guidelines, which includes 72 recommendations, will appear in the European Journal of Cardiovascular Prevention and Rehabilitation, as well as on the Web sites of both the EASD and the ESC, Dr. Standl said at a press conference that was held during the EASD meeting. Pocket guidelines also are being prepared.

The guidelines reflect a growing recognition within both fields of the common co-occurrence of diabetes and cardiovascular disease. “Every diabetologist sees cardiovascular disease, and every cardiologist sees diabetes,” Dr. Standl said.

“Between two-thirds and three-quarters of people with diabetes eventually die of a cardiovascular complication, and approximately two-thirds of patients seen for cardiac problems have diabetes, known or unknown,” added Dr. Ele Ferrannini, of the University of Pisa, Italy, and the president of EASD.

An algorithm included in the document recommends that diabetologists assess cardiovascular health in all their patients with known or unknown cardiovascular disease, using electrocardiography, echocardiography, and exercise testing. Patients with positive findings should be referred to a cardiologist for follow-up.

Similarly, cardiologists are advised to assess diabetic status in their patients using the oral glucose tolerance test (OGTT). While testing is not recommended in all cardiology patients, the decision about which cardiology patients to test can be made using the Finnish Diabetes Risk Score (FINDRISC), said Dr. Standl.

According to the EASD/ESC document, the oral glucose tolerance test is “the best method to diagnose previously unknown diabetes or prediabetes,” compared with fasting glucose measurements. However, a spokesman with the American Diabetes Association (ADA) said although the OGTT recommendation will mean greater identification of diabetes cases, it raises the risk of noncompliance. “The test is somewhat cumbersome and adds to the burden of so many things that need to be done with these patients,” Dr. Vivian Fonseca said in an interview. Dr. Fonseca, professor of medicine at Tulane University, New Orleans, is drafting similar joint guidelines on behalf of the ADA in cooperation with the American Heart Association.

Approximately two-thirds of patients seen for cardiac problems have diabetes, known or unknown. DR. FERRANNINI

COPENHAGEN — The European Association for the Study of Diabetes voiced its support for obtaining a United Nations resolution on diabetes aimed at preventing, slowing the progression of, and ultimately identifying a cure for the disease.

“Diabetes is killing more people on this planet than infectious diseases—including HIV/AIDS, infant mortality, and deaths from hunger put together. Politicians have to act now,” said Dr. Jørn Nerup of the University of Copenhagen and the Steno Diabetes Center in Gentofte, Denmark, at the annual meeting of the European Association for the Study of Diabetes (EASD). Dr. Nerup is a spokesperson for EASD.

The “Unite for Diabetes” campaign for a U.N. resolution on diabetes was launched last February by the International Diabetes Federation (IDF), which represents 192 national diabetes associations worldwide. The IDF aims to get the resolution passed by the U.N. General Assembly by the end of 2007.

Among other things, the resolution would stipulate that all U.N. member countries implement national policies for the care and prevention of diabetes, as well as fund research on the disease.

“The global health catastrophe [of diabetes] is not coming; it's here,” said Dr. Martin Silink of the Institute of Endocrinology and Diabetes in Westmead, Australia, and president-elect of the IDF.

He said it is estimated that there will be 380 million people worldwide with diabetes by the year 2025, with a “crippling” impact on health care and the economy.

No major European countries or the United States have yet formally backed the IDF campaign, but all have been approached and are considering adding their support, Dr. Silink said. He added that he expects the European countries to come up with a general European Union position. “I am aware this discussion is going on,” he said in an interview. In total, 30 countries have expressed their “high level,” if not formal, support, he noted, including formal commitments from Slovenia, Uzbekistan, Ukraine, and Georgia. “The more developed a country's health care system, the more carefully they will read and consider the wording,” Dr. Silink said.

“Lots of cases of diabetes can be prevented; complications from diabetes can often be prevented; and, even if there are complications, they can be effectively treated early. The tools are there, but the mind-set is not,” Dr. Nerup said.

COPENHAGEN — The European Association for the Study of Diabetes voiced its support for obtaining a United Nations resolution on diabetes aimed at preventing, slowing the progression of, and ultimately identifying a cure for the disease.

“Diabetes is killing more people on this planet than infectious diseases—including HIV/AIDS, infant mortality, and deaths from hunger put together. Politicians have to act now,” said Dr. Jørn Nerup of the University of Copenhagen and the Steno Diabetes Center in Gentofte, Denmark, at the annual meeting of the European Association for the Study of Diabetes (EASD). Dr. Nerup is a spokesperson for EASD.

The “Unite for Diabetes” campaign for a U.N. resolution on diabetes was launched last February by the International Diabetes Federation (IDF), which represents 192 national diabetes associations worldwide. The IDF aims to get the resolution passed by the U.N. General Assembly by the end of 2007.

Among other things, the resolution would stipulate that all U.N. member countries implement national policies for the care and prevention of diabetes, as well as fund research on the disease.

“The global health catastrophe [of diabetes] is not coming; it's here,” said Dr. Martin Silink of the Institute of Endocrinology and Diabetes in Westmead, Australia, and president-elect of the IDF.

He said it is estimated that there will be 380 million people worldwide with diabetes by the year 2025, with a “crippling” impact on health care and the economy.

No major European countries or the United States have yet formally backed the IDF campaign, but all have been approached and are considering adding their support, Dr. Silink said. He added that he expects the European countries to come up with a general European Union position. “I am aware this discussion is going on,” he said in an interview. In total, 30 countries have expressed their “high level,” if not formal, support, he noted, including formal commitments from Slovenia, Uzbekistan, Ukraine, and Georgia. “The more developed a country's health care system, the more carefully they will read and consider the wording,” Dr. Silink said.

“Lots of cases of diabetes can be prevented; complications from diabetes can often be prevented; and, even if there are complications, they can be effectively treated early. The tools are there, but the mind-set is not,” Dr. Nerup said.

COPENHAGEN — The European Association for the Study of Diabetes voiced its support for obtaining a United Nations resolution on diabetes aimed at preventing, slowing the progression of, and ultimately identifying a cure for the disease.

“Diabetes is killing more people on this planet than infectious diseases—including HIV/AIDS, infant mortality, and deaths from hunger put together. Politicians have to act now,” said Dr. Jørn Nerup of the University of Copenhagen and the Steno Diabetes Center in Gentofte, Denmark, at the annual meeting of the European Association for the Study of Diabetes (EASD). Dr. Nerup is a spokesperson for EASD.

The “Unite for Diabetes” campaign for a U.N. resolution on diabetes was launched last February by the International Diabetes Federation (IDF), which represents 192 national diabetes associations worldwide. The IDF aims to get the resolution passed by the U.N. General Assembly by the end of 2007.

Among other things, the resolution would stipulate that all U.N. member countries implement national policies for the care and prevention of diabetes, as well as fund research on the disease.

“The global health catastrophe [of diabetes] is not coming; it's here,” said Dr. Martin Silink of the Institute of Endocrinology and Diabetes in Westmead, Australia, and president-elect of the IDF.

He said it is estimated that there will be 380 million people worldwide with diabetes by the year 2025, with a “crippling” impact on health care and the economy.

No major European countries or the United States have yet formally backed the IDF campaign, but all have been approached and are considering adding their support, Dr. Silink said. He added that he expects the European countries to come up with a general European Union position. “I am aware this discussion is going on,” he said in an interview. In total, 30 countries have expressed their “high level,” if not formal, support, he noted, including formal commitments from Slovenia, Uzbekistan, Ukraine, and Georgia. “The more developed a country's health care system, the more carefully they will read and consider the wording,” Dr. Silink said.

“Lots of cases of diabetes can be prevented; complications from diabetes can often be prevented; and, even if there are complications, they can be effectively treated early. The tools are there, but the mind-set is not,” Dr. Nerup said.

COPENHAGEN — Type 1 diabetes, traditionally considered a disease of wasting, is now frequently diagnosed in children who are overweight, according to a new study. That means determining which pediatric patient has type 1 diabetes and which has type 2 is getting harder, according to Dr. Ingrid M. Libman, of the department of pediatric endocrinology at the University of Pittsburgh.

“The problem now is that the lines are blurred between what we thought was clearly defined as type 1 and 2 diabetes,” said Dr. Libman in an interview. “The distinction can no longer be made based on phenotype.”

