Robert Finn

SAN FRANCISCO — Studies have shown that over a 10-year period, about 16% of women aged 40–69 years bring a concern about their breasts to primary care physicians. In most cases, palpable breast masses turn out to be benign cysts or fibroadenomas, but breast cancer is found in 11% of women complaining of a breast lump and 4% of women with any breast complaint.

A proper evaluation of a palpable breast mass is important not only for quality care but also because a delayed cancer diagnosis due to a negative clinical exam or a negative mammogram is a common cause of malpractice awards, Dr. Leah Karliner said at a meeting on women's health sponsored by the University of California, San Francisco.

The classic characteristics of a malignant mass are well known. Cancer is more likely if there is a single lesion, if it's hard and immovable, if it has irregular borders, and if it's 2 cm or more in diameter.

“Unfortunately, cancers are often soft and cystic, movable, regular, [and] small,” said Dr. Karliner of the division of general internal medicine at the university. Also, “benign lesions can be single, like cancers are supposed to be.”

With clinical characteristics so unreliable, Dr. Karliner recommended the following algorithm when evaluating a woman with a palpable mass. Decisions are fairly simple for women above the age of 30–35 years. All such women who come in complaining of a mass should receive a diagnostic mammogram, both to evaluate the mass and to search for occult malignancies elsewhere in the same breast. According to one study of 41,000 women with self-reported breast lumps, diagnostic mammography alone has a sensitivity of 87.3% and a specificity of 84.5%.

That means diagnostic mammography misses 10%–20% of breast cancers, but the addition of ultrasound to the mammogram increases the negative predictive value to 97%.

The so-called “triple diagnosis,” consisting of a physical exam, mammography, and skilled fine-needle aspiration (FNA) biopsy misses few cancers, Dr. Karliner said. If all three tests are negative, it's safe to schedule follow-up exams every 3–6 months for a year. If all three are positive, the patient should be referred for definitive treatment. And if any one test is suggestive of malignancy, the patient should have a core or excisional biopsy.

The algorithm for younger women presenting with a self-reported lump has a more complex decision tree, with the evaluation depending on whether the physician can feel the lump and whether the woman is at high risk.

If the physician can't feel a dominant mass on physical exam and the woman is of average risk, she should return in 2–3 months for a reexamination, and if the lump is then palpable she should undergo a further work-up.

If the physician can't feel a dominant mass and the woman is at high risk, with first-degree relatives who had cancer at a young age, she should be referred to a breast surgeon or clinic for a further work-up or to be followed closely.

If the physician can feel a palpable lump in a younger woman, and if she's at average risk and the exam is not concerning, she should return for a reexamination 3–10 days after her next menses. If the lump is still palpable, she'll need a further work-up. “Even in young women, you don't just ignore it,” Dr. Karliner said. If that younger woman with a palpable lump is at high risk, or if the exam is concerning, she should be referred for ultrasound or FNA biopsy.

In these younger women, diagnostic mammography is not very useful, and should be ordered only if other results suggest malignancy, Dr. Karliner said.

Dr. Karliner stated that she had no conflicts of interest.

SAN FRANCISCO — Studies have shown that over a 10-year period, about 16% of women aged 40–69 years bring a concern about their breasts to primary care physicians. In most cases, palpable breast masses turn out to be benign cysts or fibroadenomas, but breast cancer is found in 11% of women complaining of a breast lump and 4% of women with any breast complaint.

A proper evaluation of a palpable breast mass is important not only for quality care but also because a delayed cancer diagnosis due to a negative clinical exam or a negative mammogram is a common cause of malpractice awards, Dr. Leah Karliner said at a meeting on women's health sponsored by the University of California, San Francisco.

The classic characteristics of a malignant mass are well known. Cancer is more likely if there is a single lesion, if it's hard and immovable, if it has irregular borders, and if it's 2 cm or more in diameter.

“Unfortunately, cancers are often soft and cystic, movable, regular, [and] small,” said Dr. Karliner of the division of general internal medicine at the university. Also, “benign lesions can be single, like cancers are supposed to be.”

With clinical characteristics so unreliable, Dr. Karliner recommended the following algorithm when evaluating a woman with a palpable mass. Decisions are fairly simple for women above the age of 30–35 years. All such women who come in complaining of a mass should receive a diagnostic mammogram, both to evaluate the mass and to search for occult malignancies elsewhere in the same breast. According to one study of 41,000 women with self-reported breast lumps, diagnostic mammography alone has a sensitivity of 87.3% and a specificity of 84.5%.

That means diagnostic mammography misses 10%–20% of breast cancers, but the addition of ultrasound to the mammogram increases the negative predictive value to 97%.

The so-called “triple diagnosis,” consisting of a physical exam, mammography, and skilled fine-needle aspiration (FNA) biopsy misses few cancers, Dr. Karliner said. If all three tests are negative, it's safe to schedule follow-up exams every 3–6 months for a year. If all three are positive, the patient should be referred for definitive treatment. And if any one test is suggestive of malignancy, the patient should have a core or excisional biopsy.

The algorithm for younger women presenting with a self-reported lump has a more complex decision tree, with the evaluation depending on whether the physician can feel the lump and whether the woman is at high risk.

If the physician can't feel a dominant mass on physical exam and the woman is of average risk, she should return in 2–3 months for a reexamination, and if the lump is then palpable she should undergo a further work-up.

If the physician can't feel a dominant mass and the woman is at high risk, with first-degree relatives who had cancer at a young age, she should be referred to a breast surgeon or clinic for a further work-up or to be followed closely.

If the physician can feel a palpable lump in a younger woman, and if she's at average risk and the exam is not concerning, she should return for a reexamination 3–10 days after her next menses. If the lump is still palpable, she'll need a further work-up. “Even in young women, you don't just ignore it,” Dr. Karliner said. If that younger woman with a palpable lump is at high risk, or if the exam is concerning, she should be referred for ultrasound or FNA biopsy.

In these younger women, diagnostic mammography is not very useful, and should be ordered only if other results suggest malignancy, Dr. Karliner said.

Dr. Karliner stated that she had no conflicts of interest.

SAN FRANCISCO — Studies have shown that over a 10-year period, about 16% of women aged 40–69 years bring a concern about their breasts to primary care physicians. In most cases, palpable breast masses turn out to be benign cysts or fibroadenomas, but breast cancer is found in 11% of women complaining of a breast lump and 4% of women with any breast complaint.

A proper evaluation of a palpable breast mass is important not only for quality care but also because a delayed cancer diagnosis due to a negative clinical exam or a negative mammogram is a common cause of malpractice awards, Dr. Leah Karliner said at a meeting on women's health sponsored by the University of California, San Francisco.

The classic characteristics of a malignant mass are well known. Cancer is more likely if there is a single lesion, if it's hard and immovable, if it has irregular borders, and if it's 2 cm or more in diameter.

“Unfortunately, cancers are often soft and cystic, movable, regular, [and] small,” said Dr. Karliner of the division of general internal medicine at the university. Also, “benign lesions can be single, like cancers are supposed to be.”

With clinical characteristics so unreliable, Dr. Karliner recommended the following algorithm when evaluating a woman with a palpable mass. Decisions are fairly simple for women above the age of 30–35 years. All such women who come in complaining of a mass should receive a diagnostic mammogram, both to evaluate the mass and to search for occult malignancies elsewhere in the same breast. According to one study of 41,000 women with self-reported breast lumps, diagnostic mammography alone has a sensitivity of 87.3% and a specificity of 84.5%.

That means diagnostic mammography misses 10%–20% of breast cancers, but the addition of ultrasound to the mammogram increases the negative predictive value to 97%.

The so-called “triple diagnosis,” consisting of a physical exam, mammography, and skilled fine-needle aspiration (FNA) biopsy misses few cancers, Dr. Karliner said. If all three tests are negative, it's safe to schedule follow-up exams every 3–6 months for a year. If all three are positive, the patient should be referred for definitive treatment. And if any one test is suggestive of malignancy, the patient should have a core or excisional biopsy.

The algorithm for younger women presenting with a self-reported lump has a more complex decision tree, with the evaluation depending on whether the physician can feel the lump and whether the woman is at high risk.

If the physician can't feel a dominant mass on physical exam and the woman is of average risk, she should return in 2–3 months for a reexamination, and if the lump is then palpable she should undergo a further work-up.

If the physician can't feel a dominant mass and the woman is at high risk, with first-degree relatives who had cancer at a young age, she should be referred to a breast surgeon or clinic for a further work-up or to be followed closely.

If the physician can feel a palpable lump in a younger woman, and if she's at average risk and the exam is not concerning, she should return for a reexamination 3–10 days after her next menses. If the lump is still palpable, she'll need a further work-up. “Even in young women, you don't just ignore it,” Dr. Karliner said. If that younger woman with a palpable lump is at high risk, or if the exam is concerning, she should be referred for ultrasound or FNA biopsy.

In these younger women, diagnostic mammography is not very useful, and should be ordered only if other results suggest malignancy, Dr. Karliner said.

Dr. Karliner stated that she had no conflicts of interest.

HONOLULU — Anxious children who participated in a 9-week course of cognitive-behavioral therapy (CBT) maintained improvements for at least 4 years.

The study involved 61 children, aged 7-11 years, all of whom had features of separation anxiety disorder, generalized anxiety disorder, and/or social phobia. Dr. Gail A. Bernstein of the University of Minnesota, Minneapolis, and colleagues randomized the children. In one group, patients received a 9-week manual and workbook-based CBT intervention using the FRIENDS for Life. The second arm received the CBT intervention and their parents participated in a 9-week program based on FRIENDS. Children in the third arm received no treatment.

