Elaine Zablocki

SPARKS, NEV. — Many patients with “normal” levels of LDL cholesterol go on to develop heart disease. “LDL cholesterol is an okay, but not great, predictor of coronary risk,” Dr. James A. Underberg said at the annual meeting of the American College of Preventive Medicine.

He urged physicians to look at nontraditional biomarkers that offer new insight into coronary risk and the disease process.

With LDL cholesterol, particle size is not a predictor of risk, said Dr. Underberg, president of the New York Preventive Cardiovascular Society. Instead, “particle number is a predictor and is driving the risk in these patients,” he said.

The problem is that LDL cholesterol concentrations often fail to reflect the number of LDL particles and the coronary disease risk associated with them; the number of LDL particles varies widely among patients with similar LDL cholesterol levels.

Several treatments are available for lowering the number of LDL particles, including statins, bile acid sequestrants, niacin, fibrates, and cholesterol absorption inhibitors.

“Counseling about dietary and lifestyle changes tends to get lost in the rush of daily practice because it takes time, but I think it's important,” added Dr. Underberg, also of New York University.

“Please note that recommended dietary changes should emphasize fiber and plant phytosterols, not just a low-fat, low-cholesterol diet.”

Dr. Underberg also reviewed the importance of lipoprotein (a) as a nontraditional biomarker in cardiovascular risk assessment. It has limited utility as a screening test, but can be a useful measure in patients with a family history of premature coronary disease.

When other risk factors are at an intermediate level, lipoprotein (a) can be useful in deciding how aggressively to treat. Once it has been tested, there is no need to repeat the measurement because it doesn't vary greatly over time.

The high-sensitivity C-reactive protein (CRP) test is another nontraditional but valuable method for assessing cardiovascular risk. CRP is involved in a variety of processes, and probably plays a role in the development of atherosclerosis.

It also helps in predicting coronary risk, and can be used as a prognostic indicator in acute MI. CRP levels do fluctuate, so it is reasonable to repeat this test after 2–3 weeks.

For example, CRP levels can increase in a variety of inflammatory conditions, including acute illness and viral infection, and after dental work.

Physicians should be more aggressive when considering statin use in younger women whose risk justifies use of these drugs.

The Food and Drug Administration requires a “do not use if you are pregnant or breastfeeding” label on prescription statins because of concerns about teratogenic effects. “Many younger women at high risk for cardiac problems are undertreated,” Dr. Underberg said.

“Many older women are not counseled about pregnancy risk when using statins, and they should be because they may still be considering childbearing,” he added.

Dr. Underberg encouraged physicians to discuss this issue with their patients. In order to treat a younger, high-risk, sexually active woman with statins, consider informed consent and an agreement about use of birth control. If her plans change, then the woman should stop using statins 2–3 months before stopping birth control. Consider hydrophilic statins (pravastatin and rosuvastatin) for use in women of childbearing age, since these drugs are less likely to pass the blood-placenta barrier.

Dr. Underberg is on the speakers' bureau and/or receives research funding or consulting fees from the following companies: Pfizer Inc., AstraZeneca, Sankyo Co., LipoScience Inc., DiaDexus Inc., and Forest Laboratories Inc.

SPARKS, NEV. — Many patients with “normal” levels of LDL cholesterol go on to develop heart disease. “LDL cholesterol is an okay, but not great, predictor of coronary risk,” Dr. James A. Underberg said at the annual meeting of the American College of Preventive Medicine.

He urged physicians to look at nontraditional biomarkers that offer new insight into coronary risk and the disease process.

With LDL cholesterol, particle size is not a predictor of risk, said Dr. Underberg, president of the New York Preventive Cardiovascular Society. Instead, “particle number is a predictor and is driving the risk in these patients,” he said.

The problem is that LDL cholesterol concentrations often fail to reflect the number of LDL particles and the coronary disease risk associated with them; the number of LDL particles varies widely among patients with similar LDL cholesterol levels.

Several treatments are available for lowering the number of LDL particles, including statins, bile acid sequestrants, niacin, fibrates, and cholesterol absorption inhibitors.

“Counseling about dietary and lifestyle changes tends to get lost in the rush of daily practice because it takes time, but I think it's important,” added Dr. Underberg, also of New York University.

“Please note that recommended dietary changes should emphasize fiber and plant phytosterols, not just a low-fat, low-cholesterol diet.”

Dr. Underberg also reviewed the importance of lipoprotein (a) as a nontraditional biomarker in cardiovascular risk assessment. It has limited utility as a screening test, but can be a useful measure in patients with a family history of premature coronary disease.

When other risk factors are at an intermediate level, lipoprotein (a) can be useful in deciding how aggressively to treat. Once it has been tested, there is no need to repeat the measurement because it doesn't vary greatly over time.

The high-sensitivity C-reactive protein (CRP) test is another nontraditional but valuable method for assessing cardiovascular risk. CRP is involved in a variety of processes, and probably plays a role in the development of atherosclerosis.

It also helps in predicting coronary risk, and can be used as a prognostic indicator in acute MI. CRP levels do fluctuate, so it is reasonable to repeat this test after 2–3 weeks.

For example, CRP levels can increase in a variety of inflammatory conditions, including acute illness and viral infection, and after dental work.

Physicians should be more aggressive when considering statin use in younger women whose risk justifies use of these drugs.

The Food and Drug Administration requires a “do not use if you are pregnant or breastfeeding” label on prescription statins because of concerns about teratogenic effects. “Many younger women at high risk for cardiac problems are undertreated,” Dr. Underberg said.

“Many older women are not counseled about pregnancy risk when using statins, and they should be because they may still be considering childbearing,” he added.

Dr. Underberg encouraged physicians to discuss this issue with their patients. In order to treat a younger, high-risk, sexually active woman with statins, consider informed consent and an agreement about use of birth control. If her plans change, then the woman should stop using statins 2–3 months before stopping birth control. Consider hydrophilic statins (pravastatin and rosuvastatin) for use in women of childbearing age, since these drugs are less likely to pass the blood-placenta barrier.

Dr. Underberg is on the speakers' bureau and/or receives research funding or consulting fees from the following companies: Pfizer Inc., AstraZeneca, Sankyo Co., LipoScience Inc., DiaDexus Inc., and Forest Laboratories Inc.

SPARKS, NEV. — Many patients with “normal” levels of LDL cholesterol go on to develop heart disease. “LDL cholesterol is an okay, but not great, predictor of coronary risk,” Dr. James A. Underberg said at the annual meeting of the American College of Preventive Medicine.

He urged physicians to look at nontraditional biomarkers that offer new insight into coronary risk and the disease process.

With LDL cholesterol, particle size is not a predictor of risk, said Dr. Underberg, president of the New York Preventive Cardiovascular Society. Instead, “particle number is a predictor and is driving the risk in these patients,” he said.

The problem is that LDL cholesterol concentrations often fail to reflect the number of LDL particles and the coronary disease risk associated with them; the number of LDL particles varies widely among patients with similar LDL cholesterol levels.

Several treatments are available for lowering the number of LDL particles, including statins, bile acid sequestrants, niacin, fibrates, and cholesterol absorption inhibitors.

“Counseling about dietary and lifestyle changes tends to get lost in the rush of daily practice because it takes time, but I think it's important,” added Dr. Underberg, also of New York University.

“Please note that recommended dietary changes should emphasize fiber and plant phytosterols, not just a low-fat, low-cholesterol diet.”

Dr. Underberg also reviewed the importance of lipoprotein (a) as a nontraditional biomarker in cardiovascular risk assessment. It has limited utility as a screening test, but can be a useful measure in patients with a family history of premature coronary disease.

When other risk factors are at an intermediate level, lipoprotein (a) can be useful in deciding how aggressively to treat. Once it has been tested, there is no need to repeat the measurement because it doesn't vary greatly over time.

The high-sensitivity C-reactive protein (CRP) test is another nontraditional but valuable method for assessing cardiovascular risk. CRP is involved in a variety of processes, and probably plays a role in the development of atherosclerosis.

It also helps in predicting coronary risk, and can be used as a prognostic indicator in acute MI. CRP levels do fluctuate, so it is reasonable to repeat this test after 2–3 weeks.

For example, CRP levels can increase in a variety of inflammatory conditions, including acute illness and viral infection, and after dental work.

Physicians should be more aggressive when considering statin use in younger women whose risk justifies use of these drugs.

The Food and Drug Administration requires a “do not use if you are pregnant or breastfeeding” label on prescription statins because of concerns about teratogenic effects. “Many younger women at high risk for cardiac problems are undertreated,” Dr. Underberg said.

“Many older women are not counseled about pregnancy risk when using statins, and they should be because they may still be considering childbearing,” he added.

Dr. Underberg encouraged physicians to discuss this issue with their patients. In order to treat a younger, high-risk, sexually active woman with statins, consider informed consent and an agreement about use of birth control. If her plans change, then the woman should stop using statins 2–3 months before stopping birth control. Consider hydrophilic statins (pravastatin and rosuvastatin) for use in women of childbearing age, since these drugs are less likely to pass the blood-placenta barrier.

Dr. Underberg is on the speakers' bureau and/or receives research funding or consulting fees from the following companies: Pfizer Inc., AstraZeneca, Sankyo Co., LipoScience Inc., DiaDexus Inc., and Forest Laboratories Inc.

SPARKS, NEV. – Pathological gambling is a serious and increasingly prevalent addiction, but it is treatable–particularly with group therapy, Denise F. Quirk said at the annual meeting of the American College of Preventive Medicine.

During the last decade, restrictions on gambling have eased substantially. Today, the only states that do not have some form of legalized gambling are Utah and Hawaii. At the same time, Internet-based “casinos” have dramatically increased accessibility.

This can be particularly problematic for young people who would otherwise encounter age restrictions, said Ms. Quirk, who is a certified problem gambling counselor and the assistant clinical director of the Problem Gambling Center in Reno.

For many patients, psychotherapy combined with active participation in Gamblers Anonymous has proved effective, Ms. Quirk said.

Only 8 or 10 states offer inpatient or intensive outpatient treatment for pathological gambling. Ms. Quirk refers patients who need residential treatment to the Center of Recovery in Shreveport, La. “I have sent several clients there and they've done well,” Ms. Quirk said in an interview. “They have state funding, so most clients can get 4 weeks of residential treatment for about $3,000.”

Intensive outpatient treatment typically takes 2.5 hours a day, 4 days a week, for 6 weeks. Patients meet for group therapy, with a few individual appointments included. Cognitive-behavioral therapies are effective, she said, and “group therapy works very well for these patients,” she said.