Data she presented at the annual meeting of the European Association for the Study of Diabetes showed that over 23 years of observation (1979–2002), the overall prevalence of overweight and obesity in children with newly diagnosed insulin-treated diabetes (traditionally considered type 1 disease) has more than tripled—doubling in African American children (from 30% to 62%) and quadrupling in white children (from 6% to 26%).

“In some cases we now have no clear way of distinguishing what kind of diabetes someone has based on how they look,” she said, adding that acanthosis nigricans, traditionally associated with type 2 diabetes, is now commonly found in overweight patients with type 1 disease as well.

Subjects diagnosed in period I (1979–1989) and period II (1990–98) were tested for beta-cell autoimmunity. In those with autoimmune positivity (known as diabetes type 1a), there was a similar increase in the prevalence of obesity between periods I and II: 6% to 21% among whites and 22% to 43% among African Americans. For period III (1999–2002), autoimmune antibodies are still being measured, she said. Autoimmune-negative subjects in the study may have had type 2 diabetes or type 1b—an insulin-dependent, nonautoimmune form of the disorder.

Dr. Libman said physicians might frequently face a new presentation of diabetes in which patients may actually have a confusing combination of characteristics.

“What we argue is that some kids may have characteristics of both type 1 and type 2 disease processes going on. If they are autoimmune positive, they have type 1a diabetes; however, if they are also overweight and have acanthosis nigricans, you could argue that they may also be insulin resistant.”

While establishing a clear diagnosis may often seem essential to physicians, Dr. Libman said that in the end, it might not be so important.

“If the child is really sick, does it matter if they have type 1 or 2? You will need to treat them with insulin. If they are overweight, not sick, and diagnosed randomly, you can likely control their blood sugars with lifestyle and metformin. If their antibodies come back positive, it doesn't mean you should start insulin—but you may need to monitor them more carefully and you may have a lower threshold for starting it.”

Overweight in children may not only make them more susceptible to developing type 2 disease, but in those who are genetically susceptible, it may also increase their risk or accelerate the development of type 1 disease—the concept of “double diabetes,” she said.

COPENHAGEN — Type 1 diabetes, traditionally considered a disease of wasting, is now frequently diagnosed in children who are overweight, according to a new study. That means determining which pediatric patient has type 1 diabetes and which has type 2 is getting harder, according to Dr. Ingrid M. Libman, of the department of pediatric endocrinology at the University of Pittsburgh.

“The problem now is that the lines are blurred between what we thought was clearly defined as type 1 and 2 diabetes,” said Dr. Libman in an interview. “The distinction can no longer be made based on phenotype.”

Data she presented at the annual meeting of the European Association for the Study of Diabetes showed that over 23 years of observation (1979–2002), the overall prevalence of overweight and obesity in children with newly diagnosed insulin-treated diabetes (traditionally considered type 1 disease) has more than tripled—doubling in African American children (from 30% to 62%) and quadrupling in white children (from 6% to 26%).

“In some cases we now have no clear way of distinguishing what kind of diabetes someone has based on how they look,” she said, adding that acanthosis nigricans, traditionally associated with type 2 diabetes, is now commonly found in overweight patients with type 1 disease as well.

Subjects diagnosed in period I (1979–1989) and period II (1990–98) were tested for beta-cell autoimmunity. In those with autoimmune positivity (known as diabetes type 1a), there was a similar increase in the prevalence of obesity between periods I and II: 6% to 21% among whites and 22% to 43% among African Americans. For period III (1999–2002), autoimmune antibodies are still being measured, she said. Autoimmune-negative subjects in the study may have had type 2 diabetes or type 1b—an insulin-dependent, nonautoimmune form of the disorder.

Dr. Libman said physicians might frequently face a new presentation of diabetes in which patients may actually have a confusing combination of characteristics.

“What we argue is that some kids may have characteristics of both type 1 and type 2 disease processes going on. If they are autoimmune positive, they have type 1a diabetes; however, if they are also overweight and have acanthosis nigricans, you could argue that they may also be insulin resistant.”

While establishing a clear diagnosis may often seem essential to physicians, Dr. Libman said that in the end, it might not be so important.

“If the child is really sick, does it matter if they have type 1 or 2? You will need to treat them with insulin. If they are overweight, not sick, and diagnosed randomly, you can likely control their blood sugars with lifestyle and metformin. If their antibodies come back positive, it doesn't mean you should start insulin—but you may need to monitor them more carefully and you may have a lower threshold for starting it.”

Overweight in children may not only make them more susceptible to developing type 2 disease, but in those who are genetically susceptible, it may also increase their risk or accelerate the development of type 1 disease—the concept of “double diabetes,” she said.

COPENHAGEN — Type 1 diabetes, traditionally considered a disease of wasting, is now frequently diagnosed in children who are overweight, according to a new study. That means determining which pediatric patient has type 1 diabetes and which has type 2 is getting harder, according to Dr. Ingrid M. Libman, of the department of pediatric endocrinology at the University of Pittsburgh.

“The problem now is that the lines are blurred between what we thought was clearly defined as type 1 and 2 diabetes,” said Dr. Libman in an interview. “The distinction can no longer be made based on phenotype.”

Data she presented at the annual meeting of the European Association for the Study of Diabetes showed that over 23 years of observation (1979–2002), the overall prevalence of overweight and obesity in children with newly diagnosed insulin-treated diabetes (traditionally considered type 1 disease) has more than tripled—doubling in African American children (from 30% to 62%) and quadrupling in white children (from 6% to 26%).

“In some cases we now have no clear way of distinguishing what kind of diabetes someone has based on how they look,” she said, adding that acanthosis nigricans, traditionally associated with type 2 diabetes, is now commonly found in overweight patients with type 1 disease as well.

Subjects diagnosed in period I (1979–1989) and period II (1990–98) were tested for beta-cell autoimmunity. In those with autoimmune positivity (known as diabetes type 1a), there was a similar increase in the prevalence of obesity between periods I and II: 6% to 21% among whites and 22% to 43% among African Americans. For period III (1999–2002), autoimmune antibodies are still being measured, she said. Autoimmune-negative subjects in the study may have had type 2 diabetes or type 1b—an insulin-dependent, nonautoimmune form of the disorder.

Dr. Libman said physicians might frequently face a new presentation of diabetes in which patients may actually have a confusing combination of characteristics.

“What we argue is that some kids may have characteristics of both type 1 and type 2 disease processes going on. If they are autoimmune positive, they have type 1a diabetes; however, if they are also overweight and have acanthosis nigricans, you could argue that they may also be insulin resistant.”

While establishing a clear diagnosis may often seem essential to physicians, Dr. Libman said that in the end, it might not be so important.

“If the child is really sick, does it matter if they have type 1 or 2? You will need to treat them with insulin. If they are overweight, not sick, and diagnosed randomly, you can likely control their blood sugars with lifestyle and metformin. If their antibodies come back positive, it doesn't mean you should start insulin—but you may need to monitor them more carefully and you may have a lower threshold for starting it.”

Overweight in children may not only make them more susceptible to developing type 2 disease, but in those who are genetically susceptible, it may also increase their risk or accelerate the development of type 1 disease—the concept of “double diabetes,” she said.

A revision of the national pandemic influenza plan could help to remedy the current patchwork of state plans “that will not adequately detect and control” an influenza pandemic, according to a review by Scott D. Holmberg, Ph.D., and his colleagues at Research Triangle Institute International, Atlanta.

“The control of future pandemic and interpandemic influenza will necessarily rely on each individual state's plan to vaccinate persons and detect and contain this disease,” the investigators wrote (Emerg. Infect. Dis. 2006;12:1414–7). “The current national [Health and Human Services] pandemic influenza plan presents only a categorization and listing of steps rather than explicit direction for the states.”

The authors cite a “lack of clear guidance” at the federal level as one of the reasons for considerable disparity among the 49 states that have posted their plans for vaccination, early epidemic surveillance and detection, and containment of pandemic influenza (available online at www.cdc.gov/ncidod/EID/vol12no09/06-0369_appT1.htm

According to the review, all states agree on vaccination priority strategies as recommended by the Advisory Committee on Immunization Practices and the U.S. Department of Health and Human Services. “General agreement exists, explicit or implicit, to provide vaccination during a pandemic that is prioritized by those most likely to acquire, become ill, or die from pandemic influenza,” they noted.

In general, this means that the elderly, those with chronic diseases, and health care and infrastructure personnel will be vaccinated first; some states will include young children in this list. “We believe the estimate that such persons make up [about] 15%–20% of the population in any state is reasonable,” the researchers wrote, adding that this vaccination strategy is aimed at preventing deaths, not reducing transmission, since the latter would require much more vaccine than is currently available.

