Timothy F. Kirn

Many patients with diabetes might prefer to have some risk of minor complications from the condition than to live life saddled with the rigors of comprehensive diabetes management, according to a survey conducted by researchers at the University of Chicago.

In their 1-hour, face-to-face survey interviews with 701 patients with diabetes, investigators found that patients certainly preferred life with treatment to life with complications, Dr. Elbert S. Huang, of the section of general internal medicine at the University of Chicago, and his colleagues reported. But they also found that patients perceived comprehensive diabetes care as having many negative impacts on quality of life—impacts that they rated as about equal to a number of intermediate complications (Diabetes Care 2007;30:1–6).

The researchers described comprehensive care to the study subjects as management that entailed cholesterol-lowering drugs, aspirin, intensive blood pressure control (perhaps with more than one agent), intensive glucose control (perhaps with insulin and oral agents, and close monitoring), and diet and exercise.

The study was conducted, said Dr. Huang, because although numerous studies have shown that intensive diabetes control reduces complications and much effort and money is expended to encourage intensive management, at least 20% of patients continue to have poor glycemic control, 33% have suboptimal blood pressure, and 40% have high cholesterol. The survey may give some insight into why patients with diabetes so often do not meet recommended treatment targets, he added.

The study used a quantitative scale to rate patient preferences, or “utilities,” so answers about treatments and complications could be compared.

The patients ranked intensive control and comprehensive control significantly lower than conventional control. And, the mean rating for comprehensive care was not statistically different from the ratings for angina, diabetic neuropathy, and diabetic nephropathy. The mean rating for intensive therapy, which was demanding but not quite as taxing as comprehensive care, was similar to that of diabetic neuropathy.

Despite those overall findings, Dr. Huang noted that there was much variation in the way the patients answered the questions. The majority actually rated life with treatments as being close to perfect health, and only 18% rated life with treatments as being a significant burden on quality of life.

The heterogeneity of responses indicates that doctors need to talk to their patients in the clinic and share decision making when making treatment plans, he said.

Many patients with diabetes might prefer to have some risk of minor complications from the condition than to live life saddled with the rigors of comprehensive diabetes management, according to a survey conducted by researchers at the University of Chicago.

In their 1-hour, face-to-face survey interviews with 701 patients with diabetes, investigators found that patients certainly preferred life with treatment to life with complications, Dr. Elbert S. Huang, of the section of general internal medicine at the University of Chicago, and his colleagues reported. But they also found that patients perceived comprehensive diabetes care as having many negative impacts on quality of life—impacts that they rated as about equal to a number of intermediate complications (Diabetes Care 2007;30:1–6).

The researchers described comprehensive care to the study subjects as management that entailed cholesterol-lowering drugs, aspirin, intensive blood pressure control (perhaps with more than one agent), intensive glucose control (perhaps with insulin and oral agents, and close monitoring), and diet and exercise.

The study was conducted, said Dr. Huang, because although numerous studies have shown that intensive diabetes control reduces complications and much effort and money is expended to encourage intensive management, at least 20% of patients continue to have poor glycemic control, 33% have suboptimal blood pressure, and 40% have high cholesterol. The survey may give some insight into why patients with diabetes so often do not meet recommended treatment targets, he added.

The study used a quantitative scale to rate patient preferences, or “utilities,” so answers about treatments and complications could be compared.

The patients ranked intensive control and comprehensive control significantly lower than conventional control. And, the mean rating for comprehensive care was not statistically different from the ratings for angina, diabetic neuropathy, and diabetic nephropathy. The mean rating for intensive therapy, which was demanding but not quite as taxing as comprehensive care, was similar to that of diabetic neuropathy.

Despite those overall findings, Dr. Huang noted that there was much variation in the way the patients answered the questions. The majority actually rated life with treatments as being close to perfect health, and only 18% rated life with treatments as being a significant burden on quality of life.

The heterogeneity of responses indicates that doctors need to talk to their patients in the clinic and share decision making when making treatment plans, he said.

Many patients with diabetes might prefer to have some risk of minor complications from the condition than to live life saddled with the rigors of comprehensive diabetes management, according to a survey conducted by researchers at the University of Chicago.

In their 1-hour, face-to-face survey interviews with 701 patients with diabetes, investigators found that patients certainly preferred life with treatment to life with complications, Dr. Elbert S. Huang, of the section of general internal medicine at the University of Chicago, and his colleagues reported. But they also found that patients perceived comprehensive diabetes care as having many negative impacts on quality of life—impacts that they rated as about equal to a number of intermediate complications (Diabetes Care 2007;30:1–6).

The researchers described comprehensive care to the study subjects as management that entailed cholesterol-lowering drugs, aspirin, intensive blood pressure control (perhaps with more than one agent), intensive glucose control (perhaps with insulin and oral agents, and close monitoring), and diet and exercise.

The study was conducted, said Dr. Huang, because although numerous studies have shown that intensive diabetes control reduces complications and much effort and money is expended to encourage intensive management, at least 20% of patients continue to have poor glycemic control, 33% have suboptimal blood pressure, and 40% have high cholesterol. The survey may give some insight into why patients with diabetes so often do not meet recommended treatment targets, he added.

The study used a quantitative scale to rate patient preferences, or “utilities,” so answers about treatments and complications could be compared.

The patients ranked intensive control and comprehensive control significantly lower than conventional control. And, the mean rating for comprehensive care was not statistically different from the ratings for angina, diabetic neuropathy, and diabetic nephropathy. The mean rating for intensive therapy, which was demanding but not quite as taxing as comprehensive care, was similar to that of diabetic neuropathy.

Despite those overall findings, Dr. Huang noted that there was much variation in the way the patients answered the questions. The majority actually rated life with treatments as being close to perfect health, and only 18% rated life with treatments as being a significant burden on quality of life.

The heterogeneity of responses indicates that doctors need to talk to their patients in the clinic and share decision making when making treatment plans, he said.

A group of seven of the largest drug manufacturers has formed a consortium to study the genetics of serious adverse drug reactions.

The Serious Adverse Events Consortium will work closely with the Food and Drug Administration on the projects that it will undertake.

This group is one of several consortiums that were recently organized, with encouragement from the FDA, to support costly research initiatives. Others include the Predictive Safety Testing Consortium, the Biomarkers Consortium, and the Microarrary Quality Control project.

In its first two projects, the Serious Adverse Events Consortium will investigate genetic susceptibility to Stevens-Johnson Syndrome and also to drug-induced liver toxicity.

The scope of such projects would be beyond the capability of any one company or institution, said Arthur L. Holden, the chairman of the new consortium.

The two conditions targeted in the first two projects are so rare that it will probably be necessary to study tens of thousands of individuals.

“We really look forward to the results of these two projects,” said Dr. Janet Woodcock, deputy commissioner of FDA, in a teleconference announcing the partnership. “They will greatly increase our knowledge.”

All data from the consortium will be available for public use.

The Stevens-Johnson Syndrome project will be based at Columbia University, New York. The consortium expects that some results could be forthcoming by next year, Mr. Holden said.

The drug-induced liver toxicity project will include many patients enrolled in two European research networks. Drug-induced liver injury is now the leading cause of acute liver failure in the United States.

For the drug companies involved in the consortium, the effort could help avoid scenarios in which a few adverse events prevent the approval of drugs that cost large sums to develop.

Adverse-event susceptibility information also might prevent some drugs from being taken off the market unnecessarily, Mr. Holden said.

“It is a tragedy when a drug gets to late development, and then two or three patients develop a problem and its approval gets dropped,” said Dr. Paul Watkins, an investigator with the Drug-Induced Liver Injury Network and a professor of medicine at the University of North Carolina, Chapel Hill.

Although the initial goal of the new consortium is to develop ways to identify susceptible people, the information also could improve future drug design, noted Dr. Watkins, who is not involved in the new consortium.

Some observers may question whether genetics contributes to drug-induced liver failure.

However, “it is great the pharmaceutical companies are starting to study this area,” said Howard Coleman, who is the the chief executive officer of Genelex Corp., a Seattle-based company that completes enzyme-mediated testing of drug metabolism.

“It's good to see, because even with the most common drug reactions, this kind of work needs extraordinary numbers of patients,” he said.

