Susan London

LAS VEGAS — Fixing emergency department overcrowding will require new approaches to patient admissions and boarding, according to Dr. Peter A. Viccellio.

In contrast to popular opinion, ED overcrowding is not the result of inappropriate visits by the uninsured, illegal immigrants, or people with minor or exaggerated complaints, he said.

“There is now a compelling wealth of literature that all says the same thing: The reason we have crowding is because we have too many admissions sitting in the emergency department,” Dr. Viccellio said, referring to the practice of boarding inpatients, which has negative consequences ranging from longer wait times and increased walkouts to higher rates of medical errors, malpractice claims, and even mortality.

Thus, “what causes ED crowding is hospital crowding,” said Dr. Viccellio, clinical director of the emergency department at Stony Brook (N.Y) University Medical Center. “It's an institutional problem, not an ED problem, and therefore [the solution] probably should be an institutional solution instead of an ED solution.”

One source of hospital crowding is a sharp increase in the proportion of admissions that are unscheduled (now at 78%) and that occur at all hours of the day and on all days of the week, while hospitals cling to the old Monday through Friday, 9-to-5 approach to staffing, with a skeleton crew at other times. Another source of crowding is wide variation in the number of admissions over the course of a week.

At his center, the answer has been a full-capacity protocol that moves low-risk boarded patients out of the emergency department and distributes them throughout the hospital on inpatient floors (www.hospitalovercrowding.com

This approach has several advantages: Boarded patients on inpatient floors are at lower risk for events such as medical errors, are closer to the specialists they need, and are in a quieter environment where they can sleep, eat meals, and have some privacy.

“What we do in moving people and distributing them up the hallways solves our problem by about 50%. It's not a panacea. We are still left with the sickest patients,” he said. “But it allows us to at least unload a volume of low-risk patients and have more space to take care of the others.”

Once the full-capacity protocol was put in place, inpatient rooms often “somehow miraculously materialized” while boarded patients were in transit to the floor, he said. In fact, in the center's experience with about 4,500 boarded patients moved out of the emergency department, 28% got a room immediately, 25% got one in less than an hour, and 46% got one in roughly a hospital shift.

LAS VEGAS — Fixing emergency department overcrowding will require new approaches to patient admissions and boarding, according to Dr. Peter A. Viccellio.

In contrast to popular opinion, ED overcrowding is not the result of inappropriate visits by the uninsured, illegal immigrants, or people with minor or exaggerated complaints, he said.

“There is now a compelling wealth of literature that all says the same thing: The reason we have crowding is because we have too many admissions sitting in the emergency department,” Dr. Viccellio said, referring to the practice of boarding inpatients, which has negative consequences ranging from longer wait times and increased walkouts to higher rates of medical errors, malpractice claims, and even mortality.

Thus, “what causes ED crowding is hospital crowding,” said Dr. Viccellio, clinical director of the emergency department at Stony Brook (N.Y) University Medical Center. “It's an institutional problem, not an ED problem, and therefore [the solution] probably should be an institutional solution instead of an ED solution.”

One source of hospital crowding is a sharp increase in the proportion of admissions that are unscheduled (now at 78%) and that occur at all hours of the day and on all days of the week, while hospitals cling to the old Monday through Friday, 9-to-5 approach to staffing, with a skeleton crew at other times. Another source of crowding is wide variation in the number of admissions over the course of a week.

At his center, the answer has been a full-capacity protocol that moves low-risk boarded patients out of the emergency department and distributes them throughout the hospital on inpatient floors (www.hospitalovercrowding.com

This approach has several advantages: Boarded patients on inpatient floors are at lower risk for events such as medical errors, are closer to the specialists they need, and are in a quieter environment where they can sleep, eat meals, and have some privacy.

“What we do in moving people and distributing them up the hallways solves our problem by about 50%. It's not a panacea. We are still left with the sickest patients,” he said. “But it allows us to at least unload a volume of low-risk patients and have more space to take care of the others.”

Once the full-capacity protocol was put in place, inpatient rooms often “somehow miraculously materialized” while boarded patients were in transit to the floor, he said. In fact, in the center's experience with about 4,500 boarded patients moved out of the emergency department, 28% got a room immediately, 25% got one in less than an hour, and 46% got one in roughly a hospital shift.

LAS VEGAS — Fixing emergency department overcrowding will require new approaches to patient admissions and boarding, according to Dr. Peter A. Viccellio.

In contrast to popular opinion, ED overcrowding is not the result of inappropriate visits by the uninsured, illegal immigrants, or people with minor or exaggerated complaints, he said.

“There is now a compelling wealth of literature that all says the same thing: The reason we have crowding is because we have too many admissions sitting in the emergency department,” Dr. Viccellio said, referring to the practice of boarding inpatients, which has negative consequences ranging from longer wait times and increased walkouts to higher rates of medical errors, malpractice claims, and even mortality.

Thus, “what causes ED crowding is hospital crowding,” said Dr. Viccellio, clinical director of the emergency department at Stony Brook (N.Y) University Medical Center. “It's an institutional problem, not an ED problem, and therefore [the solution] probably should be an institutional solution instead of an ED solution.”

One source of hospital crowding is a sharp increase in the proportion of admissions that are unscheduled (now at 78%) and that occur at all hours of the day and on all days of the week, while hospitals cling to the old Monday through Friday, 9-to-5 approach to staffing, with a skeleton crew at other times. Another source of crowding is wide variation in the number of admissions over the course of a week.

At his center, the answer has been a full-capacity protocol that moves low-risk boarded patients out of the emergency department and distributes them throughout the hospital on inpatient floors (www.hospitalovercrowding.com

This approach has several advantages: Boarded patients on inpatient floors are at lower risk for events such as medical errors, are closer to the specialists they need, and are in a quieter environment where they can sleep, eat meals, and have some privacy.

“What we do in moving people and distributing them up the hallways solves our problem by about 50%. It's not a panacea. We are still left with the sickest patients,” he said. “But it allows us to at least unload a volume of low-risk patients and have more space to take care of the others.”

Once the full-capacity protocol was put in place, inpatient rooms often “somehow miraculously materialized” while boarded patients were in transit to the floor, he said. In fact, in the center's experience with about 4,500 boarded patients moved out of the emergency department, 28% got a room immediately, 25% got one in less than an hour, and 46% got one in roughly a hospital shift.

Major Finding: Participants were more likely than nonparticipants to know that alveolar destruction is a pathophysiologic feature of COPD (94% vs. 74%), to know that women are more susceptible than men to the harmful effects of smoking (90% vs. 54%), and to correctly identify COPD in patients with dyspnea (90% vs. 74%).

Data Source: A cross-sectional survey of 50 primary care physicians who participated in a COPD educational initiative and 50 similar primary care physicians who did not.

Disclosures: The initiative meetings were supported by an educational grant from Novartis Pharmaceuticals. Dr. Hanania did not have any conflicts of interest related to the study.

VANCOUVER, B.C. – A live, interactive, case-based educational initiative improved primary care physicians' knowledge of chronic obstructive pulmonary disease, according to study results reported at the meeting.

In a cross-sectional study of 50 primary care physicians who participated in the initiative and 50 similar nonparticipants, the former were more likely to know that alveolar destruction is a pathophysiologic feature of COPD (94% vs. 74%) and that women have greater susceptibility to the harmful effects of smoking (90% vs. 54%), according to Dr. Nicola A. Hanania and his coinvestigators.

Additionally, when presented with case vignettes, the participants were more likely to recognize the presence of COPD in dyspnea patients (90% vs. 74%).

“Even though this was sort of a one-time … cross-sectional survey, we believe that educational initiatives such as this one may at least improve the knowledge about COPD – both diagnosis and management,” commented Dr. Hanania, an associate professor of medicine at Baylor College of Medicine, Houston.

Explaining the need for primary care–focused efforts, he noted that “the majority of COPD patients are [seen] in the primary care arena.”

But statistics show that “COPD remains under-recognized and underdiagnosed in about 50% of the population out there, not only in the United States but in other countries as well. It also remains undertreated,” even though the GOLD (Global Initiative for Chronic Obstructive Lung Disease) guidelines now stress that it is a treatable disease.

The initiative studied – called Improving COPD Patient Outcomes: Breaking Down the Barriers to Optimal Care – was designed to improve primary care providers' knowledge and competency in the guideline-based diagnosis, staging, and management of COPD, Dr. Hanania said.

It consisted of a series of live half-day meetings conducted over a 3-month period that included short lectures, a video on correct use of inhaler devices, and small-group workshops that incorporated detailed case discussions and hands-on demonstrations and practice in the use of spirometry.

A total of 769 physicians attended the meetings. The investigators assessed the initiative's effectiveness with a case vignette–based survey, given to a randomly selected subset of 50 participants and 50 nonparticipants with similar demographics and practice characteristics.

The number of patients with COPD seen weekly was 11 for participants and 15 for nonparticipants. The mean number of years in practice was 28 and 24, respectively. And both groups were about equally divided between family physicians and internal medicine physicians. Participants were somewhat more likely to be in solo practice (45% vs. 38%) or work in a government facility (25% vs. 0%), and less likely to be in group practice (31% vs. 58%).

Survey results showed that in the area of diagnosis, the participants were more likely than the nonparticipants to recognize COPD in case vignettes of patients with dyspnea (90% vs. 74%, P = .007) and to be aware of the greater susceptibility of women compared with men to the harmful effects of smoking (90% vs. 54%, P less than .001).

Also, when asked which of several pathophysiologic features was one of COPD, participants were more likely to correctly answer alveolar destruction (94% vs. 74%, P = .007). (The other options were muscular deconditioning, synovial inflammation, and increased ventricular filling pressure.)

While the groups did not differ significantly in terms of how likely they were to use spirometry for diagnosis and staging of COPD, participants were more likely than nonparticipants to indicate that difficulty in obtaining spirometry results in the office setting was a very significant barrier to COPD management (27% vs. 12%). “Maybe they acknowledged that it is an important tool, but they cannot do it,” he commented.

The groups were statistically indistinguishable with respect to their approaches to caring for patients with repeated exacerbations and improving adherence, and their selection of appropriate maintenance therapy.

The survey also asked about barriers to managing COPD, according to Dr. Hanania.

In addition to difficulty with spirometry, the groups were similarly likely to rate as very significant a patient's nonadherence to a recommendation to stop smoking, the complexity of the medical regimen, and a lack of clarity about the staging of COPD severity.

A calculation of the initiative's quality of education index showed that participants were 50% more likely than nonparticipants to provide evidence-based, guideline-driven COPD care, Dr. Hanania reported. “We estimate that participation in this half-day program can potentially improve the care of many patients per week, but this needs to be further tested,” he commented.

“We did not attempt to look at long-term [outcomes] – retention of knowledge or practice change – which are very important,” Dr. Hanania acknowledged. But a similar, ongoing initiative, being conducted by the ACCP, is currently assessing impact on real-life practice.

That initiative is including not only physicians but also physician assistants and nurse practitioners, Dr. Hanania said. “In our primary care setting in the U.S., nonphysician extenders – PAs, nurse practitioners – play a major role in encountering COPD, and those are people we like to target.” Furthermore, their role will likely increase if health care reform proceeds and primary care physicians are overwhelmed by demand.

The initiative meetings were supported by an educational grant from Novartis Pharmaceuticals. Dr. Hanania had no relevant conflicts of interest.

Participants were 50% more likely than nonparticipants to provide evidence-based, guideline-driven COPD care.

Source DR. HANANIA

Major Finding: Participants were more likely than nonparticipants to know that alveolar destruction is a pathophysiologic feature of COPD (94% vs. 74%), to know that women are more susceptible than men to the harmful effects of smoking (90% vs. 54%), and to correctly identify COPD in patients with dyspnea (90% vs. 74%).

Data Source: A cross-sectional survey of 50 primary care physicians who participated in a COPD educational initiative and 50 similar primary care physicians who did not.

Disclosures: The initiative meetings were supported by an educational grant from Novartis Pharmaceuticals. Dr. Hanania did not have any conflicts of interest related to the study.

VANCOUVER, B.C. – A live, interactive, case-based educational initiative improved primary care physicians' knowledge of chronic obstructive pulmonary disease, according to study results reported at the meeting.

In a cross-sectional study of 50 primary care physicians who participated in the initiative and 50 similar nonparticipants, the former were more likely to know that alveolar destruction is a pathophysiologic feature of COPD (94% vs. 74%) and that women have greater susceptibility to the harmful effects of smoking (90% vs. 54%), according to Dr. Nicola A. Hanania and his coinvestigators.

Additionally, when presented with case vignettes, the participants were more likely to recognize the presence of COPD in dyspnea patients (90% vs. 74%).

“Even though this was sort of a one-time … cross-sectional survey, we believe that educational initiatives such as this one may at least improve the knowledge about COPD – both diagnosis and management,” commented Dr. Hanania, an associate professor of medicine at Baylor College of Medicine, Houston.

Explaining the need for primary care–focused efforts, he noted that “the majority of COPD patients are [seen] in the primary care arena.”

