Bruce K. Dixon

Women with type 1 diabetes who take less insulin than prescribed may be raising their risk of complications and shortening their life spans, researchers reported.

Because of various psychosocial variables, more than half of adult patients do not achieve the American Diabetes Association's glycemic targets, explained Ann E. Goebel-Fabbri, Ph.D., of the Joslin Diabetes Center and Harvard Medical School, both in Boston, and her associates. Chief among the implicated variables are general psychological distress, diabetes-specific distress, fear of hypoglycemia, concern about weight gain, and related eating-disorder behaviors.

In this 11-year study, the largest to examine the long-term effect of insulin restriction on the morbidity and mortality of women with type 1 diabetes, insulin restriction at baseline conveyed more than a threefold increase in the relative risk of death, said the authors (Diabetes Care 2008;31:1–5).

At baseline, the cohort included 234 women aged 13–60 years who had had a diagnosis of type 1 diabetes for at least 1 year, and who agreed to be followed up. Of those, 26 women died during the study period.

Mean age at follow-up was 45 years, with a range of 24–72 years.

Women reporting insulin restriction showed distinct clinical differences from those reporting appropriate insulin use.

At baseline, insulin restricters were significantly younger (aged 32 vs. 36 years) and had higher hemoglobin A_1c values (9.6% vs. 8.3%). However, there were no differences between the two groups with regard to baseline body mass index (BMI) or diabetes duration, the authors said.

Predictably, insulin restricters reported significantly lower scores on the baseline measure of diabetes self-care behaviors, and they scored higher on baseline measures of diabetes distress; fear of hypoglycemia; general psychological symptoms; eating disorder symptoms, such as bulimia; and the Eating Disorders Inventory, the researchers explained.

In addition, women who said at baseline that they restricted insulin were significantly more likely to report nephropathy and foot problems at follow-up, the researchers said, adding that self-reported rates of retinopathy, neuropathy, and cardiovascular complications at follow-up did not differ between groups.

Causes of death for 10 of 71 women reporting insulin restriction included perforated bowel with gastroparesis (1), cancer (1), cardiac events (3), hypoglycemia (1), renal failure (2), sepsis (1), and suicide in the context of retinopathy-related blindness (1).

Causes of death for 16 of 163 women reporting appropriate insulin use included cancer (1), cardiac events (11), diabetic ketoacidosis (1), sepsis (2), and unknown causes (1), Dr. Goebel-Fabbri noted in an interview.

Comparisons of both groups of deceased women found that those who had restricted insulin died at a significantly younger age, and had higher baseline hemoglobin A_1c values, poorer diabetes self-care behaviors, increased levels of diabetes-specific distress, and higher scores on measures of bulimia and other eating disorder symptoms, the scientists reported.

Compared with their living counterparts, deceased insulin restricters at baseline had higher BMI and hemoglobin A_1c values and reported more symptoms of bulimia and higher levels of diabetes-specific distress.

ELSEVIER GLOBAL MEDICAL NEWS

Women with type 1 diabetes who take less insulin than prescribed may be raising their risk of complications and shortening their life spans, researchers reported.

Because of various psychosocial variables, more than half of adult patients do not achieve the American Diabetes Association's glycemic targets, explained Ann E. Goebel-Fabbri, Ph.D., of the Joslin Diabetes Center and Harvard Medical School, both in Boston, and her associates. Chief among the implicated variables are general psychological distress, diabetes-specific distress, fear of hypoglycemia, concern about weight gain, and related eating-disorder behaviors.

In this 11-year study, the largest to examine the long-term effect of insulin restriction on the morbidity and mortality of women with type 1 diabetes, insulin restriction at baseline conveyed more than a threefold increase in the relative risk of death, said the authors (Diabetes Care 2008;31:1–5).

At baseline, the cohort included 234 women aged 13–60 years who had had a diagnosis of type 1 diabetes for at least 1 year, and who agreed to be followed up. Of those, 26 women died during the study period.

Mean age at follow-up was 45 years, with a range of 24–72 years.

Women reporting insulin restriction showed distinct clinical differences from those reporting appropriate insulin use.

At baseline, insulin restricters were significantly younger (aged 32 vs. 36 years) and had higher hemoglobin A_1c values (9.6% vs. 8.3%). However, there were no differences between the two groups with regard to baseline body mass index (BMI) or diabetes duration, the authors said.

Predictably, insulin restricters reported significantly lower scores on the baseline measure of diabetes self-care behaviors, and they scored higher on baseline measures of diabetes distress; fear of hypoglycemia; general psychological symptoms; eating disorder symptoms, such as bulimia; and the Eating Disorders Inventory, the researchers explained.

In addition, women who said at baseline that they restricted insulin were significantly more likely to report nephropathy and foot problems at follow-up, the researchers said, adding that self-reported rates of retinopathy, neuropathy, and cardiovascular complications at follow-up did not differ between groups.

Causes of death for 10 of 71 women reporting insulin restriction included perforated bowel with gastroparesis (1), cancer (1), cardiac events (3), hypoglycemia (1), renal failure (2), sepsis (1), and suicide in the context of retinopathy-related blindness (1).

Causes of death for 16 of 163 women reporting appropriate insulin use included cancer (1), cardiac events (11), diabetic ketoacidosis (1), sepsis (2), and unknown causes (1), Dr. Goebel-Fabbri noted in an interview.

Comparisons of both groups of deceased women found that those who had restricted insulin died at a significantly younger age, and had higher baseline hemoglobin A_1c values, poorer diabetes self-care behaviors, increased levels of diabetes-specific distress, and higher scores on measures of bulimia and other eating disorder symptoms, the scientists reported.

Compared with their living counterparts, deceased insulin restricters at baseline had higher BMI and hemoglobin A_1c values and reported more symptoms of bulimia and higher levels of diabetes-specific distress.

ELSEVIER GLOBAL MEDICAL NEWS

Women with type 1 diabetes who take less insulin than prescribed may be raising their risk of complications and shortening their life spans, researchers reported.

Because of various psychosocial variables, more than half of adult patients do not achieve the American Diabetes Association's glycemic targets, explained Ann E. Goebel-Fabbri, Ph.D., of the Joslin Diabetes Center and Harvard Medical School, both in Boston, and her associates. Chief among the implicated variables are general psychological distress, diabetes-specific distress, fear of hypoglycemia, concern about weight gain, and related eating-disorder behaviors.

In this 11-year study, the largest to examine the long-term effect of insulin restriction on the morbidity and mortality of women with type 1 diabetes, insulin restriction at baseline conveyed more than a threefold increase in the relative risk of death, said the authors (Diabetes Care 2008;31:1–5).

At baseline, the cohort included 234 women aged 13–60 years who had had a diagnosis of type 1 diabetes for at least 1 year, and who agreed to be followed up. Of those, 26 women died during the study period.

Mean age at follow-up was 45 years, with a range of 24–72 years.

Women reporting insulin restriction showed distinct clinical differences from those reporting appropriate insulin use.

At baseline, insulin restricters were significantly younger (aged 32 vs. 36 years) and had higher hemoglobin A_1c values (9.6% vs. 8.3%). However, there were no differences between the two groups with regard to baseline body mass index (BMI) or diabetes duration, the authors said.

Predictably, insulin restricters reported significantly lower scores on the baseline measure of diabetes self-care behaviors, and they scored higher on baseline measures of diabetes distress; fear of hypoglycemia; general psychological symptoms; eating disorder symptoms, such as bulimia; and the Eating Disorders Inventory, the researchers explained.

In addition, women who said at baseline that they restricted insulin were significantly more likely to report nephropathy and foot problems at follow-up, the researchers said, adding that self-reported rates of retinopathy, neuropathy, and cardiovascular complications at follow-up did not differ between groups.

Causes of death for 10 of 71 women reporting insulin restriction included perforated bowel with gastroparesis (1), cancer (1), cardiac events (3), hypoglycemia (1), renal failure (2), sepsis (1), and suicide in the context of retinopathy-related blindness (1).

Causes of death for 16 of 163 women reporting appropriate insulin use included cancer (1), cardiac events (11), diabetic ketoacidosis (1), sepsis (2), and unknown causes (1), Dr. Goebel-Fabbri noted in an interview.

Comparisons of both groups of deceased women found that those who had restricted insulin died at a significantly younger age, and had higher baseline hemoglobin A_1c values, poorer diabetes self-care behaviors, increased levels of diabetes-specific distress, and higher scores on measures of bulimia and other eating disorder symptoms, the scientists reported.

Compared with their living counterparts, deceased insulin restricters at baseline had higher BMI and hemoglobin A_1c values and reported more symptoms of bulimia and higher levels of diabetes-specific distress.

ELSEVIER GLOBAL MEDICAL NEWS

The distribution of children with diabetes and obesity does not parallel that of pediatric endocrinologists in the United States, largely because of geographic disparities in the supply of these specialists, according to Dr. Joyce M. Lee and colleagues at the University of Michigan, Ann Arbor.

This patient-specialist disparity is made especially acute by the growing epidemic of obesity, wrote the authors.

Data from the American Board of Pediatrics were used to estimate the number of board-certified pediatric endocrinologists by state, and national estimates of children with diabetes and obesity were derived from the National Survey of Children's Health, a representative cross-sectional random-digit-dial telephone survey of households with children aged younger than 18 years.

The investigators compared the observed ratios of obese children to pediatric endocrinologists under “index” conditions of greater supply and equitable distribution. They assumed that the ratio of the child population to specialists for each state was similar to that in the state with the largest supply, Massachusetts, where the ratio of obese children to endocrinologists was 5,132:1. The highest ratio—99,984:1—was in Mississippi. Two states, Montana and Wyoming, had no endocrinologists.

Nationwide, there were 17,741 obese children for each board-certified pediatric endocrinologist. By region, the northeast had the lowest ratio (9,994:1) and the south had the highest (25,796:1).

When the scientists examined the ratio of endocrinologists to children with diabetes, they found the best conditions in New England (113:1) and the worst in the east south-central region (594:1). The nation as a whole had a ratio of 290:1 (Journal of Pediatrics 2008;152:331–6).

With an almost sixfold difference in ratios of children with diabetes to certified pediatric endocrinologists across census divisions, and no ideal benchmark ratio for children with chronic disease to pediatric subspecialists, the authors believe it is unclear what effect this distribution has on access to the pediatric endocrinologist and health outcomes across geographic areas.

When observed ratios were compared with “index” ratios calculated under assumptions of equitable supply, the “index” ratios showed considerably less variation, the investigators explained. The data suggest that geographic differences in endocrinologist supply, not geographic differences in diabetes and obesity prevalence, might be driving the variation.

The authors point out that childhood obesity clinics are receiving increasing attention as a possible solution to the treatment of pediatric obesity. However, given the scope of the problem in the United States, “it is unclear whether childhood obesity clinics run by subspecialty providers represent a model of care that is either sustainable or effective in addressing the increasing burden,” they said.

Given this state of affairs, the role of the primary care physicians and the medical home in caring for the obese child becomes even more critical, Dr. Lee said in an interview.

“Our study may actually underestimate the ratios because most pediatric endocrinologists are affiliated with academic medical centers and spend a lot of time teaching and conducting research rather than seeing patients,” said Dr. Lee of the university's division of pediatric endocrinology.

The huge demand for obesity care and diabetes treatment is expected to continue to outpace the slow growth in new specialists, so emphasis should be placed on helping primary care pediatricians prevent and treat childhood obesity, she said.

“The American Diabetes Association states that, ideally, these children should be treated by pediatric endocrinologists, but they also can be treated by adult endocrinologists and even internists and family practitioners,” Dr. Lee said in an interview.

“The bottom line is these children need a medical home,” and that home really resides with the primary care physician, she concluded.

The distribution of children with diabetes and obesity does not parallel that of pediatric endocrinologists in the United States, largely because of geographic disparities in the supply of these specialists, according to Dr. Joyce M. Lee and colleagues at the University of Michigan, Ann Arbor.

This patient-specialist disparity is made especially acute by the growing epidemic of obesity, wrote the authors.

Data from the American Board of Pediatrics were used to estimate the number of board-certified pediatric endocrinologists by state, and national estimates of children with diabetes and obesity were derived from the National Survey of Children's Health, a representative cross-sectional random-digit-dial telephone survey of households with children aged younger than 18 years.

The investigators compared the observed ratios of obese children to pediatric endocrinologists under “index” conditions of greater supply and equitable distribution. They assumed that the ratio of the child population to specialists for each state was similar to that in the state with the largest supply, Massachusetts, where the ratio of obese children to endocrinologists was 5,132:1. The highest ratio—99,984:1—was in Mississippi. Two states, Montana and Wyoming, had no endocrinologists.

Nationwide, there were 17,741 obese children for each board-certified pediatric endocrinologist. By region, the northeast had the lowest ratio (9,994:1) and the south had the highest (25,796:1).

When the scientists examined the ratio of endocrinologists to children with diabetes, they found the best conditions in New England (113:1) and the worst in the east south-central region (594:1). The nation as a whole had a ratio of 290:1 (Journal of Pediatrics 2008;152:331–6).

With an almost sixfold difference in ratios of children with diabetes to certified pediatric endocrinologists across census divisions, and no ideal benchmark ratio for children with chronic disease to pediatric subspecialists, the authors believe it is unclear what effect this distribution has on access to the pediatric endocrinologist and health outcomes across geographic areas.

When observed ratios were compared with “index” ratios calculated under assumptions of equitable supply, the “index” ratios showed considerably less variation, the investigators explained. The data suggest that geographic differences in endocrinologist supply, not geographic differences in diabetes and obesity prevalence, might be driving the variation.

The authors point out that childhood obesity clinics are receiving increasing attention as a possible solution to the treatment of pediatric obesity. However, given the scope of the problem in the United States, “it is unclear whether childhood obesity clinics run by subspecialty providers represent a model of care that is either sustainable or effective in addressing the increasing burden,” they said.

Given this state of affairs, the role of the primary care physicians and the medical home in caring for the obese child becomes even more critical, Dr. Lee said in an interview.

“Our study may actually underestimate the ratios because most pediatric endocrinologists are affiliated with academic medical centers and spend a lot of time teaching and conducting research rather than seeing patients,” said Dr. Lee of the university's division of pediatric endocrinology.

The huge demand for obesity care and diabetes treatment is expected to continue to outpace the slow growth in new specialists, so emphasis should be placed on helping primary care pediatricians prevent and treat childhood obesity, she said.

“The American Diabetes Association states that, ideally, these children should be treated by pediatric endocrinologists, but they also can be treated by adult endocrinologists and even internists and family practitioners,” Dr. Lee said in an interview.

“The bottom line is these children need a medical home,” and that home really resides with the primary care physician, she concluded.