State plans are more variable regarding surveillance and detection, although they all plan to use the National Sentinel Physician Surveillance and the nationwide 122 Cities Mortality Reporting System. Neither system would likely detect a local outbreak of influenza within 2 weeks, the authors noted, but “to our knowledge, no health authority feels confident that earlier detection of influenza by 1–3 weeks would necessarily lead to better control or substantial retardation of an outbreak.”

Syndromic surveillance aimed at detecting influenzalike illness in emergency departments and clinics is being used in several cities, and the Centers for Disease Control plans to expand the use of syndromic surveillance to 300 clinical sites by the end of 2006.

State plans are “markedly heterogenous” in their recommendation of personal contact avoidance and prophylactic measures, with few states discussing nonpharmaceutical strategies. “Even in this computer-based economy, in which a considerable percentage of persons can work from home most of the time, this simple stratagem is not addressed in most state plans,” Dr. Holmberg and his associates commented.

Specifically, 35% of states mention voluntary self-isolation; 37% discuss closing schools, institutions, or businesses; 31% talk about quarantining institutions, persons, or households; and 25% mention contact vaccination or chemoprophylaxis. Other simple recommendations that are often neglected in the plans include avoidance of mass gatherings; shopping on off-hours; and home and work strategies such as hand washing, keeping towels separate, and avoidance of handshaking, the investigators wrote.

Although the authors point to weak federal direction as one of the reasons for the patchwork of state plans, they also acknowledge gaps in epidemiologic knowledge. “We also believe it would be prudent to begin studies and, in the interim, create expert panels to determine if masks, school closings, social isolation, and several other nonpharmaceutical strategies would be useful in reducing the illness and death caused by pandemic influenza and its spread in the community.”

A revision of the national pandemic influenza plan could help to remedy the current patchwork of state plans “that will not adequately detect and control” an influenza pandemic, according to a review by Scott D. Holmberg, Ph.D., and his colleagues at Research Triangle Institute International, Atlanta.

“The control of future pandemic and interpandemic influenza will necessarily rely on each individual state's plan to vaccinate persons and detect and contain this disease,” the investigators wrote (Emerg. Infect. Dis. 2006;12:1414–7). “The current national [Health and Human Services] pandemic influenza plan presents only a categorization and listing of steps rather than explicit direction for the states.”

The authors cite a “lack of clear guidance” at the federal level as one of the reasons for considerable disparity among the 49 states that have posted their plans for vaccination, early epidemic surveillance and detection, and containment of pandemic influenza (available online at www.cdc.gov/ncidod/EID/vol12no09/06-0369_appT1.htm

According to the review, all states agree on vaccination priority strategies as recommended by the Advisory Committee on Immunization Practices and the U.S. Department of Health and Human Services. “General agreement exists, explicit or implicit, to provide vaccination during a pandemic that is prioritized by those most likely to acquire, become ill, or die from pandemic influenza,” they noted.

In general, this means that the elderly, those with chronic diseases, and health care and infrastructure personnel will be vaccinated first; some states will include young children in this list. “We believe the estimate that such persons make up [about] 15%–20% of the population in any state is reasonable,” the researchers wrote, adding that this vaccination strategy is aimed at preventing deaths, not reducing transmission, since the latter would require much more vaccine than is currently available.

State plans are more variable regarding surveillance and detection, although they all plan to use the National Sentinel Physician Surveillance and the nationwide 122 Cities Mortality Reporting System. Neither system would likely detect a local outbreak of influenza within 2 weeks, the authors noted, but “to our knowledge, no health authority feels confident that earlier detection of influenza by 1–3 weeks would necessarily lead to better control or substantial retardation of an outbreak.”

Syndromic surveillance aimed at detecting influenzalike illness in emergency departments and clinics is being used in several cities, and the Centers for Disease Control plans to expand the use of syndromic surveillance to 300 clinical sites by the end of 2006.

State plans are “markedly heterogenous” in their recommendation of personal contact avoidance and prophylactic measures, with few states discussing nonpharmaceutical strategies. “Even in this computer-based economy, in which a considerable percentage of persons can work from home most of the time, this simple stratagem is not addressed in most state plans,” Dr. Holmberg and his associates commented.

Specifically, 35% of states mention voluntary self-isolation; 37% discuss closing schools, institutions, or businesses; 31% talk about quarantining institutions, persons, or households; and 25% mention contact vaccination or chemoprophylaxis. Other simple recommendations that are often neglected in the plans include avoidance of mass gatherings; shopping on off-hours; and home and work strategies such as hand washing, keeping towels separate, and avoidance of handshaking, the investigators wrote.

Although the authors point to weak federal direction as one of the reasons for the patchwork of state plans, they also acknowledge gaps in epidemiologic knowledge. “We also believe it would be prudent to begin studies and, in the interim, create expert panels to determine if masks, school closings, social isolation, and several other nonpharmaceutical strategies would be useful in reducing the illness and death caused by pandemic influenza and its spread in the community.”

A revision of the national pandemic influenza plan could help to remedy the current patchwork of state plans “that will not adequately detect and control” an influenza pandemic, according to a review by Scott D. Holmberg, Ph.D., and his colleagues at Research Triangle Institute International, Atlanta.

“The control of future pandemic and interpandemic influenza will necessarily rely on each individual state's plan to vaccinate persons and detect and contain this disease,” the investigators wrote (Emerg. Infect. Dis. 2006;12:1414–7). “The current national [Health and Human Services] pandemic influenza plan presents only a categorization and listing of steps rather than explicit direction for the states.”

The authors cite a “lack of clear guidance” at the federal level as one of the reasons for considerable disparity among the 49 states that have posted their plans for vaccination, early epidemic surveillance and detection, and containment of pandemic influenza (available online at www.cdc.gov/ncidod/EID/vol12no09/06-0369_appT1.htm

According to the review, all states agree on vaccination priority strategies as recommended by the Advisory Committee on Immunization Practices and the U.S. Department of Health and Human Services. “General agreement exists, explicit or implicit, to provide vaccination during a pandemic that is prioritized by those most likely to acquire, become ill, or die from pandemic influenza,” they noted.

In general, this means that the elderly, those with chronic diseases, and health care and infrastructure personnel will be vaccinated first; some states will include young children in this list. “We believe the estimate that such persons make up [about] 15%–20% of the population in any state is reasonable,” the researchers wrote, adding that this vaccination strategy is aimed at preventing deaths, not reducing transmission, since the latter would require much more vaccine than is currently available.

State plans are more variable regarding surveillance and detection, although they all plan to use the National Sentinel Physician Surveillance and the nationwide 122 Cities Mortality Reporting System. Neither system would likely detect a local outbreak of influenza within 2 weeks, the authors noted, but “to our knowledge, no health authority feels confident that earlier detection of influenza by 1–3 weeks would necessarily lead to better control or substantial retardation of an outbreak.”

Syndromic surveillance aimed at detecting influenzalike illness in emergency departments and clinics is being used in several cities, and the Centers for Disease Control plans to expand the use of syndromic surveillance to 300 clinical sites by the end of 2006.

State plans are “markedly heterogenous” in their recommendation of personal contact avoidance and prophylactic measures, with few states discussing nonpharmaceutical strategies. “Even in this computer-based economy, in which a considerable percentage of persons can work from home most of the time, this simple stratagem is not addressed in most state plans,” Dr. Holmberg and his associates commented.

Specifically, 35% of states mention voluntary self-isolation; 37% discuss closing schools, institutions, or businesses; 31% talk about quarantining institutions, persons, or households; and 25% mention contact vaccination or chemoprophylaxis. Other simple recommendations that are often neglected in the plans include avoidance of mass gatherings; shopping on off-hours; and home and work strategies such as hand washing, keeping towels separate, and avoidance of handshaking, the investigators wrote.

Although the authors point to weak federal direction as one of the reasons for the patchwork of state plans, they also acknowledge gaps in epidemiologic knowledge. “We also believe it would be prudent to begin studies and, in the interim, create expert panels to determine if masks, school closings, social isolation, and several other nonpharmaceutical strategies would be useful in reducing the illness and death caused by pandemic influenza and its spread in the community.”

BOSTON — Regular, moderate exercise can help control ventricular rate in patients with permanent atrial fibrillation, according to study results presented as a poster at the annual meeting of the Heart Rhythm Society.