“There are so many delusional and irrational beliefs associated with gambling, and those patterns must be confronted during therapy. Another gambler can sniff out irrational thinking and say directly: 'You're slipping; you want to get back into the action.'”

Two questions are helpful for screening someone with a suspected problem: “Do you lie about any aspect of your gambling?” and “Have you bet more than you intended?” said Ms. Quirk, who is also an advisory board member of the Nevada Council on Problem Gambling.

For a more detailed screening, she recommended using the DSM-IV criteria for pathological gambling (see box).

Families dealing with an Internet-based problem should put the computer in a public space, so it's relatively easy to see how people are using it.

Parents should check the browser history, so they can see what sites have been visited, Ms. Quirk suggested. “They should pay a reasonable degree of attention to their credit card usage, so they notice any unusual debts,” she said.

In any year, about 1% of the U.S. population experiences a condition known as “pathological” or “compulsive” gambling, a progressive addiction characterized by an increasing preoccupation with gambling, a need to bet more money more frequently, and restlessness or irritability when attempting to stop.

A national survey found that about 14% of adults have never gambled; 75% are low-risk, social gamblers; nearly 8% are at risk; and 1.2% are pathological gamblers. Problem gamblers, who meet one or more of the criteria for pathological gambling and are experiencing problems due to their gambling behavior, constitute another 1.5% of the adult population.

Problem gambling typically results in difficulties in personal, social, and work lives and can lead to depression, anxiety, and stress. For example, one study found that 32% of pathological gamblers and 36% of problem gamblers had been arrested, compared with 4.5% of those who had never gambled.

In another comparison, 53% of pathological gamblers and 40% of problem gamblers had been divorced, compared with 18% of those who had never gambled. Approximately 19% of pathological gamblers and 10% of problem gamblers had had mental health treatment, compared with 4% of those who had never gambled.

To find local treatment resources for gamblers, Ms. Quirk suggested calling a 24-hour national helpline, maintained by the National Council on Problem Gambling, at 800-522-4700. For more information, she recommends the National Council on Problem Gambling's Web site, www.ncpgambling.orgwww.nevadacouncil.org

DSM-IV Criteria For Pathology

The patient who has a diagnosis of pathological gambling:

▸ Is preoccupied with gambling. He or she relives past gambling experiences, plans the next venture, or thinks of ways to get gambling money.

▸ Needs increasing amounts of money for gambling to achieve the desired level of excitement.

▸ Loses control (has made repeated unsuccessful efforts to reduce or stop gambling).

▸ Is restless or irritable when attempting to reduce or stop gambling.

▸ Gambles to escape problems or relieve feelings of helplessness, guilt, anxiety, or depression.

▸ After losing money, returns another day to get even (known as “chasing” one's losses).

▸ Lies to family members, therapists, or others to conceal the extent of the gambling.

▸ Has committed illegal acts (forgery, fraud, theft, or embezzlement) to finance gambling.

▸ Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling.

▸ Seeks bailouts or relies on others to provide money to relieve a desperate financial situation caused by gambling.

SPARKS, NEV. – Pathological gambling is a serious and increasingly prevalent addiction, but it is treatable–particularly with group therapy, Denise F. Quirk said at the annual meeting of the American College of Preventive Medicine.

During the last decade, restrictions on gambling have eased substantially. Today, the only states that do not have some form of legalized gambling are Utah and Hawaii. At the same time, Internet-based “casinos” have dramatically increased accessibility.

This can be particularly problematic for young people who would otherwise encounter age restrictions, said Ms. Quirk, who is a certified problem gambling counselor and the assistant clinical director of the Problem Gambling Center in Reno.

For many patients, psychotherapy combined with active participation in Gamblers Anonymous has proved effective, Ms. Quirk said.

Only 8 or 10 states offer inpatient or intensive outpatient treatment for pathological gambling. Ms. Quirk refers patients who need residential treatment to the Center of Recovery in Shreveport, La. “I have sent several clients there and they've done well,” Ms. Quirk said in an interview. “They have state funding, so most clients can get 4 weeks of residential treatment for about $3,000.”

Intensive outpatient treatment typically takes 2.5 hours a day, 4 days a week, for 6 weeks. Patients meet for group therapy, with a few individual appointments included. Cognitive-behavioral therapies are effective, she said, and “group therapy works very well for these patients,” she said.

“There are so many delusional and irrational beliefs associated with gambling, and those patterns must be confronted during therapy. Another gambler can sniff out irrational thinking and say directly: 'You're slipping; you want to get back into the action.'”

Two questions are helpful for screening someone with a suspected problem: “Do you lie about any aspect of your gambling?” and “Have you bet more than you intended?” said Ms. Quirk, who is also an advisory board member of the Nevada Council on Problem Gambling.

For a more detailed screening, she recommended using the DSM-IV criteria for pathological gambling (see box).

Families dealing with an Internet-based problem should put the computer in a public space, so it's relatively easy to see how people are using it.

Parents should check the browser history, so they can see what sites have been visited, Ms. Quirk suggested. “They should pay a reasonable degree of attention to their credit card usage, so they notice any unusual debts,” she said.

In any year, about 1% of the U.S. population experiences a condition known as “pathological” or “compulsive” gambling, a progressive addiction characterized by an increasing preoccupation with gambling, a need to bet more money more frequently, and restlessness or irritability when attempting to stop.

A national survey found that about 14% of adults have never gambled; 75% are low-risk, social gamblers; nearly 8% are at risk; and 1.2% are pathological gamblers. Problem gamblers, who meet one or more of the criteria for pathological gambling and are experiencing problems due to their gambling behavior, constitute another 1.5% of the adult population.

Problem gambling typically results in difficulties in personal, social, and work lives and can lead to depression, anxiety, and stress. For example, one study found that 32% of pathological gamblers and 36% of problem gamblers had been arrested, compared with 4.5% of those who had never gambled.

In another comparison, 53% of pathological gamblers and 40% of problem gamblers had been divorced, compared with 18% of those who had never gambled. Approximately 19% of pathological gamblers and 10% of problem gamblers had had mental health treatment, compared with 4% of those who had never gambled.

To find local treatment resources for gamblers, Ms. Quirk suggested calling a 24-hour national helpline, maintained by the National Council on Problem Gambling, at 800-522-4700. For more information, she recommends the National Council on Problem Gambling's Web site, www.ncpgambling.orgwww.nevadacouncil.org

DSM-IV Criteria For Pathology

The patient who has a diagnosis of pathological gambling:

▸ Is preoccupied with gambling. He or she relives past gambling experiences, plans the next venture, or thinks of ways to get gambling money.

▸ Needs increasing amounts of money for gambling to achieve the desired level of excitement.

▸ Loses control (has made repeated unsuccessful efforts to reduce or stop gambling).

▸ Is restless or irritable when attempting to reduce or stop gambling.

▸ Gambles to escape problems or relieve feelings of helplessness, guilt, anxiety, or depression.

▸ After losing money, returns another day to get even (known as “chasing” one's losses).

▸ Lies to family members, therapists, or others to conceal the extent of the gambling.

▸ Has committed illegal acts (forgery, fraud, theft, or embezzlement) to finance gambling.

▸ Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling.

▸ Seeks bailouts or relies on others to provide money to relieve a desperate financial situation caused by gambling.

SPARKS, NEV. – Pathological gambling is a serious and increasingly prevalent addiction, but it is treatable–particularly with group therapy, Denise F. Quirk said at the annual meeting of the American College of Preventive Medicine.

During the last decade, restrictions on gambling have eased substantially. Today, the only states that do not have some form of legalized gambling are Utah and Hawaii. At the same time, Internet-based “casinos” have dramatically increased accessibility.

This can be particularly problematic for young people who would otherwise encounter age restrictions, said Ms. Quirk, who is a certified problem gambling counselor and the assistant clinical director of the Problem Gambling Center in Reno.

For many patients, psychotherapy combined with active participation in Gamblers Anonymous has proved effective, Ms. Quirk said.

Only 8 or 10 states offer inpatient or intensive outpatient treatment for pathological gambling. Ms. Quirk refers patients who need residential treatment to the Center of Recovery in Shreveport, La. “I have sent several clients there and they've done well,” Ms. Quirk said in an interview. “They have state funding, so most clients can get 4 weeks of residential treatment for about $3,000.”

Intensive outpatient treatment typically takes 2.5 hours a day, 4 days a week, for 6 weeks. Patients meet for group therapy, with a few individual appointments included. Cognitive-behavioral therapies are effective, she said, and “group therapy works very well for these patients,” she said.

“There are so many delusional and irrational beliefs associated with gambling, and those patterns must be confronted during therapy. Another gambler can sniff out irrational thinking and say directly: 'You're slipping; you want to get back into the action.'”

Two questions are helpful for screening someone with a suspected problem: “Do you lie about any aspect of your gambling?” and “Have you bet more than you intended?” said Ms. Quirk, who is also an advisory board member of the Nevada Council on Problem Gambling.

For a more detailed screening, she recommended using the DSM-IV criteria for pathological gambling (see box).

Families dealing with an Internet-based problem should put the computer in a public space, so it's relatively easy to see how people are using it.

Parents should check the browser history, so they can see what sites have been visited, Ms. Quirk suggested. “They should pay a reasonable degree of attention to their credit card usage, so they notice any unusual debts,” she said.

In any year, about 1% of the U.S. population experiences a condition known as “pathological” or “compulsive” gambling, a progressive addiction characterized by an increasing preoccupation with gambling, a need to bet more money more frequently, and restlessness or irritability when attempting to stop.

A national survey found that about 14% of adults have never gambled; 75% are low-risk, social gamblers; nearly 8% are at risk; and 1.2% are pathological gamblers. Problem gamblers, who meet one or more of the criteria for pathological gambling and are experiencing problems due to their gambling behavior, constitute another 1.5% of the adult population.

Problem gambling typically results in difficulties in personal, social, and work lives and can lead to depression, anxiety, and stress. For example, one study found that 32% of pathological gamblers and 36% of problem gamblers had been arrested, compared with 4.5% of those who had never gambled.

In another comparison, 53% of pathological gamblers and 40% of problem gamblers had been divorced, compared with 18% of those who had never gambled. Approximately 19% of pathological gamblers and 10% of problem gamblers had had mental health treatment, compared with 4% of those who had never gambled.

To find local treatment resources for gamblers, Ms. Quirk suggested calling a 24-hour national helpline, maintained by the National Council on Problem Gambling, at 800-522-4700. For more information, she recommends the National Council on Problem Gambling's Web site, www.ncpgambling.orgwww.nevadacouncil.org

DSM-IV Criteria For Pathology

The patient who has a diagnosis of pathological gambling:

▸ Is preoccupied with gambling. He or she relives past gambling experiences, plans the next venture, or thinks of ways to get gambling money.