At 4 years, 43% of children in the control group showed remission of their primary anxiety diagnoses, a significantly smaller proportion than the children in the CBT group (75%) or the children in the CBT plus parent training group (76%).

The National Institute of Mental Health, the University of Minnesota Academic Health Center, and the Minnesota Medical Foundation funded the study.

HONOLULU — Anxious children who participated in a 9-week course of cognitive-behavioral therapy (CBT) maintained improvements for at least 4 years.

The study involved 61 children, aged 7-11 years, all of whom had features of separation anxiety disorder, generalized anxiety disorder, and/or social phobia. Dr. Gail A. Bernstein of the University of Minnesota, Minneapolis, and colleagues randomized the children. In one group, patients received a 9-week manual and workbook-based CBT intervention using the FRIENDS for Life. The second arm received the CBT intervention and their parents participated in a 9-week program based on FRIENDS. Children in the third arm received no treatment.

At 4 years, 43% of children in the control group showed remission of their primary anxiety diagnoses, a significantly smaller proportion than the children in the CBT group (75%) or the children in the CBT plus parent training group (76%).

The National Institute of Mental Health, the University of Minnesota Academic Health Center, and the Minnesota Medical Foundation funded the study.

HONOLULU — Anxious children who participated in a 9-week course of cognitive-behavioral therapy (CBT) maintained improvements for at least 4 years.

The study involved 61 children, aged 7-11 years, all of whom had features of separation anxiety disorder, generalized anxiety disorder, and/or social phobia. Dr. Gail A. Bernstein of the University of Minnesota, Minneapolis, and colleagues randomized the children. In one group, patients received a 9-week manual and workbook-based CBT intervention using the FRIENDS for Life. The second arm received the CBT intervention and their parents participated in a 9-week program based on FRIENDS. Children in the third arm received no treatment.

At 4 years, 43% of children in the control group showed remission of their primary anxiety diagnoses, a significantly smaller proportion than the children in the CBT group (75%) or the children in the CBT plus parent training group (76%).

The National Institute of Mental Health, the University of Minnesota Academic Health Center, and the Minnesota Medical Foundation funded the study.

HONOLULU — Stress was the most frequently cited psychological factor adversely affecting the academic performance of college students, according to a survey conducted in spring 2008 by the American College Health Association.

Almost 34% of students cited stress as a factor affecting academic performance, up from 29% in spring 2000, Dr. Adele L. Martel said at the annual meeting of the American Academy of Child and Adolescent Psychiatry. Sleep was the second most common psychological factor cited by the students, rising from 21% in 2000 to 26% in 2008.

Relationship difficulties, holding steady at about 15% between 2000 and 2008, have recently been overtaken by the Internet in their impact on academic performance, said Dr. Martel, of Children's Memorial Hospital in Chicago.

Cited by only 9% of college students in 2000, the Internet affected the academic performance of nearly 17% in 2008, according to data from the National College Health Assessment, which surveyed more than 80,000 students on 106 campuses.

In 2008, 7% of students cited attention-deficit disorder, more than double the 3% who mentioned that as a factor in 2000.

A greater proportion of students also cited learning disabilities as affecting their academic performance, the rate nearly doubling between 2000 and 2008.

Alcohol use has remained steady at about 8%, except for a temporary increase to 10% in spring 2002. Dr. Martel noted that the terrorist attacks of Sept. 11, 2001, occurred within that school year, but she said she had no way of knowing whether that was a reason for the 1-year increase.

The need for mental health services for college students might be increasing, said Dr. Martel, who reported having no conflicts of interest.

Elsevier Global Medical News

HONOLULU — Stress was the most frequently cited psychological factor adversely affecting the academic performance of college students, according to a survey conducted in spring 2008 by the American College Health Association.

Almost 34% of students cited stress as a factor affecting academic performance, up from 29% in spring 2000, Dr. Adele L. Martel said at the annual meeting of the American Academy of Child and Adolescent Psychiatry. Sleep was the second most common psychological factor cited by the students, rising from 21% in 2000 to 26% in 2008.

Relationship difficulties, holding steady at about 15% between 2000 and 2008, have recently been overtaken by the Internet in their impact on academic performance, said Dr. Martel, of Children's Memorial Hospital in Chicago.

Cited by only 9% of college students in 2000, the Internet affected the academic performance of nearly 17% in 2008, according to data from the National College Health Assessment, which surveyed more than 80,000 students on 106 campuses.

In 2008, 7% of students cited attention-deficit disorder, more than double the 3% who mentioned that as a factor in 2000.

A greater proportion of students also cited learning disabilities as affecting their academic performance, the rate nearly doubling between 2000 and 2008.

Alcohol use has remained steady at about 8%, except for a temporary increase to 10% in spring 2002. Dr. Martel noted that the terrorist attacks of Sept. 11, 2001, occurred within that school year, but she said she had no way of knowing whether that was a reason for the 1-year increase.

The need for mental health services for college students might be increasing, said Dr. Martel, who reported having no conflicts of interest.

Elsevier Global Medical News

HONOLULU — Stress was the most frequently cited psychological factor adversely affecting the academic performance of college students, according to a survey conducted in spring 2008 by the American College Health Association.

Almost 34% of students cited stress as a factor affecting academic performance, up from 29% in spring 2000, Dr. Adele L. Martel said at the annual meeting of the American Academy of Child and Adolescent Psychiatry. Sleep was the second most common psychological factor cited by the students, rising from 21% in 2000 to 26% in 2008.

Relationship difficulties, holding steady at about 15% between 2000 and 2008, have recently been overtaken by the Internet in their impact on academic performance, said Dr. Martel, of Children's Memorial Hospital in Chicago.

Cited by only 9% of college students in 2000, the Internet affected the academic performance of nearly 17% in 2008, according to data from the National College Health Assessment, which surveyed more than 80,000 students on 106 campuses.

In 2008, 7% of students cited attention-deficit disorder, more than double the 3% who mentioned that as a factor in 2000.

A greater proportion of students also cited learning disabilities as affecting their academic performance, the rate nearly doubling between 2000 and 2008.

Alcohol use has remained steady at about 8%, except for a temporary increase to 10% in spring 2002. Dr. Martel noted that the terrorist attacks of Sept. 11, 2001, occurred within that school year, but she said she had no way of knowing whether that was a reason for the 1-year increase.

The need for mental health services for college students might be increasing, said Dr. Martel, who reported having no conflicts of interest.

Elsevier Global Medical News

HONOLULU — High-dose OROS methylphenidate was associated with small but statistically significant increases in systolic blood pressure and heart rate in a 6-month, open-label study in adolescents.

The study found no significant long-term increases in diastolic blood pressure or in electrocardiographic measures, Dr. Paul Hammerness said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

The findings are consistent with studies involving younger children and lower doses, said Dr. Hammerness of Massachusetts General Hospital and Harvard Medical School, Boston.

Because of concerns about possible associations between stimulant medications for attention-deficit/hyperactivity disorder (ADHD) and cardiovascular complications—including sudden cardiac death—the Food and Drug Administration in June 2009 recommended that physicians pay special attention to a child's cardiovascular system when prescribing stimulants.

The study involved 114 adolescents with a mean age of 14 years at baseline (range 12-18 years). All were healthy, and all had a diagnosis of ADHD based on full DSM-IV criteria. The trial was intended to evaluate use of OROS methylphenidate for prevention of cigarette smoking (J. Pediatr. 2009;155:84-9).

The beginning dose of OROS methylphenidate was 0.5-0.75 mg/kg per day, and that was titrated upward to a maximum of 1.5 mg/kg per day by week 3. At week 6, the mean total daily dose was 63 mg, and 50% of the participants were taking 72 mg or more.

As expected, OROS methylphenidate was highly effective in treating the participants' ADHD. Their ADHD Rating Scale scores declined from a mean of 26.9 at baseline to 9.7 at week 6.

Of the 114 participants who entered the study, 73% were male, and their mean body mass index was 22.6 kg/m

Mean systolic blood pressure at baseline was 113 mm Hg, and that increased to 117 mm Hg at 6 months, a significant increase. Mean diastolic blood pressure began at 63 mm Hg, increased significantly to 65 mm Hg at week 6, but then returned to 64 mm Hg at 6 months. Mean heart rate began at 82 beats per minute, increased significantly to 86 beats per minute at week 6, and remained at about that rate at 6 months.

The investigators found no statistically significant or clinically meaningful changes in ECG variables, including PR, QRS, or QTC.

Reasoning that any adverse cardiovascular effects of OROS methylphenidate might be restricted to certain subsets of adolescents, the investigators separately analyzed those 16 participants who met criteria for prehypertension or hypertension at baseline, based on at least one blood pressure reading above the 90th or 95th percentile. The investigators found no impact of abnormal premedication blood pressure readings on blood pressure changes during treatment.

Participants experienced no serious adverse events or serious cardiovascular adverse events during the study. Ten of the 114 subjects reported one or more subjective cardiovascular complaints, including palpitations, chest pain, and fast or racing heartbeat. Of those, six had a lifetime diagnosis of comorbid anxiety disorder.

One participant discontinued treatment because of recurrent palpitations. She had a lifetime history of comorbid generalized anxiety disorder and migraines, but she showed no change from baseline in any cardiovascular measurement, and her primary care physician did not find her complaints to be consistent with cardiac disease. She later used a different stimulant medication with no subsequent cardiovascular symptoms.

“The FDA continues to review and still concludes that the overall risk-benefit ratio supports the use of stimulant medications for ADHD,” Dr. Hammerness said. But he did recommend that clinicians carefully evaluate a child's cardiovascular symptoms and family history before prescribing stimulants.

