Heidi Splete

A strategy of high positive-end expiratory pressure combined with low tidal volume ventilation failed to improve mortality rates, although it improved oxygenation and reduced the need for rescue actions in patients with acute lung conditions, based on results from a randomized, controlled trial.

Although mechanical ventilation is essential to keep lung injury patients alive, the ventilation process can worsen their injuries, and previous studies have explored the effectiveness of various mechanical ventilation protocols. In patients with acute lung injury and acute respiratory distress syndrome (ARDS) who have increased lung weight due to edema, studies have shown that a higher positive-end expiratory pressure (PEEP) can help keep the lung from collapsing, but at the risk of further damage. Conversely, a PEEP that is too low can increase the risk for hypoxemia and the need for rescue procedures.

In the multicenter study, Dr. Maureen O. Meade of McMaster University in Hamilton, Ont., and her colleagues enrolled 985 adult patients with acute lung injury and ARDS at 30 intensive care units in Canada, Australia, and Saudi Arabia to receive two PEEP protocols to evaluate the impact on all-cause hospital mortality (JAMA 2008;299:637–45).

The experimental group was treated with a “lung open ventilation” strategy, which included recruitment maneuvers, a target tidal volume of 6 mL/kg of predicted body weight, and plateau airway pressure not to exceed 40 cm H₂O. The control group was treated with a target tidal volume of 6 mL/kg of predicted body weight and plateau airway pressure not exceeding 30 cm H₂O. Recruitment maneuvers were not used in the control group.

A total of 475 patients who received the experimental ventilation and 508 who received the control ventilation were included in the primary analysis. One patient in each group withdrew consent. The average age of experimental group patients was 55 years, and of control group patients was 57 years. There were no significant demographic differences between the groups.

All-cause hospital mortality was lower in the experimental group than in the control group (36% vs. 40%), but the difference was not significant. The researchers found no association between baseline injury severity and response to either treatment.

A total of 53 experimental patients and 47 controls developed barotrauma, and this difference was not significant.

But the experimental group's rates of refractory hypoxemia and death with refractory hypoxemia were half those of the control group: 5% vs. 10%, and 4% vs. 9%, respectively. The differences were statistically significant.

A total of 366 patients in the experimental group received at least one recruitment maneuver, and 81 of these (22%) developed a complication as a result. The most common complications were a mean arterial pressure lower than 60 mm Hg (4.5%), oxygen saturation less than 85% (4.2%), and brachycardia or tachycardia (1.8%).

The use of cointerventions was similar in both groups, and the most common interventions were sedative or narcotic infusion, vasopressors, and neuromuscular blockades. Overall use of rescue therapies was significantly lower in the experimental group than in controls (8% vs. 12%).

The study might have been limited by insufficient power to show a small mortality reduction, the researchers noted, and by the fact that the greatest benefits of the higher PEEP strategy might have been to an undefined subgroup.

They added, however, that the absence of significant harm or increased barotrauma in this study supports findings from previous research that justify a higher PEEP for the benefits of better oxygenation in patients with acute lung injury and ARDS. “The 'open-lung' strategy appeared to improve oxygenation, with fewer hypoxemia-related deaths and a lower use of rescue therapies by clinicians,” the investigators said. But the best choice of PEEP protocol remains controversial.

A higher level of PEEP will be useless if edema is not present in an injured lung, Dr. Luciano Gattinoni and Dr. Pietro Caironi of the University of Milan wrote in an accompanying editorial (JAMA 2008;299:691–3).

“Ideally, the direct assessment of lung recruitability by a dynamic lung imaging technique would allow the best physiological titration of PEEP,” they said. The lack of benefit from higher PEEP in this study and other clinical trials contrasts with findings from several experimental studies, they added, and suggests that future studies should take care to identify patients with greater lung injury and lung edema.

Until such a technique becomes widely available, results from the current study suggest that PEEP “at the highest level compatible with a plateau pressure of 28 to 30 cm H₂O and a tidal volume of 6 mL/kg of predicted body weight seems to be a reasonable alternative,” they noted.

None of the investigators disclosed any financial conflicts.

A strategy of high positive-end expiratory pressure combined with low tidal volume ventilation failed to improve mortality rates, although it improved oxygenation and reduced the need for rescue actions in patients with acute lung conditions, based on results from a randomized, controlled trial.

Although mechanical ventilation is essential to keep lung injury patients alive, the ventilation process can worsen their injuries, and previous studies have explored the effectiveness of various mechanical ventilation protocols. In patients with acute lung injury and acute respiratory distress syndrome (ARDS) who have increased lung weight due to edema, studies have shown that a higher positive-end expiratory pressure (PEEP) can help keep the lung from collapsing, but at the risk of further damage. Conversely, a PEEP that is too low can increase the risk for hypoxemia and the need for rescue procedures.

In the multicenter study, Dr. Maureen O. Meade of McMaster University in Hamilton, Ont., and her colleagues enrolled 985 adult patients with acute lung injury and ARDS at 30 intensive care units in Canada, Australia, and Saudi Arabia to receive two PEEP protocols to evaluate the impact on all-cause hospital mortality (JAMA 2008;299:637–45).

The experimental group was treated with a “lung open ventilation” strategy, which included recruitment maneuvers, a target tidal volume of 6 mL/kg of predicted body weight, and plateau airway pressure not to exceed 40 cm H₂O. The control group was treated with a target tidal volume of 6 mL/kg of predicted body weight and plateau airway pressure not exceeding 30 cm H₂O. Recruitment maneuvers were not used in the control group.

A total of 475 patients who received the experimental ventilation and 508 who received the control ventilation were included in the primary analysis. One patient in each group withdrew consent. The average age of experimental group patients was 55 years, and of control group patients was 57 years. There were no significant demographic differences between the groups.

All-cause hospital mortality was lower in the experimental group than in the control group (36% vs. 40%), but the difference was not significant. The researchers found no association between baseline injury severity and response to either treatment.

A total of 53 experimental patients and 47 controls developed barotrauma, and this difference was not significant.

But the experimental group's rates of refractory hypoxemia and death with refractory hypoxemia were half those of the control group: 5% vs. 10%, and 4% vs. 9%, respectively. The differences were statistically significant.

A total of 366 patients in the experimental group received at least one recruitment maneuver, and 81 of these (22%) developed a complication as a result. The most common complications were a mean arterial pressure lower than 60 mm Hg (4.5%), oxygen saturation less than 85% (4.2%), and brachycardia or tachycardia (1.8%).

The use of cointerventions was similar in both groups, and the most common interventions were sedative or narcotic infusion, vasopressors, and neuromuscular blockades. Overall use of rescue therapies was significantly lower in the experimental group than in controls (8% vs. 12%).

The study might have been limited by insufficient power to show a small mortality reduction, the researchers noted, and by the fact that the greatest benefits of the higher PEEP strategy might have been to an undefined subgroup.

They added, however, that the absence of significant harm or increased barotrauma in this study supports findings from previous research that justify a higher PEEP for the benefits of better oxygenation in patients with acute lung injury and ARDS. “The 'open-lung' strategy appeared to improve oxygenation, with fewer hypoxemia-related deaths and a lower use of rescue therapies by clinicians,” the investigators said. But the best choice of PEEP protocol remains controversial.

A higher level of PEEP will be useless if edema is not present in an injured lung, Dr. Luciano Gattinoni and Dr. Pietro Caironi of the University of Milan wrote in an accompanying editorial (JAMA 2008;299:691–3).

“Ideally, the direct assessment of lung recruitability by a dynamic lung imaging technique would allow the best physiological titration of PEEP,” they said. The lack of benefit from higher PEEP in this study and other clinical trials contrasts with findings from several experimental studies, they added, and suggests that future studies should take care to identify patients with greater lung injury and lung edema.

Until such a technique becomes widely available, results from the current study suggest that PEEP “at the highest level compatible with a plateau pressure of 28 to 30 cm H₂O and a tidal volume of 6 mL/kg of predicted body weight seems to be a reasonable alternative,” they noted.

None of the investigators disclosed any financial conflicts.

A strategy of high positive-end expiratory pressure combined with low tidal volume ventilation failed to improve mortality rates, although it improved oxygenation and reduced the need for rescue actions in patients with acute lung conditions, based on results from a randomized, controlled trial.

Although mechanical ventilation is essential to keep lung injury patients alive, the ventilation process can worsen their injuries, and previous studies have explored the effectiveness of various mechanical ventilation protocols. In patients with acute lung injury and acute respiratory distress syndrome (ARDS) who have increased lung weight due to edema, studies have shown that a higher positive-end expiratory pressure (PEEP) can help keep the lung from collapsing, but at the risk of further damage. Conversely, a PEEP that is too low can increase the risk for hypoxemia and the need for rescue procedures.

In the multicenter study, Dr. Maureen O. Meade of McMaster University in Hamilton, Ont., and her colleagues enrolled 985 adult patients with acute lung injury and ARDS at 30 intensive care units in Canada, Australia, and Saudi Arabia to receive two PEEP protocols to evaluate the impact on all-cause hospital mortality (JAMA 2008;299:637–45).

The experimental group was treated with a “lung open ventilation” strategy, which included recruitment maneuvers, a target tidal volume of 6 mL/kg of predicted body weight, and plateau airway pressure not to exceed 40 cm H₂O. The control group was treated with a target tidal volume of 6 mL/kg of predicted body weight and plateau airway pressure not exceeding 30 cm H₂O. Recruitment maneuvers were not used in the control group.

A total of 475 patients who received the experimental ventilation and 508 who received the control ventilation were included in the primary analysis. One patient in each group withdrew consent. The average age of experimental group patients was 55 years, and of control group patients was 57 years. There were no significant demographic differences between the groups.

All-cause hospital mortality was lower in the experimental group than in the control group (36% vs. 40%), but the difference was not significant. The researchers found no association between baseline injury severity and response to either treatment.

A total of 53 experimental patients and 47 controls developed barotrauma, and this difference was not significant.

But the experimental group's rates of refractory hypoxemia and death with refractory hypoxemia were half those of the control group: 5% vs. 10%, and 4% vs. 9%, respectively. The differences were statistically significant.

A total of 366 patients in the experimental group received at least one recruitment maneuver, and 81 of these (22%) developed a complication as a result. The most common complications were a mean arterial pressure lower than 60 mm Hg (4.5%), oxygen saturation less than 85% (4.2%), and brachycardia or tachycardia (1.8%).

