Diana Mahoney

More than three-quarters of the nation's young children have been immunized with the full series of childhood vaccines recommended by the Centers for Disease Control and Prevention.

Data from the 2007 National Immunization Survey showed that all but one vaccine in the recommended series—the fourth dose of the DTaP vaccine—reached 90% coverage last year, as did the varicella vaccine and the third dose of the seven-valent pneumococcal conjugate vaccine (PCV7), both for the first time, Dr. Julie Gerberding, director of the CDC, reported in a media briefing on the survey results.

In addition, fewer than 1% of the more than 17,000 children born between January 2004 and July 2006 represented in the survey had not received any vaccines in the recommended series by ages 19–35 months, and there were no statistically significant decreases in individual vaccine coverage from 2006 to 2007 (MMWR 2008;57:961–6).

The survey provides coverage estimates for the 4:3:1:3:3:1 immunization series for children aged 19–35 months that includes vaccines for diphtheria, tetanus, and acellular pertussis (DTaP); poliovirus; measles, mumps, and rubella (MMR); Haemophilus influenzae type b; hepatitis B; and varicella.

The coverage rates are indicative of the “ongoing success” of the country's immunization program, said Dr. Gerberding.

“This annual report card is very good. The survey indicates that we are at or above our Healthy People 2010 goal of 90% coverage for each of the vaccines [in the 4:3:1:3:3:1 series], and at 77.4%, we are close to the target of 80% for the combined series.”

Relative to the 2006 survey data, coverage levels in 2007 for one dose of the varicella vaccine increased from 89% to 90%, and coverage levels for three or more doses of the PCV7 increased from 87% to 90%, Dr. Gerberding reported.

As in previous years, the estimated vaccine coverage rates for the 4:3:1:3:3:1 series varied substantially among states, ranging from a low of 63% in Nevada to a high of 91% in Maryland. Similarly, there was substantial variation among 14 local areas surveyed, ranging from 70% in San Bernardino County, Calif., to 82% in Philadelphia.

Despite regional coverage gaps, said Dr. Gerberding, “vaccine coverage levels were similar across all racial and ethnic groups for the complete series, and there were some important gains.” Specifically, among Native American and Alaska Native children, both varicella and fourth-dose PCV7 coverage increased significantly, from 85% in 2006 to 95% in 2007 for varicella and from 63% in 2006 to 80% for PCV7 in 2007, she noted.

Dr. Gerberding noted that the recently reported surge of measles outbreaks in the United States, despite the apparent successes in the immunization program, is “a sobering aspect in our failure to protect some children from vaccine-preventable diseases.”

“Many of the children affected in these outbreaks were not adequately protected. Some were too young to be fully immunized, and some parents chose not to immunize their children,” she said.

More than three-quarters of the nation's young children have been immunized with the full series of childhood vaccines recommended by the Centers for Disease Control and Prevention.

Data from the 2007 National Immunization Survey showed that all but one vaccine in the recommended series—the fourth dose of the DTaP vaccine—reached 90% coverage last year, as did the varicella vaccine and the third dose of the seven-valent pneumococcal conjugate vaccine (PCV7), both for the first time, Dr. Julie Gerberding, director of the CDC, reported in a media briefing on the survey results.

In addition, fewer than 1% of the more than 17,000 children born between January 2004 and July 2006 represented in the survey had not received any vaccines in the recommended series by ages 19–35 months, and there were no statistically significant decreases in individual vaccine coverage from 2006 to 2007 (MMWR 2008;57:961–6).

The survey provides coverage estimates for the 4:3:1:3:3:1 immunization series for children aged 19–35 months that includes vaccines for diphtheria, tetanus, and acellular pertussis (DTaP); poliovirus; measles, mumps, and rubella (MMR); Haemophilus influenzae type b; hepatitis B; and varicella.

The coverage rates are indicative of the “ongoing success” of the country's immunization program, said Dr. Gerberding.

“This annual report card is very good. The survey indicates that we are at or above our Healthy People 2010 goal of 90% coverage for each of the vaccines [in the 4:3:1:3:3:1 series], and at 77.4%, we are close to the target of 80% for the combined series.”

Relative to the 2006 survey data, coverage levels in 2007 for one dose of the varicella vaccine increased from 89% to 90%, and coverage levels for three or more doses of the PCV7 increased from 87% to 90%, Dr. Gerberding reported.

As in previous years, the estimated vaccine coverage rates for the 4:3:1:3:3:1 series varied substantially among states, ranging from a low of 63% in Nevada to a high of 91% in Maryland. Similarly, there was substantial variation among 14 local areas surveyed, ranging from 70% in San Bernardino County, Calif., to 82% in Philadelphia.

Despite regional coverage gaps, said Dr. Gerberding, “vaccine coverage levels were similar across all racial and ethnic groups for the complete series, and there were some important gains.” Specifically, among Native American and Alaska Native children, both varicella and fourth-dose PCV7 coverage increased significantly, from 85% in 2006 to 95% in 2007 for varicella and from 63% in 2006 to 80% for PCV7 in 2007, she noted.

Dr. Gerberding noted that the recently reported surge of measles outbreaks in the United States, despite the apparent successes in the immunization program, is “a sobering aspect in our failure to protect some children from vaccine-preventable diseases.”

“Many of the children affected in these outbreaks were not adequately protected. Some were too young to be fully immunized, and some parents chose not to immunize their children,” she said.

More than three-quarters of the nation's young children have been immunized with the full series of childhood vaccines recommended by the Centers for Disease Control and Prevention.

Data from the 2007 National Immunization Survey showed that all but one vaccine in the recommended series—the fourth dose of the DTaP vaccine—reached 90% coverage last year, as did the varicella vaccine and the third dose of the seven-valent pneumococcal conjugate vaccine (PCV7), both for the first time, Dr. Julie Gerberding, director of the CDC, reported in a media briefing on the survey results.

In addition, fewer than 1% of the more than 17,000 children born between January 2004 and July 2006 represented in the survey had not received any vaccines in the recommended series by ages 19–35 months, and there were no statistically significant decreases in individual vaccine coverage from 2006 to 2007 (MMWR 2008;57:961–6).

The survey provides coverage estimates for the 4:3:1:3:3:1 immunization series for children aged 19–35 months that includes vaccines for diphtheria, tetanus, and acellular pertussis (DTaP); poliovirus; measles, mumps, and rubella (MMR); Haemophilus influenzae type b; hepatitis B; and varicella.

The coverage rates are indicative of the “ongoing success” of the country's immunization program, said Dr. Gerberding.

“This annual report card is very good. The survey indicates that we are at or above our Healthy People 2010 goal of 90% coverage for each of the vaccines [in the 4:3:1:3:3:1 series], and at 77.4%, we are close to the target of 80% for the combined series.”

Relative to the 2006 survey data, coverage levels in 2007 for one dose of the varicella vaccine increased from 89% to 90%, and coverage levels for three or more doses of the PCV7 increased from 87% to 90%, Dr. Gerberding reported.

As in previous years, the estimated vaccine coverage rates for the 4:3:1:3:3:1 series varied substantially among states, ranging from a low of 63% in Nevada to a high of 91% in Maryland. Similarly, there was substantial variation among 14 local areas surveyed, ranging from 70% in San Bernardino County, Calif., to 82% in Philadelphia.

Despite regional coverage gaps, said Dr. Gerberding, “vaccine coverage levels were similar across all racial and ethnic groups for the complete series, and there were some important gains.” Specifically, among Native American and Alaska Native children, both varicella and fourth-dose PCV7 coverage increased significantly, from 85% in 2006 to 95% in 2007 for varicella and from 63% in 2006 to 80% for PCV7 in 2007, she noted.

Dr. Gerberding noted that the recently reported surge of measles outbreaks in the United States, despite the apparent successes in the immunization program, is “a sobering aspect in our failure to protect some children from vaccine-preventable diseases.”

“Many of the children affected in these outbreaks were not adequately protected. Some were too young to be fully immunized, and some parents chose not to immunize their children,” she said.

BOSTON – Transcranial magnetic stimulation may be a promising new weapon in the pain relief arsenal of patients with chronic migraine with aura, findings of a clinical trial show.

Brain stimulation with magnetic pulses, delivered via a portable stimulation device held to the back of the head, eliminated migraine pain in about 39% of patients who were randomized to its use, according to data presented by Dr. Richard Lipton, professor of neurology and epidemiology at the Albert Einstein College of Medicine, New York.

Transcranial magnetic stimulation (TMS) is a method of focal brain simulation based on the principle of electromagnetic induction, whereby a powerful, rapidly changing extracranial magnetic field generates small intracranial currents, Dr. Lipton explained. The technology has shown promise in the treatment of various neurologic and psychiatric diseases. It is thought to interrupt neuronal excitability in the motor cortex of the brain, which has been implicated as a trigger in the cascade of migraine events, he said.

Previous studies have shown that early treatment with TMS, delivered in the clinic via a large, tabletop device, reduces pain in patients who experience migraine with aura, Dr. Lipton reported at the annual meeting of the American Headache Society.

The current study sought to assess the efficacy of the treatment when it was delivered via a portable, handheld device designed specifically to facilitate at-home treatment. In a multicenter, double-blind, parallel-group sham controlled study, 201 outpatients aged 18-68 years with a history of migraines with aura (as defined by the International Classification of Headache Disorders, 2nd ed.) were randomized to either active treatment with the TMS device or sham treatment with an identical device that similarly buzzed and vibrated but did not emit magnetic pulses. Patients were included in the study if they experienced one to eight migraines per month, and if they did not overuse headache medications.

All of the patients were directed to use their devices at the onset of aura by holding the device to the back of the head and pushing the button two times to emit two brief pulses. The patients recorded their levels of pain and symptoms in an electronic diary both at the time of treatment and then after treatment at 30 minutes, 1 hour, 2 hours, 24 hours, and 48 hours. The primary end point for the current study was pain elimination at 2 hours.

The final analysis included 164 patients, mean age 39 years, who completed the study. The majority of patients treated themselves when they were either pain free (31%) or had mild pain (40%). Nearly one-third of the patients applied the treatment when they were in moderate (23%) or severe (6%) pain, noted Dr. Lipton.

The 2-hour pain-free rates were 39% for the TMS group and 22% for the sham treatment group, yielding an absolute risk reduction of 17%, Dr. Lipton reported. “In other words, for every seven people who use a transcranial magnetic stimulator to treat a migraine attack, one person will be pain free at 2 hours,” he said.

The rates of associated symptoms “were equal or lower than the sham treatment rates,” and the number of adverse events and the number of patients experiencing adverse events were similar between both groups, Dr. Lipton reported.

The results are not as good as those achieved with standard antimigraine drugs, such as aspirin, antiemetics, triptans, or some of the new investigational drugs, but the availability of a noninvasive, nondrug treatment is important because it avoids the side effects of migraine medications, Dr. Lipton said. Future studies in patients with migraine without aura are on the horizon, he said.

Funding for this study was provided by Neuralieve Inc., developers of the TMS device, which has not yet received marketing clearance from the Food and Drug Administration.

The 2-hour pain-free rates were 39% for the TMS group and 22% for the sham treatment group. DR. LIPTON

BOSTON – Transcranial magnetic stimulation may be a promising new weapon in the pain relief arsenal of patients with chronic migraine with aura, findings of a clinical trial show.

Brain stimulation with magnetic pulses, delivered via a portable stimulation device held to the back of the head, eliminated migraine pain in about 39% of patients who were randomized to its use, according to data presented by Dr. Richard Lipton, professor of neurology and epidemiology at the Albert Einstein College of Medicine, New York.

Transcranial magnetic stimulation (TMS) is a method of focal brain simulation based on the principle of electromagnetic induction, whereby a powerful, rapidly changing extracranial magnetic field generates small intracranial currents, Dr. Lipton explained. The technology has shown promise in the treatment of various neurologic and psychiatric diseases. It is thought to interrupt neuronal excitability in the motor cortex of the brain, which has been implicated as a trigger in the cascade of migraine events, he said.

Previous studies have shown that early treatment with TMS, delivered in the clinic via a large, tabletop device, reduces pain in patients who experience migraine with aura, Dr. Lipton reported at the annual meeting of the American Headache Society.

The current study sought to assess the efficacy of the treatment when it was delivered via a portable, handheld device designed specifically to facilitate at-home treatment. In a multicenter, double-blind, parallel-group sham controlled study, 201 outpatients aged 18-68 years with a history of migraines with aura (as defined by the International Classification of Headache Disorders, 2nd ed.) were randomized to either active treatment with the TMS device or sham treatment with an identical device that similarly buzzed and vibrated but did not emit magnetic pulses. Patients were included in the study if they experienced one to eight migraines per month, and if they did not overuse headache medications.

All of the patients were directed to use their devices at the onset of aura by holding the device to the back of the head and pushing the button two times to emit two brief pulses. The patients recorded their levels of pain and symptoms in an electronic diary both at the time of treatment and then after treatment at 30 minutes, 1 hour, 2 hours, 24 hours, and 48 hours. The primary end point for the current study was pain elimination at 2 hours.