“Patients with atrial fibrillation [AF] find it difficult to exercise, so this is a new idea,” investigator Dr. Jurgita Plisiene said in an interview.

Ventricular rate increases during exercise, making it difficult for the patients to improve their exercise capacity. But Dr. Plisiene found that 4 months of twice-weekly exercise, involving walking or jogging for 60 minutes, increased exercise capacity in 10 patients with permanent AF, while also regulating the ventricular rate. “Exercise elevates the parasympathetic tone to the [atrioventricular] node and so decreases the ventricular rate,” she said.

The patients had a mean age of 59 years and a mean 10 years' duration of permanent AF. They undertook individualized, physician-directed exercise programs tailored to their physical capacity. Physical exercise tests and Holter ECG recordings were performed at baseline and after 4 months.

Results showed that the exercise program decreased the patients' mean ventricular rate by 12%. The mean rate at rest decreased from 87 to 78 beats per minute, and there was a significant ventricular rate decrease at almost every exercise level.

In addition, overall exercise capacity, as estimated by repeated lactate measurements and by questionnaires, also significantly improved. “Physical training should be taken into account in those patients in whom drug therapy does not allow the heart to reach adequate ventricular rate control during AF,” said Dr. Plisiene, a cardiologist at University Hospital in Aachen, Germany.

BOSTON — Regular, moderate exercise can help control ventricular rate in patients with permanent atrial fibrillation, according to study results presented as a poster at the annual meeting of the Heart Rhythm Society.

“Patients with atrial fibrillation [AF] find it difficult to exercise, so this is a new idea,” investigator Dr. Jurgita Plisiene said in an interview.

Ventricular rate increases during exercise, making it difficult for the patients to improve their exercise capacity. But Dr. Plisiene found that 4 months of twice-weekly exercise, involving walking or jogging for 60 minutes, increased exercise capacity in 10 patients with permanent AF, while also regulating the ventricular rate. “Exercise elevates the parasympathetic tone to the [atrioventricular] node and so decreases the ventricular rate,” she said.

The patients had a mean age of 59 years and a mean 10 years' duration of permanent AF. They undertook individualized, physician-directed exercise programs tailored to their physical capacity. Physical exercise tests and Holter ECG recordings were performed at baseline and after 4 months.

Results showed that the exercise program decreased the patients' mean ventricular rate by 12%. The mean rate at rest decreased from 87 to 78 beats per minute, and there was a significant ventricular rate decrease at almost every exercise level.

In addition, overall exercise capacity, as estimated by repeated lactate measurements and by questionnaires, also significantly improved. “Physical training should be taken into account in those patients in whom drug therapy does not allow the heart to reach adequate ventricular rate control during AF,” said Dr. Plisiene, a cardiologist at University Hospital in Aachen, Germany.

BOSTON — Regular, moderate exercise can help control ventricular rate in patients with permanent atrial fibrillation, according to study results presented as a poster at the annual meeting of the Heart Rhythm Society.

“Patients with atrial fibrillation [AF] find it difficult to exercise, so this is a new idea,” investigator Dr. Jurgita Plisiene said in an interview.

Ventricular rate increases during exercise, making it difficult for the patients to improve their exercise capacity. But Dr. Plisiene found that 4 months of twice-weekly exercise, involving walking or jogging for 60 minutes, increased exercise capacity in 10 patients with permanent AF, while also regulating the ventricular rate. “Exercise elevates the parasympathetic tone to the [atrioventricular] node and so decreases the ventricular rate,” she said.

The patients had a mean age of 59 years and a mean 10 years' duration of permanent AF. They undertook individualized, physician-directed exercise programs tailored to their physical capacity. Physical exercise tests and Holter ECG recordings were performed at baseline and after 4 months.

Results showed that the exercise program decreased the patients' mean ventricular rate by 12%. The mean rate at rest decreased from 87 to 78 beats per minute, and there was a significant ventricular rate decrease at almost every exercise level.

In addition, overall exercise capacity, as estimated by repeated lactate measurements and by questionnaires, also significantly improved. “Physical training should be taken into account in those patients in whom drug therapy does not allow the heart to reach adequate ventricular rate control during AF,” said Dr. Plisiene, a cardiologist at University Hospital in Aachen, Germany.

A revision of the national pandemic influenza plan could help to remedy the current patchwork of state plans “that will not adequately detect and control” an influenza pandemic, according to a review by Scott D. Holmberg, Ph.D., and his colleagues at Research Triangle Institute International, Atlanta.

“The control of future pandemic and interpandemic influenza will necessarily rely on each individual state's plan to vaccinate persons and detect and contain this disease,” the investigators wrote (Emerg. Infect. Dis. 2006;12:1414–7). “The current national [Health and Human Services] pandemic influenza plan presents only a categorization and listing of steps rather than explicit direction for the states.”

The authors cite a “lack of clear guidance” at the federal level as one of the reasons for the considerable disparity among the 49 states that have posted their plans for vaccination, early epidemic surveillance and detection, and containment of pandemic influenza (available online at www.cdc.gov/ncidod/EID/vol12no09/06/0369_appT1.htm

According to the review, all states agree on vaccination priority strategies as recommended by the Advisory Committee on Immunization Practices and the U.S. Department of Health and Human Services. “General agreement exists, explicit or implicit, to provide vaccination during a pandemic that is prioritized by those most likely to acquire, become ill, or die from pandemic influenza,” they noted.

In general, this means that the elderly, those with chronic diseases, and health care and infrastructure personnel will be vaccinated first; some states will include young children in this list. “We believe the estimate that such persons make up [about] 15%–20% of the population in any state is reasonable,” the researchers wrote.

State plans are more variable regarding surveillance and detection, although they all plan to use the National Sentinel Physician Surveillance and the nationwide 122 Cities Mortality Reporting System. Neither system would likely detect a local outbreak of influenza within 2 weeks, the authors noted, but “to our knowledge, no health authority feels confident that earlier detection of influenza by 1–3 weeks would necessarily lead to better control or substantial retardation of an outbreak.”

Syndromic surveillance aimed at detecting influenzalike illness in emergency departments and clinics is being used in several cities, and the Centers for Disease Control plans to expand the use of syndromic surveillance to 300 clinical sites by the end of 2006.

State plans are “markedly heterogenous” in their recommendation of personal contact avoidance and prophylactic measures, with few states discussing nonpharmaceutical strategies. “Even in this computer-based economy, in which a considerable percentage of persons can work from home most of the time, this simple stratagem is not addressed in most state plans,” Dr. Holmberg and his associates noted.

Specifically, 35% of states mention voluntary self-isolation; 37% discuss closing schools, institutions, or businesses; 31% talk about quarantining institutions, persons, or households; and 25% mention contact vaccination or chemoprophylaxis. Other simple recommendations that are often neglected in the plans include avoidance of mass gatherings; shopping on off-hours; and home and work strategies such as handwashing, keeping towels separate, and avoidance of handshaking, the investigators wrote.

Although the authors point to weak federal direction as one of the reasons for the patchwork of state plans, they also acknowledge gaps in epidemiologic knowledge.

“We also believe it would be prudent to begin studies and, in the interim, create expert panels to determine if masks, school closings, social isolation, and several other nonpharmaceutical strategies would be useful in reducing the illness and death caused by pandemic influenza and its spread in the community.”

A revision of the national pandemic influenza plan could help to remedy the current patchwork of state plans “that will not adequately detect and control” an influenza pandemic, according to a review by Scott D. Holmberg, Ph.D., and his colleagues at Research Triangle Institute International, Atlanta.

“The control of future pandemic and interpandemic influenza will necessarily rely on each individual state's plan to vaccinate persons and detect and contain this disease,” the investigators wrote (Emerg. Infect. Dis. 2006;12:1414–7). “The current national [Health and Human Services] pandemic influenza plan presents only a categorization and listing of steps rather than explicit direction for the states.”

The authors cite a “lack of clear guidance” at the federal level as one of the reasons for the considerable disparity among the 49 states that have posted their plans for vaccination, early epidemic surveillance and detection, and containment of pandemic influenza (available online at www.cdc.gov/ncidod/EID/vol12no09/06/0369_appT1.htm

According to the review, all states agree on vaccination priority strategies as recommended by the Advisory Committee on Immunization Practices and the U.S. Department of Health and Human Services. “General agreement exists, explicit or implicit, to provide vaccination during a pandemic that is prioritized by those most likely to acquire, become ill, or die from pandemic influenza,” they noted.

