Doug Brunk

SAN DIEGO — Combining an electrocardiogram with serum N-terminal pro-B-type natriuretic peptide measurements is a simple, noninvasive way to diagnose pulmonary hypertension, results from an Austrian study suggest.

“Current pulmonary hypertension diagnosis guidelines say that ECG alone is not useful in the diagnosis of pulmonary hypertension,” Dr. Diana Bonderman said in an interview at an international conference of the American Thoracic Society. “But if you combine ECG with NT-proBNP [N-terminal pro-B-type natriuretic peptide], it's going to be useful.”

The finding is clinically important, she said, because the growing awareness of pulmonary hypertension (PH), a high prevalence of postcapillary PH, and the inability to discern between pre- and postcapillary PH by transthoracic echocardiography (TTE) “have led to unnecessary right heart catheterizations.”

She and her associates prospectively analyzed data from 121 patients referred to the Medical University of Vienna between April 2007 and October 2008 for clinical and transthoracic echocardiographic suspicion of precapillary PH (systolic pulmonary artery pressure of 36 mm Hg or greater). On admission, all patients underwent TTE, serum analysis including NT-proBNP, a 6-minute walk test, and blood gas analysis.

The patients were then assigned to one of two predicted diagnostic groups: precapillary PH (defined as right ventricular strain on ECG and/or serum NT-proBNP of greater than 80 pg/mL) or no precapillary PH. Next, all patients underwent right heart catheterization, and a final diagnosis was established.

The mean age of the patients was 62 years and 59% were female, reported Dr. Bonderman, a cardiologist at the Medical University of Vienna.

By right heart catheterization, only 64 (53%) patients were diagnosed with precapillary PH. Precapillary PH was ruled out in 57 (47%) patients. By the diagnostic algorithm, 15 patients (12%) had been correctly allocated to the group without precapillary PH (true negatives). None of the allocations was a false negative.

“In the diagnostic pathway of PH, integration of the proposed algorithm subsequent to TTE may increase specificity from 0% to 19.3%, with a sensitivity of 100%,” the researchers wrote in their poster. “The incorporation of ECG and NT-proBNP into the workup of PH provides incremental diagnostic value and may significantly reduce the number of invasive assessments.”

The researchers had no conflicts of interest to disclose.

This approach to diagnosis 'may significantly reduce the number of invasive assessments.'

Source DR. BONDERMAN

SAN DIEGO — Combining an electrocardiogram with serum N-terminal pro-B-type natriuretic peptide measurements is a simple, noninvasive way to diagnose pulmonary hypertension, results from an Austrian study suggest.

“Current pulmonary hypertension diagnosis guidelines say that ECG alone is not useful in the diagnosis of pulmonary hypertension,” Dr. Diana Bonderman said in an interview at an international conference of the American Thoracic Society. “But if you combine ECG with NT-proBNP [N-terminal pro-B-type natriuretic peptide], it's going to be useful.”

The finding is clinically important, she said, because the growing awareness of pulmonary hypertension (PH), a high prevalence of postcapillary PH, and the inability to discern between pre- and postcapillary PH by transthoracic echocardiography (TTE) “have led to unnecessary right heart catheterizations.”

She and her associates prospectively analyzed data from 121 patients referred to the Medical University of Vienna between April 2007 and October 2008 for clinical and transthoracic echocardiographic suspicion of precapillary PH (systolic pulmonary artery pressure of 36 mm Hg or greater). On admission, all patients underwent TTE, serum analysis including NT-proBNP, a 6-minute walk test, and blood gas analysis.

The patients were then assigned to one of two predicted diagnostic groups: precapillary PH (defined as right ventricular strain on ECG and/or serum NT-proBNP of greater than 80 pg/mL) or no precapillary PH. Next, all patients underwent right heart catheterization, and a final diagnosis was established.

The mean age of the patients was 62 years and 59% were female, reported Dr. Bonderman, a cardiologist at the Medical University of Vienna.

By right heart catheterization, only 64 (53%) patients were diagnosed with precapillary PH. Precapillary PH was ruled out in 57 (47%) patients. By the diagnostic algorithm, 15 patients (12%) had been correctly allocated to the group without precapillary PH (true negatives). None of the allocations was a false negative.

“In the diagnostic pathway of PH, integration of the proposed algorithm subsequent to TTE may increase specificity from 0% to 19.3%, with a sensitivity of 100%,” the researchers wrote in their poster. “The incorporation of ECG and NT-proBNP into the workup of PH provides incremental diagnostic value and may significantly reduce the number of invasive assessments.”

The researchers had no conflicts of interest to disclose.

This approach to diagnosis 'may significantly reduce the number of invasive assessments.'

Source DR. BONDERMAN

SAN DIEGO — Combining an electrocardiogram with serum N-terminal pro-B-type natriuretic peptide measurements is a simple, noninvasive way to diagnose pulmonary hypertension, results from an Austrian study suggest.

“Current pulmonary hypertension diagnosis guidelines say that ECG alone is not useful in the diagnosis of pulmonary hypertension,” Dr. Diana Bonderman said in an interview at an international conference of the American Thoracic Society. “But if you combine ECG with NT-proBNP [N-terminal pro-B-type natriuretic peptide], it's going to be useful.”

The finding is clinically important, she said, because the growing awareness of pulmonary hypertension (PH), a high prevalence of postcapillary PH, and the inability to discern between pre- and postcapillary PH by transthoracic echocardiography (TTE) “have led to unnecessary right heart catheterizations.”

She and her associates prospectively analyzed data from 121 patients referred to the Medical University of Vienna between April 2007 and October 2008 for clinical and transthoracic echocardiographic suspicion of precapillary PH (systolic pulmonary artery pressure of 36 mm Hg or greater). On admission, all patients underwent TTE, serum analysis including NT-proBNP, a 6-minute walk test, and blood gas analysis.

The patients were then assigned to one of two predicted diagnostic groups: precapillary PH (defined as right ventricular strain on ECG and/or serum NT-proBNP of greater than 80 pg/mL) or no precapillary PH. Next, all patients underwent right heart catheterization, and a final diagnosis was established.

The mean age of the patients was 62 years and 59% were female, reported Dr. Bonderman, a cardiologist at the Medical University of Vienna.

By right heart catheterization, only 64 (53%) patients were diagnosed with precapillary PH. Precapillary PH was ruled out in 57 (47%) patients. By the diagnostic algorithm, 15 patients (12%) had been correctly allocated to the group without precapillary PH (true negatives). None of the allocations was a false negative.

“In the diagnostic pathway of PH, integration of the proposed algorithm subsequent to TTE may increase specificity from 0% to 19.3%, with a sensitivity of 100%,” the researchers wrote in their poster. “The incorporation of ECG and NT-proBNP into the workup of PH provides incremental diagnostic value and may significantly reduce the number of invasive assessments.”

The researchers had no conflicts of interest to disclose.

This approach to diagnosis 'may significantly reduce the number of invasive assessments.'

Source DR. BONDERMAN

Physicans preparing to deal with the anticipated spread of the novel influenza A(H1N1) virus are awaiting the results of a series of U.S. clinical trials aimed at gathering critical data about two candidate vaccines.

The studies which were initiated under the directorship of the National Institute of Allergy and Infectious Diseases, part of the National Institutes of Health, got underway at the institutes's eight Vaccine and Treatment Evaluation Units (VTEUs).

The goal was to quickly evaluate pilot vaccine lots from two manufacturers, Sanofi Pasteur and CSL Biotherapies, to determine vaccine safety and efficacy in inducing protective immune responses.

"It's an exciting event," Dr. Robert B. Belshe, an internist who directs the VTEU at St. Louis University School of Medicine, said of the trials. "We don't have a major antigenic change very often for flu. This year we are clearly in the midst of the early pandemic. But this pandemic is going to be much different than other pandemics."

In contrast to their counterparts during previous pandemics, today's clinicians have good diagnostics at their disposal.

"We know how to make vaccines, and we know how to treat influenza with antivirals. The race is on right now to make as much vaccine as possible and get it into the highest risk population, which for this particular virus is children," he said.

According to a written statement issued by the NIH, initial studies at the VTEUs were designed to examine whether one or two 15-mcg doses of H1N1 vaccine would be needed to induce a potentially protective immune response in healthy adults (aged 18–64 years old) and elderly people (aged 65 and older). They studies also were aiming to assess whether one or two 30-mcg doses would be needed. Doses would be given 21 days apart. If early data indicate that the vaccines are safe, similar trials in healthy children (aged 6 months to 17 years) will begin.

Another set of trials was planned to examine the safety and immune response in healthy adult and elderly volunteers given the seasonal flu vaccine plus a 15-mcg dose of novel H1N1 vaccine. The H1N1 vaccine would be given to different sets of volunteers either before, after, or at the same time as the seasonal flu vaccine. If early data indicate that these combinations are safe, similar trials in healthy children will start.

"I would anticipate that the monovalent H1N1 vaccine will behave exactly like the seasonal flu vaccine in terms of safety and adverse events, meaning it will probably cause some local pain, but nothing else," said Dr. Belshe, professor of infectious diseases and immunology at St. Louis University.

"The biggest challenge is, how do we get vaccine to as many high-risk people as possible? What's going to happen next year? Is this new virus going to replace the previous circulating H1 virus? I wouldn't be surprised if it did. If so, we will change the seasonal vaccine next year to include the new H1 and drop the old H1."

In previous years, Dr. Belshe has enrolled in vaccine clinical trials as a volunteer, but said he won't be doing so this time around. "We discourage investigators from vaccinating themselves. There is a time-honored tradition of physicians experimenting on themselves, but under the current system of institutional review boards and regulatory standards, that would be frowned upon," he said.

Dr. Belshe was quick to note, however, that he will take the vaccine as soon as it's available for general use. "I am certainly not afraid of the vaccine," he said. Health care workers are a high-priority group to receive immunization against the novel H1N1 virus, according to recommendations issued recently by the Centers for Disease Control and Prevention.

In the meantime, he said, being part of the national discussion on how to respond to the current pandemic "is very exciting, and to be able to provide advice and experience from our many years of clinical trials on how to successfully design a trial and answer the critical questions [has] been very rewarding."

The other VTEUs are Baylor College of Medicine, Houston; Children's Hospital Medical Center, Cincinnati; Emory University, Atlanta; Group Health Cooperative, Seattle; University of Iowa, Iowa City; University of Maryland School of Medicine, Baltimore; and Vanderbilt University, Nashville, Tenn.

Dr. Belshe has been a consultant to several manufacturers of vaccines, including MedImmune, Sanofi Pasteur, GlaxoSmithKline, and Novartis.

'The race is on right now to make as much vaccine as possible and get it into the highest risk population.'

Source DR. BELSHE

The newly identified H1N1 virus (above) could replace the previous H1 virus.

Source ©CDC

Physicans preparing to deal with the anticipated spread of the novel influenza A(H1N1) virus are awaiting the results of a series of U.S. clinical trials aimed at gathering critical data about two candidate vaccines.

The studies which were initiated under the directorship of the National Institute of Allergy and Infectious Diseases, part of the National Institutes of Health, got underway at the institutes's eight Vaccine and Treatment Evaluation Units (VTEUs).

The goal was to quickly evaluate pilot vaccine lots from two manufacturers, Sanofi Pasteur and CSL Biotherapies, to determine vaccine safety and efficacy in inducing protective immune responses.

"It's an exciting event," Dr. Robert B. Belshe, an internist who directs the VTEU at St. Louis University School of Medicine, said of the trials. "We don't have a major antigenic change very often for flu. This year we are clearly in the midst of the early pandemic. But this pandemic is going to be much different than other pandemics."

In contrast to their counterparts during previous pandemics, today's clinicians have good diagnostics at their disposal.

"We know how to make vaccines, and we know how to treat influenza with antivirals. The race is on right now to make as much vaccine as possible and get it into the highest risk population, which for this particular virus is children," he said.