The final analysis included 164 patients, mean age 39 years, who completed the study. The majority of patients treated themselves when they were either pain free (31%) or had mild pain (40%). Nearly one-third of the patients applied the treatment when they were in moderate (23%) or severe (6%) pain, noted Dr. Lipton.

The 2-hour pain-free rates were 39% for the TMS group and 22% for the sham treatment group, yielding an absolute risk reduction of 17%, Dr. Lipton reported. “In other words, for every seven people who use a transcranial magnetic stimulator to treat a migraine attack, one person will be pain free at 2 hours,” he said.

The rates of associated symptoms “were equal or lower than the sham treatment rates,” and the number of adverse events and the number of patients experiencing adverse events were similar between both groups, Dr. Lipton reported.

The results are not as good as those achieved with standard antimigraine drugs, such as aspirin, antiemetics, triptans, or some of the new investigational drugs, but the availability of a noninvasive, nondrug treatment is important because it avoids the side effects of migraine medications, Dr. Lipton said. Future studies in patients with migraine without aura are on the horizon, he said.

Funding for this study was provided by Neuralieve Inc., developers of the TMS device, which has not yet received marketing clearance from the Food and Drug Administration.

The 2-hour pain-free rates were 39% for the TMS group and 22% for the sham treatment group. DR. LIPTON

BOSTON – Transcranial magnetic stimulation may be a promising new weapon in the pain relief arsenal of patients with chronic migraine with aura, findings of a clinical trial show.

Brain stimulation with magnetic pulses, delivered via a portable stimulation device held to the back of the head, eliminated migraine pain in about 39% of patients who were randomized to its use, according to data presented by Dr. Richard Lipton, professor of neurology and epidemiology at the Albert Einstein College of Medicine, New York.

Transcranial magnetic stimulation (TMS) is a method of focal brain simulation based on the principle of electromagnetic induction, whereby a powerful, rapidly changing extracranial magnetic field generates small intracranial currents, Dr. Lipton explained. The technology has shown promise in the treatment of various neurologic and psychiatric diseases. It is thought to interrupt neuronal excitability in the motor cortex of the brain, which has been implicated as a trigger in the cascade of migraine events, he said.

Previous studies have shown that early treatment with TMS, delivered in the clinic via a large, tabletop device, reduces pain in patients who experience migraine with aura, Dr. Lipton reported at the annual meeting of the American Headache Society.

The current study sought to assess the efficacy of the treatment when it was delivered via a portable, handheld device designed specifically to facilitate at-home treatment. In a multicenter, double-blind, parallel-group sham controlled study, 201 outpatients aged 18-68 years with a history of migraines with aura (as defined by the International Classification of Headache Disorders, 2nd ed.) were randomized to either active treatment with the TMS device or sham treatment with an identical device that similarly buzzed and vibrated but did not emit magnetic pulses. Patients were included in the study if they experienced one to eight migraines per month, and if they did not overuse headache medications.

All of the patients were directed to use their devices at the onset of aura by holding the device to the back of the head and pushing the button two times to emit two brief pulses. The patients recorded their levels of pain and symptoms in an electronic diary both at the time of treatment and then after treatment at 30 minutes, 1 hour, 2 hours, 24 hours, and 48 hours. The primary end point for the current study was pain elimination at 2 hours.

The final analysis included 164 patients, mean age 39 years, who completed the study. The majority of patients treated themselves when they were either pain free (31%) or had mild pain (40%). Nearly one-third of the patients applied the treatment when they were in moderate (23%) or severe (6%) pain, noted Dr. Lipton.

The 2-hour pain-free rates were 39% for the TMS group and 22% for the sham treatment group, yielding an absolute risk reduction of 17%, Dr. Lipton reported. “In other words, for every seven people who use a transcranial magnetic stimulator to treat a migraine attack, one person will be pain free at 2 hours,” he said.

The rates of associated symptoms “were equal or lower than the sham treatment rates,” and the number of adverse events and the number of patients experiencing adverse events were similar between both groups, Dr. Lipton reported.

The results are not as good as those achieved with standard antimigraine drugs, such as aspirin, antiemetics, triptans, or some of the new investigational drugs, but the availability of a noninvasive, nondrug treatment is important because it avoids the side effects of migraine medications, Dr. Lipton said. Future studies in patients with migraine without aura are on the horizon, he said.

Funding for this study was provided by Neuralieve Inc., developers of the TMS device, which has not yet received marketing clearance from the Food and Drug Administration.

The 2-hour pain-free rates were 39% for the TMS group and 22% for the sham treatment group. DR. LIPTON

Exposure to acetaminophen might be an important risk factor for the development of asthma later in childhood, according to new data from an international asthma study.

In a sample of more than 200,000 children from 31 countries, those given the antipyretic for fever in their first year of life were about 50% more likely to have experienced asthma symptoms at age 6-7 years than were unexposed children.

Dr. Richard Beasley of the Medical Research Institute of New Zealand, Wellington, and his colleagues reported that in phase III of the International Study of Asthma and Allergies in Childhood (ISAAC), exposure to acetaminophen–known as paracetamol outside of the United States–in the first year of life was associated with significantly increased risk of severe asthma symptoms (Lancet 2008;372:1039-48).

The prevalence of asthma has increased over the past 50 years, as has the use of acetaminophen in children, the authors wrote.

Previous studies have reported associations between asthma risk and exposure to acetaminophen in utero, during infancy, and in late childhood and adulthood in populations from developed and developing countries.

The current analysis was designed to evaluate the consistency of the association between acetaminophen and asthma and to investigate one of the proposed biological mechanisms for the link–specifically, that acetaminophen exposure contributes to the development of oxidant-induced airway inflammation caused by reduced concentrations of the antioxidant glutathione in the lung and stimulation of the T helper cell 2 response.

Toward this end, parents and guardians of 205,487 children aged 6-7 years from 73 centers were asked to complete a prevalence questionnaire about symptoms of asthma, rhinoconjunctivitis, and eczema, and an environmental questionnaire about possible protective and risk factors for asthma and allergic disorders including the use of acetaminophen in the first year of life and now.

The primary outcome measure for the analysis was the association between acetaminophen use for fever in the first year of life and asthma symptoms at 6-7 years as measured by multivariate analysis.

In all, 194,555 children were included in the analysis of acetaminophen use for fever during the first year of life. Of these, 105,041 had complete covariate data and were included in the multivariate analysis. In this group, the association between asthma symptoms and acetaminophen use in the first year of life was significant (odds ratio, 1.46).

Despite the study's power, size, and multinational nature, the findings do not establish causality because of its design.

Dr. Beasley reported having received grant support and honoraria for lectures from GlaxoSmithKline Inc., the maker of acetaminophen.

Exposure to acetaminophen might be an important risk factor for the development of asthma later in childhood, according to new data from an international asthma study.

In a sample of more than 200,000 children from 31 countries, those given the antipyretic for fever in their first year of life were about 50% more likely to have experienced asthma symptoms at age 6-7 years than were unexposed children.

Dr. Richard Beasley of the Medical Research Institute of New Zealand, Wellington, and his colleagues reported that in phase III of the International Study of Asthma and Allergies in Childhood (ISAAC), exposure to acetaminophen–known as paracetamol outside of the United States–in the first year of life was associated with significantly increased risk of severe asthma symptoms (Lancet 2008;372:1039-48).

The prevalence of asthma has increased over the past 50 years, as has the use of acetaminophen in children, the authors wrote.

Previous studies have reported associations between asthma risk and exposure to acetaminophen in utero, during infancy, and in late childhood and adulthood in populations from developed and developing countries.

The current analysis was designed to evaluate the consistency of the association between acetaminophen and asthma and to investigate one of the proposed biological mechanisms for the link–specifically, that acetaminophen exposure contributes to the development of oxidant-induced airway inflammation caused by reduced concentrations of the antioxidant glutathione in the lung and stimulation of the T helper cell 2 response.

Toward this end, parents and guardians of 205,487 children aged 6-7 years from 73 centers were asked to complete a prevalence questionnaire about symptoms of asthma, rhinoconjunctivitis, and eczema, and an environmental questionnaire about possible protective and risk factors for asthma and allergic disorders including the use of acetaminophen in the first year of life and now.

The primary outcome measure for the analysis was the association between acetaminophen use for fever in the first year of life and asthma symptoms at 6-7 years as measured by multivariate analysis.

In all, 194,555 children were included in the analysis of acetaminophen use for fever during the first year of life. Of these, 105,041 had complete covariate data and were included in the multivariate analysis. In this group, the association between asthma symptoms and acetaminophen use in the first year of life was significant (odds ratio, 1.46).

Despite the study's power, size, and multinational nature, the findings do not establish causality because of its design.

Dr. Beasley reported having received grant support and honoraria for lectures from GlaxoSmithKline Inc., the maker of acetaminophen.

Exposure to acetaminophen might be an important risk factor for the development of asthma later in childhood, according to new data from an international asthma study.

In a sample of more than 200,000 children from 31 countries, those given the antipyretic for fever in their first year of life were about 50% more likely to have experienced asthma symptoms at age 6-7 years than were unexposed children.

Dr. Richard Beasley of the Medical Research Institute of New Zealand, Wellington, and his colleagues reported that in phase III of the International Study of Asthma and Allergies in Childhood (ISAAC), exposure to acetaminophen–known as paracetamol outside of the United States–in the first year of life was associated with significantly increased risk of severe asthma symptoms (Lancet 2008;372:1039-48).

The prevalence of asthma has increased over the past 50 years, as has the use of acetaminophen in children, the authors wrote.

Previous studies have reported associations between asthma risk and exposure to acetaminophen in utero, during infancy, and in late childhood and adulthood in populations from developed and developing countries.

The current analysis was designed to evaluate the consistency of the association between acetaminophen and asthma and to investigate one of the proposed biological mechanisms for the link–specifically, that acetaminophen exposure contributes to the development of oxidant-induced airway inflammation caused by reduced concentrations of the antioxidant glutathione in the lung and stimulation of the T helper cell 2 response.

Toward this end, parents and guardians of 205,487 children aged 6-7 years from 73 centers were asked to complete a prevalence questionnaire about symptoms of asthma, rhinoconjunctivitis, and eczema, and an environmental questionnaire about possible protective and risk factors for asthma and allergic disorders including the use of acetaminophen in the first year of life and now.

The primary outcome measure for the analysis was the association between acetaminophen use for fever in the first year of life and asthma symptoms at 6-7 years as measured by multivariate analysis.

In all, 194,555 children were included in the analysis of acetaminophen use for fever during the first year of life. Of these, 105,041 had complete covariate data and were included in the multivariate analysis. In this group, the association between asthma symptoms and acetaminophen use in the first year of life was significant (odds ratio, 1.46).

Despite the study's power, size, and multinational nature, the findings do not establish causality because of its design.

Dr. Beasley reported having received grant support and honoraria for lectures from GlaxoSmithKline Inc., the maker of acetaminophen.

More than three-quarters of the nation's young children have been immunized with the full series of childhood vaccines recommended by the Centers for Disease Control and Prevention, according to data released today from the agency's 2007 National Immunization Survey.

The National Immunization Survey provides coverage estimates for the 4:3:1:3:3:1 immunization series for children aged 19–35 months that includes vaccines for diphtheria, tetanus, and acellular pertussis (DTaP); poliovirus; measles, mumps, and rubella (MMR); Haemophilus influenzae type b; hepatitis B; and varicella.

All but one vaccine in the recommended series—the fourth dose of the DTaP vaccine—reached 90% coverage in 2007, including for the first time the varicella vaccine and the third dose of the seven-valent pneumococcal conjugate vaccine (PCV7), Dr. Julie Gerberding, director of the CDC, reported in a media briefing on the survey results.

Additionally, less than 1% of the more than 17,000 children born between January 2004 and July 2006 represented in the survey had not received any vaccines in the recommended series by ages 19–35 months, and there were no statistically significant decreases in individual vaccine coverage from 2006 to 2007 (MMWR 2008;57:961–6).

The coverage rates are indicative of the "ongoing success" of the country's immunization program, said Dr. Gerberding. "This annual report card is very good. The survey indicates that we are at or above our Healthy People 2010 goal of 90% coverage for each of the vaccines [in the 4:3:1:3:3:1 series], and at 77.4%, we are close to the target of 80% for the combined series."

These numbers are a reflection of "the trust that parents have in the safety of the vaccines and in the health care providers who administer them," she said.

Relative to the 2006 survey data, coverage levels in 2007 for one dose of the varicella vaccine increased from 89% to 90%, and coverage levels for three or more doses of the PCV7 increased from 87% to 90%, Dr. Gerberding reported.

As in previous years, the estimated vaccine coverage rates for the 4:3:1:3:3:1 series varied substantially among states, ranging from a low of 63% in Nevada to a high of 91% in Maryland. Similarly, there was substantial variation among 14 local areas surveyed, ranging from 70% in San Bernardino County, Calif., to 82% in Philadelphia, she said.

