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The initial phases of the vaccination plan would cover about 500,000 military personnel and 500,000 civilians, mostly health care and emergency workers who would most likely be exposed if someone contracted smallpox, officials said. Eventually as many as 10 million people in law enforcement, health care and emergency response could be offered the vaccine. Defense officials said troop vaccinations could start today. The vaccine, made of a live virus closely related to smallpox known as vaccinia, can cause death or injury in susceptible people. They could presumably decline to be vaccinated, but they would remain vulnerable to infection with vaccinia virus shed by those who had taken the vaccine. The first American troops to be vaccinated would be military specialists who would respond to a smallpox outbreak, as well as forces assigned to units in the Middle East or that could eventually deploy there, military officials said. Of the 1.4 million service members on active-duty, 350,000 to 500,000 would be vaccinated under the new policy, the officials said

The initial phases of the vaccination plan would cover about 500,000 military personnel and 500,000 civilians, mostly health care and emergency workers who would most likely be exposed if someone contracted smallpox, officials said. Eventually, as many as 10 million people in law enforcement, health care and emergency response could be offered the vaccine. Defense officials said troop vaccinations could start today. [C. Mack Sewell] and other experts said doctors need time to build up experience in administering the smallpox vaccine while avoiding danger. People at risk of complications include those whose immune systems have been weakened by cancer, AIDS or other diseases. The vaccine, made of a live virus closely related to smallpox, known as vaccinia, can cause death or injury in susceptible people. Such people could presumably decline to be vaccinated, but would remain vulnerable to infection with vaccinia virus shed by those who had taken the vaccine

Since then, the vaccine has been given only to a few thousand qualified scientists who work with the smallpox virus and the vaccine, which is made from a closely related live virus, under top security precautions in approved laboratories. After eradication, the former Soviet Union and the United States were allowed to keep stores of the smallpox virus for research, one in Russia and one at the disease control agency in Atlanta. Original plans called for destroying the stores of the virus, but they have been deferred, largely because of disclosures that the former Soviet Union secretly weaponized smallpox virus. Smallpox vaccine is the most dangerous human immunization. Before the United States stopped routine smallpox vaccinations, life-threatening complications occurred at a rate of 15 per million among those who received their first smallpox vaccination, and the number included about one to two deaths

Under one possible scenario, the vaccine could simply be kept from the public until it is licensed, which is expected in 2004. Under another, people could apply for the vaccine under the 'investigational new drug' rules of the Food and Drug Administration. Under the new drug, or IND, rules, people who make a compelling case that they need experimental medicines can be given permission to take them by the FDA. But the process is cumbersome, and it is unclear how easily smallpox vaccine could be obtained if the president chose to make it available this way. Existing stockpiles of the vaccine, which are decades old and are not currently licensed by the government for use, will be kept for use only if there were an attack before the new vaccine was available. There is enough of the old vaccine on hand to inoculate all Americans, administration officials said. Smallpox vaccine is the most dangerous human immunization. Before the United States stopped routine smallpox vaccinations, life- threatening complications occurred at a rate of 15 per million among those who received their first smallpox vaccination, and the number included about one to two deaths

The plans must wait until President Bush announces whether he will limit vaccinations to about 500,000 health care workers or offer them to all Americans. No vaccination can occur until Bush's decision because the government owns all stocks of smallpox vaccine. Many health officials, administrators and doctors said that if vaccinations resumed, it would be after New Year's Day, to avoid problems at a busy time for hospital emergency rooms. Many hospitals are short of nurses and would find it difficult to find replacements for workers out sick because of sore arms, fevers and other reactions to vaccination

The plans must wait until President Bush announces whether he will limit vaccinations to about 500,000 health care workers or offer them to all Americans. No vaccination can occur until Mr. Bush's decision because the government owns all stocks of smallpox vaccine. In the next few days, the centers' smallpox experts will review the plans to determine whether they need revision before any vaccine is released, said Thomas W. Skinner, a spokesman for the centers. The C.D.C. will be reviewing a number of issues: how many health workers the states and cities plan to vaccinate; how many clinics are ready to vaccinate; how many public health and medical response teams have been identified; and how many hospitals in each state will be able to care for smallpox patients if any cases occur. Smallpox vaccine, which is made from a live virus related to the one that causes smallpox, is considered the most dangerous immunization for humans. Before the United States stopped routine smallpox vaccinations in 1972, life-threatening complications occurred at a rate of 15 per million among those who received their first smallpox vaccination, and the number included about one to two deaths

In atrial fibrillation, the heart beats irregularly because the atria fire electrical signals in an uncontrolled and very fast way. When the signals arrive in the ventricles in an erratic pattern, the ventricles pump blood less efficiently to the body. The slower flow of blood promotes formation of clots in the atria. The danger from the blood clots promoted by atrial fibrillation is that pieces of clots will break off to lodge in arteries in the brain, causing strokes, or elsewhere in the body, damaging organs. In the studies, strokes tended to occur among those taking inadequate doses of anticoagulant drugs like warfarin (sold under the brand name Coumadin) or not taking them at all. Anticoagulants showed benefit even if the heart rhythm returned to normal. Among the drugs that have been most commonly used for atrial fibrillation, those to restore a normal rhythm, are amiodarone (sold as Cordarone), sotalol (Betapace), propafenone (Rythmol), procainamide, quinidine, flecainide (Tambocor), disopyramide, moricizine and dofetilide (Tikosyn)

BACKGROUND: There are few data available on how physicians inform patients about bad news. We surveyed internists about how they convey this information. METHODS: We surveyed internists about their activities in giving bad news to patients. One set of questions was about activities for the emotional support of the patient (11 items), and the other was about activities for creating a supportive environment for delivering bad news (9 items). The impact of demographic factors on the performance of emotionally supportive items, environmentally supportive items, and on the number of minutes reportedly spent delivering news was analyzed by analysis of variance and multiple regression analysis. RESULTS: More than half of the internists reported that they always or frequently performed 10 of the 11 emotionally supportive items and 6 of the 9 environmentally supportive items while giving bad news to patients. The average time reportedly spent in giving bad news was 27 minutes. Although training in giving bad news had a significant impact on the number of emotionally supportive items reported (P <.05), only 25% of respondents had any previous training in this area. Being older, a woman, unmarried, and having a history of major illness were also associated with reporting a greater number of emotionally supportive activities. CONCLUSIONS: Internists report that they inform patients of bad news appropriately. Some deficiencies exist, specifically in discussing prognosis and referral of patients to support groups. Physician educational efforts should include discussion of prognosis with patients as well as the availability of support groups