Susan London

Major Finding: Very low-birth-weight infants with symptomatic, postnatally acquired CMV infection had high rates of pneumonitis (73%) and late-onset sepsis (43%).

Data Source: A retrospective cohort study of 34 infants with symptomatic CMV infection.

Disclosures: None was reported.

VANCOUVER, B.C. — Postnatally acquired cytomegalovirus infection can cause severe illness in very low-birth-weight infants in the short term, based on findings from a retrospective study.

Infants in the study who became infected and symptomatic with cytomegalovirus (CMV) infection in the postnatal period had high rates of complications. In fact, their clinical and laboratory findings were similar to those of congenitally infected infants.

“Postnatal CMV infection can cause significant morbidity, and it can potentially lead to [poor] long-term outcomes,” lead investigator Dr. Sarah A. Meyer said in an interview. “It is often something that we don't think about a lot, and we just need to keep it in our mind that if we have babies that present with some of these symptoms, we should be testing them and following their outcomes.”

Much is known about congenitally acquired CMV, according to Dr. Meyer of Children's Hospital Boston. But comparatively little is know about CMV acquired in the postnatal period through breast milk.

Using hospital records for the years 1997-2009, she and her colleagues retrospectively studied 34 infants who had symptomatic, culture-positive CMV infection and were cared for in a neonatal intensive care unit.

Of the infants (all but 1 of whom met criteria for very low birth weight [VLBW]), 22 had been infected postnatally, whereas the other 12 infants (having a range of birth weights) had been infected congenitally.

Compared with their congenitally infected counterparts, the postnatally infected infants had a lower median birth weight (688 vs. 1,500 g), had a younger median gestational age (26 vs. 32 weeks), were older on the day of diagnosis (52.5 vs. 3.5 days of life), and were more likely to have been breastfed (100% vs. 67%). The proportions delivered by cesarean section were similar, she reported in a poster at the meeting.

Among those infected in the postnatal period, the time to CMV diagnosis was correlated with the length of exposure to breast milk (r = 0.84), indicating that the risk of viral transmission persisted with continued exposure. In contrast, the time to CMV diagnosis was not correlated with the day of life on which infants were first fed breast milk.

The most common complications with postnatal infection were pneumonitis (present in 73% of infants), colitis (50%), hepatosplenomegaly (36%), and intracranial findings (27%).

Relative to their congenitally infected counterparts, postnatally infected infants had generally similar clinical findings, but were more likely to have pneumonitis (73% vs. 0%) and less likely to have petechiae and purpura (10% vs. 50%) and retinitis (0% vs. 25%).

The two groups were also similar in rates of hematologic and cerebrospinal fluid laboratory abnormalities, presence of cerebrospinal fluid CMV positivity by polymerase chain reaction testing, and median blood CMV viral load.

Among the 15 infants overall with neurologic follow-up, the rate of hearing loss was 71% in those congenitally infected, compared with 13% in those postnatally infected, with numbers too small to permit statistical comparison. Rates of developmental delay and cerebral palsy were similar, although these sequelae in the postnatally infected infants also could have been related to their prematurity, noted Dr. Meyer.

A final analysis did suggest that symptomatic postnatal CMV infection may add substantial morbidity above and beyond that due to having a very low birth weight, she said.

Compared with 1,226 infants from the general VLBW population, the VLBW infants with postnatal cytomegalovirus infection had a higher rate of bronchopulmonary dysplasia (81% vs. 16%) and late-onset sepsis (43% vs. 18%). Rates of necrotizing enterocolitis and intraventricular hemorrhage did not differ significantly between the groups.

Major Finding: Very low-birth-weight infants with symptomatic, postnatally acquired CMV infection had high rates of pneumonitis (73%) and late-onset sepsis (43%).

Data Source: A retrospective cohort study of 34 infants with symptomatic CMV infection.

Disclosures: None was reported.

VANCOUVER, B.C. — Postnatally acquired cytomegalovirus infection can cause severe illness in very low-birth-weight infants in the short term, based on findings from a retrospective study.

Infants in the study who became infected and symptomatic with cytomegalovirus (CMV) infection in the postnatal period had high rates of complications. In fact, their clinical and laboratory findings were similar to those of congenitally infected infants.

“Postnatal CMV infection can cause significant morbidity, and it can potentially lead to [poor] long-term outcomes,” lead investigator Dr. Sarah A. Meyer said in an interview. “It is often something that we don't think about a lot, and we just need to keep it in our mind that if we have babies that present with some of these symptoms, we should be testing them and following their outcomes.”

Much is known about congenitally acquired CMV, according to Dr. Meyer of Children's Hospital Boston. But comparatively little is know about CMV acquired in the postnatal period through breast milk.

Using hospital records for the years 1997-2009, she and her colleagues retrospectively studied 34 infants who had symptomatic, culture-positive CMV infection and were cared for in a neonatal intensive care unit.

Of the infants (all but 1 of whom met criteria for very low birth weight [VLBW]), 22 had been infected postnatally, whereas the other 12 infants (having a range of birth weights) had been infected congenitally.

Compared with their congenitally infected counterparts, the postnatally infected infants had a lower median birth weight (688 vs. 1,500 g), had a younger median gestational age (26 vs. 32 weeks), were older on the day of diagnosis (52.5 vs. 3.5 days of life), and were more likely to have been breastfed (100% vs. 67%). The proportions delivered by cesarean section were similar, she reported in a poster at the meeting.

Among those infected in the postnatal period, the time to CMV diagnosis was correlated with the length of exposure to breast milk (r = 0.84), indicating that the risk of viral transmission persisted with continued exposure. In contrast, the time to CMV diagnosis was not correlated with the day of life on which infants were first fed breast milk.

The most common complications with postnatal infection were pneumonitis (present in 73% of infants), colitis (50%), hepatosplenomegaly (36%), and intracranial findings (27%).

Relative to their congenitally infected counterparts, postnatally infected infants had generally similar clinical findings, but were more likely to have pneumonitis (73% vs. 0%) and less likely to have petechiae and purpura (10% vs. 50%) and retinitis (0% vs. 25%).

The two groups were also similar in rates of hematologic and cerebrospinal fluid laboratory abnormalities, presence of cerebrospinal fluid CMV positivity by polymerase chain reaction testing, and median blood CMV viral load.

Among the 15 infants overall with neurologic follow-up, the rate of hearing loss was 71% in those congenitally infected, compared with 13% in those postnatally infected, with numbers too small to permit statistical comparison. Rates of developmental delay and cerebral palsy were similar, although these sequelae in the postnatally infected infants also could have been related to their prematurity, noted Dr. Meyer.

A final analysis did suggest that symptomatic postnatal CMV infection may add substantial morbidity above and beyond that due to having a very low birth weight, she said.

Compared with 1,226 infants from the general VLBW population, the VLBW infants with postnatal cytomegalovirus infection had a higher rate of bronchopulmonary dysplasia (81% vs. 16%) and late-onset sepsis (43% vs. 18%). Rates of necrotizing enterocolitis and intraventricular hemorrhage did not differ significantly between the groups.

Major Finding: Very low-birth-weight infants with symptomatic, postnatally acquired CMV infection had high rates of pneumonitis (73%) and late-onset sepsis (43%).

Data Source: A retrospective cohort study of 34 infants with symptomatic CMV infection.

Disclosures: None was reported.

VANCOUVER, B.C. — Postnatally acquired cytomegalovirus infection can cause severe illness in very low-birth-weight infants in the short term, based on findings from a retrospective study.

Infants in the study who became infected and symptomatic with cytomegalovirus (CMV) infection in the postnatal period had high rates of complications. In fact, their clinical and laboratory findings were similar to those of congenitally infected infants.

“Postnatal CMV infection can cause significant morbidity, and it can potentially lead to [poor] long-term outcomes,” lead investigator Dr. Sarah A. Meyer said in an interview. “It is often something that we don't think about a lot, and we just need to keep it in our mind that if we have babies that present with some of these symptoms, we should be testing them and following their outcomes.”

Much is known about congenitally acquired CMV, according to Dr. Meyer of Children's Hospital Boston. But comparatively little is know about CMV acquired in the postnatal period through breast milk.

Using hospital records for the years 1997-2009, she and her colleagues retrospectively studied 34 infants who had symptomatic, culture-positive CMV infection and were cared for in a neonatal intensive care unit.

Of the infants (all but 1 of whom met criteria for very low birth weight [VLBW]), 22 had been infected postnatally, whereas the other 12 infants (having a range of birth weights) had been infected congenitally.

Compared with their congenitally infected counterparts, the postnatally infected infants had a lower median birth weight (688 vs. 1,500 g), had a younger median gestational age (26 vs. 32 weeks), were older on the day of diagnosis (52.5 vs. 3.5 days of life), and were more likely to have been breastfed (100% vs. 67%). The proportions delivered by cesarean section were similar, she reported in a poster at the meeting.

Among those infected in the postnatal period, the time to CMV diagnosis was correlated with the length of exposure to breast milk (r = 0.84), indicating that the risk of viral transmission persisted with continued exposure. In contrast, the time to CMV diagnosis was not correlated with the day of life on which infants were first fed breast milk.

The most common complications with postnatal infection were pneumonitis (present in 73% of infants), colitis (50%), hepatosplenomegaly (36%), and intracranial findings (27%).

Relative to their congenitally infected counterparts, postnatally infected infants had generally similar clinical findings, but were more likely to have pneumonitis (73% vs. 0%) and less likely to have petechiae and purpura (10% vs. 50%) and retinitis (0% vs. 25%).

The two groups were also similar in rates of hematologic and cerebrospinal fluid laboratory abnormalities, presence of cerebrospinal fluid CMV positivity by polymerase chain reaction testing, and median blood CMV viral load.

Among the 15 infants overall with neurologic follow-up, the rate of hearing loss was 71% in those congenitally infected, compared with 13% in those postnatally infected, with numbers too small to permit statistical comparison. Rates of developmental delay and cerebral palsy were similar, although these sequelae in the postnatally infected infants also could have been related to their prematurity, noted Dr. Meyer.

A final analysis did suggest that symptomatic postnatal CMV infection may add substantial morbidity above and beyond that due to having a very low birth weight, she said.

Compared with 1,226 infants from the general VLBW population, the VLBW infants with postnatal cytomegalovirus infection had a higher rate of bronchopulmonary dysplasia (81% vs. 16%) and late-onset sepsis (43% vs. 18%). Rates of necrotizing enterocolitis and intraventricular hemorrhage did not differ significantly between the groups.

Major Finding: Percentage of participants doing skin self-exams at least monthly remained the same among those with a history of melanoma who were mutation carriers (73%) and doubled among unaffected mutation carriers (from 30% to 60%), but increased only slightly among noncarriers (from 38% to 44%).

Data Source: Prospective, 2-year longitudinal study among 37 individuals at high risk for melanoma.

Disclosures: Ms. Taber reported that she had no conflicts of interest related to the study.

SEATTLE — The impact of genetic testing on skin self-examination behavior among individuals at high risk for melanoma varies with personal history of the disease and test results, according to the first prospective study of this issue in a tested population.

Of 37 individuals at high risk for melanoma because of family history, those who had previously had the disease and who learned that they carried a mutation that sharply increased risk did not alter their skin self-exam behavior. Both before testing and 2 years afterward, 73% were doing these exams about every month, as is recommended, or more often.

Individuals who had not had melanoma but who learned that they carried the mutation stepped up their skin self-exam behavior: Only 30% were doing these exams at least monthly before testing, but 60% were doing so 2 years afterward.

“Researchers and genetic counselors believe that learning one's objective risk will actually motivate behavior change,” said lead investigator Jennifer M. Taber.

There are several concerns, however.

“One is that individuals who test negative will feel that their risk is so low that they don't need to engage in prevention or screening behaviors anymore, that they might feel a false sense of security and not change their behavior,” she explained.

“Another concern is that for those who test positive, they will feel a sense of fatalism—that there is nothing they can do, their risk is so high anyway, so why bother engaging in the behaviors,” she added.

Ms. Taber, a graduate student in psychology at the University of Utah in Salt Lake City, and her coinvestigators studied 37 adults from families with very high rates of melanoma. All underwent genetic testing for the p16 mutation, which sharply increases melanoma risk, and were followed for 2 years.

Nearly a third (30%) of participants were affected carriers, meaning they had a history of melanoma and had the mutation; 27% were unaffected carriers, meaning they did not have a history of the disease and did have the mutation; and 43% were noncarriers who did not have a history of the disease and did not have the mutation.