According to a written statement issued by the NIH, initial studies at the VTEUs were designed to examine whether one or two 15-mcg doses of H1N1 vaccine would be needed to induce a potentially protective immune response in healthy adults (aged 18–64 years old) and elderly people (aged 65 and older). They studies also were aiming to assess whether one or two 30-mcg doses would be needed. Doses would be given 21 days apart. If early data indicate that the vaccines are safe, similar trials in healthy children (aged 6 months to 17 years) will begin.

Another set of trials was planned to examine the safety and immune response in healthy adult and elderly volunteers given the seasonal flu vaccine plus a 15-mcg dose of novel H1N1 vaccine. The H1N1 vaccine would be given to different sets of volunteers either before, after, or at the same time as the seasonal flu vaccine. If early data indicate that these combinations are safe, similar trials in healthy children will start.

"I would anticipate that the monovalent H1N1 vaccine will behave exactly like the seasonal flu vaccine in terms of safety and adverse events, meaning it will probably cause some local pain, but nothing else," said Dr. Belshe, professor of infectious diseases and immunology at St. Louis University.

"The biggest challenge is, how do we get vaccine to as many high-risk people as possible? What's going to happen next year? Is this new virus going to replace the previous circulating H1 virus? I wouldn't be surprised if it did. If so, we will change the seasonal vaccine next year to include the new H1 and drop the old H1."

In previous years, Dr. Belshe has enrolled in vaccine clinical trials as a volunteer, but said he won't be doing so this time around. "We discourage investigators from vaccinating themselves. There is a time-honored tradition of physicians experimenting on themselves, but under the current system of institutional review boards and regulatory standards, that would be frowned upon," he said.

Dr. Belshe was quick to note, however, that he will take the vaccine as soon as it's available for general use. "I am certainly not afraid of the vaccine," he said. Health care workers are a high-priority group to receive immunization against the novel H1N1 virus, according to recommendations issued recently by the Centers for Disease Control and Prevention.

In the meantime, he said, being part of the national discussion on how to respond to the current pandemic "is very exciting, and to be able to provide advice and experience from our many years of clinical trials on how to successfully design a trial and answer the critical questions [has] been very rewarding."

The other VTEUs are Baylor College of Medicine, Houston; Children's Hospital Medical Center, Cincinnati; Emory University, Atlanta; Group Health Cooperative, Seattle; University of Iowa, Iowa City; University of Maryland School of Medicine, Baltimore; and Vanderbilt University, Nashville, Tenn.

Dr. Belshe has been a consultant to several manufacturers of vaccines, including MedImmune, Sanofi Pasteur, GlaxoSmithKline, and Novartis.

'The race is on right now to make as much vaccine as possible and get it into the highest risk population.'

Source DR. BELSHE

The newly identified H1N1 virus (above) could replace the previous H1 virus.

Source ©CDC

Physicans preparing to deal with the anticipated spread of the novel influenza A(H1N1) virus are awaiting the results of a series of U.S. clinical trials aimed at gathering critical data about two candidate vaccines.

The studies which were initiated under the directorship of the National Institute of Allergy and Infectious Diseases, part of the National Institutes of Health, got underway at the institutes's eight Vaccine and Treatment Evaluation Units (VTEUs).

The goal was to quickly evaluate pilot vaccine lots from two manufacturers, Sanofi Pasteur and CSL Biotherapies, to determine vaccine safety and efficacy in inducing protective immune responses.

"It's an exciting event," Dr. Robert B. Belshe, an internist who directs the VTEU at St. Louis University School of Medicine, said of the trials. "We don't have a major antigenic change very often for flu. This year we are clearly in the midst of the early pandemic. But this pandemic is going to be much different than other pandemics."

In contrast to their counterparts during previous pandemics, today's clinicians have good diagnostics at their disposal.

"We know how to make vaccines, and we know how to treat influenza with antivirals. The race is on right now to make as much vaccine as possible and get it into the highest risk population, which for this particular virus is children," he said.

According to a written statement issued by the NIH, initial studies at the VTEUs were designed to examine whether one or two 15-mcg doses of H1N1 vaccine would be needed to induce a potentially protective immune response in healthy adults (aged 18–64 years old) and elderly people (aged 65 and older). They studies also were aiming to assess whether one or two 30-mcg doses would be needed. Doses would be given 21 days apart. If early data indicate that the vaccines are safe, similar trials in healthy children (aged 6 months to 17 years) will begin.

Another set of trials was planned to examine the safety and immune response in healthy adult and elderly volunteers given the seasonal flu vaccine plus a 15-mcg dose of novel H1N1 vaccine. The H1N1 vaccine would be given to different sets of volunteers either before, after, or at the same time as the seasonal flu vaccine. If early data indicate that these combinations are safe, similar trials in healthy children will start.

"I would anticipate that the monovalent H1N1 vaccine will behave exactly like the seasonal flu vaccine in terms of safety and adverse events, meaning it will probably cause some local pain, but nothing else," said Dr. Belshe, professor of infectious diseases and immunology at St. Louis University.

"The biggest challenge is, how do we get vaccine to as many high-risk people as possible? What's going to happen next year? Is this new virus going to replace the previous circulating H1 virus? I wouldn't be surprised if it did. If so, we will change the seasonal vaccine next year to include the new H1 and drop the old H1."

In previous years, Dr. Belshe has enrolled in vaccine clinical trials as a volunteer, but said he won't be doing so this time around. "We discourage investigators from vaccinating themselves. There is a time-honored tradition of physicians experimenting on themselves, but under the current system of institutional review boards and regulatory standards, that would be frowned upon," he said.

Dr. Belshe was quick to note, however, that he will take the vaccine as soon as it's available for general use. "I am certainly not afraid of the vaccine," he said. Health care workers are a high-priority group to receive immunization against the novel H1N1 virus, according to recommendations issued recently by the Centers for Disease Control and Prevention.

In the meantime, he said, being part of the national discussion on how to respond to the current pandemic "is very exciting, and to be able to provide advice and experience from our many years of clinical trials on how to successfully design a trial and answer the critical questions [has] been very rewarding."

The other VTEUs are Baylor College of Medicine, Houston; Children's Hospital Medical Center, Cincinnati; Emory University, Atlanta; Group Health Cooperative, Seattle; University of Iowa, Iowa City; University of Maryland School of Medicine, Baltimore; and Vanderbilt University, Nashville, Tenn.

Dr. Belshe has been a consultant to several manufacturers of vaccines, including MedImmune, Sanofi Pasteur, GlaxoSmithKline, and Novartis.

'The race is on right now to make as much vaccine as possible and get it into the highest risk population.'

Source DR. BELSHE

The newly identified H1N1 virus (above) could replace the previous H1 virus.

Source ©CDC

NEW ORLEANS — A femoral neck T score predicts hip fracture risk in women with type 2 diabetes, but the risk is higher for a given T score and age compared with women who do not have diabetes, a multicenter study has shown.

“These findings indicate that bone mineral density T score is useful for clinical evaluation of hip fracture risk in women with type 2 diabetes, but a higher bone mineral density threshold is appropriate for diagnosis of osteoporosis compared with nondiabetic women,” researchers led by Ann V. Schwartz, Ph.D., of the department of epidemiology and biostatistics at the University of California, San Francisco, noted in a poster session at the annual scientific sessions of the American Diabetes Association.

Established methods for predicting fracture from BMD T score and age “may not apply to patients with type 2 diabetes,” the researchers wrote, because older adults with the disease “have increased risk of hip fracture in spite of higher average bone mineral density.”

To compare the fracture risk prediction in older women with and without type 2 diabetes, Dr. Schwartz and her associates used data from the National Institutes of Health-funded Study of Osteoporotic Fractures, a longitudinal cohort trial of white women aged 65 and older at four clinical centers in the United States. At the first follow-up visit, dual-energy x-ray absorptiometry ascertained hip bone mineral density in 7,917 women, including 520 with self-reported type 2 diabetes.

The mean age of those without diabetes was 73 years. Their mean femoral neck score was −1.77, and 563 (7.6%) had more than one hip fracture. The mean age of those with type 2 diabetes was 74 years. Their mean femoral neck score was −1.45, and 47 (9%) had more than one hip fracture.

A Cox regression model that controlled for age and femoral neck T score was used to estimate the 10-year risk of hip fracture, using fractures that occurred after the BMD measurement. This amounted to 68,582 person-years of follow-up.

The researchers found that age-stratified femoral neck T score underestimated the hip fracture risk in women with type 2 diabetes, and determined that the T score should be set 0.6% points higher for women with type 2 diabetes than for their peers who do not have type 2 diabetes.

The study was supported by a research grant from Amgen Inc.

NEW ORLEANS — A femoral neck T score predicts hip fracture risk in women with type 2 diabetes, but the risk is higher for a given T score and age compared with women who do not have diabetes, a multicenter study has shown.

“These findings indicate that bone mineral density T score is useful for clinical evaluation of hip fracture risk in women with type 2 diabetes, but a higher bone mineral density threshold is appropriate for diagnosis of osteoporosis compared with nondiabetic women,” researchers led by Ann V. Schwartz, Ph.D., of the department of epidemiology and biostatistics at the University of California, San Francisco, noted in a poster session at the annual scientific sessions of the American Diabetes Association.

Established methods for predicting fracture from BMD T score and age “may not apply to patients with type 2 diabetes,” the researchers wrote, because older adults with the disease “have increased risk of hip fracture in spite of higher average bone mineral density.”

To compare the fracture risk prediction in older women with and without type 2 diabetes, Dr. Schwartz and her associates used data from the National Institutes of Health-funded Study of Osteoporotic Fractures, a longitudinal cohort trial of white women aged 65 and older at four clinical centers in the United States. At the first follow-up visit, dual-energy x-ray absorptiometry ascertained hip bone mineral density in 7,917 women, including 520 with self-reported type 2 diabetes.

The mean age of those without diabetes was 73 years. Their mean femoral neck score was −1.77, and 563 (7.6%) had more than one hip fracture. The mean age of those with type 2 diabetes was 74 years. Their mean femoral neck score was −1.45, and 47 (9%) had more than one hip fracture.

A Cox regression model that controlled for age and femoral neck T score was used to estimate the 10-year risk of hip fracture, using fractures that occurred after the BMD measurement. This amounted to 68,582 person-years of follow-up.

The researchers found that age-stratified femoral neck T score underestimated the hip fracture risk in women with type 2 diabetes, and determined that the T score should be set 0.6% points higher for women with type 2 diabetes than for their peers who do not have type 2 diabetes.

The study was supported by a research grant from Amgen Inc.

NEW ORLEANS — A femoral neck T score predicts hip fracture risk in women with type 2 diabetes, but the risk is higher for a given T score and age compared with women who do not have diabetes, a multicenter study has shown.

“These findings indicate that bone mineral density T score is useful for clinical evaluation of hip fracture risk in women with type 2 diabetes, but a higher bone mineral density threshold is appropriate for diagnosis of osteoporosis compared with nondiabetic women,” researchers led by Ann V. Schwartz, Ph.D., of the department of epidemiology and biostatistics at the University of California, San Francisco, noted in a poster session at the annual scientific sessions of the American Diabetes Association.

Established methods for predicting fracture from BMD T score and age “may not apply to patients with type 2 diabetes,” the researchers wrote, because older adults with the disease “have increased risk of hip fracture in spite of higher average bone mineral density.”

To compare the fracture risk prediction in older women with and without type 2 diabetes, Dr. Schwartz and her associates used data from the National Institutes of Health-funded Study of Osteoporotic Fractures, a longitudinal cohort trial of white women aged 65 and older at four clinical centers in the United States. At the first follow-up visit, dual-energy x-ray absorptiometry ascertained hip bone mineral density in 7,917 women, including 520 with self-reported type 2 diabetes.

The mean age of those without diabetes was 73 years. Their mean femoral neck score was −1.77, and 563 (7.6%) had more than one hip fracture. The mean age of those with type 2 diabetes was 74 years. Their mean femoral neck score was −1.45, and 47 (9%) had more than one hip fracture.

A Cox regression model that controlled for age and femoral neck T score was used to estimate the 10-year risk of hip fracture, using fractures that occurred after the BMD measurement. This amounted to 68,582 person-years of follow-up.

The researchers found that age-stratified femoral neck T score underestimated the hip fracture risk in women with type 2 diabetes, and determined that the T score should be set 0.6% points higher for women with type 2 diabetes than for their peers who do not have type 2 diabetes.