The use of cointerventions was similar in both groups, and the most common interventions were sedative or narcotic infusion, vasopressors, and neuromuscular blockades. Overall use of rescue therapies was significantly lower in the experimental group than in controls (8% vs. 12%).

The study might have been limited by insufficient power to show a small mortality reduction, the researchers noted, and by the fact that the greatest benefits of the higher PEEP strategy might have been to an undefined subgroup.

They added, however, that the absence of significant harm or increased barotrauma in this study supports findings from previous research that justify a higher PEEP for the benefits of better oxygenation in patients with acute lung injury and ARDS. “The 'open-lung' strategy appeared to improve oxygenation, with fewer hypoxemia-related deaths and a lower use of rescue therapies by clinicians,” the investigators said. But the best choice of PEEP protocol remains controversial.

A higher level of PEEP will be useless if edema is not present in an injured lung, Dr. Luciano Gattinoni and Dr. Pietro Caironi of the University of Milan wrote in an accompanying editorial (JAMA 2008;299:691–3).

“Ideally, the direct assessment of lung recruitability by a dynamic lung imaging technique would allow the best physiological titration of PEEP,” they said. The lack of benefit from higher PEEP in this study and other clinical trials contrasts with findings from several experimental studies, they added, and suggests that future studies should take care to identify patients with greater lung injury and lung edema.

Until such a technique becomes widely available, results from the current study suggest that PEEP “at the highest level compatible with a plateau pressure of 28 to 30 cm H₂O and a tidal volume of 6 mL/kg of predicted body weight seems to be a reasonable alternative,” they noted.

None of the investigators disclosed any financial conflicts.

WASHINGTON — Extended-release tolterodine improved overactive bladder problems and quality of life in sexually active postmenopausal women, according to a review of patient-reported outcomes presented in a poster at the annual meeting of the American Society for Reproductive Medicine.

“Physicians should consider the potential impact of [overactive bladder] symptoms and their treatment on postmenopausal patients' sexual function and quality of life,” wrote Dr. Gloria Bachmann of the University of Medicine and Dentistry of New Jersey, New Brunswick, and her colleagues.

The study was sponsored by Pfizer Inc., the manufacturer of Detrol LA extended-release tolterodine tartrate capsules.

Data from previous studies have shown that the prevalence of overactive bladder (OAB) in women increases with age and that the urinary symptoms that are associated with the condition are also associated with reduced sexual activity and quality of life.

To determine the effectiveness of the antimuscarinic agent tolterodine for relieving urinary incontinence and OAB, the investigators reviewed data from 211 postmenopausal women with OAB whose mean age was 56 years.

Of those, 112 women received 4 mg of extended-release tolterodine to be taken within 4 hours of bedtime each day for 12 weeks, and 99 women received a placebo for the same period.

The women completed several validated instruments at baseline and again at 12 weeks.

Overall, those in the tolterodine group reported significantly less use of absorbent pads and lower urination frequency, compared with those in the placebo group. The tolterodine group also reported fewer episodes of urgent urinary incontinence, but the difference was not statistically significant from the placebo group.

In addition, results from the Patient Perception of Bladder Condition showed that more of the tolterodine patients reported improvement in their symptoms than did placebo patients (74% vs. 62%, respectively). And the number of women in the tolterodine group who reported severe OAB problems dropped from 12% at baseline to 1% after 12 weeks, compared with a drop from 12% to 3% in the placebo group.

The treatment group also reported improvements in sexual function and quality of life from baseline to 12 weeks, based on the Physical, Behavioral/Emotive, Partner-Related, and total sections of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ). By contrast, the placebo patients reported significant improvements from baseline to 12 weeks only for the Physical section of the PISQ.

The total improvement in the PISQ scores for the treatment and placebo groups were 4.5% and 1.6%, respectively.

In addition, in the tolterodine group, overall quality-of-life scores were significantly higher after 12 weeks, compared with baseline, whereas quality-of-life scores were not significantly different in the placebo group after 12 weeks, compared with baseline.

No significant adverse events were reported in either of the groups during the study period, but the results were limited by the lack of long-term follow-up data beyond 12 weeks.

Dr. Bachmann has served as a consultant to Pfizer, and her three coinvestigators are currently employed by the company.

WASHINGTON — Extended-release tolterodine improved overactive bladder problems and quality of life in sexually active postmenopausal women, according to a review of patient-reported outcomes presented in a poster at the annual meeting of the American Society for Reproductive Medicine.

“Physicians should consider the potential impact of [overactive bladder] symptoms and their treatment on postmenopausal patients' sexual function and quality of life,” wrote Dr. Gloria Bachmann of the University of Medicine and Dentistry of New Jersey, New Brunswick, and her colleagues.

The study was sponsored by Pfizer Inc., the manufacturer of Detrol LA extended-release tolterodine tartrate capsules.

Data from previous studies have shown that the prevalence of overactive bladder (OAB) in women increases with age and that the urinary symptoms that are associated with the condition are also associated with reduced sexual activity and quality of life.

To determine the effectiveness of the antimuscarinic agent tolterodine for relieving urinary incontinence and OAB, the investigators reviewed data from 211 postmenopausal women with OAB whose mean age was 56 years.

Of those, 112 women received 4 mg of extended-release tolterodine to be taken within 4 hours of bedtime each day for 12 weeks, and 99 women received a placebo for the same period.

The women completed several validated instruments at baseline and again at 12 weeks.

Overall, those in the tolterodine group reported significantly less use of absorbent pads and lower urination frequency, compared with those in the placebo group. The tolterodine group also reported fewer episodes of urgent urinary incontinence, but the difference was not statistically significant from the placebo group.

In addition, results from the Patient Perception of Bladder Condition showed that more of the tolterodine patients reported improvement in their symptoms than did placebo patients (74% vs. 62%, respectively). And the number of women in the tolterodine group who reported severe OAB problems dropped from 12% at baseline to 1% after 12 weeks, compared with a drop from 12% to 3% in the placebo group.

The treatment group also reported improvements in sexual function and quality of life from baseline to 12 weeks, based on the Physical, Behavioral/Emotive, Partner-Related, and total sections of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ). By contrast, the placebo patients reported significant improvements from baseline to 12 weeks only for the Physical section of the PISQ.

The total improvement in the PISQ scores for the treatment and placebo groups were 4.5% and 1.6%, respectively.

In addition, in the tolterodine group, overall quality-of-life scores were significantly higher after 12 weeks, compared with baseline, whereas quality-of-life scores were not significantly different in the placebo group after 12 weeks, compared with baseline.

No significant adverse events were reported in either of the groups during the study period, but the results were limited by the lack of long-term follow-up data beyond 12 weeks.

Dr. Bachmann has served as a consultant to Pfizer, and her three coinvestigators are currently employed by the company.

WASHINGTON — Extended-release tolterodine improved overactive bladder problems and quality of life in sexually active postmenopausal women, according to a review of patient-reported outcomes presented in a poster at the annual meeting of the American Society for Reproductive Medicine.

“Physicians should consider the potential impact of [overactive bladder] symptoms and their treatment on postmenopausal patients' sexual function and quality of life,” wrote Dr. Gloria Bachmann of the University of Medicine and Dentistry of New Jersey, New Brunswick, and her colleagues.

The study was sponsored by Pfizer Inc., the manufacturer of Detrol LA extended-release tolterodine tartrate capsules.

Data from previous studies have shown that the prevalence of overactive bladder (OAB) in women increases with age and that the urinary symptoms that are associated with the condition are also associated with reduced sexual activity and quality of life.

To determine the effectiveness of the antimuscarinic agent tolterodine for relieving urinary incontinence and OAB, the investigators reviewed data from 211 postmenopausal women with OAB whose mean age was 56 years.

Of those, 112 women received 4 mg of extended-release tolterodine to be taken within 4 hours of bedtime each day for 12 weeks, and 99 women received a placebo for the same period.

The women completed several validated instruments at baseline and again at 12 weeks.

Overall, those in the tolterodine group reported significantly less use of absorbent pads and lower urination frequency, compared with those in the placebo group. The tolterodine group also reported fewer episodes of urgent urinary incontinence, but the difference was not statistically significant from the placebo group.

In addition, results from the Patient Perception of Bladder Condition showed that more of the tolterodine patients reported improvement in their symptoms than did placebo patients (74% vs. 62%, respectively). And the number of women in the tolterodine group who reported severe OAB problems dropped from 12% at baseline to 1% after 12 weeks, compared with a drop from 12% to 3% in the placebo group.

The treatment group also reported improvements in sexual function and quality of life from baseline to 12 weeks, based on the Physical, Behavioral/Emotive, Partner-Related, and total sections of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ). By contrast, the placebo patients reported significant improvements from baseline to 12 weeks only for the Physical section of the PISQ.

The total improvement in the PISQ scores for the treatment and placebo groups were 4.5% and 1.6%, respectively.

In addition, in the tolterodine group, overall quality-of-life scores were significantly higher after 12 weeks, compared with baseline, whereas quality-of-life scores were not significantly different in the placebo group after 12 weeks, compared with baseline.

No significant adverse events were reported in either of the groups during the study period, but the results were limited by the lack of long-term follow-up data beyond 12 weeks.

Dr. Bachmann has served as a consultant to Pfizer, and her three coinvestigators are currently employed by the company.

WASHINGTON — Increased pregnancy rates and oocyte survival rates support the superiority of vitrification over the traditional slow-freeze cryopreservation technique, based on the results from several studies presented at the annual meeting of the American Society for Reproductive Medicine.

In vitrification, blastocysts briefly are immersed in a medium and then quickly frozen using liquid nitrogen. The debate over which method of cryopreservation yields the best clinical results continues, but emerging data from studies of vitrification appear to favor the fast-freezing method.

Early outcomes data from one study of 41 women showed that blastocyst vitrification yielded significantly more pregnancies than embryos that had been slow frozen.

In this study, Alicia L. Clifford and her colleagues at the Center for Reproductive Biology of Indiana in Indianapolis compared pregnancy rates from 30 patients who received embryos from slow-frozen eggs with 11 patients who received embryos from vitrified eggs.

Overall, 4 of 10 women in the vitrification group (40%) had positive fetal cardiac activity at 6 weeks, compared with 4 of 29 women (14%) in the slow-freeze group.

Fetal cardiac activity data were pending for one woman in each group at the time of the poster presentation.

The mean age was similar between the slow-freeze and vitrification groups (33 years vs. 31 years), and each group had an average of three embryos transferred.