The distribution of children with diabetes and obesity does not parallel that of pediatric endocrinologists in the United States, largely because of geographic disparities in the supply of these specialists, according to Dr. Joyce M. Lee and colleagues at the University of Michigan, Ann Arbor.

This patient-specialist disparity is made especially acute by the growing epidemic of obesity, wrote the authors.

Data from the American Board of Pediatrics were used to estimate the number of board-certified pediatric endocrinologists by state, and national estimates of children with diabetes and obesity were derived from the National Survey of Children's Health, a representative cross-sectional random-digit-dial telephone survey of households with children aged younger than 18 years.

The investigators compared the observed ratios of obese children to pediatric endocrinologists under “index” conditions of greater supply and equitable distribution. They assumed that the ratio of the child population to specialists for each state was similar to that in the state with the largest supply, Massachusetts, where the ratio of obese children to endocrinologists was 5,132:1. The highest ratio—99,984:1—was in Mississippi. Two states, Montana and Wyoming, had no endocrinologists.

Nationwide, there were 17,741 obese children for each board-certified pediatric endocrinologist. By region, the northeast had the lowest ratio (9,994:1) and the south had the highest (25,796:1).

When the scientists examined the ratio of endocrinologists to children with diabetes, they found the best conditions in New England (113:1) and the worst in the east south-central region (594:1). The nation as a whole had a ratio of 290:1 (Journal of Pediatrics 2008;152:331–6).

With an almost sixfold difference in ratios of children with diabetes to certified pediatric endocrinologists across census divisions, and no ideal benchmark ratio for children with chronic disease to pediatric subspecialists, the authors believe it is unclear what effect this distribution has on access to the pediatric endocrinologist and health outcomes across geographic areas.

When observed ratios were compared with “index” ratios calculated under assumptions of equitable supply, the “index” ratios showed considerably less variation, the investigators explained. The data suggest that geographic differences in endocrinologist supply, not geographic differences in diabetes and obesity prevalence, might be driving the variation.

The authors point out that childhood obesity clinics are receiving increasing attention as a possible solution to the treatment of pediatric obesity. However, given the scope of the problem in the United States, “it is unclear whether childhood obesity clinics run by subspecialty providers represent a model of care that is either sustainable or effective in addressing the increasing burden,” they said.

Given this state of affairs, the role of the primary care physicians and the medical home in caring for the obese child becomes even more critical, Dr. Lee said in an interview.

“Our study may actually underestimate the ratios because most pediatric endocrinologists are affiliated with academic medical centers and spend a lot of time teaching and conducting research rather than seeing patients,” said Dr. Lee of the university's division of pediatric endocrinology.

The huge demand for obesity care and diabetes treatment is expected to continue to outpace the slow growth in new specialists, so emphasis should be placed on helping primary care pediatricians prevent and treat childhood obesity, she said.

“The American Diabetes Association states that, ideally, these children should be treated by pediatric endocrinologists, but they also can be treated by adult endocrinologists and even internists and family practitioners,” Dr. Lee said in an interview.

“The bottom line is these children need a medical home,” and that home really resides with the primary care physician, she concluded.

The soaring numbers of commonly used drugs with soundalike and look-alike names have prompted the U.S. Pharmacopeia to ask physicians and pharmacists to include an “indication for use” on prescriptions.

This and other recommendations are contained in U.S. Pharmacopeia's 8th annual MEDMARX report, which is based on a review of more than 26,000 records submitted to the MEDMARX database from 2003 to 2006.

The records implicate nearly 1,500 drugs in medication errors due to brand or generic names that could be confused. From these data, U.S. Pharmacopeia (USP) compiled a list of more than 3,000 drug pairs that look or sound alike, a figure that is nearly double the number of pairs identified in USP's 2004 report, said Diane Cousins, R.Ph. “We were surprised to see that much of an increase in such a short time, and the concern is that this increase in products in the marketplace further raises the opportunity for error,” said Ms. Cousins, USP's vice president of health care quality and information.

USP also operates, in conjunction with the Institute for Safe Medication Practices, the Medication Errors Reporting Program (MER), which allows providers to confidentially report potential and actual medication errors directly to USP.

USP reviewed both MEDMARX and MER to summarize the variables associated with more than 26,000 look-alike and/or soundalike (LASA) errors, of which 1.4% (384) resulted in harm or death. More than 670 health care facilities contributed 26,000 records, according to the 400-page report.

“We looked at lists of the top 200 drugs prescribed and used in hospitals, and virtually every time, all of the top 10 appeared within the USP similar names list,” Ms. Cousins said in an interview.

An important finding of this year's report is the role of pharmacy staff in LASA-related errors, she said. “Although pharmacy personnel, who are generally technicians, made the majority of errors, pharmacists as a group identified, prevented, and reported more than any other staff.”

The report also identifies an emerging trend of look-alike drug names in computerized direct order entry systems as a source of confusion. “This trend will likely continue as these systems become a standard of practice,” she said, adding that the LASA-related error problem is further compounded by the indiscriminate use of suffixes, as well as look-alike packaging and labeling.

Over the 3-year period, the drug most commonly confused with others was Cefazolin, a first-generation cephalosporin antibiotic. “We found it to be confused with 15 other drugs, primarily antimicrobials, which might be explained by the fact that this is the most frequently used class of medications,” said Ms. Cousins.

Among other major paired LASAs were cardiovascular drugs, such as lisinopril and enalapril, and central nervous system agents, like trazodone and chlorpromazine.

Drug mix-ups led to seven reported fatalities, including two deaths attributed to confusion over the Alzheimer's drug Reminyl (galantamine) and the antidiabetes drug Amaryl (glimepiride).

In 2005, recognizing the high risk of confusion and subsequent fatal hypoglycemia, Ortho-McNeil Neurologics Inc. announced the name Reminyl had been changed to Razadyne to avoid confusion with Amaryl.

In another case, an autistic pediatric patient was given the wrong product when disodium EDTA (a hypercalcemia treatment) was administered instead of the chelation therapy calcium disodium EDTA, which is approved by the Food and Drug Administration for the treatment of lead poisoning and was prescribed in an attempt to help treat the patient's autism.

In another case, an emergency department physician was preparing to intubate a patient and calculated the right dose for rocuronium (Zemuron), a preintubation agent. The physician gave orders for the nurse to obtain the medication and indicated the volume to administer to the patient. The nurse obtained and administered the neuromuscular blocking agent vecuronium (Norcuron) instead. The patient received a large amount of the wrong agent, which led to a fatal heart arrhythmia.

The remaining three reported deaths involved mix-ups between the anticonvulsant primidone and prednisone; the antiepileptic drug phenytoin sodium and the barbiturate phenobarbital; and Norcuron and the heart failure treatment Natrecor (nesiritide recombinant).

Errors occur with over-the-counter medications, too. Ms. Cousins described the aural confusion when an order for Ferro-Sequel 500 mg—an iron replacement—was transcribed as Serrosequel 500 mg and the order was misread as Seroquel 500 mg—an antipsychotic.

The rate of mix-ups involving brand name versus generic drugs was about evenly split, 57% and 43%, respectively, Ms. Cousins said, adding that while most errors were made in pharmacies, many, such as the primidone-prednisone incident, are due to confusion over the prescribing physician's handwriting, which lead the pharmacist to issue the wrong drug.

“Errors also are due to physicians using short codes for medications, such as 'clon,' for clonazepam or clonapine,” she said, adding that electronically written prescriptions using a computer or label machine would eliminate many errors. “Anything that takes handwriting out of the equation is a help.”

It would also be helpful if the FDA were given more authority to force name changes during the drug review process, as has been suggested by the Institute of Medicine. It's much more difficult to correct a name confusion issue once the products are on the market.

The recommendation that physicians include indications for use in their prescriptions is not an attempt by USP to impose on privacy, Ms. Cousins said. “All that is needed are simple inclusions, such as 'for sinus,' 'for heart,' or, 'for cough,'” she said.

USP also recommends that “tall man lettering” be implemented in pharmacy software, labeling, and order writing to say, for example, “acetaZOLamide” (glaucoma) and “acetoHEXamide” (diabetes).

Where risk exists, take action to reduce the chance for error. To build awareness, USP recommends disseminating information about products that have been confused at your facility, and prohibiting verbal orders for soundalikes.

“Physicians' offices should always require a read-back from pharmacists, making sure that they both say and spell the drug name,” Ms. Cousins said.

Some errors result from physicians' use of the same abbreviation for two drugs: clon for clonazepam and clonapine. MS. COUSINS

The soaring numbers of commonly used drugs with soundalike and look-alike names have prompted the U.S. Pharmacopeia to ask physicians and pharmacists to include an “indication for use” on prescriptions.

This and other recommendations are contained in U.S. Pharmacopeia's 8th annual MEDMARX report, which is based on a review of more than 26,000 records submitted to the MEDMARX database from 2003 to 2006.

The records implicate nearly 1,500 drugs in medication errors due to brand or generic names that could be confused. From these data, U.S. Pharmacopeia (USP) compiled a list of more than 3,000 drug pairs that look or sound alike, a figure that is nearly double the number of pairs identified in USP's 2004 report, said Diane Cousins, R.Ph. “We were surprised to see that much of an increase in such a short time, and the concern is that this increase in products in the marketplace further raises the opportunity for error,” said Ms. Cousins, USP's vice president of health care quality and information.

USP also operates, in conjunction with the Institute for Safe Medication Practices, the Medication Errors Reporting Program (MER), which allows providers to confidentially report potential and actual medication errors directly to USP.

USP reviewed both MEDMARX and MER to summarize the variables associated with more than 26,000 look-alike and/or soundalike (LASA) errors, of which 1.4% (384) resulted in harm or death. More than 670 health care facilities contributed 26,000 records, according to the 400-page report.

“We looked at lists of the top 200 drugs prescribed and used in hospitals, and virtually every time, all of the top 10 appeared within the USP similar names list,” Ms. Cousins said in an interview.

An important finding of this year's report is the role of pharmacy staff in LASA-related errors, she said. “Although pharmacy personnel, who are generally technicians, made the majority of errors, pharmacists as a group identified, prevented, and reported more than any other staff.”

The report also identifies an emerging trend of look-alike drug names in computerized direct order entry systems as a source of confusion. “This trend will likely continue as these systems become a standard of practice,” she said, adding that the LASA-related error problem is further compounded by the indiscriminate use of suffixes, as well as look-alike packaging and labeling.

Over the 3-year period, the drug most commonly confused with others was Cefazolin, a first-generation cephalosporin antibiotic. “We found it to be confused with 15 other drugs, primarily antimicrobials, which might be explained by the fact that this is the most frequently used class of medications,” said Ms. Cousins.

Among other major paired LASAs were cardiovascular drugs, such as lisinopril and enalapril, and central nervous system agents, like trazodone and chlorpromazine.

Drug mix-ups led to seven reported fatalities, including two deaths attributed to confusion over the Alzheimer's drug Reminyl (galantamine) and the antidiabetes drug Amaryl (glimepiride).

In 2005, recognizing the high risk of confusion and subsequent fatal hypoglycemia, Ortho-McNeil Neurologics Inc. announced the name Reminyl had been changed to Razadyne to avoid confusion with Amaryl.

In another case, an autistic pediatric patient was given the wrong product when disodium EDTA (a hypercalcemia treatment) was administered instead of the chelation therapy calcium disodium EDTA, which is approved by the Food and Drug Administration for the treatment of lead poisoning and was prescribed in an attempt to help treat the patient's autism.

In another case, an emergency department physician was preparing to intubate a patient and calculated the right dose for rocuronium (Zemuron), a preintubation agent. The physician gave orders for the nurse to obtain the medication and indicated the volume to administer to the patient. The nurse obtained and administered the neuromuscular blocking agent vecuronium (Norcuron) instead. The patient received a large amount of the wrong agent, which led to a fatal heart arrhythmia.

The remaining three reported deaths involved mix-ups between the anticonvulsant primidone and prednisone; the antiepileptic drug phenytoin sodium and the barbiturate phenobarbital; and Norcuron and the heart failure treatment Natrecor (nesiritide recombinant).

Errors occur with over-the-counter medications, too. Ms. Cousins described the aural confusion when an order for Ferro-Sequel 500 mg—an iron replacement—was transcribed as Serrosequel 500 mg and the order was misread as Seroquel 500 mg—an antipsychotic.

The rate of mix-ups involving brand name versus generic drugs was about evenly split, 57% and 43%, respectively, Ms. Cousins said, adding that while most errors were made in pharmacies, many, such as the primidone-prednisone incident, are due to confusion over the prescribing physician's handwriting, which lead the pharmacist to issue the wrong drug.

“Errors also are due to physicians using short codes for medications, such as 'clon,' for clonazepam or clonapine,” she said, adding that electronically written prescriptions using a computer or label machine would eliminate many errors. “Anything that takes handwriting out of the equation is a help.”

It would also be helpful if the FDA were given more authority to force name changes during the drug review process, as has been suggested by the Institute of Medicine. It's much more difficult to correct a name confusion issue once the products are on the market.

The recommendation that physicians include indications for use in their prescriptions is not an attempt by USP to impose on privacy, Ms. Cousins said. “All that is needed are simple inclusions, such as 'for sinus,' 'for heart,' or, 'for cough,'” she said.

USP also recommends that “tall man lettering” be implemented in pharmacy software, labeling, and order writing to say, for example, “acetaZOLamide” (glaucoma) and “acetoHEXamide” (diabetes).

Where risk exists, take action to reduce the chance for error. To build awareness, USP recommends disseminating information about products that have been confused at your facility, and prohibiting verbal orders for soundalikes.

“Physicians' offices should always require a read-back from pharmacists, making sure that they both say and spell the drug name,” Ms. Cousins said.

Some errors result from physicians' use of the same abbreviation for two drugs: clon for clonazepam and clonapine. MS. COUSINS

The soaring numbers of commonly used drugs with soundalike and look-alike names have prompted the U.S. Pharmacopeia to ask physicians and pharmacists to include an “indication for use” on prescriptions.

This and other recommendations are contained in U.S. Pharmacopeia's 8th annual MEDMARX report, which is based on a review of more than 26,000 records submitted to the MEDMARX database from 2003 to 2006.

The records implicate nearly 1,500 drugs in medication errors due to brand or generic names that could be confused. From these data, U.S. Pharmacopeia (USP) compiled a list of more than 3,000 drug pairs that look or sound alike, a figure that is nearly double the number of pairs identified in USP's 2004 report, said Diane Cousins, R.Ph. “We were surprised to see that much of an increase in such a short time, and the concern is that this increase in products in the marketplace further raises the opportunity for error,” said Ms. Cousins, USP's vice president of health care quality and information.

USP also operates, in conjunction with the Institute for Safe Medication Practices, the Medication Errors Reporting Program (MER), which allows providers to confidentially report potential and actual medication errors directly to USP.