The study was supported by a research grant from Amgen Inc.

NEW ORLEANS — Scientists are on the cusp of understanding the role of sensory factors related to food intake control, and the orbitofrontal cortex appears to be hub of activity.

“In food intake control, sensory factors such as taste, smell, sight, and texture are first decoded in the brain as being taste and smell, independently of reward,” Dr. Edmund T. Rolls said at the annual scientific sessions of the American Diabetes Association. “Then they project into structures such as the orbitofrontal cortex, which decodes them in terms of their reward value. It is there that neurons determine if the food tastes pleasant, or smells pleasant, or looks pleasant. That is a crucial part of the brain for sending signals to make us want to eat: because of food reward.”

Dr. Rolls said that functional magnetic resonance imaging (fMRI) is helping scientists track the complex circuitry involved in food cravings and food reward. When someone finds a food pleasant, for example, fMRI reveals blood oxygen level-dependent (BOLD) signals in the orbitofrontal cortex, where scores of neurons are tuned into the sensory properties of food “like a wonderfully sensitive antenna,” he said. “The reason, I think, that you have neurons like that is so that during a meal you could have a response to one food as a reward. When you have eaten it, you no longer like that food, but then you will still like other foods. You compute that property very simply by having these neurons that respond to different combinations of foods.”

The concept is known as sensory-specific satiety: the notion that when you eat, your appetite can go down for one food, but remain high for other foods.

The reward decoding in parts of the brain such as the orbitofrontal cortex “is crucial to understand and may be different in obese people,” added Dr. Rolls, of the Oxford (England) Centre for Computational Neuroscience Research.

“Also, when we see, taste, or smell food, we're going to get autonomic responses, changes in insulin and changes in glucose. So understanding this circuitry and how it could be different in some individuals is also important to understanding obesity.”

In one study conducted by Dr. Rolls and his associates, participants rated the pleasantness of the flavor of chocolate milk and tomato juice, then half of the participants consumed chocolate milk to satiety and the other half consumed tomato juice to satiety, after which all of them underwent brain fMRI. The researchers found that the pleasantness of the flavor of the food eaten to satiety decreased, and that the decrease in pleasantness was reflected in decreased neuronal activation in the orbitofrontal cortex (Cereb. Cortex 2003;13:1064-71).

“The initial BOLD signal response indicates that the food is pleasant,” Dr. Rolls said. “As you feed to satiety, one of those foods becomes less pleasant, and the orbitofrontal cortex is no longer activated.”

Other fMRI studies have demonstrated that when fat is placed into the mouth, some neurons increase their firing rate to about 15 times per second. “There seems to be a sensing of texture reward in the orbitofrontal cortex, as well as olfactory reward, taste reward, visual reward, and temperature,” he said.

Dr. Rolls concluded his remarks by expressing doubt that endocrine or genetic factors directly contributed to the spike in obesity that has occurred over the past 3 decades.

“We think it is these sensory input signals and the rewards they produce that drive people to eat too much,” he said. “Palatability is another factor. Food companies produce highly palatable foods; that will tend to produce an imbalance with respect to our evolutionary old satiety signals. Food variety, portion size, and stress-induced eating are also factors.”

Dr. Rolls had no conflicts of interest to disclose.

NEW ORLEANS — Scientists are on the cusp of understanding the role of sensory factors related to food intake control, and the orbitofrontal cortex appears to be hub of activity.

“In food intake control, sensory factors such as taste, smell, sight, and texture are first decoded in the brain as being taste and smell, independently of reward,” Dr. Edmund T. Rolls said at the annual scientific sessions of the American Diabetes Association. “Then they project into structures such as the orbitofrontal cortex, which decodes them in terms of their reward value. It is there that neurons determine if the food tastes pleasant, or smells pleasant, or looks pleasant. That is a crucial part of the brain for sending signals to make us want to eat: because of food reward.”

Dr. Rolls said that functional magnetic resonance imaging (fMRI) is helping scientists track the complex circuitry involved in food cravings and food reward. When someone finds a food pleasant, for example, fMRI reveals blood oxygen level-dependent (BOLD) signals in the orbitofrontal cortex, where scores of neurons are tuned into the sensory properties of food “like a wonderfully sensitive antenna,” he said. “The reason, I think, that you have neurons like that is so that during a meal you could have a response to one food as a reward. When you have eaten it, you no longer like that food, but then you will still like other foods. You compute that property very simply by having these neurons that respond to different combinations of foods.”

The concept is known as sensory-specific satiety: the notion that when you eat, your appetite can go down for one food, but remain high for other foods.

The reward decoding in parts of the brain such as the orbitofrontal cortex “is crucial to understand and may be different in obese people,” added Dr. Rolls, of the Oxford (England) Centre for Computational Neuroscience Research.

“Also, when we see, taste, or smell food, we're going to get autonomic responses, changes in insulin and changes in glucose. So understanding this circuitry and how it could be different in some individuals is also important to understanding obesity.”

In one study conducted by Dr. Rolls and his associates, participants rated the pleasantness of the flavor of chocolate milk and tomato juice, then half of the participants consumed chocolate milk to satiety and the other half consumed tomato juice to satiety, after which all of them underwent brain fMRI. The researchers found that the pleasantness of the flavor of the food eaten to satiety decreased, and that the decrease in pleasantness was reflected in decreased neuronal activation in the orbitofrontal cortex (Cereb. Cortex 2003;13:1064-71).

“The initial BOLD signal response indicates that the food is pleasant,” Dr. Rolls said. “As you feed to satiety, one of those foods becomes less pleasant, and the orbitofrontal cortex is no longer activated.”

Other fMRI studies have demonstrated that when fat is placed into the mouth, some neurons increase their firing rate to about 15 times per second. “There seems to be a sensing of texture reward in the orbitofrontal cortex, as well as olfactory reward, taste reward, visual reward, and temperature,” he said.

Dr. Rolls concluded his remarks by expressing doubt that endocrine or genetic factors directly contributed to the spike in obesity that has occurred over the past 3 decades.

“We think it is these sensory input signals and the rewards they produce that drive people to eat too much,” he said. “Palatability is another factor. Food companies produce highly palatable foods; that will tend to produce an imbalance with respect to our evolutionary old satiety signals. Food variety, portion size, and stress-induced eating are also factors.”

Dr. Rolls had no conflicts of interest to disclose.

NEW ORLEANS — Scientists are on the cusp of understanding the role of sensory factors related to food intake control, and the orbitofrontal cortex appears to be hub of activity.

“In food intake control, sensory factors such as taste, smell, sight, and texture are first decoded in the brain as being taste and smell, independently of reward,” Dr. Edmund T. Rolls said at the annual scientific sessions of the American Diabetes Association. “Then they project into structures such as the orbitofrontal cortex, which decodes them in terms of their reward value. It is there that neurons determine if the food tastes pleasant, or smells pleasant, or looks pleasant. That is a crucial part of the brain for sending signals to make us want to eat: because of food reward.”

Dr. Rolls said that functional magnetic resonance imaging (fMRI) is helping scientists track the complex circuitry involved in food cravings and food reward. When someone finds a food pleasant, for example, fMRI reveals blood oxygen level-dependent (BOLD) signals in the orbitofrontal cortex, where scores of neurons are tuned into the sensory properties of food “like a wonderfully sensitive antenna,” he said. “The reason, I think, that you have neurons like that is so that during a meal you could have a response to one food as a reward. When you have eaten it, you no longer like that food, but then you will still like other foods. You compute that property very simply by having these neurons that respond to different combinations of foods.”

The concept is known as sensory-specific satiety: the notion that when you eat, your appetite can go down for one food, but remain high for other foods.

The reward decoding in parts of the brain such as the orbitofrontal cortex “is crucial to understand and may be different in obese people,” added Dr. Rolls, of the Oxford (England) Centre for Computational Neuroscience Research.

“Also, when we see, taste, or smell food, we're going to get autonomic responses, changes in insulin and changes in glucose. So understanding this circuitry and how it could be different in some individuals is also important to understanding obesity.”

In one study conducted by Dr. Rolls and his associates, participants rated the pleasantness of the flavor of chocolate milk and tomato juice, then half of the participants consumed chocolate milk to satiety and the other half consumed tomato juice to satiety, after which all of them underwent brain fMRI. The researchers found that the pleasantness of the flavor of the food eaten to satiety decreased, and that the decrease in pleasantness was reflected in decreased neuronal activation in the orbitofrontal cortex (Cereb. Cortex 2003;13:1064-71).

“The initial BOLD signal response indicates that the food is pleasant,” Dr. Rolls said. “As you feed to satiety, one of those foods becomes less pleasant, and the orbitofrontal cortex is no longer activated.”

Other fMRI studies have demonstrated that when fat is placed into the mouth, some neurons increase their firing rate to about 15 times per second. “There seems to be a sensing of texture reward in the orbitofrontal cortex, as well as olfactory reward, taste reward, visual reward, and temperature,” he said.

Dr. Rolls concluded his remarks by expressing doubt that endocrine or genetic factors directly contributed to the spike in obesity that has occurred over the past 3 decades.

“We think it is these sensory input signals and the rewards they produce that drive people to eat too much,” he said. “Palatability is another factor. Food companies produce highly palatable foods; that will tend to produce an imbalance with respect to our evolutionary old satiety signals. Food variety, portion size, and stress-induced eating are also factors.”

Dr. Rolls had no conflicts of interest to disclose.

NEW ORLEANS — Most obstetrical care providers agree that at-risk women should undergo early screening for gestational diabetes mellitus, and the majority use the 50-g, 1-hour oral glucose challenge test, results from a single-center survey showed.

“Our data suggest early screening detects a significant proportion of women with GDM [gestational diabetes mellitus],” Dr. Kimberly K. Vesco of the center for health research at Kaiser Permanente Northwest, Portland, Ore., reported in a poster at the annual scientific sessions of the American Diabetes Association. “Formal protocols for early screening of at-risk women should be established and evaluated to determine whether they lead to improvement in early screening and detection of GDM.”

Although both the American College of Obstetricians and Gynecologists and the ADA recommend screening pregnant women at risk for diabetes at the first prenatal visit, “neither organization specifies what lab test to use for early screening, e.g., fasting plasma glucose [FPG]; the 50-g, 1-hour oral glucose challenge test [OGCT]; or both,” wrote the researchers, who said they had no disclosures to report.

To find out how and why clinicians screen for diabetes in early pregnancy, the researchers surveyed 92 obstetrical care providers at Kaiser Permanente Northwest in 2007 about their first- and second-trimester GDM screening practices. They analyzed medical records of women who gave birth there from 2004 to 2006 to determine the prevalence of GDM and the proportion of women with GDM diagnosed before 24 weeks' gestation.

Of 92 clinicians, 62 (67%) returned the survey, including 33 obstetricians, 16 nurse-midwives, and 9 nurse practitioners. Four respondents did not report their degree.

The majority of providers indicated they would order GDM screening for women with a history of GDM (97% in the first trimester vs. 87% in the second trimester), those with a history of delivering a macrosomic infant (82% in the first trimester vs. 77% in the second trimester), and those who are obese (81% in the first trimester vs. 73% in the second trimester).

The 50-g OGCT was the preferred test of respondents for early screening (71% in the first trimester vs. 77% in the second trimester), followed by the FPG test (26% in the first trimester vs. 10% in the second trimester), and a combination of the two tests (8% in the first and second trimesters).

Between 2004 and 2006, 436 women were diagnosed with GDM, for a prevalence of 3.8%. The prevalence was significantly higher among obese women compared with nonobese women (6.7% vs. 2.9%).

Overall, just 4.6% of GDM diagnoses were made before 12 weeks' gestation and 10.9% prior to 24 weeks' gestation. Among obese women with GDM, 5.4% were diagnosed prior to 12 weeks and 14.8% prior to 24 weeks' gestation. In addition, the researchers wrote, “despite the majority of providers indicating that they would screen obese women at the first prenatal visit, the proportion of obese women screened was only 16% prior to 12 weeks and 29% prior to 24 weeks.”