Despite regional coverage gaps, noted Dr. Gerberding, "vaccine coverage levels were similar across all racial and ethnic groups for the complete series, and there were some important gains."

Specifically, among Native American and Alaska Native children, both varicella and fourth-dose PCV7 coverage increased significantly, from 85% in 2006 to 95% in 2007 for varicella and from 63% in 2006 to 80% for PCV7 in 2007, she said.

Belying the apparent successes in the immunization program is the recently reported surge in U.S. measles outbreaks (MMWR 2008;57:893–6), which is "a sobering aspect in our failure to protect some children from vaccine-preventable diseases," said Dr. Gerberding. "Many of the children affected in these outbreaks were not adequately protected. Some were too young to be fully immunized, and some parents chose not to immunize their children."

The measles outbreaks serve as an important reminder to maintain heightened vigilance "and not take the benefits of immunizations for granted," said Dr. Anne Schuchat, who is director of the CDC's National Center for Immunization and Respiratory Diseases. "We're doing well, but we're not finished. Achieving high [coverage] levels is important for preventing major resurgences in diseases like measles."

The survey estimates state and national coverage levels and provides information on specific local areas, "but we don't have information for every local area," Dr. Schuchat pointed out. "If nonimmunized kids are clustered in small areas of the United States, that might not be visible in national or state coverage rates, yet that clustering is enough to lead to measles transmission."

'Vaccine coverage levels were similar across all racial and ethnic groups for the complete series.' DR. GERBERDING

More than three-quarters of the nation's young children have been immunized with the full series of childhood vaccines recommended by the Centers for Disease Control and Prevention, according to data released today from the agency's 2007 National Immunization Survey.

The National Immunization Survey provides coverage estimates for the 4:3:1:3:3:1 immunization series for children aged 19–35 months that includes vaccines for diphtheria, tetanus, and acellular pertussis (DTaP); poliovirus; measles, mumps, and rubella (MMR); Haemophilus influenzae type b; hepatitis B; and varicella.

All but one vaccine in the recommended series—the fourth dose of the DTaP vaccine—reached 90% coverage in 2007, including for the first time the varicella vaccine and the third dose of the seven-valent pneumococcal conjugate vaccine (PCV7), Dr. Julie Gerberding, director of the CDC, reported in a media briefing on the survey results.

Additionally, less than 1% of the more than 17,000 children born between January 2004 and July 2006 represented in the survey had not received any vaccines in the recommended series by ages 19–35 months, and there were no statistically significant decreases in individual vaccine coverage from 2006 to 2007 (MMWR 2008;57:961–6).

The coverage rates are indicative of the "ongoing success" of the country's immunization program, said Dr. Gerberding. "This annual report card is very good. The survey indicates that we are at or above our Healthy People 2010 goal of 90% coverage for each of the vaccines [in the 4:3:1:3:3:1 series], and at 77.4%, we are close to the target of 80% for the combined series."

These numbers are a reflection of "the trust that parents have in the safety of the vaccines and in the health care providers who administer them," she said.

Relative to the 2006 survey data, coverage levels in 2007 for one dose of the varicella vaccine increased from 89% to 90%, and coverage levels for three or more doses of the PCV7 increased from 87% to 90%, Dr. Gerberding reported.

As in previous years, the estimated vaccine coverage rates for the 4:3:1:3:3:1 series varied substantially among states, ranging from a low of 63% in Nevada to a high of 91% in Maryland. Similarly, there was substantial variation among 14 local areas surveyed, ranging from 70% in San Bernardino County, Calif., to 82% in Philadelphia, she said.

Despite regional coverage gaps, noted Dr. Gerberding, "vaccine coverage levels were similar across all racial and ethnic groups for the complete series, and there were some important gains."

Specifically, among Native American and Alaska Native children, both varicella and fourth-dose PCV7 coverage increased significantly, from 85% in 2006 to 95% in 2007 for varicella and from 63% in 2006 to 80% for PCV7 in 2007, she said.

Belying the apparent successes in the immunization program is the recently reported surge in U.S. measles outbreaks (MMWR 2008;57:893–6), which is "a sobering aspect in our failure to protect some children from vaccine-preventable diseases," said Dr. Gerberding. "Many of the children affected in these outbreaks were not adequately protected. Some were too young to be fully immunized, and some parents chose not to immunize their children."

The measles outbreaks serve as an important reminder to maintain heightened vigilance "and not take the benefits of immunizations for granted," said Dr. Anne Schuchat, who is director of the CDC's National Center for Immunization and Respiratory Diseases. "We're doing well, but we're not finished. Achieving high [coverage] levels is important for preventing major resurgences in diseases like measles."

The survey estimates state and national coverage levels and provides information on specific local areas, "but we don't have information for every local area," Dr. Schuchat pointed out. "If nonimmunized kids are clustered in small areas of the United States, that might not be visible in national or state coverage rates, yet that clustering is enough to lead to measles transmission."

'Vaccine coverage levels were similar across all racial and ethnic groups for the complete series.' DR. GERBERDING

More than three-quarters of the nation's young children have been immunized with the full series of childhood vaccines recommended by the Centers for Disease Control and Prevention, according to data released today from the agency's 2007 National Immunization Survey.

The National Immunization Survey provides coverage estimates for the 4:3:1:3:3:1 immunization series for children aged 19–35 months that includes vaccines for diphtheria, tetanus, and acellular pertussis (DTaP); poliovirus; measles, mumps, and rubella (MMR); Haemophilus influenzae type b; hepatitis B; and varicella.

All but one vaccine in the recommended series—the fourth dose of the DTaP vaccine—reached 90% coverage in 2007, including for the first time the varicella vaccine and the third dose of the seven-valent pneumococcal conjugate vaccine (PCV7), Dr. Julie Gerberding, director of the CDC, reported in a media briefing on the survey results.

Additionally, less than 1% of the more than 17,000 children born between January 2004 and July 2006 represented in the survey had not received any vaccines in the recommended series by ages 19–35 months, and there were no statistically significant decreases in individual vaccine coverage from 2006 to 2007 (MMWR 2008;57:961–6).

The coverage rates are indicative of the "ongoing success" of the country's immunization program, said Dr. Gerberding. "This annual report card is very good. The survey indicates that we are at or above our Healthy People 2010 goal of 90% coverage for each of the vaccines [in the 4:3:1:3:3:1 series], and at 77.4%, we are close to the target of 80% for the combined series."

These numbers are a reflection of "the trust that parents have in the safety of the vaccines and in the health care providers who administer them," she said.

Relative to the 2006 survey data, coverage levels in 2007 for one dose of the varicella vaccine increased from 89% to 90%, and coverage levels for three or more doses of the PCV7 increased from 87% to 90%, Dr. Gerberding reported.

As in previous years, the estimated vaccine coverage rates for the 4:3:1:3:3:1 series varied substantially among states, ranging from a low of 63% in Nevada to a high of 91% in Maryland. Similarly, there was substantial variation among 14 local areas surveyed, ranging from 70% in San Bernardino County, Calif., to 82% in Philadelphia, she said.

Despite regional coverage gaps, noted Dr. Gerberding, "vaccine coverage levels were similar across all racial and ethnic groups for the complete series, and there were some important gains."

Specifically, among Native American and Alaska Native children, both varicella and fourth-dose PCV7 coverage increased significantly, from 85% in 2006 to 95% in 2007 for varicella and from 63% in 2006 to 80% for PCV7 in 2007, she said.

Belying the apparent successes in the immunization program is the recently reported surge in U.S. measles outbreaks (MMWR 2008;57:893–6), which is "a sobering aspect in our failure to protect some children from vaccine-preventable diseases," said Dr. Gerberding. "Many of the children affected in these outbreaks were not adequately protected. Some were too young to be fully immunized, and some parents chose not to immunize their children."

The measles outbreaks serve as an important reminder to maintain heightened vigilance "and not take the benefits of immunizations for granted," said Dr. Anne Schuchat, who is director of the CDC's National Center for Immunization and Respiratory Diseases. "We're doing well, but we're not finished. Achieving high [coverage] levels is important for preventing major resurgences in diseases like measles."

The survey estimates state and national coverage levels and provides information on specific local areas, "but we don't have information for every local area," Dr. Schuchat pointed out. "If nonimmunized kids are clustered in small areas of the United States, that might not be visible in national or state coverage rates, yet that clustering is enough to lead to measles transmission."

'Vaccine coverage levels were similar across all racial and ethnic groups for the complete series.' DR. GERBERDING

CHICAGO — Fertility preservation options should be presented to patients as early after the diagnosis of rheumatoid arthritis, systemic lupus erythematosus, and scleroderma as possible.

These rheumatologic diseases often strike both men and women during their childbearing years, and the diseases themselves as well as the long-term therapies used to treat them can have a negative impact on reproductive health.

“It's important to recognize that [while] many of the innovative technologies available today to treat life-threatening diseases and to provide patients with the promise of life after their disease, whether it be cancer, rheumatic disease, or other type of life-threatening condition … many of these drug treatments can be devastating in terms of reproductive health,” according to Marybeth Gerrity, Ph.D., executive director of the Oncofertility Consortium at Northwestern University, Chicago.

“While many of us who treat patients with chronic diseases sometimes have a tendency to think in terms of, 'That's the least of your worries,' it's increasingly becoming a concern of survivors to look at these sorts of quality of life issues and so we need to change our mind set,” she said at a symposium sponsored by the American College of Rheumatology.

In order to effect this change, it's important not only to consider the pharmacology and reproductive impact of the drugs being used to treat rheumatologic diseases, but also to have a heightened awareness of the types of standard fertility preservation options, “so you can at least have your receptors retuned to some of the things that may be appropriate for your patients,” Dr. Gerrity said.

The list of drugs used to manage and treat rheumatic diseases that are known to affect reproductive health include, but may not be limited to, cyclophosphamide, chlorambucil, nonsteroidal anti-inflammatory drugs (NSAIDs), sulfasalazine, methotrexate, and leflunomide, she said.

With respect to cyclophosphamide treatment for lupus nephritis, for example, while the cytotoxic-induced damage is reversible in some tissues of rapidly dividing cells, the damage to the ovary, with its limited number of germ cells, tends to be progressive and irreversible, she said, noting that, “in studies, up to 70% of adult female patients taking daily oral cyclophosphamide and nearly half of those receiving a monthly intravenous pulse developed amenorrhea and experienced permanent ovarian failure within a year of first dose.”

The alkylating agent chlorambucil has been shown to affect both male and female fertility. “Studies have shown that adult and adolescent women taking chlorambucil exhibit an increased rate of ovarian failure,” Dr. Gerrity said. “[The drug] may cause an arrest in follicular maturation, stromal fibrosis, and a decreased number of ova in the ovary, leading to delayed onset of menstruation and amenorrhea.”

In adolescent and adult male patients, chlorambucil, either alone or in combination with prednisone or azathioprine, has been linked to temporary azoospermia. “This may be due to inhibition of DNA synthesis in developing sperm and damage to the cells of the seminiferous epithelium,” noted Dr. Gerrity.

Male patients taking sulfasalazine, methotrexate, cyclophosphamide, and leflunomide may also face the risk of oligospermia and impaired sperm motility, while women taking NSAIDs may have trouble conceiving because the drugs can inhibit blastocyst implantation, Dr. Gerrity said.

Among the “routine” fertility preservation options available to patients, Dr. Gerrity explained, are sperm banking, testicular tissue banking, GnRH analogs or antagonists, and donor sperm for men and embryo or egg banking and emergency in vitro fertilization, ovarian tissue cryopreservation, donor eggs, and gestational carriers for women.

“Embryo banking and in vitro fertilization are routine in the infertility clinic and involve stimulating women with high doses of fertility drugs to cause them to produce a lot of eggs that can be fertilized in the laboratory to produce embryos that can then be stored for later implantation.”

However, there are drawbacks to this option: “It's expensive, and it requires at least 3 weeks of preparation and treatment before egg retrieval, which may not be medically reasonable for some patients,” she said.

Another roadblock, until recently, was the fact that banking of eggs had been technologically impossible, and banking of embryos required a sperm source. “For some people without a partner, facing a life-threatening disease or long-term therapy that would impair their fertility, the prospect of undergoing a $12,000 procedure to retrieve eggs and then having to pick the man of their dreams out of a catalog is an overwhelming prospect,” Dr. Gerrity said.

Fortunately, thanks to a “political fluke” in Europe, there have been tremendous advances within the last year, leading to the ability to successfully freeze eggs for later fertilization.

“About 2 years ago, the Italian government made the freezing of human embryos illegal in that country, meaning that all of the patients in Italy undergoing [in vitro fertilization] could only add sperm to eggs that could safely be returned to their uterus—usually two to three eggs,” Dr. Gerrity explained.

Faced with the prospect of having to waste the majority of eggs retrieved from patients, “the Italian scientists kicked into gear and solved the problem we've been working on for more than 20 years: They broke the code on how to freeze eggs, so now frozen eggs yield the same pregnancy and fertilization rates as fresh eggs,” she said. “For the patients needing to bank eggs before starting fertility-impairing drug treatment, at least they don't also have to select a sperm donor on the spot.”