In a second study of 84 oocytes from 42 women, oocyte survival rates were significantly higher when they were frozen using vitrification than slow frozen. Dr. Susan Sarajari and colleagues at the University of California, Los Angeles, and her colleagues thawed 44 oocytes that were slow frozen and 40 oocytes that were frozen using vitrification after 2 days in order to test their viability.

Overall, 17 of the 40 vitrified oocytes survived (42%), compared with 11 of the 44 slow-frozen oocytes (25%). The surviving oocytes from each group were selected for in vitro maturation (IVM), incubated, and then reassessed after 24 hours.

“The number and percent of oocytes that matured by IVM was also higher in the vitrification group,” the researchers noted, although the difference was not statistically significant (eight oocytes in the vitrification group vs. five in the slow-freeze group).

Cryopreservation of immature oocytes by any method has clinical application potential for women at risk of losing ovarian function for any reason and for women who simply wish to preserve their fertility, but larger outcome studies are needed to confirm the most effective techniques.

None of the authors of either study had any financial conflicts to disclose.

WASHINGTON — Increased pregnancy rates and oocyte survival rates support the superiority of vitrification over the traditional slow-freeze cryopreservation technique, based on the results from several studies presented at the annual meeting of the American Society for Reproductive Medicine.

In vitrification, blastocysts briefly are immersed in a medium and then quickly frozen using liquid nitrogen. The debate over which method of cryopreservation yields the best clinical results continues, but emerging data from studies of vitrification appear to favor the fast-freezing method.

Early outcomes data from one study of 41 women showed that blastocyst vitrification yielded significantly more pregnancies than embryos that had been slow frozen.

In this study, Alicia L. Clifford and her colleagues at the Center for Reproductive Biology of Indiana in Indianapolis compared pregnancy rates from 30 patients who received embryos from slow-frozen eggs with 11 patients who received embryos from vitrified eggs.

Overall, 4 of 10 women in the vitrification group (40%) had positive fetal cardiac activity at 6 weeks, compared with 4 of 29 women (14%) in the slow-freeze group.

Fetal cardiac activity data were pending for one woman in each group at the time of the poster presentation.

The mean age was similar between the slow-freeze and vitrification groups (33 years vs. 31 years), and each group had an average of three embryos transferred.

In a second study of 84 oocytes from 42 women, oocyte survival rates were significantly higher when they were frozen using vitrification than slow frozen. Dr. Susan Sarajari and colleagues at the University of California, Los Angeles, and her colleagues thawed 44 oocytes that were slow frozen and 40 oocytes that were frozen using vitrification after 2 days in order to test their viability.

Overall, 17 of the 40 vitrified oocytes survived (42%), compared with 11 of the 44 slow-frozen oocytes (25%). The surviving oocytes from each group were selected for in vitro maturation (IVM), incubated, and then reassessed after 24 hours.

“The number and percent of oocytes that matured by IVM was also higher in the vitrification group,” the researchers noted, although the difference was not statistically significant (eight oocytes in the vitrification group vs. five in the slow-freeze group).

Cryopreservation of immature oocytes by any method has clinical application potential for women at risk of losing ovarian function for any reason and for women who simply wish to preserve their fertility, but larger outcome studies are needed to confirm the most effective techniques.

None of the authors of either study had any financial conflicts to disclose.

WASHINGTON — Increased pregnancy rates and oocyte survival rates support the superiority of vitrification over the traditional slow-freeze cryopreservation technique, based on the results from several studies presented at the annual meeting of the American Society for Reproductive Medicine.

In vitrification, blastocysts briefly are immersed in a medium and then quickly frozen using liquid nitrogen. The debate over which method of cryopreservation yields the best clinical results continues, but emerging data from studies of vitrification appear to favor the fast-freezing method.

Early outcomes data from one study of 41 women showed that blastocyst vitrification yielded significantly more pregnancies than embryos that had been slow frozen.

In this study, Alicia L. Clifford and her colleagues at the Center for Reproductive Biology of Indiana in Indianapolis compared pregnancy rates from 30 patients who received embryos from slow-frozen eggs with 11 patients who received embryos from vitrified eggs.

Overall, 4 of 10 women in the vitrification group (40%) had positive fetal cardiac activity at 6 weeks, compared with 4 of 29 women (14%) in the slow-freeze group.

Fetal cardiac activity data were pending for one woman in each group at the time of the poster presentation.

The mean age was similar between the slow-freeze and vitrification groups (33 years vs. 31 years), and each group had an average of three embryos transferred.

In a second study of 84 oocytes from 42 women, oocyte survival rates were significantly higher when they were frozen using vitrification than slow frozen. Dr. Susan Sarajari and colleagues at the University of California, Los Angeles, and her colleagues thawed 44 oocytes that were slow frozen and 40 oocytes that were frozen using vitrification after 2 days in order to test their viability.

Overall, 17 of the 40 vitrified oocytes survived (42%), compared with 11 of the 44 slow-frozen oocytes (25%). The surviving oocytes from each group were selected for in vitro maturation (IVM), incubated, and then reassessed after 24 hours.

“The number and percent of oocytes that matured by IVM was also higher in the vitrification group,” the researchers noted, although the difference was not statistically significant (eight oocytes in the vitrification group vs. five in the slow-freeze group).

Cryopreservation of immature oocytes by any method has clinical application potential for women at risk of losing ovarian function for any reason and for women who simply wish to preserve their fertility, but larger outcome studies are needed to confirm the most effective techniques.

None of the authors of either study had any financial conflicts to disclose.

CHICAGO — Bone density was no different in children treated with oral glucocorticoids for hemangiomas of infancy than it was in healthy controls, according to a presentation at the annual meeting of the Society for Pediatric Dermatology.

Although oral glucocorticoids are considered the first choice for the treatment of infant hemangiomas, concerns persist about the risk that these children will develop osteoporosis because glucocorticoids may prevent the formation of new bone, wrote Dr. Amy J. Nopper, of the Children's Mercy Hospitals and Clinics in Kansas City, Mo.

To assess the possible impact of systemic glucocorticoids on bone density, she and her colleagues compared 35 infants (mean age 44 months) who received glucocorticoids for hemangiomas for an average of 8.5 months with 35 controls. The average treatment dose was 2.2 mg/kg per day of prednisolone. The average body mass index was approximately 16 kg/m

The researchers measured the children's bone density after they had been off treatment for at least 1 year and found that the average spinal bone mineral density was the same (0.6 g/m

The results support findings from other studies that show steroid use to treat hemangiomas in early childhood does not prevent children from catching up in growth and achieving normal adult height, Dr. Nopper noted.

CHICAGO — Bone density was no different in children treated with oral glucocorticoids for hemangiomas of infancy than it was in healthy controls, according to a presentation at the annual meeting of the Society for Pediatric Dermatology.

Although oral glucocorticoids are considered the first choice for the treatment of infant hemangiomas, concerns persist about the risk that these children will develop osteoporosis because glucocorticoids may prevent the formation of new bone, wrote Dr. Amy J. Nopper, of the Children's Mercy Hospitals and Clinics in Kansas City, Mo.

To assess the possible impact of systemic glucocorticoids on bone density, she and her colleagues compared 35 infants (mean age 44 months) who received glucocorticoids for hemangiomas for an average of 8.5 months with 35 controls. The average treatment dose was 2.2 mg/kg per day of prednisolone. The average body mass index was approximately 16 kg/m

The researchers measured the children's bone density after they had been off treatment for at least 1 year and found that the average spinal bone mineral density was the same (0.6 g/m

The results support findings from other studies that show steroid use to treat hemangiomas in early childhood does not prevent children from catching up in growth and achieving normal adult height, Dr. Nopper noted.

CHICAGO — Bone density was no different in children treated with oral glucocorticoids for hemangiomas of infancy than it was in healthy controls, according to a presentation at the annual meeting of the Society for Pediatric Dermatology.

Although oral glucocorticoids are considered the first choice for the treatment of infant hemangiomas, concerns persist about the risk that these children will develop osteoporosis because glucocorticoids may prevent the formation of new bone, wrote Dr. Amy J. Nopper, of the Children's Mercy Hospitals and Clinics in Kansas City, Mo.

To assess the possible impact of systemic glucocorticoids on bone density, she and her colleagues compared 35 infants (mean age 44 months) who received glucocorticoids for hemangiomas for an average of 8.5 months with 35 controls. The average treatment dose was 2.2 mg/kg per day of prednisolone. The average body mass index was approximately 16 kg/m

The researchers measured the children's bone density after they had been off treatment for at least 1 year and found that the average spinal bone mineral density was the same (0.6 g/m

The results support findings from other studies that show steroid use to treat hemangiomas in early childhood does not prevent children from catching up in growth and achieving normal adult height, Dr. Nopper noted.

Rates of chlamydia, gonorrhea, and syphilis increased in the United States during the past year and continued recent upward trends, according to a report from the Centers for Disease Control and Prevention

“Young women, racial and ethnic populations, and men who have sex with men are particularly hard hit by these diseases,” Dr. John M. Douglas Jr., director of the CDC's Division of Sexually Transmitted Disease Prevention, said in a teleconference sponsored by the CDC.

The report emphasizes both the magnitude of the diseases and the persistent racial disparity, Dr. Douglas said.

All three diseases are treatable, especially when they are diagnosed early. If left untreated, however, the severe health consequences include pelvic inflammatory disease, infertility, increased risk for HIV infection, organ damage, and death. The direct medical costs associated with STDs in the United States were estimated at nearly $15 billion in 2006, the researchers stated in the report, “Sexually Transmitted Disease Surveillance 2006,” which was presented in a telebriefing.

Of the three diseases, the increased chlamydia rates represent the greatest public health impact, said Dr. Douglas.

In 2006, the national rate of reported cases of chlamydia increased by 5.6% from 2005 to 2006. Specifically, the reported rate was 347.8 cases per 100,000 persons in 2006, compared with 329.4 cases per 100,000 persons in 2005. The increase may reflect increased screening for chlamydia and improved diagnostic tests, but it likely also reflects an increase in the number of infections, the researchers said.

Chlamydia hits hardest among adolescent girls and young women—the highest chlamydia rate was reported in young women aged 15–19 years (2,863 cases per 100,000 persons) followed by women aged 20–24 years (2,797 cases per 100,000 persons). And racial disparity is high: The chlamydia rate was highest among black women, whose rate was more than seven times higher than that of white women and more than twice as high as that of Hispanic women.

