Robert Finn

SAN FRANCISCO — Implementing a simple system of reading back medical orders reduced the error rate from 9.1% to zero in an inpatient pediatric unit, according to a poster presentation at the annual meeting of the Pediatric Academic Societies.

“Although this was a small study, these results are very encouraging,” Dr. Michael Vossmeyer of Cincinnati Children's Hospital Medical Center said in a prepared statement. At Cincinnati Children's Hospital, rounds are conducted inside patients' rooms. The attending physician or chief resident communicates the order orally, and the resident physician enters it into the computer system.

Baseline data were gathered on 5 consecutive days. Each day, all orders entered during rounds were audited by an attending physician without the knowledge of the residents. Of 77 consecutive orders, 7 were found to contain errors. Most of the errors were in dosages that would not have affected patient safety, but in two instances the intern wrote down the wrong drug.

Then Dr. Vossmeyer instituted the new process. Before leaving the patient's room, the resident would read back the orders to the attending physician, and the attending would sign the orders only if they were correct.

The procedure added less than 90 seconds to each patient visit, and it was well accepted by the staff.

Once again, data were collected on 5 consecutive days without the knowledge of the residents. Of 75 orders, there was not a single error.

“We're doing a follow-up study to determine if the results are sustainable and the process is reliable, but they appear to be very generalizable,” Dr. Vossmeyer said in the statement. “That's particularly important for tertiary patients, such as children with organ transplants, where proper doses mean so much.” The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

SAN FRANCISCO — Implementing a simple system of reading back medical orders reduced the error rate from 9.1% to zero in an inpatient pediatric unit, according to a poster presentation at the annual meeting of the Pediatric Academic Societies.

“Although this was a small study, these results are very encouraging,” Dr. Michael Vossmeyer of Cincinnati Children's Hospital Medical Center said in a prepared statement. At Cincinnati Children's Hospital, rounds are conducted inside patients' rooms. The attending physician or chief resident communicates the order orally, and the resident physician enters it into the computer system.

Baseline data were gathered on 5 consecutive days. Each day, all orders entered during rounds were audited by an attending physician without the knowledge of the residents. Of 77 consecutive orders, 7 were found to contain errors. Most of the errors were in dosages that would not have affected patient safety, but in two instances the intern wrote down the wrong drug.

Then Dr. Vossmeyer instituted the new process. Before leaving the patient's room, the resident would read back the orders to the attending physician, and the attending would sign the orders only if they were correct.

The procedure added less than 90 seconds to each patient visit, and it was well accepted by the staff.

Once again, data were collected on 5 consecutive days without the knowledge of the residents. Of 75 orders, there was not a single error.

“We're doing a follow-up study to determine if the results are sustainable and the process is reliable, but they appear to be very generalizable,” Dr. Vossmeyer said in the statement. “That's particularly important for tertiary patients, such as children with organ transplants, where proper doses mean so much.” The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

SAN FRANCISCO — Implementing a simple system of reading back medical orders reduced the error rate from 9.1% to zero in an inpatient pediatric unit, according to a poster presentation at the annual meeting of the Pediatric Academic Societies.

“Although this was a small study, these results are very encouraging,” Dr. Michael Vossmeyer of Cincinnati Children's Hospital Medical Center said in a prepared statement. At Cincinnati Children's Hospital, rounds are conducted inside patients' rooms. The attending physician or chief resident communicates the order orally, and the resident physician enters it into the computer system.

Baseline data were gathered on 5 consecutive days. Each day, all orders entered during rounds were audited by an attending physician without the knowledge of the residents. Of 77 consecutive orders, 7 were found to contain errors. Most of the errors were in dosages that would not have affected patient safety, but in two instances the intern wrote down the wrong drug.

Then Dr. Vossmeyer instituted the new process. Before leaving the patient's room, the resident would read back the orders to the attending physician, and the attending would sign the orders only if they were correct.

The procedure added less than 90 seconds to each patient visit, and it was well accepted by the staff.

Once again, data were collected on 5 consecutive days without the knowledge of the residents. Of 75 orders, there was not a single error.

“We're doing a follow-up study to determine if the results are sustainable and the process is reliable, but they appear to be very generalizable,” Dr. Vossmeyer said in the statement. “That's particularly important for tertiary patients, such as children with organ transplants, where proper doses mean so much.” The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

SAN FRANCISCO — The diagnosis of appendicitis is notoriously difficult in children, with estimates of misdiagnosis rates ranging from 28%–57% for children over the age of 12 and up to 100% for children under 2 years of age.

But the diagnosis may be made with high specificity using a combination of C-reactive protein and white blood cell levels, suggest the findings of a poster presented by Dr. Karen Y. Kwan and Dr. Alan L. Nager at the annual meeting of the Pediatric Academic Societies.

In particular, a C-reactive protein (CRP) level of 1.0 mg/dL or greater combined with a WBC count of 15,000 cells/mm

The study, conducted at the University of Southern California, Los Angeles, involved 209 patients aged 1–18 years presenting at a tertiary urban children's hospital with abdominal pain suspicious for acute appendicitis.

In addition to history, physical exam, x-ray studies, and histopathology, the investigators conducted blood tests for CRP, WBC, D-lactate, and procalcitonin.

Two to 6 weeks following discharge from the emergency department, investigators followed up with the patients to determine the ultimate diagnosis.

Of the 209 patients, 115 (55%) had confirmed appendicitis and 94 (45%) were negative for appendicitis. Among the diagnoses for children negative for appendicitis were constipation, gastroenteritis, pyelonephritis, ovarian torsion, and neoplasm.

The mean D-lactate values did not differ between patients who were positive and negative for appendicitis. The values of the other three lab markers did differ significantly; in each case patients with appendicitis had a significantly higher level than patients without.

Using a cutoff value of 1.0 mg/dL of CRP alone would yield a sensitivity of 84% and a specificity of 70%. A combination of that CRP cutoff with a WBC cutoff greater than 15,000 cells/mm

The investigators noted that there are several reasons to interpret their findings with caution. First, 85% of the patients were Hispanic, and they came from a largely indigent population. In addition, one cannot exclude the possibility that acute or chronic diseases may skew the laboratory values.

The meeting was sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediatric Association, and the American Academy of Pediatrics.

SAN FRANCISCO — The diagnosis of appendicitis is notoriously difficult in children, with estimates of misdiagnosis rates ranging from 28%–57% for children over the age of 12 and up to 100% for children under 2 years of age.

But the diagnosis may be made with high specificity using a combination of C-reactive protein and white blood cell levels, suggest the findings of a poster presented by Dr. Karen Y. Kwan and Dr. Alan L. Nager at the annual meeting of the Pediatric Academic Societies.

In particular, a C-reactive protein (CRP) level of 1.0 mg/dL or greater combined with a WBC count of 15,000 cells/mm

The study, conducted at the University of Southern California, Los Angeles, involved 209 patients aged 1–18 years presenting at a tertiary urban children's hospital with abdominal pain suspicious for acute appendicitis.

In addition to history, physical exam, x-ray studies, and histopathology, the investigators conducted blood tests for CRP, WBC, D-lactate, and procalcitonin.

Two to 6 weeks following discharge from the emergency department, investigators followed up with the patients to determine the ultimate diagnosis.

Of the 209 patients, 115 (55%) had confirmed appendicitis and 94 (45%) were negative for appendicitis. Among the diagnoses for children negative for appendicitis were constipation, gastroenteritis, pyelonephritis, ovarian torsion, and neoplasm.

The mean D-lactate values did not differ between patients who were positive and negative for appendicitis. The values of the other three lab markers did differ significantly; in each case patients with appendicitis had a significantly higher level than patients without.

Using a cutoff value of 1.0 mg/dL of CRP alone would yield a sensitivity of 84% and a specificity of 70%. A combination of that CRP cutoff with a WBC cutoff greater than 15,000 cells/mm

The investigators noted that there are several reasons to interpret their findings with caution. First, 85% of the patients were Hispanic, and they came from a largely indigent population. In addition, one cannot exclude the possibility that acute or chronic diseases may skew the laboratory values.

The meeting was sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediatric Association, and the American Academy of Pediatrics.