But statistics show that “COPD remains under-recognized and underdiagnosed in about 50% of the population out there, not only in the United States but in other countries as well. It also remains undertreated,” even though the GOLD (Global Initiative for Chronic Obstructive Lung Disease) guidelines now stress that it is a treatable disease.

The initiative studied – called Improving COPD Patient Outcomes: Breaking Down the Barriers to Optimal Care – was designed to improve primary care providers' knowledge and competency in the guideline-based diagnosis, staging, and management of COPD, Dr. Hanania said.

It consisted of a series of live half-day meetings conducted over a 3-month period that included short lectures, a video on correct use of inhaler devices, and small-group workshops that incorporated detailed case discussions and hands-on demonstrations and practice in the use of spirometry.

A total of 769 physicians attended the meetings. The investigators assessed the initiative's effectiveness with a case vignette–based survey, given to a randomly selected subset of 50 participants and 50 nonparticipants with similar demographics and practice characteristics.

The number of patients with COPD seen weekly was 11 for participants and 15 for nonparticipants. The mean number of years in practice was 28 and 24, respectively. And both groups were about equally divided between family physicians and internal medicine physicians. Participants were somewhat more likely to be in solo practice (45% vs. 38%) or work in a government facility (25% vs. 0%), and less likely to be in group practice (31% vs. 58%).

Survey results showed that in the area of diagnosis, the participants were more likely than the nonparticipants to recognize COPD in case vignettes of patients with dyspnea (90% vs. 74%, P = .007) and to be aware of the greater susceptibility of women compared with men to the harmful effects of smoking (90% vs. 54%, P less than .001).

Also, when asked which of several pathophysiologic features was one of COPD, participants were more likely to correctly answer alveolar destruction (94% vs. 74%, P = .007). (The other options were muscular deconditioning, synovial inflammation, and increased ventricular filling pressure.)

While the groups did not differ significantly in terms of how likely they were to use spirometry for diagnosis and staging of COPD, participants were more likely than nonparticipants to indicate that difficulty in obtaining spirometry results in the office setting was a very significant barrier to COPD management (27% vs. 12%). “Maybe they acknowledged that it is an important tool, but they cannot do it,” he commented.

The groups were statistically indistinguishable with respect to their approaches to caring for patients with repeated exacerbations and improving adherence, and their selection of appropriate maintenance therapy.

The survey also asked about barriers to managing COPD, according to Dr. Hanania.

In addition to difficulty with spirometry, the groups were similarly likely to rate as very significant a patient's nonadherence to a recommendation to stop smoking, the complexity of the medical regimen, and a lack of clarity about the staging of COPD severity.

A calculation of the initiative's quality of education index showed that participants were 50% more likely than nonparticipants to provide evidence-based, guideline-driven COPD care, Dr. Hanania reported. “We estimate that participation in this half-day program can potentially improve the care of many patients per week, but this needs to be further tested,” he commented.

“We did not attempt to look at long-term [outcomes] – retention of knowledge or practice change – which are very important,” Dr. Hanania acknowledged. But a similar, ongoing initiative, being conducted by the ACCP, is currently assessing impact on real-life practice.

That initiative is including not only physicians but also physician assistants and nurse practitioners, Dr. Hanania said. “In our primary care setting in the U.S., nonphysician extenders – PAs, nurse practitioners – play a major role in encountering COPD, and those are people we like to target.” Furthermore, their role will likely increase if health care reform proceeds and primary care physicians are overwhelmed by demand.

The initiative meetings were supported by an educational grant from Novartis Pharmaceuticals. Dr. Hanania had no relevant conflicts of interest.

Participants were 50% more likely than nonparticipants to provide evidence-based, guideline-driven COPD care.

Source DR. HANANIA

Major Finding: Participants were more likely than nonparticipants to know that alveolar destruction is a pathophysiologic feature of COPD (94% vs. 74%), to know that women are more susceptible than men to the harmful effects of smoking (90% vs. 54%), and to correctly identify COPD in patients with dyspnea (90% vs. 74%).

Data Source: A cross-sectional survey of 50 primary care physicians who participated in a COPD educational initiative and 50 similar primary care physicians who did not.

Disclosures: The initiative meetings were supported by an educational grant from Novartis Pharmaceuticals. Dr. Hanania did not have any conflicts of interest related to the study.

VANCOUVER, B.C. – A live, interactive, case-based educational initiative improved primary care physicians' knowledge of chronic obstructive pulmonary disease, according to study results reported at the meeting.

In a cross-sectional study of 50 primary care physicians who participated in the initiative and 50 similar nonparticipants, the former were more likely to know that alveolar destruction is a pathophysiologic feature of COPD (94% vs. 74%) and that women have greater susceptibility to the harmful effects of smoking (90% vs. 54%), according to Dr. Nicola A. Hanania and his coinvestigators.

Additionally, when presented with case vignettes, the participants were more likely to recognize the presence of COPD in dyspnea patients (90% vs. 74%).

“Even though this was sort of a one-time … cross-sectional survey, we believe that educational initiatives such as this one may at least improve the knowledge about COPD – both diagnosis and management,” commented Dr. Hanania, an associate professor of medicine at Baylor College of Medicine, Houston.

Explaining the need for primary care–focused efforts, he noted that “the majority of COPD patients are [seen] in the primary care arena.”

But statistics show that “COPD remains under-recognized and underdiagnosed in about 50% of the population out there, not only in the United States but in other countries as well. It also remains undertreated,” even though the GOLD (Global Initiative for Chronic Obstructive Lung Disease) guidelines now stress that it is a treatable disease.

The initiative studied – called Improving COPD Patient Outcomes: Breaking Down the Barriers to Optimal Care – was designed to improve primary care providers' knowledge and competency in the guideline-based diagnosis, staging, and management of COPD, Dr. Hanania said.

It consisted of a series of live half-day meetings conducted over a 3-month period that included short lectures, a video on correct use of inhaler devices, and small-group workshops that incorporated detailed case discussions and hands-on demonstrations and practice in the use of spirometry.

A total of 769 physicians attended the meetings. The investigators assessed the initiative's effectiveness with a case vignette–based survey, given to a randomly selected subset of 50 participants and 50 nonparticipants with similar demographics and practice characteristics.

The number of patients with COPD seen weekly was 11 for participants and 15 for nonparticipants. The mean number of years in practice was 28 and 24, respectively. And both groups were about equally divided between family physicians and internal medicine physicians. Participants were somewhat more likely to be in solo practice (45% vs. 38%) or work in a government facility (25% vs. 0%), and less likely to be in group practice (31% vs. 58%).

Survey results showed that in the area of diagnosis, the participants were more likely than the nonparticipants to recognize COPD in case vignettes of patients with dyspnea (90% vs. 74%, P = .007) and to be aware of the greater susceptibility of women compared with men to the harmful effects of smoking (90% vs. 54%, P less than .001).

Also, when asked which of several pathophysiologic features was one of COPD, participants were more likely to correctly answer alveolar destruction (94% vs. 74%, P = .007). (The other options were muscular deconditioning, synovial inflammation, and increased ventricular filling pressure.)

While the groups did not differ significantly in terms of how likely they were to use spirometry for diagnosis and staging of COPD, participants were more likely than nonparticipants to indicate that difficulty in obtaining spirometry results in the office setting was a very significant barrier to COPD management (27% vs. 12%). “Maybe they acknowledged that it is an important tool, but they cannot do it,” he commented.

The groups were statistically indistinguishable with respect to their approaches to caring for patients with repeated exacerbations and improving adherence, and their selection of appropriate maintenance therapy.

The survey also asked about barriers to managing COPD, according to Dr. Hanania.

In addition to difficulty with spirometry, the groups were similarly likely to rate as very significant a patient's nonadherence to a recommendation to stop smoking, the complexity of the medical regimen, and a lack of clarity about the staging of COPD severity.

A calculation of the initiative's quality of education index showed that participants were 50% more likely than nonparticipants to provide evidence-based, guideline-driven COPD care, Dr. Hanania reported. “We estimate that participation in this half-day program can potentially improve the care of many patients per week, but this needs to be further tested,” he commented.

“We did not attempt to look at long-term [outcomes] – retention of knowledge or practice change – which are very important,” Dr. Hanania acknowledged. But a similar, ongoing initiative, being conducted by the ACCP, is currently assessing impact on real-life practice.

That initiative is including not only physicians but also physician assistants and nurse practitioners, Dr. Hanania said. “In our primary care setting in the U.S., nonphysician extenders – PAs, nurse practitioners – play a major role in encountering COPD, and those are people we like to target.” Furthermore, their role will likely increase if health care reform proceeds and primary care physicians are overwhelmed by demand.

The initiative meetings were supported by an educational grant from Novartis Pharmaceuticals. Dr. Hanania had no relevant conflicts of interest.

Participants were 50% more likely than nonparticipants to provide evidence-based, guideline-driven COPD care.

Source DR. HANANIA

Major Finding: The percentage of hospitalizations that involved an antibiotic-resistant infection rose from 0.12% in 1997 to 0.46% in 2006. Patients with resistant infections were increasingly younger and less likely to have health insurance.

Data Source: A retrospective analysis of a weighted sample of 370.3 million U.S. hospitalizations.

Disclosures: Dr. Mainous did not report having any conflicts of interest related to the study.

SEATTLE – Antibiotic-resistant infections are becoming more common in hospitalizations, and the profile of patients with these infections is changing, according to a retrospective study of about 370 million U.S. hospitalizations spanning a recent 10-year period.

During 1997-2006, the percentage of those having a diagnosis of antibiotic-resistant infection nearly quadrupled, researchers reported at the meeting

The mean age of the patients with resistant infections fell by 22 years, and the proportion with health insurance decreased by 7%. In addition, those who were uninsured had a shorter length of stay than did their insured counterparts.

“There has been a steady upward trend,” said lead investigator Arch G. Mainous III, Ph.D. “Resistant infections now account for almost 2.5% of infection-related hospitalizations, and we have to assume that that will only go up.”

Better strategies to combat rising resistance are needed, both in the community (for example, a tighter control of physicians' prescribing practices and the elimination of avenues by which people obtain antibiotics without a prescription) and in hospitals (such as the use of better infection control measures), he said.

The findings suggest that insurance status may influence the care of inpatients with resistant infections, noted Dr. Mainous. “Either people without insurance are being discharged prematurely, or people with insurance are [being kept] in the hospital longer than they need to be [so that hospitals can] make money.”

The researchers analyzed data from the National Hospital Discharge Survey for the years 1997-2006. Survey participants are a nationally representative sample of short-stay, children's, and general hospitals. They evaluated hospitalizations by looking for diagnosis codes for infections and drug resistance. National estimates were based on a weighted 370.3 million hospitalizations.

Results showed that the annual number of infection-related hospitalizations with resistance rose by nearly 136,000 (or 327%) between 1997 and 2006, reported Dr. Mainous, a professor in the department of family medicine at the Medical University of South Carolina in Charleston.

Among all hospitalizations, the percentage having a diagnosis of resistant infection increased from 0.12% to 0.46%. And among just infection-related hospitalizations, the percentage having a diagnosis of resistance increased from 0.66% to 2.40%.

The mean age of patients having resistant infections fell sharply, from 65.7 years in 1997 to 44.2 years in 2006. The rise in these infections was greatest among patients younger than 18 years of age.

By far, the most common resistance found was to penicillin, with penicillin-resistant infections accounting for 94% of all resistant infections. Infections having isolated vancomycin resistance came in a distant second, at 3%.

In a favorable 10-year trend, hospitalizations that involved resistance were more likely to end in routine discharge.

Growing awareness of antibiotic resistance may have altered coding practices during the study period, Dr. Mainous acknowledged. Additionally, the study was limited by the inability to tell if infections arose in the hospital or in the community, and how severe they were.

Major Finding: The percentage of hospitalizations that involved an antibiotic-resistant infection rose from 0.12% in 1997 to 0.46% in 2006. Patients with resistant infections were increasingly younger and less likely to have health insurance.

Data Source: A retrospective analysis of a weighted sample of 370.3 million U.S. hospitalizations.

Disclosures: Dr. Mainous did not report having any conflicts of interest related to the study.

SEATTLE – Antibiotic-resistant infections are becoming more common in hospitalizations, and the profile of patients with these infections is changing, according to a retrospective study of about 370 million U.S. hospitalizations spanning a recent 10-year period.

During 1997-2006, the percentage of those having a diagnosis of antibiotic-resistant infection nearly quadrupled, researchers reported at the meeting

The mean age of the patients with resistant infections fell by 22 years, and the proportion with health insurance decreased by 7%. In addition, those who were uninsured had a shorter length of stay than did their insured counterparts.

“There has been a steady upward trend,” said lead investigator Arch G. Mainous III, Ph.D. “Resistant infections now account for almost 2.5% of infection-related hospitalizations, and we have to assume that that will only go up.”

Better strategies to combat rising resistance are needed, both in the community (for example, a tighter control of physicians' prescribing practices and the elimination of avenues by which people obtain antibiotics without a prescription) and in hospitals (such as the use of better infection control measures), he said.