Monthly skin self-exams are recommended for all individuals from families with high rates of melanoma, regardless of their genetic test results, Ms. Taber noted, because even those with a negative result have a lifetime probability of the disease twice that of the general population.

The investigators classified the participants' skin self-exam behavior, according to the number of these exams performed in a 6-month period, as being on target (four to eight exams); overscreening (more than eight), which may actually hamper detection of changes; and underscreening (fewer than four), which may lead to missed lesions.

Two years after testing, the percentage of participants who were either on target or overscreening remained at the same high baseline level among affected carriers (73%) and had doubled among unaffected carriers (from 30% to 60%), but had increased only slightly among noncarriers (from 38% to 44%), Ms. Taber reported.

When the results were viewed another way, the percentage of participants who improved their skin self-exam practice during the 2-year period—to comply with the once-a-month recommendation—was 46% in the affected carrier group, 60% in the unaffected carrier group, and 25% in the noncarrier group.

In a subanalysis of the noncarriers, those who were underscreening at 2 years gave as their reason being busy or forgetful, feeling unqualified to perform the exams, and/or believing that their risk was not high enough, Ms. Taber reported.

The consistent finding of a link between an improvement in self-exam behavior and perceived control over detecting melanoma early has implications for strategies to increase this behavior, Ms. Taber said.

The barriers cited by noncarriers who were underscreening provide valuable insight specifically for individuals having negative genetic test results, she said

Perhaps counseling sessions should “target perceived importance of skin self-exams to make sure that individuals realize that their risk is high enough that they should be performing these behaviors, and perhaps do something like reminder or booster sessions for these individuals,” she said.

Major Finding: Percentage of participants doing skin self-exams at least monthly remained the same among those with a history of melanoma who were mutation carriers (73%) and doubled among unaffected mutation carriers (from 30% to 60%), but increased only slightly among noncarriers (from 38% to 44%).

Data Source: Prospective, 2-year longitudinal study among 37 individuals at high risk for melanoma.

Disclosures: Ms. Taber reported that she had no conflicts of interest related to the study.

SEATTLE — The impact of genetic testing on skin self-examination behavior among individuals at high risk for melanoma varies with personal history of the disease and test results, according to the first prospective study of this issue in a tested population.

Of 37 individuals at high risk for melanoma because of family history, those who had previously had the disease and who learned that they carried a mutation that sharply increased risk did not alter their skin self-exam behavior. Both before testing and 2 years afterward, 73% were doing these exams about every month, as is recommended, or more often.

Individuals who had not had melanoma but who learned that they carried the mutation stepped up their skin self-exam behavior: Only 30% were doing these exams at least monthly before testing, but 60% were doing so 2 years afterward.

“Researchers and genetic counselors believe that learning one's objective risk will actually motivate behavior change,” said lead investigator Jennifer M. Taber.

There are several concerns, however.

“One is that individuals who test negative will feel that their risk is so low that they don't need to engage in prevention or screening behaviors anymore, that they might feel a false sense of security and not change their behavior,” she explained.

“Another concern is that for those who test positive, they will feel a sense of fatalism—that there is nothing they can do, their risk is so high anyway, so why bother engaging in the behaviors,” she added.

Ms. Taber, a graduate student in psychology at the University of Utah in Salt Lake City, and her coinvestigators studied 37 adults from families with very high rates of melanoma. All underwent genetic testing for the p16 mutation, which sharply increases melanoma risk, and were followed for 2 years.

Nearly a third (30%) of participants were affected carriers, meaning they had a history of melanoma and had the mutation; 27% were unaffected carriers, meaning they did not have a history of the disease and did have the mutation; and 43% were noncarriers who did not have a history of the disease and did not have the mutation.

Monthly skin self-exams are recommended for all individuals from families with high rates of melanoma, regardless of their genetic test results, Ms. Taber noted, because even those with a negative result have a lifetime probability of the disease twice that of the general population.

The investigators classified the participants' skin self-exam behavior, according to the number of these exams performed in a 6-month period, as being on target (four to eight exams); overscreening (more than eight), which may actually hamper detection of changes; and underscreening (fewer than four), which may lead to missed lesions.

Two years after testing, the percentage of participants who were either on target or overscreening remained at the same high baseline level among affected carriers (73%) and had doubled among unaffected carriers (from 30% to 60%), but had increased only slightly among noncarriers (from 38% to 44%), Ms. Taber reported.

When the results were viewed another way, the percentage of participants who improved their skin self-exam practice during the 2-year period—to comply with the once-a-month recommendation—was 46% in the affected carrier group, 60% in the unaffected carrier group, and 25% in the noncarrier group.

In a subanalysis of the noncarriers, those who were underscreening at 2 years gave as their reason being busy or forgetful, feeling unqualified to perform the exams, and/or believing that their risk was not high enough, Ms. Taber reported.

The consistent finding of a link between an improvement in self-exam behavior and perceived control over detecting melanoma early has implications for strategies to increase this behavior, Ms. Taber said.

The barriers cited by noncarriers who were underscreening provide valuable insight specifically for individuals having negative genetic test results, she said

Perhaps counseling sessions should “target perceived importance of skin self-exams to make sure that individuals realize that their risk is high enough that they should be performing these behaviors, and perhaps do something like reminder or booster sessions for these individuals,” she said.

Major Finding: Percentage of participants doing skin self-exams at least monthly remained the same among those with a history of melanoma who were mutation carriers (73%) and doubled among unaffected mutation carriers (from 30% to 60%), but increased only slightly among noncarriers (from 38% to 44%).

Data Source: Prospective, 2-year longitudinal study among 37 individuals at high risk for melanoma.

Disclosures: Ms. Taber reported that she had no conflicts of interest related to the study.

SEATTLE — The impact of genetic testing on skin self-examination behavior among individuals at high risk for melanoma varies with personal history of the disease and test results, according to the first prospective study of this issue in a tested population.

Of 37 individuals at high risk for melanoma because of family history, those who had previously had the disease and who learned that they carried a mutation that sharply increased risk did not alter their skin self-exam behavior. Both before testing and 2 years afterward, 73% were doing these exams about every month, as is recommended, or more often.

Individuals who had not had melanoma but who learned that they carried the mutation stepped up their skin self-exam behavior: Only 30% were doing these exams at least monthly before testing, but 60% were doing so 2 years afterward.

“Researchers and genetic counselors believe that learning one's objective risk will actually motivate behavior change,” said lead investigator Jennifer M. Taber.

There are several concerns, however.

“One is that individuals who test negative will feel that their risk is so low that they don't need to engage in prevention or screening behaviors anymore, that they might feel a false sense of security and not change their behavior,” she explained.

“Another concern is that for those who test positive, they will feel a sense of fatalism—that there is nothing they can do, their risk is so high anyway, so why bother engaging in the behaviors,” she added.

Ms. Taber, a graduate student in psychology at the University of Utah in Salt Lake City, and her coinvestigators studied 37 adults from families with very high rates of melanoma. All underwent genetic testing for the p16 mutation, which sharply increases melanoma risk, and were followed for 2 years.

Nearly a third (30%) of participants were affected carriers, meaning they had a history of melanoma and had the mutation; 27% were unaffected carriers, meaning they did not have a history of the disease and did have the mutation; and 43% were noncarriers who did not have a history of the disease and did not have the mutation.

Monthly skin self-exams are recommended for all individuals from families with high rates of melanoma, regardless of their genetic test results, Ms. Taber noted, because even those with a negative result have a lifetime probability of the disease twice that of the general population.

The investigators classified the participants' skin self-exam behavior, according to the number of these exams performed in a 6-month period, as being on target (four to eight exams); overscreening (more than eight), which may actually hamper detection of changes; and underscreening (fewer than four), which may lead to missed lesions.

Two years after testing, the percentage of participants who were either on target or overscreening remained at the same high baseline level among affected carriers (73%) and had doubled among unaffected carriers (from 30% to 60%), but had increased only slightly among noncarriers (from 38% to 44%), Ms. Taber reported.

When the results were viewed another way, the percentage of participants who improved their skin self-exam practice during the 2-year period—to comply with the once-a-month recommendation—was 46% in the affected carrier group, 60% in the unaffected carrier group, and 25% in the noncarrier group.

In a subanalysis of the noncarriers, those who were underscreening at 2 years gave as their reason being busy or forgetful, feeling unqualified to perform the exams, and/or believing that their risk was not high enough, Ms. Taber reported.

The consistent finding of a link between an improvement in self-exam behavior and perceived control over detecting melanoma early has implications for strategies to increase this behavior, Ms. Taber said.

The barriers cited by noncarriers who were underscreening provide valuable insight specifically for individuals having negative genetic test results, she said

Perhaps counseling sessions should “target perceived importance of skin self-exams to make sure that individuals realize that their risk is high enough that they should be performing these behaviors, and perhaps do something like reminder or booster sessions for these individuals,” she said.

Major Finding: Perceived burdensomeness was independently associated with suicidal ideation among patients with chronic pain, and a model including this measure correctly classified 95% of patients as to the presence or absence of suicide ideation.

Data Source: A retrospective study of 109 patients in a military population with chronic pain referred to a psychology clinic.

Disclosures: Dr. Kanzler reported that she had no conflicts of interest related to the study.

SEATTLE — Asking patients with chronic pain a single question—“Do you believe it would be better for everyone involved if you were to die?”—can determine whether he or she is having suicidal thoughts or wishes, findings from a retrospective study suggest.

Among 109 patients with chronic pain, patients' perceptions that they were a burden to others as assessed with this question was the sole independent predictor of suicide ideation even after depression and hopelessness were taken into account.

A model including perceived burdensomeness, in addition to conventional risk factors, correctly classified 95% of the patients regarding the presence or absence of suicide ideation.

“It's important to consider perceived burdensomeness in the patients that you see,” advised lead investigator Kathryn E. Kanzler, Psy.D., who is a captain in the U.S. Air Force and a psychologist at Lackland Air Force Base in San Antonio.

“Just one question—that's all it takes to get kind of a quick snapshot of what's going on.”

Patients with chronic conditions may be uniquely attuned to the impact of their health on their caregivers, Dr. Kanzler told attendees of the annual meeting of the Society of Behavioral Medicine.

“Research has found that self-perceived burden … can have a direct impact on significant medical decision making,” she said, such as choosing to reduce or entirely skip dialysis.

In the study, she and her colleagues reviewed the medical records of 109 outpatients with chronic pain who were referred to a psychology clinic for evaluation and possible behavioral and psychosocial interventions. All were active or retired military personnel, or their dependents or family members.

The patients were age 42 years on average. The majority were married (72%), female (65%), and white (66%).

The leading primary cause of pain was headache/migraine (seen in 28% of patients), followed by chronic low back pain (16%), fibromyalgia (13%), temporomandibular or myofascial pain (9%), arthritis (3%), and complex regional pain syndrome (1%). The remaining patients (30%) had pain secondary to other conditions, such as cancer or orthopedic injuries.

The investigators used responses on the Beck Depression Inventory–Second Edition (BDI-II) to assess patients' hopelessness, suicide ideation, and depression.

Perceived burdensomeness was assessed from responses to a single statement, “It would be better for everyone involved if I were to die,” with possible response options ranging from 1 (never or none of the time) to 5 (always or a great many times).

Overall, 7% of patients were found to have suicide ideation, Dr. Kanzler reported. A logistic regression model including age, sex, race, marital status, depression, and hopelessness improved the ability to predict suicide ideation above a null model.

Adding patients' perceived burdensomeness to this model further improved the ability to predict suicide ideation and also improved model fit.

When controlling for depression and hopelessness, perceived burdensomeness was the sole independent predictor of suicide ideation.

There was no difference in the findings between patients who did and did not have an identified caregiver, a finding that corroborated those from other studies suggesting that perceived burdensomeness may apply to the people who are important in one's life generally.

Perceived burdensomeness performed better at correctly classifying patients without suicide ideation (98%) than at correctly classifying those with suicide ideation (63%).

“We hope this study adds to the understanding of the really complex relationship between chronic pain and suicide ideation,” Dr. Kanzler said. “Perceived burdensomeness as a risk factor might help explain high rates of suicide ideation beyond the types of things that definitely, immediately come to mind.”