Because of the high rate of chlamydia in young women, the CDC recommends screening sexually active women younger than 26 years for the disease. Chlamydia screening is also recommended for older women with new or multiple sex partners, because these women are also at increased risk. Based on recent studies showing that chlamydia reinfection can occur in women whose partners remain untreated, the CDC's treatment guidelines include retesting patients 3 months after treatment.

Screening is one of the most effective and underutilized tools to prevent and treat chlamydia in all populations, Dr. Douglas emphasized. “Providers know the recommendations but don't assume that it applies to the population that they are dealing with,” he said.

“If there are providers who don't think the young women in their practice don't have chlamydia, they should think again,” noted Dr. Stuart Berman, chief epidemiologist at the Division of Sexually Transmitted Disease Prevention.

Gonorrhea rates increased for the second consecutive year, following a plateau in reported disease rates from 1997 to 2005. “The racial disparities are stark,” in reported gonorrhea cases, Dr. Douglas said. Overall, the rate among blacks is 18 times higher than in whites, he said.

Gonorrhea rates also continue to vary by region. As in previous years, the southern region of the United States had the highest overall gonorrhea rate in 2006, at 159 cases per 100,000 persons. But rates in the South rose by 12.3% in 2006, representing the first notable increase in 8 years.

“We are also concerned about increases in the West,” Dr. Douglas said. Gonorrhea cases in the West increased by 2.9% between 2005 and 2006, contributing to a 32% increase between 2002 and 2006. “We will need to monitor the data to determine whether this is an emerging trend.”

Untreated gonorrhea can, among other complications, increase a person's risk for HIV if he or she is exposed. But gonorrhea treatment has become more challenging, because evidence of fluoroquinolone resistance—especially among men who have sex with men—prompted the CDC in April 2007 to stop recommending fluoroquinolones as treatment for any gonorrhea cases. As an alternative, the CDC recommends cephalosporins to treat gonorrhea.

Rates of primary and secondary syphilis rate in the United States increased by nearly 14% from 2005 to 2006, but the most notable increase has occurred among men who have sex with men. Syphilis rates among that group increased by 54% from 2002 to 2006, Dr. Douglas said.

Although syphilis has the least impact on the population as a whole, the rise in reported cases for the sixth consecutive year in women and men is cause for concern, Dr. Douglas said, given a steady decrease during the 1990s.

Overall, the recent rises in reportable STD rates speak to the need for more awareness among the public and health care providers about screening and prevention, said Dr. Douglas.

The report's data provide an incomplete picture of sexually transmitted diseases in the United States, the researchers cautioned, because many cases of chlamydia, gonorrhea, and syphilis are not reported. In addition, some types of STDs, including genital herpes and human papillomavirus, are not tracked by the CDC but contribute to the overall disease burden of STDs, he noted. “These are large numbers of infections, and this is a hidden epidemic that people are not aware of,” added Dr. Berman.

To view the complete report, visit www.cdc.gov/std/stats

Rates of chlamydia, gonorrhea, and syphilis increased in the United States during the past year and continued recent upward trends, according to a report from the Centers for Disease Control and Prevention

“Young women, racial and ethnic populations, and men who have sex with men are particularly hard hit by these diseases,” Dr. John M. Douglas Jr., director of the CDC's Division of Sexually Transmitted Disease Prevention, said in a teleconference sponsored by the CDC.

The report emphasizes both the magnitude of the diseases and the persistent racial disparity, Dr. Douglas said.

All three diseases are treatable, especially when they are diagnosed early. If left untreated, however, the severe health consequences include pelvic inflammatory disease, infertility, increased risk for HIV infection, organ damage, and death. The direct medical costs associated with STDs in the United States were estimated at nearly $15 billion in 2006, the researchers stated in the report, “Sexually Transmitted Disease Surveillance 2006,” which was presented in a telebriefing.

Of the three diseases, the increased chlamydia rates represent the greatest public health impact, said Dr. Douglas.

In 2006, the national rate of reported cases of chlamydia increased by 5.6% from 2005 to 2006. Specifically, the reported rate was 347.8 cases per 100,000 persons in 2006, compared with 329.4 cases per 100,000 persons in 2005. The increase may reflect increased screening for chlamydia and improved diagnostic tests, but it likely also reflects an increase in the number of infections, the researchers said.

Chlamydia hits hardest among adolescent girls and young women—the highest chlamydia rate was reported in young women aged 15–19 years (2,863 cases per 100,000 persons) followed by women aged 20–24 years (2,797 cases per 100,000 persons). And racial disparity is high: The chlamydia rate was highest among black women, whose rate was more than seven times higher than that of white women and more than twice as high as that of Hispanic women.

Because of the high rate of chlamydia in young women, the CDC recommends screening sexually active women younger than 26 years for the disease. Chlamydia screening is also recommended for older women with new or multiple sex partners, because these women are also at increased risk. Based on recent studies showing that chlamydia reinfection can occur in women whose partners remain untreated, the CDC's treatment guidelines include retesting patients 3 months after treatment.

Screening is one of the most effective and underutilized tools to prevent and treat chlamydia in all populations, Dr. Douglas emphasized. “Providers know the recommendations but don't assume that it applies to the population that they are dealing with,” he said.

“If there are providers who don't think the young women in their practice don't have chlamydia, they should think again,” noted Dr. Stuart Berman, chief epidemiologist at the Division of Sexually Transmitted Disease Prevention.

Gonorrhea rates increased for the second consecutive year, following a plateau in reported disease rates from 1997 to 2005. “The racial disparities are stark,” in reported gonorrhea cases, Dr. Douglas said. Overall, the rate among blacks is 18 times higher than in whites, he said.

Gonorrhea rates also continue to vary by region. As in previous years, the southern region of the United States had the highest overall gonorrhea rate in 2006, at 159 cases per 100,000 persons. But rates in the South rose by 12.3% in 2006, representing the first notable increase in 8 years.

“We are also concerned about increases in the West,” Dr. Douglas said. Gonorrhea cases in the West increased by 2.9% between 2005 and 2006, contributing to a 32% increase between 2002 and 2006. “We will need to monitor the data to determine whether this is an emerging trend.”

Untreated gonorrhea can, among other complications, increase a person's risk for HIV if he or she is exposed. But gonorrhea treatment has become more challenging, because evidence of fluoroquinolone resistance—especially among men who have sex with men—prompted the CDC in April 2007 to stop recommending fluoroquinolones as treatment for any gonorrhea cases. As an alternative, the CDC recommends cephalosporins to treat gonorrhea.

Rates of primary and secondary syphilis rate in the United States increased by nearly 14% from 2005 to 2006, but the most notable increase has occurred among men who have sex with men. Syphilis rates among that group increased by 54% from 2002 to 2006, Dr. Douglas said.

Although syphilis has the least impact on the population as a whole, the rise in reported cases for the sixth consecutive year in women and men is cause for concern, Dr. Douglas said, given a steady decrease during the 1990s.

Overall, the recent rises in reportable STD rates speak to the need for more awareness among the public and health care providers about screening and prevention, said Dr. Douglas.

The report's data provide an incomplete picture of sexually transmitted diseases in the United States, the researchers cautioned, because many cases of chlamydia, gonorrhea, and syphilis are not reported. In addition, some types of STDs, including genital herpes and human papillomavirus, are not tracked by the CDC but contribute to the overall disease burden of STDs, he noted. “These are large numbers of infections, and this is a hidden epidemic that people are not aware of,” added Dr. Berman.

To view the complete report, visit www.cdc.gov/std/stats

Rates of chlamydia, gonorrhea, and syphilis increased in the United States during the past year and continued recent upward trends, according to a report from the Centers for Disease Control and Prevention

“Young women, racial and ethnic populations, and men who have sex with men are particularly hard hit by these diseases,” Dr. John M. Douglas Jr., director of the CDC's Division of Sexually Transmitted Disease Prevention, said in a teleconference sponsored by the CDC.

The report emphasizes both the magnitude of the diseases and the persistent racial disparity, Dr. Douglas said.

All three diseases are treatable, especially when they are diagnosed early. If left untreated, however, the severe health consequences include pelvic inflammatory disease, infertility, increased risk for HIV infection, organ damage, and death. The direct medical costs associated with STDs in the United States were estimated at nearly $15 billion in 2006, the researchers stated in the report, “Sexually Transmitted Disease Surveillance 2006,” which was presented in a telebriefing.

Of the three diseases, the increased chlamydia rates represent the greatest public health impact, said Dr. Douglas.

In 2006, the national rate of reported cases of chlamydia increased by 5.6% from 2005 to 2006. Specifically, the reported rate was 347.8 cases per 100,000 persons in 2006, compared with 329.4 cases per 100,000 persons in 2005. The increase may reflect increased screening for chlamydia and improved diagnostic tests, but it likely also reflects an increase in the number of infections, the researchers said.

Chlamydia hits hardest among adolescent girls and young women—the highest chlamydia rate was reported in young women aged 15–19 years (2,863 cases per 100,000 persons) followed by women aged 20–24 years (2,797 cases per 100,000 persons). And racial disparity is high: The chlamydia rate was highest among black women, whose rate was more than seven times higher than that of white women and more than twice as high as that of Hispanic women.

Because of the high rate of chlamydia in young women, the CDC recommends screening sexually active women younger than 26 years for the disease. Chlamydia screening is also recommended for older women with new or multiple sex partners, because these women are also at increased risk. Based on recent studies showing that chlamydia reinfection can occur in women whose partners remain untreated, the CDC's treatment guidelines include retesting patients 3 months after treatment.

Screening is one of the most effective and underutilized tools to prevent and treat chlamydia in all populations, Dr. Douglas emphasized. “Providers know the recommendations but don't assume that it applies to the population that they are dealing with,” he said.

“If there are providers who don't think the young women in their practice don't have chlamydia, they should think again,” noted Dr. Stuart Berman, chief epidemiologist at the Division of Sexually Transmitted Disease Prevention.

Gonorrhea rates increased for the second consecutive year, following a plateau in reported disease rates from 1997 to 2005. “The racial disparities are stark,” in reported gonorrhea cases, Dr. Douglas said. Overall, the rate among blacks is 18 times higher than in whites, he said.

Gonorrhea rates also continue to vary by region. As in previous years, the southern region of the United States had the highest overall gonorrhea rate in 2006, at 159 cases per 100,000 persons. But rates in the South rose by 12.3% in 2006, representing the first notable increase in 8 years.