USP reviewed both MEDMARX and MER to summarize the variables associated with more than 26,000 look-alike and/or soundalike (LASA) errors, of which 1.4% (384) resulted in harm or death. More than 670 health care facilities contributed 26,000 records, according to the 400-page report.

“We looked at lists of the top 200 drugs prescribed and used in hospitals, and virtually every time, all of the top 10 appeared within the USP similar names list,” Ms. Cousins said in an interview.

An important finding of this year's report is the role of pharmacy staff in LASA-related errors, she said. “Although pharmacy personnel, who are generally technicians, made the majority of errors, pharmacists as a group identified, prevented, and reported more than any other staff.”

The report also identifies an emerging trend of look-alike drug names in computerized direct order entry systems as a source of confusion. “This trend will likely continue as these systems become a standard of practice,” she said, adding that the LASA-related error problem is further compounded by the indiscriminate use of suffixes, as well as look-alike packaging and labeling.

Over the 3-year period, the drug most commonly confused with others was Cefazolin, a first-generation cephalosporin antibiotic. “We found it to be confused with 15 other drugs, primarily antimicrobials, which might be explained by the fact that this is the most frequently used class of medications,” said Ms. Cousins.

Among other major paired LASAs were cardiovascular drugs, such as lisinopril and enalapril, and central nervous system agents, like trazodone and chlorpromazine.

Drug mix-ups led to seven reported fatalities, including two deaths attributed to confusion over the Alzheimer's drug Reminyl (galantamine) and the antidiabetes drug Amaryl (glimepiride).

In 2005, recognizing the high risk of confusion and subsequent fatal hypoglycemia, Ortho-McNeil Neurologics Inc. announced the name Reminyl had been changed to Razadyne to avoid confusion with Amaryl.

In another case, an autistic pediatric patient was given the wrong product when disodium EDTA (a hypercalcemia treatment) was administered instead of the chelation therapy calcium disodium EDTA, which is approved by the Food and Drug Administration for the treatment of lead poisoning and was prescribed in an attempt to help treat the patient's autism.

In another case, an emergency department physician was preparing to intubate a patient and calculated the right dose for rocuronium (Zemuron), a preintubation agent. The physician gave orders for the nurse to obtain the medication and indicated the volume to administer to the patient. The nurse obtained and administered the neuromuscular blocking agent vecuronium (Norcuron) instead. The patient received a large amount of the wrong agent, which led to a fatal heart arrhythmia.

The remaining three reported deaths involved mix-ups between the anticonvulsant primidone and prednisone; the antiepileptic drug phenytoin sodium and the barbiturate phenobarbital; and Norcuron and the heart failure treatment Natrecor (nesiritide recombinant).

Errors occur with over-the-counter medications, too. Ms. Cousins described the aural confusion when an order for Ferro-Sequel 500 mg—an iron replacement—was transcribed as Serrosequel 500 mg and the order was misread as Seroquel 500 mg—an antipsychotic.

The rate of mix-ups involving brand name versus generic drugs was about evenly split, 57% and 43%, respectively, Ms. Cousins said, adding that while most errors were made in pharmacies, many, such as the primidone-prednisone incident, are due to confusion over the prescribing physician's handwriting, which lead the pharmacist to issue the wrong drug.

“Errors also are due to physicians using short codes for medications, such as 'clon,' for clonazepam or clonapine,” she said, adding that electronically written prescriptions using a computer or label machine would eliminate many errors. “Anything that takes handwriting out of the equation is a help.”

It would also be helpful if the FDA were given more authority to force name changes during the drug review process, as has been suggested by the Institute of Medicine. It's much more difficult to correct a name confusion issue once the products are on the market.

The recommendation that physicians include indications for use in their prescriptions is not an attempt by USP to impose on privacy, Ms. Cousins said. “All that is needed are simple inclusions, such as 'for sinus,' 'for heart,' or, 'for cough,'” she said.

USP also recommends that “tall man lettering” be implemented in pharmacy software, labeling, and order writing to say, for example, “acetaZOLamide” (glaucoma) and “acetoHEXamide” (diabetes).

Where risk exists, take action to reduce the chance for error. To build awareness, USP recommends disseminating information about products that have been confused at your facility, and prohibiting verbal orders for soundalikes.

“Physicians' offices should always require a read-back from pharmacists, making sure that they both say and spell the drug name,” Ms. Cousins said.

Some errors result from physicians' use of the same abbreviation for two drugs: clon for clonazepam and clonapine. MS. COUSINS

Children with multiple prescriptions and those whose parents lack English skills are at increased risk of having preventable adverse drug events, according to a Boston study.

“Further attention should be directed toward improved communication among health care providers and patients,” said Dr. Stephanie O. Zandieh of Cornell University, New York, and the Komansky Center for Children's Health at New York-Presbyterian Hospital and associates.

In the prospective cohort of patients aged under 21 years who were seen from July 2002 to April 2003 at six urban and suburban practice sites in Boston, the primary outcome measure was the presence of a preventable adverse drug event (ADE), defined as actual harm from medication use (J. Pediatr. 2008;152:225–31).

Telephone surveys were used to gather information about race, ethnicity, reported annual family income, parental educational attainment, and parental self-reported English proficiency.

Independent variables, such as socioeconomic characteristics, poverty status, health care access, and medication regimen complexity, were determined by both telephone interviews and chart reviews.

The study logged more than 21,000 visits by 14,000 patients, 3,838 of whom received a prescription. Of those, the researchers studied 1,689 patients who both completed the 10-day survey and had a chart review; they received 2,155 prescriptions.

The study population was 49% white, 15% black, 21% Hispanic, and 14% “other”; because of rounding, these percentages do not add up to 100%, the investigators said. Two-thirds of Hispanics studied had limited English proficiency, compared with 16% of blacks, 3% of whites, and 23% of the “other” group of Native Americans, Asians, and Native Pacific Islanders.

“We found 283 ADEs occurred in 242 children (14% [of total 1,689 patients]), of which 57 were preventable in 56 children and 226 were nonpreventable ADEs in 186 children,” the investigators said, adding that about 10% of the children who had a preventable ADE also experienced a nonpreventable event.

None of the preventable ADEs was life threatening or fatal, 14% were serious, and 86% were considered significant. As an example of a serious ADE, the investigators described a 9-year-old child with streptococcal pharyngitis for whom amoxicillin was prescribed and whose parent did not complete the course of medicine, resulting in a return visit for persistent symptoms.

A total of 40 preventable ADEs (70%) occurred during parental administration of medication, and 15 (26%) occurred during ordering, they said, adding that the most common drugs involved in preventable ADEs were amoxicillin or amoxicillin-clavulanate (26%), inhaled steroids (11%), topical antifungals (7%), antihistamines (7%), and inhaled bronchodilators (5%).

In their univariate analysis of the data, the researchers found that children of parents who said they spoke English poorly were twice as likely to have a preventable ADE, compared with children of parents who spoke English very well.

Similarly, children with less than a year of continuous care were more likely to have a preventable ADE than those with more continuity of care.

In multivariate analysis, only children with multiple prescriptions were at increased risk of having a preventable ADE.

Of no surprise was the finding that children with chronic illnesses had more mediations prescribed, increasing their risk of a preventable adverse event, they wrote.

“We do not believe that these findings are caused by prescribing of less-familiar medications, because most drugs resulting in preventable ADEs were associated with common medications, such as antibiotics.”

The more likely explanation, they added, is that providers did not sufficiently or accurately communicate medication administration information to parents, because most preventable ADEs occurred during home administration.

Children with multiple prescriptions and those whose parents lack English skills are at increased risk of having preventable adverse drug events, according to a Boston study.

“Further attention should be directed toward improved communication among health care providers and patients,” said Dr. Stephanie O. Zandieh of Cornell University, New York, and the Komansky Center for Children's Health at New York-Presbyterian Hospital and associates.

In the prospective cohort of patients aged under 21 years who were seen from July 2002 to April 2003 at six urban and suburban practice sites in Boston, the primary outcome measure was the presence of a preventable adverse drug event (ADE), defined as actual harm from medication use (J. Pediatr. 2008;152:225–31).

Telephone surveys were used to gather information about race, ethnicity, reported annual family income, parental educational attainment, and parental self-reported English proficiency.

Independent variables, such as socioeconomic characteristics, poverty status, health care access, and medication regimen complexity, were determined by both telephone interviews and chart reviews.

The study logged more than 21,000 visits by 14,000 patients, 3,838 of whom received a prescription. Of those, the researchers studied 1,689 patients who both completed the 10-day survey and had a chart review; they received 2,155 prescriptions.

The study population was 49% white, 15% black, 21% Hispanic, and 14% “other”; because of rounding, these percentages do not add up to 100%, the investigators said. Two-thirds of Hispanics studied had limited English proficiency, compared with 16% of blacks, 3% of whites, and 23% of the “other” group of Native Americans, Asians, and Native Pacific Islanders.

“We found 283 ADEs occurred in 242 children (14% [of total 1,689 patients]), of which 57 were preventable in 56 children and 226 were nonpreventable ADEs in 186 children,” the investigators said, adding that about 10% of the children who had a preventable ADE also experienced a nonpreventable event.

None of the preventable ADEs was life threatening or fatal, 14% were serious, and 86% were considered significant. As an example of a serious ADE, the investigators described a 9-year-old child with streptococcal pharyngitis for whom amoxicillin was prescribed and whose parent did not complete the course of medicine, resulting in a return visit for persistent symptoms.

A total of 40 preventable ADEs (70%) occurred during parental administration of medication, and 15 (26%) occurred during ordering, they said, adding that the most common drugs involved in preventable ADEs were amoxicillin or amoxicillin-clavulanate (26%), inhaled steroids (11%), topical antifungals (7%), antihistamines (7%), and inhaled bronchodilators (5%).

In their univariate analysis of the data, the researchers found that children of parents who said they spoke English poorly were twice as likely to have a preventable ADE, compared with children of parents who spoke English very well.

Similarly, children with less than a year of continuous care were more likely to have a preventable ADE than those with more continuity of care.

In multivariate analysis, only children with multiple prescriptions were at increased risk of having a preventable ADE.

Of no surprise was the finding that children with chronic illnesses had more mediations prescribed, increasing their risk of a preventable adverse event, they wrote.

“We do not believe that these findings are caused by prescribing of less-familiar medications, because most drugs resulting in preventable ADEs were associated with common medications, such as antibiotics.”

The more likely explanation, they added, is that providers did not sufficiently or accurately communicate medication administration information to parents, because most preventable ADEs occurred during home administration.

Children with multiple prescriptions and those whose parents lack English skills are at increased risk of having preventable adverse drug events, according to a Boston study.

“Further attention should be directed toward improved communication among health care providers and patients,” said Dr. Stephanie O. Zandieh of Cornell University, New York, and the Komansky Center for Children's Health at New York-Presbyterian Hospital and associates.

In the prospective cohort of patients aged under 21 years who were seen from July 2002 to April 2003 at six urban and suburban practice sites in Boston, the primary outcome measure was the presence of a preventable adverse drug event (ADE), defined as actual harm from medication use (J. Pediatr. 2008;152:225–31).

Telephone surveys were used to gather information about race, ethnicity, reported annual family income, parental educational attainment, and parental self-reported English proficiency.

Independent variables, such as socioeconomic characteristics, poverty status, health care access, and medication regimen complexity, were determined by both telephone interviews and chart reviews.

The study logged more than 21,000 visits by 14,000 patients, 3,838 of whom received a prescription. Of those, the researchers studied 1,689 patients who both completed the 10-day survey and had a chart review; they received 2,155 prescriptions.

The study population was 49% white, 15% black, 21% Hispanic, and 14% “other”; because of rounding, these percentages do not add up to 100%, the investigators said. Two-thirds of Hispanics studied had limited English proficiency, compared with 16% of blacks, 3% of whites, and 23% of the “other” group of Native Americans, Asians, and Native Pacific Islanders.

“We found 283 ADEs occurred in 242 children (14% [of total 1,689 patients]), of which 57 were preventable in 56 children and 226 were nonpreventable ADEs in 186 children,” the investigators said, adding that about 10% of the children who had a preventable ADE also experienced a nonpreventable event.

None of the preventable ADEs was life threatening or fatal, 14% were serious, and 86% were considered significant. As an example of a serious ADE, the investigators described a 9-year-old child with streptococcal pharyngitis for whom amoxicillin was prescribed and whose parent did not complete the course of medicine, resulting in a return visit for persistent symptoms.

A total of 40 preventable ADEs (70%) occurred during parental administration of medication, and 15 (26%) occurred during ordering, they said, adding that the most common drugs involved in preventable ADEs were amoxicillin or amoxicillin-clavulanate (26%), inhaled steroids (11%), topical antifungals (7%), antihistamines (7%), and inhaled bronchodilators (5%).

In their univariate analysis of the data, the researchers found that children of parents who said they spoke English poorly were twice as likely to have a preventable ADE, compared with children of parents who spoke English very well.

Similarly, children with less than a year of continuous care were more likely to have a preventable ADE than those with more continuity of care.

In multivariate analysis, only children with multiple prescriptions were at increased risk of having a preventable ADE.

Of no surprise was the finding that children with chronic illnesses had more mediations prescribed, increasing their risk of a preventable adverse event, they wrote.

“We do not believe that these findings are caused by prescribing of less-familiar medications, because most drugs resulting in preventable ADEs were associated with common medications, such as antibiotics.”

The more likely explanation, they added, is that providers did not sufficiently or accurately communicate medication administration information to parents, because most preventable ADEs occurred during home administration.

The distribution of children with diabetes and obesity does not parallel that of pediatric endocrinologists in the United States, largely because of geographic disparities in the supply of these specialists, according to Dr. Joyce M. Lee and colleagues at the University of Michigan, Ann Arbor.

This patient-specialist disparity is made especially acute by the growing epidemic of obesity, the authors report.

Data from the American Board of Pediatrics were used to estimate the number of board-certified pediatric endocrinologists by state, and national estimates of children with diabetes and obesity were derived from the National Survey of Children's Health, a representative cross-sectional random-digit-dial telephone survey of households with children younger than 18 years of age.

The investigators compared the observed ratios of obese children to pediatric endocrinologists under “index” conditions of greater supply and equitable distribution. They assumed that the ratio of the child population to specialists for each state was similar to that in the state with the largest supply, Massachusetts, where the ratio of obese children to endocrinologists was 5,132:1.

The highest ratio—99,984:1—was in Mississippi. Two states, Montana and Wyoming, had no endocrinologists.

Nationwide, there were 17,741 obese children for each board-certified pediatric endocrinologist. By region, the northeast had the lowest ratio (9,994:1) and the south had the highest (25,796:1).

When the scientists examined the ratio of endocrinologists to children with diabetes, they found the best conditions in New England (113:1) and the worst in the east south-central region (594:1).