The consortium members include Abbott, GlaxoSmithKline, Johnson & Johnson Pharmaceutical Research and Development, Pfizer, Roche, Sanofi-Aventis, Wyeth, Illumina Inc., and research groups at Newcastle (England) University and Columbia University.

A group of seven of the largest drug manufacturers has formed a consortium to study the genetics of serious adverse drug reactions.

The Serious Adverse Events Consortium will work closely with the Food and Drug Administration on the projects that it will undertake.

This group is one of several consortiums that were recently organized, with encouragement from the FDA, to support costly research initiatives. Others include the Predictive Safety Testing Consortium, the Biomarkers Consortium, and the Microarrary Quality Control project.

In its first two projects, the Serious Adverse Events Consortium will investigate genetic susceptibility to Stevens-Johnson Syndrome and also to drug-induced liver toxicity.

The scope of such projects would be beyond the capability of any one company or institution, said Arthur L. Holden, the chairman of the new consortium.

The two conditions targeted in the first two projects are so rare that it will probably be necessary to study tens of thousands of individuals.

“We really look forward to the results of these two projects,” said Dr. Janet Woodcock, deputy commissioner of FDA, in a teleconference announcing the partnership. “They will greatly increase our knowledge.”

All data from the consortium will be available for public use.

The Stevens-Johnson Syndrome project will be based at Columbia University, New York. The consortium expects that some results could be forthcoming by next year, Mr. Holden said.

The drug-induced liver toxicity project will include many patients enrolled in two European research networks. Drug-induced liver injury is now the leading cause of acute liver failure in the United States.

For the drug companies involved in the consortium, the effort could help avoid scenarios in which a few adverse events prevent the approval of drugs that cost large sums to develop.

Adverse-event susceptibility information also might prevent some drugs from being taken off the market unnecessarily, Mr. Holden said.

“It is a tragedy when a drug gets to late development, and then two or three patients develop a problem and its approval gets dropped,” said Dr. Paul Watkins, an investigator with the Drug-Induced Liver Injury Network and a professor of medicine at the University of North Carolina, Chapel Hill.

Although the initial goal of the new consortium is to develop ways to identify susceptible people, the information also could improve future drug design, noted Dr. Watkins, who is not involved in the new consortium.

Some observers may question whether genetics contributes to drug-induced liver failure.

However, “it is great the pharmaceutical companies are starting to study this area,” said Howard Coleman, who is the the chief executive officer of Genelex Corp., a Seattle-based company that completes enzyme-mediated testing of drug metabolism.

“It's good to see, because even with the most common drug reactions, this kind of work needs extraordinary numbers of patients,” he said.

The consortium members include Abbott, GlaxoSmithKline, Johnson & Johnson Pharmaceutical Research and Development, Pfizer, Roche, Sanofi-Aventis, Wyeth, Illumina Inc., and research groups at Newcastle (England) University and Columbia University.

A group of seven of the largest drug manufacturers has formed a consortium to study the genetics of serious adverse drug reactions.

The Serious Adverse Events Consortium will work closely with the Food and Drug Administration on the projects that it will undertake.

This group is one of several consortiums that were recently organized, with encouragement from the FDA, to support costly research initiatives. Others include the Predictive Safety Testing Consortium, the Biomarkers Consortium, and the Microarrary Quality Control project.

In its first two projects, the Serious Adverse Events Consortium will investigate genetic susceptibility to Stevens-Johnson Syndrome and also to drug-induced liver toxicity.

The scope of such projects would be beyond the capability of any one company or institution, said Arthur L. Holden, the chairman of the new consortium.

The two conditions targeted in the first two projects are so rare that it will probably be necessary to study tens of thousands of individuals.

“We really look forward to the results of these two projects,” said Dr. Janet Woodcock, deputy commissioner of FDA, in a teleconference announcing the partnership. “They will greatly increase our knowledge.”

All data from the consortium will be available for public use.

The Stevens-Johnson Syndrome project will be based at Columbia University, New York. The consortium expects that some results could be forthcoming by next year, Mr. Holden said.

The drug-induced liver toxicity project will include many patients enrolled in two European research networks. Drug-induced liver injury is now the leading cause of acute liver failure in the United States.

For the drug companies involved in the consortium, the effort could help avoid scenarios in which a few adverse events prevent the approval of drugs that cost large sums to develop.

Adverse-event susceptibility information also might prevent some drugs from being taken off the market unnecessarily, Mr. Holden said.

“It is a tragedy when a drug gets to late development, and then two or three patients develop a problem and its approval gets dropped,” said Dr. Paul Watkins, an investigator with the Drug-Induced Liver Injury Network and a professor of medicine at the University of North Carolina, Chapel Hill.

Although the initial goal of the new consortium is to develop ways to identify susceptible people, the information also could improve future drug design, noted Dr. Watkins, who is not involved in the new consortium.

Some observers may question whether genetics contributes to drug-induced liver failure.

However, “it is great the pharmaceutical companies are starting to study this area,” said Howard Coleman, who is the the chief executive officer of Genelex Corp., a Seattle-based company that completes enzyme-mediated testing of drug metabolism.

“It's good to see, because even with the most common drug reactions, this kind of work needs extraordinary numbers of patients,” he said.

The consortium members include Abbott, GlaxoSmithKline, Johnson & Johnson Pharmaceutical Research and Development, Pfizer, Roche, Sanofi-Aventis, Wyeth, Illumina Inc., and research groups at Newcastle (England) University and Columbia University.

Hospitalists discharge patients an average of almost 1 day earlier than do nonhospitalist physicians. The difference is greater for patients with conditions like stroke that require close monitoring, according to a study.

The likelihood of readmission or mortality is not greater in those discharged earlier, reported Dr. William Southern and colleagues at Montefiore Medical Center, Albert Einstein College of Medicine, New York.

Dr. Southern's study looked at data from all 9,037 patients seen at the center's teaching hospital, Weiler Hospital, from 2002 to 2004. The study compared the lengths of stay and outcomes of patients cared for by a hospitalist faculty-member team versus patients cared for by faculty who were not hospitalists and who spent no more than 2 months per year on inpatient service (Arch. Intern. Med. 2007;167:1869–74).

Their analysis showed patients seen by hospitalists stayed an average of 5.0 days, versus 5.9 days for those seen by nonhospitalists.

The biggest reductions in stay for the hospitalists were stroke patients (a mean of 8.6 days vs. 12.5 days), sepsis (8.6 days vs. 12.3 days), pneumonia (6.9 days vs. 8.4 days), heart failure (4.6 days vs. 5.8 days), and asthma/chronic obstructive pulmonary disease (3.5 days vs. 4.5 days).

Dr. Southern said these patients could likely benefit most from close monitoring.

Only arrhythmia patients had a longer stay in the care of a hospitalist (4.3 days vs. 4.0 days).

The complexity of discharge planning also appeared to be a factor, Dr. Southern said.

The study indicated that for patients going home, hospitalist care reduced the mean length of hospital stay by less than half a day. For those going to home health care, the reduction was about a day, and for those going to a skilled nursing facility, it was about 2 days.

These reductions can probably be attributed to hospitalist physicians having greater familiarity in working with ancillary staff, such as social workers or discharge planners, Dr. Southern said.

One shortcoming of the study was that only 5 hospitalist groups were included, versus 54 nonhospitalist groups. It would be easier for an outlier among the hospitalist groups to influence mean length of stay.

And although the study found no significant differences in 30-day mortality and in-hospital mortality, it was not large enough to detect small possible differences, he said.

Hospitalists discharge patients an average of almost 1 day earlier than do nonhospitalist physicians. The difference is greater for patients with conditions like stroke that require close monitoring, according to a study.

The likelihood of readmission or mortality is not greater in those discharged earlier, reported Dr. William Southern and colleagues at Montefiore Medical Center, Albert Einstein College of Medicine, New York.

Dr. Southern's study looked at data from all 9,037 patients seen at the center's teaching hospital, Weiler Hospital, from 2002 to 2004. The study compared the lengths of stay and outcomes of patients cared for by a hospitalist faculty-member team versus patients cared for by faculty who were not hospitalists and who spent no more than 2 months per year on inpatient service (Arch. Intern. Med. 2007;167:1869–74).