The findings suggest that insurance status may influence the care of inpatients with resistant infections, noted Dr. Mainous. “Either people without insurance are being discharged prematurely, or people with insurance are [being kept] in the hospital longer than they need to be [so that hospitals can] make money.”

The researchers analyzed data from the National Hospital Discharge Survey for the years 1997-2006. Survey participants are a nationally representative sample of short-stay, children's, and general hospitals. They evaluated hospitalizations by looking for diagnosis codes for infections and drug resistance. National estimates were based on a weighted 370.3 million hospitalizations.

Results showed that the annual number of infection-related hospitalizations with resistance rose by nearly 136,000 (or 327%) between 1997 and 2006, reported Dr. Mainous, a professor in the department of family medicine at the Medical University of South Carolina in Charleston.

Among all hospitalizations, the percentage having a diagnosis of resistant infection increased from 0.12% to 0.46%. And among just infection-related hospitalizations, the percentage having a diagnosis of resistance increased from 0.66% to 2.40%.

The mean age of patients having resistant infections fell sharply, from 65.7 years in 1997 to 44.2 years in 2006. The rise in these infections was greatest among patients younger than 18 years of age.

By far, the most common resistance found was to penicillin, with penicillin-resistant infections accounting for 94% of all resistant infections. Infections having isolated vancomycin resistance came in a distant second, at 3%.

In a favorable 10-year trend, hospitalizations that involved resistance were more likely to end in routine discharge.

Growing awareness of antibiotic resistance may have altered coding practices during the study period, Dr. Mainous acknowledged. Additionally, the study was limited by the inability to tell if infections arose in the hospital or in the community, and how severe they were.

Major Finding: The percentage of hospitalizations that involved an antibiotic-resistant infection rose from 0.12% in 1997 to 0.46% in 2006. Patients with resistant infections were increasingly younger and less likely to have health insurance.

Data Source: A retrospective analysis of a weighted sample of 370.3 million U.S. hospitalizations.

Disclosures: Dr. Mainous did not report having any conflicts of interest related to the study.

SEATTLE – Antibiotic-resistant infections are becoming more common in hospitalizations, and the profile of patients with these infections is changing, according to a retrospective study of about 370 million U.S. hospitalizations spanning a recent 10-year period.

During 1997-2006, the percentage of those having a diagnosis of antibiotic-resistant infection nearly quadrupled, researchers reported at the meeting

The mean age of the patients with resistant infections fell by 22 years, and the proportion with health insurance decreased by 7%. In addition, those who were uninsured had a shorter length of stay than did their insured counterparts.

“There has been a steady upward trend,” said lead investigator Arch G. Mainous III, Ph.D. “Resistant infections now account for almost 2.5% of infection-related hospitalizations, and we have to assume that that will only go up.”

Better strategies to combat rising resistance are needed, both in the community (for example, a tighter control of physicians' prescribing practices and the elimination of avenues by which people obtain antibiotics without a prescription) and in hospitals (such as the use of better infection control measures), he said.

The findings suggest that insurance status may influence the care of inpatients with resistant infections, noted Dr. Mainous. “Either people without insurance are being discharged prematurely, or people with insurance are [being kept] in the hospital longer than they need to be [so that hospitals can] make money.”

The researchers analyzed data from the National Hospital Discharge Survey for the years 1997-2006. Survey participants are a nationally representative sample of short-stay, children's, and general hospitals. They evaluated hospitalizations by looking for diagnosis codes for infections and drug resistance. National estimates were based on a weighted 370.3 million hospitalizations.

Results showed that the annual number of infection-related hospitalizations with resistance rose by nearly 136,000 (or 327%) between 1997 and 2006, reported Dr. Mainous, a professor in the department of family medicine at the Medical University of South Carolina in Charleston.

Among all hospitalizations, the percentage having a diagnosis of resistant infection increased from 0.12% to 0.46%. And among just infection-related hospitalizations, the percentage having a diagnosis of resistance increased from 0.66% to 2.40%.

The mean age of patients having resistant infections fell sharply, from 65.7 years in 1997 to 44.2 years in 2006. The rise in these infections was greatest among patients younger than 18 years of age.

By far, the most common resistance found was to penicillin, with penicillin-resistant infections accounting for 94% of all resistant infections. Infections having isolated vancomycin resistance came in a distant second, at 3%.

In a favorable 10-year trend, hospitalizations that involved resistance were more likely to end in routine discharge.

Growing awareness of antibiotic resistance may have altered coding practices during the study period, Dr. Mainous acknowledged. Additionally, the study was limited by the inability to tell if infections arose in the hospital or in the community, and how severe they were.

Major Finding: Some 24% of refrigerators used to store DTaP vaccine experienced freezing temperatures. The higher the percentage of refrigerators with prolonged freezing in a health region, the higher that region's rate of pertussis.

Data Source: An observational study of 54 vaccine refrigerators in 13 community health centers having about 580,000 outpatient visits annually.

Disclosures: Dr. McColloster said he did not have any conflicts of interest related to the study.

SEATTLE – Inadvertent freezing of the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine while it is being stored in vaccine refrigerators may be contributing to the rise in pertussis in the community, new data suggest.

Using continuous data loggers, investigators at the Baylor College of Medicine in Houston found that one-quarter of 54 vaccine refrigerators in the city's community health centers had temperatures that dipped into the freezing range, most commonly at night and on weekends.

There was a significant 76% correlation between the percentage of vaccine refrigerators in a health region that had prolonged freezing temperatures and that region's rate of pertussis, the investigators reported at the meeting.

The study establishes only correlation, and there are many possible confounders and explanations, said investigator Dr. Patrick J. McColloster, an associate professor of family medicine at the college.

“But I think though that one thing that has been neglected in looking at the pertussis outbreaks in the United States is inadvertent freezing and the instability of DTaP – back to the cold chain again,” he said, referring to the practice of ensuring that the vaccine is continuously kept at the recommended temperature.

In interviews, nursing staff at the centers were skeptical of the freezing because they more often noticed warm temperatures during the workday, he commented. “Whenever they opened and closed the refrigerator doors, they always made sure [the temperature] was within normal range, and if it was a little too hot, they would just crank the refrigerator up a bit more. So basically, they were freezing the vaccines like crazy.”

Explaining the rationale for the study, Dr. McColloster noted that the incidence of pertussis fell in the 10 years after introduction of the DTP (diphtheria, tetanus, pertussis) vaccine, but it actually rose in the 9 years after subsequent introduction of the DTaP vaccine.

“All the studies that are out there are saying it's due to seasonal variation, unvaccinated pediatric clusters, and declining adult immunity,” Dr. McColloster said. “Gee, it doesn't have anything to do with DTaP, does it?”

The impact of failure of the vaccine cold chain on the occurrence of pertussis has not been studied in the United States. “DTaP uses aluminum as an adjuvant (just like DTP does), but it's a little bit different in that it's more sensitive to freezing,” he explained. In fact, the manufacturer recommends discarding any vaccine exposed to freezing temperatures.

In the study, the investigators attached data loggers to 54 vaccine refrigerators in 13 Community Health Centers in the Harris County Hospital District of Houston. The centers provide approximately 580,000 outpatient visits each year to an indigent population.

The loggers sampled the refrigerator temperature every minute for at least 6 days. Data from the first hour were discarded to allow the logger's temperature to equilibrate.

The centers' own procedure for cold chain monitoring consisted of twice-daily readings from approved digital thermometers during weekday work hours, as mandated by the Centers for Disease Control and Prevention.

The investigators obtained data on the incidence of pertussis in the district for the years 2005-2009 from the City of Houston Health Department.

Results showed that 48% of refrigerators maintained temperature in the correct range (2°C to 8°C), Dr. McColloster reported. But 19% experienced cold temperatures (0.1°C to 1.9°C) and 24% experienced freezing ones (0°C or lower). The remaining 9% had temperatures rising into the warm range (greater than 8°C), but this usually was so transient that it was unlikely to alter temperature of the vaccine itself, he said.

Among the refrigerators with freezing temperatures, the average time spent at freezing was 2 hours per day. Freezing usually occurred on nights and over weekends.

Across the six health regions within the district, the percentage of refrigerators in the region having freezing temperatures for more than 2 hours daily ranged from 14% to 80%. And the average annual pertussis rate ranged from 2.9 to 6.3 cases per 100,000 population.

The higher the percentage of refrigerators in a region experiencing freezing temperatures for more than 2 hours daily, the higher the pertussis rate for that region (P less than .05), Dr. McColloster reported.

Major Finding: Some 24% of refrigerators used to store DTaP vaccine experienced freezing temperatures. The higher the percentage of refrigerators with prolonged freezing in a health region, the higher that region's rate of pertussis.

Data Source: An observational study of 54 vaccine refrigerators in 13 community health centers having about 580,000 outpatient visits annually.

Disclosures: Dr. McColloster said he did not have any conflicts of interest related to the study.

SEATTLE – Inadvertent freezing of the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine while it is being stored in vaccine refrigerators may be contributing to the rise in pertussis in the community, new data suggest.

Using continuous data loggers, investigators at the Baylor College of Medicine in Houston found that one-quarter of 54 vaccine refrigerators in the city's community health centers had temperatures that dipped into the freezing range, most commonly at night and on weekends.

There was a significant 76% correlation between the percentage of vaccine refrigerators in a health region that had prolonged freezing temperatures and that region's rate of pertussis, the investigators reported at the meeting.

The study establishes only correlation, and there are many possible confounders and explanations, said investigator Dr. Patrick J. McColloster, an associate professor of family medicine at the college.

“But I think though that one thing that has been neglected in looking at the pertussis outbreaks in the United States is inadvertent freezing and the instability of DTaP – back to the cold chain again,” he said, referring to the practice of ensuring that the vaccine is continuously kept at the recommended temperature.

In interviews, nursing staff at the centers were skeptical of the freezing because they more often noticed warm temperatures during the workday, he commented. “Whenever they opened and closed the refrigerator doors, they always made sure [the temperature] was within normal range, and if it was a little too hot, they would just crank the refrigerator up a bit more. So basically, they were freezing the vaccines like crazy.”

Explaining the rationale for the study, Dr. McColloster noted that the incidence of pertussis fell in the 10 years after introduction of the DTP (diphtheria, tetanus, pertussis) vaccine, but it actually rose in the 9 years after subsequent introduction of the DTaP vaccine.

“All the studies that are out there are saying it's due to seasonal variation, unvaccinated pediatric clusters, and declining adult immunity,” Dr. McColloster said. “Gee, it doesn't have anything to do with DTaP, does it?”

The impact of failure of the vaccine cold chain on the occurrence of pertussis has not been studied in the United States. “DTaP uses aluminum as an adjuvant (just like DTP does), but it's a little bit different in that it's more sensitive to freezing,” he explained. In fact, the manufacturer recommends discarding any vaccine exposed to freezing temperatures.

In the study, the investigators attached data loggers to 54 vaccine refrigerators in 13 Community Health Centers in the Harris County Hospital District of Houston. The centers provide approximately 580,000 outpatient visits each year to an indigent population.

The loggers sampled the refrigerator temperature every minute for at least 6 days. Data from the first hour were discarded to allow the logger's temperature to equilibrate.

The centers' own procedure for cold chain monitoring consisted of twice-daily readings from approved digital thermometers during weekday work hours, as mandated by the Centers for Disease Control and Prevention.

The investigators obtained data on the incidence of pertussis in the district for the years 2005-2009 from the City of Houston Health Department.

Results showed that 48% of refrigerators maintained temperature in the correct range (2°C to 8°C), Dr. McColloster reported. But 19% experienced cold temperatures (0.1°C to 1.9°C) and 24% experienced freezing ones (0°C or lower). The remaining 9% had temperatures rising into the warm range (greater than 8°C), but this usually was so transient that it was unlikely to alter temperature of the vaccine itself, he said.

Among the refrigerators with freezing temperatures, the average time spent at freezing was 2 hours per day. Freezing usually occurred on nights and over weekends.

Across the six health regions within the district, the percentage of refrigerators in the region having freezing temperatures for more than 2 hours daily ranged from 14% to 80%. And the average annual pertussis rate ranged from 2.9 to 6.3 cases per 100,000 population.

The higher the percentage of refrigerators in a region experiencing freezing temperatures for more than 2 hours daily, the higher the pertussis rate for that region (P less than .05), Dr. McColloster reported.

Major Finding: Some 24% of refrigerators used to store DTaP vaccine experienced freezing temperatures. The higher the percentage of refrigerators with prolonged freezing in a health region, the higher that region's rate of pertussis.

Data Source: An observational study of 54 vaccine refrigerators in 13 community health centers having about 580,000 outpatient visits annually.

Disclosures: Dr. McColloster said he did not have any conflicts of interest related to the study.

SEATTLE – Inadvertent freezing of the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine while it is being stored in vaccine refrigerators may be contributing to the rise in pertussis in the community, new data suggest.