Importantly, she noted, perceived burdensomeness is modifiable, in contrast to many other risk factors for suicide ideation, such as age and sex. “Some kind of a cognitive intervention might be useful,” she proposed, such as intervening to change the meaning of the cognition of perceived burdensomeness.

Encouraging increased communication with the key people in a patient's life may also be beneficial, according to Dr. Kanzler. “Sometimes, especially in our population, there is not necessarily an identified caregiver, but this perceived burdensomeness kind of affects the whole group that surrounds that person,” she explained.

Major Finding: Perceived burdensomeness was independently associated with suicidal ideation among patients with chronic pain, and a model including this measure correctly classified 95% of patients as to the presence or absence of suicide ideation.

Data Source: A retrospective study of 109 patients in a military population with chronic pain referred to a psychology clinic.

Disclosures: Dr. Kanzler reported that she had no conflicts of interest related to the study.

SEATTLE — Asking patients with chronic pain a single question—“Do you believe it would be better for everyone involved if you were to die?”—can determine whether he or she is having suicidal thoughts or wishes, findings from a retrospective study suggest.

Among 109 patients with chronic pain, patients' perceptions that they were a burden to others as assessed with this question was the sole independent predictor of suicide ideation even after depression and hopelessness were taken into account.

A model including perceived burdensomeness, in addition to conventional risk factors, correctly classified 95% of the patients regarding the presence or absence of suicide ideation.

“It's important to consider perceived burdensomeness in the patients that you see,” advised lead investigator Kathryn E. Kanzler, Psy.D., who is a captain in the U.S. Air Force and a psychologist at Lackland Air Force Base in San Antonio.

“Just one question—that's all it takes to get kind of a quick snapshot of what's going on.”

Patients with chronic conditions may be uniquely attuned to the impact of their health on their caregivers, Dr. Kanzler told attendees of the annual meeting of the Society of Behavioral Medicine.

“Research has found that self-perceived burden … can have a direct impact on significant medical decision making,” she said, such as choosing to reduce or entirely skip dialysis.

In the study, she and her colleagues reviewed the medical records of 109 outpatients with chronic pain who were referred to a psychology clinic for evaluation and possible behavioral and psychosocial interventions. All were active or retired military personnel, or their dependents or family members.

The patients were age 42 years on average. The majority were married (72%), female (65%), and white (66%).

The leading primary cause of pain was headache/migraine (seen in 28% of patients), followed by chronic low back pain (16%), fibromyalgia (13%), temporomandibular or myofascial pain (9%), arthritis (3%), and complex regional pain syndrome (1%). The remaining patients (30%) had pain secondary to other conditions, such as cancer or orthopedic injuries.

The investigators used responses on the Beck Depression Inventory–Second Edition (BDI-II) to assess patients' hopelessness, suicide ideation, and depression.

Perceived burdensomeness was assessed from responses to a single statement, “It would be better for everyone involved if I were to die,” with possible response options ranging from 1 (never or none of the time) to 5 (always or a great many times).

Overall, 7% of patients were found to have suicide ideation, Dr. Kanzler reported. A logistic regression model including age, sex, race, marital status, depression, and hopelessness improved the ability to predict suicide ideation above a null model.

Adding patients' perceived burdensomeness to this model further improved the ability to predict suicide ideation and also improved model fit.

When controlling for depression and hopelessness, perceived burdensomeness was the sole independent predictor of suicide ideation.

There was no difference in the findings between patients who did and did not have an identified caregiver, a finding that corroborated those from other studies suggesting that perceived burdensomeness may apply to the people who are important in one's life generally.

Perceived burdensomeness performed better at correctly classifying patients without suicide ideation (98%) than at correctly classifying those with suicide ideation (63%).

“We hope this study adds to the understanding of the really complex relationship between chronic pain and suicide ideation,” Dr. Kanzler said. “Perceived burdensomeness as a risk factor might help explain high rates of suicide ideation beyond the types of things that definitely, immediately come to mind.”

Importantly, she noted, perceived burdensomeness is modifiable, in contrast to many other risk factors for suicide ideation, such as age and sex. “Some kind of a cognitive intervention might be useful,” she proposed, such as intervening to change the meaning of the cognition of perceived burdensomeness.

Encouraging increased communication with the key people in a patient's life may also be beneficial, according to Dr. Kanzler. “Sometimes, especially in our population, there is not necessarily an identified caregiver, but this perceived burdensomeness kind of affects the whole group that surrounds that person,” she explained.

Major Finding: Perceived burdensomeness was independently associated with suicidal ideation among patients with chronic pain, and a model including this measure correctly classified 95% of patients as to the presence or absence of suicide ideation.

Data Source: A retrospective study of 109 patients in a military population with chronic pain referred to a psychology clinic.

Disclosures: Dr. Kanzler reported that she had no conflicts of interest related to the study.

SEATTLE — Asking patients with chronic pain a single question—“Do you believe it would be better for everyone involved if you were to die?”—can determine whether he or she is having suicidal thoughts or wishes, findings from a retrospective study suggest.

Among 109 patients with chronic pain, patients' perceptions that they were a burden to others as assessed with this question was the sole independent predictor of suicide ideation even after depression and hopelessness were taken into account.

A model including perceived burdensomeness, in addition to conventional risk factors, correctly classified 95% of the patients regarding the presence or absence of suicide ideation.

“It's important to consider perceived burdensomeness in the patients that you see,” advised lead investigator Kathryn E. Kanzler, Psy.D., who is a captain in the U.S. Air Force and a psychologist at Lackland Air Force Base in San Antonio.

“Just one question—that's all it takes to get kind of a quick snapshot of what's going on.”

Patients with chronic conditions may be uniquely attuned to the impact of their health on their caregivers, Dr. Kanzler told attendees of the annual meeting of the Society of Behavioral Medicine.

“Research has found that self-perceived burden … can have a direct impact on significant medical decision making,” she said, such as choosing to reduce or entirely skip dialysis.

In the study, she and her colleagues reviewed the medical records of 109 outpatients with chronic pain who were referred to a psychology clinic for evaluation and possible behavioral and psychosocial interventions. All were active or retired military personnel, or their dependents or family members.

The patients were age 42 years on average. The majority were married (72%), female (65%), and white (66%).

The leading primary cause of pain was headache/migraine (seen in 28% of patients), followed by chronic low back pain (16%), fibromyalgia (13%), temporomandibular or myofascial pain (9%), arthritis (3%), and complex regional pain syndrome (1%). The remaining patients (30%) had pain secondary to other conditions, such as cancer or orthopedic injuries.

The investigators used responses on the Beck Depression Inventory–Second Edition (BDI-II) to assess patients' hopelessness, suicide ideation, and depression.

Perceived burdensomeness was assessed from responses to a single statement, “It would be better for everyone involved if I were to die,” with possible response options ranging from 1 (never or none of the time) to 5 (always or a great many times).

Overall, 7% of patients were found to have suicide ideation, Dr. Kanzler reported. A logistic regression model including age, sex, race, marital status, depression, and hopelessness improved the ability to predict suicide ideation above a null model.

Adding patients' perceived burdensomeness to this model further improved the ability to predict suicide ideation and also improved model fit.

When controlling for depression and hopelessness, perceived burdensomeness was the sole independent predictor of suicide ideation.

There was no difference in the findings between patients who did and did not have an identified caregiver, a finding that corroborated those from other studies suggesting that perceived burdensomeness may apply to the people who are important in one's life generally.

Perceived burdensomeness performed better at correctly classifying patients without suicide ideation (98%) than at correctly classifying those with suicide ideation (63%).

“We hope this study adds to the understanding of the really complex relationship between chronic pain and suicide ideation,” Dr. Kanzler said. “Perceived burdensomeness as a risk factor might help explain high rates of suicide ideation beyond the types of things that definitely, immediately come to mind.”

Importantly, she noted, perceived burdensomeness is modifiable, in contrast to many other risk factors for suicide ideation, such as age and sex. “Some kind of a cognitive intervention might be useful,” she proposed, such as intervening to change the meaning of the cognition of perceived burdensomeness.

Encouraging increased communication with the key people in a patient's life may also be beneficial, according to Dr. Kanzler. “Sometimes, especially in our population, there is not necessarily an identified caregiver, but this perceived burdensomeness kind of affects the whole group that surrounds that person,” she explained.

Major Finding: Women undergoing angiography who rated their health as fair or poor had twice the risk of CVD events and death as peers who rated their health as very good or excellent even after objective measures of health were taken into account.

Data Source: Observational study of 900 participants in the Women's Ischemia Syndrome Evaluation.

Disclosures: Dr. Rutledge reported that he had no conflicts of interest related to the study.

SEATTLE — Women undergoing angiography who rated their health as fair or poor had twice the risk of cardiovascular events and death, compared with women who rated their health as good or excellent, new data show.

Providers should be alert to the possibility of adverse events in such women, even when they appear relatively healthy by objective criteria, according to a study of 900 women undergoing coronary angiography in which nearly 4 in 10 self-rated their health as fair or poor.

This association appeared to be largely attributable to the women's functional capacity, assessed on a scale ranging from the ability to perform simple self-care tasks to the ability to participate in strenuous sports.

“In a clinical population … we observed evidence that not only are poor and fair self-rated health strongly associated with clinical outcomes, but they are common,” said lead investigator Thomas Rutledge, Ph.D. “This suggests that there is a large population of care-seeking patients out there for whom self-rated health is rarely assessed but is potentially quite important to understanding their actual healthiness.”

He and his colleagues analyzed data from the Women's Ischemia Syndrome Evaluation (WISE), a multicenter study of women undergoing coronary angiography because of symptoms of myo-cardial ischemia.

At baseline, the women were asked to rate their health using a five-category classification: poor, fair, good, very good, or excellent.

Study investigators collected numerous objective measures of health: CVD risk factors (diabetes, body mass index, dyslipidemia, hypertension, current smoking status), coronary artery disease severity score (assessed from angiography), and demographic factors (age, education, and race).

They also collected dimensions related to the subjective experience of symptoms: mental health treatment (assessed from self-reported current use of antidepressants and anxiolytics), cardiac symptoms, and functional capacity (assessed with the Duke Activity Status Index [DASI]).

The 900 women with complete data had a median follow-up of 5.9 years, according to Dr. Rutledge, associate professor in residence at the University of California, San Diego.

They were an average age of 60 years, and 17% were of minority races/ethnicities. Most (80%) had at least a high school education. About 40% had significant coronary artery disease, defined as the presence of stenosis of at least 50% on angiography.

Overall, 10% of the women rated their health as poor, 29% as fair, 35% as good, 19% as very good, and 6% as excellent.

The combined rate of CVD events (myocardial infarction, stroke, heart failure) and death for these groups was 39%, 24%, 21%, 11%, and 8%, respectively.

With the exception of coronary artery disease severity score, all of the objective and subjective measures studied varied significantly across the five categories of self-rated health.

After adjustment for demographic and CVD risk factors, women with fair self-rated health had a 2.0-fold increased risk of CVD events and death and women with poor self-rated health had a 2.1-fold increased risk compared with their counterparts who had very good or excellent self-rated health combined.

The findings were essentially the same after additional adjustment for use of antidepressants or anxiolytics, or for cardiac symptoms. In contrast, the associations were no longer significant after additional adjustment for functional status, as assessed with DASI scores.

Self-rated health seems to capture more than is typically measured during an office visit and it can be easily assessed with a single question, Dr. Rutledge said.

Major Finding: Women undergoing angiography who rated their health as fair or poor had twice the risk of CVD events and death as peers who rated their health as very good or excellent even after objective measures of health were taken into account.

Data Source: Observational study of 900 participants in the Women's Ischemia Syndrome Evaluation.

Disclosures: Dr. Rutledge reported that he had no conflicts of interest related to the study.

SEATTLE — Women undergoing angiography who rated their health as fair or poor had twice the risk of cardiovascular events and death, compared with women who rated their health as good or excellent, new data show.

Providers should be alert to the possibility of adverse events in such women, even when they appear relatively healthy by objective criteria, according to a study of 900 women undergoing coronary angiography in which nearly 4 in 10 self-rated their health as fair or poor.

This association appeared to be largely attributable to the women's functional capacity, assessed on a scale ranging from the ability to perform simple self-care tasks to the ability to participate in strenuous sports.

“In a clinical population … we observed evidence that not only are poor and fair self-rated health strongly associated with clinical outcomes, but they are common,” said lead investigator Thomas Rutledge, Ph.D. “This suggests that there is a large population of care-seeking patients out there for whom self-rated health is rarely assessed but is potentially quite important to understanding their actual healthiness.”