In particular, clinicians should look for a family history of cardiovascular disease at a young age, such as QT syndrome, cardiomyopathy, or a cousin who died suddenly during exercise.

Dr. Hammerness acknowledged serving as a speaker for, receiving research funds from, or participating in CME activities or professional talks supported by Abbott, McNeil, and Shire Pharmaceuticals; and participating in research studies funded by Bristol Myers Squibb, Cephalon, Eli Lilly & Co., Johnson & Johnson, McNeil, New River, Novartis, Organon, Otsuka, Pfizer Inc., Shire, and Takeda. This study was sponsored by McNeil, which markets OROS methylphenidate under the brand name Concerta.

HONOLULU — High-dose OROS methylphenidate was associated with small but statistically significant increases in systolic blood pressure and heart rate in a 6-month, open-label study in adolescents.

The study found no significant long-term increases in diastolic blood pressure or in electrocardiographic measures, Dr. Paul Hammerness said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

The findings are consistent with studies involving younger children and lower doses, said Dr. Hammerness of Massachusetts General Hospital and Harvard Medical School, Boston.

Because of concerns about possible associations between stimulant medications for attention-deficit/hyperactivity disorder (ADHD) and cardiovascular complications—including sudden cardiac death—the Food and Drug Administration in June 2009 recommended that physicians pay special attention to a child's cardiovascular system when prescribing stimulants.

The study involved 114 adolescents with a mean age of 14 years at baseline (range 12-18 years). All were healthy, and all had a diagnosis of ADHD based on full DSM-IV criteria. The trial was intended to evaluate use of OROS methylphenidate for prevention of cigarette smoking (J. Pediatr. 2009;155:84-9).

The beginning dose of OROS methylphenidate was 0.5-0.75 mg/kg per day, and that was titrated upward to a maximum of 1.5 mg/kg per day by week 3. At week 6, the mean total daily dose was 63 mg, and 50% of the participants were taking 72 mg or more.

As expected, OROS methylphenidate was highly effective in treating the participants' ADHD. Their ADHD Rating Scale scores declined from a mean of 26.9 at baseline to 9.7 at week 6.

Of the 114 participants who entered the study, 73% were male, and their mean body mass index was 22.6 kg/m

Mean systolic blood pressure at baseline was 113 mm Hg, and that increased to 117 mm Hg at 6 months, a significant increase. Mean diastolic blood pressure began at 63 mm Hg, increased significantly to 65 mm Hg at week 6, but then returned to 64 mm Hg at 6 months. Mean heart rate began at 82 beats per minute, increased significantly to 86 beats per minute at week 6, and remained at about that rate at 6 months.

The investigators found no statistically significant or clinically meaningful changes in ECG variables, including PR, QRS, or QTC.

Reasoning that any adverse cardiovascular effects of OROS methylphenidate might be restricted to certain subsets of adolescents, the investigators separately analyzed those 16 participants who met criteria for prehypertension or hypertension at baseline, based on at least one blood pressure reading above the 90th or 95th percentile. The investigators found no impact of abnormal premedication blood pressure readings on blood pressure changes during treatment.

Participants experienced no serious adverse events or serious cardiovascular adverse events during the study. Ten of the 114 subjects reported one or more subjective cardiovascular complaints, including palpitations, chest pain, and fast or racing heartbeat. Of those, six had a lifetime diagnosis of comorbid anxiety disorder.

One participant discontinued treatment because of recurrent palpitations. She had a lifetime history of comorbid generalized anxiety disorder and migraines, but she showed no change from baseline in any cardiovascular measurement, and her primary care physician did not find her complaints to be consistent with cardiac disease. She later used a different stimulant medication with no subsequent cardiovascular symptoms.

“The FDA continues to review and still concludes that the overall risk-benefit ratio supports the use of stimulant medications for ADHD,” Dr. Hammerness said. But he did recommend that clinicians carefully evaluate a child's cardiovascular symptoms and family history before prescribing stimulants.

In particular, clinicians should look for a family history of cardiovascular disease at a young age, such as QT syndrome, cardiomyopathy, or a cousin who died suddenly during exercise.

Dr. Hammerness acknowledged serving as a speaker for, receiving research funds from, or participating in CME activities or professional talks supported by Abbott, McNeil, and Shire Pharmaceuticals; and participating in research studies funded by Bristol Myers Squibb, Cephalon, Eli Lilly & Co., Johnson & Johnson, McNeil, New River, Novartis, Organon, Otsuka, Pfizer Inc., Shire, and Takeda. This study was sponsored by McNeil, which markets OROS methylphenidate under the brand name Concerta.

HONOLULU — High-dose OROS methylphenidate was associated with small but statistically significant increases in systolic blood pressure and heart rate in a 6-month, open-label study in adolescents.

The study found no significant long-term increases in diastolic blood pressure or in electrocardiographic measures, Dr. Paul Hammerness said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

The findings are consistent with studies involving younger children and lower doses, said Dr. Hammerness of Massachusetts General Hospital and Harvard Medical School, Boston.

Because of concerns about possible associations between stimulant medications for attention-deficit/hyperactivity disorder (ADHD) and cardiovascular complications—including sudden cardiac death—the Food and Drug Administration in June 2009 recommended that physicians pay special attention to a child's cardiovascular system when prescribing stimulants.

The study involved 114 adolescents with a mean age of 14 years at baseline (range 12-18 years). All were healthy, and all had a diagnosis of ADHD based on full DSM-IV criteria. The trial was intended to evaluate use of OROS methylphenidate for prevention of cigarette smoking (J. Pediatr. 2009;155:84-9).

The beginning dose of OROS methylphenidate was 0.5-0.75 mg/kg per day, and that was titrated upward to a maximum of 1.5 mg/kg per day by week 3. At week 6, the mean total daily dose was 63 mg, and 50% of the participants were taking 72 mg or more.

As expected, OROS methylphenidate was highly effective in treating the participants' ADHD. Their ADHD Rating Scale scores declined from a mean of 26.9 at baseline to 9.7 at week 6.

Of the 114 participants who entered the study, 73% were male, and their mean body mass index was 22.6 kg/m

Mean systolic blood pressure at baseline was 113 mm Hg, and that increased to 117 mm Hg at 6 months, a significant increase. Mean diastolic blood pressure began at 63 mm Hg, increased significantly to 65 mm Hg at week 6, but then returned to 64 mm Hg at 6 months. Mean heart rate began at 82 beats per minute, increased significantly to 86 beats per minute at week 6, and remained at about that rate at 6 months.

The investigators found no statistically significant or clinically meaningful changes in ECG variables, including PR, QRS, or QTC.

Reasoning that any adverse cardiovascular effects of OROS methylphenidate might be restricted to certain subsets of adolescents, the investigators separately analyzed those 16 participants who met criteria for prehypertension or hypertension at baseline, based on at least one blood pressure reading above the 90th or 95th percentile. The investigators found no impact of abnormal premedication blood pressure readings on blood pressure changes during treatment.

Participants experienced no serious adverse events or serious cardiovascular adverse events during the study. Ten of the 114 subjects reported one or more subjective cardiovascular complaints, including palpitations, chest pain, and fast or racing heartbeat. Of those, six had a lifetime diagnosis of comorbid anxiety disorder.

One participant discontinued treatment because of recurrent palpitations. She had a lifetime history of comorbid generalized anxiety disorder and migraines, but she showed no change from baseline in any cardiovascular measurement, and her primary care physician did not find her complaints to be consistent with cardiac disease. She later used a different stimulant medication with no subsequent cardiovascular symptoms.

“The FDA continues to review and still concludes that the overall risk-benefit ratio supports the use of stimulant medications for ADHD,” Dr. Hammerness said. But he did recommend that clinicians carefully evaluate a child's cardiovascular symptoms and family history before prescribing stimulants.

In particular, clinicians should look for a family history of cardiovascular disease at a young age, such as QT syndrome, cardiomyopathy, or a cousin who died suddenly during exercise.

Dr. Hammerness acknowledged serving as a speaker for, receiving research funds from, or participating in CME activities or professional talks supported by Abbott, McNeil, and Shire Pharmaceuticals; and participating in research studies funded by Bristol Myers Squibb, Cephalon, Eli Lilly & Co., Johnson & Johnson, McNeil, New River, Novartis, Organon, Otsuka, Pfizer Inc., Shire, and Takeda. This study was sponsored by McNeil, which markets OROS methylphenidate under the brand name Concerta.

The U.S. Senate's Homeland Security and Governmental Affairs Committee held a hearing to determine why vaccine for pandemic influenza A(H1N1) virus is taking so long to reach the 159 million Americans in the designated high-risk groups.

As of Nov. 23, 34% of the vaccine needed for the initial target groups was available.

In a letter to Health and Human Services Secretary Kathleen Sebelius, Sen. Joe Lieberman (I-Conn.), who chairs the committee, together with ranking minority member Sen. Susan M. Collins (R-Maine), criticized the HHS's decision to designate nearly half the U.S. population in one of the high-risk groups.

“I share your disappointment in the initial production and the supply constraints that we have today,” Dr. Anne Schuchat said in her opening statement at the hearing. Dr. Schuchat is director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention. “We have all been victim to the biologic processes of a slow-growing virus, and it really underscores the needs for those long-term investments in the technology and the production capacity. But production is accelerating and substantial amounts are becoming available.”

The committee's letter to Secretary Sebelius pointed out that an HHS advisory committee had prepared a contingency plan for an extreme vaccine shortage. According to that plan, vaccine would have been reserved for the 42 million Americans at greatest risk. But that plan was never implemented.