SAN FRANCISCO — The diagnosis of appendicitis is notoriously difficult in children, with estimates of misdiagnosis rates ranging from 28%–57% for children over the age of 12 and up to 100% for children under 2 years of age.

But the diagnosis may be made with high specificity using a combination of C-reactive protein and white blood cell levels, suggest the findings of a poster presented by Dr. Karen Y. Kwan and Dr. Alan L. Nager at the annual meeting of the Pediatric Academic Societies.

In particular, a C-reactive protein (CRP) level of 1.0 mg/dL or greater combined with a WBC count of 15,000 cells/mm

The study, conducted at the University of Southern California, Los Angeles, involved 209 patients aged 1–18 years presenting at a tertiary urban children's hospital with abdominal pain suspicious for acute appendicitis.

In addition to history, physical exam, x-ray studies, and histopathology, the investigators conducted blood tests for CRP, WBC, D-lactate, and procalcitonin.

Two to 6 weeks following discharge from the emergency department, investigators followed up with the patients to determine the ultimate diagnosis.

Of the 209 patients, 115 (55%) had confirmed appendicitis and 94 (45%) were negative for appendicitis. Among the diagnoses for children negative for appendicitis were constipation, gastroenteritis, pyelonephritis, ovarian torsion, and neoplasm.

The mean D-lactate values did not differ between patients who were positive and negative for appendicitis. The values of the other three lab markers did differ significantly; in each case patients with appendicitis had a significantly higher level than patients without.

Using a cutoff value of 1.0 mg/dL of CRP alone would yield a sensitivity of 84% and a specificity of 70%. A combination of that CRP cutoff with a WBC cutoff greater than 15,000 cells/mm

The investigators noted that there are several reasons to interpret their findings with caution. First, 85% of the patients were Hispanic, and they came from a largely indigent population. In addition, one cannot exclude the possibility that acute or chronic diseases may skew the laboratory values.

The meeting was sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediatric Association, and the American Academy of Pediatrics.

DENVER — Brisk walking appears to place significant stress on knee joints, especially in obese individuals, and that may contribute to musculoskeletal injuries, Ray Browning, Ph.D., reported at the annual meeting of the American College of Sports Medicine.

When walking at 1.5 m/sec (3.4 mph), obese individuals experience about a 50% greater amount of torque at the knee joint than do normal-weight individuals. That increased amount of torque disappears when obese individuals walk at 1 m/sec (2.2 mph).

Dr. Browning, a physiology researcher at the University of Colorado, Boulder, pointed to data from the Centers for Disease Control and Prevention indicating that about one in four obese patients suffer a musculoskeletal injury when they first start walking for exercise, and that 25% of those injured patients never return to exercise. He suggested that prescribing slower walking speeds to obese patients may, in part, alleviate this problem.

The study involved 10 obese patients with an average BMI of 35.5 kg/m

High-speed video in both the sagittal and frontal planes enabled the calculation of ground reaction forces, and this in turn allowed the calculation of torque at the knee joint.

Dr. Browning attributed the increase in ground reaction forces and torque at the knee joint to the fact that obese individuals have a larger step width. In agreement with previous studies on the biomechanics of walking, the investigators found that individuals in the obese group took steps that were about 60% wider than the normal-weight individuals.

DENVER — Brisk walking appears to place significant stress on knee joints, especially in obese individuals, and that may contribute to musculoskeletal injuries, Ray Browning, Ph.D., reported at the annual meeting of the American College of Sports Medicine.

When walking at 1.5 m/sec (3.4 mph), obese individuals experience about a 50% greater amount of torque at the knee joint than do normal-weight individuals. That increased amount of torque disappears when obese individuals walk at 1 m/sec (2.2 mph).

Dr. Browning, a physiology researcher at the University of Colorado, Boulder, pointed to data from the Centers for Disease Control and Prevention indicating that about one in four obese patients suffer a musculoskeletal injury when they first start walking for exercise, and that 25% of those injured patients never return to exercise. He suggested that prescribing slower walking speeds to obese patients may, in part, alleviate this problem.

The study involved 10 obese patients with an average BMI of 35.5 kg/m

High-speed video in both the sagittal and frontal planes enabled the calculation of ground reaction forces, and this in turn allowed the calculation of torque at the knee joint.

Dr. Browning attributed the increase in ground reaction forces and torque at the knee joint to the fact that obese individuals have a larger step width. In agreement with previous studies on the biomechanics of walking, the investigators found that individuals in the obese group took steps that were about 60% wider than the normal-weight individuals.

DENVER — Brisk walking appears to place significant stress on knee joints, especially in obese individuals, and that may contribute to musculoskeletal injuries, Ray Browning, Ph.D., reported at the annual meeting of the American College of Sports Medicine.

When walking at 1.5 m/sec (3.4 mph), obese individuals experience about a 50% greater amount of torque at the knee joint than do normal-weight individuals. That increased amount of torque disappears when obese individuals walk at 1 m/sec (2.2 mph).

Dr. Browning, a physiology researcher at the University of Colorado, Boulder, pointed to data from the Centers for Disease Control and Prevention indicating that about one in four obese patients suffer a musculoskeletal injury when they first start walking for exercise, and that 25% of those injured patients never return to exercise. He suggested that prescribing slower walking speeds to obese patients may, in part, alleviate this problem.

The study involved 10 obese patients with an average BMI of 35.5 kg/m

High-speed video in both the sagittal and frontal planes enabled the calculation of ground reaction forces, and this in turn allowed the calculation of torque at the knee joint.

Dr. Browning attributed the increase in ground reaction forces and torque at the knee joint to the fact that obese individuals have a larger step width. In agreement with previous studies on the biomechanics of walking, the investigators found that individuals in the obese group took steps that were about 60% wider than the normal-weight individuals.

SAN FRANCISCO — Less than half of the younger siblings of children with autism are fully immunized, according to a small study presented by Pamela E. Green in a poster session at the annual meeting of the Pediatric Academic Societies.

The study involved 34 children who were part of a prospective study of siblings of children with autism spectrum disorders. The younger children were 3 years old when Ms. Green of Bloorview MacMillan Children's Centre, Toronto, and her colleagues documented their immunization status. The older siblings with autism had a median age of 50 months (4.2 years) at that time. Data were available for 29 of the older siblings with autism spectrum disorders, and all were fully immunized.

Only 14 (41%) of the younger siblings were fully immunized. Another 5 (15%) were partially immunized, 6 (18%) had delayed immunization, and 9 (26%) had no immunizations at all.

The investigators considered a child fully immunized if there was documentation of three doses of pentavalent vaccine (diphtheria, tetanus, pertussis, hepatitis B, and Haemophilus influenzae type b) plus a booster along with one dose of MMR. They were considered partially immunized if there were missing doses of pentavalent vaccine and/or MMR, and they were classified as delayed immunization if the MMR was not administered until 17–36 months.

The parents were questioned about what sources of information influenced their decision about immunization. Half of them said that the pediatrician was the major influence, 10% cited the Internet, 10% cited a general practitioner, and 30% cited other influences, including the media, friends, fear of autism, and their own research.

The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

SAN FRANCISCO — Less than half of the younger siblings of children with autism are fully immunized, according to a small study presented by Pamela E. Green in a poster session at the annual meeting of the Pediatric Academic Societies.

The study involved 34 children who were part of a prospective study of siblings of children with autism spectrum disorders. The younger children were 3 years old when Ms. Green of Bloorview MacMillan Children's Centre, Toronto, and her colleagues documented their immunization status. The older siblings with autism had a median age of 50 months (4.2 years) at that time. Data were available for 29 of the older siblings with autism spectrum disorders, and all were fully immunized.

Only 14 (41%) of the younger siblings were fully immunized. Another 5 (15%) were partially immunized, 6 (18%) had delayed immunization, and 9 (26%) had no immunizations at all.

The investigators considered a child fully immunized if there was documentation of three doses of pentavalent vaccine (diphtheria, tetanus, pertussis, hepatitis B, and Haemophilus influenzae type b) plus a booster along with one dose of MMR. They were considered partially immunized if there were missing doses of pentavalent vaccine and/or MMR, and they were classified as delayed immunization if the MMR was not administered until 17–36 months.