In general, this means that the elderly, those with chronic diseases, and health care and infrastructure personnel will be vaccinated first; some states will include young children in this list. “We believe the estimate that such persons make up [about] 15%–20% of the population in any state is reasonable,” the researchers wrote.

State plans are more variable regarding surveillance and detection, although they all plan to use the National Sentinel Physician Surveillance and the nationwide 122 Cities Mortality Reporting System. Neither system would likely detect a local outbreak of influenza within 2 weeks, the authors noted, but “to our knowledge, no health authority feels confident that earlier detection of influenza by 1–3 weeks would necessarily lead to better control or substantial retardation of an outbreak.”

Syndromic surveillance aimed at detecting influenzalike illness in emergency departments and clinics is being used in several cities, and the Centers for Disease Control plans to expand the use of syndromic surveillance to 300 clinical sites by the end of 2006.

State plans are “markedly heterogenous” in their recommendation of personal contact avoidance and prophylactic measures, with few states discussing nonpharmaceutical strategies. “Even in this computer-based economy, in which a considerable percentage of persons can work from home most of the time, this simple stratagem is not addressed in most state plans,” Dr. Holmberg and his associates noted.

Specifically, 35% of states mention voluntary self-isolation; 37% discuss closing schools, institutions, or businesses; 31% talk about quarantining institutions, persons, or households; and 25% mention contact vaccination or chemoprophylaxis. Other simple recommendations that are often neglected in the plans include avoidance of mass gatherings; shopping on off-hours; and home and work strategies such as handwashing, keeping towels separate, and avoidance of handshaking, the investigators wrote.

Although the authors point to weak federal direction as one of the reasons for the patchwork of state plans, they also acknowledge gaps in epidemiologic knowledge.

“We also believe it would be prudent to begin studies and, in the interim, create expert panels to determine if masks, school closings, social isolation, and several other nonpharmaceutical strategies would be useful in reducing the illness and death caused by pandemic influenza and its spread in the community.”

A revision of the national pandemic influenza plan could help to remedy the current patchwork of state plans “that will not adequately detect and control” an influenza pandemic, according to a review by Scott D. Holmberg, Ph.D., and his colleagues at Research Triangle Institute International, Atlanta.

“The control of future pandemic and interpandemic influenza will necessarily rely on each individual state's plan to vaccinate persons and detect and contain this disease,” the investigators wrote (Emerg. Infect. Dis. 2006;12:1414–7). “The current national [Health and Human Services] pandemic influenza plan presents only a categorization and listing of steps rather than explicit direction for the states.”

The authors cite a “lack of clear guidance” at the federal level as one of the reasons for the considerable disparity among the 49 states that have posted their plans for vaccination, early epidemic surveillance and detection, and containment of pandemic influenza (available online at www.cdc.gov/ncidod/EID/vol12no09/06/0369_appT1.htm

According to the review, all states agree on vaccination priority strategies as recommended by the Advisory Committee on Immunization Practices and the U.S. Department of Health and Human Services. “General agreement exists, explicit or implicit, to provide vaccination during a pandemic that is prioritized by those most likely to acquire, become ill, or die from pandemic influenza,” they noted.

In general, this means that the elderly, those with chronic diseases, and health care and infrastructure personnel will be vaccinated first; some states will include young children in this list. “We believe the estimate that such persons make up [about] 15%–20% of the population in any state is reasonable,” the researchers wrote.

State plans are more variable regarding surveillance and detection, although they all plan to use the National Sentinel Physician Surveillance and the nationwide 122 Cities Mortality Reporting System. Neither system would likely detect a local outbreak of influenza within 2 weeks, the authors noted, but “to our knowledge, no health authority feels confident that earlier detection of influenza by 1–3 weeks would necessarily lead to better control or substantial retardation of an outbreak.”

Syndromic surveillance aimed at detecting influenzalike illness in emergency departments and clinics is being used in several cities, and the Centers for Disease Control plans to expand the use of syndromic surveillance to 300 clinical sites by the end of 2006.

State plans are “markedly heterogenous” in their recommendation of personal contact avoidance and prophylactic measures, with few states discussing nonpharmaceutical strategies. “Even in this computer-based economy, in which a considerable percentage of persons can work from home most of the time, this simple stratagem is not addressed in most state plans,” Dr. Holmberg and his associates noted.

Specifically, 35% of states mention voluntary self-isolation; 37% discuss closing schools, institutions, or businesses; 31% talk about quarantining institutions, persons, or households; and 25% mention contact vaccination or chemoprophylaxis. Other simple recommendations that are often neglected in the plans include avoidance of mass gatherings; shopping on off-hours; and home and work strategies such as handwashing, keeping towels separate, and avoidance of handshaking, the investigators wrote.

Although the authors point to weak federal direction as one of the reasons for the patchwork of state plans, they also acknowledge gaps in epidemiologic knowledge.

“We also believe it would be prudent to begin studies and, in the interim, create expert panels to determine if masks, school closings, social isolation, and several other nonpharmaceutical strategies would be useful in reducing the illness and death caused by pandemic influenza and its spread in the community.”

Preexisting glaucoma behaves unpredictably during pregnancy, according to findings from a small retrospective study.

The results underscore the need for close monitoring and physician-patient communication, reported Dr. Stacey C. Brauner and colleagues at the Massachusetts Eye and Ear Infirmary at Harvard Medical School in Boston.

Although medication is often necessary to control intraocular pressure, pregnant women may be reluctant to take it because of the potential teratogenic effects.

“This reinforces the need for good communication between physician and patient to minimize the risk to the fetus while preserving vision in the patient,” the authors wrote (Arch. Ophthalmol. 2006;124:1089–94).

Whenever possible, physicians should address glaucoma management options in all women of childbearing age before they become pregnant. “With proper planning, surgical treatments such as laser trabeculoplasty can be offered in anticipation of decreasing or stopping medication use during pregnancy,” Dr. Brauner said.

The retrospective case series of 28 eyes in 15 pregnant women with preexisting glaucoma found that while the condition remained stable in most women, 36% of eyes demonstrated either an increase in intraocular pressure (IOP) or a progression of visual field loss that required an increase in medication.

Most glaucoma medications such as β-blockers, carbonic anhydrase inhibitors (topical and systemic), prostaglandin analogues, cholinergic agents, anticholinesterases, and apraclonidine hydrochloride are classified by the Food and Drug Administration as pregnancy category C, noted the authors.

“This designation indicates that studies in animals have shown adverse effects on the fetus and there are no controlled studies in women, or that studies in women and animals are unavailable,” the investigators wrote. Thus, they advise that medication should be given “only if the potential benefit to the pregnant woman justifies the potential risk to the fetus,” and should be “prescribed in collaboration with obstetricians to ensure the safety of the mother and the fetus.”

Of the 28 eyes studied, IOP remained stable in 16 (57%), with no change in the visual fields. “Many of these eyes were maintained on fewer IOP-lowering medications during pregnancy compared with before pregnancy.”

In another 5 (18%) of the 28 eyes IOP increased but with no progression in visual field loss. However, in another five eyes IOP remained stable or increased, and there was also a progression in visual field loss. (Data were inconclusive in the remaining two eyes).

Although 13 of the 15 women required medication to control their IOP during pregnancy, there was a general trend toward medication noncompliance once they became pregnant, according to the authors. Two women discontinued all medication, resulting in an increase in IOP. “There were no adverse effects of medication use during pregnancy observed in the patients or their offspring,” the authors reported.

They advise that ophthalmologists work closely with obstetricians when selecting IOP-lowering medications during pregnancy. “In our experience, obstetricians are most comfortable with the use of β-blockers,” they said.

Preexisting glaucoma behaves unpredictably during pregnancy, according to findings from a small retrospective study.

The results underscore the need for close monitoring and physician-patient communication, reported Dr. Stacey C. Brauner and colleagues at the Massachusetts Eye and Ear Infirmary at Harvard Medical School in Boston.

Although medication is often necessary to control intraocular pressure, pregnant women may be reluctant to take it because of the potential teratogenic effects.

“This reinforces the need for good communication between physician and patient to minimize the risk to the fetus while preserving vision in the patient,” the authors wrote (Arch. Ophthalmol. 2006;124:1089–94).