He and his colleagues analyzed data from the Women's Ischemia Syndrome Evaluation (WISE), a multicenter study of women undergoing coronary angiography because of symptoms of myo-cardial ischemia.

At baseline, the women were asked to rate their health using a five-category classification: poor, fair, good, very good, or excellent.

Study investigators collected numerous objective measures of health: CVD risk factors (diabetes, body mass index, dyslipidemia, hypertension, current smoking status), coronary artery disease severity score (assessed from angiography), and demographic factors (age, education, and race).

They also collected dimensions related to the subjective experience of symptoms: mental health treatment (assessed from self-reported current use of antidepressants and anxiolytics), cardiac symptoms, and functional capacity (assessed with the Duke Activity Status Index [DASI]).

The 900 women with complete data had a median follow-up of 5.9 years, according to Dr. Rutledge, associate professor in residence at the University of California, San Diego.

They were an average age of 60 years, and 17% were of minority races/ethnicities. Most (80%) had at least a high school education. About 40% had significant coronary artery disease, defined as the presence of stenosis of at least 50% on angiography.

Overall, 10% of the women rated their health as poor, 29% as fair, 35% as good, 19% as very good, and 6% as excellent.

The combined rate of CVD events (myocardial infarction, stroke, heart failure) and death for these groups was 39%, 24%, 21%, 11%, and 8%, respectively.

With the exception of coronary artery disease severity score, all of the objective and subjective measures studied varied significantly across the five categories of self-rated health.

After adjustment for demographic and CVD risk factors, women with fair self-rated health had a 2.0-fold increased risk of CVD events and death and women with poor self-rated health had a 2.1-fold increased risk compared with their counterparts who had very good or excellent self-rated health combined.

The findings were essentially the same after additional adjustment for use of antidepressants or anxiolytics, or for cardiac symptoms. In contrast, the associations were no longer significant after additional adjustment for functional status, as assessed with DASI scores.

Self-rated health seems to capture more than is typically measured during an office visit and it can be easily assessed with a single question, Dr. Rutledge said.

Major Finding: Women undergoing angiography who rated their health as fair or poor had twice the risk of CVD events and death as peers who rated their health as very good or excellent even after objective measures of health were taken into account.

Data Source: Observational study of 900 participants in the Women's Ischemia Syndrome Evaluation.

Disclosures: Dr. Rutledge reported that he had no conflicts of interest related to the study.

SEATTLE — Women undergoing angiography who rated their health as fair or poor had twice the risk of cardiovascular events and death, compared with women who rated their health as good or excellent, new data show.

Providers should be alert to the possibility of adverse events in such women, even when they appear relatively healthy by objective criteria, according to a study of 900 women undergoing coronary angiography in which nearly 4 in 10 self-rated their health as fair or poor.

This association appeared to be largely attributable to the women's functional capacity, assessed on a scale ranging from the ability to perform simple self-care tasks to the ability to participate in strenuous sports.

“In a clinical population … we observed evidence that not only are poor and fair self-rated health strongly associated with clinical outcomes, but they are common,” said lead investigator Thomas Rutledge, Ph.D. “This suggests that there is a large population of care-seeking patients out there for whom self-rated health is rarely assessed but is potentially quite important to understanding their actual healthiness.”

He and his colleagues analyzed data from the Women's Ischemia Syndrome Evaluation (WISE), a multicenter study of women undergoing coronary angiography because of symptoms of myo-cardial ischemia.

At baseline, the women were asked to rate their health using a five-category classification: poor, fair, good, very good, or excellent.

Study investigators collected numerous objective measures of health: CVD risk factors (diabetes, body mass index, dyslipidemia, hypertension, current smoking status), coronary artery disease severity score (assessed from angiography), and demographic factors (age, education, and race).

They also collected dimensions related to the subjective experience of symptoms: mental health treatment (assessed from self-reported current use of antidepressants and anxiolytics), cardiac symptoms, and functional capacity (assessed with the Duke Activity Status Index [DASI]).

The 900 women with complete data had a median follow-up of 5.9 years, according to Dr. Rutledge, associate professor in residence at the University of California, San Diego.

They were an average age of 60 years, and 17% were of minority races/ethnicities. Most (80%) had at least a high school education. About 40% had significant coronary artery disease, defined as the presence of stenosis of at least 50% on angiography.

Overall, 10% of the women rated their health as poor, 29% as fair, 35% as good, 19% as very good, and 6% as excellent.

The combined rate of CVD events (myocardial infarction, stroke, heart failure) and death for these groups was 39%, 24%, 21%, 11%, and 8%, respectively.

With the exception of coronary artery disease severity score, all of the objective and subjective measures studied varied significantly across the five categories of self-rated health.

After adjustment for demographic and CVD risk factors, women with fair self-rated health had a 2.0-fold increased risk of CVD events and death and women with poor self-rated health had a 2.1-fold increased risk compared with their counterparts who had very good or excellent self-rated health combined.

The findings were essentially the same after additional adjustment for use of antidepressants or anxiolytics, or for cardiac symptoms. In contrast, the associations were no longer significant after additional adjustment for functional status, as assessed with DASI scores.

Self-rated health seems to capture more than is typically measured during an office visit and it can be easily assessed with a single question, Dr. Rutledge said.

VANCOUVER, B.C. — Your recommendation may be the deciding factor in whether adolescents get vaccinated, and this appears to be especially true in adolescent girls, according to Dr. Paul M. Darden.

“The girls who got recommended HPV [human papillomavirus vaccine] had much higher rates of every vaccine than those who did not and in fact did much better than boys just in general,” Dr. Darden said at the annual meeting of the Pediatric Academic Societies.

This was the finding in a nationwide, cross-sectional study that assessed predictors of immunization among 36,284 adolescents 12-17 years old. The 2007 National Survey of Children’s Health used random-digit dialing to contact and poll parents by telephone about their children’s immunization status, especially the tetanus-diphtheria (Td) vaccine, the tetanus-diphtheria-pertussis (Tdap) vaccine, the meningococcal conjugate vaccine (MCV4), and HPV vaccine.

Specifically, relative to girls whose physicians had not recommended the HPV vaccine, those whose physicians had were more likely to have received that vaccine (49% vs 4%, P less than .01), but also more likely to have received the Td or Tdap vaccine (91% vs 77%, P less than .01) and the MCV4 vaccine (52% vs 30%, P less than .01).

“I think this just points out that a physician’s or health care provider’s recommendation has a huge influence on who gets a vaccine,” he commented. “They usually come to you because they trust you, and if you recommend something, they are much more likely to do it.”

An analysis of the independent predictors of up-to-date status showed the predictors “were actually the opposite of what we typically see for childhood immunizations,” said Dr. Darden, professor of pediatrics at the University of Oklahoma in Oklahoma City.

The proportion of adolescents current on both Td/Tdap and MCV4 was highest among those with Medicaid insurance, at 38%, vs. 33% among those with no insurance and 31% among those with private insurance (P less than .01).

In addition, the proportion up to date on both vaccines was highest among adolescents whose mothers had not completed high school, at 39%, vs. 33% among those whose mothers had schooling beyond this level and 31% among those whose mothers had stopped at high school (P = .02).

Speculating on the reasons for these findings, Dr. Darden noted that the costs of vaccines are covered for adolescents with Medicaid, whereas adolescents with other types of insurance or none may face substantial out-of-pocket costs.

And when it comes to the influence of maternal education, higher education has been associated with greater reluctance to vaccinate. However, he proposed that there are likely additional factors at play. “A 6–percentage point difference seems too big for just vaccine reluctance,” he said.

VANCOUVER, B.C. — Your recommendation may be the deciding factor in whether adolescents get vaccinated, and this appears to be especially true in adolescent girls, according to Dr. Paul M. Darden.

“The girls who got recommended HPV [human papillomavirus vaccine] had much higher rates of every vaccine than those who did not and in fact did much better than boys just in general,” Dr. Darden said at the annual meeting of the Pediatric Academic Societies.

This was the finding in a nationwide, cross-sectional study that assessed predictors of immunization among 36,284 adolescents 12-17 years old. The 2007 National Survey of Children’s Health used random-digit dialing to contact and poll parents by telephone about their children’s immunization status, especially the tetanus-diphtheria (Td) vaccine, the tetanus-diphtheria-pertussis (Tdap) vaccine, the meningococcal conjugate vaccine (MCV4), and HPV vaccine.

Specifically, relative to girls whose physicians had not recommended the HPV vaccine, those whose physicians had were more likely to have received that vaccine (49% vs 4%, P less than .01), but also more likely to have received the Td or Tdap vaccine (91% vs 77%, P less than .01) and the MCV4 vaccine (52% vs 30%, P less than .01).

“I think this just points out that a physician’s or health care provider’s recommendation has a huge influence on who gets a vaccine,” he commented. “They usually come to you because they trust you, and if you recommend something, they are much more likely to do it.”

An analysis of the independent predictors of up-to-date status showed the predictors “were actually the opposite of what we typically see for childhood immunizations,” said Dr. Darden, professor of pediatrics at the University of Oklahoma in Oklahoma City.

The proportion of adolescents current on both Td/Tdap and MCV4 was highest among those with Medicaid insurance, at 38%, vs. 33% among those with no insurance and 31% among those with private insurance (P less than .01).

In addition, the proportion up to date on both vaccines was highest among adolescents whose mothers had not completed high school, at 39%, vs. 33% among those whose mothers had schooling beyond this level and 31% among those whose mothers had stopped at high school (P = .02).

Speculating on the reasons for these findings, Dr. Darden noted that the costs of vaccines are covered for adolescents with Medicaid, whereas adolescents with other types of insurance or none may face substantial out-of-pocket costs.

And when it comes to the influence of maternal education, higher education has been associated with greater reluctance to vaccinate. However, he proposed that there are likely additional factors at play. “A 6–percentage point difference seems too big for just vaccine reluctance,” he said.

VANCOUVER, B.C. — Your recommendation may be the deciding factor in whether adolescents get vaccinated, and this appears to be especially true in adolescent girls, according to Dr. Paul M. Darden.

“The girls who got recommended HPV [human papillomavirus vaccine] had much higher rates of every vaccine than those who did not and in fact did much better than boys just in general,” Dr. Darden said at the annual meeting of the Pediatric Academic Societies.

This was the finding in a nationwide, cross-sectional study that assessed predictors of immunization among 36,284 adolescents 12-17 years old. The 2007 National Survey of Children’s Health used random-digit dialing to contact and poll parents by telephone about their children’s immunization status, especially the tetanus-diphtheria (Td) vaccine, the tetanus-diphtheria-pertussis (Tdap) vaccine, the meningococcal conjugate vaccine (MCV4), and HPV vaccine.

Specifically, relative to girls whose physicians had not recommended the HPV vaccine, those whose physicians had were more likely to have received that vaccine (49% vs 4%, P less than .01), but also more likely to have received the Td or Tdap vaccine (91% vs 77%, P less than .01) and the MCV4 vaccine (52% vs 30%, P less than .01).

“I think this just points out that a physician’s or health care provider’s recommendation has a huge influence on who gets a vaccine,” he commented. “They usually come to you because they trust you, and if you recommend something, they are much more likely to do it.”

An analysis of the independent predictors of up-to-date status showed the predictors “were actually the opposite of what we typically see for childhood immunizations,” said Dr. Darden, professor of pediatrics at the University of Oklahoma in Oklahoma City.

The proportion of adolescents current on both Td/Tdap and MCV4 was highest among those with Medicaid insurance, at 38%, vs. 33% among those with no insurance and 31% among those with private insurance (P less than .01).

In addition, the proportion up to date on both vaccines was highest among adolescents whose mothers had not completed high school, at 39%, vs. 33% among those whose mothers had schooling beyond this level and 31% among those whose mothers had stopped at high school (P = .02).

Speculating on the reasons for these findings, Dr. Darden noted that the costs of vaccines are covered for adolescents with Medicaid, whereas adolescents with other types of insurance or none may face substantial out-of-pocket costs.

And when it comes to the influence of maternal education, higher education has been associated with greater reluctance to vaccinate. However, he proposed that there are likely additional factors at play. “A 6–percentage point difference seems too big for just vaccine reluctance,” he said.