Using continuous data loggers, investigators at the Baylor College of Medicine in Houston found that one-quarter of 54 vaccine refrigerators in the city's community health centers had temperatures that dipped into the freezing range, most commonly at night and on weekends.

There was a significant 76% correlation between the percentage of vaccine refrigerators in a health region that had prolonged freezing temperatures and that region's rate of pertussis, the investigators reported at the meeting.

The study establishes only correlation, and there are many possible confounders and explanations, said investigator Dr. Patrick J. McColloster, an associate professor of family medicine at the college.

“But I think though that one thing that has been neglected in looking at the pertussis outbreaks in the United States is inadvertent freezing and the instability of DTaP – back to the cold chain again,” he said, referring to the practice of ensuring that the vaccine is continuously kept at the recommended temperature.

In interviews, nursing staff at the centers were skeptical of the freezing because they more often noticed warm temperatures during the workday, he commented. “Whenever they opened and closed the refrigerator doors, they always made sure [the temperature] was within normal range, and if it was a little too hot, they would just crank the refrigerator up a bit more. So basically, they were freezing the vaccines like crazy.”

Explaining the rationale for the study, Dr. McColloster noted that the incidence of pertussis fell in the 10 years after introduction of the DTP (diphtheria, tetanus, pertussis) vaccine, but it actually rose in the 9 years after subsequent introduction of the DTaP vaccine.

“All the studies that are out there are saying it's due to seasonal variation, unvaccinated pediatric clusters, and declining adult immunity,” Dr. McColloster said. “Gee, it doesn't have anything to do with DTaP, does it?”

The impact of failure of the vaccine cold chain on the occurrence of pertussis has not been studied in the United States. “DTaP uses aluminum as an adjuvant (just like DTP does), but it's a little bit different in that it's more sensitive to freezing,” he explained. In fact, the manufacturer recommends discarding any vaccine exposed to freezing temperatures.

In the study, the investigators attached data loggers to 54 vaccine refrigerators in 13 Community Health Centers in the Harris County Hospital District of Houston. The centers provide approximately 580,000 outpatient visits each year to an indigent population.

The loggers sampled the refrigerator temperature every minute for at least 6 days. Data from the first hour were discarded to allow the logger's temperature to equilibrate.

The centers' own procedure for cold chain monitoring consisted of twice-daily readings from approved digital thermometers during weekday work hours, as mandated by the Centers for Disease Control and Prevention.

The investigators obtained data on the incidence of pertussis in the district for the years 2005-2009 from the City of Houston Health Department.

Results showed that 48% of refrigerators maintained temperature in the correct range (2°C to 8°C), Dr. McColloster reported. But 19% experienced cold temperatures (0.1°C to 1.9°C) and 24% experienced freezing ones (0°C or lower). The remaining 9% had temperatures rising into the warm range (greater than 8°C), but this usually was so transient that it was unlikely to alter temperature of the vaccine itself, he said.

Among the refrigerators with freezing temperatures, the average time spent at freezing was 2 hours per day. Freezing usually occurred on nights and over weekends.

Across the six health regions within the district, the percentage of refrigerators in the region having freezing temperatures for more than 2 hours daily ranged from 14% to 80%. And the average annual pertussis rate ranged from 2.9 to 6.3 cases per 100,000 population.

The higher the percentage of refrigerators in a region experiencing freezing temperatures for more than 2 hours daily, the higher the pertussis rate for that region (P less than .05), Dr. McColloster reported.

VANCOUVER, B.C. – Chest physicians must consider a slew of diagnostic possibilities when evaluating patients with rheumatoid arthritis who have developed pulmonary abnormalities, according to Dr. Kevin R. Flaherty.

"We have to keep in mind all the different things that can go wrong in these patients when we are trying to treat them: Is this progression of the underlying disease? Is this a complication of the therapy? Or is this the development of something new, like a cancer, that’s now causing the patient’s symptoms?" he commented.

"Trying to keep all those things in our mind to sort that out is difficult, and it’s an exercise that we have to go through each and every time we see one of these patients," he told attendees at the annual meeting of the American College of Chest Physicians.

Pulmonary Manifestations of RA

"The lung is a common site for extra-articular rheumatoid arthritis," noted Dr. Flaherty, who is a pulmonologist and associate professor at the University of Michigan Health System in Ann Arbor. Of the many pulmonary manifestations of RA, interstitial lung disease causes the greatest morbidity and mortality.

The lifetime risk of interstitial lung disease is nearly 8% in patients with RA, compared with 1% in the general population (Arthritis Rheum. 2010;62:1583-91). And this disease confers a poor prognosis, with a near tripling of the risk of death and with a median survival after diagnosis of only about 2.5 years.

High-resolution computed tomography (HRCT) and pulmonary functioning testing appear to be useful for identifying interstitial lung disease early in its course, according to Dr. Flaherty.

For example, among patients within 2 years of a RA diagnosis, 44% have been found to have HRCT, pulmonary function test, and other abnormalities consistent with interstitial lung disease in the absence of symptoms (Am. J. Respir. Crit. Care Med. 1997;156:528-35).

"The [HRCT] features were mild – reticular thickening, ground glass, and not much honeycombing – suggesting maybe that we might be able to impact the disease, because I think once you get to honeycomb lung and end-stage fibrosis, our ability to impact this disease is likely to be lower," he said.

Another study among patients with recent-onset RA found abnormalities on HRCT but normal results on pulmonary function tests (Scand. J. Rheumatol. 2007;36:338-44), "suggesting that symptoms and pulmonary screening are not going to be as sensitive as HRCT screening."

As for which patients to screen for interstitial lung disease, the predictors of abnormal pulmonary function testing in the RA population are respiratory symptoms, smoking, anti–cyclic citrullinated peptide positivity, and use of prednisone (Arthritis Res. Ther. 2010;12:R104).

When it comes to monitoring interstitial lung disease, HRCT appears to be more sensitive than pulmonary function testing for detecting disease progression (Arch. Intern. Med. 2008;168:159-66). And carbon monoxide diffusing capacity at diagnosis is the best predictor of progression (Ann. Rheum. Dis. 2002;61:517-21).

"We are starting ... to see data emerging that really mirrors what we see in idiopathic lung disease, that the histopathology and the CT appearance can help us in terms of stratifying patients for risk of subsequent mortality," Dr. Flaherty said.

For example, a study of patients with RA-associated interstitial lung disease found 50% mortality in those with a usual interstitial pneumonia (UIP) histology, compared with none in those with a nonspecific interstitial pneumonia (NSIP) histology after a similar median follow-up of about 4 years (Chest 2005;127:2019-27).

A honeycomb pattern on HRCT was found only in the UIP group, suggesting that this radiographic pattern is a good surrogate for this histology, Dr. Flaherty noted. And indeed, patients having a definite UIP radiographic appearance have poorer survival (Eur. Respir. J. 2010;35:1322-8).

Rigorous studies are lacking when it comes to treating interstitial lung disease in the RA population, according to Dr. Flaherty. Case reports, case series, and retrospective analyses have assessed many immunomodulating and immunosuppressive agents, but "what we are really begging for are some prospective, well done clinical trials to help us sort all of these potential treatments out," he said.

Pulmonary Adverse Effects of RA Therapy

Pneumonitis is often a concern in patients using methotrexate to treat RA. But with low-dose therapy, only 3% of patients develop this complication after a mean treatment duration of 23 months (Chest 1996;109:933-8). "So we worry about it, but yet it’s actually a very small number of patients that develop methotrexate toxicity," Dr. Flaherty pointed out.

Anti–tumor necrosis factor (TNF) agents such as infliximab have been associated with pulmonary adverse effects and complications, including infection, atypical presentation of tuberculosis, and pulmonary fibrosis. With the last, "patients have cough and dyspnea, it can occur within months of initiating treatment, and it can be associated with high mortality," he said.

Some reports have also raised concern that anti-TNF agents may hasten progression of interstitial lung disease in patients with RA and thus increase mortality.

"The data on that are still out," Dr. Flaherty said. Evidence thus far suggests that mortality in patients treated with these agents is similar to that in their counterparts treated with traditional disease-modifying antirheumatic drugs (Ann. Rheum. Dis. 2010;69:1086-91).

Rituximab has been linked to severe infections in patients with RA, the largest share of which (40%) are pulmonary (Arthritis Rheum. 2010;62:2625-32). Only a single infection was opportunistic, and most were bacterial.

Pulmonary Cancers

Patients with RA have increased risk of lung cancer (standardized incidence ratio, 1.63) as well as for another malignancy that can involve the lung, lymphoma (Arthritis Res. Ther. 2008;10:R45), as a result of their underlying disease, long-term immunosuppression, or both.

Treatment with biologic agents has not been associated with a significantly elevated risk of lung cancer among patients with RA, according to Dr. Flaherty. But treatment with methotrexate has, with the incidence of lung cancer among methotrexate users about triple that of the general population (Arthritis Rheum. 2008;59:794-9). Users of this drug also have sharply increased rates of non-Hodgkin’s lymphoma and melanoma.

"So as we are seeing [patients] with pulmonary manifestations, we have to keep in mind their risk of cancers as well," he recommended.

Dr. Flaherty did not report any disclosures.

VANCOUVER, B.C. – Chest physicians must consider a slew of diagnostic possibilities when evaluating patients with rheumatoid arthritis who have developed pulmonary abnormalities, according to Dr. Kevin R. Flaherty.

"We have to keep in mind all the different things that can go wrong in these patients when we are trying to treat them: Is this progression of the underlying disease? Is this a complication of the therapy? Or is this the development of something new, like a cancer, that’s now causing the patient’s symptoms?" he commented.

"Trying to keep all those things in our mind to sort that out is difficult, and it’s an exercise that we have to go through each and every time we see one of these patients," he told attendees at the annual meeting of the American College of Chest Physicians.

Pulmonary Manifestations of RA

"The lung is a common site for extra-articular rheumatoid arthritis," noted Dr. Flaherty, who is a pulmonologist and associate professor at the University of Michigan Health System in Ann Arbor. Of the many pulmonary manifestations of RA, interstitial lung disease causes the greatest morbidity and mortality.

The lifetime risk of interstitial lung disease is nearly 8% in patients with RA, compared with 1% in the general population (Arthritis Rheum. 2010;62:1583-91). And this disease confers a poor prognosis, with a near tripling of the risk of death and with a median survival after diagnosis of only about 2.5 years.

High-resolution computed tomography (HRCT) and pulmonary functioning testing appear to be useful for identifying interstitial lung disease early in its course, according to Dr. Flaherty.

For example, among patients within 2 years of a RA diagnosis, 44% have been found to have HRCT, pulmonary function test, and other abnormalities consistent with interstitial lung disease in the absence of symptoms (Am. J. Respir. Crit. Care Med. 1997;156:528-35).

"The [HRCT] features were mild – reticular thickening, ground glass, and not much honeycombing – suggesting maybe that we might be able to impact the disease, because I think once you get to honeycomb lung and end-stage fibrosis, our ability to impact this disease is likely to be lower," he said.

Another study among patients with recent-onset RA found abnormalities on HRCT but normal results on pulmonary function tests (Scand. J. Rheumatol. 2007;36:338-44), "suggesting that symptoms and pulmonary screening are not going to be as sensitive as HRCT screening."

As for which patients to screen for interstitial lung disease, the predictors of abnormal pulmonary function testing in the RA population are respiratory symptoms, smoking, anti–cyclic citrullinated peptide positivity, and use of prednisone (Arthritis Res. Ther. 2010;12:R104).

When it comes to monitoring interstitial lung disease, HRCT appears to be more sensitive than pulmonary function testing for detecting disease progression (Arch. Intern. Med. 2008;168:159-66). And carbon monoxide diffusing capacity at diagnosis is the best predictor of progression (Ann. Rheum. Dis. 2002;61:517-21).

"We are starting ... to see data emerging that really mirrors what we see in idiopathic lung disease, that the histopathology and the CT appearance can help us in terms of stratifying patients for risk of subsequent mortality," Dr. Flaherty said.

For example, a study of patients with RA-associated interstitial lung disease found 50% mortality in those with a usual interstitial pneumonia (UIP) histology, compared with none in those with a nonspecific interstitial pneumonia (NSIP) histology after a similar median follow-up of about 4 years (Chest 2005;127:2019-27).

A honeycomb pattern on HRCT was found only in the UIP group, suggesting that this radiographic pattern is a good surrogate for this histology, Dr. Flaherty noted. And indeed, patients having a definite UIP radiographic appearance have poorer survival (Eur. Respir. J. 2010;35:1322-8).

Rigorous studies are lacking when it comes to treating interstitial lung disease in the RA population, according to Dr. Flaherty. Case reports, case series, and retrospective analyses have assessed many immunomodulating and immunosuppressive agents, but "what we are really begging for are some prospective, well done clinical trials to help us sort all of these potential treatments out," he said.

Pulmonary Adverse Effects of RA Therapy

Pneumonitis is often a concern in patients using methotrexate to treat RA. But with low-dose therapy, only 3% of patients develop this complication after a mean treatment duration of 23 months (Chest 1996;109:933-8). "So we worry about it, but yet it’s actually a very small number of patients that develop methotrexate toxicity," Dr. Flaherty pointed out.