The nation as a whole had a ratio of 290:1 (Journal of Pediatrics 2008;152:331–6).

With an almost sixfold difference in ratios of children with diabetes to certified pediatric endocrinologists across census divisions, and no ideal benchmark ratio for children with chronic disease to pediatric subspecialists, the authors believe it is unclear what effect this distribution has on access to the pediatric endocrinologists and health outcomes across geographic areas.

When observed ratios were compared with “index” ratios calculated under assumptions of equitable supply, the “index” ratios showed considerably less variation, the investigators explained.

The data suggest that geographic differences in endocrinologist supply, not geographic differences in diabetes and obesity prevalence, might be driving the variation.

The authors point out that childhood obesity clinics are receiving increasing attention as a possible solution to the treatment of pediatric obesity.

However, given the scope of the problem in the United States, “it is unclear whether childhood obesity clinics run by subspecialty providers represent a model of care that is either sustainable or effective in addressing the increasing burden,” the investigators said.

Given this state of affairs, the role of the primary care pediatrician and the medical home in caring for the obese child becomes even more critical, Dr. Lee said in an interview.

“Our study may actually underestimate the ratios because most pediatric endocrinologists are affiliated with academic medical centers and spend a lot of time teaching and conducting research rather than seeing patients,” said Dr. Lee of the division of pediatric endocrinology at the university.

The huge demand for obesity and diabetes treatment is expected to continue to outpace the slow growth in new specialists, so emphasis should be placed on helping primary care pediatricians prevent and treat childhood obesity, she said.

“The American Diabetes Association states that, ideally, these children should be treated by pediatric endocrinologists, but they also can be treated by adult endocrinologists and even internists and family practitioners,” Dr. Lee said in an interview.

“The bottom line is these children need a medical home, and that home really resides with the primary care pediatrician,” she concluded.

ELSEVIER GLOBAL MEDICAL NEWS

The distribution of children with diabetes and obesity does not parallel that of pediatric endocrinologists in the United States, largely because of geographic disparities in the supply of these specialists, according to Dr. Joyce M. Lee and colleagues at the University of Michigan, Ann Arbor.

This patient-specialist disparity is made especially acute by the growing epidemic of obesity, the authors report.

Data from the American Board of Pediatrics were used to estimate the number of board-certified pediatric endocrinologists by state, and national estimates of children with diabetes and obesity were derived from the National Survey of Children's Health, a representative cross-sectional random-digit-dial telephone survey of households with children younger than 18 years of age.

The investigators compared the observed ratios of obese children to pediatric endocrinologists under “index” conditions of greater supply and equitable distribution. They assumed that the ratio of the child population to specialists for each state was similar to that in the state with the largest supply, Massachusetts, where the ratio of obese children to endocrinologists was 5,132:1.

The highest ratio—99,984:1—was in Mississippi. Two states, Montana and Wyoming, had no endocrinologists.

Nationwide, there were 17,741 obese children for each board-certified pediatric endocrinologist. By region, the northeast had the lowest ratio (9,994:1) and the south had the highest (25,796:1).

When the scientists examined the ratio of endocrinologists to children with diabetes, they found the best conditions in New England (113:1) and the worst in the east south-central region (594:1).

The nation as a whole had a ratio of 290:1 (Journal of Pediatrics 2008;152:331–6).

With an almost sixfold difference in ratios of children with diabetes to certified pediatric endocrinologists across census divisions, and no ideal benchmark ratio for children with chronic disease to pediatric subspecialists, the authors believe it is unclear what effect this distribution has on access to the pediatric endocrinologists and health outcomes across geographic areas.

When observed ratios were compared with “index” ratios calculated under assumptions of equitable supply, the “index” ratios showed considerably less variation, the investigators explained.

The data suggest that geographic differences in endocrinologist supply, not geographic differences in diabetes and obesity prevalence, might be driving the variation.

The authors point out that childhood obesity clinics are receiving increasing attention as a possible solution to the treatment of pediatric obesity.

However, given the scope of the problem in the United States, “it is unclear whether childhood obesity clinics run by subspecialty providers represent a model of care that is either sustainable or effective in addressing the increasing burden,” the investigators said.

Given this state of affairs, the role of the primary care pediatrician and the medical home in caring for the obese child becomes even more critical, Dr. Lee said in an interview.

“Our study may actually underestimate the ratios because most pediatric endocrinologists are affiliated with academic medical centers and spend a lot of time teaching and conducting research rather than seeing patients,” said Dr. Lee of the division of pediatric endocrinology at the university.

The huge demand for obesity and diabetes treatment is expected to continue to outpace the slow growth in new specialists, so emphasis should be placed on helping primary care pediatricians prevent and treat childhood obesity, she said.

“The American Diabetes Association states that, ideally, these children should be treated by pediatric endocrinologists, but they also can be treated by adult endocrinologists and even internists and family practitioners,” Dr. Lee said in an interview.

“The bottom line is these children need a medical home, and that home really resides with the primary care pediatrician,” she concluded.

ELSEVIER GLOBAL MEDICAL NEWS

The distribution of children with diabetes and obesity does not parallel that of pediatric endocrinologists in the United States, largely because of geographic disparities in the supply of these specialists, according to Dr. Joyce M. Lee and colleagues at the University of Michigan, Ann Arbor.

This patient-specialist disparity is made especially acute by the growing epidemic of obesity, the authors report.

Data from the American Board of Pediatrics were used to estimate the number of board-certified pediatric endocrinologists by state, and national estimates of children with diabetes and obesity were derived from the National Survey of Children's Health, a representative cross-sectional random-digit-dial telephone survey of households with children younger than 18 years of age.

The investigators compared the observed ratios of obese children to pediatric endocrinologists under “index” conditions of greater supply and equitable distribution. They assumed that the ratio of the child population to specialists for each state was similar to that in the state with the largest supply, Massachusetts, where the ratio of obese children to endocrinologists was 5,132:1.

The highest ratio—99,984:1—was in Mississippi. Two states, Montana and Wyoming, had no endocrinologists.

Nationwide, there were 17,741 obese children for each board-certified pediatric endocrinologist. By region, the northeast had the lowest ratio (9,994:1) and the south had the highest (25,796:1).

When the scientists examined the ratio of endocrinologists to children with diabetes, they found the best conditions in New England (113:1) and the worst in the east south-central region (594:1).

The nation as a whole had a ratio of 290:1 (Journal of Pediatrics 2008;152:331–6).

With an almost sixfold difference in ratios of children with diabetes to certified pediatric endocrinologists across census divisions, and no ideal benchmark ratio for children with chronic disease to pediatric subspecialists, the authors believe it is unclear what effect this distribution has on access to the pediatric endocrinologists and health outcomes across geographic areas.

When observed ratios were compared with “index” ratios calculated under assumptions of equitable supply, the “index” ratios showed considerably less variation, the investigators explained.

The data suggest that geographic differences in endocrinologist supply, not geographic differences in diabetes and obesity prevalence, might be driving the variation.

The authors point out that childhood obesity clinics are receiving increasing attention as a possible solution to the treatment of pediatric obesity.

However, given the scope of the problem in the United States, “it is unclear whether childhood obesity clinics run by subspecialty providers represent a model of care that is either sustainable or effective in addressing the increasing burden,” the investigators said.

Given this state of affairs, the role of the primary care pediatrician and the medical home in caring for the obese child becomes even more critical, Dr. Lee said in an interview.

“Our study may actually underestimate the ratios because most pediatric endocrinologists are affiliated with academic medical centers and spend a lot of time teaching and conducting research rather than seeing patients,” said Dr. Lee of the division of pediatric endocrinology at the university.

The huge demand for obesity and diabetes treatment is expected to continue to outpace the slow growth in new specialists, so emphasis should be placed on helping primary care pediatricians prevent and treat childhood obesity, she said.

“The American Diabetes Association states that, ideally, these children should be treated by pediatric endocrinologists, but they also can be treated by adult endocrinologists and even internists and family practitioners,” Dr. Lee said in an interview.

“The bottom line is these children need a medical home, and that home really resides with the primary care pediatrician,” she concluded.

ELSEVIER GLOBAL MEDICAL NEWS

The soaring numbers of commonly used drugs with sound-alike and look-alike names have prompted the U.S. Pharmacopeia to ask physicians and pharmacists to include an “indication for use” on prescriptions.

This and other recommendations are contained in U.S. Pharmacopeia's 8th annual MEDMARX report, which is based on a review of more than 26,000 records submitted to the MEDMARX database from 2003 to 2006.

The records implicate nearly 1,500 drugs in medication errors due to brand or generic names that could be confused. From these data, U.S. Pharmacopeia (USP) compiled a list of more than 3,000 drug pairs that look or sound alike, a figure that is nearly double the number of pairs identified in USP's 2004 report, said Diane Cousins, R.Ph.

“We were surprised to see that much of an increase in such a short time, and the concern is that this increase in products in the marketplace further raises the opportunity for error,” said Ms. Cousins, USP's vice president of health care quality and information.

USP also operates, in conjunction with the Institute for Safe Medication Practices, the Medication Errors Reporting Program (MER), which allows health care professionals to confidentially report potential and actual medication errors directly to USP.

USP reviewed both MEDMARX and MER to summarize the variables associated with more than 26,000 look-alike and/or sound-alike (LASA) errors, of which 1.4% (384) resulted in harm or death. More than 670 health care facilities contributed 26,000 records, according to the 400-page report.

“We looked at lists of the top 200 drugs prescribed and used in hospitals, and virtually every time, all of the top 10 appeared within the USP similar names list,” Ms. Cousins said in an interview.

An important finding of this year's report is the role of pharmacy staff in LASA-related errors, she said. “Although pharmacy personnel, who are generally technicians, made the majority of errors, pharmacists as a group identified, prevented, and reported more than any other staff.”

The report also identifies an emerging trend of look-alike drug names in computerized direct order entry systems as a source of confusion. “This trend will likely continue as these systems become a standard of practice,” she said, adding that the LASA-related error problem is further compounded by the indiscriminate use of suffixes, as well as look-alike packaging and labeling.

Over the 3-year period, the drug most commonly confused with others was Cefazolin, a first-generation cephalosporin antibiotic. “We found it to be confused with 15 other drugs, primarily antimicrobials, which might be explained by the fact that this is the most frequently used class of medications,” said Ms. Cousins.

Among other major paired LASAs were cardiovascular medications, such as lisinopril and enalapril, and central nervous system agents, such as trazodone and chlorpromazine.

Errors occur with over-the-counter medications, too. Ms. Cousins described the aural confusion when an order for Ferro-Sequel 500 mg—an iron replacement—was transcribed as Serrosequel 500 mg and the order was misread as Seroquel 500 mg—an antipsychotic.

The rate of mix-ups involving brand name versus generic drugs was about evenly split, 57% and 43%, respectively, Ms. Cousins said, adding that while most errors were made in pharmacies, many, such as the primidone-prednisone incident, are due to confusion over the prescribing physician's handwriting, which lead the pharmacist to issue the wrong drug.

“Errors also are due to physicians using short codes for medications, such as 'clon,' for clonazepam or clonapine,” she said, adding that electronically written prescriptions using a computer or label machine would eliminate many errors.

It would be helpful if the FDA were given more authority to force name changes during the drug review process, as has been suggested by the Institute of Medicine.

The recommendation that physicians include indications for use in their prescriptions is not an attempt by USP to impose on privacy, Ms. Cousins emphasized. “All that is needed are simple inclusions, such as 'for sinus,' 'for heart,' or, 'for cough,'” she said, explaining that this also would help patients avoid confusion if they forget which vial is for which condition.

USP also recommends that “tall man lettering” be implemented in pharmacy software, labeling, and order writing to say, for example, “acetaZOLamide” (glaucoma) and “acetoHEXamide” (diabetes).

Where risk exists, take action to reduce the chance for error. USP recommends the following:

▸ Consider the potential for mix-ups before adding a drug to your formulary.

▸ Physically separate or differentiate products with similar names while they are being stored on the shelf.

▸ Disseminate information about products that have been confused at your facility, to build awareness among staff.

▸ Prohibit verbal orders for sound-alikes that have been mixed up at your facility.

“Physicians' offices should always require a read-back from pharmacists, making sure that they both say and spell the drug name,” Ms. Cousins concluded.

The concern is that this increase in look-alike products further raises the opportunity for error. MS. COUSINS

The soaring numbers of commonly used drugs with sound-alike and look-alike names have prompted the U.S. Pharmacopeia to ask physicians and pharmacists to include an “indication for use” on prescriptions.

This and other recommendations are contained in U.S. Pharmacopeia's 8th annual MEDMARX report, which is based on a review of more than 26,000 records submitted to the MEDMARX database from 2003 to 2006.

The records implicate nearly 1,500 drugs in medication errors due to brand or generic names that could be confused. From these data, U.S. Pharmacopeia (USP) compiled a list of more than 3,000 drug pairs that look or sound alike, a figure that is nearly double the number of pairs identified in USP's 2004 report, said Diane Cousins, R.Ph.

“We were surprised to see that much of an increase in such a short time, and the concern is that this increase in products in the marketplace further raises the opportunity for error,” said Ms. Cousins, USP's vice president of health care quality and information.

USP also operates, in conjunction with the Institute for Safe Medication Practices, the Medication Errors Reporting Program (MER), which allows health care professionals to confidentially report potential and actual medication errors directly to USP.

USP reviewed both MEDMARX and MER to summarize the variables associated with more than 26,000 look-alike and/or sound-alike (LASA) errors, of which 1.4% (384) resulted in harm or death. More than 670 health care facilities contributed 26,000 records, according to the 400-page report.

“We looked at lists of the top 200 drugs prescribed and used in hospitals, and virtually every time, all of the top 10 appeared within the USP similar names list,” Ms. Cousins said in an interview.

An important finding of this year's report is the role of pharmacy staff in LASA-related errors, she said. “Although pharmacy personnel, who are generally technicians, made the majority of errors, pharmacists as a group identified, prevented, and reported more than any other staff.”

The report also identifies an emerging trend of look-alike drug names in computerized direct order entry systems as a source of confusion. “This trend will likely continue as these systems become a standard of practice,” she said, adding that the LASA-related error problem is further compounded by the indiscriminate use of suffixes, as well as look-alike packaging and labeling.

Over the 3-year period, the drug most commonly confused with others was Cefazolin, a first-generation cephalosporin antibiotic. “We found it to be confused with 15 other drugs, primarily antimicrobials, which might be explained by the fact that this is the most frequently used class of medications,” said Ms. Cousins.

Among other major paired LASAs were cardiovascular medications, such as lisinopril and enalapril, and central nervous system agents, such as trazodone and chlorpromazine.

Errors occur with over-the-counter medications, too. Ms. Cousins described the aural confusion when an order for Ferro-Sequel 500 mg—an iron replacement—was transcribed as Serrosequel 500 mg and the order was misread as Seroquel 500 mg—an antipsychotic.