The 50-g, 1-hour OGCT was most commonly used for all study participants (in 75% prior to 12 weeks' gestation, in 90% between 12 and 23 weeks' gestation and in 99.6% at 24 weeks' gestation and beyond), followed by FPG (in 24% prior to 12 weeks' gestation, in 9% between 12 and 23 weeks' gestation, and in 0.4% at week 24 of gestation and beyond) and the 100-g, 3-hour oral glucose tolerance test (in 0.4% prior to 12 weeks' gestation, in 1.2% between 12 and 23 weeks' gestation, and in 0.1% at week 24 of gestation and beyond).

NEW ORLEANS — Most obstetrical care providers agree that at-risk women should undergo early screening for gestational diabetes mellitus, and the majority use the 50-g, 1-hour oral glucose challenge test, results from a single-center survey showed.

“Our data suggest early screening detects a significant proportion of women with GDM [gestational diabetes mellitus],” Dr. Kimberly K. Vesco of the center for health research at Kaiser Permanente Northwest, Portland, Ore., reported in a poster at the annual scientific sessions of the American Diabetes Association. “Formal protocols for early screening of at-risk women should be established and evaluated to determine whether they lead to improvement in early screening and detection of GDM.”

Although both the American College of Obstetricians and Gynecologists and the ADA recommend screening pregnant women at risk for diabetes at the first prenatal visit, “neither organization specifies what lab test to use for early screening, e.g., fasting plasma glucose [FPG]; the 50-g, 1-hour oral glucose challenge test [OGCT]; or both,” wrote the researchers, who said they had no disclosures to report.

To find out how and why clinicians screen for diabetes in early pregnancy, the researchers surveyed 92 obstetrical care providers at Kaiser Permanente Northwest in 2007 about their first- and second-trimester GDM screening practices. They analyzed medical records of women who gave birth there from 2004 to 2006 to determine the prevalence of GDM and the proportion of women with GDM diagnosed before 24 weeks' gestation.

Of 92 clinicians, 62 (67%) returned the survey, including 33 obstetricians, 16 nurse-midwives, and 9 nurse practitioners. Four respondents did not report their degree.

The majority of providers indicated they would order GDM screening for women with a history of GDM (97% in the first trimester vs. 87% in the second trimester), those with a history of delivering a macrosomic infant (82% in the first trimester vs. 77% in the second trimester), and those who are obese (81% in the first trimester vs. 73% in the second trimester).

The 50-g OGCT was the preferred test of respondents for early screening (71% in the first trimester vs. 77% in the second trimester), followed by the FPG test (26% in the first trimester vs. 10% in the second trimester), and a combination of the two tests (8% in the first and second trimesters).

Between 2004 and 2006, 436 women were diagnosed with GDM, for a prevalence of 3.8%. The prevalence was significantly higher among obese women compared with nonobese women (6.7% vs. 2.9%).

Overall, just 4.6% of GDM diagnoses were made before 12 weeks' gestation and 10.9% prior to 24 weeks' gestation. Among obese women with GDM, 5.4% were diagnosed prior to 12 weeks and 14.8% prior to 24 weeks' gestation. In addition, the researchers wrote, “despite the majority of providers indicating that they would screen obese women at the first prenatal visit, the proportion of obese women screened was only 16% prior to 12 weeks and 29% prior to 24 weeks.”

The 50-g, 1-hour OGCT was most commonly used for all study participants (in 75% prior to 12 weeks' gestation, in 90% between 12 and 23 weeks' gestation and in 99.6% at 24 weeks' gestation and beyond), followed by FPG (in 24% prior to 12 weeks' gestation, in 9% between 12 and 23 weeks' gestation, and in 0.4% at week 24 of gestation and beyond) and the 100-g, 3-hour oral glucose tolerance test (in 0.4% prior to 12 weeks' gestation, in 1.2% between 12 and 23 weeks' gestation, and in 0.1% at week 24 of gestation and beyond).

NEW ORLEANS — Most obstetrical care providers agree that at-risk women should undergo early screening for gestational diabetes mellitus, and the majority use the 50-g, 1-hour oral glucose challenge test, results from a single-center survey showed.

“Our data suggest early screening detects a significant proportion of women with GDM [gestational diabetes mellitus],” Dr. Kimberly K. Vesco of the center for health research at Kaiser Permanente Northwest, Portland, Ore., reported in a poster at the annual scientific sessions of the American Diabetes Association. “Formal protocols for early screening of at-risk women should be established and evaluated to determine whether they lead to improvement in early screening and detection of GDM.”

Although both the American College of Obstetricians and Gynecologists and the ADA recommend screening pregnant women at risk for diabetes at the first prenatal visit, “neither organization specifies what lab test to use for early screening, e.g., fasting plasma glucose [FPG]; the 50-g, 1-hour oral glucose challenge test [OGCT]; or both,” wrote the researchers, who said they had no disclosures to report.

To find out how and why clinicians screen for diabetes in early pregnancy, the researchers surveyed 92 obstetrical care providers at Kaiser Permanente Northwest in 2007 about their first- and second-trimester GDM screening practices. They analyzed medical records of women who gave birth there from 2004 to 2006 to determine the prevalence of GDM and the proportion of women with GDM diagnosed before 24 weeks' gestation.

Of 92 clinicians, 62 (67%) returned the survey, including 33 obstetricians, 16 nurse-midwives, and 9 nurse practitioners. Four respondents did not report their degree.

The majority of providers indicated they would order GDM screening for women with a history of GDM (97% in the first trimester vs. 87% in the second trimester), those with a history of delivering a macrosomic infant (82% in the first trimester vs. 77% in the second trimester), and those who are obese (81% in the first trimester vs. 73% in the second trimester).

The 50-g OGCT was the preferred test of respondents for early screening (71% in the first trimester vs. 77% in the second trimester), followed by the FPG test (26% in the first trimester vs. 10% in the second trimester), and a combination of the two tests (8% in the first and second trimesters).

Between 2004 and 2006, 436 women were diagnosed with GDM, for a prevalence of 3.8%. The prevalence was significantly higher among obese women compared with nonobese women (6.7% vs. 2.9%).

Overall, just 4.6% of GDM diagnoses were made before 12 weeks' gestation and 10.9% prior to 24 weeks' gestation. Among obese women with GDM, 5.4% were diagnosed prior to 12 weeks and 14.8% prior to 24 weeks' gestation. In addition, the researchers wrote, “despite the majority of providers indicating that they would screen obese women at the first prenatal visit, the proportion of obese women screened was only 16% prior to 12 weeks and 29% prior to 24 weeks.”

The 50-g, 1-hour OGCT was most commonly used for all study participants (in 75% prior to 12 weeks' gestation, in 90% between 12 and 23 weeks' gestation and in 99.6% at 24 weeks' gestation and beyond), followed by FPG (in 24% prior to 12 weeks' gestation, in 9% between 12 and 23 weeks' gestation, and in 0.4% at week 24 of gestation and beyond) and the 100-g, 3-hour oral glucose tolerance test (in 0.4% prior to 12 weeks' gestation, in 1.2% between 12 and 23 weeks' gestation, and in 0.1% at week 24 of gestation and beyond).

NEW ORLEANS — Several ongoing trials aim to address the limited success of standard interventions to reduce postpartum weight gain among women who had gestational diabetes mellitus, according to Dr. Lucinda England.

One trial at Kaiser Permanente Northern California recruits women during pregnancy and helps them in the postpartum period to reach their prepregnancy weights plus an additional 5% weight loss for those who were overweight before pregnancy. The intervention includes 3 in-person counseling sessions and 13 phone counseling sessions for up to 9 months following delivery, said Dr. England of the division of reproductive health at the Centers for Disease Control and Prevention.

In a study funded by the CDC, researchers at Brigham and Women's Hospital, Boston, are developing and evaluating a diabetes prevention program-style intervention that has been modified for postpartum women, Dr. England said at the annual scientific sessions of the American Diabetes Association.

A gestational diabetes initiative launched in New York City in 2006 uses birth certificate data from vital records to identify women with the condition. The New York City Department of Health and Mental Hygiene mails a letter to the mother outlining the risks of gestational diabetes to the mother and child, the importance of screening after delivery, and recommended lifestyle changes. Also included is a letter that the woman can take to her personal physician that contains information on screening for diabetes post partum. Other materials sent include health bulletins on weight loss, diabetes, and trans fats, as well as a guide to fitness and nutrition programs in specific neighborhoods.

“We don't yet know how to best adapt lifestyle interventions for this population,” Dr. England said.

Women with gestational diabetes face a six- to sevenfold increased risk of diabetes in the future. Previous interventions aimed at diet and physical activity appear to have only modest effects on short-term postpartum weight loss, she said. “Addressing barriers such as maternal fatigue, time constraints, and lack of child care may be critical to the success of these programs.”

The CDC estimates that 5% of pregnancies are complicated by gestational diabetes, which means about 200,000 women each year are affected. A small percentage of these women have undiagnosed preexisting diabetes; these women can be identified for early treatment through postpartum testing. The remaining women, many of whom have prediabetes, might benefit from diabetes prevention interventions, Dr. England said.

In a 2007 Cochrane review, the impact of diet, exercise, or both were compared with usual care for weight reduction in postpartum women in six trials. Diet interventions included dietary advice through group meetings, telephone calls, mail correspondence, individual dietary counseling, or prescription of a calorie-restricted diet. Exercise interventions included counseling and structured exercise programs with supervised exercise (Cochrane Database Syst. Rev. 2007;CD005627[doi:10.1002/14651858.CD005627.pub2

In a single trial of exercise alone in 33 postpartum women, no weight loss was achieved. In a single trial of diet alone in 45 postpartum women, a 1.7-kg weight loss was achieved, which reached statistical significance. In four trials of diet and exercise combined in 169 postpartum women, a 2.9-kg weight loss was achieved, which also reached statistical significance. However, Dr. England emphasized, “these trials were small.”

She said she had no conflicts of interest to disclose.

NEW ORLEANS — Several ongoing trials aim to address the limited success of standard interventions to reduce postpartum weight gain among women who had gestational diabetes mellitus, according to Dr. Lucinda England.

One trial at Kaiser Permanente Northern California recruits women during pregnancy and helps them in the postpartum period to reach their prepregnancy weights plus an additional 5% weight loss for those who were overweight before pregnancy. The intervention includes 3 in-person counseling sessions and 13 phone counseling sessions for up to 9 months following delivery, said Dr. England of the division of reproductive health at the Centers for Disease Control and Prevention.

In a study funded by the CDC, researchers at Brigham and Women's Hospital, Boston, are developing and evaluating a diabetes prevention program-style intervention that has been modified for postpartum women, Dr. England said at the annual scientific sessions of the American Diabetes Association.

A gestational diabetes initiative launched in New York City in 2006 uses birth certificate data from vital records to identify women with the condition. The New York City Department of Health and Mental Hygiene mails a letter to the mother outlining the risks of gestational diabetes to the mother and child, the importance of screening after delivery, and recommended lifestyle changes. Also included is a letter that the woman can take to her personal physician that contains information on screening for diabetes post partum. Other materials sent include health bulletins on weight loss, diabetes, and trans fats, as well as a guide to fitness and nutrition programs in specific neighborhoods.

“We don't yet know how to best adapt lifestyle interventions for this population,” Dr. England said.

Women with gestational diabetes face a six- to sevenfold increased risk of diabetes in the future. Previous interventions aimed at diet and physical activity appear to have only modest effects on short-term postpartum weight loss, she said. “Addressing barriers such as maternal fatigue, time constraints, and lack of child care may be critical to the success of these programs.”

The CDC estimates that 5% of pregnancies are complicated by gestational diabetes, which means about 200,000 women each year are affected. A small percentage of these women have undiagnosed preexisting diabetes; these women can be identified for early treatment through postpartum testing. The remaining women, many of whom have prediabetes, might benefit from diabetes prevention interventions, Dr. England said.