Whenever possible, physicians should address glaucoma management options in all women of childbearing age before they become pregnant. “With proper planning, surgical treatments such as laser trabeculoplasty can be offered in anticipation of decreasing or stopping medication use during pregnancy,” Dr. Brauner said.

The retrospective case series of 28 eyes in 15 pregnant women with preexisting glaucoma found that while the condition remained stable in most women, 36% of eyes demonstrated either an increase in intraocular pressure (IOP) or a progression of visual field loss that required an increase in medication.

Most glaucoma medications such as β-blockers, carbonic anhydrase inhibitors (topical and systemic), prostaglandin analogues, cholinergic agents, anticholinesterases, and apraclonidine hydrochloride are classified by the Food and Drug Administration as pregnancy category C, noted the authors.

“This designation indicates that studies in animals have shown adverse effects on the fetus and there are no controlled studies in women, or that studies in women and animals are unavailable,” the investigators wrote. Thus, they advise that medication should be given “only if the potential benefit to the pregnant woman justifies the potential risk to the fetus,” and should be “prescribed in collaboration with obstetricians to ensure the safety of the mother and the fetus.”

Of the 28 eyes studied, IOP remained stable in 16 (57%), with no change in the visual fields. “Many of these eyes were maintained on fewer IOP-lowering medications during pregnancy compared with before pregnancy.”

In another 5 (18%) of the 28 eyes IOP increased but with no progression in visual field loss. However, in another five eyes IOP remained stable or increased, and there was also a progression in visual field loss. (Data were inconclusive in the remaining two eyes).

Although 13 of the 15 women required medication to control their IOP during pregnancy, there was a general trend toward medication noncompliance once they became pregnant, according to the authors. Two women discontinued all medication, resulting in an increase in IOP. “There were no adverse effects of medication use during pregnancy observed in the patients or their offspring,” the authors reported.

They advise that ophthalmologists work closely with obstetricians when selecting IOP-lowering medications during pregnancy. “In our experience, obstetricians are most comfortable with the use of β-blockers,” they said.

Preexisting glaucoma behaves unpredictably during pregnancy, according to findings from a small retrospective study.

The results underscore the need for close monitoring and physician-patient communication, reported Dr. Stacey C. Brauner and colleagues at the Massachusetts Eye and Ear Infirmary at Harvard Medical School in Boston.

Although medication is often necessary to control intraocular pressure, pregnant women may be reluctant to take it because of the potential teratogenic effects.

“This reinforces the need for good communication between physician and patient to minimize the risk to the fetus while preserving vision in the patient,” the authors wrote (Arch. Ophthalmol. 2006;124:1089–94).

Whenever possible, physicians should address glaucoma management options in all women of childbearing age before they become pregnant. “With proper planning, surgical treatments such as laser trabeculoplasty can be offered in anticipation of decreasing or stopping medication use during pregnancy,” Dr. Brauner said.

The retrospective case series of 28 eyes in 15 pregnant women with preexisting glaucoma found that while the condition remained stable in most women, 36% of eyes demonstrated either an increase in intraocular pressure (IOP) or a progression of visual field loss that required an increase in medication.

Most glaucoma medications such as β-blockers, carbonic anhydrase inhibitors (topical and systemic), prostaglandin analogues, cholinergic agents, anticholinesterases, and apraclonidine hydrochloride are classified by the Food and Drug Administration as pregnancy category C, noted the authors.

“This designation indicates that studies in animals have shown adverse effects on the fetus and there are no controlled studies in women, or that studies in women and animals are unavailable,” the investigators wrote. Thus, they advise that medication should be given “only if the potential benefit to the pregnant woman justifies the potential risk to the fetus,” and should be “prescribed in collaboration with obstetricians to ensure the safety of the mother and the fetus.”

Of the 28 eyes studied, IOP remained stable in 16 (57%), with no change in the visual fields. “Many of these eyes were maintained on fewer IOP-lowering medications during pregnancy compared with before pregnancy.”

In another 5 (18%) of the 28 eyes IOP increased but with no progression in visual field loss. However, in another five eyes IOP remained stable or increased, and there was also a progression in visual field loss. (Data were inconclusive in the remaining two eyes).

Although 13 of the 15 women required medication to control their IOP during pregnancy, there was a general trend toward medication noncompliance once they became pregnant, according to the authors. Two women discontinued all medication, resulting in an increase in IOP. “There were no adverse effects of medication use during pregnancy observed in the patients or their offspring,” the authors reported.

They advise that ophthalmologists work closely with obstetricians when selecting IOP-lowering medications during pregnancy. “In our experience, obstetricians are most comfortable with the use of β-blockers,” they said.

Tamoxifen therapy may actually reduce life expectancy slightly in nonhysterectomized women at the low end of the high-risk range for breast cancer, according to an analysis based on hypothetical cohorts.

“The results of our analysis raise questions about the impact of tamoxifen for breast cancer risk reduction on short-term and longer-term mortality,” wrote Dr. Joy Melnikow of the University of California-Davis, Sacramento, and her colleagues.

“Tamoxifen for breast cancer risk reduction is unlikely to have an important effect on overall mortality for women at a 5-year breast cancer risk of 1.67% … When the effect of the poorer prognosis of the [estrogen receptor-negative breast cancers that occur among women taking tamoxifen on their breast cancer mortality is accounted for, tamoxifen is projected to reduce life expectancy slightly until women reach a minimum 2.1% 5-year breast cancer risk,” they wrote.

For women who have undergone a hysterectomy, tamoxifen becomes a more favorable approach, since the risks of endometrial cancer are eliminated in this group, they added. The study was published in the Sept. 1 issue of the journal Cancer.

Tamoxifen was approved by the Food and Drug Administration in 1998 for breast cancer prevention in women who have at least a 1.67% chance of developing the disease over the next 5 years.

The analysis used a state-transition Markov model to track tamoxifen use over a 5-year period in hypothetical cohorts of women aged 50 years or more whose 5-year breast cancer risk ranged from 1% to 5%. Health outcomes, life expectancy, and costs per life-year saved were estimated based on a 5-year risk of 1.67%, which is the threshold for risk reduction therapy used in the National Surgical Adjuvant Breast and Bowel Project (NSABP) P-1 trial.

Using outcomes described in the NSABP P-1 trial, the study examined tamoxifen's effect on reducing the risks of invasive breast cancer, ductal carcinoma in situ, and osteoporotic fractures, while increasing the risks of endometrial cancer, deep venous thrombosis, pulmonary embolism, and cataracts that require surgery.

Cost-effectiveness analyses were performed separately for hysterectomized and nonhysterectomized women, because the former no longer face tamoxifen's increased risk of endometrial cancer.

Additionally, potential prognostic differences were estimated based on the presence of either ER-positive or ER-negative breast cancers—the latter carrying a worse prognosis. “To our knowledge, no previously published analysis has accounted for the difference in prognosis for women with ER-negative cancers,” they wrote.

The findings showed that tamoxifen therapy resulted in a negligible increase in life expectancy of 1.6 days for nonhysterectomized women with a 5-year breast cancer risk of 1.67%—at an extremely high incremental cost per year of life saved ($1,335,690). At a 5% 5-year risk this cost decreased to $64,778 per life-year saved, with an improvement in mean life expectancy of 26.7 days.

For hysterectomized women the cost-effectiveness ratio was more favorable, showing a mean increase in life expectancy of 11.5 days at a cost of $177,116 per life-year saved in women with a 1.67% 5-year risk. Those with a 5% 5-year risk had a projected life expectancy improvement of 36.5 days at a cost of $46,954 per life-year saved.

The findings are highly sensitive to price of tamoxifen, which varies strikingly within the United States and between the United States and Canada, according to the authors.

The average wholesale price (AWP) in the United States is seven times higher than typical Canadian Internet pharmacy prices, they said.

Applying the Canadian drug cost to nonhysterectomized women with either a 1.67% 5-year risk reduced the incremental cost per life-year saved to $123,780 (from $1,335,690).

“For women at breast cancer risks of greater than or equal to 3%, tamoxifen at Canadian prices both may increase life expectancy and may reduce overall costs,” wrote the authors.

“For health policy makers in the U.S., this illustrates the potential effect of negotiating pharmaceutical prices at a national level and the risk of using the AWP to define the negotiated price, which is done by most Medicaid plans.”

Tamoxifen therapy may actually reduce life expectancy slightly in nonhysterectomized women at the low end of the high-risk range for breast cancer, according to an analysis based on hypothetical cohorts.