▸ Needs increasing amounts of money for gambling to achieve the desired level of excitement.

▸ Loses control (has made repeated unsuccessful efforts to reduce or stop gambling).

▸ Is restless or irritable when attempting to reduce or stop gambling.

▸ Gambles to escape problems or relieve feelings of helplessness, guilt, anxiety, or depression.

▸ After losing money, returns another day to get even (known as “chasing” one's losses).

▸ Lies to family members, therapists, or others to conceal the extent of the gambling.

▸ Has committed illegal acts (forgery, fraud, theft, or embezzlement) to finance gambling.

▸ Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling.

▸ Seeks bailouts or relies on others to provide money to relieve a desperate financial situation caused by gambling.

SPARKS, NEV. — Many patients with “normal” levels of LDL cholesterol go on to develop heart disease. “It is an okay but not great predictor of coronary risk,” Dr. James A. Underberg said at the annual meeting of the American College of Preventive Medicine.

He urged physicians to look at nontraditional biomarkers that offer new insight into coronary risk and the disease process.

With LDL cholesterol, particle size is not a predictor of risk, said Dr. Underberg, president of the New York Preventive Cardiovascular Society. Instead, “particle number is a predictor and is driving the risk in these patients,” he said.

The problem is that LDL cholesterol concentrations often fail to reflect the number of LDL particles and the coronary disease risk associated with them; the number of LDL particles varies widely among patients with similar LDL cholesterol levels. Several treatments are available for lowering the number of LDL particles, including statins, bile acid sequestrants, niacin, fibrates, and cholesterol absorption inhibitors.

“Counseling about dietary and lifestyle changes tends to get lost in the rush of daily practice because it takes time, but I think it's important,” added Dr. Underberg, also of New York University. “Please note that recommended dietary changes should emphasize fiber and plant phytosterols, not just a low-fat, low-cholesterol diet.”

Dr. Underberg also reviewed the importance of lipoprotein (a) as a nontraditional biomarker in cardiovascular risk assessment. It has limited utility as a screening test, but can be a useful measure in patients with a family history of premature coronary disease.

When other risk factors are at an intermediate level, lipoprotein (a) can be useful in deciding how aggressively to treat. Once it has been tested, there is no need to repeat the measurement because it doesn't vary greatly over time.

The high-sensitivity C-reactive protein (CRP) test is another nontraditional but valuable method for assessing cardiovascular risk. CRP is involved in a variety of processes, and probably plays a role in the development of atherosclerosis.

CRP helps to predict coronary risk, and can be used as a prognostic indicator in acute MI. CRP levels do fluctuate, so it is reasonable to repeat this test after 2–3 weeks. For example, CRP levels rise in various inflammatory conditions including acute illness and viral infection, and after dental work.

Physicians should be more aggressive when considering statin use in younger women whose risk justifies use of these drugs. The Food and Drug Administration requires a “do not use if you are pregnant or breast-feeding” label on prescription statins because of concerns about teratogenic effects. “Many younger women at high risk for cardiac problems are undertreated,” Dr. Underberg said.

“Many older women are not counseled about pregnancy risk when using statins, and they should be because they may still be considering childbearing,” he added.

He encouraged physicians to discuss this issue with their patients. In order to treat a younger, high-risk, sexually active woman with statins, consider informed consent and an agreement about use of birth control. If her plans change, the woman should stop using statins 2–3 months before stopping birth control. Consider hydrophilic statins (pravastatin and rosuvastatin) for use in women of childbearing age, since these drugs are less likely to pass the blood-placenta barrier.

Dr. Underberg is on the speakers' bureau and/or receives research funding or consulting fees from Pfizer Inc., AstraZeneca, Sankyo Co., LipoScience Inc., DiaDexus Inc., and Forest Laboratories Inc.

SPARKS, NEV. — Many patients with “normal” levels of LDL cholesterol go on to develop heart disease. “It is an okay but not great predictor of coronary risk,” Dr. James A. Underberg said at the annual meeting of the American College of Preventive Medicine.

He urged physicians to look at nontraditional biomarkers that offer new insight into coronary risk and the disease process.

With LDL cholesterol, particle size is not a predictor of risk, said Dr. Underberg, president of the New York Preventive Cardiovascular Society. Instead, “particle number is a predictor and is driving the risk in these patients,” he said.

The problem is that LDL cholesterol concentrations often fail to reflect the number of LDL particles and the coronary disease risk associated with them; the number of LDL particles varies widely among patients with similar LDL cholesterol levels. Several treatments are available for lowering the number of LDL particles, including statins, bile acid sequestrants, niacin, fibrates, and cholesterol absorption inhibitors.

“Counseling about dietary and lifestyle changes tends to get lost in the rush of daily practice because it takes time, but I think it's important,” added Dr. Underberg, also of New York University. “Please note that recommended dietary changes should emphasize fiber and plant phytosterols, not just a low-fat, low-cholesterol diet.”

Dr. Underberg also reviewed the importance of lipoprotein (a) as a nontraditional biomarker in cardiovascular risk assessment. It has limited utility as a screening test, but can be a useful measure in patients with a family history of premature coronary disease.

When other risk factors are at an intermediate level, lipoprotein (a) can be useful in deciding how aggressively to treat. Once it has been tested, there is no need to repeat the measurement because it doesn't vary greatly over time.

The high-sensitivity C-reactive protein (CRP) test is another nontraditional but valuable method for assessing cardiovascular risk. CRP is involved in a variety of processes, and probably plays a role in the development of atherosclerosis.

CRP helps to predict coronary risk, and can be used as a prognostic indicator in acute MI. CRP levels do fluctuate, so it is reasonable to repeat this test after 2–3 weeks. For example, CRP levels rise in various inflammatory conditions including acute illness and viral infection, and after dental work.

Physicians should be more aggressive when considering statin use in younger women whose risk justifies use of these drugs. The Food and Drug Administration requires a “do not use if you are pregnant or breast-feeding” label on prescription statins because of concerns about teratogenic effects. “Many younger women at high risk for cardiac problems are undertreated,” Dr. Underberg said.

“Many older women are not counseled about pregnancy risk when using statins, and they should be because they may still be considering childbearing,” he added.

He encouraged physicians to discuss this issue with their patients. In order to treat a younger, high-risk, sexually active woman with statins, consider informed consent and an agreement about use of birth control. If her plans change, the woman should stop using statins 2–3 months before stopping birth control. Consider hydrophilic statins (pravastatin and rosuvastatin) for use in women of childbearing age, since these drugs are less likely to pass the blood-placenta barrier.

Dr. Underberg is on the speakers' bureau and/or receives research funding or consulting fees from Pfizer Inc., AstraZeneca, Sankyo Co., LipoScience Inc., DiaDexus Inc., and Forest Laboratories Inc.

SPARKS, NEV. — Many patients with “normal” levels of LDL cholesterol go on to develop heart disease. “It is an okay but not great predictor of coronary risk,” Dr. James A. Underberg said at the annual meeting of the American College of Preventive Medicine.

He urged physicians to look at nontraditional biomarkers that offer new insight into coronary risk and the disease process.

With LDL cholesterol, particle size is not a predictor of risk, said Dr. Underberg, president of the New York Preventive Cardiovascular Society. Instead, “particle number is a predictor and is driving the risk in these patients,” he said.

The problem is that LDL cholesterol concentrations often fail to reflect the number of LDL particles and the coronary disease risk associated with them; the number of LDL particles varies widely among patients with similar LDL cholesterol levels. Several treatments are available for lowering the number of LDL particles, including statins, bile acid sequestrants, niacin, fibrates, and cholesterol absorption inhibitors.

“Counseling about dietary and lifestyle changes tends to get lost in the rush of daily practice because it takes time, but I think it's important,” added Dr. Underberg, also of New York University. “Please note that recommended dietary changes should emphasize fiber and plant phytosterols, not just a low-fat, low-cholesterol diet.”

Dr. Underberg also reviewed the importance of lipoprotein (a) as a nontraditional biomarker in cardiovascular risk assessment. It has limited utility as a screening test, but can be a useful measure in patients with a family history of premature coronary disease.

When other risk factors are at an intermediate level, lipoprotein (a) can be useful in deciding how aggressively to treat. Once it has been tested, there is no need to repeat the measurement because it doesn't vary greatly over time.

The high-sensitivity C-reactive protein (CRP) test is another nontraditional but valuable method for assessing cardiovascular risk. CRP is involved in a variety of processes, and probably plays a role in the development of atherosclerosis.

CRP helps to predict coronary risk, and can be used as a prognostic indicator in acute MI. CRP levels do fluctuate, so it is reasonable to repeat this test after 2–3 weeks. For example, CRP levels rise in various inflammatory conditions including acute illness and viral infection, and after dental work.

Physicians should be more aggressive when considering statin use in younger women whose risk justifies use of these drugs. The Food and Drug Administration requires a “do not use if you are pregnant or breast-feeding” label on prescription statins because of concerns about teratogenic effects. “Many younger women at high risk for cardiac problems are undertreated,” Dr. Underberg said.

“Many older women are not counseled about pregnancy risk when using statins, and they should be because they may still be considering childbearing,” he added.

He encouraged physicians to discuss this issue with their patients. In order to treat a younger, high-risk, sexually active woman with statins, consider informed consent and an agreement about use of birth control. If her plans change, the woman should stop using statins 2–3 months before stopping birth control. Consider hydrophilic statins (pravastatin and rosuvastatin) for use in women of childbearing age, since these drugs are less likely to pass the blood-placenta barrier.

Dr. Underberg is on the speakers' bureau and/or receives research funding or consulting fees from Pfizer Inc., AstraZeneca, Sankyo Co., LipoScience Inc., DiaDexus Inc., and Forest Laboratories Inc.

SPARKS, NEV. — Pathological gambling is a serious and increasingly prevalent addiction, Denise F. Quirk said at the annual meeting of the American College of Preventive Medicine.

During the last decade, restrictions on gambling have eased substantially. Today, the only states that do not have some form of legalized gambling are Utah and Hawaii. At the same time, Internet-based “casinos” have dramatically increased accessibility. This can be particularly problematic for young people who would otherwise encounter age restrictions, said Ms. Quirk, a certified problem gambling counselor and the assistant clinical director of the Problem Gambling Center in Reno.

Two questions are helpful for screening someone with a suspected problem: “Do you lie about any aspect of your gambling?” and “Have you bet more than you intended?” said Ms. Quirk, who is also an advisory board member of the Nevada Council on Problem Gambling.

For a more detailed screening, she recommended using the DSM-IV criteria for pathological gambling (see box).