In a 2007 Cochrane review, the impact of diet, exercise, or both were compared with usual care for weight reduction in postpartum women in six trials. Diet interventions included dietary advice through group meetings, telephone calls, mail correspondence, individual dietary counseling, or prescription of a calorie-restricted diet. Exercise interventions included counseling and structured exercise programs with supervised exercise (Cochrane Database Syst. Rev. 2007;CD005627[doi:10.1002/14651858.CD005627.pub2

In a single trial of exercise alone in 33 postpartum women, no weight loss was achieved. In a single trial of diet alone in 45 postpartum women, a 1.7-kg weight loss was achieved, which reached statistical significance. In four trials of diet and exercise combined in 169 postpartum women, a 2.9-kg weight loss was achieved, which also reached statistical significance. However, Dr. England emphasized, “these trials were small.”

She said she had no conflicts of interest to disclose.

NEW ORLEANS — Several ongoing trials aim to address the limited success of standard interventions to reduce postpartum weight gain among women who had gestational diabetes mellitus, according to Dr. Lucinda England.

One trial at Kaiser Permanente Northern California recruits women during pregnancy and helps them in the postpartum period to reach their prepregnancy weights plus an additional 5% weight loss for those who were overweight before pregnancy. The intervention includes 3 in-person counseling sessions and 13 phone counseling sessions for up to 9 months following delivery, said Dr. England of the division of reproductive health at the Centers for Disease Control and Prevention.

In a study funded by the CDC, researchers at Brigham and Women's Hospital, Boston, are developing and evaluating a diabetes prevention program-style intervention that has been modified for postpartum women, Dr. England said at the annual scientific sessions of the American Diabetes Association.

A gestational diabetes initiative launched in New York City in 2006 uses birth certificate data from vital records to identify women with the condition. The New York City Department of Health and Mental Hygiene mails a letter to the mother outlining the risks of gestational diabetes to the mother and child, the importance of screening after delivery, and recommended lifestyle changes. Also included is a letter that the woman can take to her personal physician that contains information on screening for diabetes post partum. Other materials sent include health bulletins on weight loss, diabetes, and trans fats, as well as a guide to fitness and nutrition programs in specific neighborhoods.

“We don't yet know how to best adapt lifestyle interventions for this population,” Dr. England said.

Women with gestational diabetes face a six- to sevenfold increased risk of diabetes in the future. Previous interventions aimed at diet and physical activity appear to have only modest effects on short-term postpartum weight loss, she said. “Addressing barriers such as maternal fatigue, time constraints, and lack of child care may be critical to the success of these programs.”

The CDC estimates that 5% of pregnancies are complicated by gestational diabetes, which means about 200,000 women each year are affected. A small percentage of these women have undiagnosed preexisting diabetes; these women can be identified for early treatment through postpartum testing. The remaining women, many of whom have prediabetes, might benefit from diabetes prevention interventions, Dr. England said.

In a 2007 Cochrane review, the impact of diet, exercise, or both were compared with usual care for weight reduction in postpartum women in six trials. Diet interventions included dietary advice through group meetings, telephone calls, mail correspondence, individual dietary counseling, or prescription of a calorie-restricted diet. Exercise interventions included counseling and structured exercise programs with supervised exercise (Cochrane Database Syst. Rev. 2007;CD005627[doi:10.1002/14651858.CD005627.pub2

In a single trial of exercise alone in 33 postpartum women, no weight loss was achieved. In a single trial of diet alone in 45 postpartum women, a 1.7-kg weight loss was achieved, which reached statistical significance. In four trials of diet and exercise combined in 169 postpartum women, a 2.9-kg weight loss was achieved, which also reached statistical significance. However, Dr. England emphasized, “these trials were small.”

She said she had no conflicts of interest to disclose.

While clinical results of some influenza A(H1NI) virus vaccine trials won't be known until late September at the earliest, planning a vaccination program for the virus is well underway.

During a 2-hour teleconference, officials from the National Vaccine Advisory Committee (NVAC) provided a wide-ranging update on activities related to novel H1N1 virus vaccine development and implementation planning.

Dr. Anne Schuchat, director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention, noted that there have been “disruptive clusters and outbreaks” of H1N1 influenza at summer camps in the United States with “remarkable heterogeneity,” with some people disproportionately affected.

“We are continuing to see illness here in the U.S., at a lower frequency than in the spring, but a very high frequency compared to a usual summer,” she said. “In the Southern hemisphere, this virus is circulating together with seasonal strains and in some cases dominating, with a mix of impact on the health sector in terms of medical capacity to keep up with it.”

Robin Robinson, Ph.D., director of the Biomedical Advanced Research and Development Authority (BARDA), an agency of the Health and Human Services department, noted that the HHS has contracted with five manufacturers to develop novel H1N1 virus vaccine: Four are producing an inactivated form of the vaccine, which will be available in pre-filled syringes and multidose vials, and one is producing a live attenuated form.

Clinical vaccine trials will be carried out in adults first, and then proceed to pediatric populations. Dr. Robinson estimated that about 20% of the entire clinical trial population will include children.

Results from the first clinical trials—which began in mid-July—are expected by late September or early October.

Dr. Jay C. Butler, director of the CDC's H1N1 Vaccine Task Force, said that a novel H1N1 virus vaccine program will not be the same as a program for H5N1 or severe pandemic, or seasonal flu. “The great unknown is how much will we possibly see an increase in disease in the fall if all other factors remain the same, such as severity, and antigenic characteristics of the virus,” he said.

Based on current epidemiology, the H1N1 Vaccine Task Force recommended that vaccine administration planning take into account certain at-risk groups, including children and staff in day care centers and in schools serving grades K-12; pregnant women; young children; persons with household contact with children less than 6 months of age; persons with underlying medical conditions; health care workers; and, when enough vaccine is available, everyone else.

Uncertainties about a vaccine rollout persist, Dr. Butler said, including the amount of vaccine required and when it will be available; its formulation; specific recommendations for use; and demand for the vaccine.

Dr. Marie McCormick, a member of NVAC who is also a professor of maternal and child health at Harvard School of Public Health, presented draft recommendations of the H1N1 Vaccine Safety Subgroup. It calls for a federal plan to monitor novel H1N1 influenza vaccine safety, “both for proper planning purposes and to provide information to the public and stakeholders (including states) about important vaccine activities.”

One key recommendation says that the need “to actively monitor vaccine recipients for vaccine adverse events is critical given that the vaccine candidates will all contain a new antigen and may be combined with adjuvants that are not part of licensed vaccines in the United States.”

Another recommendation calls for “transparent and independent review of vaccine safety data as it accumulates.”

The NVAC voted to adopt these recommendations, which will be passed along to National Vaccine Program Director Bruce G. Gellin, for consideration.

Megan C. Lindley of the National Center for Immunization and Respiratory Diseases presented draft recommendations related to financing the administration of novel H1N1 influenza vaccine. These include voluntary first-dollar insurance coverage by public and private plans; an increased federal match for Medicaid vaccine administration reimbursement; vaccine administration reimbursement for all Vaccines for Children-eligible children, including those on Medicaid; insurance reimbursements that cover all costs associated with vaccine administration; and federal funding that supports state vaccination infrastructure and vaccine implementation.

The NVAC voted to adopt these recommendations, with some minor editorial changes.

Dr. Anne Bailowitz, medical director of environmental health and emergency programs for the National Association of County and City Health Officials, expressed concern about the implementation of a novel H1N1 virus vaccine program in light of financial challenges faced by many local health departments in the United States. In 2008, she said, 27% of local health departments had budget cuts and 53% had layoffs. This year, she said, 44% of local departments have had budget cuts and 32% have had layoffs.

Establishing local partnerships will be key to successful implementation, she said. For example, options include tailoring partners to target populations, such as ob. gyns. and nurse midwives for pregnant women, defining roles for hospitals, and encouraging large businesses to immunize their own employees.

Volunteer H1N1 vaccination providers could also include student nurses, medical school students, dental students, veterinarians, emergency medical technicians, and pharmacy chain personnel.

“The time to start talking to potential partners is now,” she advised.

While clinical results of some influenza A(H1NI) virus vaccine trials won't be known until late September at the earliest, planning a vaccination program for the virus is well underway.

During a 2-hour teleconference, officials from the National Vaccine Advisory Committee (NVAC) provided a wide-ranging update on activities related to novel H1N1 virus vaccine development and implementation planning.

Dr. Anne Schuchat, director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention, noted that there have been “disruptive clusters and outbreaks” of H1N1 influenza at summer camps in the United States with “remarkable heterogeneity,” with some people disproportionately affected.

“We are continuing to see illness here in the U.S., at a lower frequency than in the spring, but a very high frequency compared to a usual summer,” she said. “In the Southern hemisphere, this virus is circulating together with seasonal strains and in some cases dominating, with a mix of impact on the health sector in terms of medical capacity to keep up with it.”

Robin Robinson, Ph.D., director of the Biomedical Advanced Research and Development Authority (BARDA), an agency of the Health and Human Services department, noted that the HHS has contracted with five manufacturers to develop novel H1N1 virus vaccine: Four are producing an inactivated form of the vaccine, which will be available in pre-filled syringes and multidose vials, and one is producing a live attenuated form.

Clinical vaccine trials will be carried out in adults first, and then proceed to pediatric populations. Dr. Robinson estimated that about 20% of the entire clinical trial population will include children.

Results from the first clinical trials—which began in mid-July—are expected by late September or early October.

Dr. Jay C. Butler, director of the CDC's H1N1 Vaccine Task Force, said that a novel H1N1 virus vaccine program will not be the same as a program for H5N1 or severe pandemic, or seasonal flu. “The great unknown is how much will we possibly see an increase in disease in the fall if all other factors remain the same, such as severity, and antigenic characteristics of the virus,” he said.

Based on current epidemiology, the H1N1 Vaccine Task Force recommended that vaccine administration planning take into account certain at-risk groups, including children and staff in day care centers and in schools serving grades K-12; pregnant women; young children; persons with household contact with children less than 6 months of age; persons with underlying medical conditions; health care workers; and, when enough vaccine is available, everyone else.

Uncertainties about a vaccine rollout persist, Dr. Butler said, including the amount of vaccine required and when it will be available; its formulation; specific recommendations for use; and demand for the vaccine.

Dr. Marie McCormick, a member of NVAC who is also a professor of maternal and child health at Harvard School of Public Health, presented draft recommendations of the H1N1 Vaccine Safety Subgroup. It calls for a federal plan to monitor novel H1N1 influenza vaccine safety, “both for proper planning purposes and to provide information to the public and stakeholders (including states) about important vaccine activities.”

One key recommendation says that the need “to actively monitor vaccine recipients for vaccine adverse events is critical given that the vaccine candidates will all contain a new antigen and may be combined with adjuvants that are not part of licensed vaccines in the United States.”

Another recommendation calls for “transparent and independent review of vaccine safety data as it accumulates.”

The NVAC voted to adopt these recommendations, which will be passed along to National Vaccine Program Director Bruce G. Gellin, for consideration.

Megan C. Lindley of the National Center for Immunization and Respiratory Diseases presented draft recommendations related to financing the administration of novel H1N1 influenza vaccine. These include voluntary first-dollar insurance coverage by public and private plans; an increased federal match for Medicaid vaccine administration reimbursement; vaccine administration reimbursement for all Vaccines for Children-eligible children, including those on Medicaid; insurance reimbursements that cover all costs associated with vaccine administration; and federal funding that supports state vaccination infrastructure and vaccine implementation.

The NVAC voted to adopt these recommendations, with some minor editorial changes.

Dr. Anne Bailowitz, medical director of environmental health and emergency programs for the National Association of County and City Health Officials, expressed concern about the implementation of a novel H1N1 virus vaccine program in light of financial challenges faced by many local health departments in the United States. In 2008, she said, 27% of local health departments had budget cuts and 53% had layoffs. This year, she said, 44% of local departments have had budget cuts and 32% have had layoffs.

Establishing local partnerships will be key to successful implementation, she said. For example, options include tailoring partners to target populations, such as ob. gyns. and nurse midwives for pregnant women, defining roles for hospitals, and encouraging large businesses to immunize their own employees.

Volunteer H1N1 vaccination providers could also include student nurses, medical school students, dental students, veterinarians, emergency medical technicians, and pharmacy chain personnel.