VANCOUVER, B.C. — Selected children with bronchiolitis who are seen in the emergency department can be safely managed with home oxygen therapy and thereby avoid hospital admission, according to Dr. Sarah M. Halstead.

In a retrospective study of more than 5,000 pediatric cases of bronchiolitis with hypoxia seen in the emergency department (ED), only 6% of children sent home on oxygen had to be admitted to the hospital at a later time, with none having adverse outcomes or requiring intensive care or placement of an advanced airway.

Moreover, the ED's overall rate of hospital admission for children with bronchiolitis fell by about a third from historical levels before the home oxygen protocol was used, based on results reported at the meeting.

“To improve clinical care, we hope that [these] data, which [do] support the safety of a home oxygen program for patients with bronchiolitis seen in the ED, will encourage other institutions to consider similar home oxygen protocols,” Dr. Halstead, the lead investigator, said in a poster.

“Increasing ED overcrowding and boarding of inpatients makes the development and analysis of this and other novel outpatient care strategies imperative,” she added.

The investigators used electronic medical records to assess outcomes among children aged 1–18 months seen in the ED with bronchiolitis during the 2005 through 2009 bronchiolitis seasons, a period when the emergency department had a home oxygen protocol in place. Children with cardiopulmonary conditions who required oxygen at baseline were excluded.

“Prior to discharge on home oxygen, we observed patients in the ED for 8 hours,” explained Dr. Halstead, a pediatrician at the Children's Hospital in Aurora, Colo.

“If they had oxygen saturations of greater than 90% on half a liter or less of nasal cannula oxygen, they were able to maintain adequate hydration without frequent deep suctioning, they had no signs of respiratory deterioration, and both the caregiver and the attending were comfortable with discharge home, then a follow-up appointment was arranged and … home oxygen was supplied for the family,” she said.

Study results were based on 5,065 cases of bronchiolitis seen in the ED, 13% of whom were discharged on home oxygen therapy. Within this group, only 6% had to be admitted at a later time'a value that did not differ significantly from the 4% seen among children discharged on room air.

The leading reason for admission after a discharge on home oxygen was an increased oxygen requirement (51%), followed by increased work of breathing (46%), parental concern or compliance issues (24%), a need for intravenous fluids (8%), and difficulties with home oxygen therapy (5%).

“There were no adverse outcomes, ICU admissions, or need for advanced airways in any of these patients,” Dr. Halstead reported.

The emergency department's overall hospital admission rate for bronchiolitis (which captured both children initially admitted and children admitted after initially being sent home) was 28% during the study period—substantially lower than the 39%–40% seen historically before implementation of the home oxygen protocol.

Because some children sent home on oxygen may have been admitted later to outside institutions, the admission rate found in the study may be an underestimate, Dr. Halstead said.

VANCOUVER, B.C. — Selected children with bronchiolitis who are seen in the emergency department can be safely managed with home oxygen therapy and thereby avoid hospital admission, according to Dr. Sarah M. Halstead.

In a retrospective study of more than 5,000 pediatric cases of bronchiolitis with hypoxia seen in the emergency department (ED), only 6% of children sent home on oxygen had to be admitted to the hospital at a later time, with none having adverse outcomes or requiring intensive care or placement of an advanced airway.

Moreover, the ED's overall rate of hospital admission for children with bronchiolitis fell by about a third from historical levels before the home oxygen protocol was used, based on results reported at the meeting.

“To improve clinical care, we hope that [these] data, which [do] support the safety of a home oxygen program for patients with bronchiolitis seen in the ED, will encourage other institutions to consider similar home oxygen protocols,” Dr. Halstead, the lead investigator, said in a poster.

“Increasing ED overcrowding and boarding of inpatients makes the development and analysis of this and other novel outpatient care strategies imperative,” she added.

The investigators used electronic medical records to assess outcomes among children aged 1–18 months seen in the ED with bronchiolitis during the 2005 through 2009 bronchiolitis seasons, a period when the emergency department had a home oxygen protocol in place. Children with cardiopulmonary conditions who required oxygen at baseline were excluded.

“Prior to discharge on home oxygen, we observed patients in the ED for 8 hours,” explained Dr. Halstead, a pediatrician at the Children's Hospital in Aurora, Colo.

“If they had oxygen saturations of greater than 90% on half a liter or less of nasal cannula oxygen, they were able to maintain adequate hydration without frequent deep suctioning, they had no signs of respiratory deterioration, and both the caregiver and the attending were comfortable with discharge home, then a follow-up appointment was arranged and … home oxygen was supplied for the family,” she said.

Study results were based on 5,065 cases of bronchiolitis seen in the ED, 13% of whom were discharged on home oxygen therapy. Within this group, only 6% had to be admitted at a later time'a value that did not differ significantly from the 4% seen among children discharged on room air.

The leading reason for admission after a discharge on home oxygen was an increased oxygen requirement (51%), followed by increased work of breathing (46%), parental concern or compliance issues (24%), a need for intravenous fluids (8%), and difficulties with home oxygen therapy (5%).

“There were no adverse outcomes, ICU admissions, or need for advanced airways in any of these patients,” Dr. Halstead reported.

The emergency department's overall hospital admission rate for bronchiolitis (which captured both children initially admitted and children admitted after initially being sent home) was 28% during the study period—substantially lower than the 39%–40% seen historically before implementation of the home oxygen protocol.

Because some children sent home on oxygen may have been admitted later to outside institutions, the admission rate found in the study may be an underestimate, Dr. Halstead said.

VANCOUVER, B.C. — Selected children with bronchiolitis who are seen in the emergency department can be safely managed with home oxygen therapy and thereby avoid hospital admission, according to Dr. Sarah M. Halstead.

In a retrospective study of more than 5,000 pediatric cases of bronchiolitis with hypoxia seen in the emergency department (ED), only 6% of children sent home on oxygen had to be admitted to the hospital at a later time, with none having adverse outcomes or requiring intensive care or placement of an advanced airway.

Moreover, the ED's overall rate of hospital admission for children with bronchiolitis fell by about a third from historical levels before the home oxygen protocol was used, based on results reported at the meeting.

“To improve clinical care, we hope that [these] data, which [do] support the safety of a home oxygen program for patients with bronchiolitis seen in the ED, will encourage other institutions to consider similar home oxygen protocols,” Dr. Halstead, the lead investigator, said in a poster.

“Increasing ED overcrowding and boarding of inpatients makes the development and analysis of this and other novel outpatient care strategies imperative,” she added.

The investigators used electronic medical records to assess outcomes among children aged 1–18 months seen in the ED with bronchiolitis during the 2005 through 2009 bronchiolitis seasons, a period when the emergency department had a home oxygen protocol in place. Children with cardiopulmonary conditions who required oxygen at baseline were excluded.

“Prior to discharge on home oxygen, we observed patients in the ED for 8 hours,” explained Dr. Halstead, a pediatrician at the Children's Hospital in Aurora, Colo.

“If they had oxygen saturations of greater than 90% on half a liter or less of nasal cannula oxygen, they were able to maintain adequate hydration without frequent deep suctioning, they had no signs of respiratory deterioration, and both the caregiver and the attending were comfortable with discharge home, then a follow-up appointment was arranged and … home oxygen was supplied for the family,” she said.

Study results were based on 5,065 cases of bronchiolitis seen in the ED, 13% of whom were discharged on home oxygen therapy. Within this group, only 6% had to be admitted at a later time'a value that did not differ significantly from the 4% seen among children discharged on room air.

The leading reason for admission after a discharge on home oxygen was an increased oxygen requirement (51%), followed by increased work of breathing (46%), parental concern or compliance issues (24%), a need for intravenous fluids (8%), and difficulties with home oxygen therapy (5%).

“There were no adverse outcomes, ICU admissions, or need for advanced airways in any of these patients,” Dr. Halstead reported.

The emergency department's overall hospital admission rate for bronchiolitis (which captured both children initially admitted and children admitted after initially being sent home) was 28% during the study period—substantially lower than the 39%–40% seen historically before implementation of the home oxygen protocol.

Because some children sent home on oxygen may have been admitted later to outside institutions, the admission rate found in the study may be an underestimate, Dr. Halstead said.

Major Finding: Adolescents participating in the Web-based intervention had a 0.19-point increase in self-management scores on a 5-point scale, whereas their peers receiving only usual care had a 0.02-point decrease.

Data Source: A randomized trial among 72 adolescents aged 13–17 years with type 1 diabetes.

Disclosures: Dr. Mulvaney reported that she had no conflicts of interest related to the study.

SEATTLE — A Web-based intervention for adolescents with type 1 diabetes helps them better manage their disease, according to findings of a randomized controlled trial.

Adolescents who accessed the Web site, which offered problem-solving activities to help them manage their disease, had a 0.19-point increase in self-management scores on a 5-point scale. Meanwhile, their peers assigned to usual care had a 0.02-point decrease.

In addition, the intervention group had a minimal change in hemoglobin A_1c levels, whereas the level rose in the control group, although this difference was not statistically significant.

“The overall results indicate that the teens thought the Web site was interesting and relevant to them, and the results of change in behavior and A_1c were promising,” lead investigator Shelagh Mulvaney, Ph.D., of Vanderbilt University in Nashville, Tenn., said at the meeting “We plan to expand the content and develop the Web site through a larger randomized trial.”

Children with type 1 diabetes typically have a rise in HbA_1c levels during adolescence, indicating worsening glycemic control, she noted. Part of this is due to the difficulty of reconciling self-management with everything else going on in their lives.

“One recent study estimated that people with type 1 diabetes have to complete 25 tasks a day for adequate self-management,” Dr. Mulvaney observed. “You can imagine that carrying out 25 tasks a day would be difficult, but then add that they have to do it around mealtimes, at school, around their friends, at parties and social gatherings, and you can see how … psychosocial barriers to self-management could come into play.”

Adolescents say such barriers—competing demands, negative emotions, social situations, conflict or tension with specific people, and planning—typically are not well addressed during their regular clinic visits, she added.

For the 11-week trial, investigators enrolled adolescents, aged 13–17 years with type 1 diabetes from a pediatric diabetes clinic. They were randomly assigned in a 1:2 ratio to usual care alone or usual care plus a Web-based intervention (www.yourway.org

The Web site featured multimedia first-person stories that modeled problem-solving techniques for self-management of diabetes, as well as problem-solving cycle activities aimed at helping adolescents apply the skills they were learning to their own lives. It also features a forum to connect with other teens, didactic presentations, and the option to ask experts for advice.

The adolescents were sent weekly e-mail prompts to use the Web site. They received up to $80 for participating in Web site activities and up to $50 for completing questionnaires.

The study results were based on 72 adolescents, 92% of whom were white; average age was 15 (Diabetes Care 2010;33:602–4). The mean time since their diabetes diagnosis was 6 years, and about half were using an insulin pump. The baseline HbA_1c level was 8.2% in the control group and 9.1% in the intervention group.

In the intervention group, seven adolescents never logged onto the Web site, Dr. Mulvaney reported. The rest completed a mean of 5.2 of the 6 stories, and a mean of 1.5 of the 2 problem-solving cycles.

The number of total online activities declined over the study period, likely because the content was no longer updated after the sixth week, she said.

Study outcomes were not statistically significant in intent-to-treat analyses. But in on-treatment analyses, adolescents in the intervention group had an increase of 0.19 points in their total self-management score, as assessed with the 5-point Diabetes Behavior Rating Scale, whereas those in the control group had a decrease of 0.02 points.

In addition, scores on a novel problem-solving scale increased by 0.06 points in the intervention group but decreased by 0.07 points in the control group, and HbA_1c levels fell by 0.01% in the intervention group but rose by 0.33% in the control group. Neither difference was statistically significant.

Adolescents in the intervention group rated the program as excellent (63%) or good (37%). On 5-point scales, they found the stories to be highly relevant (4.7 points) and realistic (4.4 points).

“Our challenges and next steps include expanding the content and increasing the duration of the study, probably to 6 months,” said Dr. Mulvaney.

“We'd like to … increase engagement by increasing interactions between users about problems, so we have created other activities that allow them to comment on each other's problems and provide support to each other directly, which they could do through the forum but they tended not to do.”

In addition, the adolescents expressed interest in some kind of role for their parents, she noted. “So we have designed a parallel parent Web site that we are pilot-testing right now,” she said.

The site,

Source Courtesy www.yourway.org

Major Finding: Adolescents participating in the Web-based intervention had a 0.19-point increase in self-management scores on a 5-point scale, whereas their peers receiving only usual care had a 0.02-point decrease.