Anti–tumor necrosis factor (TNF) agents such as infliximab have been associated with pulmonary adverse effects and complications, including infection, atypical presentation of tuberculosis, and pulmonary fibrosis. With the last, "patients have cough and dyspnea, it can occur within months of initiating treatment, and it can be associated with high mortality," he said.

Some reports have also raised concern that anti-TNF agents may hasten progression of interstitial lung disease in patients with RA and thus increase mortality.

"The data on that are still out," Dr. Flaherty said. Evidence thus far suggests that mortality in patients treated with these agents is similar to that in their counterparts treated with traditional disease-modifying antirheumatic drugs (Ann. Rheum. Dis. 2010;69:1086-91).

Rituximab has been linked to severe infections in patients with RA, the largest share of which (40%) are pulmonary (Arthritis Rheum. 2010;62:2625-32). Only a single infection was opportunistic, and most were bacterial.

Pulmonary Cancers

Patients with RA have increased risk of lung cancer (standardized incidence ratio, 1.63) as well as for another malignancy that can involve the lung, lymphoma (Arthritis Res. Ther. 2008;10:R45), as a result of their underlying disease, long-term immunosuppression, or both.

Treatment with biologic agents has not been associated with a significantly elevated risk of lung cancer among patients with RA, according to Dr. Flaherty. But treatment with methotrexate has, with the incidence of lung cancer among methotrexate users about triple that of the general population (Arthritis Rheum. 2008;59:794-9). Users of this drug also have sharply increased rates of non-Hodgkin’s lymphoma and melanoma.

"So as we are seeing [patients] with pulmonary manifestations, we have to keep in mind their risk of cancers as well," he recommended.

Dr. Flaherty did not report any disclosures.

VANCOUVER, B.C. – Chest physicians must consider a slew of diagnostic possibilities when evaluating patients with rheumatoid arthritis who have developed pulmonary abnormalities, according to Dr. Kevin R. Flaherty.

"We have to keep in mind all the different things that can go wrong in these patients when we are trying to treat them: Is this progression of the underlying disease? Is this a complication of the therapy? Or is this the development of something new, like a cancer, that’s now causing the patient’s symptoms?" he commented.

"Trying to keep all those things in our mind to sort that out is difficult, and it’s an exercise that we have to go through each and every time we see one of these patients," he told attendees at the annual meeting of the American College of Chest Physicians.

Pulmonary Manifestations of RA

"The lung is a common site for extra-articular rheumatoid arthritis," noted Dr. Flaherty, who is a pulmonologist and associate professor at the University of Michigan Health System in Ann Arbor. Of the many pulmonary manifestations of RA, interstitial lung disease causes the greatest morbidity and mortality.

The lifetime risk of interstitial lung disease is nearly 8% in patients with RA, compared with 1% in the general population (Arthritis Rheum. 2010;62:1583-91). And this disease confers a poor prognosis, with a near tripling of the risk of death and with a median survival after diagnosis of only about 2.5 years.

High-resolution computed tomography (HRCT) and pulmonary functioning testing appear to be useful for identifying interstitial lung disease early in its course, according to Dr. Flaherty.

For example, among patients within 2 years of a RA diagnosis, 44% have been found to have HRCT, pulmonary function test, and other abnormalities consistent with interstitial lung disease in the absence of symptoms (Am. J. Respir. Crit. Care Med. 1997;156:528-35).

"The [HRCT] features were mild – reticular thickening, ground glass, and not much honeycombing – suggesting maybe that we might be able to impact the disease, because I think once you get to honeycomb lung and end-stage fibrosis, our ability to impact this disease is likely to be lower," he said.

Another study among patients with recent-onset RA found abnormalities on HRCT but normal results on pulmonary function tests (Scand. J. Rheumatol. 2007;36:338-44), "suggesting that symptoms and pulmonary screening are not going to be as sensitive as HRCT screening."

As for which patients to screen for interstitial lung disease, the predictors of abnormal pulmonary function testing in the RA population are respiratory symptoms, smoking, anti–cyclic citrullinated peptide positivity, and use of prednisone (Arthritis Res. Ther. 2010;12:R104).

When it comes to monitoring interstitial lung disease, HRCT appears to be more sensitive than pulmonary function testing for detecting disease progression (Arch. Intern. Med. 2008;168:159-66). And carbon monoxide diffusing capacity at diagnosis is the best predictor of progression (Ann. Rheum. Dis. 2002;61:517-21).

"We are starting ... to see data emerging that really mirrors what we see in idiopathic lung disease, that the histopathology and the CT appearance can help us in terms of stratifying patients for risk of subsequent mortality," Dr. Flaherty said.

For example, a study of patients with RA-associated interstitial lung disease found 50% mortality in those with a usual interstitial pneumonia (UIP) histology, compared with none in those with a nonspecific interstitial pneumonia (NSIP) histology after a similar median follow-up of about 4 years (Chest 2005;127:2019-27).

A honeycomb pattern on HRCT was found only in the UIP group, suggesting that this radiographic pattern is a good surrogate for this histology, Dr. Flaherty noted. And indeed, patients having a definite UIP radiographic appearance have poorer survival (Eur. Respir. J. 2010;35:1322-8).

Rigorous studies are lacking when it comes to treating interstitial lung disease in the RA population, according to Dr. Flaherty. Case reports, case series, and retrospective analyses have assessed many immunomodulating and immunosuppressive agents, but "what we are really begging for are some prospective, well done clinical trials to help us sort all of these potential treatments out," he said.

Pulmonary Adverse Effects of RA Therapy

Pneumonitis is often a concern in patients using methotrexate to treat RA. But with low-dose therapy, only 3% of patients develop this complication after a mean treatment duration of 23 months (Chest 1996;109:933-8). "So we worry about it, but yet it’s actually a very small number of patients that develop methotrexate toxicity," Dr. Flaherty pointed out.

Anti–tumor necrosis factor (TNF) agents such as infliximab have been associated with pulmonary adverse effects and complications, including infection, atypical presentation of tuberculosis, and pulmonary fibrosis. With the last, "patients have cough and dyspnea, it can occur within months of initiating treatment, and it can be associated with high mortality," he said.

Some reports have also raised concern that anti-TNF agents may hasten progression of interstitial lung disease in patients with RA and thus increase mortality.

"The data on that are still out," Dr. Flaherty said. Evidence thus far suggests that mortality in patients treated with these agents is similar to that in their counterparts treated with traditional disease-modifying antirheumatic drugs (Ann. Rheum. Dis. 2010;69:1086-91).

Rituximab has been linked to severe infections in patients with RA, the largest share of which (40%) are pulmonary (Arthritis Rheum. 2010;62:2625-32). Only a single infection was opportunistic, and most were bacterial.

Pulmonary Cancers

Patients with RA have increased risk of lung cancer (standardized incidence ratio, 1.63) as well as for another malignancy that can involve the lung, lymphoma (Arthritis Res. Ther. 2008;10:R45), as a result of their underlying disease, long-term immunosuppression, or both.

Treatment with biologic agents has not been associated with a significantly elevated risk of lung cancer among patients with RA, according to Dr. Flaherty. But treatment with methotrexate has, with the incidence of lung cancer among methotrexate users about triple that of the general population (Arthritis Rheum. 2008;59:794-9). Users of this drug also have sharply increased rates of non-Hodgkin’s lymphoma and melanoma.

"So as we are seeing [patients] with pulmonary manifestations, we have to keep in mind their risk of cancers as well," he recommended.

Dr. Flaherty did not report any disclosures.

SEATTLE – Syncope and seizures went unrecognized as warning signs of impending sudden cardiac arrest in children and young adults, based on the results of a retrospective survey of 20 families whose children had these antecedent events.

Parental reports showed that the children fainted or had a seizure without apparent reason an average of three times before sudden cardiac arrest (SCA), according to survey results presented at the annual meeting of the North American Primary Care Research Group.

Half of them did not receive an electrocardiogram (ECG) as part of their medical evaluation for these events, either because they did not see a provider or because they saw a provider but the test was not done. Yet, some of this group had cardiac pathologies that might have been detected by the test.

"Syncope and unexplained seizure activity remain unrecognized for the most part as potential warning signs of intrinsic cardiac disorders that may lead to sudden cardiac arrest," said presenting investigator Dr. Jonathan A. Drezner, a family physician specializing in sports medicine at the University of Washington, Seattle, and team physician for the Seattle Seahawks and University of Washington Huskies.

"I strongly believe that all cases of apparently benign syncope or unexplained seizure activity deserve at minimum an ECG and probably more cardiovascular workup," he recommended.

Dr. Drezner also called for better physician education to promote cardiac evaluation in this population. In particular, "ECG is not a standard part of the workup for syncope, and it needs to be," he asserted. "That message is so simple and can be so clear. But that message is not getting out."

In an earlier study, he and his colleagues retrospectively surveyed 78 families from Parent Heart Watch, a national organization of families having children who experienced (and usually died from) SCA, about a range of antecedent symptoms.

In a finding that Dr. Drezner described as alarming, 18% of these children had at least one syncopal event and 13% had at least one unexplained seizure before their SCA.

He acknowledged that there may have been some overreporting. But "these are not things that are, probably at least not as much, affected by bias from the survey and patient population – these are actually objective events that represent true warning signs of cardiovascular disease."

To assess the medical evaluation of this subset of children, the investigators sent a follow-up survey and requested telephone interviews with their 24 families.

In all, 20 families responded: 12 whose children had syncope and 8 whose children had seizures before SCA. On average, the children were about 12 years old when these symptoms began (range, 4-20 years). Age at SCA ranged from 5 to 29 years.

A striking finding, according to Dr. Drezner, was that the children had a mean of three syncopal or seizure events, with some having as many as 10 events.

This "was not a single event – these were multiple events," he commented. "These children in some way were sort of telling you something was wrong ... and perhaps maybe not identified" with multiple events, he said.

Of the 12 children who had syncope, 7 were evaluated only by their primary care provider, 1 was evaluated only by a cardiologist, 2 were evaluated by both, and 2 were evaluated by neither.

Six of these children did not receive an ECG: four who saw only their primary care provider and did not have the test, and two who saw neither provider.

"If you look at the ultimate cause of death in these individuals, these are actually detectable –and perhaps preventable – [causes of] sudden deaths that could have been detected by an electrocardiogram," Dr. Drezner pointed out.

Final diagnoses in these children and young adults who did not get an ECG were long QT syndrome, arrhythmia, myocarditis, intramural coronary artery, and autopsy-negative sudden unexplained death.

Of the eight children who had unexplained seizures, three were evaluated only by a neurologist, one was evaluated only by a cardiologist, two were evaluated by both, and two were evaluated by neither.

Five of these children received an electroencephalogram and had normal results; all of these children were nonetheless given a pre-SCA diagnosis of nonepileptic seizure. Only a single child in this group saw a cardiologist.

Overall, four of the children with seizures did not have an ECG: three who saw only a neurologist and had a normal electroencephalogram, and one who did not see either specialist. Final diagnoses in this group were long QT syndrome, arrhythmia, anomalous coronary artery, and intramural coronary artery.

The survey had a small sample size, Dr. Drezner acknowledged. "But this is a difficult population to identify in terms of families who are willing to participate and also just children who have had cardiac arrest."

In addition, the study would have benefited from having a control group of children who had syncope or seizures, but did not go on to experience SCA, he said.

"My message that was really reinforced from this study is that syncope is not benign," Dr. Drezner said. Fainting usually does have a vasovagal etiology, he added. But "vasovagal [syncope] is a diagnosis of exclusion. ... Everyone deserves at least one ECG."

Besides lack of awareness, providers may have other reasons for not obtaining an ECG in this context, he noted. For example, "they are worried they will miss something, they are not sure how to interpret it."

And some may be concerned about false-positive results that could lead to unnecessary workups. But his team’s experience in performing screenings in high schools, using contemporary criteria for ECG interpretation, is that even the total positive rate is less than 2%.

"Prior studies show a higher false-positive rate, but those prior studies really came before we understood better how to interpret an ECG in that setting," he explained.

Dr. Drezner reported that he had no relevant financial disclosures.

SEATTLE – Syncope and seizures went unrecognized as warning signs of impending sudden cardiac arrest in children and young adults, based on the results of a retrospective survey of 20 families whose children had these antecedent events.

Parental reports showed that the children fainted or had a seizure without apparent reason an average of three times before sudden cardiac arrest (SCA), according to survey results presented at the annual meeting of the North American Primary Care Research Group.

Half of them did not receive an electrocardiogram (ECG) as part of their medical evaluation for these events, either because they did not see a provider or because they saw a provider but the test was not done. Yet, some of this group had cardiac pathologies that might have been detected by the test.

"Syncope and unexplained seizure activity remain unrecognized for the most part as potential warning signs of intrinsic cardiac disorders that may lead to sudden cardiac arrest," said presenting investigator Dr. Jonathan A. Drezner, a family physician specializing in sports medicine at the University of Washington, Seattle, and team physician for the Seattle Seahawks and University of Washington Huskies.