“The time to start talking to potential partners is now,” she advised.

While clinical results of some influenza A(H1NI) virus vaccine trials won't be known until late September at the earliest, planning a vaccination program for the virus is well underway.

During a 2-hour teleconference, officials from the National Vaccine Advisory Committee (NVAC) provided a wide-ranging update on activities related to novel H1N1 virus vaccine development and implementation planning.

Dr. Anne Schuchat, director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention, noted that there have been “disruptive clusters and outbreaks” of H1N1 influenza at summer camps in the United States with “remarkable heterogeneity,” with some people disproportionately affected.

“We are continuing to see illness here in the U.S., at a lower frequency than in the spring, but a very high frequency compared to a usual summer,” she said. “In the Southern hemisphere, this virus is circulating together with seasonal strains and in some cases dominating, with a mix of impact on the health sector in terms of medical capacity to keep up with it.”

Robin Robinson, Ph.D., director of the Biomedical Advanced Research and Development Authority (BARDA), an agency of the Health and Human Services department, noted that the HHS has contracted with five manufacturers to develop novel H1N1 virus vaccine: Four are producing an inactivated form of the vaccine, which will be available in pre-filled syringes and multidose vials, and one is producing a live attenuated form.

Clinical vaccine trials will be carried out in adults first, and then proceed to pediatric populations. Dr. Robinson estimated that about 20% of the entire clinical trial population will include children.

Results from the first clinical trials—which began in mid-July—are expected by late September or early October.

Dr. Jay C. Butler, director of the CDC's H1N1 Vaccine Task Force, said that a novel H1N1 virus vaccine program will not be the same as a program for H5N1 or severe pandemic, or seasonal flu. “The great unknown is how much will we possibly see an increase in disease in the fall if all other factors remain the same, such as severity, and antigenic characteristics of the virus,” he said.

Based on current epidemiology, the H1N1 Vaccine Task Force recommended that vaccine administration planning take into account certain at-risk groups, including children and staff in day care centers and in schools serving grades K-12; pregnant women; young children; persons with household contact with children less than 6 months of age; persons with underlying medical conditions; health care workers; and, when enough vaccine is available, everyone else.

Uncertainties about a vaccine rollout persist, Dr. Butler said, including the amount of vaccine required and when it will be available; its formulation; specific recommendations for use; and demand for the vaccine.

Dr. Marie McCormick, a member of NVAC who is also a professor of maternal and child health at Harvard School of Public Health, presented draft recommendations of the H1N1 Vaccine Safety Subgroup. It calls for a federal plan to monitor novel H1N1 influenza vaccine safety, “both for proper planning purposes and to provide information to the public and stakeholders (including states) about important vaccine activities.”

One key recommendation says that the need “to actively monitor vaccine recipients for vaccine adverse events is critical given that the vaccine candidates will all contain a new antigen and may be combined with adjuvants that are not part of licensed vaccines in the United States.”

Another recommendation calls for “transparent and independent review of vaccine safety data as it accumulates.”

The NVAC voted to adopt these recommendations, which will be passed along to National Vaccine Program Director Bruce G. Gellin, for consideration.

Megan C. Lindley of the National Center for Immunization and Respiratory Diseases presented draft recommendations related to financing the administration of novel H1N1 influenza vaccine. These include voluntary first-dollar insurance coverage by public and private plans; an increased federal match for Medicaid vaccine administration reimbursement; vaccine administration reimbursement for all Vaccines for Children-eligible children, including those on Medicaid; insurance reimbursements that cover all costs associated with vaccine administration; and federal funding that supports state vaccination infrastructure and vaccine implementation.

The NVAC voted to adopt these recommendations, with some minor editorial changes.

Dr. Anne Bailowitz, medical director of environmental health and emergency programs for the National Association of County and City Health Officials, expressed concern about the implementation of a novel H1N1 virus vaccine program in light of financial challenges faced by many local health departments in the United States. In 2008, she said, 27% of local health departments had budget cuts and 53% had layoffs. This year, she said, 44% of local departments have had budget cuts and 32% have had layoffs.

Establishing local partnerships will be key to successful implementation, she said. For example, options include tailoring partners to target populations, such as ob. gyns. and nurse midwives for pregnant women, defining roles for hospitals, and encouraging large businesses to immunize their own employees.

Volunteer H1N1 vaccination providers could also include student nurses, medical school students, dental students, veterinarians, emergency medical technicians, and pharmacy chain personnel.

“The time to start talking to potential partners is now,” she advised.

NEW ORLEANS — The costs of routine screening for prediabetes and unrecognized diabetes appear to be lower than the costs of no screening at all, results from a large analysis suggest.

“Missing a diagnosis of prediabetes or diabetes is expensive, something we tend to overlook,” Dr. Ranee Chatterjee of the department of general internal medicine at Johns Hopkins University, Baltimore, said at the annual scientific sessions of the American Diabetes Association.

In a study led by her associate, Dr. Lawrence S. Phillips, professor of medicine at Emory University, Atlanta, researchers screened 1,259 adult volunteers not known to have diabetes who participated in the Screening for Impaired Glucose Tolerance study. The adults underwent four screening tests: a random plasma and capillary glucose test and a second random plasma and capillary glucose test 1 hour after a 50-g oral glucose challenge test, followed by a definitive 75-g oral glucose tolerance test performed in the morning after an overnight fast.

The researchers drew from previous studies and from the Diabetes Prevention Program to evaluate costs over a 3-year period from a health system perspective and from a societal perspective. The health system perspective included direct medical costs associated with testing, including lab costs, follow-up, the costs of treating true positives, and costs that might be incurred by allowing medical conditions or false negatives to progress over a 3-year period.

Societal costs included the time required for the patient to undergo screening and treatment, as well as the loss of productivity that would result from treatment or from allowing those medical conditions to progress.

Dr. Chatterjee reported that 24% of the adults screened had either prediabetes or diabetes, and areas under receiver operating characteristic curves ranged from 0.64 for the rapid capillary glucose test to 0.82 for the 50-g oral glucose challenge test. After applying 70% specificity screening cutoffs, Medicare costs for testing, costs for generic metformin, and 10% false-negative estimates, the researchers projected that health system costs for each screening test over a 3-year period ranged from about $180,000 to $186,000. These were all lower than the estimated costs for no screening, which were about $206,000.

The random plasma glucose test was the least costly, but Dr. Chatterjee said that the most practical screening test to consider in this patient population may be the 50-g oral glucose challenge test, “which can be done any time of the day, does not require fasting, and could be done opportunistically during a clinical visit. It should be considered as a convenient, cost-effective method for screening adults for prediabetes and diabetes.”

Study limitations included the fact that the participants were volunteers and that the researchers used a single glucose tolerance test as their standard rather than two glucose tolerance tests. “But we felt this is what's done in gestational diabetes,” Dr. Chatterjee said. “In addition, we concentrated on treatment with metformin because we felt this is more generalizable, but it may not be the best treatment.”

She had no conflicts of interest.

'Missing a diagnosis of prediabetes or diabetes is expensive, something we tend to overlook.'

Source DR. CHATTERJEE

NEW ORLEANS — The costs of routine screening for prediabetes and unrecognized diabetes appear to be lower than the costs of no screening at all, results from a large analysis suggest.

“Missing a diagnosis of prediabetes or diabetes is expensive, something we tend to overlook,” Dr. Ranee Chatterjee of the department of general internal medicine at Johns Hopkins University, Baltimore, said at the annual scientific sessions of the American Diabetes Association.

In a study led by her associate, Dr. Lawrence S. Phillips, professor of medicine at Emory University, Atlanta, researchers screened 1,259 adult volunteers not known to have diabetes who participated in the Screening for Impaired Glucose Tolerance study. The adults underwent four screening tests: a random plasma and capillary glucose test and a second random plasma and capillary glucose test 1 hour after a 50-g oral glucose challenge test, followed by a definitive 75-g oral glucose tolerance test performed in the morning after an overnight fast.

The researchers drew from previous studies and from the Diabetes Prevention Program to evaluate costs over a 3-year period from a health system perspective and from a societal perspective. The health system perspective included direct medical costs associated with testing, including lab costs, follow-up, the costs of treating true positives, and costs that might be incurred by allowing medical conditions or false negatives to progress over a 3-year period.

Societal costs included the time required for the patient to undergo screening and treatment, as well as the loss of productivity that would result from treatment or from allowing those medical conditions to progress.

Dr. Chatterjee reported that 24% of the adults screened had either prediabetes or diabetes, and areas under receiver operating characteristic curves ranged from 0.64 for the rapid capillary glucose test to 0.82 for the 50-g oral glucose challenge test. After applying 70% specificity screening cutoffs, Medicare costs for testing, costs for generic metformin, and 10% false-negative estimates, the researchers projected that health system costs for each screening test over a 3-year period ranged from about $180,000 to $186,000. These were all lower than the estimated costs for no screening, which were about $206,000.

The random plasma glucose test was the least costly, but Dr. Chatterjee said that the most practical screening test to consider in this patient population may be the 50-g oral glucose challenge test, “which can be done any time of the day, does not require fasting, and could be done opportunistically during a clinical visit. It should be considered as a convenient, cost-effective method for screening adults for prediabetes and diabetes.”

Study limitations included the fact that the participants were volunteers and that the researchers used a single glucose tolerance test as their standard rather than two glucose tolerance tests. “But we felt this is what's done in gestational diabetes,” Dr. Chatterjee said. “In addition, we concentrated on treatment with metformin because we felt this is more generalizable, but it may not be the best treatment.”

She had no conflicts of interest.

'Missing a diagnosis of prediabetes or diabetes is expensive, something we tend to overlook.'

Source DR. CHATTERJEE

NEW ORLEANS — The costs of routine screening for prediabetes and unrecognized diabetes appear to be lower than the costs of no screening at all, results from a large analysis suggest.

“Missing a diagnosis of prediabetes or diabetes is expensive, something we tend to overlook,” Dr. Ranee Chatterjee of the department of general internal medicine at Johns Hopkins University, Baltimore, said at the annual scientific sessions of the American Diabetes Association.

In a study led by her associate, Dr. Lawrence S. Phillips, professor of medicine at Emory University, Atlanta, researchers screened 1,259 adult volunteers not known to have diabetes who participated in the Screening for Impaired Glucose Tolerance study. The adults underwent four screening tests: a random plasma and capillary glucose test and a second random plasma and capillary glucose test 1 hour after a 50-g oral glucose challenge test, followed by a definitive 75-g oral glucose tolerance test performed in the morning after an overnight fast.

The researchers drew from previous studies and from the Diabetes Prevention Program to evaluate costs over a 3-year period from a health system perspective and from a societal perspective. The health system perspective included direct medical costs associated with testing, including lab costs, follow-up, the costs of treating true positives, and costs that might be incurred by allowing medical conditions or false negatives to progress over a 3-year period.

Societal costs included the time required for the patient to undergo screening and treatment, as well as the loss of productivity that would result from treatment or from allowing those medical conditions to progress.

Dr. Chatterjee reported that 24% of the adults screened had either prediabetes or diabetes, and areas under receiver operating characteristic curves ranged from 0.64 for the rapid capillary glucose test to 0.82 for the 50-g oral glucose challenge test. After applying 70% specificity screening cutoffs, Medicare costs for testing, costs for generic metformin, and 10% false-negative estimates, the researchers projected that health system costs for each screening test over a 3-year period ranged from about $180,000 to $186,000. These were all lower than the estimated costs for no screening, which were about $206,000.

The random plasma glucose test was the least costly, but Dr. Chatterjee said that the most practical screening test to consider in this patient population may be the 50-g oral glucose challenge test, “which can be done any time of the day, does not require fasting, and could be done opportunistically during a clinical visit. It should be considered as a convenient, cost-effective method for screening adults for prediabetes and diabetes.”

Study limitations included the fact that the participants were volunteers and that the researchers used a single glucose tolerance test as their standard rather than two glucose tolerance tests. “But we felt this is what's done in gestational diabetes,” Dr. Chatterjee said. “In addition, we concentrated on treatment with metformin because we felt this is more generalizable, but it may not be the best treatment.”