Families dealing with an Internet-based problem should put the computer in a public space, so it's relatively easy to see how people are using it. Parents should check the browser history, so they can see what sites have been visited, Ms. Quirk suggested. “They should pay a reasonable degree of attention to their credit card usage, so they notice any unusual debts,” she said.

In any year, about 1% of the U.S. population experiences a condition known as “pathological” or “compulsive” gambling, a progressive addiction characterized by an increasing preoccupation with gambling, a need to bet more money more frequently, and restlessness or irritability when attempting to stop.

A national survey found that about 14% of adults have never gambled; 75% are low-risk, social gamblers; nearly 8% are at risk; and 1.2% are pathological gamblers. Problem gamblers, who meet one or more of the criteria for pathological gambling and are experiencing problems due to their gambling behavior, constitute another 1.5% of the adult population.

Problem gambling typically results in difficulties in personal, social, and work lives and can lead to depression, anxiety, and stress. For example, one study found that 32% of pathological gamblers and 36% of problem gamblers had been arrested, compared with 4.5% of those who had never gambled.

In another comparison, 53% of pathological gamblers and 40% of problem gamblers had been divorced, compared with 18% of those who had never gambled. About 19% of pathological gamblers and 10% of problem gamblers had had mental health treatment, compared with 4% of those who had never gambled.

Compulsive gambling is a treatable disorder. For many patients, psychotherapy combined with active participation in Gamblers Anonymous has proved effective, Ms. Quirk said. Only 8 or 10 states offer inpatient or intensive outpatient treatment for pathological gambling. Ms. Quirk refers patients who need residential treatment to the Center of Recovery in Shreveport, La. “I have sent several clients there and they've done well,” Ms. Quirk said in an interview. “They have state funding, so most clients can get 4 weeks of residential treatment for about $3,000.”

Intensive outpatient treatment typically takes 2.5 hours a day, 4 days a week, for 6 weeks. Patients meet for group therapy, with a few individual appointments included. Cognitive-behavioral therapies are effective and “group therapy works very well for these patients. There are so many delusional and irrational beliefs associated with gambling, and those patterns must be confronted during therapy. Another gambler can sniff out irrational thinking and say directly: 'You're slipping; you want to get back into the action.'”

To find local treatment resources for gamblers, call the National Council on Problem Gambling's 24-hour helpline, 800-522-4700. For more information, visit the National Council on Problem Gambling's Web site, www.ncpgambling.orgwww.nevadacouncil.org

DSM-IV Criteria

The patient with a diagnosis of pathological gambling:

▸ Is preoccupied with gambling (relives past gambling experiences, plans the next venture, or thinks of ways to get gambling money).

▸ Needs increasing amounts of money for gambling to achieve the desired level of excitement.

▸ Loses control (has made repeated unsuccessful efforts to reduce or stop gambling).

▸ Is restless or irritable when attempting to reduce or stop gambling.

▸ Gambles to escape problems or relieve feelings of helplessness, guilt, anxiety, or depression.

▸ After losing money, returns another day to get even (known as “chasing” one's losses).

▸ Lies to family members, therapists, or others to conceal the extent of the gambling.

▸ Has committed illegal acts (forgery, fraud, theft, or embezzlement) to finance gambling.

▸ Has jeopardized or lost a relationship, job, or educational or career opportunity because of gambling.

▸ Seeks bailouts or relies on others for money to relieve a desperate financial situation caused by gambling.

SPARKS, NEV. — Pathological gambling is a serious and increasingly prevalent addiction, Denise F. Quirk said at the annual meeting of the American College of Preventive Medicine.

During the last decade, restrictions on gambling have eased substantially. Today, the only states that do not have some form of legalized gambling are Utah and Hawaii. At the same time, Internet-based “casinos” have dramatically increased accessibility. This can be particularly problematic for young people who would otherwise encounter age restrictions, said Ms. Quirk, a certified problem gambling counselor and the assistant clinical director of the Problem Gambling Center in Reno.

Two questions are helpful for screening someone with a suspected problem: “Do you lie about any aspect of your gambling?” and “Have you bet more than you intended?” said Ms. Quirk, who is also an advisory board member of the Nevada Council on Problem Gambling.

For a more detailed screening, she recommended using the DSM-IV criteria for pathological gambling (see box).

Families dealing with an Internet-based problem should put the computer in a public space, so it's relatively easy to see how people are using it. Parents should check the browser history, so they can see what sites have been visited, Ms. Quirk suggested. “They should pay a reasonable degree of attention to their credit card usage, so they notice any unusual debts,” she said.

In any year, about 1% of the U.S. population experiences a condition known as “pathological” or “compulsive” gambling, a progressive addiction characterized by an increasing preoccupation with gambling, a need to bet more money more frequently, and restlessness or irritability when attempting to stop.

A national survey found that about 14% of adults have never gambled; 75% are low-risk, social gamblers; nearly 8% are at risk; and 1.2% are pathological gamblers. Problem gamblers, who meet one or more of the criteria for pathological gambling and are experiencing problems due to their gambling behavior, constitute another 1.5% of the adult population.

Problem gambling typically results in difficulties in personal, social, and work lives and can lead to depression, anxiety, and stress. For example, one study found that 32% of pathological gamblers and 36% of problem gamblers had been arrested, compared with 4.5% of those who had never gambled.

In another comparison, 53% of pathological gamblers and 40% of problem gamblers had been divorced, compared with 18% of those who had never gambled. About 19% of pathological gamblers and 10% of problem gamblers had had mental health treatment, compared with 4% of those who had never gambled.

Compulsive gambling is a treatable disorder. For many patients, psychotherapy combined with active participation in Gamblers Anonymous has proved effective, Ms. Quirk said. Only 8 or 10 states offer inpatient or intensive outpatient treatment for pathological gambling. Ms. Quirk refers patients who need residential treatment to the Center of Recovery in Shreveport, La. “I have sent several clients there and they've done well,” Ms. Quirk said in an interview. “They have state funding, so most clients can get 4 weeks of residential treatment for about $3,000.”

Intensive outpatient treatment typically takes 2.5 hours a day, 4 days a week, for 6 weeks. Patients meet for group therapy, with a few individual appointments included. Cognitive-behavioral therapies are effective and “group therapy works very well for these patients. There are so many delusional and irrational beliefs associated with gambling, and those patterns must be confronted during therapy. Another gambler can sniff out irrational thinking and say directly: 'You're slipping; you want to get back into the action.'”

To find local treatment resources for gamblers, call the National Council on Problem Gambling's 24-hour helpline, 800-522-4700. For more information, visit the National Council on Problem Gambling's Web site, www.ncpgambling.orgwww.nevadacouncil.org

DSM-IV Criteria

The patient with a diagnosis of pathological gambling:

▸ Is preoccupied with gambling (relives past gambling experiences, plans the next venture, or thinks of ways to get gambling money).

▸ Needs increasing amounts of money for gambling to achieve the desired level of excitement.

▸ Loses control (has made repeated unsuccessful efforts to reduce or stop gambling).

▸ Is restless or irritable when attempting to reduce or stop gambling.

▸ Gambles to escape problems or relieve feelings of helplessness, guilt, anxiety, or depression.

▸ After losing money, returns another day to get even (known as “chasing” one's losses).

▸ Lies to family members, therapists, or others to conceal the extent of the gambling.

▸ Has committed illegal acts (forgery, fraud, theft, or embezzlement) to finance gambling.

▸ Has jeopardized or lost a relationship, job, or educational or career opportunity because of gambling.

▸ Seeks bailouts or relies on others for money to relieve a desperate financial situation caused by gambling.

SPARKS, NEV. — Pathological gambling is a serious and increasingly prevalent addiction, Denise F. Quirk said at the annual meeting of the American College of Preventive Medicine.

During the last decade, restrictions on gambling have eased substantially. Today, the only states that do not have some form of legalized gambling are Utah and Hawaii. At the same time, Internet-based “casinos” have dramatically increased accessibility. This can be particularly problematic for young people who would otherwise encounter age restrictions, said Ms. Quirk, a certified problem gambling counselor and the assistant clinical director of the Problem Gambling Center in Reno.

Two questions are helpful for screening someone with a suspected problem: “Do you lie about any aspect of your gambling?” and “Have you bet more than you intended?” said Ms. Quirk, who is also an advisory board member of the Nevada Council on Problem Gambling.

For a more detailed screening, she recommended using the DSM-IV criteria for pathological gambling (see box).

Families dealing with an Internet-based problem should put the computer in a public space, so it's relatively easy to see how people are using it. Parents should check the browser history, so they can see what sites have been visited, Ms. Quirk suggested. “They should pay a reasonable degree of attention to their credit card usage, so they notice any unusual debts,” she said.

In any year, about 1% of the U.S. population experiences a condition known as “pathological” or “compulsive” gambling, a progressive addiction characterized by an increasing preoccupation with gambling, a need to bet more money more frequently, and restlessness or irritability when attempting to stop.

A national survey found that about 14% of adults have never gambled; 75% are low-risk, social gamblers; nearly 8% are at risk; and 1.2% are pathological gamblers. Problem gamblers, who meet one or more of the criteria for pathological gambling and are experiencing problems due to their gambling behavior, constitute another 1.5% of the adult population.

Problem gambling typically results in difficulties in personal, social, and work lives and can lead to depression, anxiety, and stress. For example, one study found that 32% of pathological gamblers and 36% of problem gamblers had been arrested, compared with 4.5% of those who had never gambled.

In another comparison, 53% of pathological gamblers and 40% of problem gamblers had been divorced, compared with 18% of those who had never gambled. About 19% of pathological gamblers and 10% of problem gamblers had had mental health treatment, compared with 4% of those who had never gambled.

Compulsive gambling is a treatable disorder. For many patients, psychotherapy combined with active participation in Gamblers Anonymous has proved effective, Ms. Quirk said. Only 8 or 10 states offer inpatient or intensive outpatient treatment for pathological gambling. Ms. Quirk refers patients who need residential treatment to the Center of Recovery in Shreveport, La. “I have sent several clients there and they've done well,” Ms. Quirk said in an interview. “They have state funding, so most clients can get 4 weeks of residential treatment for about $3,000.”

Intensive outpatient treatment typically takes 2.5 hours a day, 4 days a week, for 6 weeks. Patients meet for group therapy, with a few individual appointments included. Cognitive-behavioral therapies are effective and “group therapy works very well for these patients. There are so many delusional and irrational beliefs associated with gambling, and those patterns must be confronted during therapy. Another gambler can sniff out irrational thinking and say directly: 'You're slipping; you want to get back into the action.'”