The parents were questioned about what sources of information influenced their decision about immunization. Half of them said that the pediatrician was the major influence, 10% cited the Internet, 10% cited a general practitioner, and 30% cited other influences, including the media, friends, fear of autism, and their own research.

The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

SAN FRANCISCO — Less than half of the younger siblings of children with autism are fully immunized, according to a small study presented by Pamela E. Green in a poster session at the annual meeting of the Pediatric Academic Societies.

The study involved 34 children who were part of a prospective study of siblings of children with autism spectrum disorders. The younger children were 3 years old when Ms. Green of Bloorview MacMillan Children's Centre, Toronto, and her colleagues documented their immunization status. The older siblings with autism had a median age of 50 months (4.2 years) at that time. Data were available for 29 of the older siblings with autism spectrum disorders, and all were fully immunized.

Only 14 (41%) of the younger siblings were fully immunized. Another 5 (15%) were partially immunized, 6 (18%) had delayed immunization, and 9 (26%) had no immunizations at all.

The investigators considered a child fully immunized if there was documentation of three doses of pentavalent vaccine (diphtheria, tetanus, pertussis, hepatitis B, and Haemophilus influenzae type b) plus a booster along with one dose of MMR. They were considered partially immunized if there were missing doses of pentavalent vaccine and/or MMR, and they were classified as delayed immunization if the MMR was not administered until 17–36 months.

The parents were questioned about what sources of information influenced their decision about immunization. Half of them said that the pediatrician was the major influence, 10% cited the Internet, 10% cited a general practitioner, and 30% cited other influences, including the media, friends, fear of autism, and their own research.

The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

ATLANTA — Although there are no formal criteria defining metabolic syndrome in children, African American and white children show important differences in some of the components, Dr. Silva A. Arslanian said at the annual meeting of the International Society on Hypertension in Blacks.

A series of studies by Dr. Arslanian of the University of Pittsburgh and her colleagues have demonstrated that black children have lower insulin sensitivity and higher insulin secretion than do their white peers. Black children are more prone to fat accretion because of lower rates of lipolysis. And they have a limited capacity to increase insulin secretion in response to decreased insulin sensitivity.

Moreover, obese black adolescents are worse off than their white peers with respect to their diabetogenic risk profile, but better off with respect to their atherogenic risk profile.

Dr. Arslanian's research strategy is to recruit black and white children, match them on the basis of various demographic and physiologic factors, and admit them overnight to the children's research center one or more times for measurement of insulin secretion, insulin sensitivity, and other factors.

In one study, she compared 22 black with 22 white 10-year-olds with matching body mass indexes, fat composition, and visceral adipose tissue. Their average BMIs were about 18 kg/m

The product of insulin sensitivity multiplied by first-phase insulin is known as the glucose disposition index (GDI), and in most populations the GDI is constant. But the black children had a significantly higher average GDI than the white children, suggesting an inherent hypersecretion of insulin. It is not clear whether this is the result of genetic differences between the populations, environmental differences, or both.

In a more recent study, Dr. Arslanian and colleagues compared adiponectin levels and body composition in 83 African American and 78 white children, aged 8–17 years, with BMIs ranging from 14 to 50 (Diabetes Care 2006;29:51–6). Adipo- nectin levels were lower in the African American children even after controlling for Tanner stage, sex, abdominal subcutaneous and visceral adipose tissue, and leptin levels. African American children also had lower amounts of visceral fat.

In agreement with previous studies, the African Americans had lower average insulin sensitivity than the whites, but this difference disappeared after the investigators controlled for adiponectin levels. Together these findings suggest that adiponectin level is a strong marker of insulin sensitivity, and that the lower adiponectin level in African American youth may predispose them to a greater risk of insulin resistance despite lower visceral fat.

ATLANTA — Although there are no formal criteria defining metabolic syndrome in children, African American and white children show important differences in some of the components, Dr. Silva A. Arslanian said at the annual meeting of the International Society on Hypertension in Blacks.

A series of studies by Dr. Arslanian of the University of Pittsburgh and her colleagues have demonstrated that black children have lower insulin sensitivity and higher insulin secretion than do their white peers. Black children are more prone to fat accretion because of lower rates of lipolysis. And they have a limited capacity to increase insulin secretion in response to decreased insulin sensitivity.

Moreover, obese black adolescents are worse off than their white peers with respect to their diabetogenic risk profile, but better off with respect to their atherogenic risk profile.

Dr. Arslanian's research strategy is to recruit black and white children, match them on the basis of various demographic and physiologic factors, and admit them overnight to the children's research center one or more times for measurement of insulin secretion, insulin sensitivity, and other factors.

In one study, she compared 22 black with 22 white 10-year-olds with matching body mass indexes, fat composition, and visceral adipose tissue. Their average BMIs were about 18 kg/m

The product of insulin sensitivity multiplied by first-phase insulin is known as the glucose disposition index (GDI), and in most populations the GDI is constant. But the black children had a significantly higher average GDI than the white children, suggesting an inherent hypersecretion of insulin. It is not clear whether this is the result of genetic differences between the populations, environmental differences, or both.

In a more recent study, Dr. Arslanian and colleagues compared adiponectin levels and body composition in 83 African American and 78 white children, aged 8–17 years, with BMIs ranging from 14 to 50 (Diabetes Care 2006;29:51–6). Adipo- nectin levels were lower in the African American children even after controlling for Tanner stage, sex, abdominal subcutaneous and visceral adipose tissue, and leptin levels. African American children also had lower amounts of visceral fat.

In agreement with previous studies, the African Americans had lower average insulin sensitivity than the whites, but this difference disappeared after the investigators controlled for adiponectin levels. Together these findings suggest that adiponectin level is a strong marker of insulin sensitivity, and that the lower adiponectin level in African American youth may predispose them to a greater risk of insulin resistance despite lower visceral fat.

ATLANTA — Although there are no formal criteria defining metabolic syndrome in children, African American and white children show important differences in some of the components, Dr. Silva A. Arslanian said at the annual meeting of the International Society on Hypertension in Blacks.

A series of studies by Dr. Arslanian of the University of Pittsburgh and her colleagues have demonstrated that black children have lower insulin sensitivity and higher insulin secretion than do their white peers. Black children are more prone to fat accretion because of lower rates of lipolysis. And they have a limited capacity to increase insulin secretion in response to decreased insulin sensitivity.

Moreover, obese black adolescents are worse off than their white peers with respect to their diabetogenic risk profile, but better off with respect to their atherogenic risk profile.

Dr. Arslanian's research strategy is to recruit black and white children, match them on the basis of various demographic and physiologic factors, and admit them overnight to the children's research center one or more times for measurement of insulin secretion, insulin sensitivity, and other factors.

In one study, she compared 22 black with 22 white 10-year-olds with matching body mass indexes, fat composition, and visceral adipose tissue. Their average BMIs were about 18 kg/m

The product of insulin sensitivity multiplied by first-phase insulin is known as the glucose disposition index (GDI), and in most populations the GDI is constant. But the black children had a significantly higher average GDI than the white children, suggesting an inherent hypersecretion of insulin. It is not clear whether this is the result of genetic differences between the populations, environmental differences, or both.

In a more recent study, Dr. Arslanian and colleagues compared adiponectin levels and body composition in 83 African American and 78 white children, aged 8–17 years, with BMIs ranging from 14 to 50 (Diabetes Care 2006;29:51–6). Adipo- nectin levels were lower in the African American children even after controlling for Tanner stage, sex, abdominal subcutaneous and visceral adipose tissue, and leptin levels. African American children also had lower amounts of visceral fat.

In agreement with previous studies, the African Americans had lower average insulin sensitivity than the whites, but this difference disappeared after the investigators controlled for adiponectin levels. Together these findings suggest that adiponectin level is a strong marker of insulin sensitivity, and that the lower adiponectin level in African American youth may predispose them to a greater risk of insulin resistance despite lower visceral fat.

In recent years, the rate of pacemaker malfunctions has decreased while the rate of implantable cardioverter defibrillator malfunctions has increased dramatically, according to an analysis by Dr. William H. Maisel and a group of investigators from the Food and Drug Administration.