The rate of mix-ups involving brand name versus generic drugs was about evenly split, 57% and 43%, respectively, Ms. Cousins said, adding that while most errors were made in pharmacies, many, such as the primidone-prednisone incident, are due to confusion over the prescribing physician's handwriting, which lead the pharmacist to issue the wrong drug.

“Errors also are due to physicians using short codes for medications, such as 'clon,' for clonazepam or clonapine,” she said, adding that electronically written prescriptions using a computer or label machine would eliminate many errors.

It would be helpful if the FDA were given more authority to force name changes during the drug review process, as has been suggested by the Institute of Medicine.

The recommendation that physicians include indications for use in their prescriptions is not an attempt by USP to impose on privacy, Ms. Cousins emphasized. “All that is needed are simple inclusions, such as 'for sinus,' 'for heart,' or, 'for cough,'” she said, explaining that this also would help patients avoid confusion if they forget which vial is for which condition.

USP also recommends that “tall man lettering” be implemented in pharmacy software, labeling, and order writing to say, for example, “acetaZOLamide” (glaucoma) and “acetoHEXamide” (diabetes).

Where risk exists, take action to reduce the chance for error. USP recommends the following:

▸ Consider the potential for mix-ups before adding a drug to your formulary.

▸ Physically separate or differentiate products with similar names while they are being stored on the shelf.

▸ Disseminate information about products that have been confused at your facility, to build awareness among staff.

▸ Prohibit verbal orders for sound-alikes that have been mixed up at your facility.

“Physicians' offices should always require a read-back from pharmacists, making sure that they both say and spell the drug name,” Ms. Cousins concluded.

The concern is that this increase in look-alike products further raises the opportunity for error. MS. COUSINS

The soaring numbers of commonly used drugs with sound-alike and look-alike names have prompted the U.S. Pharmacopeia to ask physicians and pharmacists to include an “indication for use” on prescriptions.

This and other recommendations are contained in U.S. Pharmacopeia's 8th annual MEDMARX report, which is based on a review of more than 26,000 records submitted to the MEDMARX database from 2003 to 2006.

The records implicate nearly 1,500 drugs in medication errors due to brand or generic names that could be confused. From these data, U.S. Pharmacopeia (USP) compiled a list of more than 3,000 drug pairs that look or sound alike, a figure that is nearly double the number of pairs identified in USP's 2004 report, said Diane Cousins, R.Ph.

“We were surprised to see that much of an increase in such a short time, and the concern is that this increase in products in the marketplace further raises the opportunity for error,” said Ms. Cousins, USP's vice president of health care quality and information.

USP also operates, in conjunction with the Institute for Safe Medication Practices, the Medication Errors Reporting Program (MER), which allows health care professionals to confidentially report potential and actual medication errors directly to USP.

USP reviewed both MEDMARX and MER to summarize the variables associated with more than 26,000 look-alike and/or sound-alike (LASA) errors, of which 1.4% (384) resulted in harm or death. More than 670 health care facilities contributed 26,000 records, according to the 400-page report.

“We looked at lists of the top 200 drugs prescribed and used in hospitals, and virtually every time, all of the top 10 appeared within the USP similar names list,” Ms. Cousins said in an interview.

An important finding of this year's report is the role of pharmacy staff in LASA-related errors, she said. “Although pharmacy personnel, who are generally technicians, made the majority of errors, pharmacists as a group identified, prevented, and reported more than any other staff.”

The report also identifies an emerging trend of look-alike drug names in computerized direct order entry systems as a source of confusion. “This trend will likely continue as these systems become a standard of practice,” she said, adding that the LASA-related error problem is further compounded by the indiscriminate use of suffixes, as well as look-alike packaging and labeling.

Over the 3-year period, the drug most commonly confused with others was Cefazolin, a first-generation cephalosporin antibiotic. “We found it to be confused with 15 other drugs, primarily antimicrobials, which might be explained by the fact that this is the most frequently used class of medications,” said Ms. Cousins.

Among other major paired LASAs were cardiovascular medications, such as lisinopril and enalapril, and central nervous system agents, such as trazodone and chlorpromazine.

Errors occur with over-the-counter medications, too. Ms. Cousins described the aural confusion when an order for Ferro-Sequel 500 mg—an iron replacement—was transcribed as Serrosequel 500 mg and the order was misread as Seroquel 500 mg—an antipsychotic.

The rate of mix-ups involving brand name versus generic drugs was about evenly split, 57% and 43%, respectively, Ms. Cousins said, adding that while most errors were made in pharmacies, many, such as the primidone-prednisone incident, are due to confusion over the prescribing physician's handwriting, which lead the pharmacist to issue the wrong drug.

“Errors also are due to physicians using short codes for medications, such as 'clon,' for clonazepam or clonapine,” she said, adding that electronically written prescriptions using a computer or label machine would eliminate many errors.

It would be helpful if the FDA were given more authority to force name changes during the drug review process, as has been suggested by the Institute of Medicine.

The recommendation that physicians include indications for use in their prescriptions is not an attempt by USP to impose on privacy, Ms. Cousins emphasized. “All that is needed are simple inclusions, such as 'for sinus,' 'for heart,' or, 'for cough,'” she said, explaining that this also would help patients avoid confusion if they forget which vial is for which condition.

USP also recommends that “tall man lettering” be implemented in pharmacy software, labeling, and order writing to say, for example, “acetaZOLamide” (glaucoma) and “acetoHEXamide” (diabetes).

Where risk exists, take action to reduce the chance for error. USP recommends the following:

▸ Consider the potential for mix-ups before adding a drug to your formulary.

▸ Physically separate or differentiate products with similar names while they are being stored on the shelf.

▸ Disseminate information about products that have been confused at your facility, to build awareness among staff.

▸ Prohibit verbal orders for sound-alikes that have been mixed up at your facility.

“Physicians' offices should always require a read-back from pharmacists, making sure that they both say and spell the drug name,” Ms. Cousins concluded.

The concern is that this increase in look-alike products further raises the opportunity for error. MS. COUSINS

Researchers in Montreal have reported new evidence supporting a strong causal association between human papillomavirus infection and tonsil-related oral cancers.

The study also found that human papillomavirus (HPV) 16 seropositivity contributes substantial independent risk prediction. “HPV 16 seropositivity may thus serve as a surrogate marker for the totality of HPV exposure that is relevant in oral carcinogenesis,” wrote Dr. Javier Pintos and his associates from the division of cancer epidemiology at McGill University.

Additionally, while some researchers have reported a positive correlation between markers of sexual activity and oral cancers, this study found no such association (Oral Oncol. 2008;44:242–50).

The investigation, as part of a multicenter study coordinated by the International Agency for Research on Cancer, followed a hospital-based case-control design.

A total of 72 patients with newly diagnosed squamous cell carcinoma of the mouth and 129 controls were recruited. Among patients, the most common cancer site was the tongue (21 patients), followed by the floor of the mouth (12) and palatine tonsil (12), “other” and “unspecified” parts of the mouth (18), the palate (4), the gums (2), the oropharynx (2), and the inner lip (1).

Patients ranged in age from 25 to 84 years, though most were between 55 and 74 years; men accounted for more than 70%.

HPV DNA was detected in 6 of 129 controls (5%) and 14 of 72 patients (19%). Most viral infections among patients harbored high-risk HPV types (13 of 14 samples), compared with 4 of the 6 HPV-positive controls, the investigators said, adding that HPV 16, which was not detected among controls, was found in 13 of the 14 positive samples from the oral cancer arm.

The association between HPV and cancers of the palatine tonsils and base of tongue seem to be genuine, because it is independent from the influence of smoking and alcohol.

The study was funded by the National Cancer Institute of Canada, and the authors said they had no conflicts of interest.

ELSEVIER GLOBAL MEDICAL NEWS

Researchers in Montreal have reported new evidence supporting a strong causal association between human papillomavirus infection and tonsil-related oral cancers.

The study also found that human papillomavirus (HPV) 16 seropositivity contributes substantial independent risk prediction. “HPV 16 seropositivity may thus serve as a surrogate marker for the totality of HPV exposure that is relevant in oral carcinogenesis,” wrote Dr. Javier Pintos and his associates from the division of cancer epidemiology at McGill University.

Additionally, while some researchers have reported a positive correlation between markers of sexual activity and oral cancers, this study found no such association (Oral Oncol. 2008;44:242–50).

The investigation, as part of a multicenter study coordinated by the International Agency for Research on Cancer, followed a hospital-based case-control design.

A total of 72 patients with newly diagnosed squamous cell carcinoma of the mouth and 129 controls were recruited. Among patients, the most common cancer site was the tongue (21 patients), followed by the floor of the mouth (12) and palatine tonsil (12), “other” and “unspecified” parts of the mouth (18), the palate (4), the gums (2), the oropharynx (2), and the inner lip (1).

Patients ranged in age from 25 to 84 years, though most were between 55 and 74 years; men accounted for more than 70%.

HPV DNA was detected in 6 of 129 controls (5%) and 14 of 72 patients (19%). Most viral infections among patients harbored high-risk HPV types (13 of 14 samples), compared with 4 of the 6 HPV-positive controls, the investigators said, adding that HPV 16, which was not detected among controls, was found in 13 of the 14 positive samples from the oral cancer arm.

The association between HPV and cancers of the palatine tonsils and base of tongue seem to be genuine, because it is independent from the influence of smoking and alcohol.

The study was funded by the National Cancer Institute of Canada, and the authors said they had no conflicts of interest.

ELSEVIER GLOBAL MEDICAL NEWS

Researchers in Montreal have reported new evidence supporting a strong causal association between human papillomavirus infection and tonsil-related oral cancers.

The study also found that human papillomavirus (HPV) 16 seropositivity contributes substantial independent risk prediction. “HPV 16 seropositivity may thus serve as a surrogate marker for the totality of HPV exposure that is relevant in oral carcinogenesis,” wrote Dr. Javier Pintos and his associates from the division of cancer epidemiology at McGill University.

Additionally, while some researchers have reported a positive correlation between markers of sexual activity and oral cancers, this study found no such association (Oral Oncol. 2008;44:242–50).

The investigation, as part of a multicenter study coordinated by the International Agency for Research on Cancer, followed a hospital-based case-control design.

A total of 72 patients with newly diagnosed squamous cell carcinoma of the mouth and 129 controls were recruited. Among patients, the most common cancer site was the tongue (21 patients), followed by the floor of the mouth (12) and palatine tonsil (12), “other” and “unspecified” parts of the mouth (18), the palate (4), the gums (2), the oropharynx (2), and the inner lip (1).

Patients ranged in age from 25 to 84 years, though most were between 55 and 74 years; men accounted for more than 70%.

HPV DNA was detected in 6 of 129 controls (5%) and 14 of 72 patients (19%). Most viral infections among patients harbored high-risk HPV types (13 of 14 samples), compared with 4 of the 6 HPV-positive controls, the investigators said, adding that HPV 16, which was not detected among controls, was found in 13 of the 14 positive samples from the oral cancer arm.

The association between HPV and cancers of the palatine tonsils and base of tongue seem to be genuine, because it is independent from the influence of smoking and alcohol.

The study was funded by the National Cancer Institute of Canada, and the authors said they had no conflicts of interest.

ELSEVIER GLOBAL MEDICAL NEWS

The soaring numbers of commonly used drugs with soundalike and look-alike names have prompted U.S. Pharmacopeia to ask physicians and pharmacists to include an “indication for use” on prescriptions.

This and other recommendations are contained in U.S. Pharmacopeia's 8th annual MEDMARX report, which is based on a review of more than 26,000 records submitted to the MEDMARX database from 2003 to 2006.

The records implicate nearly 1,500 drugs in medication errors because of brand or generic names that could be confused. From these data, U.S. Pharmacopeia (USP) compiled a list of more than 3,000 drug pairs that look or sound alike, a figure that is nearly double the number of pairs identified in USP's 2004 report, said Diane Cousins, R.Ph.

“We were surprised to see that much of an increase in such a short time, and the concern is that this increase in products in the marketplace further raises the opportunity for error,” said Ms. Cousins, USP's vice president of health care quality and information.

USP also operates, in conjunction with the Institute for Safe Medication Practices, the Medication Errors Reporting Program (MER), which allows health care professionals to confidentially report potential and actual medication errors directly to USP.

USP reviewed both MEDMARX and MER to summarize the variables associated with more than 26,000 look-alike and/or soundalike (LASA) errors, of which 1.4% (384) resulted in harm or death. More than 670 health care facilities contributed 26,000 records, according to the 400-page report.

“We looked at lists of the top 200 drugs prescribed and used in hospitals, and virtually every time, all of the top 10 appeared within the USP similar names list,” Ms. Cousins said in an interview.

An important finding of this year's report is the role of pharmacy staff in LASA-related errors, she said. “Although pharmacy personnel, who are generally technicians, made the majority of errors, pharmacists as a group identified, prevented, and reported more than any other staff.”

The report also identifies an emerging trend of look-alike drug names in computerized direct order entry systems as a source of confusion. “This trend will likely continue as these systems become a standard of practice,” she said, adding that the LASA-related error problem is further compounded by the indiscriminate use of suffixes, as well as look-alike packaging and labeling.

Over the 3-year period, the drug most commonly confused with others was Cefazolin, a first-generation cephalosporin antibiotic. “We found it to be confused with 15 other drugs, primarily antimicrobials, which might be explained by the fact that this is the most frequently used class of medications,” said Ms. Cousins.

Among other major paired LASAs were cardiovascular medications, such as lisinopril and enalapril, and central nervous system agents, such as trazodone and chlorpromazine.

Drug mix-ups led to seven reported fatalities, including two deaths attributed to confusion over the Alzheimer's drug Reminyl (galantamine) and the antidiabetes drug Amaryl (glimepiride).

In 2005, recognizing the high risk of confusion and subsequent fatal hypoglycemia, Ortho-McNeil Neurologics Inc. announced that the name Reminyl had been changed to Razadyne to avoid confusion with Amaryl.

In another case, an autistic pediatric patient was given the wrong product when disodium EDTA (a hypercalcemia treatment) was administered instead of the chelation therapy calcium disodium EDTA, which is approved by the Food and Drug Administration for the treatment of lead poisoning and was prescribed in an attempt to help treat the patient's autism.

In another case, an emergency department physician was preparing to intubate a patient and calculated the dose for rocuronium (Zemuron), a preintubation agent used to assist with the procedure. The physician gave orders for the nurse to obtain the medication and indicated the volume to administer to the patient. The nurse obtained and administered the neuromuscular blocking agent vecuronium (Norcuron) instead, which led to a fatal heart arrhythmia.