“We are also concerned about increases in the West,” Dr. Douglas said. Gonorrhea cases in the West increased by 2.9% between 2005 and 2006, contributing to a 32% increase between 2002 and 2006. “We will need to monitor the data to determine whether this is an emerging trend.”

Untreated gonorrhea can, among other complications, increase a person's risk for HIV if he or she is exposed. But gonorrhea treatment has become more challenging, because evidence of fluoroquinolone resistance—especially among men who have sex with men—prompted the CDC in April 2007 to stop recommending fluoroquinolones as treatment for any gonorrhea cases. As an alternative, the CDC recommends cephalosporins to treat gonorrhea.

Rates of primary and secondary syphilis rate in the United States increased by nearly 14% from 2005 to 2006, but the most notable increase has occurred among men who have sex with men. Syphilis rates among that group increased by 54% from 2002 to 2006, Dr. Douglas said.

Although syphilis has the least impact on the population as a whole, the rise in reported cases for the sixth consecutive year in women and men is cause for concern, Dr. Douglas said, given a steady decrease during the 1990s.

Overall, the recent rises in reportable STD rates speak to the need for more awareness among the public and health care providers about screening and prevention, said Dr. Douglas.

The report's data provide an incomplete picture of sexually transmitted diseases in the United States, the researchers cautioned, because many cases of chlamydia, gonorrhea, and syphilis are not reported. In addition, some types of STDs, including genital herpes and human papillomavirus, are not tracked by the CDC but contribute to the overall disease burden of STDs, he noted. “These are large numbers of infections, and this is a hidden epidemic that people are not aware of,” added Dr. Berman.

To view the complete report, visit www.cdc.gov/std/stats

Rates of chlamydia, gonorrhea, and syphilis increased in the United States during the past year and continued recent upward trends, according to a report from the Centers for Disease Control and Prevention.

"Young women, racial and ethnic populations, and men who have sex with men are particularly hard hit by these diseases," said Dr. John M. Douglas Jr., director of the CDC's Division of Sexually Transmitted Disease Prevention.

The direct medical costs associated with STDs in the United States were estimated at nearly $15 billion in 2006, the researchers stated in the report, "Sexually Transmitted Disease Surveillance 2006," which was presented in a telebriefing.

In 2006, the national rate of reported cases of chlamydia increased by 5.6% from 2005 to 2006. Specifically, the reported rate was 347.8 cases per 100,000 persons in 2006, compared with 329.4 cases per 100,000 persons in 2005.

Chlamydia hits hardest among adolescent girls and young women—the highest chlamydia rate was reported in young women aged 15-19 years followed by women aged 20-24 years. And racial disparity is high: The chlamydia rate was highest among black women, whose rate was more than seven times higher than that of white women and more than twice as high as that of Hispanic women.

Because of the high rate of chlamydia in young women, the CDC recommends screening sexually active women younger than 26 years for the disease. Chlamydia screening also is recommended for older women with new or multiple sex partners, because these women are also at increased risk. Based on recent studies showing that chlamydia reinfection can occur in women whose partners remain untreated, the CDC's treatment guidelines include retesting patients 3 months after treatment.

"If there are providers who don't think the young women in their practice don't have chlamydia, they should think again," noted Dr. Stuart Berman, chief epidemiologist at the Division of Sexually Transmitted Disease Prevention.

Gonorrhea rates increased for the second consecutive year, following a plateau in reported disease rates from 1997 to 2005. "The racial disparities are stark," in reported gonorrhea cases, Dr. Douglas said. Overall, the rate among blacks is 18 times higher than in whites, he said.

Gonorrhea rates also continue to vary by region. As in previous years, the southern region of the United States had the highest overall gonorrhea rate in 2006, at 159 cases per 100,000 persons.

"We are also concerned about increases in the West," Dr. Douglas said. Gonorrhea cases in the West increased by 2.9% between 2005 and 2006, contributing to a 32% increase between 2002 and 2006.

Untreated gonorrhea can, among other complications, increase a person's risk for HIV if he or she is exposed. But gonorrhea treatment has become more challenging, because evidence of fluoroquinolone resistance—especially among men who have sex with men—prompted the CDC in April 2007 to stop recommending fluoroquinolones as treatment for any gonorrhea cases. As an alternative, the CDC recommends cephalosporins to treat gonorrhea.

Rates of primary and secondary syphilis in the United States increased by nearly 14% from 2005 to 2006, but the most notable increase has occurred among men who have sex with men. Syphilis rates among that group increased by 54% from 2002 to 2006, Dr. Douglas said.

The report's data provide an incomplete picture of sexually transmitted diseases in the United States, the researchers cautioned, because many cases are not reported. To view the complete report, visit www.cdc.gov/std/stats

Rates of chlamydia, gonorrhea, and syphilis increased in the United States during the past year and continued recent upward trends, according to a report from the Centers for Disease Control and Prevention.

"Young women, racial and ethnic populations, and men who have sex with men are particularly hard hit by these diseases," said Dr. John M. Douglas Jr., director of the CDC's Division of Sexually Transmitted Disease Prevention.

The direct medical costs associated with STDs in the United States were estimated at nearly $15 billion in 2006, the researchers stated in the report, "Sexually Transmitted Disease Surveillance 2006," which was presented in a telebriefing.

In 2006, the national rate of reported cases of chlamydia increased by 5.6% from 2005 to 2006. Specifically, the reported rate was 347.8 cases per 100,000 persons in 2006, compared with 329.4 cases per 100,000 persons in 2005.

Chlamydia hits hardest among adolescent girls and young women—the highest chlamydia rate was reported in young women aged 15-19 years followed by women aged 20-24 years. And racial disparity is high: The chlamydia rate was highest among black women, whose rate was more than seven times higher than that of white women and more than twice as high as that of Hispanic women.

Because of the high rate of chlamydia in young women, the CDC recommends screening sexually active women younger than 26 years for the disease. Chlamydia screening also is recommended for older women with new or multiple sex partners, because these women are also at increased risk. Based on recent studies showing that chlamydia reinfection can occur in women whose partners remain untreated, the CDC's treatment guidelines include retesting patients 3 months after treatment.

"If there are providers who don't think the young women in their practice don't have chlamydia, they should think again," noted Dr. Stuart Berman, chief epidemiologist at the Division of Sexually Transmitted Disease Prevention.

Gonorrhea rates increased for the second consecutive year, following a plateau in reported disease rates from 1997 to 2005. "The racial disparities are stark," in reported gonorrhea cases, Dr. Douglas said. Overall, the rate among blacks is 18 times higher than in whites, he said.

Gonorrhea rates also continue to vary by region. As in previous years, the southern region of the United States had the highest overall gonorrhea rate in 2006, at 159 cases per 100,000 persons.

"We are also concerned about increases in the West," Dr. Douglas said. Gonorrhea cases in the West increased by 2.9% between 2005 and 2006, contributing to a 32% increase between 2002 and 2006.

Untreated gonorrhea can, among other complications, increase a person's risk for HIV if he or she is exposed. But gonorrhea treatment has become more challenging, because evidence of fluoroquinolone resistance—especially among men who have sex with men—prompted the CDC in April 2007 to stop recommending fluoroquinolones as treatment for any gonorrhea cases. As an alternative, the CDC recommends cephalosporins to treat gonorrhea.

Rates of primary and secondary syphilis in the United States increased by nearly 14% from 2005 to 2006, but the most notable increase has occurred among men who have sex with men. Syphilis rates among that group increased by 54% from 2002 to 2006, Dr. Douglas said.

The report's data provide an incomplete picture of sexually transmitted diseases in the United States, the researchers cautioned, because many cases are not reported. To view the complete report, visit www.cdc.gov/std/stats

Rates of chlamydia, gonorrhea, and syphilis increased in the United States during the past year and continued recent upward trends, according to a report from the Centers for Disease Control and Prevention.

"Young women, racial and ethnic populations, and men who have sex with men are particularly hard hit by these diseases," said Dr. John M. Douglas Jr., director of the CDC's Division of Sexually Transmitted Disease Prevention.

The direct medical costs associated with STDs in the United States were estimated at nearly $15 billion in 2006, the researchers stated in the report, "Sexually Transmitted Disease Surveillance 2006," which was presented in a telebriefing.

In 2006, the national rate of reported cases of chlamydia increased by 5.6% from 2005 to 2006. Specifically, the reported rate was 347.8 cases per 100,000 persons in 2006, compared with 329.4 cases per 100,000 persons in 2005.

Chlamydia hits hardest among adolescent girls and young women—the highest chlamydia rate was reported in young women aged 15-19 years followed by women aged 20-24 years. And racial disparity is high: The chlamydia rate was highest among black women, whose rate was more than seven times higher than that of white women and more than twice as high as that of Hispanic women.

Because of the high rate of chlamydia in young women, the CDC recommends screening sexually active women younger than 26 years for the disease. Chlamydia screening also is recommended for older women with new or multiple sex partners, because these women are also at increased risk. Based on recent studies showing that chlamydia reinfection can occur in women whose partners remain untreated, the CDC's treatment guidelines include retesting patients 3 months after treatment.

"If there are providers who don't think the young women in their practice don't have chlamydia, they should think again," noted Dr. Stuart Berman, chief epidemiologist at the Division of Sexually Transmitted Disease Prevention.

Gonorrhea rates increased for the second consecutive year, following a plateau in reported disease rates from 1997 to 2005. "The racial disparities are stark," in reported gonorrhea cases, Dr. Douglas said. Overall, the rate among blacks is 18 times higher than in whites, he said.

Gonorrhea rates also continue to vary by region. As in previous years, the southern region of the United States had the highest overall gonorrhea rate in 2006, at 159 cases per 100,000 persons.

"We are also concerned about increases in the West," Dr. Douglas said. Gonorrhea cases in the West increased by 2.9% between 2005 and 2006, contributing to a 32% increase between 2002 and 2006.

Untreated gonorrhea can, among other complications, increase a person's risk for HIV if he or she is exposed. But gonorrhea treatment has become more challenging, because evidence of fluoroquinolone resistance—especially among men who have sex with men—prompted the CDC in April 2007 to stop recommending fluoroquinolones as treatment for any gonorrhea cases. As an alternative, the CDC recommends cephalosporins to treat gonorrhea.

Rates of primary and secondary syphilis in the United States increased by nearly 14% from 2005 to 2006, but the most notable increase has occurred among men who have sex with men. Syphilis rates among that group increased by 54% from 2002 to 2006, Dr. Douglas said.