Their analysis showed patients seen by hospitalists stayed an average of 5.0 days, versus 5.9 days for those seen by nonhospitalists.

The biggest reductions in stay for the hospitalists were stroke patients (a mean of 8.6 days vs. 12.5 days), sepsis (8.6 days vs. 12.3 days), pneumonia (6.9 days vs. 8.4 days), heart failure (4.6 days vs. 5.8 days), and asthma/chronic obstructive pulmonary disease (3.5 days vs. 4.5 days).

Dr. Southern said these patients could likely benefit most from close monitoring.

Only arrhythmia patients had a longer stay in the care of a hospitalist (4.3 days vs. 4.0 days).

The complexity of discharge planning also appeared to be a factor, Dr. Southern said.

The study indicated that for patients going home, hospitalist care reduced the mean length of hospital stay by less than half a day. For those going to home health care, the reduction was about a day, and for those going to a skilled nursing facility, it was about 2 days.

These reductions can probably be attributed to hospitalist physicians having greater familiarity in working with ancillary staff, such as social workers or discharge planners, Dr. Southern said.

One shortcoming of the study was that only 5 hospitalist groups were included, versus 54 nonhospitalist groups. It would be easier for an outlier among the hospitalist groups to influence mean length of stay.

And although the study found no significant differences in 30-day mortality and in-hospital mortality, it was not large enough to detect small possible differences, he said.

Hospitalists discharge patients an average of almost 1 day earlier than do nonhospitalist physicians. The difference is greater for patients with conditions like stroke that require close monitoring, according to a study.

The likelihood of readmission or mortality is not greater in those discharged earlier, reported Dr. William Southern and colleagues at Montefiore Medical Center, Albert Einstein College of Medicine, New York.

Dr. Southern's study looked at data from all 9,037 patients seen at the center's teaching hospital, Weiler Hospital, from 2002 to 2004. The study compared the lengths of stay and outcomes of patients cared for by a hospitalist faculty-member team versus patients cared for by faculty who were not hospitalists and who spent no more than 2 months per year on inpatient service (Arch. Intern. Med. 2007;167:1869–74).

Their analysis showed patients seen by hospitalists stayed an average of 5.0 days, versus 5.9 days for those seen by nonhospitalists.

The biggest reductions in stay for the hospitalists were stroke patients (a mean of 8.6 days vs. 12.5 days), sepsis (8.6 days vs. 12.3 days), pneumonia (6.9 days vs. 8.4 days), heart failure (4.6 days vs. 5.8 days), and asthma/chronic obstructive pulmonary disease (3.5 days vs. 4.5 days).

Dr. Southern said these patients could likely benefit most from close monitoring.

Only arrhythmia patients had a longer stay in the care of a hospitalist (4.3 days vs. 4.0 days).

The complexity of discharge planning also appeared to be a factor, Dr. Southern said.

The study indicated that for patients going home, hospitalist care reduced the mean length of hospital stay by less than half a day. For those going to home health care, the reduction was about a day, and for those going to a skilled nursing facility, it was about 2 days.

These reductions can probably be attributed to hospitalist physicians having greater familiarity in working with ancillary staff, such as social workers or discharge planners, Dr. Southern said.

One shortcoming of the study was that only 5 hospitalist groups were included, versus 54 nonhospitalist groups. It would be easier for an outlier among the hospitalist groups to influence mean length of stay.

And although the study found no significant differences in 30-day mortality and in-hospital mortality, it was not large enough to detect small possible differences, he said.

By making some simple changes, Dr. S. Germain Cassiere has dramatically reduced the amount of time patients must wait for lab tests.

As in many medical offices, his patients for many years had signed in on a sheet of paper to let the receptionist and technicians know they were there, he said. Then the patients waited for an average of 25–30 minutes, and often longer on busier days, such as Monday and Tuesday.

Dr. Cassiere's solution was to put a computer terminal with a touch screen in the waiting room to replace the paper sheet.

“The patients use the wall-mounted touch screen as a keyboard to enter their names and select what services are needed,” said Dr. Cassiere, who works in a six-physician general internal medicine practice in Shreveport, La. “The completion of this one-page data entry generates a record in the database for that particular outpatient service center.”

The technicians can see on their own computer screens the names of waiting patients and when they arrived. After patients have been called in and had their blood drawn, the technician logs them out with a click on the screen.

A program called LABRATS (Lab Registration Access Touch Screen) tracks each part of the process and can report an hourly patient count, record the number of registration technicians and phlebotomists present, and calculate the average time for every step. Monthly reports, which allow the lab staff to track trends, showed that Mondays and Tuesdays are the busiest, and therefore may require more personnel.

With the system, the average wait time for lab tests has declined 40%, to an average of about 18 minutes. The technicians and phlebotomists appreciate being accountable, knowing how they are doing, and showing their efficiency, Dr. Cassiere said.

And patients appreciate it. “They notice it takes less time. No one likes to wait.”

After patients are finished having blood drawn for tests, they are deleted from the system, so there is no conflict with HIPAA confidentiality rules, he noted.

When Dr. Cassiere first proposed the system, there was skepticism from some in administration and the information technology department at Willis-Knighton Health Systems, the health services provider he works with, about its feasibility and patient acceptability of the process.

Dr. Cassiere took that as a challenge. He developed the system himself using the same Nexus Database System he had used to develop a message-tracking system to log incoming phone calls so they are returned more reliably.

The LABRATS system has worked so well that it has been adapted for use in the general admission process and is now being deployed for use in all 12 outpatient service centers of the health service, he said.

By making some simple changes, Dr. S. Germain Cassiere has dramatically reduced the amount of time patients must wait for lab tests.

As in many medical offices, his patients for many years had signed in on a sheet of paper to let the receptionist and technicians know they were there, he said. Then the patients waited for an average of 25–30 minutes, and often longer on busier days, such as Monday and Tuesday.

Dr. Cassiere's solution was to put a computer terminal with a touch screen in the waiting room to replace the paper sheet.

“The patients use the wall-mounted touch screen as a keyboard to enter their names and select what services are needed,” said Dr. Cassiere, who works in a six-physician general internal medicine practice in Shreveport, La. “The completion of this one-page data entry generates a record in the database for that particular outpatient service center.”

The technicians can see on their own computer screens the names of waiting patients and when they arrived. After patients have been called in and had their blood drawn, the technician logs them out with a click on the screen.

A program called LABRATS (Lab Registration Access Touch Screen) tracks each part of the process and can report an hourly patient count, record the number of registration technicians and phlebotomists present, and calculate the average time for every step. Monthly reports, which allow the lab staff to track trends, showed that Mondays and Tuesdays are the busiest, and therefore may require more personnel.

With the system, the average wait time for lab tests has declined 40%, to an average of about 18 minutes. The technicians and phlebotomists appreciate being accountable, knowing how they are doing, and showing their efficiency, Dr. Cassiere said.

And patients appreciate it. “They notice it takes less time. No one likes to wait.”

After patients are finished having blood drawn for tests, they are deleted from the system, so there is no conflict with HIPAA confidentiality rules, he noted.

When Dr. Cassiere first proposed the system, there was skepticism from some in administration and the information technology department at Willis-Knighton Health Systems, the health services provider he works with, about its feasibility and patient acceptability of the process.

Dr. Cassiere took that as a challenge. He developed the system himself using the same Nexus Database System he had used to develop a message-tracking system to log incoming phone calls so they are returned more reliably.

The LABRATS system has worked so well that it has been adapted for use in the general admission process and is now being deployed for use in all 12 outpatient service centers of the health service, he said.

By making some simple changes, Dr. S. Germain Cassiere has dramatically reduced the amount of time patients must wait for lab tests.

As in many medical offices, his patients for many years had signed in on a sheet of paper to let the receptionist and technicians know they were there, he said. Then the patients waited for an average of 25–30 minutes, and often longer on busier days, such as Monday and Tuesday.

Dr. Cassiere's solution was to put a computer terminal with a touch screen in the waiting room to replace the paper sheet.

“The patients use the wall-mounted touch screen as a keyboard to enter their names and select what services are needed,” said Dr. Cassiere, who works in a six-physician general internal medicine practice in Shreveport, La. “The completion of this one-page data entry generates a record in the database for that particular outpatient service center.”