Instead the federal government gave state and local governments the discretion to decide how to distribute vaccine. “People rightly do not understand why in their area they are not eligible to get vaccinated, while individuals in a similar risk category across the state or city line are told they can get the vaccine,” the letter reads.

“We have been supporting state and local decision making on the best ways to put vaccine in the path of the priority populations,” Dr. Schuchat said.

“We know that states are carrying this out in a variety of ways. Thirty-four states so far have initiated school-located vaccine efforts. Virtually all of the states are providing vaccines to providers. Some are using lotteries to decide who gets the vaccine. Some have ethics boards. Some are focusing on high-risk providers that serve the highest-risk children or adults,” she explained.

And Dr. Schuchat noted that if the vaccine had been reserved for only the 42 million Americans at highest risk, millions of healthy school-age children would have been left out.

She said that “reasonable experts” disagreed on whether that tighter targeting would be desirable.

“I do believe that we need a thorough evaluation of the preparedness at the state and local level,” Sen. Collins said at the hearing. “It does vary enormously, because some states devote a lot of resources and some states don't. Some states are making good decisions and some states aren't. And that applies to big city health departments as well.”

“We are not waiting for states or cities to fail,” Dr. Schuchat replied. “We are working very actively, monitoring the ordering, understanding what's going on, offering assistance, and working on some of the missteps that we believe may be happening in some areas.”

At the hearing, Dr. Nicole Lurie, who is assistant secretary for preparedness and response at HHS, detailed some of the causes for the shortage. For example, while the remnants of Hurricane Ida were still menacing the Gulf Coast, some of the manufacturers' insurance carriers insisted that vaccine deliveries be delayed.

Sen. Collins focused on two other possible explanations for the shortfall: the reliance on prefilled single-use syringes and the failure to incorporate adjuvants into the vaccine formulations. Adjuvants, which are being used in H1N1 vaccines distributed in other countries, help the immune system mount a larger response to a smaller amount of vaccine, thus stretching the supply.

Dr. Lurie said that the U.S. government contracted for a mixed supply of prefilled syringes and multi-use vials. And when it became evident that there would be a shortage, the manufacturers were instructed to focus on filling the multi-use vials. Only when they had more vaccine than they could handle on those assembly lines would they start producing prefilled syringes.

The bottom line is that the issue of vials versus syringes turned out not to have an appreciable effect on the supply, Dr. Lurie said.

The adjuvant story was somewhat more complex. Dr. Lurie said that experts reviewed the decision not to use adjuvants several times, but each time they decided against changing course.

There were two main reasons, Dr. Lurie said. First, the decision to add adjuvant would take nonadjuvanted vaccine out of the system during the shift. “And number two, as I think you know, the public's confidence in vaccines in this country is just not as robust as we want it to be. Adjuvants would be a new vaccine … and we didn't really want to rock the public's confidence with a new vaccine.”

Finally, Dr. Schuchat confirmed new figures illustrating the extent of the pandemic in the United States. So far 22 million Americans have been infected with H1N1 influenza, resulting in 98,000 hospitalizations and more than 3,900 deaths.

These figures are substantially higher than those that were previously released because the CDC is no longer requiring laboratory confirmation that individual cases of influenzalike illness be confirmed as H1N1 infection before being counted.

The U.S. Senate's Homeland Security and Governmental Affairs Committee held a hearing to determine why vaccine for pandemic influenza A(H1N1) virus is taking so long to reach the 159 million Americans in the designated high-risk groups.

As of Nov. 23, 34% of the vaccine needed for the initial target groups was available.

In a letter to Health and Human Services Secretary Kathleen Sebelius, Sen. Joe Lieberman (I-Conn.), who chairs the committee, together with ranking minority member Sen. Susan M. Collins (R-Maine), criticized the HHS's decision to designate nearly half the U.S. population in one of the high-risk groups.

“I share your disappointment in the initial production and the supply constraints that we have today,” Dr. Anne Schuchat said in her opening statement at the hearing. Dr. Schuchat is director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention. “We have all been victim to the biologic processes of a slow-growing virus, and it really underscores the needs for those long-term investments in the technology and the production capacity. But production is accelerating and substantial amounts are becoming available.”

The committee's letter to Secretary Sebelius pointed out that an HHS advisory committee had prepared a contingency plan for an extreme vaccine shortage. According to that plan, vaccine would have been reserved for the 42 million Americans at greatest risk. But that plan was never implemented.

Instead the federal government gave state and local governments the discretion to decide how to distribute vaccine. “People rightly do not understand why in their area they are not eligible to get vaccinated, while individuals in a similar risk category across the state or city line are told they can get the vaccine,” the letter reads.

“We have been supporting state and local decision making on the best ways to put vaccine in the path of the priority populations,” Dr. Schuchat said.

“We know that states are carrying this out in a variety of ways. Thirty-four states so far have initiated school-located vaccine efforts. Virtually all of the states are providing vaccines to providers. Some are using lotteries to decide who gets the vaccine. Some have ethics boards. Some are focusing on high-risk providers that serve the highest-risk children or adults,” she explained.

And Dr. Schuchat noted that if the vaccine had been reserved for only the 42 million Americans at highest risk, millions of healthy school-age children would have been left out.

She said that “reasonable experts” disagreed on whether that tighter targeting would be desirable.

“I do believe that we need a thorough evaluation of the preparedness at the state and local level,” Sen. Collins said at the hearing. “It does vary enormously, because some states devote a lot of resources and some states don't. Some states are making good decisions and some states aren't. And that applies to big city health departments as well.”

“We are not waiting for states or cities to fail,” Dr. Schuchat replied. “We are working very actively, monitoring the ordering, understanding what's going on, offering assistance, and working on some of the missteps that we believe may be happening in some areas.”

At the hearing, Dr. Nicole Lurie, who is assistant secretary for preparedness and response at HHS, detailed some of the causes for the shortage. For example, while the remnants of Hurricane Ida were still menacing the Gulf Coast, some of the manufacturers' insurance carriers insisted that vaccine deliveries be delayed.

Sen. Collins focused on two other possible explanations for the shortfall: the reliance on prefilled single-use syringes and the failure to incorporate adjuvants into the vaccine formulations. Adjuvants, which are being used in H1N1 vaccines distributed in other countries, help the immune system mount a larger response to a smaller amount of vaccine, thus stretching the supply.

Dr. Lurie said that the U.S. government contracted for a mixed supply of prefilled syringes and multi-use vials. And when it became evident that there would be a shortage, the manufacturers were instructed to focus on filling the multi-use vials. Only when they had more vaccine than they could handle on those assembly lines would they start producing prefilled syringes.

The bottom line is that the issue of vials versus syringes turned out not to have an appreciable effect on the supply, Dr. Lurie said.

The adjuvant story was somewhat more complex. Dr. Lurie said that experts reviewed the decision not to use adjuvants several times, but each time they decided against changing course.

There were two main reasons, Dr. Lurie said. First, the decision to add adjuvant would take nonadjuvanted vaccine out of the system during the shift. “And number two, as I think you know, the public's confidence in vaccines in this country is just not as robust as we want it to be. Adjuvants would be a new vaccine … and we didn't really want to rock the public's confidence with a new vaccine.”

Finally, Dr. Schuchat confirmed new figures illustrating the extent of the pandemic in the United States. So far 22 million Americans have been infected with H1N1 influenza, resulting in 98,000 hospitalizations and more than 3,900 deaths.

These figures are substantially higher than those that were previously released because the CDC is no longer requiring laboratory confirmation that individual cases of influenzalike illness be confirmed as H1N1 infection before being counted.

The U.S. Senate's Homeland Security and Governmental Affairs Committee held a hearing to determine why vaccine for pandemic influenza A(H1N1) virus is taking so long to reach the 159 million Americans in the designated high-risk groups.

As of Nov. 23, 34% of the vaccine needed for the initial target groups was available.

In a letter to Health and Human Services Secretary Kathleen Sebelius, Sen. Joe Lieberman (I-Conn.), who chairs the committee, together with ranking minority member Sen. Susan M. Collins (R-Maine), criticized the HHS's decision to designate nearly half the U.S. population in one of the high-risk groups.

“I share your disappointment in the initial production and the supply constraints that we have today,” Dr. Anne Schuchat said in her opening statement at the hearing. Dr. Schuchat is director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention. “We have all been victim to the biologic processes of a slow-growing virus, and it really underscores the needs for those long-term investments in the technology and the production capacity. But production is accelerating and substantial amounts are becoming available.”

The committee's letter to Secretary Sebelius pointed out that an HHS advisory committee had prepared a contingency plan for an extreme vaccine shortage. According to that plan, vaccine would have been reserved for the 42 million Americans at greatest risk. But that plan was never implemented.

Instead the federal government gave state and local governments the discretion to decide how to distribute vaccine. “People rightly do not understand why in their area they are not eligible to get vaccinated, while individuals in a similar risk category across the state or city line are told they can get the vaccine,” the letter reads.

“We have been supporting state and local decision making on the best ways to put vaccine in the path of the priority populations,” Dr. Schuchat said.

“We know that states are carrying this out in a variety of ways. Thirty-four states so far have initiated school-located vaccine efforts. Virtually all of the states are providing vaccines to providers. Some are using lotteries to decide who gets the vaccine. Some have ethics boards. Some are focusing on high-risk providers that serve the highest-risk children or adults,” she explained.

And Dr. Schuchat noted that if the vaccine had been reserved for only the 42 million Americans at highest risk, millions of healthy school-age children would have been left out.