“The results of our analysis raise questions about the impact of tamoxifen for breast cancer risk reduction on short-term and longer-term mortality,” wrote Dr. Joy Melnikow of the University of California-Davis, Sacramento, and her colleagues.

“Tamoxifen for breast cancer risk reduction is unlikely to have an important effect on overall mortality for women at a 5-year breast cancer risk of 1.67% … When the effect of the poorer prognosis of the [estrogen receptor-negative breast cancers that occur among women taking tamoxifen on their breast cancer mortality is accounted for, tamoxifen is projected to reduce life expectancy slightly until women reach a minimum 2.1% 5-year breast cancer risk,” they wrote.

For women who have undergone a hysterectomy, tamoxifen becomes a more favorable approach, since the risks of endometrial cancer are eliminated in this group, they added. The study was published in the Sept. 1 issue of the journal Cancer.

Tamoxifen was approved by the Food and Drug Administration in 1998 for breast cancer prevention in women who have at least a 1.67% chance of developing the disease over the next 5 years.

The analysis used a state-transition Markov model to track tamoxifen use over a 5-year period in hypothetical cohorts of women aged 50 years or more whose 5-year breast cancer risk ranged from 1% to 5%. Health outcomes, life expectancy, and costs per life-year saved were estimated based on a 5-year risk of 1.67%, which is the threshold for risk reduction therapy used in the National Surgical Adjuvant Breast and Bowel Project (NSABP) P-1 trial.

Using outcomes described in the NSABP P-1 trial, the study examined tamoxifen's effect on reducing the risks of invasive breast cancer, ductal carcinoma in situ, and osteoporotic fractures, while increasing the risks of endometrial cancer, deep venous thrombosis, pulmonary embolism, and cataracts that require surgery.

Cost-effectiveness analyses were performed separately for hysterectomized and nonhysterectomized women, because the former no longer face tamoxifen's increased risk of endometrial cancer.

Additionally, potential prognostic differences were estimated based on the presence of either ER-positive or ER-negative breast cancers—the latter carrying a worse prognosis. “To our knowledge, no previously published analysis has accounted for the difference in prognosis for women with ER-negative cancers,” they wrote.

The findings showed that tamoxifen therapy resulted in a negligible increase in life expectancy of 1.6 days for nonhysterectomized women with a 5-year breast cancer risk of 1.67%—at an extremely high incremental cost per year of life saved ($1,335,690). At a 5% 5-year risk this cost decreased to $64,778 per life-year saved, with an improvement in mean life expectancy of 26.7 days.

For hysterectomized women the cost-effectiveness ratio was more favorable, showing a mean increase in life expectancy of 11.5 days at a cost of $177,116 per life-year saved in women with a 1.67% 5-year risk. Those with a 5% 5-year risk had a projected life expectancy improvement of 36.5 days at a cost of $46,954 per life-year saved.

The findings are highly sensitive to price of tamoxifen, which varies strikingly within the United States and between the United States and Canada, according to the authors.

The average wholesale price (AWP) in the United States is seven times higher than typical Canadian Internet pharmacy prices, they said.

Applying the Canadian drug cost to nonhysterectomized women with either a 1.67% 5-year risk reduced the incremental cost per life-year saved to $123,780 (from $1,335,690).

“For women at breast cancer risks of greater than or equal to 3%, tamoxifen at Canadian prices both may increase life expectancy and may reduce overall costs,” wrote the authors.

“For health policy makers in the U.S., this illustrates the potential effect of negotiating pharmaceutical prices at a national level and the risk of using the AWP to define the negotiated price, which is done by most Medicaid plans.”

Tamoxifen therapy may actually reduce life expectancy slightly in nonhysterectomized women at the low end of the high-risk range for breast cancer, according to an analysis based on hypothetical cohorts.

“The results of our analysis raise questions about the impact of tamoxifen for breast cancer risk reduction on short-term and longer-term mortality,” wrote Dr. Joy Melnikow of the University of California-Davis, Sacramento, and her colleagues.

“Tamoxifen for breast cancer risk reduction is unlikely to have an important effect on overall mortality for women at a 5-year breast cancer risk of 1.67% … When the effect of the poorer prognosis of the [estrogen receptor-negative breast cancers that occur among women taking tamoxifen on their breast cancer mortality is accounted for, tamoxifen is projected to reduce life expectancy slightly until women reach a minimum 2.1% 5-year breast cancer risk,” they wrote.

For women who have undergone a hysterectomy, tamoxifen becomes a more favorable approach, since the risks of endometrial cancer are eliminated in this group, they added. The study was published in the Sept. 1 issue of the journal Cancer.

Tamoxifen was approved by the Food and Drug Administration in 1998 for breast cancer prevention in women who have at least a 1.67% chance of developing the disease over the next 5 years.

The analysis used a state-transition Markov model to track tamoxifen use over a 5-year period in hypothetical cohorts of women aged 50 years or more whose 5-year breast cancer risk ranged from 1% to 5%. Health outcomes, life expectancy, and costs per life-year saved were estimated based on a 5-year risk of 1.67%, which is the threshold for risk reduction therapy used in the National Surgical Adjuvant Breast and Bowel Project (NSABP) P-1 trial.

Using outcomes described in the NSABP P-1 trial, the study examined tamoxifen's effect on reducing the risks of invasive breast cancer, ductal carcinoma in situ, and osteoporotic fractures, while increasing the risks of endometrial cancer, deep venous thrombosis, pulmonary embolism, and cataracts that require surgery.

Cost-effectiveness analyses were performed separately for hysterectomized and nonhysterectomized women, because the former no longer face tamoxifen's increased risk of endometrial cancer.

Additionally, potential prognostic differences were estimated based on the presence of either ER-positive or ER-negative breast cancers—the latter carrying a worse prognosis. “To our knowledge, no previously published analysis has accounted for the difference in prognosis for women with ER-negative cancers,” they wrote.

The findings showed that tamoxifen therapy resulted in a negligible increase in life expectancy of 1.6 days for nonhysterectomized women with a 5-year breast cancer risk of 1.67%—at an extremely high incremental cost per year of life saved ($1,335,690). At a 5% 5-year risk this cost decreased to $64,778 per life-year saved, with an improvement in mean life expectancy of 26.7 days.

For hysterectomized women the cost-effectiveness ratio was more favorable, showing a mean increase in life expectancy of 11.5 days at a cost of $177,116 per life-year saved in women with a 1.67% 5-year risk. Those with a 5% 5-year risk had a projected life expectancy improvement of 36.5 days at a cost of $46,954 per life-year saved.

The findings are highly sensitive to price of tamoxifen, which varies strikingly within the United States and between the United States and Canada, according to the authors.

The average wholesale price (AWP) in the United States is seven times higher than typical Canadian Internet pharmacy prices, they said.

Applying the Canadian drug cost to nonhysterectomized women with either a 1.67% 5-year risk reduced the incremental cost per life-year saved to $123,780 (from $1,335,690).

“For women at breast cancer risks of greater than or equal to 3%, tamoxifen at Canadian prices both may increase life expectancy and may reduce overall costs,” wrote the authors.

“For health policy makers in the U.S., this illustrates the potential effect of negotiating pharmaceutical prices at a national level and the risk of using the AWP to define the negotiated price, which is done by most Medicaid plans.”

PRAGUE — Ovarian transplantation in five sets of monozygotic twins who were discordant for ovarian failure has not only resulted in normal menstruation and ovulation in all recipients, but also one healthy birth and three more ongoing pregnancies, Dr. Sherman Silber reported at the annual meeting of the European Society of Human Reproduction and Embryology.

“What we once thought would be a rare thing is now a series, with great implications beyond these special cases,” said Dr. Silber from the Infertility Center of St. Louis.

Last year at the same meeting, Dr. Silber reported his first of such transplants (N. Engl. J. Med. 2005;353:58–63) from a fertile twin to her sister.

The donor, who had three naturally conceived children, had one ovary laparoscopically removed. One-third of the tissue was frozen for the donor to use in the future, and the other two-thirds were transplanted into the recipient, who had experienced premature ovarian failure at age 14.

After the procedure, the recipient conceived in her second menstrual cycle and gave birth to a healthy girl. She has since conceived again and the delivery of her second child is expected soon.

Since Dr. Silber's initial report of this procedure, he has performed it successfully in four other monozygotic twin pairs, two of whom have conceived.