To find local treatment resources for gamblers, call the National Council on Problem Gambling's 24-hour helpline, 800-522-4700. For more information, visit the National Council on Problem Gambling's Web site, www.ncpgambling.orgwww.nevadacouncil.org

DSM-IV Criteria

The patient with a diagnosis of pathological gambling:

▸ Is preoccupied with gambling (relives past gambling experiences, plans the next venture, or thinks of ways to get gambling money).

▸ Needs increasing amounts of money for gambling to achieve the desired level of excitement.

▸ Loses control (has made repeated unsuccessful efforts to reduce or stop gambling).

▸ Is restless or irritable when attempting to reduce or stop gambling.

▸ Gambles to escape problems or relieve feelings of helplessness, guilt, anxiety, or depression.

▸ After losing money, returns another day to get even (known as “chasing” one's losses).

▸ Lies to family members, therapists, or others to conceal the extent of the gambling.

▸ Has committed illegal acts (forgery, fraud, theft, or embezzlement) to finance gambling.

▸ Has jeopardized or lost a relationship, job, or educational or career opportunity because of gambling.

▸ Seeks bailouts or relies on others for money to relieve a desperate financial situation caused by gambling.

RENO, NEV. — A novel screening program developed by researchers in North Carolina was able to identify children at risk for type 2 diabetes or prediabetes, and to facilitate lifestyle interventions, Dr. Elizabeth C. Tilson said at the annual meeting of the American College of Preventive Medicine.

However, the referral rate was lower than expected.

The type 2 diabetes (T2D) program was designed to identify children aged 10–18 years with type 2 diabetes, prediabetes, or metabolic syndrome. Children diagnosed with these conditions were referred to community-based exercise programs. They also participated in eight intensive family education sessions on nutrition, diet, and exercise. After the intervention ended, they were offered continuing membership in exercise programs near their homes, at reduced rates, said Dr. Tilson, medical director of Community Care of Wake/Johnston Counties, a quality improvement care management program for Medicaid patients.

“I think it is really important to set up routine screening criteria and a screening process for diabetes and prediabetes,” Dr. Tilson said in an interview. “With the epidemic of obesity in our children, more and more and more of them are going to have diabetes or prediabetes. It's really important to set up a systematic process so we can find these children early.”

The screening tool was designed to identify children aged 10 years or older with a body mass index (BMI) at the 85th percentile or higher for their age, plus one of the following risk factors: racial/ethnic minority, family history of type 2 diabetes, acanthosis nigricans, or hypertension. Children who met the criteria were referred for an analysis of fasting lipid and blood glucose levels.

The program was supported by a broad community collaboration that included funding from a private foundation, pilot testing through the local health department, and exercise programs at the YMCA and local parks. Screening was conducted by private pediatricians, while most of the lab tests were done at WakeMed Health and Hospitals, a nonprofit hospital system based in Raleigh, N.C. The screening tool was developed by the WakeMed pediatric diabetes program in collaboration with the local public health department and local medical society.

In July 2004, the T2D screening tool was made available to pediatricians in Wake County, N.C. During the next 18 months, 89 physicians in 37 practices referred a total of 747 patients for lab tests. Of those, 81% were screened, and 45% of those who were screened had abnormal lab values. Three cases of type 2 diabetes were diagnosed.

Although the screening form did accurately select children who should be screened for diabetes and prediabetes, the referral rate was lower than expected. Only 8% of children whose BMI was in the 85th–95th percentiles were referred for lab tests, while the referral rate for children with a BMI higher than 95th percentile was 52%. “We were shocked that the referral rate was so low. Because so many children are overweight, it appears we have become desensitized to this issue,” said Dr. Tilson.

The barriers to screening children for type 2 diabetes include physicians' busy schedules and parental resistance, Dr. Tilson said. In the future, the project will work to further identify and reduce barriers to screening.

“The increasing number of referrals shows that [the] T2D [program] and area pediatricians have formed effective partnerships,” she said. “However, the referral rates at present are not what we would like to see. Even when you have a system set up, you still have to work hard to maximize that system and really make sure you're identifying all the at-risk kids.”

For more information and copies of the screening form, e-mail Dr. Tilson at elizabeth.tilson@co.wake.nc.us

RENO, NEV. — A novel screening program developed by researchers in North Carolina was able to identify children at risk for type 2 diabetes or prediabetes, and to facilitate lifestyle interventions, Dr. Elizabeth C. Tilson said at the annual meeting of the American College of Preventive Medicine.

However, the referral rate was lower than expected.

The type 2 diabetes (T2D) program was designed to identify children aged 10–18 years with type 2 diabetes, prediabetes, or metabolic syndrome. Children diagnosed with these conditions were referred to community-based exercise programs. They also participated in eight intensive family education sessions on nutrition, diet, and exercise. After the intervention ended, they were offered continuing membership in exercise programs near their homes, at reduced rates, said Dr. Tilson, medical director of Community Care of Wake/Johnston Counties, a quality improvement care management program for Medicaid patients.

“I think it is really important to set up routine screening criteria and a screening process for diabetes and prediabetes,” Dr. Tilson said in an interview. “With the epidemic of obesity in our children, more and more and more of them are going to have diabetes or prediabetes. It's really important to set up a systematic process so we can find these children early.”

The screening tool was designed to identify children aged 10 years or older with a body mass index (BMI) at the 85th percentile or higher for their age, plus one of the following risk factors: racial/ethnic minority, family history of type 2 diabetes, acanthosis nigricans, or hypertension. Children who met the criteria were referred for an analysis of fasting lipid and blood glucose levels.

The program was supported by a broad community collaboration that included funding from a private foundation, pilot testing through the local health department, and exercise programs at the YMCA and local parks. Screening was conducted by private pediatricians, while most of the lab tests were done at WakeMed Health and Hospitals, a nonprofit hospital system based in Raleigh, N.C. The screening tool was developed by the WakeMed pediatric diabetes program in collaboration with the local public health department and local medical society.

In July 2004, the T2D screening tool was made available to pediatricians in Wake County, N.C. During the next 18 months, 89 physicians in 37 practices referred a total of 747 patients for lab tests. Of those, 81% were screened, and 45% of those who were screened had abnormal lab values. Three cases of type 2 diabetes were diagnosed.

Although the screening form did accurately select children who should be screened for diabetes and prediabetes, the referral rate was lower than expected. Only 8% of children whose BMI was in the 85th–95th percentiles were referred for lab tests, while the referral rate for children with a BMI higher than 95th percentile was 52%. “We were shocked that the referral rate was so low. Because so many children are overweight, it appears we have become desensitized to this issue,” said Dr. Tilson.

The barriers to screening children for type 2 diabetes include physicians' busy schedules and parental resistance, Dr. Tilson said. In the future, the project will work to further identify and reduce barriers to screening.

“The increasing number of referrals shows that [the] T2D [program] and area pediatricians have formed effective partnerships,” she said. “However, the referral rates at present are not what we would like to see. Even when you have a system set up, you still have to work hard to maximize that system and really make sure you're identifying all the at-risk kids.”

For more information and copies of the screening form, e-mail Dr. Tilson at elizabeth.tilson@co.wake.nc.us

RENO, NEV. — A novel screening program developed by researchers in North Carolina was able to identify children at risk for type 2 diabetes or prediabetes, and to facilitate lifestyle interventions, Dr. Elizabeth C. Tilson said at the annual meeting of the American College of Preventive Medicine.

However, the referral rate was lower than expected.

The type 2 diabetes (T2D) program was designed to identify children aged 10–18 years with type 2 diabetes, prediabetes, or metabolic syndrome. Children diagnosed with these conditions were referred to community-based exercise programs. They also participated in eight intensive family education sessions on nutrition, diet, and exercise. After the intervention ended, they were offered continuing membership in exercise programs near their homes, at reduced rates, said Dr. Tilson, medical director of Community Care of Wake/Johnston Counties, a quality improvement care management program for Medicaid patients.

“I think it is really important to set up routine screening criteria and a screening process for diabetes and prediabetes,” Dr. Tilson said in an interview. “With the epidemic of obesity in our children, more and more and more of them are going to have diabetes or prediabetes. It's really important to set up a systematic process so we can find these children early.”

The screening tool was designed to identify children aged 10 years or older with a body mass index (BMI) at the 85th percentile or higher for their age, plus one of the following risk factors: racial/ethnic minority, family history of type 2 diabetes, acanthosis nigricans, or hypertension. Children who met the criteria were referred for an analysis of fasting lipid and blood glucose levels.

The program was supported by a broad community collaboration that included funding from a private foundation, pilot testing through the local health department, and exercise programs at the YMCA and local parks. Screening was conducted by private pediatricians, while most of the lab tests were done at WakeMed Health and Hospitals, a nonprofit hospital system based in Raleigh, N.C. The screening tool was developed by the WakeMed pediatric diabetes program in collaboration with the local public health department and local medical society.

In July 2004, the T2D screening tool was made available to pediatricians in Wake County, N.C. During the next 18 months, 89 physicians in 37 practices referred a total of 747 patients for lab tests. Of those, 81% were screened, and 45% of those who were screened had abnormal lab values. Three cases of type 2 diabetes were diagnosed.

Although the screening form did accurately select children who should be screened for diabetes and prediabetes, the referral rate was lower than expected. Only 8% of children whose BMI was in the 85th–95th percentiles were referred for lab tests, while the referral rate for children with a BMI higher than 95th percentile was 52%. “We were shocked that the referral rate was so low. Because so many children are overweight, it appears we have become desensitized to this issue,” said Dr. Tilson.

The barriers to screening children for type 2 diabetes include physicians' busy schedules and parental resistance, Dr. Tilson said. In the future, the project will work to further identify and reduce barriers to screening.

“The increasing number of referrals shows that [the] T2D [program] and area pediatricians have formed effective partnerships,” she said. “However, the referral rates at present are not what we would like to see. Even when you have a system set up, you still have to work hard to maximize that system and really make sure you're identifying all the at-risk kids.”

For more information and copies of the screening form, e-mail Dr. Tilson at elizabeth.tilson@co.wake.nc.us

Intracapsular tonsillectomy performed with a microdebrider results in less pain and quicker recovery than does tonsillectomy involving electrocautery, Dr. Craig S. Derkay said at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

A study of 300 patients aged 2–17 years found that, compared with the electrocautery group, the microdebrider group returned to normal activities an average of 1.5 days earlier and stopped taking pain medications 2.5 days earlier.

Intracapsular tonsillectomy performed with a microdebrider “seems to result in a quicker recovery and resumption of normal activities than standard tonsillectomy. Because this method leaves the connective tissue capsule intact, the muscles of the pharynx aren't exposed to secretions and food, so patients experience less pain and are able to start eating sooner,” Dr. Derkay, director of pediatric otolaryngology at Eastern Virginia Medical School in Norfolk, said in an interview.