The technicians can see on their own computer screens the names of waiting patients and when they arrived. After patients have been called in and had their blood drawn, the technician logs them out with a click on the screen.

A program called LABRATS (Lab Registration Access Touch Screen) tracks each part of the process and can report an hourly patient count, record the number of registration technicians and phlebotomists present, and calculate the average time for every step. Monthly reports, which allow the lab staff to track trends, showed that Mondays and Tuesdays are the busiest, and therefore may require more personnel.

With the system, the average wait time for lab tests has declined 40%, to an average of about 18 minutes. The technicians and phlebotomists appreciate being accountable, knowing how they are doing, and showing their efficiency, Dr. Cassiere said.

And patients appreciate it. “They notice it takes less time. No one likes to wait.”

After patients are finished having blood drawn for tests, they are deleted from the system, so there is no conflict with HIPAA confidentiality rules, he noted.

When Dr. Cassiere first proposed the system, there was skepticism from some in administration and the information technology department at Willis-Knighton Health Systems, the health services provider he works with, about its feasibility and patient acceptability of the process.

Dr. Cassiere took that as a challenge. He developed the system himself using the same Nexus Database System he had used to develop a message-tracking system to log incoming phone calls so they are returned more reliably.

The LABRATS system has worked so well that it has been adapted for use in the general admission process and is now being deployed for use in all 12 outpatient service centers of the health service, he said.

LOS ANGELES — HIV-positive patients on antiretroviral therapy who are prescribed lipid-lowering agents do not respond to those drugs as well as other patients do, according to a large retrospective study.

The HIV patients were 57% as likely to reach the National Cholesterol Education Program's Adult Treatment Panel III (ATP-III) lipid goals with treatment, compared with those not HIV infected, Michael Silverberg, Ph.D., of the division of research, Kaiser Permanente Northern California, Oakland, and his colleagues said in a poster presentation at the 14th Conference on Retroviruses and Opportunistic Infections.

The HIV patients also had a mean drop in total cholesterol that was 4 percentage points lower than the change in controls (a mean reduction of 18% vs. 22%), a drop in LDL cholesterol that was 2 percentage points lower (22% vs. 24%), and a drop in triglycerides that was 17 percentage points lower (36% vs. 53%). The researchers analyzed data from all the HIV patients in their health system seen between 1996 and 2005 who met the ATP-III definition of dyslipidemia, and compared them each with 10 controls, matched for age, sex, and first year of lipidemia, who also received lipid-lowering therapy.

HIV patients on a regimen of a protease inhibitor plus a nonnucleoside reverse transcriptase inhibitor had the lowest reductions in total cholesterol and triglycerides of any of the HIV patients. Their mean reduction in total cholesterol was 17%, and their mean reduction in triglycerides was 16%.

The most common lipid-lowering therapy used in the patients and the controls was a statin; pravastatin was used more commonly in the HIV patients, he said.

LOS ANGELES — HIV-positive patients on antiretroviral therapy who are prescribed lipid-lowering agents do not respond to those drugs as well as other patients do, according to a large retrospective study.

The HIV patients were 57% as likely to reach the National Cholesterol Education Program's Adult Treatment Panel III (ATP-III) lipid goals with treatment, compared with those not HIV infected, Michael Silverberg, Ph.D., of the division of research, Kaiser Permanente Northern California, Oakland, and his colleagues said in a poster presentation at the 14th Conference on Retroviruses and Opportunistic Infections.

The HIV patients also had a mean drop in total cholesterol that was 4 percentage points lower than the change in controls (a mean reduction of 18% vs. 22%), a drop in LDL cholesterol that was 2 percentage points lower (22% vs. 24%), and a drop in triglycerides that was 17 percentage points lower (36% vs. 53%). The researchers analyzed data from all the HIV patients in their health system seen between 1996 and 2005 who met the ATP-III definition of dyslipidemia, and compared them each with 10 controls, matched for age, sex, and first year of lipidemia, who also received lipid-lowering therapy.

HIV patients on a regimen of a protease inhibitor plus a nonnucleoside reverse transcriptase inhibitor had the lowest reductions in total cholesterol and triglycerides of any of the HIV patients. Their mean reduction in total cholesterol was 17%, and their mean reduction in triglycerides was 16%.

The most common lipid-lowering therapy used in the patients and the controls was a statin; pravastatin was used more commonly in the HIV patients, he said.

LOS ANGELES — HIV-positive patients on antiretroviral therapy who are prescribed lipid-lowering agents do not respond to those drugs as well as other patients do, according to a large retrospective study.

The HIV patients were 57% as likely to reach the National Cholesterol Education Program's Adult Treatment Panel III (ATP-III) lipid goals with treatment, compared with those not HIV infected, Michael Silverberg, Ph.D., of the division of research, Kaiser Permanente Northern California, Oakland, and his colleagues said in a poster presentation at the 14th Conference on Retroviruses and Opportunistic Infections.

The HIV patients also had a mean drop in total cholesterol that was 4 percentage points lower than the change in controls (a mean reduction of 18% vs. 22%), a drop in LDL cholesterol that was 2 percentage points lower (22% vs. 24%), and a drop in triglycerides that was 17 percentage points lower (36% vs. 53%). The researchers analyzed data from all the HIV patients in their health system seen between 1996 and 2005 who met the ATP-III definition of dyslipidemia, and compared them each with 10 controls, matched for age, sex, and first year of lipidemia, who also received lipid-lowering therapy.

HIV patients on a regimen of a protease inhibitor plus a nonnucleoside reverse transcriptase inhibitor had the lowest reductions in total cholesterol and triglycerides of any of the HIV patients. Their mean reduction in total cholesterol was 17%, and their mean reduction in triglycerides was 16%.

The most common lipid-lowering therapy used in the patients and the controls was a statin; pravastatin was used more commonly in the HIV patients, he said.

CHICAGO — When advancing a patient with type 2 diabetes to insulin therapy, the choice of whether to use mealtime insulin plus a basal insulin at bedtime or just a mealtime mix of rapid- and longer-acting insulin does not make a difference.

However, in a head-to-head trial of the two strategies, a slightly higher proportion of the patients given basal plus mealtime insulin achieved a hemoglobin A_1c (HbA_1c) level below 7%, with a lower dose of insulin needed, Dr. Julio Rosenstock said at the annual scientific sessions of the American Diabetes Association.

“Basal-bolus therapy in our trial was associated with a slightly greater reduction in A_1c from baseline, a 2.1% reduction versus 1.9% reduction.” But “clinically meaningful achievements in glycemic control can be achieved with both basal-bolus therapy and prandial-premix therapy in combination with oral agents in patients with type 2 diabetes previously treated with insulin glargine plus oral agents,” added Dr. Rosenstock, an endocrinologist in Dallas.

In the trial, one group of 187 adult patients who had been on insulin glargine plus oral agents but who were not well-controlled were put on a regimen of glargine insulin in the evenings together with lispro insulin at mealtime. A second group of 187 similar patients were put on a 50/50 mix of lispro insulin and NPL (neutral protamine lispro) insulin.

At the end of 24 weeks, 50% of those on the regimen that included evening basal insulin glargine had an HbA_1c equal to or below 6.5%, compared with 35% of those on the mealtime-mix regimen. In addition, 69% and 54%, respectively, achieved an HbA_1c equal to or below 7%.

Overall, the mean HbA_1c levels of the groups dropped from 8.9% in both groups to 6.8% in the basal group and 7% in the mealtime-mix group.

CHICAGO — When advancing a patient with type 2 diabetes to insulin therapy, the choice of whether to use mealtime insulin plus a basal insulin at bedtime or just a mealtime mix of rapid- and longer-acting insulin does not make a difference.

However, in a head-to-head trial of the two strategies, a slightly higher proportion of the patients given basal plus mealtime insulin achieved a hemoglobin A_1c (HbA_1c) level below 7%, with a lower dose of insulin needed, Dr. Julio Rosenstock said at the annual scientific sessions of the American Diabetes Association.