Using data that device manufacturers are required to report to the FDA, the investigators were able to determine that from 1990 to 2002, 2.25 million pacemakers and 416,000 implantable cardioverter-defibrillators (ICDs) were implanted in the United States. During that same period, 8,834 pacemakers and 8,489 ICDs were explanted because of confirmed malfunctions (JAMA 2006;295:1901–6).

The annual rate of malfunctioning devices ranged from 1.4 to 9/1,000 implants for pacemakers and from 7.9 to 38.6/1,000 implants for ICDs. Overall, the ICD malfunction replacement rate was significantly higher than the pacemaker malfunction replacement rate.

The annual pacemaker malfunction replacement rate waned significantly during the years covered by the study. During the final year of the study the pacemaker malfunction replacement rate was 1.4/1,000 devices, the lowest rate of any year in the study.

In contrast, the ICD malfunction replacement rate trended down during the first half of the study, reaching its nadir between 1994 and 1998, but then the rate increased markedly from 1999 through 2001 before falling somewhat in 2002. The ICD malfunction replacement rate for the final 3 years of the study was 26.8/1,000 implants, a statistically significant increase of more than 3 times the ICD malfunction replacement rate for the mid-1990s and more than 10 times the rate of pacemaker malfunctions during that same period.

Device malfunction was directly responsible for deaths in 30 pacemaker patients and 31 ICD patients. Malfunctions of pacemakers and ICDs were equally likely to result in death, but patients with ICDs were 5.6 times more likely to die of device malfunction because of the smaller number of ICD patients.

Hardware malfunctions were by far the most common type of malfunction in both pacemakers and ICDs, comprising 80% of the total. Integral device software or “firmware” was the cause of malfunction 4% of the time; miscellaneous malfunctions including physical damage, foreign material contamination, manufacturing errors, and so on caused 12% of malfunctions; and the manufacturers were unable to determine the cause of the malfunction in 5% of the cases.

Battery/capacitor abnormalities together with electrical issues accounted for more than half the hardware problems in both pacemakers and ICDs. Battery/capacitor abnormalities and charge-circuit abnormalities each accounted for a significantly higher percentage of malfunctions in ICDs than pacemakers. On the other hand, hermetic-seal abnormalities affected a much greater proportion of pacemakers than of ICDs. In absolute numbers, hermetic-seal abnormalities were responsible for 1,082 pacemaker malfunctions and only a single ICD malfunction. This was due primarily to a single manufacturer's repeated problems in multiple pacemaker models in the early 1990s.

The estimates of malfunction numbers and rates included in the study are likely to be underestimates of the true rates. Any devices that were not explanted, not returned to the manufacturer, or found by the manufacturer to be working normally were not counted as malfunctioning. Furthermore, the investigators excluded biventricular pacemakers and ICDs from the analysis because relatively few of those devices were implanted during the study period.

But the biggest source of uncounted malfunctions probably came about because of the investigators' exclusion of malfunctions that involved pacemaker or ICD leads.

In an accompanying editorial, Dr. Bruce L. Wilkoff of Case Western Reserve University, Cleveland, noted that the device, its leads, the chosen programmed parameters, and the patient's response are all interdependent (JAMA 2006;295:1944–6). The malfunction rate of this entire system is probably the most important measure of reliability, he wrote, “but it is also the most elusive because no single measure captures all elements in a verifiable fashion.”

He acknowledged that lead dysfunction can be related to design issues, implantation technique, the patient's activities, and the patient's anatomy and physiology, and that lead malfunctions were appropriately excluded from the analysis.

In recent years, the rate of pacemaker malfunctions has decreased while the rate of implantable cardioverter defibrillator malfunctions has increased dramatically, according to an analysis by Dr. William H. Maisel and a group of investigators from the Food and Drug Administration.

Using data that device manufacturers are required to report to the FDA, the investigators were able to determine that from 1990 to 2002, 2.25 million pacemakers and 416,000 implantable cardioverter-defibrillators (ICDs) were implanted in the United States. During that same period, 8,834 pacemakers and 8,489 ICDs were explanted because of confirmed malfunctions (JAMA 2006;295:1901–6).

The annual rate of malfunctioning devices ranged from 1.4 to 9/1,000 implants for pacemakers and from 7.9 to 38.6/1,000 implants for ICDs. Overall, the ICD malfunction replacement rate was significantly higher than the pacemaker malfunction replacement rate.

The annual pacemaker malfunction replacement rate waned significantly during the years covered by the study. During the final year of the study the pacemaker malfunction replacement rate was 1.4/1,000 devices, the lowest rate of any year in the study.

In contrast, the ICD malfunction replacement rate trended down during the first half of the study, reaching its nadir between 1994 and 1998, but then the rate increased markedly from 1999 through 2001 before falling somewhat in 2002. The ICD malfunction replacement rate for the final 3 years of the study was 26.8/1,000 implants, a statistically significant increase of more than 3 times the ICD malfunction replacement rate for the mid-1990s and more than 10 times the rate of pacemaker malfunctions during that same period.

Device malfunction was directly responsible for deaths in 30 pacemaker patients and 31 ICD patients. Malfunctions of pacemakers and ICDs were equally likely to result in death, but patients with ICDs were 5.6 times more likely to die of device malfunction because of the smaller number of ICD patients.

Hardware malfunctions were by far the most common type of malfunction in both pacemakers and ICDs, comprising 80% of the total. Integral device software or “firmware” was the cause of malfunction 4% of the time; miscellaneous malfunctions including physical damage, foreign material contamination, manufacturing errors, and so on caused 12% of malfunctions; and the manufacturers were unable to determine the cause of the malfunction in 5% of the cases.

Battery/capacitor abnormalities together with electrical issues accounted for more than half the hardware problems in both pacemakers and ICDs. Battery/capacitor abnormalities and charge-circuit abnormalities each accounted for a significantly higher percentage of malfunctions in ICDs than pacemakers. On the other hand, hermetic-seal abnormalities affected a much greater proportion of pacemakers than of ICDs. In absolute numbers, hermetic-seal abnormalities were responsible for 1,082 pacemaker malfunctions and only a single ICD malfunction. This was due primarily to a single manufacturer's repeated problems in multiple pacemaker models in the early 1990s.

The estimates of malfunction numbers and rates included in the study are likely to be underestimates of the true rates. Any devices that were not explanted, not returned to the manufacturer, or found by the manufacturer to be working normally were not counted as malfunctioning. Furthermore, the investigators excluded biventricular pacemakers and ICDs from the analysis because relatively few of those devices were implanted during the study period.

But the biggest source of uncounted malfunctions probably came about because of the investigators' exclusion of malfunctions that involved pacemaker or ICD leads.

In an accompanying editorial, Dr. Bruce L. Wilkoff of Case Western Reserve University, Cleveland, noted that the device, its leads, the chosen programmed parameters, and the patient's response are all interdependent (JAMA 2006;295:1944–6). The malfunction rate of this entire system is probably the most important measure of reliability, he wrote, “but it is also the most elusive because no single measure captures all elements in a verifiable fashion.”

He acknowledged that lead dysfunction can be related to design issues, implantation technique, the patient's activities, and the patient's anatomy and physiology, and that lead malfunctions were appropriately excluded from the analysis.

In recent years, the rate of pacemaker malfunctions has decreased while the rate of implantable cardioverter defibrillator malfunctions has increased dramatically, according to an analysis by Dr. William H. Maisel and a group of investigators from the Food and Drug Administration.

Using data that device manufacturers are required to report to the FDA, the investigators were able to determine that from 1990 to 2002, 2.25 million pacemakers and 416,000 implantable cardioverter-defibrillators (ICDs) were implanted in the United States. During that same period, 8,834 pacemakers and 8,489 ICDs were explanted because of confirmed malfunctions (JAMA 2006;295:1901–6).

The annual rate of malfunctioning devices ranged from 1.4 to 9/1,000 implants for pacemakers and from 7.9 to 38.6/1,000 implants for ICDs. Overall, the ICD malfunction replacement rate was significantly higher than the pacemaker malfunction replacement rate.

The annual pacemaker malfunction replacement rate waned significantly during the years covered by the study. During the final year of the study the pacemaker malfunction replacement rate was 1.4/1,000 devices, the lowest rate of any year in the study.