She said that “reasonable experts” disagreed on whether that tighter targeting would be desirable.

“I do believe that we need a thorough evaluation of the preparedness at the state and local level,” Sen. Collins said at the hearing. “It does vary enormously, because some states devote a lot of resources and some states don't. Some states are making good decisions and some states aren't. And that applies to big city health departments as well.”

“We are not waiting for states or cities to fail,” Dr. Schuchat replied. “We are working very actively, monitoring the ordering, understanding what's going on, offering assistance, and working on some of the missteps that we believe may be happening in some areas.”

At the hearing, Dr. Nicole Lurie, who is assistant secretary for preparedness and response at HHS, detailed some of the causes for the shortage. For example, while the remnants of Hurricane Ida were still menacing the Gulf Coast, some of the manufacturers' insurance carriers insisted that vaccine deliveries be delayed.

Sen. Collins focused on two other possible explanations for the shortfall: the reliance on prefilled single-use syringes and the failure to incorporate adjuvants into the vaccine formulations. Adjuvants, which are being used in H1N1 vaccines distributed in other countries, help the immune system mount a larger response to a smaller amount of vaccine, thus stretching the supply.

Dr. Lurie said that the U.S. government contracted for a mixed supply of prefilled syringes and multi-use vials. And when it became evident that there would be a shortage, the manufacturers were instructed to focus on filling the multi-use vials. Only when they had more vaccine than they could handle on those assembly lines would they start producing prefilled syringes.

The bottom line is that the issue of vials versus syringes turned out not to have an appreciable effect on the supply, Dr. Lurie said.

The adjuvant story was somewhat more complex. Dr. Lurie said that experts reviewed the decision not to use adjuvants several times, but each time they decided against changing course.

There were two main reasons, Dr. Lurie said. First, the decision to add adjuvant would take nonadjuvanted vaccine out of the system during the shift. “And number two, as I think you know, the public's confidence in vaccines in this country is just not as robust as we want it to be. Adjuvants would be a new vaccine … and we didn't really want to rock the public's confidence with a new vaccine.”

Finally, Dr. Schuchat confirmed new figures illustrating the extent of the pandemic in the United States. So far 22 million Americans have been infected with H1N1 influenza, resulting in 98,000 hospitalizations and more than 3,900 deaths.

These figures are substantially higher than those that were previously released because the CDC is no longer requiring laboratory confirmation that individual cases of influenzalike illness be confirmed as H1N1 infection before being counted.

HONOLULU – Children who experience bereavement, especially the loss of a parent, are significantly more likely to exhibit symptoms of separation anxiety and conduct disorder than those who have not experienced such a loss, a large longitudinal study shows.

In addition, bereavement is associated with a great risk of developing substance abuse problems, Julie B. Kaplow, Ph.D., and her colleagues wrote for a poster presentation at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

The data came from the Great Smoky Mountains Study of Youth, a longitudinal study of a representative sample of children from 11 counties in western North Carolina. Children were aged 9, 11, and 13 years at the time of enrollment, and investigators interviewed them annually for 14 years using the Life Events and Psychiatric Disorders sections of the Child and Adolescent Psychiatric Assessment.

For the purposes of the bereavement study, the investigators compared 172 children who had lost a parent (biological, foster/adoptive, or other parental figure), 815 who had lost a relative other than a parent (grandparent, aunt, or uncle), and 235 who had experienced no loss.

Investigators focused on the interview during which the loss was reported, as well as the interviews immediately before and after the index interview, wrote Dr. Kaplow, of the department of psychology at the University of Michigan, Ann Arbor.

There were some baseline differences among the groups. Children in the parent-bereaved group were significantly more likely to live in poverty (42% vs. 22% in the other-bereaved group and 23% in the nonbereaved group).

Before the loss, children in the parent-bereaved group also were significantly more likely to report substance abuse (14% vs. 4% in the other two groups). In addition, children in the parent-bereaved group had significantly lower global functioning scores.

After controlling for sex, age, race/ethnicity, poverty, and previous psychiatric symptoms, the investigators found that children in both of the bereaved groups were significantly more likely to report symptoms of separation anxiety than were children in the nonbereaved group. Children in the parent-bereaved group were twice as likely to show symptoms of conduct disorder than were those in the nonbereaved group, and children in the other-bereaved group were twice as likely to show symptoms of depression than either those in the parent-bereaved or nonbereaved groups.

Even after controlling for their higher rates of substance abuse at baseline, children in the parent-bereaved and other-bereaved groups showed a significantly higher risk of developing substance abuse after the loss than were nonbereaved children. The investigators speculated that this may be attributable to the bereaved individuals' poor coping skills and desire to self-medicate.

The investigators said the higher risk of conduct disorder symptoms after the loss could be tied to secondary stressors. “Parental discipline has been shown to suffer following the death of the other parent and is likely to be associated with new-onset behavioral problems in bereaved children,” they wrote.

The investigators stated that they had no conflicts of interest related to their presentation.

HONOLULU – Children who experience bereavement, especially the loss of a parent, are significantly more likely to exhibit symptoms of separation anxiety and conduct disorder than those who have not experienced such a loss, a large longitudinal study shows.

In addition, bereavement is associated with a great risk of developing substance abuse problems, Julie B. Kaplow, Ph.D., and her colleagues wrote for a poster presentation at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

The data came from the Great Smoky Mountains Study of Youth, a longitudinal study of a representative sample of children from 11 counties in western North Carolina. Children were aged 9, 11, and 13 years at the time of enrollment, and investigators interviewed them annually for 14 years using the Life Events and Psychiatric Disorders sections of the Child and Adolescent Psychiatric Assessment.

For the purposes of the bereavement study, the investigators compared 172 children who had lost a parent (biological, foster/adoptive, or other parental figure), 815 who had lost a relative other than a parent (grandparent, aunt, or uncle), and 235 who had experienced no loss.

Investigators focused on the interview during which the loss was reported, as well as the interviews immediately before and after the index interview, wrote Dr. Kaplow, of the department of psychology at the University of Michigan, Ann Arbor.

There were some baseline differences among the groups. Children in the parent-bereaved group were significantly more likely to live in poverty (42% vs. 22% in the other-bereaved group and 23% in the nonbereaved group).

Before the loss, children in the parent-bereaved group also were significantly more likely to report substance abuse (14% vs. 4% in the other two groups). In addition, children in the parent-bereaved group had significantly lower global functioning scores.

After controlling for sex, age, race/ethnicity, poverty, and previous psychiatric symptoms, the investigators found that children in both of the bereaved groups were significantly more likely to report symptoms of separation anxiety than were children in the nonbereaved group. Children in the parent-bereaved group were twice as likely to show symptoms of conduct disorder than were those in the nonbereaved group, and children in the other-bereaved group were twice as likely to show symptoms of depression than either those in the parent-bereaved or nonbereaved groups.

Even after controlling for their higher rates of substance abuse at baseline, children in the parent-bereaved and other-bereaved groups showed a significantly higher risk of developing substance abuse after the loss than were nonbereaved children. The investigators speculated that this may be attributable to the bereaved individuals' poor coping skills and desire to self-medicate.

The investigators said the higher risk of conduct disorder symptoms after the loss could be tied to secondary stressors. “Parental discipline has been shown to suffer following the death of the other parent and is likely to be associated with new-onset behavioral problems in bereaved children,” they wrote.

The investigators stated that they had no conflicts of interest related to their presentation.

HONOLULU – Children who experience bereavement, especially the loss of a parent, are significantly more likely to exhibit symptoms of separation anxiety and conduct disorder than those who have not experienced such a loss, a large longitudinal study shows.

In addition, bereavement is associated with a great risk of developing substance abuse problems, Julie B. Kaplow, Ph.D., and her colleagues wrote for a poster presentation at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

The data came from the Great Smoky Mountains Study of Youth, a longitudinal study of a representative sample of children from 11 counties in western North Carolina. Children were aged 9, 11, and 13 years at the time of enrollment, and investigators interviewed them annually for 14 years using the Life Events and Psychiatric Disorders sections of the Child and Adolescent Psychiatric Assessment.

For the purposes of the bereavement study, the investigators compared 172 children who had lost a parent (biological, foster/adoptive, or other parental figure), 815 who had lost a relative other than a parent (grandparent, aunt, or uncle), and 235 who had experienced no loss.

Investigators focused on the interview during which the loss was reported, as well as the interviews immediately before and after the index interview, wrote Dr. Kaplow, of the department of psychology at the University of Michigan, Ann Arbor.

There were some baseline differences among the groups. Children in the parent-bereaved group were significantly more likely to live in poverty (42% vs. 22% in the other-bereaved group and 23% in the nonbereaved group).

Before the loss, children in the parent-bereaved group also were significantly more likely to report substance abuse (14% vs. 4% in the other two groups). In addition, children in the parent-bereaved group had significantly lower global functioning scores.

After controlling for sex, age, race/ethnicity, poverty, and previous psychiatric symptoms, the investigators found that children in both of the bereaved groups were significantly more likely to report symptoms of separation anxiety than were children in the nonbereaved group. Children in the parent-bereaved group were twice as likely to show symptoms of conduct disorder than were those in the nonbereaved group, and children in the other-bereaved group were twice as likely to show symptoms of depression than either those in the parent-bereaved or nonbereaved groups.

Even after controlling for their higher rates of substance abuse at baseline, children in the parent-bereaved and other-bereaved groups showed a significantly higher risk of developing substance abuse after the loss than were nonbereaved children. The investigators speculated that this may be attributable to the bereaved individuals' poor coping skills and desire to self-medicate.