Data Source: A randomized trial among 72 adolescents aged 13–17 years with type 1 diabetes.

Disclosures: Dr. Mulvaney reported that she had no conflicts of interest related to the study.

SEATTLE — A Web-based intervention for adolescents with type 1 diabetes helps them better manage their disease, according to findings of a randomized controlled trial.

Adolescents who accessed the Web site, which offered problem-solving activities to help them manage their disease, had a 0.19-point increase in self-management scores on a 5-point scale. Meanwhile, their peers assigned to usual care had a 0.02-point decrease.

In addition, the intervention group had a minimal change in hemoglobin A_1c levels, whereas the level rose in the control group, although this difference was not statistically significant.

“The overall results indicate that the teens thought the Web site was interesting and relevant to them, and the results of change in behavior and A_1c were promising,” lead investigator Shelagh Mulvaney, Ph.D., of Vanderbilt University in Nashville, Tenn., said at the meeting “We plan to expand the content and develop the Web site through a larger randomized trial.”

Children with type 1 diabetes typically have a rise in HbA_1c levels during adolescence, indicating worsening glycemic control, she noted. Part of this is due to the difficulty of reconciling self-management with everything else going on in their lives.

“One recent study estimated that people with type 1 diabetes have to complete 25 tasks a day for adequate self-management,” Dr. Mulvaney observed. “You can imagine that carrying out 25 tasks a day would be difficult, but then add that they have to do it around mealtimes, at school, around their friends, at parties and social gatherings, and you can see how … psychosocial barriers to self-management could come into play.”

Adolescents say such barriers—competing demands, negative emotions, social situations, conflict or tension with specific people, and planning—typically are not well addressed during their regular clinic visits, she added.

For the 11-week trial, investigators enrolled adolescents, aged 13–17 years with type 1 diabetes from a pediatric diabetes clinic. They were randomly assigned in a 1:2 ratio to usual care alone or usual care plus a Web-based intervention (www.yourway.org

The Web site featured multimedia first-person stories that modeled problem-solving techniques for self-management of diabetes, as well as problem-solving cycle activities aimed at helping adolescents apply the skills they were learning to their own lives. It also features a forum to connect with other teens, didactic presentations, and the option to ask experts for advice.

The adolescents were sent weekly e-mail prompts to use the Web site. They received up to $80 for participating in Web site activities and up to $50 for completing questionnaires.

The study results were based on 72 adolescents, 92% of whom were white; average age was 15 (Diabetes Care 2010;33:602–4). The mean time since their diabetes diagnosis was 6 years, and about half were using an insulin pump. The baseline HbA_1c level was 8.2% in the control group and 9.1% in the intervention group.

In the intervention group, seven adolescents never logged onto the Web site, Dr. Mulvaney reported. The rest completed a mean of 5.2 of the 6 stories, and a mean of 1.5 of the 2 problem-solving cycles.

The number of total online activities declined over the study period, likely because the content was no longer updated after the sixth week, she said.

Study outcomes were not statistically significant in intent-to-treat analyses. But in on-treatment analyses, adolescents in the intervention group had an increase of 0.19 points in their total self-management score, as assessed with the 5-point Diabetes Behavior Rating Scale, whereas those in the control group had a decrease of 0.02 points.

In addition, scores on a novel problem-solving scale increased by 0.06 points in the intervention group but decreased by 0.07 points in the control group, and HbA_1c levels fell by 0.01% in the intervention group but rose by 0.33% in the control group. Neither difference was statistically significant.

Adolescents in the intervention group rated the program as excellent (63%) or good (37%). On 5-point scales, they found the stories to be highly relevant (4.7 points) and realistic (4.4 points).

“Our challenges and next steps include expanding the content and increasing the duration of the study, probably to 6 months,” said Dr. Mulvaney.

“We'd like to … increase engagement by increasing interactions between users about problems, so we have created other activities that allow them to comment on each other's problems and provide support to each other directly, which they could do through the forum but they tended not to do.”

In addition, the adolescents expressed interest in some kind of role for their parents, she noted. “So we have designed a parallel parent Web site that we are pilot-testing right now,” she said.

The site,

Source Courtesy www.yourway.org

Major Finding: Adolescents participating in the Web-based intervention had a 0.19-point increase in self-management scores on a 5-point scale, whereas their peers receiving only usual care had a 0.02-point decrease.

Data Source: A randomized trial among 72 adolescents aged 13–17 years with type 1 diabetes.

Disclosures: Dr. Mulvaney reported that she had no conflicts of interest related to the study.

SEATTLE — A Web-based intervention for adolescents with type 1 diabetes helps them better manage their disease, according to findings of a randomized controlled trial.

Adolescents who accessed the Web site, which offered problem-solving activities to help them manage their disease, had a 0.19-point increase in self-management scores on a 5-point scale. Meanwhile, their peers assigned to usual care had a 0.02-point decrease.

In addition, the intervention group had a minimal change in hemoglobin A_1c levels, whereas the level rose in the control group, although this difference was not statistically significant.

“The overall results indicate that the teens thought the Web site was interesting and relevant to them, and the results of change in behavior and A_1c were promising,” lead investigator Shelagh Mulvaney, Ph.D., of Vanderbilt University in Nashville, Tenn., said at the meeting “We plan to expand the content and develop the Web site through a larger randomized trial.”

Children with type 1 diabetes typically have a rise in HbA_1c levels during adolescence, indicating worsening glycemic control, she noted. Part of this is due to the difficulty of reconciling self-management with everything else going on in their lives.

“One recent study estimated that people with type 1 diabetes have to complete 25 tasks a day for adequate self-management,” Dr. Mulvaney observed. “You can imagine that carrying out 25 tasks a day would be difficult, but then add that they have to do it around mealtimes, at school, around their friends, at parties and social gatherings, and you can see how … psychosocial barriers to self-management could come into play.”

Adolescents say such barriers—competing demands, negative emotions, social situations, conflict or tension with specific people, and planning—typically are not well addressed during their regular clinic visits, she added.

For the 11-week trial, investigators enrolled adolescents, aged 13–17 years with type 1 diabetes from a pediatric diabetes clinic. They were randomly assigned in a 1:2 ratio to usual care alone or usual care plus a Web-based intervention (www.yourway.org

The Web site featured multimedia first-person stories that modeled problem-solving techniques for self-management of diabetes, as well as problem-solving cycle activities aimed at helping adolescents apply the skills they were learning to their own lives. It also features a forum to connect with other teens, didactic presentations, and the option to ask experts for advice.

The adolescents were sent weekly e-mail prompts to use the Web site. They received up to $80 for participating in Web site activities and up to $50 for completing questionnaires.

The study results were based on 72 adolescents, 92% of whom were white; average age was 15 (Diabetes Care 2010;33:602–4). The mean time since their diabetes diagnosis was 6 years, and about half were using an insulin pump. The baseline HbA_1c level was 8.2% in the control group and 9.1% in the intervention group.

In the intervention group, seven adolescents never logged onto the Web site, Dr. Mulvaney reported. The rest completed a mean of 5.2 of the 6 stories, and a mean of 1.5 of the 2 problem-solving cycles.

The number of total online activities declined over the study period, likely because the content was no longer updated after the sixth week, she said.

Study outcomes were not statistically significant in intent-to-treat analyses. But in on-treatment analyses, adolescents in the intervention group had an increase of 0.19 points in their total self-management score, as assessed with the 5-point Diabetes Behavior Rating Scale, whereas those in the control group had a decrease of 0.02 points.

In addition, scores on a novel problem-solving scale increased by 0.06 points in the intervention group but decreased by 0.07 points in the control group, and HbA_1c levels fell by 0.01% in the intervention group but rose by 0.33% in the control group. Neither difference was statistically significant.

Adolescents in the intervention group rated the program as excellent (63%) or good (37%). On 5-point scales, they found the stories to be highly relevant (4.7 points) and realistic (4.4 points).

“Our challenges and next steps include expanding the content and increasing the duration of the study, probably to 6 months,” said Dr. Mulvaney.

“We'd like to … increase engagement by increasing interactions between users about problems, so we have created other activities that allow them to comment on each other's problems and provide support to each other directly, which they could do through the forum but they tended not to do.”

In addition, the adolescents expressed interest in some kind of role for their parents, she noted. “So we have designed a parallel parent Web site that we are pilot-testing right now,” she said.

The site,

Source Courtesy www.yourway.org

Major Finding: Patients referred to an Internet-based program increased the minutes spent in aerobic walking from 27 minutes at baseline to 72 minutes at 6 weeks.

Data Source: A pilot cohort study involving six pairs of family medicine providers and 37 sedentary patients who were overweight, had coronary artery disease, and/or had diabetes.

Disclosures: One of the study's coinvestigators is a consultant to Omron Healthcare, which manufactures the pedometers used in the walking program.

SEATTLE — An Internet-based program increased walking to a clinically meaningful level among sedentary patients with comorbidities in a pilot study of the primary care–based intervention.

The 37 patients in the study—all of whom were overweight, had coronary artery disease, and/or had diabetes—increased their total daily step count by 1.3-fold and their total daily aerobic step count by 2.7-fold, reported David Goodrich, Ed.D., of the University of Michigan in Ann Arbor.

By the end of the 6-week program, the patients were logging 72 minutes of aerobic walking each week on average, up from just 27 minutes at baseline.

“That's half the duration of our Surgeon General's recommendation,” Dr. Goodrich noted.

Few primary care interventions have been effective for promoting physical activity among patients with comorbidities, he said. “Physicians are often uncomfortable counseling patients because of time constraints, they have liability concerns if an accident were to occur while a patient were exercising (such as a heart attack), they are not trained in exercise prescription, and there is a lack of interventions that they can use that are time and cost effective,” he explained.

The walking program, called Stepping Up to Health, targets people with or at risk for chronic disease and encourages them to use pedometers that upload data to the Internet.

The investigators conducted a study to develop and test a clinical interface that would facilitate referral of patients to the program by primary care providers and allow them to monitor the patients' progress and safety.

Six pairs of family physicians and medical assistants participated in developing the Web site, which had a referral page, displayed patients' walking goals and actual step counts from the pedometers, and documented any exercise-related adverse events. The site was then tested among the providers during routine clinical care.

To be eligible, patients had to be sedentary and overweight, have coronary artery disease and/or type 2 diabetes, use the Internet, and be sufficiently motivated.

Of 139 patients referred to the program, 37 (27%) enrolled; they had a mean age of 45 years. The majority were female (65%), white (92%), and had at least some college education (92%). In terms of comorbidities, 97% of the patients were obese, 22% had diabetes, and 8% had coronary artery disease.

“There was a clinically significant increase in steps,” he reported, with patients increasing their average number of steps per day by 1.3-fold (from 4,520 to 6,013), average number of aerobic steps per day by 2.7-fold (from 406 to 1,114), and number of minutes of aerobic walking per week by 2.7-fold (from 27 to 72).

Most of the patients who completed a satisfaction survey agreed or strongly agreed that the program was useful (94%), increased the amount they walked (85%), was easy to use (94%), and that they liked working with it (88%).

Many providers said that if the program had interfaced with electronic medical records, there would have been more prompting to use it, he noted. Also, physicians perceived the referral process to be burdensome and to add a competing priority.

Major Finding: Patients referred to an Internet-based program increased the minutes spent in aerobic walking from 27 minutes at baseline to 72 minutes at 6 weeks.

Data Source: A pilot cohort study involving six pairs of family medicine providers and 37 sedentary patients who were overweight, had coronary artery disease, and/or had diabetes.

Disclosures: One of the study's coinvestigators is a consultant to Omron Healthcare, which manufactures the pedometers used in the walking program.

SEATTLE — An Internet-based program increased walking to a clinically meaningful level among sedentary patients with comorbidities in a pilot study of the primary care–based intervention.

The 37 patients in the study—all of whom were overweight, had coronary artery disease, and/or had diabetes—increased their total daily step count by 1.3-fold and their total daily aerobic step count by 2.7-fold, reported David Goodrich, Ed.D., of the University of Michigan in Ann Arbor.

By the end of the 6-week program, the patients were logging 72 minutes of aerobic walking each week on average, up from just 27 minutes at baseline.

“That's half the duration of our Surgeon General's recommendation,” Dr. Goodrich noted.