She had no conflicts of interest.

'Missing a diagnosis of prediabetes or diabetes is expensive, something we tend to overlook.'

Source DR. CHATTERJEE

SAN DIEGO – Work on the fifth edition of American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders is well underway, and at least one psychiatrist thinks that alcohol-related neurobehavioral syndrome should be included.

Fetal alcohol spectrum disorder “has never been part of our taxonomy, and yet many psychiatrists wind up seeing these patients,” said Dr. Howard B. Moss, associate director for clinical and translational research at the National Institute on Alcohol Abuse and Alcoholism, Bethesda, Md., and a member of the DSM-V Task Force. “It would be helpful to have in the DSM so psychiatrists can bill for services as well as provide some sort of diagnosis for these patients.”

At the annual scientific conference of the Research Society on Alcoholism, Dr. Moss discussed the perceived shortcomings of the APA's current classification system, the DSM-IV, which was first published in 1994 and was updated in 2000.

First, he said, the DSM-IV tends to emphasize reliability over validity. “This is particularly problematic when you talk about the construction of psychiatric syndromes: whether or not the disorders as described in the DSM-IV represent conditions that clinicians actually see in their office, or whether they represent idealized conditions that really don't fit any given patient when you see them in real life,” Dr. Moss said.

Issues surrounding severity, disability, and quantitative scaling of mental disorders “are pretty much absent,” he added. “The thought is, through enhancing one's capacity to measure severity, disability, and quantitative aspects of the phenotype of interest in the DSM-V, you will be able to improve the quality of the diagnosis and perhaps increase its validity.”

The DSM-IV is also characterized by high rates of psychiatric comorbidity, he said, noting that some patients seen in clinical practice might meet diagnostic criteria for five or more mental disorders simultaneously. This suggests that “perhaps we're not doing a great job in terms of accurately describing the nature of the syndromes that are physically present.”

The extensive use of “not otherwise specified” criteria (NOS) in the DSM-IV is another concern. “NOS means that a patient sitting across from you has something that looks like a disorder that's in the DSM, but does not really meet any of the criteria specific for that disorder,” Dr. Moss said. “There's also treatment nonspecificity, and there has been a concern about a lack of biomarkers available for these criteria. Several individuals have stated that the DSM-IV hinders progress in [mental health care] because of its lack of validity.”

The DSM-V Task Force, launched in 2006, is chaired by David J. Kupfer, professor and chairman of the department of psychiatry at the University of Pittsburgh Medical Center. The vice chair is Dr. Darrel A. Regier, who directs the APA's division of research and is executive director of the American Psychiatric Institute for Research and Education. They oversee 13 work groups composed of more than 120 researchers and clinicians, including a work group on substance-related disorders (www.dsm5.org

Each work group is permitted to seek input from outside advisers to help identify specific issues in specific areas, but those advisers undergo a strict vetting process, Dr. Moss said, “such that individuals who have what is deemed as a conflict of interest due to their receipt of research grant dollars or consulting dollars from the pharmaceutical industry are eliminated from being able to participate. There is a threshold, but if an overwhelming amount of your research looks like it comes from the pharmaceutical industry, then you're asked not to participate.”

Publication of the DSM-V is expected in 2012, and the International Classification of Diseases-11 should be completed and published by 2014. According to timeline projections, field trials of the DSM-V should be currently underway, but “it is unclear as to what the field trials are going to look like, how they are going to be funded, and what sort of format they are going to take,” Dr. Moss commented.

Because of his position on fetal alcohol spectrum disorder, he has submitted a white paper arguing for the inclusion of alcohol-related neurodevelopmental disorder in the DSM-V. However, certain requisite questions must be answered before a new diagnosis is added to the DSM-V, he said. These include questions such as: Is the syndrome associated with clinically significant limitations in functioning or distress? Is the entity distinct from normal behavioral variations? Does the syndrome have diagnostic validity using one or more diagnostic validators?

Other questions might include: Does the proposed entity characterize a distinct group of people who need appropriate clinical attention? Have enough data been published on a wide range of topics related to the entity to warrant its inclusion in the DSM? Is there evidence for any effect of biological, psychological, or psychosocial treatment for a given disorder?

Dr. John E. Helzer, a psychiatrist who directs the Health Behavior Research Center at the University of Vermont, Burlington, said there are clear drawbacks to revising the DSM-IV, including disruption to clinicians and investigators, “because we have to learn to apply new diagnostic definitions. It sacrifices a longitudinal perspective because if you do population prevalence surveys with one set of diagnostic criteria and go out a few years later and do a different survey with a different set of criteria, it's very hard to compare the results.”

However, in his opinion, the shaping of the DSM-V provides an opportunity to create a more quantitative approach to making psychiatric diagnoses. “DSM has always been a categorical system; you either have a diagnosis or you don't,” said Dr. Helzer, a co-author of the Diagnostic Interview Schedule. “It does not allow for gradations of severity. If we can use things like item response theory and differential weighting to have a scaled score rather than a yes/no diagnosis, that's going to be immensely helpful, not only clinically but also in terms of our research work.”

He described the DSM-IV as a top-down diagnostic system and the DSM-V as a bottom-up diagnostic system. A top-down system “begins with expert committees that propose disorders, they decide the criteria and the thresholds, and that becomes a classification system,” he explained.

A bottom-up system, on the other hand, begins “with a large pool of data on problems; we use statistical analysis to identify thresholds, and that becomes a classification system,” Dr. Helzer said.

“The difference is the input of the clinical experts. There is heavy input of clinical experts in the top-down approach versus very little in the bottom-up approach,” he said.

“It's a very legitimate question about which of the two [approaches] would be more appropriate and give us a more valid diagnosis, but it seems that this is an opportune time for us to make this comparison.”

It would be helpful to have fetal alcohol spectrum disorder in the DSM so psychiatrists can bill for services.

Source DR. MOSS

SAN DIEGO – Work on the fifth edition of American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders is well underway, and at least one psychiatrist thinks that alcohol-related neurobehavioral syndrome should be included.

Fetal alcohol spectrum disorder “has never been part of our taxonomy, and yet many psychiatrists wind up seeing these patients,” said Dr. Howard B. Moss, associate director for clinical and translational research at the National Institute on Alcohol Abuse and Alcoholism, Bethesda, Md., and a member of the DSM-V Task Force. “It would be helpful to have in the DSM so psychiatrists can bill for services as well as provide some sort of diagnosis for these patients.”

At the annual scientific conference of the Research Society on Alcoholism, Dr. Moss discussed the perceived shortcomings of the APA's current classification system, the DSM-IV, which was first published in 1994 and was updated in 2000.

First, he said, the DSM-IV tends to emphasize reliability over validity. “This is particularly problematic when you talk about the construction of psychiatric syndromes: whether or not the disorders as described in the DSM-IV represent conditions that clinicians actually see in their office, or whether they represent idealized conditions that really don't fit any given patient when you see them in real life,” Dr. Moss said.

Issues surrounding severity, disability, and quantitative scaling of mental disorders “are pretty much absent,” he added. “The thought is, through enhancing one's capacity to measure severity, disability, and quantitative aspects of the phenotype of interest in the DSM-V, you will be able to improve the quality of the diagnosis and perhaps increase its validity.”

The DSM-IV is also characterized by high rates of psychiatric comorbidity, he said, noting that some patients seen in clinical practice might meet diagnostic criteria for five or more mental disorders simultaneously. This suggests that “perhaps we're not doing a great job in terms of accurately describing the nature of the syndromes that are physically present.”

The extensive use of “not otherwise specified” criteria (NOS) in the DSM-IV is another concern. “NOS means that a patient sitting across from you has something that looks like a disorder that's in the DSM, but does not really meet any of the criteria specific for that disorder,” Dr. Moss said. “There's also treatment nonspecificity, and there has been a concern about a lack of biomarkers available for these criteria. Several individuals have stated that the DSM-IV hinders progress in [mental health care] because of its lack of validity.”

The DSM-V Task Force, launched in 2006, is chaired by David J. Kupfer, professor and chairman of the department of psychiatry at the University of Pittsburgh Medical Center. The vice chair is Dr. Darrel A. Regier, who directs the APA's division of research and is executive director of the American Psychiatric Institute for Research and Education. They oversee 13 work groups composed of more than 120 researchers and clinicians, including a work group on substance-related disorders (www.dsm5.org

Each work group is permitted to seek input from outside advisers to help identify specific issues in specific areas, but those advisers undergo a strict vetting process, Dr. Moss said, “such that individuals who have what is deemed as a conflict of interest due to their receipt of research grant dollars or consulting dollars from the pharmaceutical industry are eliminated from being able to participate. There is a threshold, but if an overwhelming amount of your research looks like it comes from the pharmaceutical industry, then you're asked not to participate.”

Publication of the DSM-V is expected in 2012, and the International Classification of Diseases-11 should be completed and published by 2014. According to timeline projections, field trials of the DSM-V should be currently underway, but “it is unclear as to what the field trials are going to look like, how they are going to be funded, and what sort of format they are going to take,” Dr. Moss commented.

Because of his position on fetal alcohol spectrum disorder, he has submitted a white paper arguing for the inclusion of alcohol-related neurodevelopmental disorder in the DSM-V. However, certain requisite questions must be answered before a new diagnosis is added to the DSM-V, he said. These include questions such as: Is the syndrome associated with clinically significant limitations in functioning or distress? Is the entity distinct from normal behavioral variations? Does the syndrome have diagnostic validity using one or more diagnostic validators?

Other questions might include: Does the proposed entity characterize a distinct group of people who need appropriate clinical attention? Have enough data been published on a wide range of topics related to the entity to warrant its inclusion in the DSM? Is there evidence for any effect of biological, psychological, or psychosocial treatment for a given disorder?

Dr. John E. Helzer, a psychiatrist who directs the Health Behavior Research Center at the University of Vermont, Burlington, said there are clear drawbacks to revising the DSM-IV, including disruption to clinicians and investigators, “because we have to learn to apply new diagnostic definitions. It sacrifices a longitudinal perspective because if you do population prevalence surveys with one set of diagnostic criteria and go out a few years later and do a different survey with a different set of criteria, it's very hard to compare the results.”

However, in his opinion, the shaping of the DSM-V provides an opportunity to create a more quantitative approach to making psychiatric diagnoses. “DSM has always been a categorical system; you either have a diagnosis or you don't,” said Dr. Helzer, a co-author of the Diagnostic Interview Schedule. “It does not allow for gradations of severity. If we can use things like item response theory and differential weighting to have a scaled score rather than a yes/no diagnosis, that's going to be immensely helpful, not only clinically but also in terms of our research work.”

He described the DSM-IV as a top-down diagnostic system and the DSM-V as a bottom-up diagnostic system. A top-down system “begins with expert committees that propose disorders, they decide the criteria and the thresholds, and that becomes a classification system,” he explained.

A bottom-up system, on the other hand, begins “with a large pool of data on problems; we use statistical analysis to identify thresholds, and that becomes a classification system,” Dr. Helzer said.

“The difference is the input of the clinical experts. There is heavy input of clinical experts in the top-down approach versus very little in the bottom-up approach,” he said.

“It's a very legitimate question about which of the two [approaches] would be more appropriate and give us a more valid diagnosis, but it seems that this is an opportune time for us to make this comparison.”

It would be helpful to have fetal alcohol spectrum disorder in the DSM so psychiatrists can bill for services.

Source DR. MOSS

SAN DIEGO – Work on the fifth edition of American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders is well underway, and at least one psychiatrist thinks that alcohol-related neurobehavioral syndrome should be included.

Fetal alcohol spectrum disorder “has never been part of our taxonomy, and yet many psychiatrists wind up seeing these patients,” said Dr. Howard B. Moss, associate director for clinical and translational research at the National Institute on Alcohol Abuse and Alcoholism, Bethesda, Md., and a member of the DSM-V Task Force. “It would be helpful to have in the DSM so psychiatrists can bill for services as well as provide some sort of diagnosis for these patients.”

At the annual scientific conference of the Research Society on Alcoholism, Dr. Moss discussed the perceived shortcomings of the APA's current classification system, the DSM-IV, which was first published in 1994 and was updated in 2000.