The investigators said the higher risk of conduct disorder symptoms after the loss could be tied to secondary stressors. “Parental discipline has been shown to suffer following the death of the other parent and is likely to be associated with new-onset behavioral problems in bereaved children,” they wrote.

The investigators stated that they had no conflicts of interest related to their presentation.

HONOLULU – Stress was the most frequently cited psychological factor adversely affecting the academic performance of college students, according to a survey conducted in spring 2008 by the American College Health Association.

Almost 34% of students cited stress as a factor affecting academic performance, up from 29% in spring 2000, Dr. Adele L. Martel said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Sleep was the second most common psychological factor cited by the students, rising from 21% in 2000 to 26% in 2008.

Relationship difficulties, holding steady at about 15% between 2000 and 2008, have recently been overtaken by the Internet in their impact on academic performance, said Dr. Martel, who is affiliated with Children's Memorial Hospital in Chicago.

Cited by only 9% of college students in 2000, the Internet affected the academic performance of nearly 17% in 2008, according to data from the National College Health Assessment, which surveyed more than 80,000 students on 106 campuses.

In 2008, 7% of students cited attention-deficit disorder, more than double the 3% who mentioned that as a factor in 2000.

A greater proportion of students also cited learning disabilities as affecting their academic performance, the rate nearly doubling between 2000 and 2008.

Alcohol use has remained steady at about 8%, except for a temporary increase to 10% in spring 2002. Dr. Martel noted that the terrorist attacks of Sept. 11, 2001, occurred within that school year, but she said she had no way of knowing whether that was a reason for the 1-year increase.

Even when the proportion of students citing a certain factor remains about the same from 1 year to the next, the need for mental health services for college students might be increasing.

“The percentages are staying the same, but we know we have more college students, so the numbers are higher,” Dr. Martel said.

In 2000, the total undergraduate fall enrollment in degree-granting institutions was 13.2 million, and this rose to approximately 15.5 million individuals in 2008.

Dr. Martel said she had no conflicts of interest related to her presentation.

HONOLULU – Stress was the most frequently cited psychological factor adversely affecting the academic performance of college students, according to a survey conducted in spring 2008 by the American College Health Association.

Almost 34% of students cited stress as a factor affecting academic performance, up from 29% in spring 2000, Dr. Adele L. Martel said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Sleep was the second most common psychological factor cited by the students, rising from 21% in 2000 to 26% in 2008.

Relationship difficulties, holding steady at about 15% between 2000 and 2008, have recently been overtaken by the Internet in their impact on academic performance, said Dr. Martel, who is affiliated with Children's Memorial Hospital in Chicago.

Cited by only 9% of college students in 2000, the Internet affected the academic performance of nearly 17% in 2008, according to data from the National College Health Assessment, which surveyed more than 80,000 students on 106 campuses.

In 2008, 7% of students cited attention-deficit disorder, more than double the 3% who mentioned that as a factor in 2000.

A greater proportion of students also cited learning disabilities as affecting their academic performance, the rate nearly doubling between 2000 and 2008.

Alcohol use has remained steady at about 8%, except for a temporary increase to 10% in spring 2002. Dr. Martel noted that the terrorist attacks of Sept. 11, 2001, occurred within that school year, but she said she had no way of knowing whether that was a reason for the 1-year increase.

Even when the proportion of students citing a certain factor remains about the same from 1 year to the next, the need for mental health services for college students might be increasing.

“The percentages are staying the same, but we know we have more college students, so the numbers are higher,” Dr. Martel said.

In 2000, the total undergraduate fall enrollment in degree-granting institutions was 13.2 million, and this rose to approximately 15.5 million individuals in 2008.

Dr. Martel said she had no conflicts of interest related to her presentation.

HONOLULU – Stress was the most frequently cited psychological factor adversely affecting the academic performance of college students, according to a survey conducted in spring 2008 by the American College Health Association.

Almost 34% of students cited stress as a factor affecting academic performance, up from 29% in spring 2000, Dr. Adele L. Martel said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Sleep was the second most common psychological factor cited by the students, rising from 21% in 2000 to 26% in 2008.

Relationship difficulties, holding steady at about 15% between 2000 and 2008, have recently been overtaken by the Internet in their impact on academic performance, said Dr. Martel, who is affiliated with Children's Memorial Hospital in Chicago.

Cited by only 9% of college students in 2000, the Internet affected the academic performance of nearly 17% in 2008, according to data from the National College Health Assessment, which surveyed more than 80,000 students on 106 campuses.

In 2008, 7% of students cited attention-deficit disorder, more than double the 3% who mentioned that as a factor in 2000.

A greater proportion of students also cited learning disabilities as affecting their academic performance, the rate nearly doubling between 2000 and 2008.

Alcohol use has remained steady at about 8%, except for a temporary increase to 10% in spring 2002. Dr. Martel noted that the terrorist attacks of Sept. 11, 2001, occurred within that school year, but she said she had no way of knowing whether that was a reason for the 1-year increase.

Even when the proportion of students citing a certain factor remains about the same from 1 year to the next, the need for mental health services for college students might be increasing.

“The percentages are staying the same, but we know we have more college students, so the numbers are higher,” Dr. Martel said.

In 2000, the total undergraduate fall enrollment in degree-granting institutions was 13.2 million, and this rose to approximately 15.5 million individuals in 2008.

Dr. Martel said she had no conflicts of interest related to her presentation.

HONOLULU – Anxious children who participated in a 9-week course of cognitive-behavioral therapy maintained improvements for at least 4 years, especially if their parents also received training, according to a randomized, placebo-controlled trial.

This is the longest follow-up study of cognitive-behavioral therapy (CBT) for anxious children in which comparison with a control group was possible, wrote Dr. Gail A. Bernstein of the University of Minnesota, Minneapolis. Dr. Bernstein was the lead author of the study, which was presented during a poster session at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

The study involved 61 children, aged 7–11 years, all of whom had features of separation anxiety disorder, generalized anxiety disorder, and/or social phobia. Investigators randomized the children by school into one of three treatment conditions. In one group, the children received a 9-week manual- and workbook-based CBT intervention using the FRIENDS for Life, a school-based anxiety prevention program. In the second arm, the children received the CBT intervention and, in addition, their parents participated in a 9-week concurrent training group based on the FRIENDS program. Children in the third arm received no treatment.

Six months after the treatment phase of the study, the 24 control families were offered treatment. Five of these families were randomly assigned to the CBT group, 7 were randomly assigned to CBT plus parent training, and 12 families declined treatment. Of those 12 families, 8 continued to participate in the assessments at years 2, 3, and 4.

All groups–including the controls–showed improvement in anxiety symptoms. However, at the 4-year follow-up, 43% of children in the control group showed remission of their primary anxiety diagnoses, a significantly smaller proportion than the children in the CBT group (75%) or the children in the CBT plus parent training group (76%).

Also at 4 years, only 29% of the children in the CBT plus parent training group qualified for an anxiety diagnosis. This is significantly lower than those in the CBT group (67%) or the control group (57%).

The child-plus-parent group also had significantly better scores at 4 years on the clinician severity rating (CSR) of the Anxiety Disorders Interview Schedule. At baseline the mean composite CSR scores for the three groups ranged between 2.4 and 3.9 on a scale from 0 to 8. At the 4-year follow-up the mean composite CSR score for the child–plus-parent training group had declined to 0.76. This was a significantly lower than the CBT alone group (2.25) and the control group (1.86).

Other studies have conducted long-term follow-up of CBT in anxious children, but the investigators wrote that this was the first in which comparison with a control group was possible in the 4 years after treatment. Of six other follow-up studies, only one maintained the control group, and that was for only 2 years. The other studies provided CBT to the control participants during or shortly after the intervention phase.

Dr. Bernstein reported no conflicts of interest related to her presentation. Her research was funded by the National Institute of Mental Health, the University of Minnesota Academic Health Center, and the Minnesota Medical Foundation.

HONOLULU – Anxious children who participated in a 9-week course of cognitive-behavioral therapy maintained improvements for at least 4 years, especially if their parents also received training, according to a randomized, placebo-controlled trial.

This is the longest follow-up study of cognitive-behavioral therapy (CBT) for anxious children in which comparison with a control group was possible, wrote Dr. Gail A. Bernstein of the University of Minnesota, Minneapolis. Dr. Bernstein was the lead author of the study, which was presented during a poster session at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

The study involved 61 children, aged 7–11 years, all of whom had features of separation anxiety disorder, generalized anxiety disorder, and/or social phobia. Investigators randomized the children by school into one of three treatment conditions. In one group, the children received a 9-week manual- and workbook-based CBT intervention using the FRIENDS for Life, a school-based anxiety prevention program. In the second arm, the children received the CBT intervention and, in addition, their parents participated in a 9-week concurrent training group based on the FRIENDS program. Children in the third arm received no treatment.

Six months after the treatment phase of the study, the 24 control families were offered treatment. Five of these families were randomly assigned to the CBT group, 7 were randomly assigned to CBT plus parent training, and 12 families declined treatment. Of those 12 families, 8 continued to participate in the assessments at years 2, 3, and 4.

All groups–including the controls–showed improvement in anxiety symptoms. However, at the 4-year follow-up, 43% of children in the control group showed remission of their primary anxiety diagnoses, a significantly smaller proportion than the children in the CBT group (75%) or the children in the CBT plus parent training group (76%).

Also at 4 years, only 29% of the children in the CBT plus parent training group qualified for an anxiety diagnosis. This is significantly lower than those in the CBT group (67%) or the control group (57%).