The third recipient is trying to conceive and the fourth is waiting to finish her medical training before trying to get pregnant. “This is not an arduous or difficult procedure for either patient,” noted Dr. Silber in an interview, both the donor and recipient can return home the next day.

“It is much like a laparoscopy with lysis of adhesions.” The advantage of the procedure over egg donation is that it allows long-term fertility and natural conception, he added.

He reported that the postoperative pattern for all recipients is very similar, with the resumption of menstruation occurring roughly 2.5 months post procedure and ovulatory cycles generally resuming another 2 months after that.

PRAGUE — Ovarian transplantation in five sets of monozygotic twins who were discordant for ovarian failure has not only resulted in normal menstruation and ovulation in all recipients, but also one healthy birth and three more ongoing pregnancies, Dr. Sherman Silber reported at the annual meeting of the European Society of Human Reproduction and Embryology.

“What we once thought would be a rare thing is now a series, with great implications beyond these special cases,” said Dr. Silber from the Infertility Center of St. Louis.

Last year at the same meeting, Dr. Silber reported his first of such transplants (N. Engl. J. Med. 2005;353:58–63) from a fertile twin to her sister.

The donor, who had three naturally conceived children, had one ovary laparoscopically removed. One-third of the tissue was frozen for the donor to use in the future, and the other two-thirds were transplanted into the recipient, who had experienced premature ovarian failure at age 14.

After the procedure, the recipient conceived in her second menstrual cycle and gave birth to a healthy girl. She has since conceived again and the delivery of her second child is expected soon.

Since Dr. Silber's initial report of this procedure, he has performed it successfully in four other monozygotic twin pairs, two of whom have conceived.

The third recipient is trying to conceive and the fourth is waiting to finish her medical training before trying to get pregnant. “This is not an arduous or difficult procedure for either patient,” noted Dr. Silber in an interview, both the donor and recipient can return home the next day.

“It is much like a laparoscopy with lysis of adhesions.” The advantage of the procedure over egg donation is that it allows long-term fertility and natural conception, he added.

He reported that the postoperative pattern for all recipients is very similar, with the resumption of menstruation occurring roughly 2.5 months post procedure and ovulatory cycles generally resuming another 2 months after that.

PRAGUE — Ovarian transplantation in five sets of monozygotic twins who were discordant for ovarian failure has not only resulted in normal menstruation and ovulation in all recipients, but also one healthy birth and three more ongoing pregnancies, Dr. Sherman Silber reported at the annual meeting of the European Society of Human Reproduction and Embryology.

“What we once thought would be a rare thing is now a series, with great implications beyond these special cases,” said Dr. Silber from the Infertility Center of St. Louis.

Last year at the same meeting, Dr. Silber reported his first of such transplants (N. Engl. J. Med. 2005;353:58–63) from a fertile twin to her sister.

The donor, who had three naturally conceived children, had one ovary laparoscopically removed. One-third of the tissue was frozen for the donor to use in the future, and the other two-thirds were transplanted into the recipient, who had experienced premature ovarian failure at age 14.

After the procedure, the recipient conceived in her second menstrual cycle and gave birth to a healthy girl. She has since conceived again and the delivery of her second child is expected soon.

Since Dr. Silber's initial report of this procedure, he has performed it successfully in four other monozygotic twin pairs, two of whom have conceived.

The third recipient is trying to conceive and the fourth is waiting to finish her medical training before trying to get pregnant. “This is not an arduous or difficult procedure for either patient,” noted Dr. Silber in an interview, both the donor and recipient can return home the next day.

“It is much like a laparoscopy with lysis of adhesions.” The advantage of the procedure over egg donation is that it allows long-term fertility and natural conception, he added.

He reported that the postoperative pattern for all recipients is very similar, with the resumption of menstruation occurring roughly 2.5 months post procedure and ovulatory cycles generally resuming another 2 months after that.

SAN ANTONIO — An intervention program aimed at couples who are first-time parents may help them cope with the transition to parenthood and with maintaining the quality of their relationship, according to the results of a pilot study.

The Family Foundations program, developed at Pennsylvania State University, Hershey, is aimed at helping couples manage conflict and keep their relationships strong while also learning how to coparent, explained Marni Kan, who presented the study at the annual meeting of the Society for Prevention Research.

“We give couples a lot of information about what it's going to be like to be a family of three [instead of two], and we get them to think about how they will interact, how they want things to be, how they are going to divide up the labor, and whether they want the same things for their child,” she said in an interview.

The pilot project randomized 115 couples who were expecting their first child either to the Family Foundations intervention program or to no treatment, starting at 22 weeks' gestation. Couples in the treatment program received four classes prenatally and another four when their child was 4–6 months old.

Video clips of new parents interacting provided the basis for many of the discussions. “The little snide comments that come out between parents … make people realize how dangerous that type of thing can be if it goes on for any length of time,” Ms. Kan said.

Data on demographics, individual well-being, and relationship quality were collected from all study participants at baseline and at the end of the study. Couples in the intervention group were also mailed a questionnaire after the birth of their child asking about their parenting experiences.

The study found that among all couples, mothers and fathers reported that their love for each other decreased over time, with mothers' love decreasing significantly more than fathers'. Mothers reported more conflict than fathers did, but levels of conflict increased for both mothers and fathers with time.

Parenting difficulties in the intervention group were less strongly associated with the quality of the couple's relationship, which was not the case with couples in the control group, Ms. Kan noted.

SAN ANTONIO — An intervention program aimed at couples who are first-time parents may help them cope with the transition to parenthood and with maintaining the quality of their relationship, according to the results of a pilot study.

The Family Foundations program, developed at Pennsylvania State University, Hershey, is aimed at helping couples manage conflict and keep their relationships strong while also learning how to coparent, explained Marni Kan, who presented the study at the annual meeting of the Society for Prevention Research.

“We give couples a lot of information about what it's going to be like to be a family of three [instead of two], and we get them to think about how they will interact, how they want things to be, how they are going to divide up the labor, and whether they want the same things for their child,” she said in an interview.

The pilot project randomized 115 couples who were expecting their first child either to the Family Foundations intervention program or to no treatment, starting at 22 weeks' gestation. Couples in the treatment program received four classes prenatally and another four when their child was 4–6 months old.

Video clips of new parents interacting provided the basis for many of the discussions. “The little snide comments that come out between parents … make people realize how dangerous that type of thing can be if it goes on for any length of time,” Ms. Kan said.

Data on demographics, individual well-being, and relationship quality were collected from all study participants at baseline and at the end of the study. Couples in the intervention group were also mailed a questionnaire after the birth of their child asking about their parenting experiences.

The study found that among all couples, mothers and fathers reported that their love for each other decreased over time, with mothers' love decreasing significantly more than fathers'. Mothers reported more conflict than fathers did, but levels of conflict increased for both mothers and fathers with time.

Parenting difficulties in the intervention group were less strongly associated with the quality of the couple's relationship, which was not the case with couples in the control group, Ms. Kan noted.

SAN ANTONIO — An intervention program aimed at couples who are first-time parents may help them cope with the transition to parenthood and with maintaining the quality of their relationship, according to the results of a pilot study.

The Family Foundations program, developed at Pennsylvania State University, Hershey, is aimed at helping couples manage conflict and keep their relationships strong while also learning how to coparent, explained Marni Kan, who presented the study at the annual meeting of the Society for Prevention Research.

“We give couples a lot of information about what it's going to be like to be a family of three [instead of two], and we get them to think about how they will interact, how they want things to be, how they are going to divide up the labor, and whether they want the same things for their child,” she said in an interview.

The pilot project randomized 115 couples who were expecting their first child either to the Family Foundations intervention program or to no treatment, starting at 22 weeks' gestation. Couples in the treatment program received four classes prenatally and another four when their child was 4–6 months old.

Video clips of new parents interacting provided the basis for many of the discussions. “The little snide comments that come out between parents … make people realize how dangerous that type of thing can be if it goes on for any length of time,” Ms. Kan said.

Data on demographics, individual well-being, and relationship quality were collected from all study participants at baseline and at the end of the study. Couples in the intervention group were also mailed a questionnaire after the birth of their child asking about their parenting experiences.

The study found that among all couples, mothers and fathers reported that their love for each other decreased over time, with mothers' love decreasing significantly more than fathers'. Mothers reported more conflict than fathers did, but levels of conflict increased for both mothers and fathers with time.

Parenting difficulties in the intervention group were less strongly associated with the quality of the couple's relationship, which was not the case with couples in the control group, Ms. Kan noted.