“Basal-bolus therapy in our trial was associated with a slightly greater reduction in A_1c from baseline, a 2.1% reduction versus 1.9% reduction.” But “clinically meaningful achievements in glycemic control can be achieved with both basal-bolus therapy and prandial-premix therapy in combination with oral agents in patients with type 2 diabetes previously treated with insulin glargine plus oral agents,” added Dr. Rosenstock, an endocrinologist in Dallas.

In the trial, one group of 187 adult patients who had been on insulin glargine plus oral agents but who were not well-controlled were put on a regimen of glargine insulin in the evenings together with lispro insulin at mealtime. A second group of 187 similar patients were put on a 50/50 mix of lispro insulin and NPL (neutral protamine lispro) insulin.

At the end of 24 weeks, 50% of those on the regimen that included evening basal insulin glargine had an HbA_1c equal to or below 6.5%, compared with 35% of those on the mealtime-mix regimen. In addition, 69% and 54%, respectively, achieved an HbA_1c equal to or below 7%.

Overall, the mean HbA_1c levels of the groups dropped from 8.9% in both groups to 6.8% in the basal group and 7% in the mealtime-mix group.

CHICAGO — When advancing a patient with type 2 diabetes to insulin therapy, the choice of whether to use mealtime insulin plus a basal insulin at bedtime or just a mealtime mix of rapid- and longer-acting insulin does not make a difference.

However, in a head-to-head trial of the two strategies, a slightly higher proportion of the patients given basal plus mealtime insulin achieved a hemoglobin A_1c (HbA_1c) level below 7%, with a lower dose of insulin needed, Dr. Julio Rosenstock said at the annual scientific sessions of the American Diabetes Association.

“Basal-bolus therapy in our trial was associated with a slightly greater reduction in A_1c from baseline, a 2.1% reduction versus 1.9% reduction.” But “clinically meaningful achievements in glycemic control can be achieved with both basal-bolus therapy and prandial-premix therapy in combination with oral agents in patients with type 2 diabetes previously treated with insulin glargine plus oral agents,” added Dr. Rosenstock, an endocrinologist in Dallas.

In the trial, one group of 187 adult patients who had been on insulin glargine plus oral agents but who were not well-controlled were put on a regimen of glargine insulin in the evenings together with lispro insulin at mealtime. A second group of 187 similar patients were put on a 50/50 mix of lispro insulin and NPL (neutral protamine lispro) insulin.

At the end of 24 weeks, 50% of those on the regimen that included evening basal insulin glargine had an HbA_1c equal to or below 6.5%, compared with 35% of those on the mealtime-mix regimen. In addition, 69% and 54%, respectively, achieved an HbA_1c equal to or below 7%.

Overall, the mean HbA_1c levels of the groups dropped from 8.9% in both groups to 6.8% in the basal group and 7% in the mealtime-mix group.

A mother who smokes and breast-feeds appears to be giving her infant a dose of nicotine that significantly interferes with the baby's sleep, according to the results of a study.

Infants spent an average of about a third less time sleeping after their mothers smoked just prior to breast-feeding, compared with when the mothers refrained, wrote Julie A. Mennella, Ph.D., and her associates at the Monell Chemical Senses Center in Philadelphia.

Nicotine is not listed as a drug that is contraindicated during breast-feeding because the benefits of breast-feeding are considered to be so great, they noted.

But the presence of nicotine in breast milk could have many adverse consequences. Mothers who smoke are known to wean their children earlier than are mothers who do not. It might be that sleep-deprived infants tend to be fussier and, if the sleep deprivation occurs because of smoking, the fussiness may stop when the mother stops breast-feeding. That in turn may reinforce a smoking mother's decision to wean. Sleep also is known to be important for learning and development, and therefore disruption of sleep caused by smoking could have lasting consequences. Lastly, adolescents whose mothers smoked during their early life are more likely to smoke, and this may sometimes be because they recognize the flavors from breast milk and come to appreciate them.

The study was conducted with 15 volunteer mother-infant pairs. The average age of the infants was 4 months. The mothers were brought into a testing center twice, and told to refrain from smoking for 12 hours before each testing session, with the last breast-feeding done about 2.5 hours before the session. During one testing session, they were allowed to smoke at least one cigarette, in a separate room from the infant, and during one session they were not (Pediatrics 2007;120:497–502).

Nicotine levels in breast milk were measured at baseline and after smoking. The infants' sleep and awake times were monitored using an ambulatory monitor for 3.5 hours. Nicotine stored in breast milk reaches peak levels about 30–60 minutes after smoking, then declines fairly rapidly.

During the smoking session, the estimated dose of nicotine delivered to the infants was a mean of 549 ng/kg, compared with 127 ng/kg during the nonsmoking session. During the nonsmoking session, the infants slept a mean of 84.5 minutes, compared with 53.4 minutes during the smoking session. All but two of the infants slept less during the smoking session.

Both active sleep and quiet sleep were reduced with smoking, and the duration of the longest bout of sleep declined from a mean of 60 minutes during the nonsmoking session to a mean of 37 minutes during the smoking session.

A mother who smokes and breast-feeds appears to be giving her infant a dose of nicotine that significantly interferes with the baby's sleep, according to the results of a study.

Infants spent an average of about a third less time sleeping after their mothers smoked just prior to breast-feeding, compared with when the mothers refrained, wrote Julie A. Mennella, Ph.D., and her associates at the Monell Chemical Senses Center in Philadelphia.

Nicotine is not listed as a drug that is contraindicated during breast-feeding because the benefits of breast-feeding are considered to be so great, they noted.

But the presence of nicotine in breast milk could have many adverse consequences. Mothers who smoke are known to wean their children earlier than are mothers who do not. It might be that sleep-deprived infants tend to be fussier and, if the sleep deprivation occurs because of smoking, the fussiness may stop when the mother stops breast-feeding. That in turn may reinforce a smoking mother's decision to wean. Sleep also is known to be important for learning and development, and therefore disruption of sleep caused by smoking could have lasting consequences. Lastly, adolescents whose mothers smoked during their early life are more likely to smoke, and this may sometimes be because they recognize the flavors from breast milk and come to appreciate them.

The study was conducted with 15 volunteer mother-infant pairs. The average age of the infants was 4 months. The mothers were brought into a testing center twice, and told to refrain from smoking for 12 hours before each testing session, with the last breast-feeding done about 2.5 hours before the session. During one testing session, they were allowed to smoke at least one cigarette, in a separate room from the infant, and during one session they were not (Pediatrics 2007;120:497–502).

Nicotine levels in breast milk were measured at baseline and after smoking. The infants' sleep and awake times were monitored using an ambulatory monitor for 3.5 hours. Nicotine stored in breast milk reaches peak levels about 30–60 minutes after smoking, then declines fairly rapidly.

During the smoking session, the estimated dose of nicotine delivered to the infants was a mean of 549 ng/kg, compared with 127 ng/kg during the nonsmoking session. During the nonsmoking session, the infants slept a mean of 84.5 minutes, compared with 53.4 minutes during the smoking session. All but two of the infants slept less during the smoking session.

Both active sleep and quiet sleep were reduced with smoking, and the duration of the longest bout of sleep declined from a mean of 60 minutes during the nonsmoking session to a mean of 37 minutes during the smoking session.

A mother who smokes and breast-feeds appears to be giving her infant a dose of nicotine that significantly interferes with the baby's sleep, according to the results of a study.

Infants spent an average of about a third less time sleeping after their mothers smoked just prior to breast-feeding, compared with when the mothers refrained, wrote Julie A. Mennella, Ph.D., and her associates at the Monell Chemical Senses Center in Philadelphia.

Nicotine is not listed as a drug that is contraindicated during breast-feeding because the benefits of breast-feeding are considered to be so great, they noted.

But the presence of nicotine in breast milk could have many adverse consequences. Mothers who smoke are known to wean their children earlier than are mothers who do not. It might be that sleep-deprived infants tend to be fussier and, if the sleep deprivation occurs because of smoking, the fussiness may stop when the mother stops breast-feeding. That in turn may reinforce a smoking mother's decision to wean. Sleep also is known to be important for learning and development, and therefore disruption of sleep caused by smoking could have lasting consequences. Lastly, adolescents whose mothers smoked during their early life are more likely to smoke, and this may sometimes be because they recognize the flavors from breast milk and come to appreciate them.