Although the success rates associated with frozen egg fertilization are high, the technology is still considered investigational in the United States, “which of course is an issue when dealing with third-party payers.”

A new frontier for fertility preservation in women is ovarian tissue cryopreservation, whereby portions of the ovary or the entire ovary are removed and the cortical tissue is frozen and later reimplanted into the patient. “This is a technique that we are using extensively in young girls and prepubertal girls with cancer and in patients who have to begin so quickly that taking 3 weeks out to stimulate ovaries is just not possible,” said Dr. Gerrity. “Although the freezing of the tissue is simple, the challenge has been in 'waking it up' once it's reimplanted. This has been the focus of research over the last 2–3 years, and it has paid off. In the past 6 months, there have been reports of about 14 pregnancies with transplanted ovarian tissue following chronic treatment or chemotherapy.”

Upon implantation, all of the women began menstrual cycling again and became pregnant spontaneously, she said. This technique is only an option for those patients who can be withdrawn from their fertility-compromising drugs or drugs that are contraindicated in pregnancy for the period of conception and gestation, she added.

For patients who cannot carry a pregnancy because it would be unsafe or unwise to withdraw from therapy, “gestational carriers may be the best option,” said Dr. Gerrity. “Unlike true surrogates, who lend their eggs and their uterus, gestational surrogates just lend their uterus to the effort, carrying to term the fertilized embryos from the patient and her partner.”

In order to determine the best fertility preservation option for an individual patient, “it's important to have the patient sit down with a reproductive endocrinologist,” Dr. Gerrity stressed. “As the part of this process, it's critical that [the referring physician] keeps an open line of communication with the reproductive endocrinologist. Be clear about what you can do in terms of treatment,” she said.

CHICAGO — Fertility preservation options should be presented to patients as early after the diagnosis of rheumatoid arthritis, systemic lupus erythematosus, and scleroderma as possible.

These rheumatologic diseases often strike both men and women during their childbearing years, and the diseases themselves as well as the long-term therapies used to treat them can have a negative impact on reproductive health.

“It's important to recognize that [while] many of the innovative technologies available today to treat life-threatening diseases and to provide patients with the promise of life after their disease, whether it be cancer, rheumatic disease, or other type of life-threatening condition … many of these drug treatments can be devastating in terms of reproductive health,” according to Marybeth Gerrity, Ph.D., executive director of the Oncofertility Consortium at Northwestern University, Chicago.

“While many of us who treat patients with chronic diseases sometimes have a tendency to think in terms of, 'That's the least of your worries,' it's increasingly becoming a concern of survivors to look at these sorts of quality of life issues and so we need to change our mind set,” she said at a symposium sponsored by the American College of Rheumatology.

In order to effect this change, it's important not only to consider the pharmacology and reproductive impact of the drugs being used to treat rheumatologic diseases, but also to have a heightened awareness of the types of standard fertility preservation options, “so you can at least have your receptors retuned to some of the things that may be appropriate for your patients,” Dr. Gerrity said.

The list of drugs used to manage and treat rheumatic diseases that are known to affect reproductive health include, but may not be limited to, cyclophosphamide, chlorambucil, nonsteroidal anti-inflammatory drugs (NSAIDs), sulfasalazine, methotrexate, and leflunomide, she said.

With respect to cyclophosphamide treatment for lupus nephritis, for example, while the cytotoxic-induced damage is reversible in some tissues of rapidly dividing cells, the damage to the ovary, with its limited number of germ cells, tends to be progressive and irreversible, she said, noting that, “in studies, up to 70% of adult female patients taking daily oral cyclophosphamide and nearly half of those receiving a monthly intravenous pulse developed amenorrhea and experienced permanent ovarian failure within a year of first dose.”

The alkylating agent chlorambucil has been shown to affect both male and female fertility. “Studies have shown that adult and adolescent women taking chlorambucil exhibit an increased rate of ovarian failure,” Dr. Gerrity said. “[The drug] may cause an arrest in follicular maturation, stromal fibrosis, and a decreased number of ova in the ovary, leading to delayed onset of menstruation and amenorrhea.”

In adolescent and adult male patients, chlorambucil, either alone or in combination with prednisone or azathioprine, has been linked to temporary azoospermia. “This may be due to inhibition of DNA synthesis in developing sperm and damage to the cells of the seminiferous epithelium,” noted Dr. Gerrity.

Male patients taking sulfasalazine, methotrexate, cyclophosphamide, and leflunomide may also face the risk of oligospermia and impaired sperm motility, while women taking NSAIDs may have trouble conceiving because the drugs can inhibit blastocyst implantation, Dr. Gerrity said.

Among the “routine” fertility preservation options available to patients, Dr. Gerrity explained, are sperm banking, testicular tissue banking, GnRH analogs or antagonists, and donor sperm for men and embryo or egg banking and emergency in vitro fertilization, ovarian tissue cryopreservation, donor eggs, and gestational carriers for women.

“Embryo banking and in vitro fertilization are routine in the infertility clinic and involve stimulating women with high doses of fertility drugs to cause them to produce a lot of eggs that can be fertilized in the laboratory to produce embryos that can then be stored for later implantation.”

However, there are drawbacks to this option: “It's expensive, and it requires at least 3 weeks of preparation and treatment before egg retrieval, which may not be medically reasonable for some patients,” she said.

Another roadblock, until recently, was the fact that banking of eggs had been technologically impossible, and banking of embryos required a sperm source. “For some people without a partner, facing a life-threatening disease or long-term therapy that would impair their fertility, the prospect of undergoing a $12,000 procedure to retrieve eggs and then having to pick the man of their dreams out of a catalog is an overwhelming prospect,” Dr. Gerrity said.

Fortunately, thanks to a “political fluke” in Europe, there have been tremendous advances within the last year, leading to the ability to successfully freeze eggs for later fertilization.

“About 2 years ago, the Italian government made the freezing of human embryos illegal in that country, meaning that all of the patients in Italy undergoing [in vitro fertilization] could only add sperm to eggs that could safely be returned to their uterus—usually two to three eggs,” Dr. Gerrity explained.

Faced with the prospect of having to waste the majority of eggs retrieved from patients, “the Italian scientists kicked into gear and solved the problem we've been working on for more than 20 years: They broke the code on how to freeze eggs, so now frozen eggs yield the same pregnancy and fertilization rates as fresh eggs,” she said. “For the patients needing to bank eggs before starting fertility-impairing drug treatment, at least they don't also have to select a sperm donor on the spot.”

Although the success rates associated with frozen egg fertilization are high, the technology is still considered investigational in the United States, “which of course is an issue when dealing with third-party payers.”

A new frontier for fertility preservation in women is ovarian tissue cryopreservation, whereby portions of the ovary or the entire ovary are removed and the cortical tissue is frozen and later reimplanted into the patient. “This is a technique that we are using extensively in young girls and prepubertal girls with cancer and in patients who have to begin so quickly that taking 3 weeks out to stimulate ovaries is just not possible,” said Dr. Gerrity. “Although the freezing of the tissue is simple, the challenge has been in 'waking it up' once it's reimplanted. This has been the focus of research over the last 2–3 years, and it has paid off. In the past 6 months, there have been reports of about 14 pregnancies with transplanted ovarian tissue following chronic treatment or chemotherapy.”

Upon implantation, all of the women began menstrual cycling again and became pregnant spontaneously, she said. This technique is only an option for those patients who can be withdrawn from their fertility-compromising drugs or drugs that are contraindicated in pregnancy for the period of conception and gestation, she added.

For patients who cannot carry a pregnancy because it would be unsafe or unwise to withdraw from therapy, “gestational carriers may be the best option,” said Dr. Gerrity. “Unlike true surrogates, who lend their eggs and their uterus, gestational surrogates just lend their uterus to the effort, carrying to term the fertilized embryos from the patient and her partner.”

In order to determine the best fertility preservation option for an individual patient, “it's important to have the patient sit down with a reproductive endocrinologist,” Dr. Gerrity stressed. “As the part of this process, it's critical that [the referring physician] keeps an open line of communication with the reproductive endocrinologist. Be clear about what you can do in terms of treatment,” she said.

CHICAGO — Fertility preservation options should be presented to patients as early after the diagnosis of rheumatoid arthritis, systemic lupus erythematosus, and scleroderma as possible.

These rheumatologic diseases often strike both men and women during their childbearing years, and the diseases themselves as well as the long-term therapies used to treat them can have a negative impact on reproductive health.

“It's important to recognize that [while] many of the innovative technologies available today to treat life-threatening diseases and to provide patients with the promise of life after their disease, whether it be cancer, rheumatic disease, or other type of life-threatening condition … many of these drug treatments can be devastating in terms of reproductive health,” according to Marybeth Gerrity, Ph.D., executive director of the Oncofertility Consortium at Northwestern University, Chicago.

“While many of us who treat patients with chronic diseases sometimes have a tendency to think in terms of, 'That's the least of your worries,' it's increasingly becoming a concern of survivors to look at these sorts of quality of life issues and so we need to change our mind set,” she said at a symposium sponsored by the American College of Rheumatology.

In order to effect this change, it's important not only to consider the pharmacology and reproductive impact of the drugs being used to treat rheumatologic diseases, but also to have a heightened awareness of the types of standard fertility preservation options, “so you can at least have your receptors retuned to some of the things that may be appropriate for your patients,” Dr. Gerrity said.

The list of drugs used to manage and treat rheumatic diseases that are known to affect reproductive health include, but may not be limited to, cyclophosphamide, chlorambucil, nonsteroidal anti-inflammatory drugs (NSAIDs), sulfasalazine, methotrexate, and leflunomide, she said.

With respect to cyclophosphamide treatment for lupus nephritis, for example, while the cytotoxic-induced damage is reversible in some tissues of rapidly dividing cells, the damage to the ovary, with its limited number of germ cells, tends to be progressive and irreversible, she said, noting that, “in studies, up to 70% of adult female patients taking daily oral cyclophosphamide and nearly half of those receiving a monthly intravenous pulse developed amenorrhea and experienced permanent ovarian failure within a year of first dose.”

The alkylating agent chlorambucil has been shown to affect both male and female fertility. “Studies have shown that adult and adolescent women taking chlorambucil exhibit an increased rate of ovarian failure,” Dr. Gerrity said. “[The drug] may cause an arrest in follicular maturation, stromal fibrosis, and a decreased number of ova in the ovary, leading to delayed onset of menstruation and amenorrhea.”

In adolescent and adult male patients, chlorambucil, either alone or in combination with prednisone or azathioprine, has been linked to temporary azoospermia. “This may be due to inhibition of DNA synthesis in developing sperm and damage to the cells of the seminiferous epithelium,” noted Dr. Gerrity.

Male patients taking sulfasalazine, methotrexate, cyclophosphamide, and leflunomide may also face the risk of oligospermia and impaired sperm motility, while women taking NSAIDs may have trouble conceiving because the drugs can inhibit blastocyst implantation, Dr. Gerrity said.

Among the “routine” fertility preservation options available to patients, Dr. Gerrity explained, are sperm banking, testicular tissue banking, GnRH analogs or antagonists, and donor sperm for men and embryo or egg banking and emergency in vitro fertilization, ovarian tissue cryopreservation, donor eggs, and gestational carriers for women.

“Embryo banking and in vitro fertilization are routine in the infertility clinic and involve stimulating women with high doses of fertility drugs to cause them to produce a lot of eggs that can be fertilized in the laboratory to produce embryos that can then be stored for later implantation.”

However, there are drawbacks to this option: “It's expensive, and it requires at least 3 weeks of preparation and treatment before egg retrieval, which may not be medically reasonable for some patients,” she said.

Another roadblock, until recently, was the fact that banking of eggs had been technologically impossible, and banking of embryos required a sperm source. “For some people without a partner, facing a life-threatening disease or long-term therapy that would impair their fertility, the prospect of undergoing a $12,000 procedure to retrieve eggs and then having to pick the man of their dreams out of a catalog is an overwhelming prospect,” Dr. Gerrity said.

Fortunately, thanks to a “political fluke” in Europe, there have been tremendous advances within the last year, leading to the ability to successfully freeze eggs for later fertilization.

“About 2 years ago, the Italian government made the freezing of human embryos illegal in that country, meaning that all of the patients in Italy undergoing [in vitro fertilization] could only add sperm to eggs that could safely be returned to their uterus—usually two to three eggs,” Dr. Gerrity explained.

Faced with the prospect of having to waste the majority of eggs retrieved from patients, “the Italian scientists kicked into gear and solved the problem we've been working on for more than 20 years: They broke the code on how to freeze eggs, so now frozen eggs yield the same pregnancy and fertilization rates as fresh eggs,” she said. “For the patients needing to bank eggs before starting fertility-impairing drug treatment, at least they don't also have to select a sperm donor on the spot.”

Although the success rates associated with frozen egg fertilization are high, the technology is still considered investigational in the United States, “which of course is an issue when dealing with third-party payers.”