Few primary care interventions have been effective for promoting physical activity among patients with comorbidities, he said. “Physicians are often uncomfortable counseling patients because of time constraints, they have liability concerns if an accident were to occur while a patient were exercising (such as a heart attack), they are not trained in exercise prescription, and there is a lack of interventions that they can use that are time and cost effective,” he explained.

The walking program, called Stepping Up to Health, targets people with or at risk for chronic disease and encourages them to use pedometers that upload data to the Internet.

The investigators conducted a study to develop and test a clinical interface that would facilitate referral of patients to the program by primary care providers and allow them to monitor the patients' progress and safety.

Six pairs of family physicians and medical assistants participated in developing the Web site, which had a referral page, displayed patients' walking goals and actual step counts from the pedometers, and documented any exercise-related adverse events. The site was then tested among the providers during routine clinical care.

To be eligible, patients had to be sedentary and overweight, have coronary artery disease and/or type 2 diabetes, use the Internet, and be sufficiently motivated.

Of 139 patients referred to the program, 37 (27%) enrolled; they had a mean age of 45 years. The majority were female (65%), white (92%), and had at least some college education (92%). In terms of comorbidities, 97% of the patients were obese, 22% had diabetes, and 8% had coronary artery disease.

“There was a clinically significant increase in steps,” he reported, with patients increasing their average number of steps per day by 1.3-fold (from 4,520 to 6,013), average number of aerobic steps per day by 2.7-fold (from 406 to 1,114), and number of minutes of aerobic walking per week by 2.7-fold (from 27 to 72).

Most of the patients who completed a satisfaction survey agreed or strongly agreed that the program was useful (94%), increased the amount they walked (85%), was easy to use (94%), and that they liked working with it (88%).

Many providers said that if the program had interfaced with electronic medical records, there would have been more prompting to use it, he noted. Also, physicians perceived the referral process to be burdensome and to add a competing priority.

Major Finding: Patients referred to an Internet-based program increased the minutes spent in aerobic walking from 27 minutes at baseline to 72 minutes at 6 weeks.

Data Source: A pilot cohort study involving six pairs of family medicine providers and 37 sedentary patients who were overweight, had coronary artery disease, and/or had diabetes.

Disclosures: One of the study's coinvestigators is a consultant to Omron Healthcare, which manufactures the pedometers used in the walking program.

SEATTLE — An Internet-based program increased walking to a clinically meaningful level among sedentary patients with comorbidities in a pilot study of the primary care–based intervention.

The 37 patients in the study—all of whom were overweight, had coronary artery disease, and/or had diabetes—increased their total daily step count by 1.3-fold and their total daily aerobic step count by 2.7-fold, reported David Goodrich, Ed.D., of the University of Michigan in Ann Arbor.

By the end of the 6-week program, the patients were logging 72 minutes of aerobic walking each week on average, up from just 27 minutes at baseline.

“That's half the duration of our Surgeon General's recommendation,” Dr. Goodrich noted.

Few primary care interventions have been effective for promoting physical activity among patients with comorbidities, he said. “Physicians are often uncomfortable counseling patients because of time constraints, they have liability concerns if an accident were to occur while a patient were exercising (such as a heart attack), they are not trained in exercise prescription, and there is a lack of interventions that they can use that are time and cost effective,” he explained.

The walking program, called Stepping Up to Health, targets people with or at risk for chronic disease and encourages them to use pedometers that upload data to the Internet.

The investigators conducted a study to develop and test a clinical interface that would facilitate referral of patients to the program by primary care providers and allow them to monitor the patients' progress and safety.

Six pairs of family physicians and medical assistants participated in developing the Web site, which had a referral page, displayed patients' walking goals and actual step counts from the pedometers, and documented any exercise-related adverse events. The site was then tested among the providers during routine clinical care.

To be eligible, patients had to be sedentary and overweight, have coronary artery disease and/or type 2 diabetes, use the Internet, and be sufficiently motivated.

Of 139 patients referred to the program, 37 (27%) enrolled; they had a mean age of 45 years. The majority were female (65%), white (92%), and had at least some college education (92%). In terms of comorbidities, 97% of the patients were obese, 22% had diabetes, and 8% had coronary artery disease.

“There was a clinically significant increase in steps,” he reported, with patients increasing their average number of steps per day by 1.3-fold (from 4,520 to 6,013), average number of aerobic steps per day by 2.7-fold (from 406 to 1,114), and number of minutes of aerobic walking per week by 2.7-fold (from 27 to 72).

Most of the patients who completed a satisfaction survey agreed or strongly agreed that the program was useful (94%), increased the amount they walked (85%), was easy to use (94%), and that they liked working with it (88%).

Many providers said that if the program had interfaced with electronic medical records, there would have been more prompting to use it, he noted. Also, physicians perceived the referral process to be burdensome and to add a competing priority.

Major Finding: Adolescents whose parents were sent personalized text messages reminding them that their child needed vaccines were 2.5 times more likely to receive the MCV4 vaccine, the Tdap vaccine, or both.

Data Source: A randomized trial among 361 low-income urban adolescents and their parents.

Disclosures: Dr. Stockwell reported that she had no financial conflicts, but that one of the study's investigators is on an advisory board for and has received research funding from Merck.

VANCOUVER, B.C. — Text messages reminding parents that their adolescents need vaccines are an effective and efficient means of improving immunization rates in this population, according to findings of a randomized trial.

Adolescents whose parents were sent automated, personalized text message reminders that included walk-in times for vaccination were 2.5 times more likely to receive the meningococcal conjugate (MCV4) vaccine, the tetanus-diphtheria-pertussis (Tdap) vaccine, or both.

The observed gains in immunization rates were greater than those seen previously with reminder and recall strategies, lead investigator Dr. Melissa S. Stockwell said.

In fact, this strategy works so well that busy clinics with many competing priorities will need to be prepared to meet the increased demand for vaccines.

“The actual texting is instantaneous and fast, but you have the repercussions of bringing all those kids in,” she explained. One option is to stagger the messages to control the numbers of adolescents who might show up at one time.

The trial was conducted in six networked primary care practices in New York City among parents who had a child aged 11–18 years needing the MCV4 vaccine, the Tdap vaccine, or both, and had a cell phone number in the system. The practices were randomized to a control (usual care) group or an intervention (Text4Health) group.

In intervention practices, parents were sent text message reminders that were automatically generated using data from a linked immunization registry. The reminders were sent up to five times over a 7-week period until the adolescent had received the two target vaccines.

“Based on our focus group [of parents], they really wanted the messages to be personal,” said Dr. Stockwell, a pediatrician at Columbia University in New York. So the messages included their child's name, their clinic's name, and walk-in times for vaccination, plus offered the option of switching between English and Spanish.

Study results reported in a poster were based on 195 adolescents in the intervention group and 166 in the control group. The adolescents were 16 years old on average, 55% were Hispanic, and 80% had public health insurance.

In the intervention group, 821 text messages were sent. Just 6% of parents were found to have wrong numbers, and 3% opted out of receiving the messages.

At 24 weeks, adolescents in the intervention group had a higher rate of receipt of the MCV4 vaccine, Tdap vaccine, or both, compared with their peers in the control group (35% vs. 17%)—for a significant difference between groups of 18%. After adjustment for potential confounders, the intervention was associated with 2.5-fold higher odds of receiving these vaccines.

Adolescents in the intervention group also had a higher rate of receipt of any other needed vaccines, such as the human papillomavirus vaccine and the hepatitis A vaccine (42% vs. 29.5%), with a difference between groups of 12.5%.

The estimated cost of the intervention, assuming that it was sustained for 2 years in a hypothetical cohort of 100,000 adolescents, was $1.71 per adolescent immunized and $0.42 per additional vaccine delivered.

A text message “stays on the phone, so it might sort of be a constant reminder, or the information—especially the walk-in times—is right there so they can send their child at that time,” she said.

Major Finding: Adolescents whose parents were sent personalized text messages reminding them that their child needed vaccines were 2.5 times more likely to receive the MCV4 vaccine, the Tdap vaccine, or both.

Data Source: A randomized trial among 361 low-income urban adolescents and their parents.

Disclosures: Dr. Stockwell reported that she had no financial conflicts, but that one of the study's investigators is on an advisory board for and has received research funding from Merck.

VANCOUVER, B.C. — Text messages reminding parents that their adolescents need vaccines are an effective and efficient means of improving immunization rates in this population, according to findings of a randomized trial.

Adolescents whose parents were sent automated, personalized text message reminders that included walk-in times for vaccination were 2.5 times more likely to receive the meningococcal conjugate (MCV4) vaccine, the tetanus-diphtheria-pertussis (Tdap) vaccine, or both.

The observed gains in immunization rates were greater than those seen previously with reminder and recall strategies, lead investigator Dr. Melissa S. Stockwell said.

In fact, this strategy works so well that busy clinics with many competing priorities will need to be prepared to meet the increased demand for vaccines.

“The actual texting is instantaneous and fast, but you have the repercussions of bringing all those kids in,” she explained. One option is to stagger the messages to control the numbers of adolescents who might show up at one time.

The trial was conducted in six networked primary care practices in New York City among parents who had a child aged 11–18 years needing the MCV4 vaccine, the Tdap vaccine, or both, and had a cell phone number in the system. The practices were randomized to a control (usual care) group or an intervention (Text4Health) group.

In intervention practices, parents were sent text message reminders that were automatically generated using data from a linked immunization registry. The reminders were sent up to five times over a 7-week period until the adolescent had received the two target vaccines.

“Based on our focus group [of parents], they really wanted the messages to be personal,” said Dr. Stockwell, a pediatrician at Columbia University in New York. So the messages included their child's name, their clinic's name, and walk-in times for vaccination, plus offered the option of switching between English and Spanish.

Study results reported in a poster were based on 195 adolescents in the intervention group and 166 in the control group. The adolescents were 16 years old on average, 55% were Hispanic, and 80% had public health insurance.

In the intervention group, 821 text messages were sent. Just 6% of parents were found to have wrong numbers, and 3% opted out of receiving the messages.

At 24 weeks, adolescents in the intervention group had a higher rate of receipt of the MCV4 vaccine, Tdap vaccine, or both, compared with their peers in the control group (35% vs. 17%)—for a significant difference between groups of 18%. After adjustment for potential confounders, the intervention was associated with 2.5-fold higher odds of receiving these vaccines.

Adolescents in the intervention group also had a higher rate of receipt of any other needed vaccines, such as the human papillomavirus vaccine and the hepatitis A vaccine (42% vs. 29.5%), with a difference between groups of 12.5%.

The estimated cost of the intervention, assuming that it was sustained for 2 years in a hypothetical cohort of 100,000 adolescents, was $1.71 per adolescent immunized and $0.42 per additional vaccine delivered.

A text message “stays on the phone, so it might sort of be a constant reminder, or the information—especially the walk-in times—is right there so they can send their child at that time,” she said.

Major Finding: Adolescents whose parents were sent personalized text messages reminding them that their child needed vaccines were 2.5 times more likely to receive the MCV4 vaccine, the Tdap vaccine, or both.

Data Source: A randomized trial among 361 low-income urban adolescents and their parents.

Disclosures: Dr. Stockwell reported that she had no financial conflicts, but that one of the study's investigators is on an advisory board for and has received research funding from Merck.

VANCOUVER, B.C. — Text messages reminding parents that their adolescents need vaccines are an effective and efficient means of improving immunization rates in this population, according to findings of a randomized trial.

Adolescents whose parents were sent automated, personalized text message reminders that included walk-in times for vaccination were 2.5 times more likely to receive the meningococcal conjugate (MCV4) vaccine, the tetanus-diphtheria-pertussis (Tdap) vaccine, or both.

The observed gains in immunization rates were greater than those seen previously with reminder and recall strategies, lead investigator Dr. Melissa S. Stockwell said.

In fact, this strategy works so well that busy clinics with many competing priorities will need to be prepared to meet the increased demand for vaccines.

“The actual texting is instantaneous and fast, but you have the repercussions of bringing all those kids in,” she explained. One option is to stagger the messages to control the numbers of adolescents who might show up at one time.

The trial was conducted in six networked primary care practices in New York City among parents who had a child aged 11–18 years needing the MCV4 vaccine, the Tdap vaccine, or both, and had a cell phone number in the system. The practices were randomized to a control (usual care) group or an intervention (Text4Health) group.

In intervention practices, parents were sent text message reminders that were automatically generated using data from a linked immunization registry. The reminders were sent up to five times over a 7-week period until the adolescent had received the two target vaccines.