The study was conducted with 15 volunteer mother-infant pairs. The average age of the infants was 4 months. The mothers were brought into a testing center twice, and told to refrain from smoking for 12 hours before each testing session, with the last breast-feeding done about 2.5 hours before the session. During one testing session, they were allowed to smoke at least one cigarette, in a separate room from the infant, and during one session they were not (Pediatrics 2007;120:497–502).

Nicotine levels in breast milk were measured at baseline and after smoking. The infants' sleep and awake times were monitored using an ambulatory monitor for 3.5 hours. Nicotine stored in breast milk reaches peak levels about 30–60 minutes after smoking, then declines fairly rapidly.

During the smoking session, the estimated dose of nicotine delivered to the infants was a mean of 549 ng/kg, compared with 127 ng/kg during the nonsmoking session. During the nonsmoking session, the infants slept a mean of 84.5 minutes, compared with 53.4 minutes during the smoking session. All but two of the infants slept less during the smoking session.

Both active sleep and quiet sleep were reduced with smoking, and the duration of the longest bout of sleep declined from a mean of 60 minutes during the nonsmoking session to a mean of 37 minutes during the smoking session.

The U.S. Army's report that its 2006 suicide rate was the highest in the 26 years it has been keeping records was greeted with concern by experts, but also with some circumspection.

Some suggested that it might reflect stress from the duration of the wars in Iraq and Afghanistan, but no one immediately jumped to major criticism of the military or its efforts at mental health provision and promotion.

The “report underscores even more powerfully the urgency of getting our soldiers the care and assistance they need before they deploy, while they are in combat, and most importantly, when they return,” Sen. John Kerry (D-Mass.) said in a statement.

“Although a 1-year increase does not make for a significant and lasting increase from a scientific perspective, it's certainly alarming, particularly when you take into consideration the documented high rates of posttraumatic stress disorder and depression among those having served in combat in Iraq and Afghanistan,” M. David Rudd, Ph.D., chair of the department of psychology at Texas Tech University, Lubbock, said in an interview.

“This problem is certainly different from the Gulf War, when I was an Army psychologist,” added Dr. Rudd, a past president of the American Association of Suicidology. “The prolonged nature of the conflict and limited troops has resulted in some challenging and unforeseen mental health consequences.”

According to the 2006 Army Suicide Event Report, there were 99 suicides among active-duty personnel in 2006, with two more suspicious deaths still under investigation. Twenty-seven of those suicide deaths occurred in Iraq, and three occurred in Afghanistan. The report also counted 948 serious suicide attempts that were not successful.

Of the suicides, 71% involved the use of firearms. Seventy percent of the individuals were under 25 years of age, and 10% were female. Ninety-eight percent of the persons were enlisted, and 91% were from the regular army.

In announcing the report, Col. Elspeth C. Ritchie, MC USA, a psychiatry consultant to the Army Surgeon General, said that the investigators were unable to find a direct relationship between deployment, combat, and suicide, although they looked closely.

Instead, the common features were those associated with suicide in general: financial problems, previous mental illness, and failed marital relationships. In fact, a failed marital relationship accounted for 55% of the completed suicides and 40% of the attempted suicides.

“Very often, a young soldier gets a 'Dear John' or a 'Dear Jane' letter and then takes his weapon and shoots himself,” Dr. Ritchie said at a Pentagon news conference.

She did note, however, that repeated deployment put a strain on relationships.

The suicide rate for the entire 500,000-person Army, the report said, was 17.3 per 100,000 persons. That is the highest rate since the Army began counting in 1980.

That rate, however, is not that different from what one sees in the general population, if one considers only those of the same demographic of young males, Army officials and others have said. The rate for males of a comparable age is 18.6 per 100,000.

The highest number of suicides in the Army was 102 in 1991, the year of the Persian Gulf War. The lowest rate was 9.1 per 100,000 in 2001. In 2005, the Army had 88 suicides.

A few days after the Army report, the Army National Guard's Suicide Prevention Program announced that the National Guard has had 42 suicides through Aug. 13 for fiscal year 2007, which ranks suicide as the third most common cause of death behind combat and accidents.

Since the start of the Iraq War, the Army and the Veterans Administration have been overwhelmed by the mental health needs of military personnel. Both have come in for criticism, but both also have worked to increase funding and services and, in the case of the Army, to reduce some of the stigma that has been attached to seeking mental health help in the military.

The Army is currently seeking to recruit an additional 250 mental health professionals, including psychiatrists, but both the Army and the VA have reported that they are having a hard time finding such personnel.

It is estimated that 20% of soldiers returning from the current wars have signs of posttraumatic stress disorder.

The Army's contention that suicides are not tied to combat and deployment is very plausible because it is consistent with what is seen in other branches of the service, said Dr. (Lt. Col.) Steven Pflanz, chief of the Air Force Suicide Prevention Program, which is seen as a model for all the military branches.

“We see the same stuff that you see in civilian populations—legal, financial, marital problems,” he said.

The high rate of suicide in the Army is not surprising because it is made up of young males who have guns at hand, said Mark Kaplan, Dr.P.H., professor of community health at Portland (Ore.) State University, who recently published a study showing that male veterans are twice as likely to commit suicide as their counterparts with no military experience.

Although this year's increase might represent some reflection of a growing disaffection for the war among soldiers, it may also just be a 1-year blip, he said. “There needs to be more aggressive interventions. But there may be limits to how much you can bring rates down,” he noted.

The U.S. Army's report that its 2006 suicide rate was the highest in the 26 years it has been keeping records was greeted with concern by experts, but also with some circumspection.

Some suggested that it might reflect stress from the duration of the wars in Iraq and Afghanistan, but no one immediately jumped to major criticism of the military or its efforts at mental health provision and promotion.

The “report underscores even more powerfully the urgency of getting our soldiers the care and assistance they need before they deploy, while they are in combat, and most importantly, when they return,” Sen. John Kerry (D-Mass.) said in a statement.

“Although a 1-year increase does not make for a significant and lasting increase from a scientific perspective, it's certainly alarming, particularly when you take into consideration the documented high rates of posttraumatic stress disorder and depression among those having served in combat in Iraq and Afghanistan,” M. David Rudd, Ph.D., chair of the department of psychology at Texas Tech University, Lubbock, said in an interview.

“This problem is certainly different from the Gulf War, when I was an Army psychologist,” added Dr. Rudd, a past president of the American Association of Suicidology. “The prolonged nature of the conflict and limited troops has resulted in some challenging and unforeseen mental health consequences.”

According to the 2006 Army Suicide Event Report, there were 99 suicides among active-duty personnel in 2006, with two more suspicious deaths still under investigation. Twenty-seven of those suicide deaths occurred in Iraq, and three occurred in Afghanistan. The report also counted 948 serious suicide attempts that were not successful.

Of the suicides, 71% involved the use of firearms. Seventy percent of the individuals were under 25 years of age, and 10% were female. Ninety-eight percent of the persons were enlisted, and 91% were from the regular army.

In announcing the report, Col. Elspeth C. Ritchie, MC USA, a psychiatry consultant to the Army Surgeon General, said that the investigators were unable to find a direct relationship between deployment, combat, and suicide, although they looked closely.

Instead, the common features were those associated with suicide in general: financial problems, previous mental illness, and failed marital relationships. In fact, a failed marital relationship accounted for 55% of the completed suicides and 40% of the attempted suicides.

“Very often, a young soldier gets a 'Dear John' or a 'Dear Jane' letter and then takes his weapon and shoots himself,” Dr. Ritchie said at a Pentagon news conference.

She did note, however, that repeated deployment put a strain on relationships.

The suicide rate for the entire 500,000-person Army, the report said, was 17.3 per 100,000 persons. That is the highest rate since the Army began counting in 1980.

That rate, however, is not that different from what one sees in the general population, if one considers only those of the same demographic of young males, Army officials and others have said. The rate for males of a comparable age is 18.6 per 100,000.

The highest number of suicides in the Army was 102 in 1991, the year of the Persian Gulf War. The lowest rate was 9.1 per 100,000 in 2001. In 2005, the Army had 88 suicides.

A few days after the Army report, the Army National Guard's Suicide Prevention Program announced that the National Guard has had 42 suicides through Aug. 13 for fiscal year 2007, which ranks suicide as the third most common cause of death behind combat and accidents.