In contrast, the ICD malfunction replacement rate trended down during the first half of the study, reaching its nadir between 1994 and 1998, but then the rate increased markedly from 1999 through 2001 before falling somewhat in 2002. The ICD malfunction replacement rate for the final 3 years of the study was 26.8/1,000 implants, a statistically significant increase of more than 3 times the ICD malfunction replacement rate for the mid-1990s and more than 10 times the rate of pacemaker malfunctions during that same period.

Device malfunction was directly responsible for deaths in 30 pacemaker patients and 31 ICD patients. Malfunctions of pacemakers and ICDs were equally likely to result in death, but patients with ICDs were 5.6 times more likely to die of device malfunction because of the smaller number of ICD patients.

Hardware malfunctions were by far the most common type of malfunction in both pacemakers and ICDs, comprising 80% of the total. Integral device software or “firmware” was the cause of malfunction 4% of the time; miscellaneous malfunctions including physical damage, foreign material contamination, manufacturing errors, and so on caused 12% of malfunctions; and the manufacturers were unable to determine the cause of the malfunction in 5% of the cases.

Battery/capacitor abnormalities together with electrical issues accounted for more than half the hardware problems in both pacemakers and ICDs. Battery/capacitor abnormalities and charge-circuit abnormalities each accounted for a significantly higher percentage of malfunctions in ICDs than pacemakers. On the other hand, hermetic-seal abnormalities affected a much greater proportion of pacemakers than of ICDs. In absolute numbers, hermetic-seal abnormalities were responsible for 1,082 pacemaker malfunctions and only a single ICD malfunction. This was due primarily to a single manufacturer's repeated problems in multiple pacemaker models in the early 1990s.

The estimates of malfunction numbers and rates included in the study are likely to be underestimates of the true rates. Any devices that were not explanted, not returned to the manufacturer, or found by the manufacturer to be working normally were not counted as malfunctioning. Furthermore, the investigators excluded biventricular pacemakers and ICDs from the analysis because relatively few of those devices were implanted during the study period.

But the biggest source of uncounted malfunctions probably came about because of the investigators' exclusion of malfunctions that involved pacemaker or ICD leads.

In an accompanying editorial, Dr. Bruce L. Wilkoff of Case Western Reserve University, Cleveland, noted that the device, its leads, the chosen programmed parameters, and the patient's response are all interdependent (JAMA 2006;295:1944–6). The malfunction rate of this entire system is probably the most important measure of reliability, he wrote, “but it is also the most elusive because no single measure captures all elements in a verifiable fashion.”

He acknowledged that lead dysfunction can be related to design issues, implantation technique, the patient's activities, and the patient's anatomy and physiology, and that lead malfunctions were appropriately excluded from the analysis.

SAN FRANCISCO – Recent studies show that direct behavioral incentives are effective in treating substance abuse that is comorbid with psychiatric disorders. But contingency management can be difficult to implement in real-world settings, Dr. Steven L. Batki said at the annual meeting of the American Academy of Clinical Psychiatrists.

Motivational enhancement therapy, which is based on the Prochaska and DiClemente stages of change model (J. Consulting Clin. Psychol. 1983;51:390–5), may be a better fit to everyday clinical practice, said Dr. Batki, professor of psychiatry and behavioral sciences at the State University of New York, Syracuse.

“Many of us are old enough to remember the old token economy in schizophrenia, where you give direct behavioral incentives for behaviors,” Dr. Batki said. “This stuff works.” The problem is that in most institutional settings, it is difficult to bring the powers that be around to the notion of paying people not to use drugs.

Furthermore, contingency management works only if the target behavior is monitored frequently, with breath tests for alcohol or urine tests for drugs, for instance.

The “fishbowl” system, a type of contingency management, has actually demonstrated its effectiveness in substance abuse disorders, and it has the added advantage of being relatively inexpensive for the institution to implement. In this system, patients get the privilege of drawing a random card from a fishbowl when they have a negative urine test or have attended a 12-step meeting, for example.

Half the cards are winners. Patients have a 50% chance of winning a $1 prize, 1 chance in 16 of winning a $20 prize, and 1 chance in 500 of winning a $100 prize. Studies of the fishbowl system in alcohol abusers show a significant increase in time to the first heavy drinking episode, and studies with cocaine abusers show a significantly longer duration of cocaine abstinence than when control treatments are used.

In an outpatient setting, however, motivational enhancement therapy is more practical. It's based on several assumptions: that substance use disorders are common, that change often takes a long time, that the pace of change is variable, that knowledge is usually not sufficient to motivate change, and that relapse is the norm.

The therapy and the motivational interviewing that forms its basic technique require the therapist to recognize what stage the patient is in, in terms of readiness to change. If the patient is in the “precontemplation” stage, where he or she isn't even considering changing his drug or alcohol use, it's pointless for the therapist to encourage the patient to develop specific plans to change. Instead, the therapist's objectives are to help the patient identify his or her goals, provide information about the substance use, and bolster the patient's self-efficacy.

“The bottom line is if you have somebody come into your office who has no intention of stopping drug use, it's probably a waste of time to refer [him or her] to a residential treatment program,” Dr. Batki said. “Just talk about, 'Hey, what are you getting out of drugs? Are you concerned by the negatives? What are the positives for you? How do you balance those?'”

If the patient has reached the “contemplation” stage, where he or she is considering change but remains ambivalent, the therapist's objective is to help the patient recognize the discrepancy between goals and behavior and to elicit self-motivational statements.

When the patient reaches the “determination” stage, where he or she is committed to change, the therapist should strengthen that commitment and help the patient plan specific strategies.

Then, when the patient has reached the “action” stage, where he or she is actively involved in implementing these plans, the therapist's job is to identify and manage new barriers that may arise and to keep alert for relapse or impending relapse.

The next stage is “maintenance,” where the patient has made the change, and the therapist's objective is to ensure the stability of the change and to foster the patient's personal development. If the patient enters the “relapse” stage, where undesirable behaviors have returned, the therapist must identify the relapse when it occurs, reestablish self-efficacy and commitment, and help the patient develop behavioral strategies.

Finally, if the patient's change is very stable, he or she is said to have entered the “termination” stage, and the therapist should assure the patient of the stability of that change.

Throughout all of this, the therapist should give advice only when the patient is receptive and should target that advice to the patient's state of change. The therapist should also recognize that it's up to the individual whether to change and how to change. The therapist should also help individuals decrease the desirability of the substance abuse and help them identify other behaviors to replace the positive aspects of the substance abuse.

The therapist should demonstrate empathy by developing and communicating an understanding of the individual's situation and feelings about the behavior, and by helping the patient explore his or her pain related to the behavior. And the therapist should help the individual identify and understand relevant risks of the behavior and negative consequences of the behavior.

In a motivational interview, the therapist should avoid closed-end leading questions such as, “Don't you know that alcohol is bad for you?” And the therapist should practice reflective listening, mirroring what the patient says. This approach deepens the conversation, creates a sense of safety, and helps patients understand themselves.

SAN FRANCISCO – Recent studies show that direct behavioral incentives are effective in treating substance abuse that is comorbid with psychiatric disorders. But contingency management can be difficult to implement in real-world settings, Dr. Steven L. Batki said at the annual meeting of the American Academy of Clinical Psychiatrists.

Motivational enhancement therapy, which is based on the Prochaska and DiClemente stages of change model (J. Consulting Clin. Psychol. 1983;51:390–5), may be a better fit to everyday clinical practice, said Dr. Batki, professor of psychiatry and behavioral sciences at the State University of New York, Syracuse.

“Many of us are old enough to remember the old token economy in schizophrenia, where you give direct behavioral incentives for behaviors,” Dr. Batki said. “This stuff works.” The problem is that in most institutional settings, it is difficult to bring the powers that be around to the notion of paying people not to use drugs.

Furthermore, contingency management works only if the target behavior is monitored frequently, with breath tests for alcohol or urine tests for drugs, for instance.

The “fishbowl” system, a type of contingency management, has actually demonstrated its effectiveness in substance abuse disorders, and it has the added advantage of being relatively inexpensive for the institution to implement. In this system, patients get the privilege of drawing a random card from a fishbowl when they have a negative urine test or have attended a 12-step meeting, for example.