The prospective, single-blind, randomized controlled trial was funded by a grant from Medtronic Inc., which markets the debrider used in the study. A total of 300 children with obstructive sleep disorders were enrolled. Half received tonsillectomy using low-wattage electrocautery (15 watts); half received microdebrider intracapsular tonsillectomy. Adjuvant therapy was standardized, and the only variation was in the instrument used to remove the tonsils.

Dr. Derkay, who disclaimed any financial interest in Medtronic or the device, described the microdebrider as a powered instrument connected to suction and irrigation, with a small blade rotating 2,000 times per minute.

The researchers used validated quality- of-life scales before and after the operation, and a special visual scale (FACES) for younger children. Parents filled out diaries every 12 hours until their children were fully recovered; nurses called them every day with reminders.

Intraoperative blood loss, surgical complications, and emergency department visits were similar in both groups.

The microdebrider method was associated with significantly shorter time needed to return to normal activities (2.5 days vs. 4 days) and to stop taking pain medication (4 days vs. 6.5 days).

Dr. Derkay also reported statistically significant improvements in quality- of-life measures related to emotional distress and activity limitations. “The results in this prospective study confirm favorable results seen in previous retrospective studies,” Dr. Derkay said.

In addition to comparing two different tonsillectomy methods, the researchers followed evidence-based measures to attain the best possible outcomes in both groups.

They used standardized adjuvant therapy including intraoperative and postoperative ampicillin and dexamethasone, and pre- and postincisional bupivacaine. “That resulted in the electrocautery patients actually doing better than we thought they would do,” Dr. Derkay said. “But the microdebrider patients did even better.”

Because most otolaryngologists already use the microdebrider frequently for endoscopic sinus surgery, it will be relatively easy for them to make the transition to this new form of tonsillectomy, Dr. Derkay said in an interview.

Innovations in surgical therapy need to justify their existence via improved outcomes and/or decreased costs, Dr. Derkay said. At his institution there is no additional charge to set up the microdebrider, and the disposable blades cost approximately $100.

Intracapsular tonsillectomy performed with a microdebrider results in less pain and quicker recovery than does tonsillectomy involving electrocautery, Dr. Craig S. Derkay said at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

A study of 300 patients aged 2–17 years found that, compared with the electrocautery group, the microdebrider group returned to normal activities an average of 1.5 days earlier and stopped taking pain medications 2.5 days earlier.

Intracapsular tonsillectomy performed with a microdebrider “seems to result in a quicker recovery and resumption of normal activities than standard tonsillectomy. Because this method leaves the connective tissue capsule intact, the muscles of the pharynx aren't exposed to secretions and food, so patients experience less pain and are able to start eating sooner,” Dr. Derkay, director of pediatric otolaryngology at Eastern Virginia Medical School in Norfolk, said in an interview.

The prospective, single-blind, randomized controlled trial was funded by a grant from Medtronic Inc., which markets the debrider used in the study. A total of 300 children with obstructive sleep disorders were enrolled. Half received tonsillectomy using low-wattage electrocautery (15 watts); half received microdebrider intracapsular tonsillectomy. Adjuvant therapy was standardized, and the only variation was in the instrument used to remove the tonsils.

Dr. Derkay, who disclaimed any financial interest in Medtronic or the device, described the microdebrider as a powered instrument connected to suction and irrigation, with a small blade rotating 2,000 times per minute.

The researchers used validated quality- of-life scales before and after the operation, and a special visual scale (FACES) for younger children. Parents filled out diaries every 12 hours until their children were fully recovered; nurses called them every day with reminders.

Intraoperative blood loss, surgical complications, and emergency department visits were similar in both groups.

The microdebrider method was associated with significantly shorter time needed to return to normal activities (2.5 days vs. 4 days) and to stop taking pain medication (4 days vs. 6.5 days).

Dr. Derkay also reported statistically significant improvements in quality- of-life measures related to emotional distress and activity limitations. “The results in this prospective study confirm favorable results seen in previous retrospective studies,” Dr. Derkay said.

In addition to comparing two different tonsillectomy methods, the researchers followed evidence-based measures to attain the best possible outcomes in both groups.

They used standardized adjuvant therapy including intraoperative and postoperative ampicillin and dexamethasone, and pre- and postincisional bupivacaine. “That resulted in the electrocautery patients actually doing better than we thought they would do,” Dr. Derkay said. “But the microdebrider patients did even better.”

Because most otolaryngologists already use the microdebrider frequently for endoscopic sinus surgery, it will be relatively easy for them to make the transition to this new form of tonsillectomy, Dr. Derkay said in an interview.

Innovations in surgical therapy need to justify their existence via improved outcomes and/or decreased costs, Dr. Derkay said. At his institution there is no additional charge to set up the microdebrider, and the disposable blades cost approximately $100.

Intracapsular tonsillectomy performed with a microdebrider results in less pain and quicker recovery than does tonsillectomy involving electrocautery, Dr. Craig S. Derkay said at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

A study of 300 patients aged 2–17 years found that, compared with the electrocautery group, the microdebrider group returned to normal activities an average of 1.5 days earlier and stopped taking pain medications 2.5 days earlier.

Intracapsular tonsillectomy performed with a microdebrider “seems to result in a quicker recovery and resumption of normal activities than standard tonsillectomy. Because this method leaves the connective tissue capsule intact, the muscles of the pharynx aren't exposed to secretions and food, so patients experience less pain and are able to start eating sooner,” Dr. Derkay, director of pediatric otolaryngology at Eastern Virginia Medical School in Norfolk, said in an interview.

The prospective, single-blind, randomized controlled trial was funded by a grant from Medtronic Inc., which markets the debrider used in the study. A total of 300 children with obstructive sleep disorders were enrolled. Half received tonsillectomy using low-wattage electrocautery (15 watts); half received microdebrider intracapsular tonsillectomy. Adjuvant therapy was standardized, and the only variation was in the instrument used to remove the tonsils.

Dr. Derkay, who disclaimed any financial interest in Medtronic or the device, described the microdebrider as a powered instrument connected to suction and irrigation, with a small blade rotating 2,000 times per minute.

The researchers used validated quality- of-life scales before and after the operation, and a special visual scale (FACES) for younger children. Parents filled out diaries every 12 hours until their children were fully recovered; nurses called them every day with reminders.

Intraoperative blood loss, surgical complications, and emergency department visits were similar in both groups.

The microdebrider method was associated with significantly shorter time needed to return to normal activities (2.5 days vs. 4 days) and to stop taking pain medication (4 days vs. 6.5 days).

Dr. Derkay also reported statistically significant improvements in quality- of-life measures related to emotional distress and activity limitations. “The results in this prospective study confirm favorable results seen in previous retrospective studies,” Dr. Derkay said.

In addition to comparing two different tonsillectomy methods, the researchers followed evidence-based measures to attain the best possible outcomes in both groups.

They used standardized adjuvant therapy including intraoperative and postoperative ampicillin and dexamethasone, and pre- and postincisional bupivacaine. “That resulted in the electrocautery patients actually doing better than we thought they would do,” Dr. Derkay said. “But the microdebrider patients did even better.”

Because most otolaryngologists already use the microdebrider frequently for endoscopic sinus surgery, it will be relatively easy for them to make the transition to this new form of tonsillectomy, Dr. Derkay said in an interview.

Innovations in surgical therapy need to justify their existence via improved outcomes and/or decreased costs, Dr. Derkay said. At his institution there is no additional charge to set up the microdebrider, and the disposable blades cost approximately $100.

LOS ANGELES — Topical ciprofloxacin/dexamethasone is effective in treating acute otitis media with otorrhea through tympanostomy tubes, Dr. Joseph E. Dohar wrote in a poster presentation at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

Topical ciprofloxacin 0.3% and dexamethasone 0.1%, marketed as Ciprodex sterile otic suspension, produced more clinical cures, earlier cessation of otorrhea, and caused fewer side effects than oral amoxicillin/clavulanate potassium (Augmentin), wrote Dr. Dohar, an otolaryngologist at the Children's Hospital of Pittsburgh. Alcon Laboratories, maker of Ciprodex, sponsored the study.

Dr. Dohar is a clinical investigator, consultant, and speaker for the company.

“My personal experience has been extremely favorable when using topical ciprofloxacin/dexamethasone,” Dr. Dohar said in an interview.

“The topical combination is superior to systemic antibiotics, due to better cure rates, more effective killing of bacteria, less treatment-related resistance, and far fewer side effects.”

In this observer-masked, prospective multicenter trial, 80 children aged 6 months to 8 years (mean 2 years) with acute otitis media and otorrhea were randomized to treatment with either topical ciprofloxacin/dexamethasone drops or a 5-mL oral suspension of 600 mg amoxicillin/42.9 mg clavulanate potassium.

The median time to cessation of otorrhea was 4 days in the ciprofloxacin/dexamethasone group and 7 days in the amoxicillin/clavulanic acid group.

Ciprofloxacin/dexamethasone also had fewer side effects.

Of the children receiving the drops, 5% complained of ear pain, compared with 20% of children taking the suspension had diarrhea.

The treatment failure rate was 17% for ciprofloxacin/dexamethasone and 41% for amoxicillin/clavulanic acid.

These results are impressive, Dr. Dohar said in an interview.

“The study design was meticulous, and a relatively small sample size resulted in such a positive outcome. It is rare in the modern era of anti-infectives to be able to demonstrate superiority.”

LOS ANGELES — Topical ciprofloxacin/dexamethasone is effective in treating acute otitis media with otorrhea through tympanostomy tubes, Dr. Joseph E. Dohar wrote in a poster presentation at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

Topical ciprofloxacin 0.3% and dexamethasone 0.1%, marketed as Ciprodex sterile otic suspension, produced more clinical cures, earlier cessation of otorrhea, and caused fewer side effects than oral amoxicillin/clavulanate potassium (Augmentin), wrote Dr. Dohar, an otolaryngologist at the Children's Hospital of Pittsburgh. Alcon Laboratories, maker of Ciprodex, sponsored the study.

Dr. Dohar is a clinical investigator, consultant, and speaker for the company.

“My personal experience has been extremely favorable when using topical ciprofloxacin/dexamethasone,” Dr. Dohar said in an interview.

“The topical combination is superior to systemic antibiotics, due to better cure rates, more effective killing of bacteria, less treatment-related resistance, and far fewer side effects.”