The remaining three reported deaths involved mix-ups between the anticonvulsant primidone and prednisone; the antiepileptic drug phenytoin sodium and the barbiturate phenobarbital; and Norcuron and the heart failure treatment Natrecor (nesiritide recombinant).

Errors occur with over-the-counter medications, too. Ms. Cousins described the aural confusion when an order for Ferro-Sequel 500 mg–an iron replacement–was transcribed as Serrosequel 500 mg and the order was misread as Seroquel 500 mg–an antipsychotic.

The rate of mix-ups involving brand name versus generic drugs was about evenly split, 57% and 43%, respectively, Ms. Cousins said, adding that while most errors were made in pharmacies, many, such as the primidone-prednisone incident, are due to confusion over the prescribing physician's handwriting, which lead the pharmacist to issue the wrong drug.

“Errors also are due to physicians using short codes for medications, such as 'clon,' for clonazepam or clonapine,” she said, adding that electronically written prescriptions using a computer or label machine would eliminate many errors. “Anything that takes handwriting out of the equation is a help.”

It would also be helpful if the FDA were given more authority to force name changes during the drug review process, as has been suggested by the Institute of Medicine. It's much more difficult to correct a name confusion issue once the products are on the market.

The recommendation that physicians include indications for use in prescriptions is not an attempt by USP to impose on privacy, she emphasized: “All that is needed are simple inclusions, such as 'for sinus,' 'for heart,' or, 'for cough.' ”

USP also recommends that “tall man lettering” be implemented in pharmacy software, labeling, and order writing to say, for example, “acetaZOLamide” (glaucoma) and “acetoHEXamide” (diabetes).

Where risk exists, take action to reduce the chance for error. USP recommends the following:

▸ Consider the potential for mix-ups before adding a drug to your formulary.

▸ Physically separate or differentiate products with similar names while they are being stored on the shelf.

▸ Disseminate information about products that have been confused at your facility, to build awareness among staff.

▸ Prohibit verbal orders for soundalikes that have been mixed up at your facility.

“Physicians' offices should always require a read-back from pharmacists, making sure that they both say and spell the drug name, especially for these often confusing drug pairs,” Ms. Cousins said.

The drug withthe most mix-ups, cefazolin, was confused with 15 other drugs, primarily antimicrobials. MS. COUSINS

The soaring numbers of commonly used drugs with soundalike and look-alike names have prompted U.S. Pharmacopeia to ask physicians and pharmacists to include an “indication for use” on prescriptions.

This and other recommendations are contained in U.S. Pharmacopeia's 8th annual MEDMARX report, which is based on a review of more than 26,000 records submitted to the MEDMARX database from 2003 to 2006.

The records implicate nearly 1,500 drugs in medication errors because of brand or generic names that could be confused. From these data, U.S. Pharmacopeia (USP) compiled a list of more than 3,000 drug pairs that look or sound alike, a figure that is nearly double the number of pairs identified in USP's 2004 report, said Diane Cousins, R.Ph.

“We were surprised to see that much of an increase in such a short time, and the concern is that this increase in products in the marketplace further raises the opportunity for error,” said Ms. Cousins, USP's vice president of health care quality and information.

USP also operates, in conjunction with the Institute for Safe Medication Practices, the Medication Errors Reporting Program (MER), which allows health care professionals to confidentially report potential and actual medication errors directly to USP.

USP reviewed both MEDMARX and MER to summarize the variables associated with more than 26,000 look-alike and/or soundalike (LASA) errors, of which 1.4% (384) resulted in harm or death. More than 670 health care facilities contributed 26,000 records, according to the 400-page report.

“We looked at lists of the top 200 drugs prescribed and used in hospitals, and virtually every time, all of the top 10 appeared within the USP similar names list,” Ms. Cousins said in an interview.

An important finding of this year's report is the role of pharmacy staff in LASA-related errors, she said. “Although pharmacy personnel, who are generally technicians, made the majority of errors, pharmacists as a group identified, prevented, and reported more than any other staff.”

The report also identifies an emerging trend of look-alike drug names in computerized direct order entry systems as a source of confusion. “This trend will likely continue as these systems become a standard of practice,” she said, adding that the LASA-related error problem is further compounded by the indiscriminate use of suffixes, as well as look-alike packaging and labeling.

Over the 3-year period, the drug most commonly confused with others was Cefazolin, a first-generation cephalosporin antibiotic. “We found it to be confused with 15 other drugs, primarily antimicrobials, which might be explained by the fact that this is the most frequently used class of medications,” said Ms. Cousins.

Among other major paired LASAs were cardiovascular medications, such as lisinopril and enalapril, and central nervous system agents, such as trazodone and chlorpromazine.

Drug mix-ups led to seven reported fatalities, including two deaths attributed to confusion over the Alzheimer's drug Reminyl (galantamine) and the antidiabetes drug Amaryl (glimepiride).

In 2005, recognizing the high risk of confusion and subsequent fatal hypoglycemia, Ortho-McNeil Neurologics Inc. announced that the name Reminyl had been changed to Razadyne to avoid confusion with Amaryl.

In another case, an autistic pediatric patient was given the wrong product when disodium EDTA (a hypercalcemia treatment) was administered instead of the chelation therapy calcium disodium EDTA, which is approved by the Food and Drug Administration for the treatment of lead poisoning and was prescribed in an attempt to help treat the patient's autism.

In another case, an emergency department physician was preparing to intubate a patient and calculated the dose for rocuronium (Zemuron), a preintubation agent used to assist with the procedure. The physician gave orders for the nurse to obtain the medication and indicated the volume to administer to the patient. The nurse obtained and administered the neuromuscular blocking agent vecuronium (Norcuron) instead, which led to a fatal heart arrhythmia.

The remaining three reported deaths involved mix-ups between the anticonvulsant primidone and prednisone; the antiepileptic drug phenytoin sodium and the barbiturate phenobarbital; and Norcuron and the heart failure treatment Natrecor (nesiritide recombinant).

Errors occur with over-the-counter medications, too. Ms. Cousins described the aural confusion when an order for Ferro-Sequel 500 mg–an iron replacement–was transcribed as Serrosequel 500 mg and the order was misread as Seroquel 500 mg–an antipsychotic.

The rate of mix-ups involving brand name versus generic drugs was about evenly split, 57% and 43%, respectively, Ms. Cousins said, adding that while most errors were made in pharmacies, many, such as the primidone-prednisone incident, are due to confusion over the prescribing physician's handwriting, which lead the pharmacist to issue the wrong drug.

“Errors also are due to physicians using short codes for medications, such as 'clon,' for clonazepam or clonapine,” she said, adding that electronically written prescriptions using a computer or label machine would eliminate many errors. “Anything that takes handwriting out of the equation is a help.”

It would also be helpful if the FDA were given more authority to force name changes during the drug review process, as has been suggested by the Institute of Medicine. It's much more difficult to correct a name confusion issue once the products are on the market.

The recommendation that physicians include indications for use in prescriptions is not an attempt by USP to impose on privacy, she emphasized: “All that is needed are simple inclusions, such as 'for sinus,' 'for heart,' or, 'for cough.' ”

USP also recommends that “tall man lettering” be implemented in pharmacy software, labeling, and order writing to say, for example, “acetaZOLamide” (glaucoma) and “acetoHEXamide” (diabetes).

Where risk exists, take action to reduce the chance for error. USP recommends the following:

▸ Consider the potential for mix-ups before adding a drug to your formulary.

▸ Physically separate or differentiate products with similar names while they are being stored on the shelf.

▸ Disseminate information about products that have been confused at your facility, to build awareness among staff.

▸ Prohibit verbal orders for soundalikes that have been mixed up at your facility.

“Physicians' offices should always require a read-back from pharmacists, making sure that they both say and spell the drug name, especially for these often confusing drug pairs,” Ms. Cousins said.

The drug withthe most mix-ups, cefazolin, was confused with 15 other drugs, primarily antimicrobials. MS. COUSINS

The soaring numbers of commonly used drugs with soundalike and look-alike names have prompted U.S. Pharmacopeia to ask physicians and pharmacists to include an “indication for use” on prescriptions.

This and other recommendations are contained in U.S. Pharmacopeia's 8th annual MEDMARX report, which is based on a review of more than 26,000 records submitted to the MEDMARX database from 2003 to 2006.

The records implicate nearly 1,500 drugs in medication errors because of brand or generic names that could be confused. From these data, U.S. Pharmacopeia (USP) compiled a list of more than 3,000 drug pairs that look or sound alike, a figure that is nearly double the number of pairs identified in USP's 2004 report, said Diane Cousins, R.Ph.

“We were surprised to see that much of an increase in such a short time, and the concern is that this increase in products in the marketplace further raises the opportunity for error,” said Ms. Cousins, USP's vice president of health care quality and information.

USP also operates, in conjunction with the Institute for Safe Medication Practices, the Medication Errors Reporting Program (MER), which allows health care professionals to confidentially report potential and actual medication errors directly to USP.

USP reviewed both MEDMARX and MER to summarize the variables associated with more than 26,000 look-alike and/or soundalike (LASA) errors, of which 1.4% (384) resulted in harm or death. More than 670 health care facilities contributed 26,000 records, according to the 400-page report.

“We looked at lists of the top 200 drugs prescribed and used in hospitals, and virtually every time, all of the top 10 appeared within the USP similar names list,” Ms. Cousins said in an interview.

An important finding of this year's report is the role of pharmacy staff in LASA-related errors, she said. “Although pharmacy personnel, who are generally technicians, made the majority of errors, pharmacists as a group identified, prevented, and reported more than any other staff.”

The report also identifies an emerging trend of look-alike drug names in computerized direct order entry systems as a source of confusion. “This trend will likely continue as these systems become a standard of practice,” she said, adding that the LASA-related error problem is further compounded by the indiscriminate use of suffixes, as well as look-alike packaging and labeling.

Over the 3-year period, the drug most commonly confused with others was Cefazolin, a first-generation cephalosporin antibiotic. “We found it to be confused with 15 other drugs, primarily antimicrobials, which might be explained by the fact that this is the most frequently used class of medications,” said Ms. Cousins.

Among other major paired LASAs were cardiovascular medications, such as lisinopril and enalapril, and central nervous system agents, such as trazodone and chlorpromazine.

Drug mix-ups led to seven reported fatalities, including two deaths attributed to confusion over the Alzheimer's drug Reminyl (galantamine) and the antidiabetes drug Amaryl (glimepiride).

In 2005, recognizing the high risk of confusion and subsequent fatal hypoglycemia, Ortho-McNeil Neurologics Inc. announced that the name Reminyl had been changed to Razadyne to avoid confusion with Amaryl.

In another case, an autistic pediatric patient was given the wrong product when disodium EDTA (a hypercalcemia treatment) was administered instead of the chelation therapy calcium disodium EDTA, which is approved by the Food and Drug Administration for the treatment of lead poisoning and was prescribed in an attempt to help treat the patient's autism.

In another case, an emergency department physician was preparing to intubate a patient and calculated the dose for rocuronium (Zemuron), a preintubation agent used to assist with the procedure. The physician gave orders for the nurse to obtain the medication and indicated the volume to administer to the patient. The nurse obtained and administered the neuromuscular blocking agent vecuronium (Norcuron) instead, which led to a fatal heart arrhythmia.

The remaining three reported deaths involved mix-ups between the anticonvulsant primidone and prednisone; the antiepileptic drug phenytoin sodium and the barbiturate phenobarbital; and Norcuron and the heart failure treatment Natrecor (nesiritide recombinant).

Errors occur with over-the-counter medications, too. Ms. Cousins described the aural confusion when an order for Ferro-Sequel 500 mg–an iron replacement–was transcribed as Serrosequel 500 mg and the order was misread as Seroquel 500 mg–an antipsychotic.

The rate of mix-ups involving brand name versus generic drugs was about evenly split, 57% and 43%, respectively, Ms. Cousins said, adding that while most errors were made in pharmacies, many, such as the primidone-prednisone incident, are due to confusion over the prescribing physician's handwriting, which lead the pharmacist to issue the wrong drug.

“Errors also are due to physicians using short codes for medications, such as 'clon,' for clonazepam or clonapine,” she said, adding that electronically written prescriptions using a computer or label machine would eliminate many errors. “Anything that takes handwriting out of the equation is a help.”

It would also be helpful if the FDA were given more authority to force name changes during the drug review process, as has been suggested by the Institute of Medicine. It's much more difficult to correct a name confusion issue once the products are on the market.

The recommendation that physicians include indications for use in prescriptions is not an attempt by USP to impose on privacy, she emphasized: “All that is needed are simple inclusions, such as 'for sinus,' 'for heart,' or, 'for cough.' ”

USP also recommends that “tall man lettering” be implemented in pharmacy software, labeling, and order writing to say, for example, “acetaZOLamide” (glaucoma) and “acetoHEXamide” (diabetes).

Where risk exists, take action to reduce the chance for error. USP recommends the following:

▸ Consider the potential for mix-ups before adding a drug to your formulary.

▸ Physically separate or differentiate products with similar names while they are being stored on the shelf.

▸ Disseminate information about products that have been confused at your facility, to build awareness among staff.

▸ Prohibit verbal orders for soundalikes that have been mixed up at your facility.

“Physicians' offices should always require a read-back from pharmacists, making sure that they both say and spell the drug name, especially for these often confusing drug pairs,” Ms. Cousins said.

The drug withthe most mix-ups, cefazolin, was confused with 15 other drugs, primarily antimicrobials. MS. COUSINS

CHICAGO – Until recently, research on secrecy in adolescence focused largely on the emotional and physical costs of hiding misdeeds or risky behavior from parents.

But an investigation conducted a few years ago into both the advantages and disadvantages of secrecy in adolescence found quite different results.

That study, undertaken by Dr. Catrin Finkenauer and her colleagues in the Netherlands, found that adolescents who keep secrets from parents clearly contributed to the adolescents' overall feeling of emotional autonomy.

Those advantages of keeping secrets were seen even after controlling for the influence of disclosure, quality of the parent-child relationship, frequency of contact with friends and peers, depressive mood, and physical complaints such as headaches, stomachaches, and nausea.

“Secrecy should contribute to the process of individuation among children and adolescents,” Dr. Finkenauer and her colleagues wrote (J. Youth Adolesc. 2002;31:123–36).

However, three studies presented at a meeting sponsored by the Society for Research on Adolescence lend support to the notion that secrecy and nondisclosure are most damaging in early adolescence. The studies also back up the finding that such secrecy and nondisclosure are potentially beneficial to developing autonomy in the late teens.

In a longitudinal study, Dutch researchers conducted four annual interviews with more than 300 students, beginning at age 13 years. They reported that younger adolescents who hid information from their parents tended to internalize problems and to have less self-concept clarity and poor individuation, according to Loes Keijsers, Ph.D.