“Based on our focus group [of parents], they really wanted the messages to be personal,” said Dr. Stockwell, a pediatrician at Columbia University in New York. So the messages included their child's name, their clinic's name, and walk-in times for vaccination, plus offered the option of switching between English and Spanish.

Study results reported in a poster were based on 195 adolescents in the intervention group and 166 in the control group. The adolescents were 16 years old on average, 55% were Hispanic, and 80% had public health insurance.

In the intervention group, 821 text messages were sent. Just 6% of parents were found to have wrong numbers, and 3% opted out of receiving the messages.

At 24 weeks, adolescents in the intervention group had a higher rate of receipt of the MCV4 vaccine, Tdap vaccine, or both, compared with their peers in the control group (35% vs. 17%)—for a significant difference between groups of 18%. After adjustment for potential confounders, the intervention was associated with 2.5-fold higher odds of receiving these vaccines.

Adolescents in the intervention group also had a higher rate of receipt of any other needed vaccines, such as the human papillomavirus vaccine and the hepatitis A vaccine (42% vs. 29.5%), with a difference between groups of 12.5%.

The estimated cost of the intervention, assuming that it was sustained for 2 years in a hypothetical cohort of 100,000 adolescents, was $1.71 per adolescent immunized and $0.42 per additional vaccine delivered.

A text message “stays on the phone, so it might sort of be a constant reminder, or the information—especially the walk-in times—is right there so they can send their child at that time,” she said.

Major Finding: Adolescents assigned to a stepped intervention were 1.8 times more likely to receive new vaccines and 1.7 times more likely to have a recent well-child visit than those given usual care.

Data Source: Randomized, controlled trial involving 6,684 high-risk adolescents.

Disclosures: Dr. Szilagyi reported that he had no conflicts of interest related to the study.

VANCOUVER, B.C. — A stepped intervention in primary care practices can improve rates of immunization and well-child visits among urban adolescents at high risk for poor health outcomes.

Data from a randomized trial conducted in Rochester, N.Y., showed that adolescents assigned to the intervention were 1.8 times more likely to receive new vaccines than were their peers assigned to usual care. In addition, they were 1.7 times more likely to have made a well-child visit in the past year.

“A stepped tracking-reminder-recall-outreach program can improve immunization rates for high-risk urban adolescents, and it has spillover benefits on improving preventive care visits,” lead investigator Dr. Peter G. Szilagyi said.

“The bottom line, I think, is that a public health approach within primary care can measurably improve the quality of care for urban adolescents,” he added.

National immunization guidelines recommend reminders, recalls, and outreach for very high-risk groups, but “for urban adolescents, these interventions have not been tested. And there are virtually no studies that have been shown to improve well-child care visit rates for urban adolescents,” noted Dr. Szilagyi, professor and chief of the division of general pediatrics and professor at the center for community health at the University of Rochester.

The 15-month trial was conducted in eight primary care practices among adolescents aged 11–15 years. Within each practice, the adolescents were randomized to an intervention group or a control group given usual care.

In the intervention group, outreach workers tracked all adolescents to monitor their immunization status. For those identified as being behind, progressively intense measures were used until they were up to date: reminders, then recalls, and finally outreach in the form of a home visit, which was used to assess barriers to care and link the families with social services.

The investigators assessed rates of receipt for three new vaccines for adolescents—meningococcal conjugate (MCV4); tetanus, diphtheria, and pertussis (Tdap); and human papillomavirus (HPV) vaccines—and rates of well-child care visits in the past year.

Analyses were based on 3,365 adolescents in the intervention group and 3,319 adolescents in the control group. They were a mean 13.5 years old, and half were male. Most were black (63%) or Hispanic (23%), and most had Medicaid (73%).

Results showed that in the intervention group, 71% of adolescents needed reminders and recall, and 12% needed home visits.

After adjustment for potential confounders, relative to their peers in the control group, adolescents in the intervention group were a significant 1.8 times more likely to have received all three vaccines at the study's end, Dr. Szilagyi said.

In absolute terms, 44% of adolescents in the intervention group were fully immunized at that point, compared with 32% in the control group. Differences were significant for each vaccine as well.

Similarly, after statistical adjustment, adolescents in the intervention group were a significant 1.7 times more likely to have had a well-child visit in the past year at the study's end, he said.

In absolute terms, 67% in the intervention group had made such a visit, compared with 55% in the control group.

Improvements in rates of these outcomes were similar by age, sex, race/ethnicity, and type of insurance, he noted.

The cost of the intervention (excluding research costs) was $43 per year per adolescent. The cost per additional fully vaccinated adolescent was $465, and the cost per additional adolescent with a recent well-child visit was $417.

“I think the costs are somewhat high, although we have debated this hotly within our group,” he commented. “We need to improve the efficiencies of this program and reduce the costs.”

The percentage of adolescents who were up to date on all three vaccines at baseline was low (12%–13%) in the study population, so the intervention might have a smaller impact in populations with higher baseline rates, Dr. Szilagyi cautioned.

The multifaceted nature of the intervention is likely to be important in this setting. Studies have shown that reminders and recalls work in the general population, but not in disadvantaged groups.

Major Finding: Adolescents assigned to a stepped intervention were 1.8 times more likely to receive new vaccines and 1.7 times more likely to have a recent well-child visit than those given usual care.

Data Source: Randomized, controlled trial involving 6,684 high-risk adolescents.

Disclosures: Dr. Szilagyi reported that he had no conflicts of interest related to the study.

VANCOUVER, B.C. — A stepped intervention in primary care practices can improve rates of immunization and well-child visits among urban adolescents at high risk for poor health outcomes.

Data from a randomized trial conducted in Rochester, N.Y., showed that adolescents assigned to the intervention were 1.8 times more likely to receive new vaccines than were their peers assigned to usual care. In addition, they were 1.7 times more likely to have made a well-child visit in the past year.

“A stepped tracking-reminder-recall-outreach program can improve immunization rates for high-risk urban adolescents, and it has spillover benefits on improving preventive care visits,” lead investigator Dr. Peter G. Szilagyi said.

“The bottom line, I think, is that a public health approach within primary care can measurably improve the quality of care for urban adolescents,” he added.

National immunization guidelines recommend reminders, recalls, and outreach for very high-risk groups, but “for urban adolescents, these interventions have not been tested. And there are virtually no studies that have been shown to improve well-child care visit rates for urban adolescents,” noted Dr. Szilagyi, professor and chief of the division of general pediatrics and professor at the center for community health at the University of Rochester.

The 15-month trial was conducted in eight primary care practices among adolescents aged 11–15 years. Within each practice, the adolescents were randomized to an intervention group or a control group given usual care.

In the intervention group, outreach workers tracked all adolescents to monitor their immunization status. For those identified as being behind, progressively intense measures were used until they were up to date: reminders, then recalls, and finally outreach in the form of a home visit, which was used to assess barriers to care and link the families with social services.

The investigators assessed rates of receipt for three new vaccines for adolescents—meningococcal conjugate (MCV4); tetanus, diphtheria, and pertussis (Tdap); and human papillomavirus (HPV) vaccines—and rates of well-child care visits in the past year.

Analyses were based on 3,365 adolescents in the intervention group and 3,319 adolescents in the control group. They were a mean 13.5 years old, and half were male. Most were black (63%) or Hispanic (23%), and most had Medicaid (73%).

Results showed that in the intervention group, 71% of adolescents needed reminders and recall, and 12% needed home visits.

After adjustment for potential confounders, relative to their peers in the control group, adolescents in the intervention group were a significant 1.8 times more likely to have received all three vaccines at the study's end, Dr. Szilagyi said.

In absolute terms, 44% of adolescents in the intervention group were fully immunized at that point, compared with 32% in the control group. Differences were significant for each vaccine as well.

Similarly, after statistical adjustment, adolescents in the intervention group were a significant 1.7 times more likely to have had a well-child visit in the past year at the study's end, he said.

In absolute terms, 67% in the intervention group had made such a visit, compared with 55% in the control group.

Improvements in rates of these outcomes were similar by age, sex, race/ethnicity, and type of insurance, he noted.

The cost of the intervention (excluding research costs) was $43 per year per adolescent. The cost per additional fully vaccinated adolescent was $465, and the cost per additional adolescent with a recent well-child visit was $417.

“I think the costs are somewhat high, although we have debated this hotly within our group,” he commented. “We need to improve the efficiencies of this program and reduce the costs.”

The percentage of adolescents who were up to date on all three vaccines at baseline was low (12%–13%) in the study population, so the intervention might have a smaller impact in populations with higher baseline rates, Dr. Szilagyi cautioned.

The multifaceted nature of the intervention is likely to be important in this setting. Studies have shown that reminders and recalls work in the general population, but not in disadvantaged groups.

Major Finding: Adolescents assigned to a stepped intervention were 1.8 times more likely to receive new vaccines and 1.7 times more likely to have a recent well-child visit than those given usual care.

Data Source: Randomized, controlled trial involving 6,684 high-risk adolescents.

Disclosures: Dr. Szilagyi reported that he had no conflicts of interest related to the study.

VANCOUVER, B.C. — A stepped intervention in primary care practices can improve rates of immunization and well-child visits among urban adolescents at high risk for poor health outcomes.

Data from a randomized trial conducted in Rochester, N.Y., showed that adolescents assigned to the intervention were 1.8 times more likely to receive new vaccines than were their peers assigned to usual care. In addition, they were 1.7 times more likely to have made a well-child visit in the past year.

“A stepped tracking-reminder-recall-outreach program can improve immunization rates for high-risk urban adolescents, and it has spillover benefits on improving preventive care visits,” lead investigator Dr. Peter G. Szilagyi said.

“The bottom line, I think, is that a public health approach within primary care can measurably improve the quality of care for urban adolescents,” he added.

National immunization guidelines recommend reminders, recalls, and outreach for very high-risk groups, but “for urban adolescents, these interventions have not been tested. And there are virtually no studies that have been shown to improve well-child care visit rates for urban adolescents,” noted Dr. Szilagyi, professor and chief of the division of general pediatrics and professor at the center for community health at the University of Rochester.

The 15-month trial was conducted in eight primary care practices among adolescents aged 11–15 years. Within each practice, the adolescents were randomized to an intervention group or a control group given usual care.

In the intervention group, outreach workers tracked all adolescents to monitor their immunization status. For those identified as being behind, progressively intense measures were used until they were up to date: reminders, then recalls, and finally outreach in the form of a home visit, which was used to assess barriers to care and link the families with social services.

The investigators assessed rates of receipt for three new vaccines for adolescents—meningococcal conjugate (MCV4); tetanus, diphtheria, and pertussis (Tdap); and human papillomavirus (HPV) vaccines—and rates of well-child care visits in the past year.

Analyses were based on 3,365 adolescents in the intervention group and 3,319 adolescents in the control group. They were a mean 13.5 years old, and half were male. Most were black (63%) or Hispanic (23%), and most had Medicaid (73%).

Results showed that in the intervention group, 71% of adolescents needed reminders and recall, and 12% needed home visits.

After adjustment for potential confounders, relative to their peers in the control group, adolescents in the intervention group were a significant 1.8 times more likely to have received all three vaccines at the study's end, Dr. Szilagyi said.

In absolute terms, 44% of adolescents in the intervention group were fully immunized at that point, compared with 32% in the control group. Differences were significant for each vaccine as well.

Similarly, after statistical adjustment, adolescents in the intervention group were a significant 1.7 times more likely to have had a well-child visit in the past year at the study's end, he said.

In absolute terms, 67% in the intervention group had made such a visit, compared with 55% in the control group.

Improvements in rates of these outcomes were similar by age, sex, race/ethnicity, and type of insurance, he noted.

The cost of the intervention (excluding research costs) was $43 per year per adolescent. The cost per additional fully vaccinated adolescent was $465, and the cost per additional adolescent with a recent well-child visit was $417.

“I think the costs are somewhat high, although we have debated this hotly within our group,” he commented. “We need to improve the efficiencies of this program and reduce the costs.”

The percentage of adolescents who were up to date on all three vaccines at baseline was low (12%–13%) in the study population, so the intervention might have a smaller impact in populations with higher baseline rates, Dr. Szilagyi cautioned.

The multifaceted nature of the intervention is likely to be important in this setting. Studies have shown that reminders and recalls work in the general population, but not in disadvantaged groups.