In this observer-masked, prospective multicenter trial, 80 children aged 6 months to 8 years (mean 2 years) with acute otitis media and otorrhea were randomized to treatment with either topical ciprofloxacin/dexamethasone drops or a 5-mL oral suspension of 600 mg amoxicillin/42.9 mg clavulanate potassium.

The median time to cessation of otorrhea was 4 days in the ciprofloxacin/dexamethasone group and 7 days in the amoxicillin/clavulanic acid group.

Ciprofloxacin/dexamethasone also had fewer side effects.

Of the children receiving the drops, 5% complained of ear pain, compared with 20% of children taking the suspension had diarrhea.

The treatment failure rate was 17% for ciprofloxacin/dexamethasone and 41% for amoxicillin/clavulanic acid.

These results are impressive, Dr. Dohar said in an interview.

“The study design was meticulous, and a relatively small sample size resulted in such a positive outcome. It is rare in the modern era of anti-infectives to be able to demonstrate superiority.”

LOS ANGELES — Topical ciprofloxacin/dexamethasone is effective in treating acute otitis media with otorrhea through tympanostomy tubes, Dr. Joseph E. Dohar wrote in a poster presentation at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

Topical ciprofloxacin 0.3% and dexamethasone 0.1%, marketed as Ciprodex sterile otic suspension, produced more clinical cures, earlier cessation of otorrhea, and caused fewer side effects than oral amoxicillin/clavulanate potassium (Augmentin), wrote Dr. Dohar, an otolaryngologist at the Children's Hospital of Pittsburgh. Alcon Laboratories, maker of Ciprodex, sponsored the study.

Dr. Dohar is a clinical investigator, consultant, and speaker for the company.

“My personal experience has been extremely favorable when using topical ciprofloxacin/dexamethasone,” Dr. Dohar said in an interview.

“The topical combination is superior to systemic antibiotics, due to better cure rates, more effective killing of bacteria, less treatment-related resistance, and far fewer side effects.”

In this observer-masked, prospective multicenter trial, 80 children aged 6 months to 8 years (mean 2 years) with acute otitis media and otorrhea were randomized to treatment with either topical ciprofloxacin/dexamethasone drops or a 5-mL oral suspension of 600 mg amoxicillin/42.9 mg clavulanate potassium.

The median time to cessation of otorrhea was 4 days in the ciprofloxacin/dexamethasone group and 7 days in the amoxicillin/clavulanic acid group.

Ciprofloxacin/dexamethasone also had fewer side effects.

Of the children receiving the drops, 5% complained of ear pain, compared with 20% of children taking the suspension had diarrhea.

The treatment failure rate was 17% for ciprofloxacin/dexamethasone and 41% for amoxicillin/clavulanic acid.

These results are impressive, Dr. Dohar said in an interview.

“The study design was meticulous, and a relatively small sample size resulted in such a positive outcome. It is rare in the modern era of anti-infectives to be able to demonstrate superiority.”

SAN DIEGO — A few pioneering health care organizations have set up local information networks to share electronic health data, and there are interesting lessons to be learned from these examples, according to Gordon J. Apple, a health lawyer based in St. Paul, Minn., who spoke at the annual meeting of the American Health Lawyers Association.

He compared the Santa Barbara Care Data Exchange with the Indianapolis Network for Patient Care, two projects that have similar goals but use different technologies and organizational structures.

The Santa Barbara project developed as a public/private collaboration, and today is organized as a nonprofit with a “community stakeholder” board of directors, including physicians, chief financial officers, chief operating officers, a chief information officer, and a consumer and business advocate.

It uses peer-to-peer Internet technology, the same method college students use to share music files. “This is a pointer system,” Mr. Apple said. It can identify where data are stored within the system, and “it provides the physician with a patient-centered view of clinical and administrative results. However, it is not an electronic medical record.”

Efforts like these are expensive, and the Santa Barbara project has run into problems. Insufficient grassroots support has been an issue, Mr. Apple said. The data exchange received a $10 million grant from the California HealthCare Foundation and $400,000 from the federal government.

The Indianapolis Network for Patient Care has been functioning for more than 7 years. “Five hospital systems that at one time were probably fierce competitors are now cooperating,” Mr. Apple said.

Indianapolis started with a small project, one everyone could agree was really needed. At first, when a patient came into the emergency department, physicians could access limited data from participating hospitals. This effort was originally funded through a National Library of Medicine grant, but when the grant expired, the participants chose to continue the project.

Today, the expanded Indianapolis network can be used for any treatment purpose. With the patient's permission, physicians can access a complete medical history.

Indianapolis uses a data warehouse system. Each institution stores its data in a separate database, but all the databases use the same structure and the same coding processes. The system can pull out and combine information as needed.

The Regenstrief Institute, a nonprofit affiliated with Indiana University, Indianapolis, manages the network. Indianapolis didn't set up a separate entity to deal with these issues. Instead, the network is governed by a contractual agreement signed by all users. “Regenstrief acts as the hub of the wheel,” Mr. Apple said.

Before it went into effect, this draft agreement was reviewed and approved by clinicians, compliance officers, lawyers, risk managers, and information system personnel in a cooperative, consensus-building process. “This wasn't something where the information technology folks said, 'let's put this out and make the doctors use it.' They actually spoke with the physicians and looked at all the issues before rolling this out,” Mr. Apple said.

He pointed out a second key difference: The Santa Barbara network allows doctors to pull up computer files so they can access each other's information, but the information is unstructured. Physicians are, in effect, accessing copies of paper files. In Indianapolis, the data are entered in a structured format, so it's possible to search for and compare key data items. Test results are tagged so that other computers in the network can recognize them.

Neither network offers a truly interoperable electronic health record, and Mr. Gordon said it will be years before we get one: “When you get all the different players in a community together, you see just how difficult it can be to reach agreement.” Some hospitals and health systems will seek more robust technology. Others will say they can't afford that level of sophistication. The challenge will be to agree on a “lowest common denominator” that meets technological, legal, quality, and research requirements.

SAN DIEGO — A few pioneering health care organizations have set up local information networks to share electronic health data, and there are interesting lessons to be learned from these examples, according to Gordon J. Apple, a health lawyer based in St. Paul, Minn., who spoke at the annual meeting of the American Health Lawyers Association.

He compared the Santa Barbara Care Data Exchange with the Indianapolis Network for Patient Care, two projects that have similar goals but use different technologies and organizational structures.

The Santa Barbara project developed as a public/private collaboration, and today is organized as a nonprofit with a “community stakeholder” board of directors, including physicians, chief financial officers, chief operating officers, a chief information officer, and a consumer and business advocate.

It uses peer-to-peer Internet technology, the same method college students use to share music files. “This is a pointer system,” Mr. Apple said. It can identify where data are stored within the system, and “it provides the physician with a patient-centered view of clinical and administrative results. However, it is not an electronic medical record.”

Efforts like these are expensive, and the Santa Barbara project has run into problems. Insufficient grassroots support has been an issue, Mr. Apple said. The data exchange received a $10 million grant from the California HealthCare Foundation and $400,000 from the federal government.

The Indianapolis Network for Patient Care has been functioning for more than 7 years. “Five hospital systems that at one time were probably fierce competitors are now cooperating,” Mr. Apple said.

Indianapolis started with a small project, one everyone could agree was really needed. At first, when a patient came into the emergency department, physicians could access limited data from participating hospitals. This effort was originally funded through a National Library of Medicine grant, but when the grant expired, the participants chose to continue the project.

Today, the expanded Indianapolis network can be used for any treatment purpose. With the patient's permission, physicians can access a complete medical history.

Indianapolis uses a data warehouse system. Each institution stores its data in a separate database, but all the databases use the same structure and the same coding processes. The system can pull out and combine information as needed.

The Regenstrief Institute, a nonprofit affiliated with Indiana University, Indianapolis, manages the network. Indianapolis didn't set up a separate entity to deal with these issues. Instead, the network is governed by a contractual agreement signed by all users. “Regenstrief acts as the hub of the wheel,” Mr. Apple said.

Before it went into effect, this draft agreement was reviewed and approved by clinicians, compliance officers, lawyers, risk managers, and information system personnel in a cooperative, consensus-building process. “This wasn't something where the information technology folks said, 'let's put this out and make the doctors use it.' They actually spoke with the physicians and looked at all the issues before rolling this out,” Mr. Apple said.

He pointed out a second key difference: The Santa Barbara network allows doctors to pull up computer files so they can access each other's information, but the information is unstructured. Physicians are, in effect, accessing copies of paper files. In Indianapolis, the data are entered in a structured format, so it's possible to search for and compare key data items. Test results are tagged so that other computers in the network can recognize them.

Neither network offers a truly interoperable electronic health record, and Mr. Gordon said it will be years before we get one: “When you get all the different players in a community together, you see just how difficult it can be to reach agreement.” Some hospitals and health systems will seek more robust technology. Others will say they can't afford that level of sophistication. The challenge will be to agree on a “lowest common denominator” that meets technological, legal, quality, and research requirements.

SAN DIEGO — A few pioneering health care organizations have set up local information networks to share electronic health data, and there are interesting lessons to be learned from these examples, according to Gordon J. Apple, a health lawyer based in St. Paul, Minn., who spoke at the annual meeting of the American Health Lawyers Association.

He compared the Santa Barbara Care Data Exchange with the Indianapolis Network for Patient Care, two projects that have similar goals but use different technologies and organizational structures.

The Santa Barbara project developed as a public/private collaboration, and today is organized as a nonprofit with a “community stakeholder” board of directors, including physicians, chief financial officers, chief operating officers, a chief information officer, and a consumer and business advocate.

It uses peer-to-peer Internet technology, the same method college students use to share music files. “This is a pointer system,” Mr. Apple said. It can identify where data are stored within the system, and “it provides the physician with a patient-centered view of clinical and administrative results. However, it is not an electronic medical record.”

Efforts like these are expensive, and the Santa Barbara project has run into problems. Insufficient grassroots support has been an issue, Mr. Apple said. The data exchange received a $10 million grant from the California HealthCare Foundation and $400,000 from the federal government.

The Indianapolis Network for Patient Care has been functioning for more than 7 years. “Five hospital systems that at one time were probably fierce competitors are now cooperating,” Mr. Apple said.

Indianapolis started with a small project, one everyone could agree was really needed. At first, when a patient came into the emergency department, physicians could access limited data from participating hospitals. This effort was originally funded through a National Library of Medicine grant, but when the grant expired, the participants chose to continue the project.

Today, the expanded Indianapolis network can be used for any treatment purpose. With the patient's permission, physicians can access a complete medical history.

Indianapolis uses a data warehouse system. Each institution stores its data in a separate database, but all the databases use the same structure and the same coding processes. The system can pull out and combine information as needed.