A new frontier for fertility preservation in women is ovarian tissue cryopreservation, whereby portions of the ovary or the entire ovary are removed and the cortical tissue is frozen and later reimplanted into the patient. “This is a technique that we are using extensively in young girls and prepubertal girls with cancer and in patients who have to begin so quickly that taking 3 weeks out to stimulate ovaries is just not possible,” said Dr. Gerrity. “Although the freezing of the tissue is simple, the challenge has been in 'waking it up' once it's reimplanted. This has been the focus of research over the last 2–3 years, and it has paid off. In the past 6 months, there have been reports of about 14 pregnancies with transplanted ovarian tissue following chronic treatment or chemotherapy.”

Upon implantation, all of the women began menstrual cycling again and became pregnant spontaneously, she said. This technique is only an option for those patients who can be withdrawn from their fertility-compromising drugs or drugs that are contraindicated in pregnancy for the period of conception and gestation, she added.

For patients who cannot carry a pregnancy because it would be unsafe or unwise to withdraw from therapy, “gestational carriers may be the best option,” said Dr. Gerrity. “Unlike true surrogates, who lend their eggs and their uterus, gestational surrogates just lend their uterus to the effort, carrying to term the fertilized embryos from the patient and her partner.”

In order to determine the best fertility preservation option for an individual patient, “it's important to have the patient sit down with a reproductive endocrinologist,” Dr. Gerrity stressed. “As the part of this process, it's critical that [the referring physician] keeps an open line of communication with the reproductive endocrinologist. Be clear about what you can do in terms of treatment,” she said.

By and large, pediatricians and endocrinologists agree on the division of roles in the management of children with insulin-dependent diabetes. However, there is some dissension about who should take lead responsibility for certain preventive, routine, and diabetes-specific aspects of care, according to a survey of pediatric care providers in North Carolina.

The 32-question survey was designed to “examine physicians' views on the distinct and complementary roles of general and subspecialty physicians in providing routine care, diabetes-specific care, family education, and care coordination,” Dr. Steven E. Wegner of AccessCare in Morrisville, N. C., and his colleagues said (Pediatrics 2008;122:e383-7).

The researchers sent the questionnaire to a convenience sample of 201 pediatricians in a not-for-profit medical home managed care organization in North Carolina (AccessCare) and all of the state's active endocrinologists in February 2007; 132 pediatricians and 36 endocrinologists completed the survey.

Nearly all of the respondents agreed that the primary care physician (PCP) should be responsible for treating minor illnesses and injuries, performing well-child check-ups, and administering and tracking immunizations, but the endocrinologists were divided in their preference for certain aspects of routine care, the researchers said.

For example, although 95% of the PCPs preferred lead responsibility for the completion of required forms and 93% preferred lead responsibility for the provision of routine anticipatory guidance, only 44% and 59% of the endocrinologists agreed, respectively. Among the endocrinologists, 9% believed they should have primary responsibility for form completion and 47% believed the responsibility should be shared.

Similarly, 6% of the endocrinologists preferred lead responsibility for providing routine guidance; 35% thought this aspect of care should be comanaged. With respect to routine monitoring of growth and development, 73% of the PCPs thought they should take the lead and 27% thought it should be comanaged.

Among the endocrinologists, 34% preferred that PCPs have primary responsibility; 17% thought endocrinologists should lead, and 49% believed it should be comanaged.

Regarding diabetes-specific care, subspecialist leadership was preferred by the PCPs and the endocrinologists for teaching patients how to use insulin pumps and glucometers, but there was disagreement regarding preferred treatment leads for prescribing diabetes medications and supplies, screening for thyroid disorders and microalbuminuria, tracking hemoglobin A1c, adjusting insulin doses, screening for dyslipidemia, and monitoring blood sugar.

While the majority of endocrinologists saw themselves as leads for these aspects of care, the PCPs were split between their preference for subspecialty leadership and comanagement, according to Dr. Wegner and his associates.

“This response among subspecialists may reflect the complexity of dosing regimens, as well as the small number of children with [insulin-dependent diabetes] that any one pediatrician follows,” they said.

“Among PCPs, this response may reflect their recognition for the frequency of insulin adjustments and the convenience to families for receiving at least some diabetes-specific care at the PCP office.”

Preferences for family education and care coordination “were fairly evenly split [among both groups] between comanagement and lead by subspecialists,” they said. “Comanagement was favored for referrals for mental health by both physician groups, but there were significant differences as to who should lead communication with school or day care personnel regarding medicines and referrals to ophthalmologists.”

The survey findings provide “an important foundation for defining and developing a new partnership with increased interaction between PCPs and endocrinologists,” Dr. Wegner and his associates said.

The results also point to areas in need of increased efforts, such as education, consultation, and communication, they stated.

The elements critical to the successful collaboration between endocrinologists and PCPs in medical homes for children with insulin-dependent diabetes include the development of preferred communication processes among all parties; referral pathways with indicators for initial diagnosis, ongoing management, and return to primary care; quality measures; payment incentives; and practice-based research investments, they said.

The study authors noted having no relevant financial interests to disclose.

By and large, pediatricians and endocrinologists agree on the division of roles in the management of children with insulin-dependent diabetes. However, there is some dissension about who should take lead responsibility for certain preventive, routine, and diabetes-specific aspects of care, according to a survey of pediatric care providers in North Carolina.

The 32-question survey was designed to “examine physicians' views on the distinct and complementary roles of general and subspecialty physicians in providing routine care, diabetes-specific care, family education, and care coordination,” Dr. Steven E. Wegner of AccessCare in Morrisville, N. C., and his colleagues said (Pediatrics 2008;122:e383-7).

The researchers sent the questionnaire to a convenience sample of 201 pediatricians in a not-for-profit medical home managed care organization in North Carolina (AccessCare) and all of the state's active endocrinologists in February 2007; 132 pediatricians and 36 endocrinologists completed the survey.

Nearly all of the respondents agreed that the primary care physician (PCP) should be responsible for treating minor illnesses and injuries, performing well-child check-ups, and administering and tracking immunizations, but the endocrinologists were divided in their preference for certain aspects of routine care, the researchers said.

For example, although 95% of the PCPs preferred lead responsibility for the completion of required forms and 93% preferred lead responsibility for the provision of routine anticipatory guidance, only 44% and 59% of the endocrinologists agreed, respectively. Among the endocrinologists, 9% believed they should have primary responsibility for form completion and 47% believed the responsibility should be shared.

Similarly, 6% of the endocrinologists preferred lead responsibility for providing routine guidance; 35% thought this aspect of care should be comanaged. With respect to routine monitoring of growth and development, 73% of the PCPs thought they should take the lead and 27% thought it should be comanaged.

Among the endocrinologists, 34% preferred that PCPs have primary responsibility; 17% thought endocrinologists should lead, and 49% believed it should be comanaged.

Regarding diabetes-specific care, subspecialist leadership was preferred by the PCPs and the endocrinologists for teaching patients how to use insulin pumps and glucometers, but there was disagreement regarding preferred treatment leads for prescribing diabetes medications and supplies, screening for thyroid disorders and microalbuminuria, tracking hemoglobin A1c, adjusting insulin doses, screening for dyslipidemia, and monitoring blood sugar.

While the majority of endocrinologists saw themselves as leads for these aspects of care, the PCPs were split between their preference for subspecialty leadership and comanagement, according to Dr. Wegner and his associates.

“This response among subspecialists may reflect the complexity of dosing regimens, as well as the small number of children with [insulin-dependent diabetes] that any one pediatrician follows,” they said.

“Among PCPs, this response may reflect their recognition for the frequency of insulin adjustments and the convenience to families for receiving at least some diabetes-specific care at the PCP office.”

Preferences for family education and care coordination “were fairly evenly split [among both groups] between comanagement and lead by subspecialists,” they said. “Comanagement was favored for referrals for mental health by both physician groups, but there were significant differences as to who should lead communication with school or day care personnel regarding medicines and referrals to ophthalmologists.”

The survey findings provide “an important foundation for defining and developing a new partnership with increased interaction between PCPs and endocrinologists,” Dr. Wegner and his associates said.

The results also point to areas in need of increased efforts, such as education, consultation, and communication, they stated.

The elements critical to the successful collaboration between endocrinologists and PCPs in medical homes for children with insulin-dependent diabetes include the development of preferred communication processes among all parties; referral pathways with indicators for initial diagnosis, ongoing management, and return to primary care; quality measures; payment incentives; and practice-based research investments, they said.

The study authors noted having no relevant financial interests to disclose.

By and large, pediatricians and endocrinologists agree on the division of roles in the management of children with insulin-dependent diabetes. However, there is some dissension about who should take lead responsibility for certain preventive, routine, and diabetes-specific aspects of care, according to a survey of pediatric care providers in North Carolina.

The 32-question survey was designed to “examine physicians' views on the distinct and complementary roles of general and subspecialty physicians in providing routine care, diabetes-specific care, family education, and care coordination,” Dr. Steven E. Wegner of AccessCare in Morrisville, N. C., and his colleagues said (Pediatrics 2008;122:e383-7).

The researchers sent the questionnaire to a convenience sample of 201 pediatricians in a not-for-profit medical home managed care organization in North Carolina (AccessCare) and all of the state's active endocrinologists in February 2007; 132 pediatricians and 36 endocrinologists completed the survey.

Nearly all of the respondents agreed that the primary care physician (PCP) should be responsible for treating minor illnesses and injuries, performing well-child check-ups, and administering and tracking immunizations, but the endocrinologists were divided in their preference for certain aspects of routine care, the researchers said.

For example, although 95% of the PCPs preferred lead responsibility for the completion of required forms and 93% preferred lead responsibility for the provision of routine anticipatory guidance, only 44% and 59% of the endocrinologists agreed, respectively. Among the endocrinologists, 9% believed they should have primary responsibility for form completion and 47% believed the responsibility should be shared.

Similarly, 6% of the endocrinologists preferred lead responsibility for providing routine guidance; 35% thought this aspect of care should be comanaged. With respect to routine monitoring of growth and development, 73% of the PCPs thought they should take the lead and 27% thought it should be comanaged.

Among the endocrinologists, 34% preferred that PCPs have primary responsibility; 17% thought endocrinologists should lead, and 49% believed it should be comanaged.

Regarding diabetes-specific care, subspecialist leadership was preferred by the PCPs and the endocrinologists for teaching patients how to use insulin pumps and glucometers, but there was disagreement regarding preferred treatment leads for prescribing diabetes medications and supplies, screening for thyroid disorders and microalbuminuria, tracking hemoglobin A1c, adjusting insulin doses, screening for dyslipidemia, and monitoring blood sugar.

While the majority of endocrinologists saw themselves as leads for these aspects of care, the PCPs were split between their preference for subspecialty leadership and comanagement, according to Dr. Wegner and his associates.

“This response among subspecialists may reflect the complexity of dosing regimens, as well as the small number of children with [insulin-dependent diabetes] that any one pediatrician follows,” they said.

“Among PCPs, this response may reflect their recognition for the frequency of insulin adjustments and the convenience to families for receiving at least some diabetes-specific care at the PCP office.”

Preferences for family education and care coordination “were fairly evenly split [among both groups] between comanagement and lead by subspecialists,” they said. “Comanagement was favored for referrals for mental health by both physician groups, but there were significant differences as to who should lead communication with school or day care personnel regarding medicines and referrals to ophthalmologists.”

The survey findings provide “an important foundation for defining and developing a new partnership with increased interaction between PCPs and endocrinologists,” Dr. Wegner and his associates said.

The results also point to areas in need of increased efforts, such as education, consultation, and communication, they stated.

The elements critical to the successful collaboration between endocrinologists and PCPs in medical homes for children with insulin-dependent diabetes include the development of preferred communication processes among all parties; referral pathways with indicators for initial diagnosis, ongoing management, and return to primary care; quality measures; payment incentives; and practice-based research investments, they said.

The study authors noted having no relevant financial interests to disclose.

A sharp rise in the number of adult hospitalizations and deaths attributable to Clostridium difficile infection over a 6-year period has investigators calling for increased allocation of public health resources aimed at the prevention of disease caused by the gastrointestinal pathogen.

In a population-based analysis of adult hospitalizations related to C. difficile-associated disease (CDAD) between 2000 and 2005, Dr. Marya D. Zilberberg of the University of Massachusetts School of Public Health and Health Sciences, Amherst, and colleagues determined that the incidence of adult CDAD hospitalizations rose from 5.5 cases per 10,000 population in 2000 to 11.2 per 10,000 population in 2005. Furthermore, by applying published population-based CDAD mortality estimates for 2000–2004 to the annual CDAD hospitalization volumes, they reported that the CDAD-related, age-adjusted case fatality rate rose from 1.2% in 2000 to 2.2% in 2004.

“We detected a 23% annual increase in CDAD hospitalizations in the 6-year period from 2000 through 2005,” they wrote. “Moreover, the absolute number of CDAD hospitalizations more than doubled in all age groups except the youngest, for whom they increased by 74.1% over the study period.” The rate of increase in the incidence of CDAD was steepest in those aged 85 years and older, and followed by those aged 65–84 years, those aged 45–64 years, and those aged 18–44 years (Emerg. Infect. Dis. 2008;14:929-31).