First, he said, the DSM-IV tends to emphasize reliability over validity. “This is particularly problematic when you talk about the construction of psychiatric syndromes: whether or not the disorders as described in the DSM-IV represent conditions that clinicians actually see in their office, or whether they represent idealized conditions that really don't fit any given patient when you see them in real life,” Dr. Moss said.

Issues surrounding severity, disability, and quantitative scaling of mental disorders “are pretty much absent,” he added. “The thought is, through enhancing one's capacity to measure severity, disability, and quantitative aspects of the phenotype of interest in the DSM-V, you will be able to improve the quality of the diagnosis and perhaps increase its validity.”

The DSM-IV is also characterized by high rates of psychiatric comorbidity, he said, noting that some patients seen in clinical practice might meet diagnostic criteria for five or more mental disorders simultaneously. This suggests that “perhaps we're not doing a great job in terms of accurately describing the nature of the syndromes that are physically present.”

The extensive use of “not otherwise specified” criteria (NOS) in the DSM-IV is another concern. “NOS means that a patient sitting across from you has something that looks like a disorder that's in the DSM, but does not really meet any of the criteria specific for that disorder,” Dr. Moss said. “There's also treatment nonspecificity, and there has been a concern about a lack of biomarkers available for these criteria. Several individuals have stated that the DSM-IV hinders progress in [mental health care] because of its lack of validity.”

The DSM-V Task Force, launched in 2006, is chaired by David J. Kupfer, professor and chairman of the department of psychiatry at the University of Pittsburgh Medical Center. The vice chair is Dr. Darrel A. Regier, who directs the APA's division of research and is executive director of the American Psychiatric Institute for Research and Education. They oversee 13 work groups composed of more than 120 researchers and clinicians, including a work group on substance-related disorders (www.dsm5.org

Each work group is permitted to seek input from outside advisers to help identify specific issues in specific areas, but those advisers undergo a strict vetting process, Dr. Moss said, “such that individuals who have what is deemed as a conflict of interest due to their receipt of research grant dollars or consulting dollars from the pharmaceutical industry are eliminated from being able to participate. There is a threshold, but if an overwhelming amount of your research looks like it comes from the pharmaceutical industry, then you're asked not to participate.”

Publication of the DSM-V is expected in 2012, and the International Classification of Diseases-11 should be completed and published by 2014. According to timeline projections, field trials of the DSM-V should be currently underway, but “it is unclear as to what the field trials are going to look like, how they are going to be funded, and what sort of format they are going to take,” Dr. Moss commented.

Because of his position on fetal alcohol spectrum disorder, he has submitted a white paper arguing for the inclusion of alcohol-related neurodevelopmental disorder in the DSM-V. However, certain requisite questions must be answered before a new diagnosis is added to the DSM-V, he said. These include questions such as: Is the syndrome associated with clinically significant limitations in functioning or distress? Is the entity distinct from normal behavioral variations? Does the syndrome have diagnostic validity using one or more diagnostic validators?

Other questions might include: Does the proposed entity characterize a distinct group of people who need appropriate clinical attention? Have enough data been published on a wide range of topics related to the entity to warrant its inclusion in the DSM? Is there evidence for any effect of biological, psychological, or psychosocial treatment for a given disorder?

Dr. John E. Helzer, a psychiatrist who directs the Health Behavior Research Center at the University of Vermont, Burlington, said there are clear drawbacks to revising the DSM-IV, including disruption to clinicians and investigators, “because we have to learn to apply new diagnostic definitions. It sacrifices a longitudinal perspective because if you do population prevalence surveys with one set of diagnostic criteria and go out a few years later and do a different survey with a different set of criteria, it's very hard to compare the results.”

However, in his opinion, the shaping of the DSM-V provides an opportunity to create a more quantitative approach to making psychiatric diagnoses. “DSM has always been a categorical system; you either have a diagnosis or you don't,” said Dr. Helzer, a co-author of the Diagnostic Interview Schedule. “It does not allow for gradations of severity. If we can use things like item response theory and differential weighting to have a scaled score rather than a yes/no diagnosis, that's going to be immensely helpful, not only clinically but also in terms of our research work.”

He described the DSM-IV as a top-down diagnostic system and the DSM-V as a bottom-up diagnostic system. A top-down system “begins with expert committees that propose disorders, they decide the criteria and the thresholds, and that becomes a classification system,” he explained.

A bottom-up system, on the other hand, begins “with a large pool of data on problems; we use statistical analysis to identify thresholds, and that becomes a classification system,” Dr. Helzer said.

“The difference is the input of the clinical experts. There is heavy input of clinical experts in the top-down approach versus very little in the bottom-up approach,” he said.

“It's a very legitimate question about which of the two [approaches] would be more appropriate and give us a more valid diagnosis, but it seems that this is an opportune time for us to make this comparison.”

It would be helpful to have fetal alcohol spectrum disorder in the DSM so psychiatrists can bill for services.

Source DR. MOSS

SAN DIEGO – Mood or anxiety disorders, drug dependence, and nicotine dependence that co-occur with alcohol dependence can have negative effects on the long-term persistence of alcohol dependence.

Those are key conclusions from a 3-year follow-up of data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).

“The effects of specific co-occurring psychiatric disorders on the persistence of alcohol problems are not well understood,” Sharon Samet, Ph.D., and Deborah Hasin, Ph.D., of the department of psychiatry at Columbia University, New York, and the New York State Psychiatric Institute, reported in a poster presented at the annual scientific conference of the Research Society on Alcoholism.

“In patient samples, major depression is associated with greater risk for relapse to drinking and to alcohol dependence following treatment,” they wrote.

“Patient samples provide important information about individuals in alcohol treatment, but these samples represent a small proportion of the total number of individuals with alcohol dependence. The present study uses general population data.”

Dr. Samet and Dr. Hasin evaluated data from a nationally representative sample of adults who were interviewed in 2001-2002 for NESARC Wave 1 and re-interviewed in 2004-2005 for NESARC Wave 2. They used the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV (AUDADIS-IV) to diagnose DSM-IV alcohol dependence and other psychiatric disorders.

Then they used logistic regression to estimate the odds of persistence of alcohol dependence at follow-up among individuals who had co-occurring mood, anxiety, and substance disorders in the year before baseline or on year 1 or year 2 of follow-up, compared with individuals without comorbidity.

They adjusted the analyses for age, gender, race/ethnicity, education, employment status, marital status, and alcohol treatment.

At baseline, 1,172 individuals met criteria for DSM-IV alcohol dependence. Of those, 422 (36%) manifested persistence of alcohol dependence at follow-up.

Persistent alcohol use during the 3-year follow-up was predicted by major depressive episode (odds ratio 1.47), dysthymia (OR 1.96), and mania (OR 2.11), panic disorder (OR 2.19) and generalized anxiety disorder (OR 1.94), and nicotine (OR 1.74) and drug dependence (OR 1.94).

“This study improves on earlier studies of comorbidity in a number of ways,” Dr. Samet and Dr. Hasin wrote in their poster. “The strengths of this study include first, a large representative general population sample that avoided potential biases of treated samples; second, the longitudinal collection of data that avoided potential recall problems in retrospective studies; and third, an extensively tested valid and reliable diagnostic measure.”

The study was supported by the National Institute on Alcohol Abuse and Alcoholism and by the New York State Psychiatric Institute.

SAN DIEGO – Mood or anxiety disorders, drug dependence, and nicotine dependence that co-occur with alcohol dependence can have negative effects on the long-term persistence of alcohol dependence.

Those are key conclusions from a 3-year follow-up of data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).

“The effects of specific co-occurring psychiatric disorders on the persistence of alcohol problems are not well understood,” Sharon Samet, Ph.D., and Deborah Hasin, Ph.D., of the department of psychiatry at Columbia University, New York, and the New York State Psychiatric Institute, reported in a poster presented at the annual scientific conference of the Research Society on Alcoholism.

“In patient samples, major depression is associated with greater risk for relapse to drinking and to alcohol dependence following treatment,” they wrote.

“Patient samples provide important information about individuals in alcohol treatment, but these samples represent a small proportion of the total number of individuals with alcohol dependence. The present study uses general population data.”

Dr. Samet and Dr. Hasin evaluated data from a nationally representative sample of adults who were interviewed in 2001-2002 for NESARC Wave 1 and re-interviewed in 2004-2005 for NESARC Wave 2. They used the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV (AUDADIS-IV) to diagnose DSM-IV alcohol dependence and other psychiatric disorders.

Then they used logistic regression to estimate the odds of persistence of alcohol dependence at follow-up among individuals who had co-occurring mood, anxiety, and substance disorders in the year before baseline or on year 1 or year 2 of follow-up, compared with individuals without comorbidity.

They adjusted the analyses for age, gender, race/ethnicity, education, employment status, marital status, and alcohol treatment.

At baseline, 1,172 individuals met criteria for DSM-IV alcohol dependence. Of those, 422 (36%) manifested persistence of alcohol dependence at follow-up.

Persistent alcohol use during the 3-year follow-up was predicted by major depressive episode (odds ratio 1.47), dysthymia (OR 1.96), and mania (OR 2.11), panic disorder (OR 2.19) and generalized anxiety disorder (OR 1.94), and nicotine (OR 1.74) and drug dependence (OR 1.94).

“This study improves on earlier studies of comorbidity in a number of ways,” Dr. Samet and Dr. Hasin wrote in their poster. “The strengths of this study include first, a large representative general population sample that avoided potential biases of treated samples; second, the longitudinal collection of data that avoided potential recall problems in retrospective studies; and third, an extensively tested valid and reliable diagnostic measure.”

The study was supported by the National Institute on Alcohol Abuse and Alcoholism and by the New York State Psychiatric Institute.

SAN DIEGO – Mood or anxiety disorders, drug dependence, and nicotine dependence that co-occur with alcohol dependence can have negative effects on the long-term persistence of alcohol dependence.

Those are key conclusions from a 3-year follow-up of data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).

“The effects of specific co-occurring psychiatric disorders on the persistence of alcohol problems are not well understood,” Sharon Samet, Ph.D., and Deborah Hasin, Ph.D., of the department of psychiatry at Columbia University, New York, and the New York State Psychiatric Institute, reported in a poster presented at the annual scientific conference of the Research Society on Alcoholism.

“In patient samples, major depression is associated with greater risk for relapse to drinking and to alcohol dependence following treatment,” they wrote.

“Patient samples provide important information about individuals in alcohol treatment, but these samples represent a small proportion of the total number of individuals with alcohol dependence. The present study uses general population data.”

Dr. Samet and Dr. Hasin evaluated data from a nationally representative sample of adults who were interviewed in 2001-2002 for NESARC Wave 1 and re-interviewed in 2004-2005 for NESARC Wave 2. They used the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV (AUDADIS-IV) to diagnose DSM-IV alcohol dependence and other psychiatric disorders.

Then they used logistic regression to estimate the odds of persistence of alcohol dependence at follow-up among individuals who had co-occurring mood, anxiety, and substance disorders in the year before baseline or on year 1 or year 2 of follow-up, compared with individuals without comorbidity.

They adjusted the analyses for age, gender, race/ethnicity, education, employment status, marital status, and alcohol treatment.

At baseline, 1,172 individuals met criteria for DSM-IV alcohol dependence. Of those, 422 (36%) manifested persistence of alcohol dependence at follow-up.

Persistent alcohol use during the 3-year follow-up was predicted by major depressive episode (odds ratio 1.47), dysthymia (OR 1.96), and mania (OR 2.11), panic disorder (OR 2.19) and generalized anxiety disorder (OR 1.94), and nicotine (OR 1.74) and drug dependence (OR 1.94).

“This study improves on earlier studies of comorbidity in a number of ways,” Dr. Samet and Dr. Hasin wrote in their poster. “The strengths of this study include first, a large representative general population sample that avoided potential biases of treated samples; second, the longitudinal collection of data that avoided potential recall problems in retrospective studies; and third, an extensively tested valid and reliable diagnostic measure.”

The study was supported by the National Institute on Alcohol Abuse and Alcoholism and by the New York State Psychiatric Institute.