Since the start of the Iraq War, the Army and the Veterans Administration have been overwhelmed by the mental health needs of military personnel. Both have come in for criticism, but both also have worked to increase funding and services and, in the case of the Army, to reduce some of the stigma that has been attached to seeking mental health help in the military.

The Army is currently seeking to recruit an additional 250 mental health professionals, including psychiatrists, but both the Army and the VA have reported that they are having a hard time finding such personnel.

It is estimated that 20% of soldiers returning from the current wars have signs of posttraumatic stress disorder.

The Army's contention that suicides are not tied to combat and deployment is very plausible because it is consistent with what is seen in other branches of the service, said Dr. (Lt. Col.) Steven Pflanz, chief of the Air Force Suicide Prevention Program, which is seen as a model for all the military branches.

“We see the same stuff that you see in civilian populations—legal, financial, marital problems,” he said.

The high rate of suicide in the Army is not surprising because it is made up of young males who have guns at hand, said Mark Kaplan, Dr.P.H., professor of community health at Portland (Ore.) State University, who recently published a study showing that male veterans are twice as likely to commit suicide as their counterparts with no military experience.

Although this year's increase might represent some reflection of a growing disaffection for the war among soldiers, it may also just be a 1-year blip, he said. “There needs to be more aggressive interventions. But there may be limits to how much you can bring rates down,” he noted.

The U.S. Army's report that its 2006 suicide rate was the highest in the 26 years it has been keeping records was greeted with concern by experts, but also with some circumspection.

Some suggested that it might reflect stress from the duration of the wars in Iraq and Afghanistan, but no one immediately jumped to major criticism of the military or its efforts at mental health provision and promotion.

The “report underscores even more powerfully the urgency of getting our soldiers the care and assistance they need before they deploy, while they are in combat, and most importantly, when they return,” Sen. John Kerry (D-Mass.) said in a statement.

“Although a 1-year increase does not make for a significant and lasting increase from a scientific perspective, it's certainly alarming, particularly when you take into consideration the documented high rates of posttraumatic stress disorder and depression among those having served in combat in Iraq and Afghanistan,” M. David Rudd, Ph.D., chair of the department of psychology at Texas Tech University, Lubbock, said in an interview.

“This problem is certainly different from the Gulf War, when I was an Army psychologist,” added Dr. Rudd, a past president of the American Association of Suicidology. “The prolonged nature of the conflict and limited troops has resulted in some challenging and unforeseen mental health consequences.”

According to the 2006 Army Suicide Event Report, there were 99 suicides among active-duty personnel in 2006, with two more suspicious deaths still under investigation. Twenty-seven of those suicide deaths occurred in Iraq, and three occurred in Afghanistan. The report also counted 948 serious suicide attempts that were not successful.

Of the suicides, 71% involved the use of firearms. Seventy percent of the individuals were under 25 years of age, and 10% were female. Ninety-eight percent of the persons were enlisted, and 91% were from the regular army.

In announcing the report, Col. Elspeth C. Ritchie, MC USA, a psychiatry consultant to the Army Surgeon General, said that the investigators were unable to find a direct relationship between deployment, combat, and suicide, although they looked closely.

Instead, the common features were those associated with suicide in general: financial problems, previous mental illness, and failed marital relationships. In fact, a failed marital relationship accounted for 55% of the completed suicides and 40% of the attempted suicides.

“Very often, a young soldier gets a 'Dear John' or a 'Dear Jane' letter and then takes his weapon and shoots himself,” Dr. Ritchie said at a Pentagon news conference.

She did note, however, that repeated deployment put a strain on relationships.

The suicide rate for the entire 500,000-person Army, the report said, was 17.3 per 100,000 persons. That is the highest rate since the Army began counting in 1980.

That rate, however, is not that different from what one sees in the general population, if one considers only those of the same demographic of young males, Army officials and others have said. The rate for males of a comparable age is 18.6 per 100,000.

The highest number of suicides in the Army was 102 in 1991, the year of the Persian Gulf War. The lowest rate was 9.1 per 100,000 in 2001. In 2005, the Army had 88 suicides.

A few days after the Army report, the Army National Guard's Suicide Prevention Program announced that the National Guard has had 42 suicides through Aug. 13 for fiscal year 2007, which ranks suicide as the third most common cause of death behind combat and accidents.

Since the start of the Iraq War, the Army and the Veterans Administration have been overwhelmed by the mental health needs of military personnel. Both have come in for criticism, but both also have worked to increase funding and services and, in the case of the Army, to reduce some of the stigma that has been attached to seeking mental health help in the military.

The Army is currently seeking to recruit an additional 250 mental health professionals, including psychiatrists, but both the Army and the VA have reported that they are having a hard time finding such personnel.

It is estimated that 20% of soldiers returning from the current wars have signs of posttraumatic stress disorder.

The Army's contention that suicides are not tied to combat and deployment is very plausible because it is consistent with what is seen in other branches of the service, said Dr. (Lt. Col.) Steven Pflanz, chief of the Air Force Suicide Prevention Program, which is seen as a model for all the military branches.

“We see the same stuff that you see in civilian populations—legal, financial, marital problems,” he said.

The high rate of suicide in the Army is not surprising because it is made up of young males who have guns at hand, said Mark Kaplan, Dr.P.H., professor of community health at Portland (Ore.) State University, who recently published a study showing that male veterans are twice as likely to commit suicide as their counterparts with no military experience.

Although this year's increase might represent some reflection of a growing disaffection for the war among soldiers, it may also just be a 1-year blip, he said. “There needs to be more aggressive interventions. But there may be limits to how much you can bring rates down,” he noted.

LOS ANGELES — HIV-infected persons are now almost as likely to die of lung cancer as they are of non-Hodgkin's lymphoma, and they are more likely to die of lung cancer than of Kaposi's sarcoma, according to a large cohort of patients in developed countries.

Data from a cohort of 23,437 HIV-infected individuals followed since 1999 show that HIV-infected individuals in developed countries are now more likely to die of a cancer not traditionally associated with AIDS as they are to die of an AIDS-defining cancer, said Dr. Antonella D'Arminio Monforte of the University of Milan.

In the cohort, 193 individuals died from a non-AIDS-defining malignancy while 112 died from an AIDS-defining malignancy. The most common fatal non-AIDS cancer in the cohort was lung cancer (62 deaths), she said at the 14th Conference on Retroviruses and Opportunistic Infections.

The cohort, known as the DAD (Data Collection on Adverse Events of Anti-HIV Drugs) study group, had 82 deaths from non-Hodgkin's lymphoma and 28 deaths from Kaposi's sarcoma. There also were two deaths from cervical cancer, the last of the three AIDS-defining cancers considered in Dr. D'Arminio Monforte's study.

Of the 193 non-AIDS-defining cancer deaths, there were, in addition to the 62 lung cancer deaths (32%), 25 gastrointestinal (13%), 16 liver (8%), 20 hematologic system (10%), and 20 anal cancer deaths (10%). The cancers seen less frequently included 18 urogenital cancers (9%), 9 cancers of the upper airways (5%), and 21 other cancers (11%).

Analysis of the data revealed that heterosexual persons and intravenous drug users had a lower risk of AIDS-defining fatal malignancy than did homosexual males, and both types of cancer were related to the patient's latest CD4 T-cell count.

The association between the CD4 count and fatal malignancy was such that there was a 37% reduction in fatal, AIDS-defining malignancy for every doubling of the CD4 count and a 39% reduction in fatal, non-AIDS-defining malignancy for every doubling of the CD4 count.

The DAD study cohort pools patients from 11 cohorts in Europe, the United States, and Australia.

LOS ANGELES — HIV-infected persons are now almost as likely to die of lung cancer as they are of non-Hodgkin's lymphoma, and they are more likely to die of lung cancer than of Kaposi's sarcoma, according to a large cohort of patients in developed countries.

Data from a cohort of 23,437 HIV-infected individuals followed since 1999 show that HIV-infected individuals in developed countries are now more likely to die of a cancer not traditionally associated with AIDS as they are to die of an AIDS-defining cancer, said Dr. Antonella D'Arminio Monforte of the University of Milan.