The numbers help explain the increasing mortality rates related to CDAD, the authors wrote, referring specifically to a recent report documenting a 35% per year increase in the number of CDAD deaths from 1999 through 2004 (Emerg. Infect. Dis. 2007;13:1417-9).

“By observing a 23% per year increase in the volume of hospitalizations with CDAD during 2000–2005, we demonstrate that at least half of the reported mortality increase with CDAD is due to an increase in the incidence of hospitalizations with this severe infection,” they stated, noting the increased hospitalization likely represents the effects of increased virulence of the organism and growing resistance to some antibiotics.

Data for the current analysis were obtained from the National Inpatient Sample, which is a 20% sample of U.S. community hospitals, weighted to provide national estimates. The researchers identified CDAD by ICD-9-CM code 8.45 for intestinal infection with C. difficile, and age-stratified the number of discharges per year. Using U.S. census data on numerical and demographic characteristics of the U.S. population from 2000 to 2005, they calculated age-specific hospitalization incidence rates and fitted linear models to describe the age-specific growth.

“The rapid rate of growth of CDAD-related hospitalizations and mortality is alarming, particularly in view of the aging population. If this rate of rise, along with the increase in virulence and diminished susceptibility to antimicrobial drug treatments, persists, C. difficile-associated disease will result not only in a considerable strain on the health care system but also in rising numbers of deaths.” For this reason, “research into the best preventive strategies … is a public health imperative.”

A sharp rise in the number of adult hospitalizations and deaths attributable to Clostridium difficile infection over a 6-year period has investigators calling for increased allocation of public health resources aimed at the prevention of disease caused by the gastrointestinal pathogen.

In a population-based analysis of adult hospitalizations related to C. difficile-associated disease (CDAD) between 2000 and 2005, Dr. Marya D. Zilberberg of the University of Massachusetts School of Public Health and Health Sciences, Amherst, and colleagues determined that the incidence of adult CDAD hospitalizations rose from 5.5 cases per 10,000 population in 2000 to 11.2 per 10,000 population in 2005. Furthermore, by applying published population-based CDAD mortality estimates for 2000–2004 to the annual CDAD hospitalization volumes, they reported that the CDAD-related, age-adjusted case fatality rate rose from 1.2% in 2000 to 2.2% in 2004.

“We detected a 23% annual increase in CDAD hospitalizations in the 6-year period from 2000 through 2005,” they wrote. “Moreover, the absolute number of CDAD hospitalizations more than doubled in all age groups except the youngest, for whom they increased by 74.1% over the study period.” The rate of increase in the incidence of CDAD was steepest in those aged 85 years and older, and followed by those aged 65–84 years, those aged 45–64 years, and those aged 18–44 years (Emerg. Infect. Dis. 2008;14:929-31).

The numbers help explain the increasing mortality rates related to CDAD, the authors wrote, referring specifically to a recent report documenting a 35% per year increase in the number of CDAD deaths from 1999 through 2004 (Emerg. Infect. Dis. 2007;13:1417-9).

“By observing a 23% per year increase in the volume of hospitalizations with CDAD during 2000–2005, we demonstrate that at least half of the reported mortality increase with CDAD is due to an increase in the incidence of hospitalizations with this severe infection,” they stated, noting the increased hospitalization likely represents the effects of increased virulence of the organism and growing resistance to some antibiotics.

Data for the current analysis were obtained from the National Inpatient Sample, which is a 20% sample of U.S. community hospitals, weighted to provide national estimates. The researchers identified CDAD by ICD-9-CM code 8.45 for intestinal infection with C. difficile, and age-stratified the number of discharges per year. Using U.S. census data on numerical and demographic characteristics of the U.S. population from 2000 to 2005, they calculated age-specific hospitalization incidence rates and fitted linear models to describe the age-specific growth.

“The rapid rate of growth of CDAD-related hospitalizations and mortality is alarming, particularly in view of the aging population. If this rate of rise, along with the increase in virulence and diminished susceptibility to antimicrobial drug treatments, persists, C. difficile-associated disease will result not only in a considerable strain on the health care system but also in rising numbers of deaths.” For this reason, “research into the best preventive strategies … is a public health imperative.”

A sharp rise in the number of adult hospitalizations and deaths attributable to Clostridium difficile infection over a 6-year period has investigators calling for increased allocation of public health resources aimed at the prevention of disease caused by the gastrointestinal pathogen.

In a population-based analysis of adult hospitalizations related to C. difficile-associated disease (CDAD) between 2000 and 2005, Dr. Marya D. Zilberberg of the University of Massachusetts School of Public Health and Health Sciences, Amherst, and colleagues determined that the incidence of adult CDAD hospitalizations rose from 5.5 cases per 10,000 population in 2000 to 11.2 per 10,000 population in 2005. Furthermore, by applying published population-based CDAD mortality estimates for 2000–2004 to the annual CDAD hospitalization volumes, they reported that the CDAD-related, age-adjusted case fatality rate rose from 1.2% in 2000 to 2.2% in 2004.

“We detected a 23% annual increase in CDAD hospitalizations in the 6-year period from 2000 through 2005,” they wrote. “Moreover, the absolute number of CDAD hospitalizations more than doubled in all age groups except the youngest, for whom they increased by 74.1% over the study period.” The rate of increase in the incidence of CDAD was steepest in those aged 85 years and older, and followed by those aged 65–84 years, those aged 45–64 years, and those aged 18–44 years (Emerg. Infect. Dis. 2008;14:929-31).

The numbers help explain the increasing mortality rates related to CDAD, the authors wrote, referring specifically to a recent report documenting a 35% per year increase in the number of CDAD deaths from 1999 through 2004 (Emerg. Infect. Dis. 2007;13:1417-9).

“By observing a 23% per year increase in the volume of hospitalizations with CDAD during 2000–2005, we demonstrate that at least half of the reported mortality increase with CDAD is due to an increase in the incidence of hospitalizations with this severe infection,” they stated, noting the increased hospitalization likely represents the effects of increased virulence of the organism and growing resistance to some antibiotics.

Data for the current analysis were obtained from the National Inpatient Sample, which is a 20% sample of U.S. community hospitals, weighted to provide national estimates. The researchers identified CDAD by ICD-9-CM code 8.45 for intestinal infection with C. difficile, and age-stratified the number of discharges per year. Using U.S. census data on numerical and demographic characteristics of the U.S. population from 2000 to 2005, they calculated age-specific hospitalization incidence rates and fitted linear models to describe the age-specific growth.

“The rapid rate of growth of CDAD-related hospitalizations and mortality is alarming, particularly in view of the aging population. If this rate of rise, along with the increase in virulence and diminished susceptibility to antimicrobial drug treatments, persists, C. difficile-associated disease will result not only in a considerable strain on the health care system but also in rising numbers of deaths.” For this reason, “research into the best preventive strategies … is a public health imperative.”

BOSTON – The efficacy of occipital nerve stimulation in the first clinical trial of its use in the treatment of refractory migraines suggests that the technique may be a promising option for individuals who have not responded to medication or other established therapies, according to Dr. Joel Saper.

The neurostimulation technique was associated with a significant reduction in both the number of headache days per month and the intensity of pain in nearly 40% of patients with chronic migraine who were randomized to its use in a multicenter feasibility trial, reported Dr. Saper, founder and director of a head pain treatment and research center in Ann Arbor, Mich.

Occipital nerve stimulation (ONS) is achieved by the delivery of asymmetric biphasic electrical pulses via subcutaneous wires attached to the tissue surrounding the occipital nerve, located between the back of the neck and the skull. This form of peripheral nerve stimulation is thought to modulate the path of the migraine circuit and, by so doing, to interrupt the pain signals, said Dr. Saper.

Although previous studies have assessed ONS for the treatment of migraine and other headaches, as well as for occipital neuralgia, these have mostly been retrospective analyses, case series, or uncontrolled trials, he noted.

In the current investigation, called the ONSTIM (Occipital Nerve Stimulation for the Treatment of Intractable Migraine) study, Dr. Saper and colleagues randomized, in a 2:1:1 design, 110 patients from nine centers to one of three conditions: adjustable stimulation, in which patients received the neurostimulator and were able to control the level of stimulation; preset stimulation, or the device-control group, in which the level of stimulation was not adjustable; and standard medical management.

All of the patients included in the study experienced 15 headache days per month, as per ICHD-II (International Classification of Headache Disorders, second edition) criteria for chronic migraine, and none were responsive to available medical therapies. Prior to randomization, all of the patients received diagnostic occipital nerve block (ONB). The first eight patients who failed ONB formed an ancillary group and were offered ONS.

Of the 110 patients, 66 completed the electronic diary data for the 3-month follow-up period, including 28 in the adjustable-stimulation group; 16 in the present-stimulation group; 17 in the medical-management group; and 5 in the ancillary group.

In the final analysis, the investigators used nonparametric methods to compare the ONS intervention group with the two control-condition groups for reduction in headache days per month, decrease in overall pain intensity on a 0–10 scale, and responder rate (defined as a 50% drop in headache days per month and a minimum 3-point drop in overall pain intensity from baseline), Dr. Saper explained.

With respect to headache days per month, the mean reduction from baseline in the device-intervention group was 27%, compared with 9% and 4% for the device- and medication-control groups, respectively. The mean drop in overall pain intensity was 1.5 points for patients in the intervention group, compared with 0.5 and 0.6 in the device and medication controls, he said.

In terms of treatment response, 39% of the patients in the intervention group experienced at least a 50% decrease in headache days per month and a minimum 3-point drop in pain intensity at 3 months, Dr. Saper said. In contrast, only 6% of the device-control group and none of the medically managed patients responded to therapy, he said at the annual meeting of the American Headache Society.

Of interest, he noted, “two of the patients in the ancillary group–all of whom failed ONB–responded to ONS, indicating that ONB may not be predictive of response to ONS.”

No adverse events and no “unanticipated” adverse device events occurred, said Dr. Saper.

“The most common adverse device event was lead migration, which occurred in 12 of the 51 implanted subjects.” Other adverse device events, particularly battery failure, “were consistent with the literature,” he said.

Although additional randomized controlled trials are needed, the findings are important, “particularly to the population of chronic migraine sufferers who do not respond to aggressive medical therapy,” Dr. David Dodick, one of the ONSTIM investigators, said in a symposium on neurostimulation for refractory primary headache disorders at the annual meeting.

If further studies demonstrate the safety and efficacy of ONS, leading to approval and commercialization of the technology, he said, “there may be some relief in sight for these patients.”

The ONSTIM study was sponsored by Medtronic Inc., the developer of the neurostimulation device, and was conducted under an investigational device exemption according to the Food and Drug Administration's device-approval procedures.

Two patients who failed occipital nerve block responded to the stimulation technique. DR. SAPER

BOSTON – The efficacy of occipital nerve stimulation in the first clinical trial of its use in the treatment of refractory migraines suggests that the technique may be a promising option for individuals who have not responded to medication or other established therapies, according to Dr. Joel Saper.

The neurostimulation technique was associated with a significant reduction in both the number of headache days per month and the intensity of pain in nearly 40% of patients with chronic migraine who were randomized to its use in a multicenter feasibility trial, reported Dr. Saper, founder and director of a head pain treatment and research center in Ann Arbor, Mich.

Occipital nerve stimulation (ONS) is achieved by the delivery of asymmetric biphasic electrical pulses via subcutaneous wires attached to the tissue surrounding the occipital nerve, located between the back of the neck and the skull. This form of peripheral nerve stimulation is thought to modulate the path of the migraine circuit and, by so doing, to interrupt the pain signals, said Dr. Saper.

Although previous studies have assessed ONS for the treatment of migraine and other headaches, as well as for occipital neuralgia, these have mostly been retrospective analyses, case series, or uncontrolled trials, he noted.

In the current investigation, called the ONSTIM (Occipital Nerve Stimulation for the Treatment of Intractable Migraine) study, Dr. Saper and colleagues randomized, in a 2:1:1 design, 110 patients from nine centers to one of three conditions: adjustable stimulation, in which patients received the neurostimulator and were able to control the level of stimulation; preset stimulation, or the device-control group, in which the level of stimulation was not adjustable; and standard medical management.

All of the patients included in the study experienced 15 headache days per month, as per ICHD-II (International Classification of Headache Disorders, second edition) criteria for chronic migraine, and none were responsive to available medical therapies. Prior to randomization, all of the patients received diagnostic occipital nerve block (ONB). The first eight patients who failed ONB formed an ancillary group and were offered ONS.

Of the 110 patients, 66 completed the electronic diary data for the 3-month follow-up period, including 28 in the adjustable-stimulation group; 16 in the present-stimulation group; 17 in the medical-management group; and 5 in the ancillary group.