The Regenstrief Institute, a nonprofit affiliated with Indiana University, Indianapolis, manages the network. Indianapolis didn't set up a separate entity to deal with these issues. Instead, the network is governed by a contractual agreement signed by all users. “Regenstrief acts as the hub of the wheel,” Mr. Apple said.

Before it went into effect, this draft agreement was reviewed and approved by clinicians, compliance officers, lawyers, risk managers, and information system personnel in a cooperative, consensus-building process. “This wasn't something where the information technology folks said, 'let's put this out and make the doctors use it.' They actually spoke with the physicians and looked at all the issues before rolling this out,” Mr. Apple said.

He pointed out a second key difference: The Santa Barbara network allows doctors to pull up computer files so they can access each other's information, but the information is unstructured. Physicians are, in effect, accessing copies of paper files. In Indianapolis, the data are entered in a structured format, so it's possible to search for and compare key data items. Test results are tagged so that other computers in the network can recognize them.

Neither network offers a truly interoperable electronic health record, and Mr. Gordon said it will be years before we get one: “When you get all the different players in a community together, you see just how difficult it can be to reach agreement.” Some hospitals and health systems will seek more robust technology. Others will say they can't afford that level of sophistication. The challenge will be to agree on a “lowest common denominator” that meets technological, legal, quality, and research requirements.

SAN DIEGO — Physicians will face many questions about the new Medicare Part D benefit as patients decide whether to enroll and which plan to select in the voluntary prescription drug program, Elizabeth Carder-Thompson said at the annual meeting of the American Health Lawyers Association.

CMS has begun posting informational resources on its Web site, and additional materials will become available. The best resource at this time is the "Outreach Toolkit," available by download or on CD-ROM, said Ms. Carder-Thompson, a lawyer with Reed Smith LLP.

"The Outreach Toolkit doesn't answer all the questions we want answered, but it's a good start," she said.

Enrollment for Part D began on Nov. 15, 2005, and patients must enroll by May 15, 2006, or face a financial penalty when they do. The new coverage goes into effect Jan. 1, 2006, and the interim discount drug card program ends at that time. This means Medicare beneficiaries will need to make fairly complicated choices within a short time. There will be at least two Part D prescription drug plans available in each geographic area, and possibly several subplans.

A Kaiser Family Foundation survey, conducted March/April 2005, found that seniors are more likely to turn to their doctor (49%) or pharmacist (33%) for help in making these decisions, rather than to Medicare information sources (23%). About two-thirds (68%) of those surveyed said they did not have a good understanding of the new benefit.

In October, Part D started sending marketing materials. CMS distributed its "Medicare and You," handbook to all beneficiaries via mail, with a description of the new benefit. A "Plan Comparison Web Tool" and "Medicare Personal Plan Finder" are posted at www.medicare.gov

According to Robert J. Hill, also of Reed Smith LLP, the CMS marketing guidelines on Part D include a great deal of material that will affect physicians. For example, enrollment cannot be taken at the point of care, such as a physician's office. If physicians offer their patients information on any Part D plan then they must offer information on all available Part D plans.

Once Part D becomes effective, doctors will face a different set of concerns, Ms. Carder-Thompson said. When a plan doesn't cover a prescribed drug, physicians will need to provide supporting statements in order to get an exception, but many details are not clear at this time.

SAN DIEGO — Physicians will face many questions about the new Medicare Part D benefit as patients decide whether to enroll and which plan to select in the voluntary prescription drug program, Elizabeth Carder-Thompson said at the annual meeting of the American Health Lawyers Association.

CMS has begun posting informational resources on its Web site, and additional materials will become available. The best resource at this time is the "Outreach Toolkit," available by download or on CD-ROM, said Ms. Carder-Thompson, a lawyer with Reed Smith LLP.

"The Outreach Toolkit doesn't answer all the questions we want answered, but it's a good start," she said.

Enrollment for Part D began on Nov. 15, 2005, and patients must enroll by May 15, 2006, or face a financial penalty when they do. The new coverage goes into effect Jan. 1, 2006, and the interim discount drug card program ends at that time. This means Medicare beneficiaries will need to make fairly complicated choices within a short time. There will be at least two Part D prescription drug plans available in each geographic area, and possibly several subplans.

A Kaiser Family Foundation survey, conducted March/April 2005, found that seniors are more likely to turn to their doctor (49%) or pharmacist (33%) for help in making these decisions, rather than to Medicare information sources (23%). About two-thirds (68%) of those surveyed said they did not have a good understanding of the new benefit.

In October, Part D started sending marketing materials. CMS distributed its "Medicare and You," handbook to all beneficiaries via mail, with a description of the new benefit. A "Plan Comparison Web Tool" and "Medicare Personal Plan Finder" are posted at www.medicare.gov

According to Robert J. Hill, also of Reed Smith LLP, the CMS marketing guidelines on Part D include a great deal of material that will affect physicians. For example, enrollment cannot be taken at the point of care, such as a physician's office. If physicians offer their patients information on any Part D plan then they must offer information on all available Part D plans.

Once Part D becomes effective, doctors will face a different set of concerns, Ms. Carder-Thompson said. When a plan doesn't cover a prescribed drug, physicians will need to provide supporting statements in order to get an exception, but many details are not clear at this time.

SAN DIEGO — Physicians will face many questions about the new Medicare Part D benefit as patients decide whether to enroll and which plan to select in the voluntary prescription drug program, Elizabeth Carder-Thompson said at the annual meeting of the American Health Lawyers Association.

CMS has begun posting informational resources on its Web site, and additional materials will become available. The best resource at this time is the "Outreach Toolkit," available by download or on CD-ROM, said Ms. Carder-Thompson, a lawyer with Reed Smith LLP.

"The Outreach Toolkit doesn't answer all the questions we want answered, but it's a good start," she said.

Enrollment for Part D began on Nov. 15, 2005, and patients must enroll by May 15, 2006, or face a financial penalty when they do. The new coverage goes into effect Jan. 1, 2006, and the interim discount drug card program ends at that time. This means Medicare beneficiaries will need to make fairly complicated choices within a short time. There will be at least two Part D prescription drug plans available in each geographic area, and possibly several subplans.

A Kaiser Family Foundation survey, conducted March/April 2005, found that seniors are more likely to turn to their doctor (49%) or pharmacist (33%) for help in making these decisions, rather than to Medicare information sources (23%). About two-thirds (68%) of those surveyed said they did not have a good understanding of the new benefit.

In October, Part D started sending marketing materials. CMS distributed its "Medicare and You," handbook to all beneficiaries via mail, with a description of the new benefit. A "Plan Comparison Web Tool" and "Medicare Personal Plan Finder" are posted at www.medicare.gov

According to Robert J. Hill, also of Reed Smith LLP, the CMS marketing guidelines on Part D include a great deal of material that will affect physicians. For example, enrollment cannot be taken at the point of care, such as a physician's office. If physicians offer their patients information on any Part D plan then they must offer information on all available Part D plans.

Once Part D becomes effective, doctors will face a different set of concerns, Ms. Carder-Thompson said. When a plan doesn't cover a prescribed drug, physicians will need to provide supporting statements in order to get an exception, but many details are not clear at this time.

SAN DIEGO — Physicians will face many questions in the coming months about the new Medicare Part D voluntary prescription drug program, Elizabeth Carder-Thompson said at the annual meeting of the American Health Lawyers Association.

The Centers for Medicare and Medicaid Services posts informational resources on its Web site, and additional materials will become available over the next few months. The best resource at this time is the “Outreach Toolkit,” available by download or on CD-ROM, said Ms. Carder-Thompson, a lawyer with Reed Smith LLP.

The new coverage goes into effect Jan. 1, 2006, and the interim discount drug card program ends at that time, leaving Medicare beneficiaries to make fairly complicated choices within a short time.

There will be at least two Part D prescription drug plans available in each geographic area, and plans may include several subplans.

In October 2005, Part D plans will start to send marketing materials. CMS will distribute its “Medicare and You” handbook to all beneficiaries via mail, with a description of the new benefit. A “Plan Comparison Web Tool” and “Medicare Personal Plan Finder” will be posted at www.medicare.gov

Once Part D becomes effective, doctors will face a different set of concerns, she said. When a plan doesn't cover a prescribed drug, MDs must provide supporting statements to get an exception, but many details are not clear at this time.

SAN DIEGO — Physicians will face many questions in the coming months about the new Medicare Part D voluntary prescription drug program, Elizabeth Carder-Thompson said at the annual meeting of the American Health Lawyers Association.

The Centers for Medicare and Medicaid Services posts informational resources on its Web site, and additional materials will become available over the next few months. The best resource at this time is the “Outreach Toolkit,” available by download or on CD-ROM, said Ms. Carder-Thompson, a lawyer with Reed Smith LLP.

The new coverage goes into effect Jan. 1, 2006, and the interim discount drug card program ends at that time, leaving Medicare beneficiaries to make fairly complicated choices within a short time.

There will be at least two Part D prescription drug plans available in each geographic area, and plans may include several subplans.

In October 2005, Part D plans will start to send marketing materials. CMS will distribute its “Medicare and You” handbook to all beneficiaries via mail, with a description of the new benefit. A “Plan Comparison Web Tool” and “Medicare Personal Plan Finder” will be posted at www.medicare.gov

Once Part D becomes effective, doctors will face a different set of concerns, she said. When a plan doesn't cover a prescribed drug, MDs must provide supporting statements to get an exception, but many details are not clear at this time.

SAN DIEGO — Physicians will face many questions in the coming months about the new Medicare Part D voluntary prescription drug program, Elizabeth Carder-Thompson said at the annual meeting of the American Health Lawyers Association.

The Centers for Medicare and Medicaid Services posts informational resources on its Web site, and additional materials will become available over the next few months. The best resource at this time is the “Outreach Toolkit,” available by download or on CD-ROM, said Ms. Carder-Thompson, a lawyer with Reed Smith LLP.

The new coverage goes into effect Jan. 1, 2006, and the interim discount drug card program ends at that time, leaving Medicare beneficiaries to make fairly complicated choices within a short time.

There will be at least two Part D prescription drug plans available in each geographic area, and plans may include several subplans.

In October 2005, Part D plans will start to send marketing materials. CMS will distribute its “Medicare and You” handbook to all beneficiaries via mail, with a description of the new benefit. A “Plan Comparison Web Tool” and “Medicare Personal Plan Finder” will be posted at www.medicare.gov

Once Part D becomes effective, doctors will face a different set of concerns, she said. When a plan doesn't cover a prescribed drug, MDs must provide supporting statements to get an exception, but many details are not clear at this time.