In the cohort, 193 individuals died from a non-AIDS-defining malignancy while 112 died from an AIDS-defining malignancy. The most common fatal non-AIDS cancer in the cohort was lung cancer (62 deaths), she said at the 14th Conference on Retroviruses and Opportunistic Infections.

The cohort, known as the DAD (Data Collection on Adverse Events of Anti-HIV Drugs) study group, had 82 deaths from non-Hodgkin's lymphoma and 28 deaths from Kaposi's sarcoma. There also were two deaths from cervical cancer, the last of the three AIDS-defining cancers considered in Dr. D'Arminio Monforte's study.

Of the 193 non-AIDS-defining cancer deaths, there were, in addition to the 62 lung cancer deaths (32%), 25 gastrointestinal (13%), 16 liver (8%), 20 hematologic system (10%), and 20 anal cancer deaths (10%). The cancers seen less frequently included 18 urogenital cancers (9%), 9 cancers of the upper airways (5%), and 21 other cancers (11%).

Analysis of the data revealed that heterosexual persons and intravenous drug users had a lower risk of AIDS-defining fatal malignancy than did homosexual males, and both types of cancer were related to the patient's latest CD4 T-cell count.

The association between the CD4 count and fatal malignancy was such that there was a 37% reduction in fatal, AIDS-defining malignancy for every doubling of the CD4 count and a 39% reduction in fatal, non-AIDS-defining malignancy for every doubling of the CD4 count.

The DAD study cohort pools patients from 11 cohorts in Europe, the United States, and Australia.

LOS ANGELES — HIV-infected persons are now almost as likely to die of lung cancer as they are of non-Hodgkin's lymphoma, and they are more likely to die of lung cancer than of Kaposi's sarcoma, according to a large cohort of patients in developed countries.

Data from a cohort of 23,437 HIV-infected individuals followed since 1999 show that HIV-infected individuals in developed countries are now more likely to die of a cancer not traditionally associated with AIDS as they are to die of an AIDS-defining cancer, said Dr. Antonella D'Arminio Monforte of the University of Milan.

In the cohort, 193 individuals died from a non-AIDS-defining malignancy while 112 died from an AIDS-defining malignancy. The most common fatal non-AIDS cancer in the cohort was lung cancer (62 deaths), she said at the 14th Conference on Retroviruses and Opportunistic Infections.

The cohort, known as the DAD (Data Collection on Adverse Events of Anti-HIV Drugs) study group, had 82 deaths from non-Hodgkin's lymphoma and 28 deaths from Kaposi's sarcoma. There also were two deaths from cervical cancer, the last of the three AIDS-defining cancers considered in Dr. D'Arminio Monforte's study.

Of the 193 non-AIDS-defining cancer deaths, there were, in addition to the 62 lung cancer deaths (32%), 25 gastrointestinal (13%), 16 liver (8%), 20 hematologic system (10%), and 20 anal cancer deaths (10%). The cancers seen less frequently included 18 urogenital cancers (9%), 9 cancers of the upper airways (5%), and 21 other cancers (11%).

Analysis of the data revealed that heterosexual persons and intravenous drug users had a lower risk of AIDS-defining fatal malignancy than did homosexual males, and both types of cancer were related to the patient's latest CD4 T-cell count.

The association between the CD4 count and fatal malignancy was such that there was a 37% reduction in fatal, AIDS-defining malignancy for every doubling of the CD4 count and a 39% reduction in fatal, non-AIDS-defining malignancy for every doubling of the CD4 count.

The DAD study cohort pools patients from 11 cohorts in Europe, the United States, and Australia.

SAN DIEGO — If a patient with depression comes into the office and says that his antidepressant has stopped working, the drug you gave him probably was never working at all, Dr. Mark Zimmerman said at the annual meeting of the American Psychiatric Association.

That patient probably had a placebo response, said Dr. Zimmerman, director of outpatient psychiatric services at Rhode Island Hospital, Providence.

Dr. Zimmerman said he was interested in why antidepressants seem to “poop out” when patients take them long term, and so he conducted a meta-analysis of continuation studies.

He identified four extension studies—the only type of continuation study that can be analyzed for its placebo effect-related relapse; in these studies, the patients were treated for their acute depression with a selective serotonin reuptake inhibitor for 6–8 weeks, followed by a continuation phase in which patients continued to take their drug for up to an additional year.

Dr. Zimmerman pooled the studies' data and used a method first described in 1993 to estimate the percentage of cases that can be attributed to a loss of placebo response (Am. J. Psychiatry 1993;150:562-5).

Using that formula, he estimated that 84% of the patients who relapsed during the continuation period were most probably patients whose response was a placebo response.

“The bottom line is that, overwhelmingly, relapse in studies occurs in people who are placebo responders,” he said. “It is not due to receptor down-regulation or up-regulation.”

Dr. Zimmerman also noted that continuation studies are not clinical practice, and that in clinical practice placebo response rates are probably higher than the 24%–30% rate described in trials because patients have higher expectations than those enrolled in studies.

“More of our patients are placebo responders than in clinical trials, and perhaps we shouldn't attribute as much of their gain to the particular molecule they are taking,” he said.

SAN DIEGO — If a patient with depression comes into the office and says that his antidepressant has stopped working, the drug you gave him probably was never working at all, Dr. Mark Zimmerman said at the annual meeting of the American Psychiatric Association.

That patient probably had a placebo response, said Dr. Zimmerman, director of outpatient psychiatric services at Rhode Island Hospital, Providence.

Dr. Zimmerman said he was interested in why antidepressants seem to “poop out” when patients take them long term, and so he conducted a meta-analysis of continuation studies.

He identified four extension studies—the only type of continuation study that can be analyzed for its placebo effect-related relapse; in these studies, the patients were treated for their acute depression with a selective serotonin reuptake inhibitor for 6–8 weeks, followed by a continuation phase in which patients continued to take their drug for up to an additional year.

Dr. Zimmerman pooled the studies' data and used a method first described in 1993 to estimate the percentage of cases that can be attributed to a loss of placebo response (Am. J. Psychiatry 1993;150:562-5).

Using that formula, he estimated that 84% of the patients who relapsed during the continuation period were most probably patients whose response was a placebo response.

“The bottom line is that, overwhelmingly, relapse in studies occurs in people who are placebo responders,” he said. “It is not due to receptor down-regulation or up-regulation.”

Dr. Zimmerman also noted that continuation studies are not clinical practice, and that in clinical practice placebo response rates are probably higher than the 24%–30% rate described in trials because patients have higher expectations than those enrolled in studies.

“More of our patients are placebo responders than in clinical trials, and perhaps we shouldn't attribute as much of their gain to the particular molecule they are taking,” he said.

SAN DIEGO — If a patient with depression comes into the office and says that his antidepressant has stopped working, the drug you gave him probably was never working at all, Dr. Mark Zimmerman said at the annual meeting of the American Psychiatric Association.

That patient probably had a placebo response, said Dr. Zimmerman, director of outpatient psychiatric services at Rhode Island Hospital, Providence.

Dr. Zimmerman said he was interested in why antidepressants seem to “poop out” when patients take them long term, and so he conducted a meta-analysis of continuation studies.

He identified four extension studies—the only type of continuation study that can be analyzed for its placebo effect-related relapse; in these studies, the patients were treated for their acute depression with a selective serotonin reuptake inhibitor for 6–8 weeks, followed by a continuation phase in which patients continued to take their drug for up to an additional year.

Dr. Zimmerman pooled the studies' data and used a method first described in 1993 to estimate the percentage of cases that can be attributed to a loss of placebo response (Am. J. Psychiatry 1993;150:562-5).

Using that formula, he estimated that 84% of the patients who relapsed during the continuation period were most probably patients whose response was a placebo response.

“The bottom line is that, overwhelmingly, relapse in studies occurs in people who are placebo responders,” he said. “It is not due to receptor down-regulation or up-regulation.”

Dr. Zimmerman also noted that continuation studies are not clinical practice, and that in clinical practice placebo response rates are probably higher than the 24%–30% rate described in trials because patients have higher expectations than those enrolled in studies.

“More of our patients are placebo responders than in clinical trials, and perhaps we shouldn't attribute as much of their gain to the particular molecule they are taking,” he said.