In the final analysis, the investigators used nonparametric methods to compare the ONS intervention group with the two control-condition groups for reduction in headache days per month, decrease in overall pain intensity on a 0–10 scale, and responder rate (defined as a 50% drop in headache days per month and a minimum 3-point drop in overall pain intensity from baseline), Dr. Saper explained.

With respect to headache days per month, the mean reduction from baseline in the device-intervention group was 27%, compared with 9% and 4% for the device- and medication-control groups, respectively. The mean drop in overall pain intensity was 1.5 points for patients in the intervention group, compared with 0.5 and 0.6 in the device and medication controls, he said.

In terms of treatment response, 39% of the patients in the intervention group experienced at least a 50% decrease in headache days per month and a minimum 3-point drop in pain intensity at 3 months, Dr. Saper said. In contrast, only 6% of the device-control group and none of the medically managed patients responded to therapy, he said at the annual meeting of the American Headache Society.

Of interest, he noted, “two of the patients in the ancillary group–all of whom failed ONB–responded to ONS, indicating that ONB may not be predictive of response to ONS.”

No adverse events and no “unanticipated” adverse device events occurred, said Dr. Saper.

“The most common adverse device event was lead migration, which occurred in 12 of the 51 implanted subjects.” Other adverse device events, particularly battery failure, “were consistent with the literature,” he said.

Although additional randomized controlled trials are needed, the findings are important, “particularly to the population of chronic migraine sufferers who do not respond to aggressive medical therapy,” Dr. David Dodick, one of the ONSTIM investigators, said in a symposium on neurostimulation for refractory primary headache disorders at the annual meeting.

If further studies demonstrate the safety and efficacy of ONS, leading to approval and commercialization of the technology, he said, “there may be some relief in sight for these patients.”

The ONSTIM study was sponsored by Medtronic Inc., the developer of the neurostimulation device, and was conducted under an investigational device exemption according to the Food and Drug Administration's device-approval procedures.

Two patients who failed occipital nerve block responded to the stimulation technique. DR. SAPER

BOSTON – The efficacy of occipital nerve stimulation in the first clinical trial of its use in the treatment of refractory migraines suggests that the technique may be a promising option for individuals who have not responded to medication or other established therapies, according to Dr. Joel Saper.

The neurostimulation technique was associated with a significant reduction in both the number of headache days per month and the intensity of pain in nearly 40% of patients with chronic migraine who were randomized to its use in a multicenter feasibility trial, reported Dr. Saper, founder and director of a head pain treatment and research center in Ann Arbor, Mich.

Occipital nerve stimulation (ONS) is achieved by the delivery of asymmetric biphasic electrical pulses via subcutaneous wires attached to the tissue surrounding the occipital nerve, located between the back of the neck and the skull. This form of peripheral nerve stimulation is thought to modulate the path of the migraine circuit and, by so doing, to interrupt the pain signals, said Dr. Saper.

Although previous studies have assessed ONS for the treatment of migraine and other headaches, as well as for occipital neuralgia, these have mostly been retrospective analyses, case series, or uncontrolled trials, he noted.

In the current investigation, called the ONSTIM (Occipital Nerve Stimulation for the Treatment of Intractable Migraine) study, Dr. Saper and colleagues randomized, in a 2:1:1 design, 110 patients from nine centers to one of three conditions: adjustable stimulation, in which patients received the neurostimulator and were able to control the level of stimulation; preset stimulation, or the device-control group, in which the level of stimulation was not adjustable; and standard medical management.

All of the patients included in the study experienced 15 headache days per month, as per ICHD-II (International Classification of Headache Disorders, second edition) criteria for chronic migraine, and none were responsive to available medical therapies. Prior to randomization, all of the patients received diagnostic occipital nerve block (ONB). The first eight patients who failed ONB formed an ancillary group and were offered ONS.

Of the 110 patients, 66 completed the electronic diary data for the 3-month follow-up period, including 28 in the adjustable-stimulation group; 16 in the present-stimulation group; 17 in the medical-management group; and 5 in the ancillary group.

In the final analysis, the investigators used nonparametric methods to compare the ONS intervention group with the two control-condition groups for reduction in headache days per month, decrease in overall pain intensity on a 0–10 scale, and responder rate (defined as a 50% drop in headache days per month and a minimum 3-point drop in overall pain intensity from baseline), Dr. Saper explained.

With respect to headache days per month, the mean reduction from baseline in the device-intervention group was 27%, compared with 9% and 4% for the device- and medication-control groups, respectively. The mean drop in overall pain intensity was 1.5 points for patients in the intervention group, compared with 0.5 and 0.6 in the device and medication controls, he said.

In terms of treatment response, 39% of the patients in the intervention group experienced at least a 50% decrease in headache days per month and a minimum 3-point drop in pain intensity at 3 months, Dr. Saper said. In contrast, only 6% of the device-control group and none of the medically managed patients responded to therapy, he said at the annual meeting of the American Headache Society.

Of interest, he noted, “two of the patients in the ancillary group–all of whom failed ONB–responded to ONS, indicating that ONB may not be predictive of response to ONS.”

No adverse events and no “unanticipated” adverse device events occurred, said Dr. Saper.

“The most common adverse device event was lead migration, which occurred in 12 of the 51 implanted subjects.” Other adverse device events, particularly battery failure, “were consistent with the literature,” he said.

Although additional randomized controlled trials are needed, the findings are important, “particularly to the population of chronic migraine sufferers who do not respond to aggressive medical therapy,” Dr. David Dodick, one of the ONSTIM investigators, said in a symposium on neurostimulation for refractory primary headache disorders at the annual meeting.

If further studies demonstrate the safety and efficacy of ONS, leading to approval and commercialization of the technology, he said, “there may be some relief in sight for these patients.”

The ONSTIM study was sponsored by Medtronic Inc., the developer of the neurostimulation device, and was conducted under an investigational device exemption according to the Food and Drug Administration's device-approval procedures.

Two patients who failed occipital nerve block responded to the stimulation technique. DR. SAPER

Fewer Americans are being diagnosed with lung cancer, yet more are being hospitalized for it.

The federal government's Agency for Healthcare Research and Quality has released new data showing that the number of hospital admissions associated with a principal diagnosis of lung cancer remained stable between 1995 and 2006, while the number of hospitalizations with lung cancer as a secondary diagnosis increased 15%—despite a steady decline in the number of Americans diagnosed with the disease during the same period.

The discrepancy can be largely attributed to the fact that patients with lung cancer are living longer thanks to therapeutic advances and are receiving more in-hospital treatments, including surgery and chemotherapy, according to the report (www.ahrq.gov/news/nn/nn111208.htm

A statistical analysis of hospital stays for lung cancer, using the 2006 Nationwide Inpatient sample database, showed that of the 535,700 hospitalizations citing a lung cancer diagnosis in 2006, 149,900 were principally for lung cancer and 386,000 had lung cancer as a secondary diagnosis.

“Overall, the total number of lung cancer-related hospitalizations has increased 10% since 1995, ranging from 475,600 stays in 1999 to a high of 542,200 stays in 2005,” according to the report. The aggregate cost for all lung cancer-related hospitalizations was more than $6 billion, the authors noted.

Approximately 63% of hospitalized lung cancer patients in 2006 were 65 years or older, and only 2.4% were younger than 44 years. When patients younger than 45 years were hospitalized, twice as many stays involved a secondary diagnosis of lung cancer, “potentially indicating follow-up hospitalizations for sequelae of lung cancer,” the authors wrote.

With respect to gender, men were hospitalized for lung cancer overall more frequently than were women, and men older than 65 years had the highest rates of hospitalization for all lung cancer patients.

The highest rate of hospitalizations with lung cancer as a primary diagnosis was observed in the South, with 89 admissions per 100,000 persons, compared with approximately 30, 55, and 34 per 100,000, respectively, in the Northeast, Midwest, and West. In contrast, the highest rate of lung cancer stays overall was seen in the Northeast, with 178 stays per 100,000 persons, compared with 137, 109, and 81 in the Midwest, South, and West, respectively.

Medicare was the most common payer both for principal and secondary stays, and private insurance was the second most common. Uninsured patients accounted for 3.6% of principal lung cancer admissions and 1.8% of secondary admissions, both of which are less than the 5.8% average rate of uninsured nonmaternal, non-neonatal hospitalizations, the authors said.

The rates of in-hospital deaths associated with lung cancer hospitalization in 2006 were 13% of patients with a principal lung cancer diagnosis and 8.6% of patients with a secondary diagnosis—both of which are substantially higher than the 2.6% observed for the average nonmaternal, nonneonatal hospitalization.

An evaluation of common procedures associated with lung cancer-related hospitalizations showed that cancer (lung cancer, other cancer, secondary malignancies) or some type of maintenance therapy (radiology, chemotherapy) accounted for approximately 40% of all hospital stays. Respiratory diagnoses—such as pneumonia, chronic obstructive pulmonary disease, respiratory failure, and pulmonary heart disease, among others—were also common reasons for lung cancer-associated hospital stays, the authors wrote.

When procedures were performed during lung cancer stays, the four most common among patients hospitalized primarily for lung cancer were diagnostic bronchoscopy and biopsy of the bronchus (49%); lobectomy or pneumonectomy (31%); incision of pleura, thoracentesis, chest drainage (16%); and blood transfusion (11%). The four most common procedures when lung cancer was the secondary diagnosis were blood transfusion (15%); respiratory intubation and mechanical ventilation (10%); incision of pleura, thoracentesis, chest drainage (9%); and diagnostic bronchoscopy and biopsy of the bronchus (8%).

Procedures common to all hospitalizations included therapeutic radiology, cancer chemotherapy, and upper gastrointestinal endoscopies and biopsies, they wrote.

Fewer Americans are being diagnosed with lung cancer, yet more are being hospitalized for it.

The federal government's Agency for Healthcare Research and Quality has released new data showing that the number of hospital admissions associated with a principal diagnosis of lung cancer remained stable between 1995 and 2006, while the number of hospitalizations with lung cancer as a secondary diagnosis increased 15%—despite a steady decline in the number of Americans diagnosed with the disease during the same period.

The discrepancy can be largely attributed to the fact that patients with lung cancer are living longer thanks to therapeutic advances and are receiving more in-hospital treatments, including surgery and chemotherapy, according to the report (www.ahrq.gov/news/nn/nn111208.htm

A statistical analysis of hospital stays for lung cancer, using the 2006 Nationwide Inpatient sample database, showed that of the 535,700 hospitalizations citing a lung cancer diagnosis in 2006, 149,900 were principally for lung cancer and 386,000 had lung cancer as a secondary diagnosis.

“Overall, the total number of lung cancer-related hospitalizations has increased 10% since 1995, ranging from 475,600 stays in 1999 to a high of 542,200 stays in 2005,” according to the report. The aggregate cost for all lung cancer-related hospitalizations was more than $6 billion, the authors noted.

Approximately 63% of hospitalized lung cancer patients in 2006 were 65 years or older, and only 2.4% were younger than 44 years. When patients younger than 45 years were hospitalized, twice as many stays involved a secondary diagnosis of lung cancer, “potentially indicating follow-up hospitalizations for sequelae of lung cancer,” the authors wrote.

With respect to gender, men were hospitalized for lung cancer overall more frequently than were women, and men older than 65 years had the highest rates of hospitalization for all lung cancer patients.

The highest rate of hospitalizations with lung cancer as a primary diagnosis was observed in the South, with 89 admissions per 100,000 persons, compared with approximately 30, 55, and 34 per 100,000, respectively, in the Northeast, Midwest, and West. In contrast, the highest rate of lung cancer stays overall was seen in the Northeast, with 178 stays per 100,000 persons, compared with 137, 109, and 81 in the Midwest, South, and West, respectively.

Medicare was the most common payer both for principal and secondary stays, and private insurance was the second most common. Uninsured patients accounted for 3.6% of principal lung cancer admissions and 1.8% of secondary admissions, both of which are less than the 5.8% average rate of uninsured nonmaternal, non-neonatal hospitalizations, the authors said.

The rates of in-hospital deaths associated with lung cancer hospitalization in 2006 were 13% of patients with a principal lung cancer diagnosis and 8.6% of patients with a secondary diagnosis—both of which are substantially higher than the 2.6% observed for the average nonmaternal, nonneonatal hospitalization.

An evaluation of common procedures associated with lung cancer-related hospitalizations showed that cancer (lung cancer, other cancer, secondary malignancies) or some type of maintenance therapy (radiology, chemotherapy) accounted for approximately 40% of all hospital stays. Respiratory diagnoses—such as pneumonia, chronic obstructive pulmonary disease, respiratory failure, and pulmonary heart disease, among others—were also common reasons for lung cancer-associated hospital stays, the authors wrote.

When procedures were performed during lung cancer stays, the four most common among patients hospitalized primarily for lung cancer were diagnostic bronchoscopy and biopsy of the bronchus (49%); lobectomy or pneumonectomy (31%); incision of pleura, thoracentesis, chest drainage (16%); and blood transfusion (11%). The four most common procedures when lung cancer was the secondary diagnosis were blood transfusion (15%); respiratory intubation and mechanical ventilation (10%); incision of pleura, thoracentesis, chest drainage (9%); and diagnostic bronchoscopy and biopsy of the bronchus (8%).