Half the cards are winners. Patients have a 50% chance of winning a $1 prize, 1 chance in 16 of winning a $20 prize, and 1 chance in 500 of winning a $100 prize. Studies of the fishbowl system in alcohol abusers show a significant increase in time to the first heavy drinking episode, and studies with cocaine abusers show a significantly longer duration of cocaine abstinence than when control treatments are used.

In an outpatient setting, however, motivational enhancement therapy is more practical. It's based on several assumptions: that substance use disorders are common, that change often takes a long time, that the pace of change is variable, that knowledge is usually not sufficient to motivate change, and that relapse is the norm.

The therapy and the motivational interviewing that forms its basic technique require the therapist to recognize what stage the patient is in, in terms of readiness to change. If the patient is in the “precontemplation” stage, where he or she isn't even considering changing his drug or alcohol use, it's pointless for the therapist to encourage the patient to develop specific plans to change. Instead, the therapist's objectives are to help the patient identify his or her goals, provide information about the substance use, and bolster the patient's self-efficacy.

“The bottom line is if you have somebody come into your office who has no intention of stopping drug use, it's probably a waste of time to refer [him or her] to a residential treatment program,” Dr. Batki said. “Just talk about, 'Hey, what are you getting out of drugs? Are you concerned by the negatives? What are the positives for you? How do you balance those?'”

If the patient has reached the “contemplation” stage, where he or she is considering change but remains ambivalent, the therapist's objective is to help the patient recognize the discrepancy between goals and behavior and to elicit self-motivational statements.

When the patient reaches the “determination” stage, where he or she is committed to change, the therapist should strengthen that commitment and help the patient plan specific strategies.

Then, when the patient has reached the “action” stage, where he or she is actively involved in implementing these plans, the therapist's job is to identify and manage new barriers that may arise and to keep alert for relapse or impending relapse.

The next stage is “maintenance,” where the patient has made the change, and the therapist's objective is to ensure the stability of the change and to foster the patient's personal development. If the patient enters the “relapse” stage, where undesirable behaviors have returned, the therapist must identify the relapse when it occurs, reestablish self-efficacy and commitment, and help the patient develop behavioral strategies.

Finally, if the patient's change is very stable, he or she is said to have entered the “termination” stage, and the therapist should assure the patient of the stability of that change.

Throughout all of this, the therapist should give advice only when the patient is receptive and should target that advice to the patient's state of change. The therapist should also recognize that it's up to the individual whether to change and how to change. The therapist should also help individuals decrease the desirability of the substance abuse and help them identify other behaviors to replace the positive aspects of the substance abuse.

The therapist should demonstrate empathy by developing and communicating an understanding of the individual's situation and feelings about the behavior, and by helping the patient explore his or her pain related to the behavior. And the therapist should help the individual identify and understand relevant risks of the behavior and negative consequences of the behavior.

In a motivational interview, the therapist should avoid closed-end leading questions such as, “Don't you know that alcohol is bad for you?” And the therapist should practice reflective listening, mirroring what the patient says. This approach deepens the conversation, creates a sense of safety, and helps patients understand themselves.

SAN FRANCISCO – Recent studies show that direct behavioral incentives are effective in treating substance abuse that is comorbid with psychiatric disorders. But contingency management can be difficult to implement in real-world settings, Dr. Steven L. Batki said at the annual meeting of the American Academy of Clinical Psychiatrists.

Motivational enhancement therapy, which is based on the Prochaska and DiClemente stages of change model (J. Consulting Clin. Psychol. 1983;51:390–5), may be a better fit to everyday clinical practice, said Dr. Batki, professor of psychiatry and behavioral sciences at the State University of New York, Syracuse.

“Many of us are old enough to remember the old token economy in schizophrenia, where you give direct behavioral incentives for behaviors,” Dr. Batki said. “This stuff works.” The problem is that in most institutional settings, it is difficult to bring the powers that be around to the notion of paying people not to use drugs.

Furthermore, contingency management works only if the target behavior is monitored frequently, with breath tests for alcohol or urine tests for drugs, for instance.

The “fishbowl” system, a type of contingency management, has actually demonstrated its effectiveness in substance abuse disorders, and it has the added advantage of being relatively inexpensive for the institution to implement. In this system, patients get the privilege of drawing a random card from a fishbowl when they have a negative urine test or have attended a 12-step meeting, for example.

Half the cards are winners. Patients have a 50% chance of winning a $1 prize, 1 chance in 16 of winning a $20 prize, and 1 chance in 500 of winning a $100 prize. Studies of the fishbowl system in alcohol abusers show a significant increase in time to the first heavy drinking episode, and studies with cocaine abusers show a significantly longer duration of cocaine abstinence than when control treatments are used.

In an outpatient setting, however, motivational enhancement therapy is more practical. It's based on several assumptions: that substance use disorders are common, that change often takes a long time, that the pace of change is variable, that knowledge is usually not sufficient to motivate change, and that relapse is the norm.

The therapy and the motivational interviewing that forms its basic technique require the therapist to recognize what stage the patient is in, in terms of readiness to change. If the patient is in the “precontemplation” stage, where he or she isn't even considering changing his drug or alcohol use, it's pointless for the therapist to encourage the patient to develop specific plans to change. Instead, the therapist's objectives are to help the patient identify his or her goals, provide information about the substance use, and bolster the patient's self-efficacy.

“The bottom line is if you have somebody come into your office who has no intention of stopping drug use, it's probably a waste of time to refer [him or her] to a residential treatment program,” Dr. Batki said. “Just talk about, 'Hey, what are you getting out of drugs? Are you concerned by the negatives? What are the positives for you? How do you balance those?'”

If the patient has reached the “contemplation” stage, where he or she is considering change but remains ambivalent, the therapist's objective is to help the patient recognize the discrepancy between goals and behavior and to elicit self-motivational statements.

When the patient reaches the “determination” stage, where he or she is committed to change, the therapist should strengthen that commitment and help the patient plan specific strategies.

Then, when the patient has reached the “action” stage, where he or she is actively involved in implementing these plans, the therapist's job is to identify and manage new barriers that may arise and to keep alert for relapse or impending relapse.

The next stage is “maintenance,” where the patient has made the change, and the therapist's objective is to ensure the stability of the change and to foster the patient's personal development. If the patient enters the “relapse” stage, where undesirable behaviors have returned, the therapist must identify the relapse when it occurs, reestablish self-efficacy and commitment, and help the patient develop behavioral strategies.

Finally, if the patient's change is very stable, he or she is said to have entered the “termination” stage, and the therapist should assure the patient of the stability of that change.

Throughout all of this, the therapist should give advice only when the patient is receptive and should target that advice to the patient's state of change. The therapist should also recognize that it's up to the individual whether to change and how to change. The therapist should also help individuals decrease the desirability of the substance abuse and help them identify other behaviors to replace the positive aspects of the substance abuse.

The therapist should demonstrate empathy by developing and communicating an understanding of the individual's situation and feelings about the behavior, and by helping the patient explore his or her pain related to the behavior. And the therapist should help the individual identify and understand relevant risks of the behavior and negative consequences of the behavior.

In a motivational interview, the therapist should avoid closed-end leading questions such as, “Don't you know that alcohol is bad for you?” And the therapist should practice reflective listening, mirroring what the patient says. This approach deepens the conversation, creates a sense of safety, and helps patients understand themselves.

SAN FRANCISCO – Several studies have shown that depictions of smoking in films influence adolescents to begin smoking themselves, but a new study appears to show that teens are more influenced when the bad guys smoke than when the good guys do.

After adjusting for number of covariates, Dr. Susanne E. Tanski and Dr. James D. Sargent of Dartmouth Medical School, Lebanon, N.H., determined that every 20 exposures to smoking by villains increased the odds that the child would begin smoking by 30%, and every 20 exposures to smoking by a “mixed” character increased the odds of smoking initiation by 16%. Both those increases were statistically significant, but there was no statistically significant increase in the odds that exposures to smoking by heroes would lead a child to begin smoking.

The study, presented in a poster session at the annual meeting of the Pediatric Academic Societies, involved a telephone survey of 6,521 U.S. adolescents who were recruited in 2003 by random digit dialing. About 73% of them were followed up both 8 months and 16 months later. At each survey, the adolescents were asked whether they had tried smoking and whether they had seen 50 movies randomly selected from a list of 500 popular movies that were released between 1998 and 2002.