The report's data provide an incomplete picture of sexually transmitted diseases in the United States, the researchers cautioned, because many cases are not reported. To view the complete report, visit www.cdc.gov/std/stats

Early initiation of methotrexate can postpone the development of cataracts requiring surgery in juvenile idiopathic arthritis patients who are at high risk due to posterior adhesions at diagnosis with uveitis, said Dr. Karen M. Sijssens.

Cataract surgery in eyes with inflamed uveas is difficult. The presence of posterior adhesions (synechia) at diagnosis and the treatment of uveitis with corticosteroids have been tied to an increased risk of cataracts in children with JIA who develop uveitis.

To evaluate cataract risk factors and determine effective treatments, Dr. Sijssens of the University Medical Center Utrecht (the Netherlands) and colleagues analyzed 53 children diagnosed with JIA before age 16. Fifty-one had JIA-associated uveitis; 2 had antinuclear antibody-positive uveitis (Am. J. Ophthalmol. 2007;144:574–9).

Uveitis was the first manifestation of JIA in 12 children, and arthritis was the first manifestation of JIA in 41 children.

Overall, 11 of the 12 children (92%) for whom uveitis was the first presenting symptom of JIA required cataract surgery significantly sooner after diagnosis, versus the 16 of the 41 children (39%) for whom arthritis was the first sign of JIA (3.5 years vs. 6.6 years).

Posterior synechia were present at uveitis diagnosis in 15 children. Even after controlling for the use of periocular corticosteroids, children with posterior synechia required cataract surgery significantly sooner than the 33 children without adhesions (3.0 years vs. 8.5 years).

But the need for cataract surgery was significantly delayed in the 17 children treated with methotrexate during the first year after uveitis diagnosis, versus the 25 children not treated with methotrexate (7.0 years vs. 3.5 years). The presence of adhesions was approximately the same in both the methotrexate-treated and untreated children.

The delayed development of cataracts requiring surgery in the methotrexate-treated children may be due to better inflammation control, the researchers noted. “Another explanation may be that treatment with methotrexate diminishes the need for treatment with topical or systemic corticosteroids,” they wrote.

Study limitations include its small size and the fact that no patients were studied who had methotrexate and uveitis as the first JIA symptom, the authors noted.

Early initiation of methotrexate can postpone the development of cataracts requiring surgery in juvenile idiopathic arthritis patients who are at high risk due to posterior adhesions at diagnosis with uveitis, said Dr. Karen M. Sijssens.

Cataract surgery in eyes with inflamed uveas is difficult. The presence of posterior adhesions (synechia) at diagnosis and the treatment of uveitis with corticosteroids have been tied to an increased risk of cataracts in children with JIA who develop uveitis.

To evaluate cataract risk factors and determine effective treatments, Dr. Sijssens of the University Medical Center Utrecht (the Netherlands) and colleagues analyzed 53 children diagnosed with JIA before age 16. Fifty-one had JIA-associated uveitis; 2 had antinuclear antibody-positive uveitis (Am. J. Ophthalmol. 2007;144:574–9).

Uveitis was the first manifestation of JIA in 12 children, and arthritis was the first manifestation of JIA in 41 children.

Overall, 11 of the 12 children (92%) for whom uveitis was the first presenting symptom of JIA required cataract surgery significantly sooner after diagnosis, versus the 16 of the 41 children (39%) for whom arthritis was the first sign of JIA (3.5 years vs. 6.6 years).

Posterior synechia were present at uveitis diagnosis in 15 children. Even after controlling for the use of periocular corticosteroids, children with posterior synechia required cataract surgery significantly sooner than the 33 children without adhesions (3.0 years vs. 8.5 years).

But the need for cataract surgery was significantly delayed in the 17 children treated with methotrexate during the first year after uveitis diagnosis, versus the 25 children not treated with methotrexate (7.0 years vs. 3.5 years). The presence of adhesions was approximately the same in both the methotrexate-treated and untreated children.

The delayed development of cataracts requiring surgery in the methotrexate-treated children may be due to better inflammation control, the researchers noted. “Another explanation may be that treatment with methotrexate diminishes the need for treatment with topical or systemic corticosteroids,” they wrote.

Study limitations include its small size and the fact that no patients were studied who had methotrexate and uveitis as the first JIA symptom, the authors noted.

Early initiation of methotrexate can postpone the development of cataracts requiring surgery in juvenile idiopathic arthritis patients who are at high risk due to posterior adhesions at diagnosis with uveitis, said Dr. Karen M. Sijssens.

Cataract surgery in eyes with inflamed uveas is difficult. The presence of posterior adhesions (synechia) at diagnosis and the treatment of uveitis with corticosteroids have been tied to an increased risk of cataracts in children with JIA who develop uveitis.

To evaluate cataract risk factors and determine effective treatments, Dr. Sijssens of the University Medical Center Utrecht (the Netherlands) and colleagues analyzed 53 children diagnosed with JIA before age 16. Fifty-one had JIA-associated uveitis; 2 had antinuclear antibody-positive uveitis (Am. J. Ophthalmol. 2007;144:574–9).

Uveitis was the first manifestation of JIA in 12 children, and arthritis was the first manifestation of JIA in 41 children.

Overall, 11 of the 12 children (92%) for whom uveitis was the first presenting symptom of JIA required cataract surgery significantly sooner after diagnosis, versus the 16 of the 41 children (39%) for whom arthritis was the first sign of JIA (3.5 years vs. 6.6 years).

Posterior synechia were present at uveitis diagnosis in 15 children. Even after controlling for the use of periocular corticosteroids, children with posterior synechia required cataract surgery significantly sooner than the 33 children without adhesions (3.0 years vs. 8.5 years).

But the need for cataract surgery was significantly delayed in the 17 children treated with methotrexate during the first year after uveitis diagnosis, versus the 25 children not treated with methotrexate (7.0 years vs. 3.5 years). The presence of adhesions was approximately the same in both the methotrexate-treated and untreated children.

The delayed development of cataracts requiring surgery in the methotrexate-treated children may be due to better inflammation control, the researchers noted. “Another explanation may be that treatment with methotrexate diminishes the need for treatment with topical or systemic corticosteroids,” they wrote.

Study limitations include its small size and the fact that no patients were studied who had methotrexate and uveitis as the first JIA symptom, the authors noted.

MINNEAPOLIS – Adults with Arnold-Chiari type I malformations are at greater risk for sleep-disordered breathing, compared with healthy controls, based on data presented at the annual meeting of the Associated Professional Sleep Societies.

In light of this finding, “We should be screening all Arnold-Chiari I patients for sleep-disordered breathing,” said Dr. Nate Watson, a neurologist at the University of Washington, Seattle.

The displaced brain structures that characterize Arnold-Chiari I (AC-1), a benign developmental brain anomaly, can compress the brainstem, impeding breathing, he said.

To better assess the risk of sleep-disordered breathing in AC-1 patients, Dr. Watson and his colleagues compared 18 women with AC-1 (mean age 36 years) with 35 age- and sex-matched controls.

The researchers used several subjective questionnaires including the Epworth Sleepiness Scale to assess sleep-disordered breathing and sleepiness. Based on these results, the AC-1 patients were at significantly greater risk for sleep-disordered breathing, compared with controls (69% vs. 20%). Specifically, the results from the questionnaires showed that three factors–snoring, sleepiness, and obesity/hypertension–were significantly more common among AC-1 patients vs. controls, and occurred in 44% vs. 6%, 78% vs. 46%, and 64% vs. 34%, respectively.

The AC-1 patients were significantly more likely to report other symptoms associated with sleep-disordered breathing, including nighttime choking or gasping and nighttime shortness of breath, compared with controls. And when they woke up, the AC-1 patients also reported sore throats, heartburn, and headaches significantly more often than did the control patients.

In addition, the AC-1 patients reported sleeping significantly fewer hours (6.3 hours versus 7.6 hours) and taking significantly longer to fall asleep (61.4 minutes versus 18.6 minutes), compared with controls.

Consider decompressive surgery for patients if respiration is their main complaint, but remember that they need to be followed, said Dr. Watson during the discussion after his presentation. Previous studies indicate that decompression surgery makes a difference. Data from 16 consecutive patients with AC-1 malformations showed a significant improvement in the central apnea index from 14.9 to 1.3 based on full-night polysomnography conducted approximately 200 days after decompression surgery (Neurology 2006;66:136-8).

Future studies of AC-1 patients need to continue to focus on objective measures and comparison of patients before and after they have decompressive surgery, Dr. Watson said.

MINNEAPOLIS – Adults with Arnold-Chiari type I malformations are at greater risk for sleep-disordered breathing, compared with healthy controls, based on data presented at the annual meeting of the Associated Professional Sleep Societies.

In light of this finding, “We should be screening all Arnold-Chiari I patients for sleep-disordered breathing,” said Dr. Nate Watson, a neurologist at the University of Washington, Seattle.

The displaced brain structures that characterize Arnold-Chiari I (AC-1), a benign developmental brain anomaly, can compress the brainstem, impeding breathing, he said.

To better assess the risk of sleep-disordered breathing in AC-1 patients, Dr. Watson and his colleagues compared 18 women with AC-1 (mean age 36 years) with 35 age- and sex-matched controls.

The researchers used several subjective questionnaires including the Epworth Sleepiness Scale to assess sleep-disordered breathing and sleepiness. Based on these results, the AC-1 patients were at significantly greater risk for sleep-disordered breathing, compared with controls (69% vs. 20%). Specifically, the results from the questionnaires showed that three factors–snoring, sleepiness, and obesity/hypertension–were significantly more common among AC-1 patients vs. controls, and occurred in 44% vs. 6%, 78% vs. 46%, and 64% vs. 34%, respectively.

The AC-1 patients were significantly more likely to report other symptoms associated with sleep-disordered breathing, including nighttime choking or gasping and nighttime shortness of breath, compared with controls. And when they woke up, the AC-1 patients also reported sore throats, heartburn, and headaches significantly more often than did the control patients.

In addition, the AC-1 patients reported sleeping significantly fewer hours (6.3 hours versus 7.6 hours) and taking significantly longer to fall asleep (61.4 minutes versus 18.6 minutes), compared with controls.

Consider decompressive surgery for patients if respiration is their main complaint, but remember that they need to be followed, said Dr. Watson during the discussion after his presentation. Previous studies indicate that decompression surgery makes a difference. Data from 16 consecutive patients with AC-1 malformations showed a significant improvement in the central apnea index from 14.9 to 1.3 based on full-night polysomnography conducted approximately 200 days after decompression surgery (Neurology 2006;66:136-8).