Furthermore, keeping secrets was associated with externalizing problems throughout the four years of adolescence studied, said Dr. Keijsers, research associate at the University of Utrecht (the Netherlands).

“Initially, children with the highest secrecy scores also had the highest depression scores, and in later adolescence, secrecy no longer predicted depression,” she reported.

She added that secrecy was related to anxiety only in the early teens. “There seemed to be a stronger manifestation of the darker side of secrecy in early adolescence.”

In addition, adolescents were more likely to keep secrets if they had unsatisfactory relationships with their parents, although secrecy increased through the four years in both low- and high-satisfaction groups, Dr. Keijsers said.

In highly satisfying parent-child relationships, secrecy was a negative influence on self-concept clarity, which was the opposite of what the investigators had hypothesized, she said. However, as the participants got older, that effect diminished and by age 16, secrecy was positively linked to self-concept clarity in high-satisfaction families.

In addition, a correlation was found between secrecy and aggression, in that adolescents who were more aggressive had more secrets, Dr. Keijsers said.

“Secrecy predicted aggression over time, so that the children that had relatively more secrets at age 13 were likely to be higher in their aggression scores at each of the following intervals.”

The study also confirmed that secrecy from parents had much stronger consequences than did disclosure. Tom Frijns, Ph.D., who conducted a separate analysis of the data for a poster presentation, said he separated “disclosure and secrecy, and found that it's actually secrecy that has all the predictive power regarding externalizing and internalizing problems.”

And as had been suggested by earlier research, secrecy and nondisclosure increase over time, and secrecy was more prevalent among boys.

Further, relationship quality was related to secrecy and nondisclosure only among girls.

“Overall, it's what kids don't tell their parents that predicts their maladjustment. They want autonomy faster than their parents are willing to grant it, so they claim it by keeping more secrets about their activities,” Dr. Frijns said in an interview.

In his study of 218 fifth-grade students and their mothers, Dr. Robert D. Laird explored the interplay among strategic nondisclosure (secrecy), parent-child relationship quality, and behavioral problems.

The sample was split evenly between girls and boys; most were 11 years old at the time of the interview, and three-quarters lived in a two-parent home. The sample reflected the ethnic diversity of south Louisiana and included roughly equal numbers of white and black adolescents, said Dr. Laird of the University of New Orleans.

The children were presented with five scenarios in which they had misbehaved or broken a family rule, and they were asked to indicate their likely response (tell all, tell if asked, provide selective information, keep it a secret, or lie).

“Overall, the highest scores were reported for the 'if asked' items and indicated that adolescents usually tell their parents everything if the parents explicitly ask the right questions,” Dr. Laird said, adding that the gap between “telling all” and “telling if asked” suggest that parental questioning might be important, contrary to previous findings.

The preteens reported “telling all” most often for the “at a friend's house with no adult around” scenario. It was for this same scenario that children were least likely to be secretive or to lie.

In contrast, adolescents were least likely to “tell all” and most likely to try to keep it a secret or lie after watching or listening to a forbidden TV show or music, Dr. Laird said, adding that secrecy was highest for personal issues, such as dating.

“These data also suggest that adolescents may be using strategic disclosure to expand their autonomy over issues in the personal domain,” he said.

Dr. Laird also found that “telling all” was associated with fewer behavior problems; “telling if asked” was associated with less delinquent behavior and rule breaking but not with less depressed mood; and selective disclosure, keeping secrets, and lying were linked to more internalizing and externalizing problems.

Together, the pattern suggests that children are most honest and forthcoming for the scenario involving unsupervised time at a friend's house.

“Part of their motivation is to hide things they don't want their parents to know about, while another part of their motivation is to carve out things they don't think their parents should know about,” according to Dr. Laird.

Clinicians should be aware of these motivations so they can help families sort them out and reduce conflict without prompting undue interrogations by parents.

“There's a lot of evidence showing that if parents have to ask their children what they're up to, it's already a bad situation, and for the clinician to urge parents to ask a whole lot of questions endangers an already shaky relationship,” he said.

As in the Dutch study, youngsters were more likely to disclose information to parents with whom they had good relationships.

Predictably, delinquent behavior was lowest when children revealed more, and the frequency with which kids tell about their misbehavior is more strongly linked to delinquent behavior when family conflict is high, Dr. Laird noted.

“This pattern is consistent with our hypothesis that strategic disclosure is less problematic, and may be a sign of autonomy, when the parent-child relationship quality is high,” he said.

Depressed mood was less prevalent among children who reported hiding very little, especially when conflict was low. Among those who hid more information, however, those with the least conflict reported the most depressed mood.

“Our results replicate prior work showing that hiding is linked with more behavior problems and telling with fewer behavior problems,” Dr. Laird said.

“Although we looked at a more limited age group, our findings are similar to the Dutch findings by Dr. Keijsers and colleagues, whose age-related results make a lot of sense,” he said, adding that keeping an occasional secret is not harmful.

“With my 11- and 12-year-olds, it's hard to imagine that keeping secrets in any situation is good, but by the time a person is 17 or 18, there are things in your life that your parents don't need to know about,” Dr. Laird said.

A third approach to investigating adolescents' management of information was taken by researchers at the University of Rochester (N.Y.), who used Web-based daily diary methods to examine daily variations in secrecy and disclosure with mothers.

In this study, participants were poor 9th and 10th graders recruited from an urban high school. The sample had a mean age of 15 years and consisted of 108 students. Fifty of the students were boys.

Each day for 2 weeks, e-mail links were sent to the adolescents' e-mail accounts. “Most of the kids had access to the Internet, and if they didn't have an e-mail account, we gave them a 14-day account on Gmail,” said lead author Judi Smetana, Ph.D., professor of psychiatry. Those with no Internet access at home completed surveys at school.

The teens, most of whom lived chaotic, mobile lives, were rated on “how much they concealed or kept secret from mother,” and on “how much they told or disclosed today without mother asking,” as well as on measures of relationship quality and time spent that day with their mothers.

Also in the mix were bad behavior items relating to risky or unsafe behavior, activities that parents might not approve of, issues relating to school, and personal thoughts and actions.

As in Dr. Laird's study, the teens were more secretive about personal matters than they were about risky or bad behavior, which Dr. Smetana found surprising. Overall, levels of secrecy and disclosure, reported on a daily basis, were low and uncorrelated.

And as in Dr. Keijsers' study, secrecy was associated with problem behavior and negative interactions, Dr. Smetana said. However, Dr. Smetana added that the willingness of adolescents to disclose to their mothers fluctuated, depending on the quality of the relationship.

The next phase of the research will include adolescents' fathers and best friends.

“We still need to learn more about whether disclosure and secrecy are related to parental knowledge and problem behaviors,” she said.

'In later adolescence, secrecy no longer predicted depression.' DR. KEIJSERS

'With my 11- and 12-year-olds, it's hard to imagine that keeping secrets in any situation is good.' DR. LAIRD

CHICAGO – Until recently, research on secrecy in adolescence focused largely on the emotional and physical costs of hiding misdeeds or risky behavior from parents.

But an investigation conducted a few years ago into both the advantages and disadvantages of secrecy in adolescence found quite different results.

That study, undertaken by Dr. Catrin Finkenauer and her colleagues in the Netherlands, found that adolescents who keep secrets from parents clearly contributed to the adolescents' overall feeling of emotional autonomy.

Those advantages of keeping secrets were seen even after controlling for the influence of disclosure, quality of the parent-child relationship, frequency of contact with friends and peers, depressive mood, and physical complaints such as headaches, stomachaches, and nausea.

“Secrecy should contribute to the process of individuation among children and adolescents,” Dr. Finkenauer and her colleagues wrote (J. Youth Adolesc. 2002;31:123–36).

However, three studies presented at a meeting sponsored by the Society for Research on Adolescence lend support to the notion that secrecy and nondisclosure are most damaging in early adolescence. The studies also back up the finding that such secrecy and nondisclosure are potentially beneficial to developing autonomy in the late teens.

In a longitudinal study, Dutch researchers conducted four annual interviews with more than 300 students, beginning at age 13 years. They reported that younger adolescents who hid information from their parents tended to internalize problems and to have less self-concept clarity and poor individuation, according to Loes Keijsers, Ph.D.

Furthermore, keeping secrets was associated with externalizing problems throughout the four years of adolescence studied, said Dr. Keijsers, research associate at the University of Utrecht (the Netherlands).

“Initially, children with the highest secrecy scores also had the highest depression scores, and in later adolescence, secrecy no longer predicted depression,” she reported.

She added that secrecy was related to anxiety only in the early teens. “There seemed to be a stronger manifestation of the darker side of secrecy in early adolescence.”

In addition, adolescents were more likely to keep secrets if they had unsatisfactory relationships with their parents, although secrecy increased through the four years in both low- and high-satisfaction groups, Dr. Keijsers said.

In highly satisfying parent-child relationships, secrecy was a negative influence on self-concept clarity, which was the opposite of what the investigators had hypothesized, she said. However, as the participants got older, that effect diminished and by age 16, secrecy was positively linked to self-concept clarity in high-satisfaction families.

In addition, a correlation was found between secrecy and aggression, in that adolescents who were more aggressive had more secrets, Dr. Keijsers said.

“Secrecy predicted aggression over time, so that the children that had relatively more secrets at age 13 were likely to be higher in their aggression scores at each of the following intervals.”

The study also confirmed that secrecy from parents had much stronger consequences than did disclosure. Tom Frijns, Ph.D., who conducted a separate analysis of the data for a poster presentation, said he separated “disclosure and secrecy, and found that it's actually secrecy that has all the predictive power regarding externalizing and internalizing problems.”

And as had been suggested by earlier research, secrecy and nondisclosure increase over time, and secrecy was more prevalent among boys.

Further, relationship quality was related to secrecy and nondisclosure only among girls.

“Overall, it's what kids don't tell their parents that predicts their maladjustment. They want autonomy faster than their parents are willing to grant it, so they claim it by keeping more secrets about their activities,” Dr. Frijns said in an interview.

In his study of 218 fifth-grade students and their mothers, Dr. Robert D. Laird explored the interplay among strategic nondisclosure (secrecy), parent-child relationship quality, and behavioral problems.

The sample was split evenly between girls and boys; most were 11 years old at the time of the interview, and three-quarters lived in a two-parent home. The sample reflected the ethnic diversity of south Louisiana and included roughly equal numbers of white and black adolescents, said Dr. Laird of the University of New Orleans.

The children were presented with five scenarios in which they had misbehaved or broken a family rule, and they were asked to indicate their likely response (tell all, tell if asked, provide selective information, keep it a secret, or lie).

“Overall, the highest scores were reported for the 'if asked' items and indicated that adolescents usually tell their parents everything if the parents explicitly ask the right questions,” Dr. Laird said, adding that the gap between “telling all” and “telling if asked” suggest that parental questioning might be important, contrary to previous findings.

The preteens reported “telling all” most often for the “at a friend's house with no adult around” scenario. It was for this same scenario that children were least likely to be secretive or to lie.

In contrast, adolescents were least likely to “tell all” and most likely to try to keep it a secret or lie after watching or listening to a forbidden TV show or music, Dr. Laird said, adding that secrecy was highest for personal issues, such as dating.

“These data also suggest that adolescents may be using strategic disclosure to expand their autonomy over issues in the personal domain,” he said.

Dr. Laird also found that “telling all” was associated with fewer behavior problems; “telling if asked” was associated with less delinquent behavior and rule breaking but not with less depressed mood; and selective disclosure, keeping secrets, and lying were linked to more internalizing and externalizing problems.

Together, the pattern suggests that children are most honest and forthcoming for the scenario involving unsupervised time at a friend's house.

“Part of their motivation is to hide things they don't want their parents to know about, while another part of their motivation is to carve out things they don't think their parents should know about,” according to Dr. Laird.

Clinicians should be aware of these motivations so they can help families sort them out and reduce conflict without prompting undue interrogations by parents.

“There's a lot of evidence showing that if parents have to ask their children what they're up to, it's already a bad situation, and for the clinician to urge parents to ask a whole lot of questions endangers an already shaky relationship,” he said.

As in the Dutch study, youngsters were more likely to disclose information to parents with whom they had good relationships.

Predictably, delinquent behavior was lowest when children revealed more, and the frequency with which kids tell about their misbehavior is more strongly linked to delinquent behavior when family conflict is high, Dr. Laird noted.

“This pattern is consistent with our hypothesis that strategic disclosure is less problematic, and may be a sign of autonomy, when the parent-child relationship quality is high,” he said.

Depressed mood was less prevalent among children who reported hiding very little, especially when conflict was low. Among those who hid more information, however, those with the least conflict reported the most depressed mood.

“Our results replicate prior work showing that hiding is linked with more behavior problems and telling with fewer behavior problems,” Dr. Laird said.

“Although we looked at a more limited age group, our findings are similar to the Dutch findings by Dr. Keijsers and colleagues, whose age-related results make a lot of sense,” he said, adding that keeping an occasional secret is not harmful.

“With my 11- and 12-year-olds, it's hard to imagine that keeping secrets in any situation is good, but by the time a person is 17 or 18, there are things in your life that your parents don't need to know about,” Dr. Laird said.

A third approach to investigating adolescents' management of information was taken by researchers at the University of Rochester (N.Y.), who used Web-based daily diary methods to examine daily variations in secrecy and disclosure with mothers.

In this study, participants were poor 9th and 10th graders recruited from an urban high school. The sample had a mean age of 15 years and consisted of 108 students. Fifty of the students were boys.

Each day for 2 weeks, e-mail links were sent to the adolescents' e-mail accounts. “Most of the kids had access to the Internet, and if they didn't have an e-mail account, we gave them a 14-day account on Gmail,” said lead author Judi Smetana, Ph.D., professor of psychiatry. Those with no Internet access at home completed surveys at school.

The teens, most of whom lived chaotic, mobile lives, were rated on “how much they concealed or kept secret from mother,” and on “how much they told or disclosed today without mother asking,” as well as on measures of relationship quality and time spent that day with their mothers.

Also in the mix were bad behavior items relating to risky or unsafe behavior, activities that parents might not approve of, issues relating to school, and personal thoughts and actions.

As in Dr. Laird's study, the teens were more secretive about personal matters than they were about risky or bad behavior, which Dr. Smetana found surprising. Overall, levels of secrecy and disclosure, reported on a daily basis, were low and uncorrelated.

And as in Dr. Keijsers' study, secrecy was associated with problem behavior and negative interactions, Dr. Smetana said. However, Dr. Smetana added that the willingness of adolescents to disclose to their mothers fluctuated, depending on the quality of the relationship.

The next phase of the research will include adolescents' fathers and best friends.

“We still need to learn more about whether disclosure and secrecy are related to parental knowledge and problem behaviors,” she said.