In all, 18% of the adolescents had tried smoking by the 16-month follow-up.

Trained coders identified 3,630 characters in those 500 movies, assessed smoking status, and classified each character as positive, negative, or mixed/neutral. In all, 64% of the characters were classified as good guys, 14% of the characters were classified as bad guys, and the remaining 22% were classified as mixed or neutral.

Only 13% of the good guys were observed smoking, compared with 22% of the bad guys and 20% of the mixed or neutral characters. Given the much larger numbers of good guys in movies, however, the typical adolescent had far greater exposure to good-guy smoking than to bad-guy smoking.

The odds ratios were adjusted for social demographics, other social influences, personality factors, and parenting style.

Smoking initiation also was significantly associated with increasing age, male gender, school performance, friend or parent smoking, and rebelliousness.

SAN FRANCISCO – Several studies have shown that depictions of smoking in films influence adolescents to begin smoking themselves, but a new study appears to show that teens are more influenced when the bad guys smoke than when the good guys do.

After adjusting for number of covariates, Dr. Susanne E. Tanski and Dr. James D. Sargent of Dartmouth Medical School, Lebanon, N.H., determined that every 20 exposures to smoking by villains increased the odds that the child would begin smoking by 30%, and every 20 exposures to smoking by a “mixed” character increased the odds of smoking initiation by 16%. Both those increases were statistically significant, but there was no statistically significant increase in the odds that exposures to smoking by heroes would lead a child to begin smoking.

The study, presented in a poster session at the annual meeting of the Pediatric Academic Societies, involved a telephone survey of 6,521 U.S. adolescents who were recruited in 2003 by random digit dialing. About 73% of them were followed up both 8 months and 16 months later. At each survey, the adolescents were asked whether they had tried smoking and whether they had seen 50 movies randomly selected from a list of 500 popular movies that were released between 1998 and 2002.

In all, 18% of the adolescents had tried smoking by the 16-month follow-up.

Trained coders identified 3,630 characters in those 500 movies, assessed smoking status, and classified each character as positive, negative, or mixed/neutral. In all, 64% of the characters were classified as good guys, 14% of the characters were classified as bad guys, and the remaining 22% were classified as mixed or neutral.

Only 13% of the good guys were observed smoking, compared with 22% of the bad guys and 20% of the mixed or neutral characters. Given the much larger numbers of good guys in movies, however, the typical adolescent had far greater exposure to good-guy smoking than to bad-guy smoking.

The odds ratios were adjusted for social demographics, other social influences, personality factors, and parenting style.

Smoking initiation also was significantly associated with increasing age, male gender, school performance, friend or parent smoking, and rebelliousness.

SAN FRANCISCO – Several studies have shown that depictions of smoking in films influence adolescents to begin smoking themselves, but a new study appears to show that teens are more influenced when the bad guys smoke than when the good guys do.

After adjusting for number of covariates, Dr. Susanne E. Tanski and Dr. James D. Sargent of Dartmouth Medical School, Lebanon, N.H., determined that every 20 exposures to smoking by villains increased the odds that the child would begin smoking by 30%, and every 20 exposures to smoking by a “mixed” character increased the odds of smoking initiation by 16%. Both those increases were statistically significant, but there was no statistically significant increase in the odds that exposures to smoking by heroes would lead a child to begin smoking.

The study, presented in a poster session at the annual meeting of the Pediatric Academic Societies, involved a telephone survey of 6,521 U.S. adolescents who were recruited in 2003 by random digit dialing. About 73% of them were followed up both 8 months and 16 months later. At each survey, the adolescents were asked whether they had tried smoking and whether they had seen 50 movies randomly selected from a list of 500 popular movies that were released between 1998 and 2002.

In all, 18% of the adolescents had tried smoking by the 16-month follow-up.

Trained coders identified 3,630 characters in those 500 movies, assessed smoking status, and classified each character as positive, negative, or mixed/neutral. In all, 64% of the characters were classified as good guys, 14% of the characters were classified as bad guys, and the remaining 22% were classified as mixed or neutral.

Only 13% of the good guys were observed smoking, compared with 22% of the bad guys and 20% of the mixed or neutral characters. Given the much larger numbers of good guys in movies, however, the typical adolescent had far greater exposure to good-guy smoking than to bad-guy smoking.

The odds ratios were adjusted for social demographics, other social influences, personality factors, and parenting style.

Smoking initiation also was significantly associated with increasing age, male gender, school performance, friend or parent smoking, and rebelliousness.

SAN FRANCISCO – Young children adopted from foreign orphanages show initial delays in nonverbal social communication, developmental behaviors, and adaptive behaviors that resolve within 6 months to 1 year, according to two posters that were presented at the annual meeting of the Pediatric Academic Societies.

The results suggest that it may be more difficult to read the social cues of institutionalized children shortly after adoption and that it may be worthwhile to focus attention on helping these children develop better means of social communication, wrote Dr. Yasmin Senturias of Children's Hospital Medical Center of Akron, Ohio, and Dr. Anne Roth of Yale University, New Haven, Conn., and their colleagues.

Both of the studies were conducted on the same group of 23 adoptees, who were 9–24 months old at the time of adoption. Eighteen of the children came from China and the remainder came from Russia and other Eastern European countries.

In the study on nonverbal social communication, the children were compared with age-matched controls from a study on nonadopted children.

The assessment involved videotaped observation of 25 semistructured situations designed to elicit interaction between a tester and a child with minimal verbal cueing. The videotapes were scored based on the frequency of events showing behavioral regulation, social interaction, and joint attention.

At baseline, the international adoptees showed significantly lower frequencies of social interaction, joint attention, and total nonverbal social communication than the controls. These differences disappeared completely 6 months later, with the adoptees and controls showing virtually identical scores and no statistically significant differences.

The study on adaptive skills and developmental outcomes was based on three measuring tools: International Adoption Questionnaires given to parents; the Bayley Scales of Infant Development, which yielded a Mental Developmental Index (MDI) score and a Psychomotor Developmental Index (PDI) score; and the Vineland Adaptive Behavior Scale, which measures personal and social skills used for everyday living.

Fifty-two percent of parents reported gross motor delays at the time of adoption, and that declined to 0% at 1 year. Likewise, parents said that 21% of the children had fine motor delays initially, and that declined to 5% at 1 year. Speech and language delays, however, did not show such substantial improvement. Thirty-four percent of parents reported speech and language delays at the time of adoption, and that declined to 25% 1 year later, wrote Dr. Senturias and Dr. Roth.

The MDI and PDI scores both increased significantly over the course of the study, from 78 and 79 respectively at baseline to 99 and 104 respectively 1 year later. Both increases were statistically significant. (A score of 100 is considered average, and every 16 points below 100 represents one standard deviation from the mean.)

The Vineland scores demonstrated significant improvement over 12 months in all domains, including communication skills, daily living skills, socialization skills, and motor skills.

The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

SAN FRANCISCO – Young children adopted from foreign orphanages show initial delays in nonverbal social communication, developmental behaviors, and adaptive behaviors that resolve within 6 months to 1 year, according to two posters that were presented at the annual meeting of the Pediatric Academic Societies.

The results suggest that it may be more difficult to read the social cues of institutionalized children shortly after adoption and that it may be worthwhile to focus attention on helping these children develop better means of social communication, wrote Dr. Yasmin Senturias of Children's Hospital Medical Center of Akron, Ohio, and Dr. Anne Roth of Yale University, New Haven, Conn., and their colleagues.

Both of the studies were conducted on the same group of 23 adoptees, who were 9–24 months old at the time of adoption. Eighteen of the children came from China and the remainder came from Russia and other Eastern European countries.

In the study on nonverbal social communication, the children were compared with age-matched controls from a study on nonadopted children.

The assessment involved videotaped observation of 25 semistructured situations designed to elicit interaction between a tester and a child with minimal verbal cueing. The videotapes were scored based on the frequency of events showing behavioral regulation, social interaction, and joint attention.

At baseline, the international adoptees showed significantly lower frequencies of social interaction, joint attention, and total nonverbal social communication than the controls. These differences disappeared completely 6 months later, with the adoptees and controls showing virtually identical scores and no statistically significant differences.