Procedures common to all hospitalizations included therapeutic radiology, cancer chemotherapy, and upper gastrointestinal endoscopies and biopsies, they wrote.

Fewer Americans are being diagnosed with lung cancer, yet more are being hospitalized for it.

The federal government's Agency for Healthcare Research and Quality has released new data showing that the number of hospital admissions associated with a principal diagnosis of lung cancer remained stable between 1995 and 2006, while the number of hospitalizations with lung cancer as a secondary diagnosis increased 15%—despite a steady decline in the number of Americans diagnosed with the disease during the same period.

The discrepancy can be largely attributed to the fact that patients with lung cancer are living longer thanks to therapeutic advances and are receiving more in-hospital treatments, including surgery and chemotherapy, according to the report (www.ahrq.gov/news/nn/nn111208.htm

A statistical analysis of hospital stays for lung cancer, using the 2006 Nationwide Inpatient sample database, showed that of the 535,700 hospitalizations citing a lung cancer diagnosis in 2006, 149,900 were principally for lung cancer and 386,000 had lung cancer as a secondary diagnosis.

“Overall, the total number of lung cancer-related hospitalizations has increased 10% since 1995, ranging from 475,600 stays in 1999 to a high of 542,200 stays in 2005,” according to the report. The aggregate cost for all lung cancer-related hospitalizations was more than $6 billion, the authors noted.

Approximately 63% of hospitalized lung cancer patients in 2006 were 65 years or older, and only 2.4% were younger than 44 years. When patients younger than 45 years were hospitalized, twice as many stays involved a secondary diagnosis of lung cancer, “potentially indicating follow-up hospitalizations for sequelae of lung cancer,” the authors wrote.

With respect to gender, men were hospitalized for lung cancer overall more frequently than were women, and men older than 65 years had the highest rates of hospitalization for all lung cancer patients.

The highest rate of hospitalizations with lung cancer as a primary diagnosis was observed in the South, with 89 admissions per 100,000 persons, compared with approximately 30, 55, and 34 per 100,000, respectively, in the Northeast, Midwest, and West. In contrast, the highest rate of lung cancer stays overall was seen in the Northeast, with 178 stays per 100,000 persons, compared with 137, 109, and 81 in the Midwest, South, and West, respectively.

Medicare was the most common payer both for principal and secondary stays, and private insurance was the second most common. Uninsured patients accounted for 3.6% of principal lung cancer admissions and 1.8% of secondary admissions, both of which are less than the 5.8% average rate of uninsured nonmaternal, non-neonatal hospitalizations, the authors said.

The rates of in-hospital deaths associated with lung cancer hospitalization in 2006 were 13% of patients with a principal lung cancer diagnosis and 8.6% of patients with a secondary diagnosis—both of which are substantially higher than the 2.6% observed for the average nonmaternal, nonneonatal hospitalization.

An evaluation of common procedures associated with lung cancer-related hospitalizations showed that cancer (lung cancer, other cancer, secondary malignancies) or some type of maintenance therapy (radiology, chemotherapy) accounted for approximately 40% of all hospital stays. Respiratory diagnoses—such as pneumonia, chronic obstructive pulmonary disease, respiratory failure, and pulmonary heart disease, among others—were also common reasons for lung cancer-associated hospital stays, the authors wrote.

When procedures were performed during lung cancer stays, the four most common among patients hospitalized primarily for lung cancer were diagnostic bronchoscopy and biopsy of the bronchus (49%); lobectomy or pneumonectomy (31%); incision of pleura, thoracentesis, chest drainage (16%); and blood transfusion (11%). The four most common procedures when lung cancer was the secondary diagnosis were blood transfusion (15%); respiratory intubation and mechanical ventilation (10%); incision of pleura, thoracentesis, chest drainage (9%); and diagnostic bronchoscopy and biopsy of the bronchus (8%).

Procedures common to all hospitalizations included therapeutic radiology, cancer chemotherapy, and upper gastrointestinal endoscopies and biopsies, they wrote.

BOSTON – Disordered eating is an important risk factor for suicidal ideation in adolescents and appears to contribute an additional amount of variance above and beyond traditional risk factors, a study has shown.

The findings suggest that disordered eating should be included as a variable in risk models for adolescent suicidal ideation, Amy M. Brausch said at the annual conference of the American Association of Suicidology.

Using data collected from 392 adolescents as part of a mental health screening at an urban American high school during the 2005–2006 school year, Ms. Brausch and her colleagues at Northern Illinois University in DeKalb evaluated the impact of disordered eating and body image on a suicidal ideation model that also included the traditional risk factors of depression, hopelessness, and past suicidal behavior. Previous studies have identified body dissatisfaction as a risk factor for depression and eating disorders–both of which have been associated with suicide. But few studies have considered body image and disordered eating as unique risk factors, Ms. Brausch said.

In the current study, all of the participants, mean age 15 years, completed the Reynolds Adolescent Depression Scale-2nd Edition, the Beck Hopelessness Scale, the Self-Harm Behavior Questionnaire, the Multidimensional Body-Self Relations Questionnaire, the Eating Attitudes Test, and the Suicidal Ideation Questionnaire to assess depression, hopelessness, past suicidal behavior, body image, disordered eating, and current suicidal ideation.

The investigators ran a hierarchical linear regression with suicidal ideation as the dependent variable and determined that depression, hopelessness, and past suicidal behavior all accounted for a significant amount of variance for current suicidal ideation, Ms. Brausch reported. Disordered eating and body image, together, accounted for a small but significant amount of variance in the overall model, she said, noting that, when considered alone, disordered eating was a significant predictor of ideation, while body image was not.

“Overall, the level of disordered eating was low because of the community sample,” Ms. Brausch said. “Generally, disordered eating and suicidal ideation were related, and higher levels of disordered eating were associated with higher levels of suicidal ideation.”

The fact that disordered eating was a significant predictor of suicidal ideation, while body image was not, is an interesting finding, said Ms. Brausch, “especially since a study I presented [at the American Association of Suicidology meeting] in 2005 did find relationships between body image and suicidal ideation” (Body Image 2007;4:207–12).

One possible explanation is that the current study used a different measure of body image than was used in the 2005 study, Ms. Brausch suggested. “This study used the Multidimensional Body-Self Relations Questionnaire [MBSRQ], which focuses on assessing body satisfaction, appearance satisfaction, and so forth, while the 2005 study used the Body Investment Scale [BIS], which focuses on assessing comfort with touch, body care, body protection, and body attitudes/feelings,” she said. “My hypothesis is that the factors of body image that are most influential in suicidal ideation are the body investment pieces, as measured by the BIS. The MBSRQ subscales were predictive of depressive symptoms but not suicidal ideation, indicating to me the body satisfaction facets of body image may be more associated with depression.”

The association between disordered eating and suicidal ideation indicates that including disordered eating as a variable in risk models for adolescent suicidal ideation might contribute more variance beyond traditional risk factors, and as such might have important screening implications, Ms. Brausch concluded.

BOSTON – Disordered eating is an important risk factor for suicidal ideation in adolescents and appears to contribute an additional amount of variance above and beyond traditional risk factors, a study has shown.

The findings suggest that disordered eating should be included as a variable in risk models for adolescent suicidal ideation, Amy M. Brausch said at the annual conference of the American Association of Suicidology.

Using data collected from 392 adolescents as part of a mental health screening at an urban American high school during the 2005–2006 school year, Ms. Brausch and her colleagues at Northern Illinois University in DeKalb evaluated the impact of disordered eating and body image on a suicidal ideation model that also included the traditional risk factors of depression, hopelessness, and past suicidal behavior. Previous studies have identified body dissatisfaction as a risk factor for depression and eating disorders–both of which have been associated with suicide. But few studies have considered body image and disordered eating as unique risk factors, Ms. Brausch said.

In the current study, all of the participants, mean age 15 years, completed the Reynolds Adolescent Depression Scale-2nd Edition, the Beck Hopelessness Scale, the Self-Harm Behavior Questionnaire, the Multidimensional Body-Self Relations Questionnaire, the Eating Attitudes Test, and the Suicidal Ideation Questionnaire to assess depression, hopelessness, past suicidal behavior, body image, disordered eating, and current suicidal ideation.

The investigators ran a hierarchical linear regression with suicidal ideation as the dependent variable and determined that depression, hopelessness, and past suicidal behavior all accounted for a significant amount of variance for current suicidal ideation, Ms. Brausch reported. Disordered eating and body image, together, accounted for a small but significant amount of variance in the overall model, she said, noting that, when considered alone, disordered eating was a significant predictor of ideation, while body image was not.

“Overall, the level of disordered eating was low because of the community sample,” Ms. Brausch said. “Generally, disordered eating and suicidal ideation were related, and higher levels of disordered eating were associated with higher levels of suicidal ideation.”

The fact that disordered eating was a significant predictor of suicidal ideation, while body image was not, is an interesting finding, said Ms. Brausch, “especially since a study I presented [at the American Association of Suicidology meeting] in 2005 did find relationships between body image and suicidal ideation” (Body Image 2007;4:207–12).

One possible explanation is that the current study used a different measure of body image than was used in the 2005 study, Ms. Brausch suggested. “This study used the Multidimensional Body-Self Relations Questionnaire [MBSRQ], which focuses on assessing body satisfaction, appearance satisfaction, and so forth, while the 2005 study used the Body Investment Scale [BIS], which focuses on assessing comfort with touch, body care, body protection, and body attitudes/feelings,” she said. “My hypothesis is that the factors of body image that are most influential in suicidal ideation are the body investment pieces, as measured by the BIS. The MBSRQ subscales were predictive of depressive symptoms but not suicidal ideation, indicating to me the body satisfaction facets of body image may be more associated with depression.”

The association between disordered eating and suicidal ideation indicates that including disordered eating as a variable in risk models for adolescent suicidal ideation might contribute more variance beyond traditional risk factors, and as such might have important screening implications, Ms. Brausch concluded.

BOSTON – Disordered eating is an important risk factor for suicidal ideation in adolescents and appears to contribute an additional amount of variance above and beyond traditional risk factors, a study has shown.

The findings suggest that disordered eating should be included as a variable in risk models for adolescent suicidal ideation, Amy M. Brausch said at the annual conference of the American Association of Suicidology.

Using data collected from 392 adolescents as part of a mental health screening at an urban American high school during the 2005–2006 school year, Ms. Brausch and her colleagues at Northern Illinois University in DeKalb evaluated the impact of disordered eating and body image on a suicidal ideation model that also included the traditional risk factors of depression, hopelessness, and past suicidal behavior. Previous studies have identified body dissatisfaction as a risk factor for depression and eating disorders–both of which have been associated with suicide. But few studies have considered body image and disordered eating as unique risk factors, Ms. Brausch said.

In the current study, all of the participants, mean age 15 years, completed the Reynolds Adolescent Depression Scale-2nd Edition, the Beck Hopelessness Scale, the Self-Harm Behavior Questionnaire, the Multidimensional Body-Self Relations Questionnaire, the Eating Attitudes Test, and the Suicidal Ideation Questionnaire to assess depression, hopelessness, past suicidal behavior, body image, disordered eating, and current suicidal ideation.

The investigators ran a hierarchical linear regression with suicidal ideation as the dependent variable and determined that depression, hopelessness, and past suicidal behavior all accounted for a significant amount of variance for current suicidal ideation, Ms. Brausch reported. Disordered eating and body image, together, accounted for a small but significant amount of variance in the overall model, she said, noting that, when considered alone, disordered eating was a significant predictor of ideation, while body image was not.

“Overall, the level of disordered eating was low because of the community sample,” Ms. Brausch said. “Generally, disordered eating and suicidal ideation were related, and higher levels of disordered eating were associated with higher levels of suicidal ideation.”

The fact that disordered eating was a significant predictor of suicidal ideation, while body image was not, is an interesting finding, said Ms. Brausch, “especially since a study I presented [at the American Association of Suicidology meeting] in 2005 did find relationships between body image and suicidal ideation” (Body Image 2007;4:207–12).

One possible explanation is that the current study used a different measure of body image than was used in the 2005 study, Ms. Brausch suggested. “This study used the Multidimensional Body-Self Relations Questionnaire [MBSRQ], which focuses on assessing body satisfaction, appearance satisfaction, and so forth, while the 2005 study used the Body Investment Scale [BIS], which focuses on assessing comfort with touch, body care, body protection, and body attitudes/feelings,” she said. “My hypothesis is that the factors of body image that are most influential in suicidal ideation are the body investment pieces, as measured by the BIS. The MBSRQ subscales were predictive of depressive symptoms but not suicidal ideation, indicating to me the body satisfaction facets of body image may be more associated with depression.”

The association between disordered eating and suicidal ideation indicates that including disordered eating as a variable in risk models for adolescent suicidal ideation might contribute more variance beyond traditional risk factors, and as such might have important screening implications, Ms. Brausch concluded.