'In later adolescence, secrecy no longer predicted depression.' DR. KEIJSERS

'With my 11- and 12-year-olds, it's hard to imagine that keeping secrets in any situation is good.' DR. LAIRD

CHICAGO – Until recently, research on secrecy in adolescence focused largely on the emotional and physical costs of hiding misdeeds or risky behavior from parents.

But an investigation conducted a few years ago into both the advantages and disadvantages of secrecy in adolescence found quite different results.

That study, undertaken by Dr. Catrin Finkenauer and her colleagues in the Netherlands, found that adolescents who keep secrets from parents clearly contributed to the adolescents' overall feeling of emotional autonomy.

Those advantages of keeping secrets were seen even after controlling for the influence of disclosure, quality of the parent-child relationship, frequency of contact with friends and peers, depressive mood, and physical complaints such as headaches, stomachaches, and nausea.

“Secrecy should contribute to the process of individuation among children and adolescents,” Dr. Finkenauer and her colleagues wrote (J. Youth Adolesc. 2002;31:123–36).

However, three studies presented at a meeting sponsored by the Society for Research on Adolescence lend support to the notion that secrecy and nondisclosure are most damaging in early adolescence. The studies also back up the finding that such secrecy and nondisclosure are potentially beneficial to developing autonomy in the late teens.

In a longitudinal study, Dutch researchers conducted four annual interviews with more than 300 students, beginning at age 13 years. They reported that younger adolescents who hid information from their parents tended to internalize problems and to have less self-concept clarity and poor individuation, according to Loes Keijsers, Ph.D.

Furthermore, keeping secrets was associated with externalizing problems throughout the four years of adolescence studied, said Dr. Keijsers, research associate at the University of Utrecht (the Netherlands).

“Initially, children with the highest secrecy scores also had the highest depression scores, and in later adolescence, secrecy no longer predicted depression,” she reported.

She added that secrecy was related to anxiety only in the early teens. “There seemed to be a stronger manifestation of the darker side of secrecy in early adolescence.”

In addition, adolescents were more likely to keep secrets if they had unsatisfactory relationships with their parents, although secrecy increased through the four years in both low- and high-satisfaction groups, Dr. Keijsers said.

In highly satisfying parent-child relationships, secrecy was a negative influence on self-concept clarity, which was the opposite of what the investigators had hypothesized, she said. However, as the participants got older, that effect diminished and by age 16, secrecy was positively linked to self-concept clarity in high-satisfaction families.

In addition, a correlation was found between secrecy and aggression, in that adolescents who were more aggressive had more secrets, Dr. Keijsers said.

“Secrecy predicted aggression over time, so that the children that had relatively more secrets at age 13 were likely to be higher in their aggression scores at each of the following intervals.”

The study also confirmed that secrecy from parents had much stronger consequences than did disclosure. Tom Frijns, Ph.D., who conducted a separate analysis of the data for a poster presentation, said he separated “disclosure and secrecy, and found that it's actually secrecy that has all the predictive power regarding externalizing and internalizing problems.”

And as had been suggested by earlier research, secrecy and nondisclosure increase over time, and secrecy was more prevalent among boys.

Further, relationship quality was related to secrecy and nondisclosure only among girls.

“Overall, it's what kids don't tell their parents that predicts their maladjustment. They want autonomy faster than their parents are willing to grant it, so they claim it by keeping more secrets about their activities,” Dr. Frijns said in an interview.

In his study of 218 fifth-grade students and their mothers, Dr. Robert D. Laird explored the interplay among strategic nondisclosure (secrecy), parent-child relationship quality, and behavioral problems.

The sample was split evenly between girls and boys; most were 11 years old at the time of the interview, and three-quarters lived in a two-parent home. The sample reflected the ethnic diversity of south Louisiana and included roughly equal numbers of white and black adolescents, said Dr. Laird of the University of New Orleans.

The children were presented with five scenarios in which they had misbehaved or broken a family rule, and they were asked to indicate their likely response (tell all, tell if asked, provide selective information, keep it a secret, or lie).

“Overall, the highest scores were reported for the 'if asked' items and indicated that adolescents usually tell their parents everything if the parents explicitly ask the right questions,” Dr. Laird said, adding that the gap between “telling all” and “telling if asked” suggest that parental questioning might be important, contrary to previous findings.

The preteens reported “telling all” most often for the “at a friend's house with no adult around” scenario. It was for this same scenario that children were least likely to be secretive or to lie.

In contrast, adolescents were least likely to “tell all” and most likely to try to keep it a secret or lie after watching or listening to a forbidden TV show or music, Dr. Laird said, adding that secrecy was highest for personal issues, such as dating.

“These data also suggest that adolescents may be using strategic disclosure to expand their autonomy over issues in the personal domain,” he said.

Dr. Laird also found that “telling all” was associated with fewer behavior problems; “telling if asked” was associated with less delinquent behavior and rule breaking but not with less depressed mood; and selective disclosure, keeping secrets, and lying were linked to more internalizing and externalizing problems.

Together, the pattern suggests that children are most honest and forthcoming for the scenario involving unsupervised time at a friend's house.

“Part of their motivation is to hide things they don't want their parents to know about, while another part of their motivation is to carve out things they don't think their parents should know about,” according to Dr. Laird.

Clinicians should be aware of these motivations so they can help families sort them out and reduce conflict without prompting undue interrogations by parents.

“There's a lot of evidence showing that if parents have to ask their children what they're up to, it's already a bad situation, and for the clinician to urge parents to ask a whole lot of questions endangers an already shaky relationship,” he said.

As in the Dutch study, youngsters were more likely to disclose information to parents with whom they had good relationships.

Predictably, delinquent behavior was lowest when children revealed more, and the frequency with which kids tell about their misbehavior is more strongly linked to delinquent behavior when family conflict is high, Dr. Laird noted.

“This pattern is consistent with our hypothesis that strategic disclosure is less problematic, and may be a sign of autonomy, when the parent-child relationship quality is high,” he said.

Depressed mood was less prevalent among children who reported hiding very little, especially when conflict was low. Among those who hid more information, however, those with the least conflict reported the most depressed mood.

“Our results replicate prior work showing that hiding is linked with more behavior problems and telling with fewer behavior problems,” Dr. Laird said.

“Although we looked at a more limited age group, our findings are similar to the Dutch findings by Dr. Keijsers and colleagues, whose age-related results make a lot of sense,” he said, adding that keeping an occasional secret is not harmful.

“With my 11- and 12-year-olds, it's hard to imagine that keeping secrets in any situation is good, but by the time a person is 17 or 18, there are things in your life that your parents don't need to know about,” Dr. Laird said.

A third approach to investigating adolescents' management of information was taken by researchers at the University of Rochester (N.Y.), who used Web-based daily diary methods to examine daily variations in secrecy and disclosure with mothers.

In this study, participants were poor 9th and 10th graders recruited from an urban high school. The sample had a mean age of 15 years and consisted of 108 students. Fifty of the students were boys.

Each day for 2 weeks, e-mail links were sent to the adolescents' e-mail accounts. “Most of the kids had access to the Internet, and if they didn't have an e-mail account, we gave them a 14-day account on Gmail,” said lead author Judi Smetana, Ph.D., professor of psychiatry. Those with no Internet access at home completed surveys at school.

The teens, most of whom lived chaotic, mobile lives, were rated on “how much they concealed or kept secret from mother,” and on “how much they told or disclosed today without mother asking,” as well as on measures of relationship quality and time spent that day with their mothers.

Also in the mix were bad behavior items relating to risky or unsafe behavior, activities that parents might not approve of, issues relating to school, and personal thoughts and actions.

As in Dr. Laird's study, the teens were more secretive about personal matters than they were about risky or bad behavior, which Dr. Smetana found surprising. Overall, levels of secrecy and disclosure, reported on a daily basis, were low and uncorrelated.

And as in Dr. Keijsers' study, secrecy was associated with problem behavior and negative interactions, Dr. Smetana said. However, Dr. Smetana added that the willingness of adolescents to disclose to their mothers fluctuated, depending on the quality of the relationship.

The next phase of the research will include adolescents' fathers and best friends.

“We still need to learn more about whether disclosure and secrecy are related to parental knowledge and problem behaviors,” she said.

'In later adolescence, secrecy no longer predicted depression.' DR. KEIJSERS

'With my 11- and 12-year-olds, it's hard to imagine that keeping secrets in any situation is good.' DR. LAIRD

CHICAGO – Bullying over the Internet is common, and it is associated with symptoms of psychopathology in boys and girls, according to researchers at the University of Florida in Gainesville.

“Peer victimization using the medium of cyberspace … carries similar negative repercussions for adolescent adjustment compared to more traditional, face-to-face forms of victimization,” Lisa M. Sontag of the department of psychology at the university and her colleagues reported. Their study was presented in a poster session at a meeting sponsored by the Society for Adolescent Research.

They found that among a study population of 268 middle school students, almost 40% said they had been targets of cyberbullying. More girls than boys reported being harassed (46% vs.35%), but the difference was not significant.

The student sample, drawn from two large public schools in the Gainesville area, was 66% female, had a mean age of 12 years, and a racial composition that was 50% white, one-fourth black, 10% Hispanic, and the rest “other.”

The mean family socioeconomic status boiled down to “some college and occupation level comparable to clerical worker or small-business owner.”

Participants were categorized as “cybervictims” if they responded yes to either of the following questions: “I have been directly teased or hassled in a mean way through e-mail, instant messenger, or text messaging, or have had someone tease me on a Web site in the past 6 months”; or “I have had rumors or mean things said about me to other people on a Web site, e-mail, instant messenger, or text message in the past 6 months.”

The 105 students who reported being bullied rated significantly higher on all four measures of psychopathology used in the study, including “internalizing distress,” “social aggression,” “proactive aggression,” and “reactive aggression,” Ms. Sontag said in an interview.

“This suggests that cyberbullying has negative effects, but I want to caution that this assessment was done at a single time point, rather than over a period of time, so we can't conclusively determine cause and effect,” she said. “It's possible that kids who are higher in anxious and depressive symptoms are more prone to be bullied.”

Proactive aggression, which is unprovoked, often is used to establish social dominance, while reactive aggression is the tendency to interpret benign situations as threatening. Social aggression is aimed at damaging another person's social reputation through gossip, rumor, or other actions designed to humiliate the victim.

It's important for clinicians and researchers interested in either assessing or examining aggressive behavior or the effects of victimization on mental health outcomes to consider the impact of cyberbullying in middle school and high school, she said.

The 105 students who reported being bullied rated far higher on measures of psychopathology. MS. SONTAG

CHICAGO – Bullying over the Internet is common, and it is associated with symptoms of psychopathology in boys and girls, according to researchers at the University of Florida in Gainesville.

“Peer victimization using the medium of cyberspace … carries similar negative repercussions for adolescent adjustment compared to more traditional, face-to-face forms of victimization,” Lisa M. Sontag of the department of psychology at the university and her colleagues reported. Their study was presented in a poster session at a meeting sponsored by the Society for Adolescent Research.

They found that among a study population of 268 middle school students, almost 40% said they had been targets of cyberbullying. More girls than boys reported being harassed (46% vs.35%), but the difference was not significant.

The student sample, drawn from two large public schools in the Gainesville area, was 66% female, had a mean age of 12 years, and a racial composition that was 50% white, one-fourth black, 10% Hispanic, and the rest “other.”

The mean family socioeconomic status boiled down to “some college and occupation level comparable to clerical worker or small-business owner.”

Participants were categorized as “cybervictims” if they responded yes to either of the following questions: “I have been directly teased or hassled in a mean way through e-mail, instant messenger, or text messaging, or have had someone tease me on a Web site in the past 6 months”; or “I have had rumors or mean things said about me to other people on a Web site, e-mail, instant messenger, or text message in the past 6 months.”

The 105 students who reported being bullied rated significantly higher on all four measures of psychopathology used in the study, including “internalizing distress,” “social aggression,” “proactive aggression,” and “reactive aggression,” Ms. Sontag said in an interview.

“This suggests that cyberbullying has negative effects, but I want to caution that this assessment was done at a single time point, rather than over a period of time, so we can't conclusively determine cause and effect,” she said. “It's possible that kids who are higher in anxious and depressive symptoms are more prone to be bullied.”

Proactive aggression, which is unprovoked, often is used to establish social dominance, while reactive aggression is the tendency to interpret benign situations as threatening. Social aggression is aimed at damaging another person's social reputation through gossip, rumor, or other actions designed to humiliate the victim.

It's important for clinicians and researchers interested in either assessing or examining aggressive behavior or the effects of victimization on mental health outcomes to consider the impact of cyberbullying in middle school and high school, she said.

The 105 students who reported being bullied rated far higher on measures of psychopathology. MS. SONTAG

CHICAGO – Bullying over the Internet is common, and it is associated with symptoms of psychopathology in boys and girls, according to researchers at the University of Florida in Gainesville.

“Peer victimization using the medium of cyberspace … carries similar negative repercussions for adolescent adjustment compared to more traditional, face-to-face forms of victimization,” Lisa M. Sontag of the department of psychology at the university and her colleagues reported. Their study was presented in a poster session at a meeting sponsored by the Society for Adolescent Research.

They found that among a study population of 268 middle school students, almost 40% said they had been targets of cyberbullying. More girls than boys reported being harassed (46% vs.35%), but the difference was not significant.

The student sample, drawn from two large public schools in the Gainesville area, was 66% female, had a mean age of 12 years, and a racial composition that was 50% white, one-fourth black, 10% Hispanic, and the rest “other.”

The mean family socioeconomic status boiled down to “some college and occupation level comparable to clerical worker or small-business owner.”

Participants were categorized as “cybervictims” if they responded yes to either of the following questions: “I have been directly teased or hassled in a mean way through e-mail, instant messenger, or text messaging, or have had someone tease me on a Web site in the past 6 months”; or “I have had rumors or mean things said about me to other people on a Web site, e-mail, instant messenger, or text message in the past 6 months.”

The 105 students who reported being bullied rated significantly higher on all four measures of psychopathology used in the study, including “internalizing distress,” “social aggression,” “proactive aggression,” and “reactive aggression,” Ms. Sontag said in an interview.

“This suggests that cyberbullying has negative effects, but I want to caution that this assessment was done at a single time point, rather than over a period of time, so we can't conclusively determine cause and effect,” she said. “It's possible that kids who are higher in anxious and depressive symptoms are more prone to be bullied.”

Proactive aggression, which is unprovoked, often is used to establish social dominance, while reactive aggression is the tendency to interpret benign situations as threatening. Social aggression is aimed at damaging another person's social reputation through gossip, rumor, or other actions designed to humiliate the victim.

It's important for clinicians and researchers interested in either assessing or examining aggressive behavior or the effects of victimization on mental health outcomes to consider the impact of cyberbullying in middle school and high school, she said.

The 105 students who reported being bullied rated far higher on measures of psychopathology. MS. SONTAG