The study on adaptive skills and developmental outcomes was based on three measuring tools: International Adoption Questionnaires given to parents; the Bayley Scales of Infant Development, which yielded a Mental Developmental Index (MDI) score and a Psychomotor Developmental Index (PDI) score; and the Vineland Adaptive Behavior Scale, which measures personal and social skills used for everyday living.

Fifty-two percent of parents reported gross motor delays at the time of adoption, and that declined to 0% at 1 year. Likewise, parents said that 21% of the children had fine motor delays initially, and that declined to 5% at 1 year. Speech and language delays, however, did not show such substantial improvement. Thirty-four percent of parents reported speech and language delays at the time of adoption, and that declined to 25% 1 year later, wrote Dr. Senturias and Dr. Roth.

The MDI and PDI scores both increased significantly over the course of the study, from 78 and 79 respectively at baseline to 99 and 104 respectively 1 year later. Both increases were statistically significant. (A score of 100 is considered average, and every 16 points below 100 represents one standard deviation from the mean.)

The Vineland scores demonstrated significant improvement over 12 months in all domains, including communication skills, daily living skills, socialization skills, and motor skills.

The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

SAN FRANCISCO – Young children adopted from foreign orphanages show initial delays in nonverbal social communication, developmental behaviors, and adaptive behaviors that resolve within 6 months to 1 year, according to two posters that were presented at the annual meeting of the Pediatric Academic Societies.

The results suggest that it may be more difficult to read the social cues of institutionalized children shortly after adoption and that it may be worthwhile to focus attention on helping these children develop better means of social communication, wrote Dr. Yasmin Senturias of Children's Hospital Medical Center of Akron, Ohio, and Dr. Anne Roth of Yale University, New Haven, Conn., and their colleagues.

Both of the studies were conducted on the same group of 23 adoptees, who were 9–24 months old at the time of adoption. Eighteen of the children came from China and the remainder came from Russia and other Eastern European countries.

In the study on nonverbal social communication, the children were compared with age-matched controls from a study on nonadopted children.

The assessment involved videotaped observation of 25 semistructured situations designed to elicit interaction between a tester and a child with minimal verbal cueing. The videotapes were scored based on the frequency of events showing behavioral regulation, social interaction, and joint attention.

At baseline, the international adoptees showed significantly lower frequencies of social interaction, joint attention, and total nonverbal social communication than the controls. These differences disappeared completely 6 months later, with the adoptees and controls showing virtually identical scores and no statistically significant differences.

The study on adaptive skills and developmental outcomes was based on three measuring tools: International Adoption Questionnaires given to parents; the Bayley Scales of Infant Development, which yielded a Mental Developmental Index (MDI) score and a Psychomotor Developmental Index (PDI) score; and the Vineland Adaptive Behavior Scale, which measures personal and social skills used for everyday living.

Fifty-two percent of parents reported gross motor delays at the time of adoption, and that declined to 0% at 1 year. Likewise, parents said that 21% of the children had fine motor delays initially, and that declined to 5% at 1 year. Speech and language delays, however, did not show such substantial improvement. Thirty-four percent of parents reported speech and language delays at the time of adoption, and that declined to 25% 1 year later, wrote Dr. Senturias and Dr. Roth.

The MDI and PDI scores both increased significantly over the course of the study, from 78 and 79 respectively at baseline to 99 and 104 respectively 1 year later. Both increases were statistically significant. (A score of 100 is considered average, and every 16 points below 100 represents one standard deviation from the mean.)

The Vineland scores demonstrated significant improvement over 12 months in all domains, including communication skills, daily living skills, socialization skills, and motor skills.

The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

SAN FRANCISCO – Children with autism are significantly less likely to have a medical home, compared with children without autism and also compared with children who have other special health care needs, according to data from a large national survey presented in a poster at the annual meeting of the Pediatric Academic Societies.

Dr. Dana Hargunani and her colleagues from the Oregon Health and Science University, Portland, analyzed data from the National Survey of Children's Health, which was administered to more than 100,000 U.S. households in 2003 and 2004 by the National Center for Health Statistics.

For the purposes of this study, the investigators considered a child aged 0–17 years to have a medical home if he or she has a personal doctor or nurse who spends enough time and communicates well with the parent and child, and if the child had at least one preventive medical care visit during the previous 12 months. Additional criteria for determining whether a child has a medical home included whether the child usually or always gets needed care and advice from the personal doctor or nurse and is consistently able to access needed specialist care.

One-half of 1% of the children whose parents were surveyed were reported to have autism. Of those, 25.6% were reported to have a medical home, a significantly smaller percentage than the 46.3% of children without autism and the 44.7% of children who have other special health care needs.

Parents of autistic children also reported significantly less access to specialist care–67.2% compared with 84.8% of children without autism and 79.4% of children with other special health care needs.

Autistic children were significantly less likely to have the benefit of care coordination, compared with children without autism (45.4% vs. 58%). A similar comparison between autistic children and children with other special health care needs showed no statistically significant difference.

“Children with autism face significant barriers to the receipt of health care they need and deserve,” wrote the investigators. Physicians “must address this disparity by further investigating the underlying challenges for families with autistic children.”

The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO – Children with autism are significantly less likely to have a medical home, compared with children without autism and also compared with children who have other special health care needs, according to data from a large national survey presented in a poster at the annual meeting of the Pediatric Academic Societies.

Dr. Dana Hargunani and her colleagues from the Oregon Health and Science University, Portland, analyzed data from the National Survey of Children's Health, which was administered to more than 100,000 U.S. households in 2003 and 2004 by the National Center for Health Statistics.

For the purposes of this study, the investigators considered a child aged 0–17 years to have a medical home if he or she has a personal doctor or nurse who spends enough time and communicates well with the parent and child, and if the child had at least one preventive medical care visit during the previous 12 months. Additional criteria for determining whether a child has a medical home included whether the child usually or always gets needed care and advice from the personal doctor or nurse and is consistently able to access needed specialist care.

One-half of 1% of the children whose parents were surveyed were reported to have autism. Of those, 25.6% were reported to have a medical home, a significantly smaller percentage than the 46.3% of children without autism and the 44.7% of children who have other special health care needs.

Parents of autistic children also reported significantly less access to specialist care–67.2% compared with 84.8% of children without autism and 79.4% of children with other special health care needs.

Autistic children were significantly less likely to have the benefit of care coordination, compared with children without autism (45.4% vs. 58%). A similar comparison between autistic children and children with other special health care needs showed no statistically significant difference.

“Children with autism face significant barriers to the receipt of health care they need and deserve,” wrote the investigators. Physicians “must address this disparity by further investigating the underlying challenges for families with autistic children.”

The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO – Children with autism are significantly less likely to have a medical home, compared with children without autism and also compared with children who have other special health care needs, according to data from a large national survey presented in a poster at the annual meeting of the Pediatric Academic Societies.

Dr. Dana Hargunani and her colleagues from the Oregon Health and Science University, Portland, analyzed data from the National Survey of Children's Health, which was administered to more than 100,000 U.S. households in 2003 and 2004 by the National Center for Health Statistics.

For the purposes of this study, the investigators considered a child aged 0–17 years to have a medical home if he or she has a personal doctor or nurse who spends enough time and communicates well with the parent and child, and if the child had at least one preventive medical care visit during the previous 12 months. Additional criteria for determining whether a child has a medical home included whether the child usually or always gets needed care and advice from the personal doctor or nurse and is consistently able to access needed specialist care.

One-half of 1% of the children whose parents were surveyed were reported to have autism. Of those, 25.6% were reported to have a medical home, a significantly smaller percentage than the 46.3% of children without autism and the 44.7% of children who have other special health care needs.

Parents of autistic children also reported significantly less access to specialist care–67.2% compared with 84.8% of children without autism and 79.4% of children with other special health care needs.

Autistic children were significantly less likely to have the benefit of care coordination, compared with children without autism (45.4% vs. 58%). A similar comparison between autistic children and children with other special health care needs showed no statistically significant difference.

“Children with autism face significant barriers to the receipt of health care they need and deserve,” wrote the investigators. Physicians “must address this disparity by further investigating the underlying challenges for families with autistic children.”

The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

ELSEVIER GLOBAL MEDICAL NEWS