The child-plus-parent group also had significantly better scores at 4 years on the clinician severity rating (CSR) of the Anxiety Disorders Interview Schedule. At baseline the mean composite CSR scores for the three groups ranged between 2.4 and 3.9 on a scale from 0 to 8. At the 4-year follow-up the mean composite CSR score for the child–plus-parent training group had declined to 0.76. This was a significantly lower than the CBT alone group (2.25) and the control group (1.86).

Other studies have conducted long-term follow-up of CBT in anxious children, but the investigators wrote that this was the first in which comparison with a control group was possible in the 4 years after treatment. Of six other follow-up studies, only one maintained the control group, and that was for only 2 years. The other studies provided CBT to the control participants during or shortly after the intervention phase.

Dr. Bernstein reported no conflicts of interest related to her presentation. Her research was funded by the National Institute of Mental Health, the University of Minnesota Academic Health Center, and the Minnesota Medical Foundation.

HONOLULU – Anxious children who participated in a 9-week course of cognitive-behavioral therapy maintained improvements for at least 4 years, especially if their parents also received training, according to a randomized, placebo-controlled trial.

This is the longest follow-up study of cognitive-behavioral therapy (CBT) for anxious children in which comparison with a control group was possible, wrote Dr. Gail A. Bernstein of the University of Minnesota, Minneapolis. Dr. Bernstein was the lead author of the study, which was presented during a poster session at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

The study involved 61 children, aged 7–11 years, all of whom had features of separation anxiety disorder, generalized anxiety disorder, and/or social phobia. Investigators randomized the children by school into one of three treatment conditions. In one group, the children received a 9-week manual- and workbook-based CBT intervention using the FRIENDS for Life, a school-based anxiety prevention program. In the second arm, the children received the CBT intervention and, in addition, their parents participated in a 9-week concurrent training group based on the FRIENDS program. Children in the third arm received no treatment.

Six months after the treatment phase of the study, the 24 control families were offered treatment. Five of these families were randomly assigned to the CBT group, 7 were randomly assigned to CBT plus parent training, and 12 families declined treatment. Of those 12 families, 8 continued to participate in the assessments at years 2, 3, and 4.

All groups–including the controls–showed improvement in anxiety symptoms. However, at the 4-year follow-up, 43% of children in the control group showed remission of their primary anxiety diagnoses, a significantly smaller proportion than the children in the CBT group (75%) or the children in the CBT plus parent training group (76%).

Also at 4 years, only 29% of the children in the CBT plus parent training group qualified for an anxiety diagnosis. This is significantly lower than those in the CBT group (67%) or the control group (57%).

The child-plus-parent group also had significantly better scores at 4 years on the clinician severity rating (CSR) of the Anxiety Disorders Interview Schedule. At baseline the mean composite CSR scores for the three groups ranged between 2.4 and 3.9 on a scale from 0 to 8. At the 4-year follow-up the mean composite CSR score for the child–plus-parent training group had declined to 0.76. This was a significantly lower than the CBT alone group (2.25) and the control group (1.86).

Other studies have conducted long-term follow-up of CBT in anxious children, but the investigators wrote that this was the first in which comparison with a control group was possible in the 4 years after treatment. Of six other follow-up studies, only one maintained the control group, and that was for only 2 years. The other studies provided CBT to the control participants during or shortly after the intervention phase.

Dr. Bernstein reported no conflicts of interest related to her presentation. Her research was funded by the National Institute of Mental Health, the University of Minnesota Academic Health Center, and the Minnesota Medical Foundation.

SAN FRANCISCO — Repeating a negative stool cytotoxicity assay for Clostridium difficile rarely returns a different result if done within the first 3 days, according to a retrospective study involving more than 10,000 patients.

This is true even during a C. difficile epidemic, Dr. Joe Dylewski said in an interview at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. Dr. Dylewski of St. Mary's Hospital, Montreal, presented his results during a poster session.

The study involved 10,882 patients and 16,665 stool specimens submitted for toxin testing between January 2001 and March 2008. Dr. Dylewski divided the samples into two time periods to reflect an epidemic of C. difficile–associated diarrhea that began in April 2002.

Overall, the positivity rate of the cytotoxicity assay was 27% during the epidemic and 15% during the nonepidemic period. Among samples that initially tested negative, fewer than 1% changed to positive if tests were repeated within the first day. Repeat testing of negative results yielded positive results in 6% during day 2 and in 3% during day 3.

After day 3, the percentage of positive results after initial negative findings rose to 7%, 9%, 12%, and 13% on days 4, 5, 6, and 7, respectively.

“Repeat testing during the first 3 days is probably not beneficial even during an epidemic,” Dr. Dylewski said in the interview at the meeting, sponsored by the American Society for Microbiology. He was particularly critical of repeat testing on the same day of the initial test, which occurred in 698 cases. It takes about 2 days to return a negative result from the C. difficile cytotoxicity assay, so most of these repeat stool samples were sent to the lab before results from the initial sample could have been received.

He attributed these decisions to an erroneous belief among physicians that a second test always is necessary. But even that doesn't explain why he sometimes received three samples from the same patient within that first day. “The order is 'C. diff. times three,'” he said. “So [the patient has] three bowel movements on the same day, and they send all three [samples] down on the same day.”

Of the 698 cases of same-day repeat testing, the initial test was positive in 225 cases and negative in 473. On repeat testing, no results switched from positive to negative, and only two (0.4%) switched from negative to positive.

“It makes sense to retest after 3 days if the patient is still symptomatic and your index of suspicion is high and you haven't started empiric therapy,” he said.

If, after 3 days, the result is still negative but the index of suspicion remains high, there are two ways to proceed. One is to start empiric therapy, and the other is to refer the patient to colonoscopy.

“It's a little bit different when you're in an epidemic situation … because patients get really sick really quickly,” Dr. Dylewski said. During an epidemic, patients with an initial negative result must be followed closely if the index of suspicion is high. “You still need to follow them, potentially treat empirically, or repeat the test after a certain number of days, because you can be wrong, but it's not often.”

But even during an epidemic, he advised, “it should not be routine to say, 'I'm going to do multiple specimens in order to detect it.'”

Dr. Dylewski reported no conflicts of interest related to his study.

SAN FRANCISCO — Repeating a negative stool cytotoxicity assay for Clostridium difficile rarely returns a different result if done within the first 3 days, according to a retrospective study involving more than 10,000 patients.

This is true even during a C. difficile epidemic, Dr. Joe Dylewski said in an interview at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. Dr. Dylewski of St. Mary's Hospital, Montreal, presented his results during a poster session.

The study involved 10,882 patients and 16,665 stool specimens submitted for toxin testing between January 2001 and March 2008. Dr. Dylewski divided the samples into two time periods to reflect an epidemic of C. difficile–associated diarrhea that began in April 2002.

Overall, the positivity rate of the cytotoxicity assay was 27% during the epidemic and 15% during the nonepidemic period. Among samples that initially tested negative, fewer than 1% changed to positive if tests were repeated within the first day. Repeat testing of negative results yielded positive results in 6% during day 2 and in 3% during day 3.

After day 3, the percentage of positive results after initial negative findings rose to 7%, 9%, 12%, and 13% on days 4, 5, 6, and 7, respectively.

“Repeat testing during the first 3 days is probably not beneficial even during an epidemic,” Dr. Dylewski said in the interview at the meeting, sponsored by the American Society for Microbiology. He was particularly critical of repeat testing on the same day of the initial test, which occurred in 698 cases. It takes about 2 days to return a negative result from the C. difficile cytotoxicity assay, so most of these repeat stool samples were sent to the lab before results from the initial sample could have been received.

He attributed these decisions to an erroneous belief among physicians that a second test always is necessary. But even that doesn't explain why he sometimes received three samples from the same patient within that first day. “The order is 'C. diff. times three,'” he said. “So [the patient has] three bowel movements on the same day, and they send all three [samples] down on the same day.”

Of the 698 cases of same-day repeat testing, the initial test was positive in 225 cases and negative in 473. On repeat testing, no results switched from positive to negative, and only two (0.4%) switched from negative to positive.

“It makes sense to retest after 3 days if the patient is still symptomatic and your index of suspicion is high and you haven't started empiric therapy,” he said.

If, after 3 days, the result is still negative but the index of suspicion remains high, there are two ways to proceed. One is to start empiric therapy, and the other is to refer the patient to colonoscopy.

“It's a little bit different when you're in an epidemic situation … because patients get really sick really quickly,” Dr. Dylewski said. During an epidemic, patients with an initial negative result must be followed closely if the index of suspicion is high. “You still need to follow them, potentially treat empirically, or repeat the test after a certain number of days, because you can be wrong, but it's not often.”

But even during an epidemic, he advised, “it should not be routine to say, 'I'm going to do multiple specimens in order to detect it.'”

Dr. Dylewski reported no conflicts of interest related to his study.

SAN FRANCISCO — Repeating a negative stool cytotoxicity assay for Clostridium difficile rarely returns a different result if done within the first 3 days, according to a retrospective study involving more than 10,000 patients.

This is true even during a C. difficile epidemic, Dr. Joe Dylewski said in an interview at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. Dr. Dylewski of St. Mary's Hospital, Montreal, presented his results during a poster session.

The study involved 10,882 patients and 16,665 stool specimens submitted for toxin testing between January 2001 and March 2008. Dr. Dylewski divided the samples into two time periods to reflect an epidemic of C. difficile–associated diarrhea that began in April 2002.

Overall, the positivity rate of the cytotoxicity assay was 27% during the epidemic and 15% during the nonepidemic period. Among samples that initially tested negative, fewer than 1% changed to positive if tests were repeated within the first day. Repeat testing of negative results yielded positive results in 6% during day 2 and in 3% during day 3.