"I strongly believe that all cases of apparently benign syncope or unexplained seizure activity deserve at minimum an ECG and probably more cardiovascular workup," he recommended.

Dr. Drezner also called for better physician education to promote cardiac evaluation in this population. In particular, "ECG is not a standard part of the workup for syncope, and it needs to be," he asserted. "That message is so simple and can be so clear. But that message is not getting out."

In an earlier study, he and his colleagues retrospectively surveyed 78 families from Parent Heart Watch, a national organization of families having children who experienced (and usually died from) SCA, about a range of antecedent symptoms.

In a finding that Dr. Drezner described as alarming, 18% of these children had at least one syncopal event and 13% had at least one unexplained seizure before their SCA.

He acknowledged that there may have been some overreporting. But "these are not things that are, probably at least not as much, affected by bias from the survey and patient population – these are actually objective events that represent true warning signs of cardiovascular disease."

To assess the medical evaluation of this subset of children, the investigators sent a follow-up survey and requested telephone interviews with their 24 families.

In all, 20 families responded: 12 whose children had syncope and 8 whose children had seizures before SCA. On average, the children were about 12 years old when these symptoms began (range, 4-20 years). Age at SCA ranged from 5 to 29 years.

A striking finding, according to Dr. Drezner, was that the children had a mean of three syncopal or seizure events, with some having as many as 10 events.

This "was not a single event – these were multiple events," he commented. "These children in some way were sort of telling you something was wrong ... and perhaps maybe not identified" with multiple events, he said.

Of the 12 children who had syncope, 7 were evaluated only by their primary care provider, 1 was evaluated only by a cardiologist, 2 were evaluated by both, and 2 were evaluated by neither.

Six of these children did not receive an ECG: four who saw only their primary care provider and did not have the test, and two who saw neither provider.

"If you look at the ultimate cause of death in these individuals, these are actually detectable –and perhaps preventable – [causes of] sudden deaths that could have been detected by an electrocardiogram," Dr. Drezner pointed out.

Final diagnoses in these children and young adults who did not get an ECG were long QT syndrome, arrhythmia, myocarditis, intramural coronary artery, and autopsy-negative sudden unexplained death.

Of the eight children who had unexplained seizures, three were evaluated only by a neurologist, one was evaluated only by a cardiologist, two were evaluated by both, and two were evaluated by neither.

Five of these children received an electroencephalogram and had normal results; all of these children were nonetheless given a pre-SCA diagnosis of nonepileptic seizure. Only a single child in this group saw a cardiologist.

Overall, four of the children with seizures did not have an ECG: three who saw only a neurologist and had a normal electroencephalogram, and one who did not see either specialist. Final diagnoses in this group were long QT syndrome, arrhythmia, anomalous coronary artery, and intramural coronary artery.

The survey had a small sample size, Dr. Drezner acknowledged. "But this is a difficult population to identify in terms of families who are willing to participate and also just children who have had cardiac arrest."

In addition, the study would have benefited from having a control group of children who had syncope or seizures, but did not go on to experience SCA, he said.

"My message that was really reinforced from this study is that syncope is not benign," Dr. Drezner said. Fainting usually does have a vasovagal etiology, he added. But "vasovagal [syncope] is a diagnosis of exclusion. ... Everyone deserves at least one ECG."

Besides lack of awareness, providers may have other reasons for not obtaining an ECG in this context, he noted. For example, "they are worried they will miss something, they are not sure how to interpret it."

And some may be concerned about false-positive results that could lead to unnecessary workups. But his team’s experience in performing screenings in high schools, using contemporary criteria for ECG interpretation, is that even the total positive rate is less than 2%.

"Prior studies show a higher false-positive rate, but those prior studies really came before we understood better how to interpret an ECG in that setting," he explained.

Dr. Drezner reported that he had no relevant financial disclosures.

SEATTLE – Syncope and seizures went unrecognized as warning signs of impending sudden cardiac arrest in children and young adults, based on the results of a retrospective survey of 20 families whose children had these antecedent events.

Parental reports showed that the children fainted or had a seizure without apparent reason an average of three times before sudden cardiac arrest (SCA), according to survey results presented at the annual meeting of the North American Primary Care Research Group.

Half of them did not receive an electrocardiogram (ECG) as part of their medical evaluation for these events, either because they did not see a provider or because they saw a provider but the test was not done. Yet, some of this group had cardiac pathologies that might have been detected by the test.

"Syncope and unexplained seizure activity remain unrecognized for the most part as potential warning signs of intrinsic cardiac disorders that may lead to sudden cardiac arrest," said presenting investigator Dr. Jonathan A. Drezner, a family physician specializing in sports medicine at the University of Washington, Seattle, and team physician for the Seattle Seahawks and University of Washington Huskies.

"I strongly believe that all cases of apparently benign syncope or unexplained seizure activity deserve at minimum an ECG and probably more cardiovascular workup," he recommended.

Dr. Drezner also called for better physician education to promote cardiac evaluation in this population. In particular, "ECG is not a standard part of the workup for syncope, and it needs to be," he asserted. "That message is so simple and can be so clear. But that message is not getting out."

In an earlier study, he and his colleagues retrospectively surveyed 78 families from Parent Heart Watch, a national organization of families having children who experienced (and usually died from) SCA, about a range of antecedent symptoms.

In a finding that Dr. Drezner described as alarming, 18% of these children had at least one syncopal event and 13% had at least one unexplained seizure before their SCA.

He acknowledged that there may have been some overreporting. But "these are not things that are, probably at least not as much, affected by bias from the survey and patient population – these are actually objective events that represent true warning signs of cardiovascular disease."

To assess the medical evaluation of this subset of children, the investigators sent a follow-up survey and requested telephone interviews with their 24 families.

In all, 20 families responded: 12 whose children had syncope and 8 whose children had seizures before SCA. On average, the children were about 12 years old when these symptoms began (range, 4-20 years). Age at SCA ranged from 5 to 29 years.

A striking finding, according to Dr. Drezner, was that the children had a mean of three syncopal or seizure events, with some having as many as 10 events.

This "was not a single event – these were multiple events," he commented. "These children in some way were sort of telling you something was wrong ... and perhaps maybe not identified" with multiple events, he said.

Of the 12 children who had syncope, 7 were evaluated only by their primary care provider, 1 was evaluated only by a cardiologist, 2 were evaluated by both, and 2 were evaluated by neither.

Six of these children did not receive an ECG: four who saw only their primary care provider and did not have the test, and two who saw neither provider.

"If you look at the ultimate cause of death in these individuals, these are actually detectable –and perhaps preventable – [causes of] sudden deaths that could have been detected by an electrocardiogram," Dr. Drezner pointed out.

Final diagnoses in these children and young adults who did not get an ECG were long QT syndrome, arrhythmia, myocarditis, intramural coronary artery, and autopsy-negative sudden unexplained death.

Of the eight children who had unexplained seizures, three were evaluated only by a neurologist, one was evaluated only by a cardiologist, two were evaluated by both, and two were evaluated by neither.

Five of these children received an electroencephalogram and had normal results; all of these children were nonetheless given a pre-SCA diagnosis of nonepileptic seizure. Only a single child in this group saw a cardiologist.

Overall, four of the children with seizures did not have an ECG: three who saw only a neurologist and had a normal electroencephalogram, and one who did not see either specialist. Final diagnoses in this group were long QT syndrome, arrhythmia, anomalous coronary artery, and intramural coronary artery.

The survey had a small sample size, Dr. Drezner acknowledged. "But this is a difficult population to identify in terms of families who are willing to participate and also just children who have had cardiac arrest."

In addition, the study would have benefited from having a control group of children who had syncope or seizures, but did not go on to experience SCA, he said.

"My message that was really reinforced from this study is that syncope is not benign," Dr. Drezner said. Fainting usually does have a vasovagal etiology, he added. But "vasovagal [syncope] is a diagnosis of exclusion. ... Everyone deserves at least one ECG."

Besides lack of awareness, providers may have other reasons for not obtaining an ECG in this context, he noted. For example, "they are worried they will miss something, they are not sure how to interpret it."

And some may be concerned about false-positive results that could lead to unnecessary workups. But his team’s experience in performing screenings in high schools, using contemporary criteria for ECG interpretation, is that even the total positive rate is less than 2%.

"Prior studies show a higher false-positive rate, but those prior studies really came before we understood better how to interpret an ECG in that setting," he explained.

Dr. Drezner reported that he had no relevant financial disclosures.

SEATTLE – Syncope and seizures went unrecognized as warning signs of impending sudden cardiac arrest in children and young adults, based on the results of a retrospective survey of 20 families whose children had these antecedent events.

Parental reports showed that the children fainted or had a seizure without apparent reason an average of three times before sudden cardiac arrest (SCA), according to survey results presented at the annual meeting of the North American Primary Care Research Group.

Half of them did not receive an electrocardiogram (ECG) as part of their medical evaluation for these events, either because they did not see a provider or because they saw a provider but the test was not done. Yet, some of this group had cardiac pathologies that might have been detected by the test.

"Syncope and unexplained seizure activity remain unrecognized for the most part as potential warning signs of intrinsic cardiac disorders that may lead to sudden cardiac arrest," said presenting investigator Dr. Jonathan A. Drezner, a family physician specializing in sports medicine at the University of Washington, Seattle, and team physician for the Seattle Seahawks and University of Washington Huskies.

"I strongly believe that all cases of apparently benign syncope or unexplained seizure activity deserve at minimum an ECG and probably more cardiovascular workup," he recommended.

Dr. Drezner also called for better physician education to promote cardiac evaluation in this population. In particular, "ECG is not a standard part of the workup for syncope, and it needs to be," he asserted. "That message is so simple and can be so clear. But that message is not getting out."

In an earlier study, he and his colleagues retrospectively surveyed 78 families from Parent Heart Watch, a national organization of families having children who experienced (and usually died from) SCA, about a range of antecedent symptoms.

In a finding that Dr. Drezner described as alarming, 18% of these children had at least one syncopal event and 13% had at least one unexplained seizure before their SCA.

He acknowledged that there may have been some overreporting. But "these are not things that are, probably at least not as much, affected by bias from the survey and patient population – these are actually objective events that represent true warning signs of cardiovascular disease."

To assess the medical evaluation of this subset of children, the investigators sent a follow-up survey and requested telephone interviews with their 24 families.

In all, 20 families responded: 12 whose children had syncope and 8 whose children had seizures before SCA. On average, the children were about 12 years old when these symptoms began (range, 4-20 years). Age at SCA ranged from 5 to 29 years.

A striking finding, according to Dr. Drezner, was that the children had a mean of three syncopal or seizure events, with some having as many as 10 events.

This "was not a single event – these were multiple events," he commented. "These children in some way were sort of telling you something was wrong ... and perhaps maybe not identified" with multiple events, he said.

Of the 12 children who had syncope, 7 were evaluated only by their primary care provider, 1 was evaluated only by a cardiologist, 2 were evaluated by both, and 2 were evaluated by neither.

Six of these children did not receive an ECG: four who saw only their primary care provider and did not have the test, and two who saw neither provider.

"If you look at the ultimate cause of death in these individuals, these are actually detectable –and perhaps preventable – [causes of] sudden deaths that could have been detected by an electrocardiogram," Dr. Drezner pointed out.

Final diagnoses in these children and young adults who did not get an ECG were long QT syndrome, arrhythmia, myocarditis, intramural coronary artery, and autopsy-negative sudden unexplained death.

Of the eight children who had unexplained seizures, three were evaluated only by a neurologist, one was evaluated only by a cardiologist, two were evaluated by both, and two were evaluated by neither.

Five of these children received an electroencephalogram and had normal results; all of these children were nonetheless given a pre-SCA diagnosis of nonepileptic seizure. Only a single child in this group saw a cardiologist.

Overall, four of the children with seizures did not have an ECG: three who saw only a neurologist and had a normal electroencephalogram, and one who did not see either specialist. Final diagnoses in this group were long QT syndrome, arrhythmia, anomalous coronary artery, and intramural coronary artery.

The survey had a small sample size, Dr. Drezner acknowledged. "But this is a difficult population to identify in terms of families who are willing to participate and also just children who have had cardiac arrest."

In addition, the study would have benefited from having a control group of children who had syncope or seizures, but did not go on to experience SCA, he said.

"My message that was really reinforced from this study is that syncope is not benign," Dr. Drezner said. Fainting usually does have a vasovagal etiology, he added. But "vasovagal [syncope] is a diagnosis of exclusion. ... Everyone deserves at least one ECG."

Besides lack of awareness, providers may have other reasons for not obtaining an ECG in this context, he noted. For example, "they are worried they will miss something, they are not sure how to interpret it."

And some may be concerned about false-positive results that could lead to unnecessary workups. But his team’s experience in performing screenings in high schools, using contemporary criteria for ECG interpretation, is that even the total positive rate is less than 2%.