Future studies of AC-1 patients need to continue to focus on objective measures and comparison of patients before and after they have decompressive surgery, Dr. Watson said.

MINNEAPOLIS – Adults with Arnold-Chiari type I malformations are at greater risk for sleep-disordered breathing, compared with healthy controls, based on data presented at the annual meeting of the Associated Professional Sleep Societies.

In light of this finding, “We should be screening all Arnold-Chiari I patients for sleep-disordered breathing,” said Dr. Nate Watson, a neurologist at the University of Washington, Seattle.

The displaced brain structures that characterize Arnold-Chiari I (AC-1), a benign developmental brain anomaly, can compress the brainstem, impeding breathing, he said.

To better assess the risk of sleep-disordered breathing in AC-1 patients, Dr. Watson and his colleagues compared 18 women with AC-1 (mean age 36 years) with 35 age- and sex-matched controls.

The researchers used several subjective questionnaires including the Epworth Sleepiness Scale to assess sleep-disordered breathing and sleepiness. Based on these results, the AC-1 patients were at significantly greater risk for sleep-disordered breathing, compared with controls (69% vs. 20%). Specifically, the results from the questionnaires showed that three factors–snoring, sleepiness, and obesity/hypertension–were significantly more common among AC-1 patients vs. controls, and occurred in 44% vs. 6%, 78% vs. 46%, and 64% vs. 34%, respectively.

The AC-1 patients were significantly more likely to report other symptoms associated with sleep-disordered breathing, including nighttime choking or gasping and nighttime shortness of breath, compared with controls. And when they woke up, the AC-1 patients also reported sore throats, heartburn, and headaches significantly more often than did the control patients.

In addition, the AC-1 patients reported sleeping significantly fewer hours (6.3 hours versus 7.6 hours) and taking significantly longer to fall asleep (61.4 minutes versus 18.6 minutes), compared with controls.

Consider decompressive surgery for patients if respiration is their main complaint, but remember that they need to be followed, said Dr. Watson during the discussion after his presentation. Previous studies indicate that decompression surgery makes a difference. Data from 16 consecutive patients with AC-1 malformations showed a significant improvement in the central apnea index from 14.9 to 1.3 based on full-night polysomnography conducted approximately 200 days after decompression surgery (Neurology 2006;66:136-8).

Future studies of AC-1 patients need to continue to focus on objective measures and comparison of patients before and after they have decompressive surgery, Dr. Watson said.

WASHINGTON – Psychiatric comorbidities and a history of abuse are often associated with functional gastrointestinal problems, said Dr. Kevin W. Olden at the annual meeting of the American Academy of Clinical Psychiatrists.

“There is no doubt that psychiatry has a lot to offer patients with irritable bowel syndrome and the entire spectrum of gastrointestinal disorders,” said Dr. Olden, director of the division of gastroenterology and hepatology, University of Arkansas, Little Rock.

Four psychiatric diagnoses that are often present in patients with functional gastrointestinal disorders are panic disorder, generalized anxiety disorder, mood disorders (mainly depression), and somatoform disorders. As many as 44% of patients with IBS meet the diagnostic criteria for panic disorder, Dr. Olden noted (Gastroenterol. Clin. N. Am. 2003;32:477-506). In addition, Dr. Olden cited a study in which major depression was identified in 30%-90% of patients with irritable bowel syndrome. The presence of depression can influence patients' ability to seek care for IBS and their ability to cope with it, he said.

The impact of abuse on subsequent psychological problems and comorbid functional gastrointestinal disorders is an area worthy of further research, Dr. Olden said. In a survey of 206 patients who presented to a GI clinic, more than half of the patients with functional GI problems reported a history of abuse, and significantly more of these patients reported abuse, compared with those who had organic GI problems (53% vs. 37%) (Ann. Intern. Med. 1990;113:828-33).

When treatment with antidepressants relieves the gastrointestinal symptoms in some patients, they report fewer physician visits and improved ability to perform daily activities, Dr. Olden said.

WASHINGTON – Psychiatric comorbidities and a history of abuse are often associated with functional gastrointestinal problems, said Dr. Kevin W. Olden at the annual meeting of the American Academy of Clinical Psychiatrists.

“There is no doubt that psychiatry has a lot to offer patients with irritable bowel syndrome and the entire spectrum of gastrointestinal disorders,” said Dr. Olden, director of the division of gastroenterology and hepatology, University of Arkansas, Little Rock.

Four psychiatric diagnoses that are often present in patients with functional gastrointestinal disorders are panic disorder, generalized anxiety disorder, mood disorders (mainly depression), and somatoform disorders. As many as 44% of patients with IBS meet the diagnostic criteria for panic disorder, Dr. Olden noted (Gastroenterol. Clin. N. Am. 2003;32:477-506). In addition, Dr. Olden cited a study in which major depression was identified in 30%-90% of patients with irritable bowel syndrome. The presence of depression can influence patients' ability to seek care for IBS and their ability to cope with it, he said.

The impact of abuse on subsequent psychological problems and comorbid functional gastrointestinal disorders is an area worthy of further research, Dr. Olden said. In a survey of 206 patients who presented to a GI clinic, more than half of the patients with functional GI problems reported a history of abuse, and significantly more of these patients reported abuse, compared with those who had organic GI problems (53% vs. 37%) (Ann. Intern. Med. 1990;113:828-33).

When treatment with antidepressants relieves the gastrointestinal symptoms in some patients, they report fewer physician visits and improved ability to perform daily activities, Dr. Olden said.

WASHINGTON – Psychiatric comorbidities and a history of abuse are often associated with functional gastrointestinal problems, said Dr. Kevin W. Olden at the annual meeting of the American Academy of Clinical Psychiatrists.

“There is no doubt that psychiatry has a lot to offer patients with irritable bowel syndrome and the entire spectrum of gastrointestinal disorders,” said Dr. Olden, director of the division of gastroenterology and hepatology, University of Arkansas, Little Rock.

Four psychiatric diagnoses that are often present in patients with functional gastrointestinal disorders are panic disorder, generalized anxiety disorder, mood disorders (mainly depression), and somatoform disorders. As many as 44% of patients with IBS meet the diagnostic criteria for panic disorder, Dr. Olden noted (Gastroenterol. Clin. N. Am. 2003;32:477-506). In addition, Dr. Olden cited a study in which major depression was identified in 30%-90% of patients with irritable bowel syndrome. The presence of depression can influence patients' ability to seek care for IBS and their ability to cope with it, he said.

The impact of abuse on subsequent psychological problems and comorbid functional gastrointestinal disorders is an area worthy of further research, Dr. Olden said. In a survey of 206 patients who presented to a GI clinic, more than half of the patients with functional GI problems reported a history of abuse, and significantly more of these patients reported abuse, compared with those who had organic GI problems (53% vs. 37%) (Ann. Intern. Med. 1990;113:828-33).

When treatment with antidepressants relieves the gastrointestinal symptoms in some patients, they report fewer physician visits and improved ability to perform daily activities, Dr. Olden said.

The Alzheimer's Association has released new recommendations to guide end-of-life care for dementia patients in nursing homes; the recommendations focus on planning for end-of-life care as soon as possible after a dementia diagnosis is made.

The evidence-based recommendations, which were released at the Alzheimer's Association's 15th Annual Dementia Care Conference in Chicago, have been supported by more than 30 organizations, including the American Medical Directors Association, which has a clinical practice guideline on this same issue, as well as a new tool kit on palliative care/end of life. “AMDA fully supports individualized care in persons with dementia and recognizes how important end-of-life care planning is when a diagnosis of dementia is made,” said Jacqueline Vance, AMDA's director of clinical affairs.

The recommendations state that the goals of end-of-life care should include following the resident's wishes as closely as possible, which is easier if a patient-centered care plan is designed early. This includes documenting a patient's preferences for medical treatment once he or she reaches an advanced stage of dementia and designating a proxy to make decisions on the patient's behalf when he or she can no longer do so.

In addition, the care goals include supporting families, other residents, and nursing home staff when a resident is actively dying and after the person has died. And finally, end-of-life care plans must be flexible enough to accommodate changes in a resident's preferences.

The end-of-life care recommendations are the third of three phases of a document—Dementia Care Practice Recommendations for Assisted Living Residences and Nursing Homes—that was conceived as part of the Alzheimer's Association Quality Residential Care campaign. Phase 1 of the recommendations focused on basic care for dementia patients, with attention to nutrition, pain management, and social involvement. Phase 2 provided guidance for managing wandering, falling, and the need for physical restraint in dementia patients.

The phase 3 recommendations emphasize developing consistent, personalized care to the extent possible and increasing staff members' knowledge of residents' preferences. The recommendations fall into the following categories, which include guidelines for end-of-life care for dementia patients:

▸ Communications with residents and family members. Schedule regular care planning meetings that the resident, proxy decision maker, and other family members can attend (even if only by conference call). Effective communications means acknowledging the cultural and spiritual beliefs of the resident and family and taking these beliefs into account.

Be sure to allow residents and families time to respond to questions and help them understand what policies and situations would cause a resident to be moved to palliative care or a hospice.

▸ Decision making. Discuss a resident's preferences and doctor's directions, such as “comfort care only,” “do not resuscitate,” or “do not hospitalize.” Involve the resident as much as possible, because a dementia diagnosis doesn't mean that the person lacks the ability to make decisions regarding their care. But it is important to designate a proxy decision maker who can make decisions on the resident's behalf when necessary.

▸ Hospice service issues. When a resident and his or her family members opt for hospice care, establish a plan for communication about the resident's health and care issues and identify which hospice or residence staff members will be the primary contact for family members.

▸ Assessing physical symptoms. Pain-assessment guidelines are addressed in detail in phase 1 of the recommendations, but monitoring pain is just as important when a patient is actively dying. Comfort care strategies may include such things as placing a fan in the room on a low setting to move air and make breathing easier.

▸ Assessing behavioral symptoms. Behavior changes in dementia patients at the end of life may be signs of distress, so be sure that staff members know to report any differences, such as hallucinations, changes in arousal level, or mood, or striking out in discomfort or distress. Determine whether the cause of the behavior is physical or emotional and use nondrug methods to help, such as reducing environmental irritants or providing companionship for an isolated resident.