After day 3, the percentage of positive results after initial negative findings rose to 7%, 9%, 12%, and 13% on days 4, 5, 6, and 7, respectively.

“Repeat testing during the first 3 days is probably not beneficial even during an epidemic,” Dr. Dylewski said in the interview at the meeting, sponsored by the American Society for Microbiology. He was particularly critical of repeat testing on the same day of the initial test, which occurred in 698 cases. It takes about 2 days to return a negative result from the C. difficile cytotoxicity assay, so most of these repeat stool samples were sent to the lab before results from the initial sample could have been received.

He attributed these decisions to an erroneous belief among physicians that a second test always is necessary. But even that doesn't explain why he sometimes received three samples from the same patient within that first day. “The order is 'C. diff. times three,'” he said. “So [the patient has] three bowel movements on the same day, and they send all three [samples] down on the same day.”

Of the 698 cases of same-day repeat testing, the initial test was positive in 225 cases and negative in 473. On repeat testing, no results switched from positive to negative, and only two (0.4%) switched from negative to positive.

“It makes sense to retest after 3 days if the patient is still symptomatic and your index of suspicion is high and you haven't started empiric therapy,” he said.

If, after 3 days, the result is still negative but the index of suspicion remains high, there are two ways to proceed. One is to start empiric therapy, and the other is to refer the patient to colonoscopy.

“It's a little bit different when you're in an epidemic situation … because patients get really sick really quickly,” Dr. Dylewski said. During an epidemic, patients with an initial negative result must be followed closely if the index of suspicion is high. “You still need to follow them, potentially treat empirically, or repeat the test after a certain number of days, because you can be wrong, but it's not often.”

But even during an epidemic, he advised, “it should not be routine to say, 'I'm going to do multiple specimens in order to detect it.'”

Dr. Dylewski reported no conflicts of interest related to his study.

SAN FRANCISCO — A delay in administering adequate antimicrobial therapy is strongly associated with elevated mortality in patients with bloodstream infections, according to a prospective study involving 381 patients.

The association between therapeutic delay and mortality was seen not only in patients with severe sepsis or septic shock, but also in patients with less-severe sepsis or with bloodstream infections not involving systemic inflammatory response syndrome, according to a poster presentation by Dr. Ana Fernández-Cruz at the Interscience Conference on Antimicrobial Agents and Chemotherapy, sponsored by the American Society for Microbiology.

Each hour of delay in administering adequate antimicrobial therapy increased the risk of death by an average of 1.4%, wrote Dr. Fernández-Cruz and her colleagues from the Hospital General Universitario Gregorio Marañón, Madrid. The mean time from blood culture to adequate antimicrobial therapy was 12.9 hours, and the median time was 4.5 hours.

Overall, the initial antibiotic treatment was adequate in 74% of the patients and inadequate in the remaining 26%. The investigators defined adequate antimicrobial therapy as the administration of an antimicrobial to which the microorganism isolated in the blood culture was susceptible in vitro according to the antibiogram.

The study included all patients with a microbiologically significant bloodstream infection at a 1,450-bed tertiary care hospital during a 3-month period. Of the 381 patients, 61% were male; their median age was 64 years, and 72% of their infections were hospital acquired or health care associated.

According to the Bone sepsis score when the blood culture was taken, 68% of the patients had sepsis, 15% had severe sepsis, 7% had septic shock, and 6% had a bloodstream infection without systemic anti-inflammatory response syndrome.

Mortality increased with delay in adequate antimicrobial therapy, irrespective of the severity of sepsis. For example, among patients with severe sepsis, a 20-hour delay corresponded to about 25% mortality, and a 100-hour delay corresponded to about 90% mortality. Among patients with a bloodstream infection without systemic anti-inflammatory response syndrome, mortality was about 10% with a 20-hour delay, and about 40% with a 100-hour delay.

At discharge, 16.5% of the patients had died. In a multivariate analysis, three variables emerged as independent predictors of mortality. For each hour of delay from blood culture to adequate antimicrobial therapy, the risk of death increased by an average of 1.4%. For each one-point increase in the patient's Charlson score, the risk of death increased by a mean of 24%. And for each year of age, the risk of death increased by a mean of 1.9%. The multivariate analysis was adjusted for place of acquisition, McCabe and Jackson classification, Charlson Index, underlying disease, sepsis score, bloodstream infection source, hospital ward, previous length of stay, and previous antimicrobial therapy.

The investigators reported no relevant conflicts of interest.

SAN FRANCISCO — A delay in administering adequate antimicrobial therapy is strongly associated with elevated mortality in patients with bloodstream infections, according to a prospective study involving 381 patients.

The association between therapeutic delay and mortality was seen not only in patients with severe sepsis or septic shock, but also in patients with less-severe sepsis or with bloodstream infections not involving systemic inflammatory response syndrome, according to a poster presentation by Dr. Ana Fernández-Cruz at the Interscience Conference on Antimicrobial Agents and Chemotherapy, sponsored by the American Society for Microbiology.

Each hour of delay in administering adequate antimicrobial therapy increased the risk of death by an average of 1.4%, wrote Dr. Fernández-Cruz and her colleagues from the Hospital General Universitario Gregorio Marañón, Madrid. The mean time from blood culture to adequate antimicrobial therapy was 12.9 hours, and the median time was 4.5 hours.

Overall, the initial antibiotic treatment was adequate in 74% of the patients and inadequate in the remaining 26%. The investigators defined adequate antimicrobial therapy as the administration of an antimicrobial to which the microorganism isolated in the blood culture was susceptible in vitro according to the antibiogram.

The study included all patients with a microbiologically significant bloodstream infection at a 1,450-bed tertiary care hospital during a 3-month period. Of the 381 patients, 61% were male; their median age was 64 years, and 72% of their infections were hospital acquired or health care associated.

According to the Bone sepsis score when the blood culture was taken, 68% of the patients had sepsis, 15% had severe sepsis, 7% had septic shock, and 6% had a bloodstream infection without systemic anti-inflammatory response syndrome.

Mortality increased with delay in adequate antimicrobial therapy, irrespective of the severity of sepsis. For example, among patients with severe sepsis, a 20-hour delay corresponded to about 25% mortality, and a 100-hour delay corresponded to about 90% mortality. Among patients with a bloodstream infection without systemic anti-inflammatory response syndrome, mortality was about 10% with a 20-hour delay, and about 40% with a 100-hour delay.

At discharge, 16.5% of the patients had died. In a multivariate analysis, three variables emerged as independent predictors of mortality. For each hour of delay from blood culture to adequate antimicrobial therapy, the risk of death increased by an average of 1.4%. For each one-point increase in the patient's Charlson score, the risk of death increased by a mean of 24%. And for each year of age, the risk of death increased by a mean of 1.9%. The multivariate analysis was adjusted for place of acquisition, McCabe and Jackson classification, Charlson Index, underlying disease, sepsis score, bloodstream infection source, hospital ward, previous length of stay, and previous antimicrobial therapy.

The investigators reported no relevant conflicts of interest.

SAN FRANCISCO — A delay in administering adequate antimicrobial therapy is strongly associated with elevated mortality in patients with bloodstream infections, according to a prospective study involving 381 patients.

The association between therapeutic delay and mortality was seen not only in patients with severe sepsis or septic shock, but also in patients with less-severe sepsis or with bloodstream infections not involving systemic inflammatory response syndrome, according to a poster presentation by Dr. Ana Fernández-Cruz at the Interscience Conference on Antimicrobial Agents and Chemotherapy, sponsored by the American Society for Microbiology.

Each hour of delay in administering adequate antimicrobial therapy increased the risk of death by an average of 1.4%, wrote Dr. Fernández-Cruz and her colleagues from the Hospital General Universitario Gregorio Marañón, Madrid. The mean time from blood culture to adequate antimicrobial therapy was 12.9 hours, and the median time was 4.5 hours.

Overall, the initial antibiotic treatment was adequate in 74% of the patients and inadequate in the remaining 26%. The investigators defined adequate antimicrobial therapy as the administration of an antimicrobial to which the microorganism isolated in the blood culture was susceptible in vitro according to the antibiogram.

The study included all patients with a microbiologically significant bloodstream infection at a 1,450-bed tertiary care hospital during a 3-month period. Of the 381 patients, 61% were male; their median age was 64 years, and 72% of their infections were hospital acquired or health care associated.

According to the Bone sepsis score when the blood culture was taken, 68% of the patients had sepsis, 15% had severe sepsis, 7% had septic shock, and 6% had a bloodstream infection without systemic anti-inflammatory response syndrome.

Mortality increased with delay in adequate antimicrobial therapy, irrespective of the severity of sepsis. For example, among patients with severe sepsis, a 20-hour delay corresponded to about 25% mortality, and a 100-hour delay corresponded to about 90% mortality. Among patients with a bloodstream infection without systemic anti-inflammatory response syndrome, mortality was about 10% with a 20-hour delay, and about 40% with a 100-hour delay.

At discharge, 16.5% of the patients had died. In a multivariate analysis, three variables emerged as independent predictors of mortality. For each hour of delay from blood culture to adequate antimicrobial therapy, the risk of death increased by an average of 1.4%. For each one-point increase in the patient's Charlson score, the risk of death increased by a mean of 24%. And for each year of age, the risk of death increased by a mean of 1.9%. The multivariate analysis was adjusted for place of acquisition, McCabe and Jackson classification, Charlson Index, underlying disease, sepsis score, bloodstream infection source, hospital ward, previous length of stay, and previous antimicrobial therapy.

The investigators reported no relevant conflicts of interest.