"Prior studies show a higher false-positive rate, but those prior studies really came before we understood better how to interpret an ECG in that setting," he explained.

Dr. Drezner reported that he had no relevant financial disclosures.

SEATTLE – Syncope and seizures went unrecognized as warning signs of impending sudden cardiac arrest in children and young adults, based on the results of a retrospective survey of 20 families whose children had these antecedent events.

Parental reports showed that the children fainted or had a seizure without apparent reason an average of three times before sudden cardiac arrest (SCA), according to survey results presented at the annual meeting of the North American Primary Care Research Group.

Half of them did not receive an electrocardiogram (ECG) as part of their medical evaluation for these events, either because they did not see a provider or because they saw a provider but the test was not done. Yet, some of this group had cardiac pathologies that might have been detected by the test.

"Syncope and unexplained seizure activity remain unrecognized for the most part as potential warning signs of intrinsic cardiac disorders that may lead to sudden cardiac arrest," said presenting investigator Dr. Jonathan A. Drezner, a family physician specializing in sports medicine at the University of Washington, Seattle, and team physician for the Seattle Seahawks and University of Washington Huskies.

"I strongly believe that all cases of apparently benign syncope or unexplained seizure activity deserve at minimum an ECG and probably more cardiovascular workup," he recommended.

Dr. Drezner also called for better physician education to promote cardiac evaluation in this population. In particular, "ECG is not a standard part of the workup for syncope, and it needs to be," he asserted. "That message is so simple and can be so clear. But that message is not getting out."

In an earlier study, he and his colleagues retrospectively surveyed 78 families from Parent Heart Watch, a national organization of families having children who experienced (and usually died from) SCA, about a range of antecedent symptoms.

In a finding that Dr. Drezner described as alarming, 18% of these children had at least one syncopal event and 13% had at least one unexplained seizure before their SCA.

He acknowledged that there may have been some overreporting. But "these are not things that are, probably at least not as much, affected by bias from the survey and patient population – these are actually objective events that represent true warning signs of cardiovascular disease."

To assess the medical evaluation of this subset of children, the investigators sent a follow-up survey and requested telephone interviews with their 24 families.

In all, 20 families responded: 12 whose children had syncope and 8 whose children had seizures before SCA. On average, the children were about 12 years old when these symptoms began (range, 4-20 years). Age at SCA ranged from 5 to 29 years.

A striking finding, according to Dr. Drezner, was that the children had a mean of three syncopal or seizure events, with some having as many as 10 events.

This "was not a single event – these were multiple events," he commented. "These children in some way were sort of telling you something was wrong ... and perhaps maybe not identified" with multiple events, he said.

Of the 12 children who had syncope, 7 were evaluated only by their primary care provider, 1 was evaluated only by a cardiologist, 2 were evaluated by both, and 2 were evaluated by neither.

Six of these children did not receive an ECG: four who saw only their primary care provider and did not have the test, and two who saw neither provider.

"If you look at the ultimate cause of death in these individuals, these are actually detectable –and perhaps preventable – [causes of] sudden deaths that could have been detected by an electrocardiogram," Dr. Drezner pointed out.

Final diagnoses in these children and young adults who did not get an ECG were long QT syndrome, arrhythmia, myocarditis, intramural coronary artery, and autopsy-negative sudden unexplained death.

Of the eight children who had unexplained seizures, three were evaluated only by a neurologist, one was evaluated only by a cardiologist, two were evaluated by both, and two were evaluated by neither.

Five of these children received an electroencephalogram and had normal results; all of these children were nonetheless given a pre-SCA diagnosis of nonepileptic seizure. Only a single child in this group saw a cardiologist.

Overall, four of the children with seizures did not have an ECG: three who saw only a neurologist and had a normal electroencephalogram, and one who did not see either specialist. Final diagnoses in this group were long QT syndrome, arrhythmia, anomalous coronary artery, and intramural coronary artery.

The survey had a small sample size, Dr. Drezner acknowledged. "But this is a difficult population to identify in terms of families who are willing to participate and also just children who have had cardiac arrest."

In addition, the study would have benefited from having a control group of children who had syncope or seizures, but did not go on to experience SCA, he said.

"My message that was really reinforced from this study is that syncope is not benign," Dr. Drezner said. Fainting usually does have a vasovagal etiology, he added. But "vasovagal [syncope] is a diagnosis of exclusion. ... Everyone deserves at least one ECG."

Besides lack of awareness, providers may have other reasons for not obtaining an ECG in this context, he noted. For example, "they are worried they will miss something, they are not sure how to interpret it."

And some may be concerned about false-positive results that could lead to unnecessary workups. But his team’s experience in performing screenings in high schools, using contemporary criteria for ECG interpretation, is that even the total positive rate is less than 2%.

"Prior studies show a higher false-positive rate, but those prior studies really came before we understood better how to interpret an ECG in that setting," he explained.

Dr. Drezner reported that he had no relevant financial disclosures.

SEATTLE – Syncope and seizures went unrecognized as warning signs of impending sudden cardiac arrest in children and young adults, based on the results of a retrospective survey of 20 families whose children had these antecedent events.

Parental reports showed that the children fainted or had a seizure without apparent reason an average of three times before sudden cardiac arrest (SCA), according to survey results presented at the annual meeting of the North American Primary Care Research Group.

Half of them did not receive an electrocardiogram (ECG) as part of their medical evaluation for these events, either because they did not see a provider or because they saw a provider but the test was not done. Yet, some of this group had cardiac pathologies that might have been detected by the test.

"Syncope and unexplained seizure activity remain unrecognized for the most part as potential warning signs of intrinsic cardiac disorders that may lead to sudden cardiac arrest," said presenting investigator Dr. Jonathan A. Drezner, a family physician specializing in sports medicine at the University of Washington, Seattle, and team physician for the Seattle Seahawks and University of Washington Huskies.

"I strongly believe that all cases of apparently benign syncope or unexplained seizure activity deserve at minimum an ECG and probably more cardiovascular workup," he recommended.

Dr. Drezner also called for better physician education to promote cardiac evaluation in this population. In particular, "ECG is not a standard part of the workup for syncope, and it needs to be," he asserted. "That message is so simple and can be so clear. But that message is not getting out."

In an earlier study, he and his colleagues retrospectively surveyed 78 families from Parent Heart Watch, a national organization of families having children who experienced (and usually died from) SCA, about a range of antecedent symptoms.

In a finding that Dr. Drezner described as alarming, 18% of these children had at least one syncopal event and 13% had at least one unexplained seizure before their SCA.

He acknowledged that there may have been some overreporting. But "these are not things that are, probably at least not as much, affected by bias from the survey and patient population – these are actually objective events that represent true warning signs of cardiovascular disease."

To assess the medical evaluation of this subset of children, the investigators sent a follow-up survey and requested telephone interviews with their 24 families.

In all, 20 families responded: 12 whose children had syncope and 8 whose children had seizures before SCA. On average, the children were about 12 years old when these symptoms began (range, 4-20 years). Age at SCA ranged from 5 to 29 years.

A striking finding, according to Dr. Drezner, was that the children had a mean of three syncopal or seizure events, with some having as many as 10 events.

This "was not a single event – these were multiple events," he commented. "These children in some way were sort of telling you something was wrong ... and perhaps maybe not identified" with multiple events, he said.

Of the 12 children who had syncope, 7 were evaluated only by their primary care provider, 1 was evaluated only by a cardiologist, 2 were evaluated by both, and 2 were evaluated by neither.

Six of these children did not receive an ECG: four who saw only their primary care provider and did not have the test, and two who saw neither provider.

"If you look at the ultimate cause of death in these individuals, these are actually detectable –and perhaps preventable – [causes of] sudden deaths that could have been detected by an electrocardiogram," Dr. Drezner pointed out.

Final diagnoses in these children and young adults who did not get an ECG were long QT syndrome, arrhythmia, myocarditis, intramural coronary artery, and autopsy-negative sudden unexplained death.

Of the eight children who had unexplained seizures, three were evaluated only by a neurologist, one was evaluated only by a cardiologist, two were evaluated by both, and two were evaluated by neither.

Five of these children received an electroencephalogram and had normal results; all of these children were nonetheless given a pre-SCA diagnosis of nonepileptic seizure. Only a single child in this group saw a cardiologist.

Overall, four of the children with seizures did not have an ECG: three who saw only a neurologist and had a normal electroencephalogram, and one who did not see either specialist. Final diagnoses in this group were long QT syndrome, arrhythmia, anomalous coronary artery, and intramural coronary artery.

The survey had a small sample size, Dr. Drezner acknowledged. "But this is a difficult population to identify in terms of families who are willing to participate and also just children who have had cardiac arrest."

In addition, the study would have benefited from having a control group of children who had syncope or seizures, but did not go on to experience SCA, he said.

"My message that was really reinforced from this study is that syncope is not benign," Dr. Drezner said. Fainting usually does have a vasovagal etiology, he added. But "vasovagal [syncope] is a diagnosis of exclusion. ... Everyone deserves at least one ECG."

Besides lack of awareness, providers may have other reasons for not obtaining an ECG in this context, he noted. For example, "they are worried they will miss something, they are not sure how to interpret it."

And some may be concerned about false-positive results that could lead to unnecessary workups. But his team’s experience in performing screenings in high schools, using contemporary criteria for ECG interpretation, is that even the total positive rate is less than 2%.

"Prior studies show a higher false-positive rate, but those prior studies really came before we understood better how to interpret an ECG in that setting," he explained.

Dr. Drezner reported that he had no relevant financial disclosures.

VANCOUVER, B.C. – Recent research on the use of home testing for the diagnosis of obstructive sleep apnea and initiation of therapy suggests that "home testing is here to stay," Dr. Charles W. Atwood Jr. told attendees at the annual meeting of the American College of Chest Physicians.

For more than 30 years, physicians have relied on the traditional polysomnography performed in the sleep laboratory to diagnose sleep apnea, according to Dr. Atwood. But with growing awareness of the condition and its prevalence, the number of people needing testing could overwhelm capacity.

"If you take the millions and millions and millions of people in the United States alone who have sleep apnea and try to feed them through the relatively small funnel of traditional sleep labs, then you are going to have big bottlenecks," he said, adding that such bottlenecks already exist in some areas.

However, home-testing devices must meet certain key requirements before they are ready for widespread use. For example, they have to be simpler than those used in the lab. "Perhaps we can get by with fewer [physiological] signals, but we need to understand what the key signals are," commented Dr. Atwood, a pulmonologist and sleep medicine specialist with the VA Pittsburgh Healthcare System and the University of Pittsburgh Medical Center.

Home testing devices will also need to be accurate, with high sensitivity and specificity, and "there is no single device I would say today that is perfect in both these regards," he noted. Finally, they must be easy to use and durable, given the demands of in-home use.

Roughly 95 studies conducted between 1990 and 2006 evaluated home testing (also called portable monitoring) for the diagnosis of obstructive sleep apnea. Collectively, they had some limitations, such as their single-site nature, small and usually homogeneous populations, and varying degrees of rigor in design.

"And they frequently focused on the highest-risk subjects: These were middle-aged men who were overweight, snored, and were sleepy, so [they were] the very low-hanging fruit for typical sleep apnea," Dr. Atwood said.

These studies showed mixed results when it came to the diagnostic performance of home testing relative to lab testing. "There is no perfect study, at least so far, in this area, but some have come pretty close," he commented.

Three more recent studies suggest that home testing is at least not inferior to lab testing for sleep apnea diagnosis and initiation of continuous positive airway pressure (CPAP) therapy, according to Dr. Atwood.

In the first study, conducted among 68 people with a high likelihood of sleep apnea, the apnea-hypopnea index on CPAP and Sleep Apnea Quality of Life Index scores at 3 months did not differ significantly between a sleep lab approach and an ambulatory approach (Ann. Intern. Med. 2007;146:157-66). The rate of adherence to CPAP was better with the latter.

In the second study, which involved 102 patients with sleep apnea symptoms and no major comorbidities, all of a variety of sleep and quality of life outcomes after 4 weeks of CPAP were similar with a standard lab diagnosis and treatment approach vs. a home approach (Chest 2010;138:257-63).

The third study, the Veterans Sleep Apnea Treatment Trial (VSATT), is the largest study of home testing in North America to date, according to Dr. Atwood, who is one of the principal investigators.

"The VA is ill equipped to manage sleep apnea in a conventional way because we have relatively few numbers of traditional sleep labs, and those sleep labs that do exist tend to be kind of small," he noted. Also, there are geographic disparities, with some veterans having virtually no access to sleep labs.

"Our study differed from basically all of the other studies in the literature in that we had very broad inclusion criteria and very nonrestrictive exclusion criteria," Dr. Atwood noted. For example, patients with comorbidities could participate as long as their condition was stable.

The patients were randomized to lab testing or home testing, followed by initiation of CPAP for those with positive results.

Among the 223 who were started on CPAP, the home and lab groups had similar demographics. The average apnea-hypopnea index was 41 for the former and 45 for the latter. The Functional Outcomes of Sleep Questionnaire (FOSQ) total score was about 15 in each group.