▸ Psychosocial and spiritual support. Residents with dementia can still find comfort in meaningful interactions. Staff members need to know a resident's religious or cultural outlook if possible and provide appropriate psychological and spiritual support. And don't forget the family. Grieving for a patient with dementia at the end of life can be a long, emotionally draining experience for family members. A trained nurse or staff member can help by explaining some of the signs of approaching death so that families know what to expect and by offering resources for dealing with feelings of guilt and grief.

▸ Family participation in end-of-life care. Staff members can support families who want to feel involved in the comfort of the resident at the end of life by providing pillows and blankets for overnight stays and offering comforting music, books, and anything else that might help family members spend meaningful time with loved ones.

▸ Staff training. Dementia-specific end-of-life training for nursing home residents is an important part of providing quality care. Staff members need to be able to recognize the signs that death is imminent, and they need to be trained in pain management and communication skills so that they can explain the resident's condition to family members.

▸ Death and bereavement. When one of the residents dies, encourage the staff members who were involved in caring for that person to pay tribute to them with a poem, card, or other acknowledgment. Also, consider conducting periodic in-house memorial services to bring together residents, staff, and family members to recognize the lives of residents who have died.

For a complete version of the Dementia Care Practice Recommendations for Assisted Living Residences and Nursing Homes, visit www.alz.org/documents/DCPRPhase3_.pdf

The Alzheimer's Association has released new recommendations to guide end-of-life care for dementia patients in nursing homes; the recommendations focus on planning for end-of-life care as soon as possible after a dementia diagnosis is made.

The evidence-based recommendations, which were released at the Alzheimer's Association's 15th Annual Dementia Care Conference in Chicago, have been supported by more than 30 organizations, including the American Medical Directors Association, which has a clinical practice guideline on this same issue, as well as a new tool kit on palliative care/end of life. “AMDA fully supports individualized care in persons with dementia and recognizes how important end-of-life care planning is when a diagnosis of dementia is made,” said Jacqueline Vance, AMDA's director of clinical affairs.

The recommendations state that the goals of end-of-life care should include following the resident's wishes as closely as possible, which is easier if a patient-centered care plan is designed early. This includes documenting a patient's preferences for medical treatment once he or she reaches an advanced stage of dementia and designating a proxy to make decisions on the patient's behalf when he or she can no longer do so.

In addition, the care goals include supporting families, other residents, and nursing home staff when a resident is actively dying and after the person has died. And finally, end-of-life care plans must be flexible enough to accommodate changes in a resident's preferences.

The end-of-life care recommendations are the third of three phases of a document—Dementia Care Practice Recommendations for Assisted Living Residences and Nursing Homes—that was conceived as part of the Alzheimer's Association Quality Residential Care campaign. Phase 1 of the recommendations focused on basic care for dementia patients, with attention to nutrition, pain management, and social involvement. Phase 2 provided guidance for managing wandering, falling, and the need for physical restraint in dementia patients.

The phase 3 recommendations emphasize developing consistent, personalized care to the extent possible and increasing staff members' knowledge of residents' preferences. The recommendations fall into the following categories, which include guidelines for end-of-life care for dementia patients:

▸ Communications with residents and family members. Schedule regular care planning meetings that the resident, proxy decision maker, and other family members can attend (even if only by conference call). Effective communications means acknowledging the cultural and spiritual beliefs of the resident and family and taking these beliefs into account.

Be sure to allow residents and families time to respond to questions and help them understand what policies and situations would cause a resident to be moved to palliative care or a hospice.

▸ Decision making. Discuss a resident's preferences and doctor's directions, such as “comfort care only,” “do not resuscitate,” or “do not hospitalize.” Involve the resident as much as possible, because a dementia diagnosis doesn't mean that the person lacks the ability to make decisions regarding their care. But it is important to designate a proxy decision maker who can make decisions on the resident's behalf when necessary.

▸ Hospice service issues. When a resident and his or her family members opt for hospice care, establish a plan for communication about the resident's health and care issues and identify which hospice or residence staff members will be the primary contact for family members.

▸ Assessing physical symptoms. Pain-assessment guidelines are addressed in detail in phase 1 of the recommendations, but monitoring pain is just as important when a patient is actively dying. Comfort care strategies may include such things as placing a fan in the room on a low setting to move air and make breathing easier.

▸ Assessing behavioral symptoms. Behavior changes in dementia patients at the end of life may be signs of distress, so be sure that staff members know to report any differences, such as hallucinations, changes in arousal level, or mood, or striking out in discomfort or distress. Determine whether the cause of the behavior is physical or emotional and use nondrug methods to help, such as reducing environmental irritants or providing companionship for an isolated resident.

▸ Psychosocial and spiritual support. Residents with dementia can still find comfort in meaningful interactions. Staff members need to know a resident's religious or cultural outlook if possible and provide appropriate psychological and spiritual support. And don't forget the family. Grieving for a patient with dementia at the end of life can be a long, emotionally draining experience for family members. A trained nurse or staff member can help by explaining some of the signs of approaching death so that families know what to expect and by offering resources for dealing with feelings of guilt and grief.

▸ Family participation in end-of-life care. Staff members can support families who want to feel involved in the comfort of the resident at the end of life by providing pillows and blankets for overnight stays and offering comforting music, books, and anything else that might help family members spend meaningful time with loved ones.

▸ Staff training. Dementia-specific end-of-life training for nursing home residents is an important part of providing quality care. Staff members need to be able to recognize the signs that death is imminent, and they need to be trained in pain management and communication skills so that they can explain the resident's condition to family members.

▸ Death and bereavement. When one of the residents dies, encourage the staff members who were involved in caring for that person to pay tribute to them with a poem, card, or other acknowledgment. Also, consider conducting periodic in-house memorial services to bring together residents, staff, and family members to recognize the lives of residents who have died.

For a complete version of the Dementia Care Practice Recommendations for Assisted Living Residences and Nursing Homes, visit www.alz.org/documents/DCPRPhase3_.pdf

The Alzheimer's Association has released new recommendations to guide end-of-life care for dementia patients in nursing homes; the recommendations focus on planning for end-of-life care as soon as possible after a dementia diagnosis is made.

The evidence-based recommendations, which were released at the Alzheimer's Association's 15th Annual Dementia Care Conference in Chicago, have been supported by more than 30 organizations, including the American Medical Directors Association, which has a clinical practice guideline on this same issue, as well as a new tool kit on palliative care/end of life. “AMDA fully supports individualized care in persons with dementia and recognizes how important end-of-life care planning is when a diagnosis of dementia is made,” said Jacqueline Vance, AMDA's director of clinical affairs.

The recommendations state that the goals of end-of-life care should include following the resident's wishes as closely as possible, which is easier if a patient-centered care plan is designed early. This includes documenting a patient's preferences for medical treatment once he or she reaches an advanced stage of dementia and designating a proxy to make decisions on the patient's behalf when he or she can no longer do so.

In addition, the care goals include supporting families, other residents, and nursing home staff when a resident is actively dying and after the person has died. And finally, end-of-life care plans must be flexible enough to accommodate changes in a resident's preferences.

The end-of-life care recommendations are the third of three phases of a document—Dementia Care Practice Recommendations for Assisted Living Residences and Nursing Homes—that was conceived as part of the Alzheimer's Association Quality Residential Care campaign. Phase 1 of the recommendations focused on basic care for dementia patients, with attention to nutrition, pain management, and social involvement. Phase 2 provided guidance for managing wandering, falling, and the need for physical restraint in dementia patients.

The phase 3 recommendations emphasize developing consistent, personalized care to the extent possible and increasing staff members' knowledge of residents' preferences. The recommendations fall into the following categories, which include guidelines for end-of-life care for dementia patients:

▸ Communications with residents and family members. Schedule regular care planning meetings that the resident, proxy decision maker, and other family members can attend (even if only by conference call). Effective communications means acknowledging the cultural and spiritual beliefs of the resident and family and taking these beliefs into account.

Be sure to allow residents and families time to respond to questions and help them understand what policies and situations would cause a resident to be moved to palliative care or a hospice.

▸ Decision making. Discuss a resident's preferences and doctor's directions, such as “comfort care only,” “do not resuscitate,” or “do not hospitalize.” Involve the resident as much as possible, because a dementia diagnosis doesn't mean that the person lacks the ability to make decisions regarding their care. But it is important to designate a proxy decision maker who can make decisions on the resident's behalf when necessary.

▸ Hospice service issues. When a resident and his or her family members opt for hospice care, establish a plan for communication about the resident's health and care issues and identify which hospice or residence staff members will be the primary contact for family members.

▸ Assessing physical symptoms. Pain-assessment guidelines are addressed in detail in phase 1 of the recommendations, but monitoring pain is just as important when a patient is actively dying. Comfort care strategies may include such things as placing a fan in the room on a low setting to move air and make breathing easier.

▸ Assessing behavioral symptoms. Behavior changes in dementia patients at the end of life may be signs of distress, so be sure that staff members know to report any differences, such as hallucinations, changes in arousal level, or mood, or striking out in discomfort or distress. Determine whether the cause of the behavior is physical or emotional and use nondrug methods to help, such as reducing environmental irritants or providing companionship for an isolated resident.

▸ Psychosocial and spiritual support. Residents with dementia can still find comfort in meaningful interactions. Staff members need to know a resident's religious or cultural outlook if possible and provide appropriate psychological and spiritual support. And don't forget the family. Grieving for a patient with dementia at the end of life can be a long, emotionally draining experience for family members. A trained nurse or staff member can help by explaining some of the signs of approaching death so that families know what to expect and by offering resources for dealing with feelings of guilt and grief.

▸ Family participation in end-of-life care. Staff members can support families who want to feel involved in the comfort of the resident at the end of life by providing pillows and blankets for overnight stays and offering comforting music, books, and anything else that might help family members spend meaningful time with loved ones.

▸ Staff training. Dementia-specific end-of-life training for nursing home residents is an important part of providing quality care. Staff members need to be able to recognize the signs that death is imminent, and they need to be trained in pain management and communication skills so that they can explain the resident's condition to family members.

▸ Death and bereavement. When one of the residents dies, encourage the staff members who were involved in caring for that person to pay tribute to them with a poem, card, or other acknowledgment. Also, consider conducting periodic in-house memorial services to bring together residents, staff, and family members to recognize the lives of residents who have died.

For a complete version of the Dementia Care Practice Recommendations for Assisted Living Residences and Nursing Homes, visit www.alz.org/documents/DCPRPhase3_.pdf