Results showed that the mean adjusted improvement in FOSQ total score between baseline and 3 months was identical in the two groups, at 1.79 points. And within each group, patients had significant improvements in the total score as well as its individual components.

Both home and lab groups also had significant improvements on the Epworth Sleepiness Scale (–2.6 and –2.9, respectively), the mental health component of the 12-item Short Form Health Survey (+2.5 and +3.0), and the Center for Epidemiologic Studies–Depression scale (–1.4 and –2.2). Neither group improved significantly on the psychovigilance task or the physical health component of the 12-item Short Form Health Survey.

When it came to adherence, which was monitored with smart cards, the mean adjusted number of CPAP hours daily was 3.42 in the home group and 2.99 in the lab group, a difference that was not significant. Cost-effectiveness analyses are still ongoing.

"We concluded that the functional improvement with CPAP for sleep apnea is not worse when treated in the home setting vs. the sleep lab," Dr. Atwood said. "We believe that the implication is that home-based sleep apnea diagnosis and initiation of CPAP therapy is an effective way to treat sleep apnea."

Despite all of the accumulating favorable findings for home testing, Dr. Atwood was skeptical that it will entirely replace laboratory polysomnography.

"Home sleep apnea testing is part of the future, but it’s unlikely to be the whole future," he contended. "The way to think about home sleep apnea testing now is not ‘either/or,’ but really to begin to integrate home sleep testing with full polysomnography in a clinically rational way."

Dr. Atwood reported that he received research support from Embla, Resmed, and Respironics, and is a consultant to Embla and Itamar Medical, all of which manufacture testing and treatment devices for sleep disorders.

VANCOUVER, B.C. – Recent research on the use of home testing for the diagnosis of obstructive sleep apnea and initiation of therapy suggests that "home testing is here to stay," Dr. Charles W. Atwood Jr. told attendees at the annual meeting of the American College of Chest Physicians.

For more than 30 years, physicians have relied on the traditional polysomnography performed in the sleep laboratory to diagnose sleep apnea, according to Dr. Atwood. But with growing awareness of the condition and its prevalence, the number of people needing testing could overwhelm capacity.

"If you take the millions and millions and millions of people in the United States alone who have sleep apnea and try to feed them through the relatively small funnel of traditional sleep labs, then you are going to have big bottlenecks," he said, adding that such bottlenecks already exist in some areas.

However, home-testing devices must meet certain key requirements before they are ready for widespread use. For example, they have to be simpler than those used in the lab. "Perhaps we can get by with fewer [physiological] signals, but we need to understand what the key signals are," commented Dr. Atwood, a pulmonologist and sleep medicine specialist with the VA Pittsburgh Healthcare System and the University of Pittsburgh Medical Center.

Home testing devices will also need to be accurate, with high sensitivity and specificity, and "there is no single device I would say today that is perfect in both these regards," he noted. Finally, they must be easy to use and durable, given the demands of in-home use.

Roughly 95 studies conducted between 1990 and 2006 evaluated home testing (also called portable monitoring) for the diagnosis of obstructive sleep apnea. Collectively, they had some limitations, such as their single-site nature, small and usually homogeneous populations, and varying degrees of rigor in design.

"And they frequently focused on the highest-risk subjects: These were middle-aged men who were overweight, snored, and were sleepy, so [they were] the very low-hanging fruit for typical sleep apnea," Dr. Atwood said.

These studies showed mixed results when it came to the diagnostic performance of home testing relative to lab testing. "There is no perfect study, at least so far, in this area, but some have come pretty close," he commented.

Three more recent studies suggest that home testing is at least not inferior to lab testing for sleep apnea diagnosis and initiation of continuous positive airway pressure (CPAP) therapy, according to Dr. Atwood.

In the first study, conducted among 68 people with a high likelihood of sleep apnea, the apnea-hypopnea index on CPAP and Sleep Apnea Quality of Life Index scores at 3 months did not differ significantly between a sleep lab approach and an ambulatory approach (Ann. Intern. Med. 2007;146:157-66). The rate of adherence to CPAP was better with the latter.

In the second study, which involved 102 patients with sleep apnea symptoms and no major comorbidities, all of a variety of sleep and quality of life outcomes after 4 weeks of CPAP were similar with a standard lab diagnosis and treatment approach vs. a home approach (Chest 2010;138:257-63).

The third study, the Veterans Sleep Apnea Treatment Trial (VSATT), is the largest study of home testing in North America to date, according to Dr. Atwood, who is one of the principal investigators.

"The VA is ill equipped to manage sleep apnea in a conventional way because we have relatively few numbers of traditional sleep labs, and those sleep labs that do exist tend to be kind of small," he noted. Also, there are geographic disparities, with some veterans having virtually no access to sleep labs.

"Our study differed from basically all of the other studies in the literature in that we had very broad inclusion criteria and very nonrestrictive exclusion criteria," Dr. Atwood noted. For example, patients with comorbidities could participate as long as their condition was stable.

The patients were randomized to lab testing or home testing, followed by initiation of CPAP for those with positive results.

Among the 223 who were started on CPAP, the home and lab groups had similar demographics. The average apnea-hypopnea index was 41 for the former and 45 for the latter. The Functional Outcomes of Sleep Questionnaire (FOSQ) total score was about 15 in each group.

Results showed that the mean adjusted improvement in FOSQ total score between baseline and 3 months was identical in the two groups, at 1.79 points. And within each group, patients had significant improvements in the total score as well as its individual components.

Both home and lab groups also had significant improvements on the Epworth Sleepiness Scale (–2.6 and –2.9, respectively), the mental health component of the 12-item Short Form Health Survey (+2.5 and +3.0), and the Center for Epidemiologic Studies–Depression scale (–1.4 and –2.2). Neither group improved significantly on the psychovigilance task or the physical health component of the 12-item Short Form Health Survey.

When it came to adherence, which was monitored with smart cards, the mean adjusted number of CPAP hours daily was 3.42 in the home group and 2.99 in the lab group, a difference that was not significant. Cost-effectiveness analyses are still ongoing.

"We concluded that the functional improvement with CPAP for sleep apnea is not worse when treated in the home setting vs. the sleep lab," Dr. Atwood said. "We believe that the implication is that home-based sleep apnea diagnosis and initiation of CPAP therapy is an effective way to treat sleep apnea."

Despite all of the accumulating favorable findings for home testing, Dr. Atwood was skeptical that it will entirely replace laboratory polysomnography.

"Home sleep apnea testing is part of the future, but it’s unlikely to be the whole future," he contended. "The way to think about home sleep apnea testing now is not ‘either/or,’ but really to begin to integrate home sleep testing with full polysomnography in a clinically rational way."

Dr. Atwood reported that he received research support from Embla, Resmed, and Respironics, and is a consultant to Embla and Itamar Medical, all of which manufacture testing and treatment devices for sleep disorders.

VANCOUVER, B.C. – Recent research on the use of home testing for the diagnosis of obstructive sleep apnea and initiation of therapy suggests that "home testing is here to stay," Dr. Charles W. Atwood Jr. told attendees at the annual meeting of the American College of Chest Physicians.

For more than 30 years, physicians have relied on the traditional polysomnography performed in the sleep laboratory to diagnose sleep apnea, according to Dr. Atwood. But with growing awareness of the condition and its prevalence, the number of people needing testing could overwhelm capacity.

"If you take the millions and millions and millions of people in the United States alone who have sleep apnea and try to feed them through the relatively small funnel of traditional sleep labs, then you are going to have big bottlenecks," he said, adding that such bottlenecks already exist in some areas.

However, home-testing devices must meet certain key requirements before they are ready for widespread use. For example, they have to be simpler than those used in the lab. "Perhaps we can get by with fewer [physiological] signals, but we need to understand what the key signals are," commented Dr. Atwood, a pulmonologist and sleep medicine specialist with the VA Pittsburgh Healthcare System and the University of Pittsburgh Medical Center.

Home testing devices will also need to be accurate, with high sensitivity and specificity, and "there is no single device I would say today that is perfect in both these regards," he noted. Finally, they must be easy to use and durable, given the demands of in-home use.

Roughly 95 studies conducted between 1990 and 2006 evaluated home testing (also called portable monitoring) for the diagnosis of obstructive sleep apnea. Collectively, they had some limitations, such as their single-site nature, small and usually homogeneous populations, and varying degrees of rigor in design.

"And they frequently focused on the highest-risk subjects: These were middle-aged men who were overweight, snored, and were sleepy, so [they were] the very low-hanging fruit for typical sleep apnea," Dr. Atwood said.

These studies showed mixed results when it came to the diagnostic performance of home testing relative to lab testing. "There is no perfect study, at least so far, in this area, but some have come pretty close," he commented.

Three more recent studies suggest that home testing is at least not inferior to lab testing for sleep apnea diagnosis and initiation of continuous positive airway pressure (CPAP) therapy, according to Dr. Atwood.

In the first study, conducted among 68 people with a high likelihood of sleep apnea, the apnea-hypopnea index on CPAP and Sleep Apnea Quality of Life Index scores at 3 months did not differ significantly between a sleep lab approach and an ambulatory approach (Ann. Intern. Med. 2007;146:157-66). The rate of adherence to CPAP was better with the latter.

In the second study, which involved 102 patients with sleep apnea symptoms and no major comorbidities, all of a variety of sleep and quality of life outcomes after 4 weeks of CPAP were similar with a standard lab diagnosis and treatment approach vs. a home approach (Chest 2010;138:257-63).

The third study, the Veterans Sleep Apnea Treatment Trial (VSATT), is the largest study of home testing in North America to date, according to Dr. Atwood, who is one of the principal investigators.

"The VA is ill equipped to manage sleep apnea in a conventional way because we have relatively few numbers of traditional sleep labs, and those sleep labs that do exist tend to be kind of small," he noted. Also, there are geographic disparities, with some veterans having virtually no access to sleep labs.

"Our study differed from basically all of the other studies in the literature in that we had very broad inclusion criteria and very nonrestrictive exclusion criteria," Dr. Atwood noted. For example, patients with comorbidities could participate as long as their condition was stable.

The patients were randomized to lab testing or home testing, followed by initiation of CPAP for those with positive results.

Among the 223 who were started on CPAP, the home and lab groups had similar demographics. The average apnea-hypopnea index was 41 for the former and 45 for the latter. The Functional Outcomes of Sleep Questionnaire (FOSQ) total score was about 15 in each group.

Results showed that the mean adjusted improvement in FOSQ total score between baseline and 3 months was identical in the two groups, at 1.79 points. And within each group, patients had significant improvements in the total score as well as its individual components.

Both home and lab groups also had significant improvements on the Epworth Sleepiness Scale (–2.6 and –2.9, respectively), the mental health component of the 12-item Short Form Health Survey (+2.5 and +3.0), and the Center for Epidemiologic Studies–Depression scale (–1.4 and –2.2). Neither group improved significantly on the psychovigilance task or the physical health component of the 12-item Short Form Health Survey.

When it came to adherence, which was monitored with smart cards, the mean adjusted number of CPAP hours daily was 3.42 in the home group and 2.99 in the lab group, a difference that was not significant. Cost-effectiveness analyses are still ongoing.

"We concluded that the functional improvement with CPAP for sleep apnea is not worse when treated in the home setting vs. the sleep lab," Dr. Atwood said. "We believe that the implication is that home-based sleep apnea diagnosis and initiation of CPAP therapy is an effective way to treat sleep apnea."

Despite all of the accumulating favorable findings for home testing, Dr. Atwood was skeptical that it will entirely replace laboratory polysomnography.

"Home sleep apnea testing is part of the future, but it’s unlikely to be the whole future," he contended. "The way to think about home sleep apnea testing now is not ‘either/or,’ but really to begin to integrate home sleep testing with full polysomnography in a clinically rational way."

Dr. Atwood reported that he received research support from Embla, Resmed, and Respironics, and is a consultant to Embla and Itamar Medical, all of which manufacture testing and treatment devices for sleep disorders.

SEATTLE – More than half of parents reported they would be willing to have their child screened for HIV, according to a survey conducted in an academic community-based clinic in west Texas.

"Our outcome is very encouraging that a good majority of parents do see the need for [screening]," Stephanie Caples, Ph.D., said in an interview. "I was going into [the study] speculating that nobody would want their child screened because we are such a conservative little part of Texas, even though Medicine is saying very differently – the girls are coming in very young with [sexually transmitted infections] STIs and pregnancies."

Of the 78 parents polled, all of whom had children aged 10-24 years, more than half strongly agreed or agreed that they would be willing to have their child screened, researchers reported at the annual meeting of the North American Primary Care Research Group.

Additionally, when asked what the appropriate age for screening to begin is, 44% thought it should start between ages 11 and 15.

In addition to agreeing that they would be willing to screen their child, the parents "were able to hit the average age right on the money ... as far as what we are seeing in the clinic, children who are coming through and reporting that they are sexually active," she added.

The Centers for Disease Control and Prevention favors routine, voluntary HIV screening for adolescents because the HIV rate is rising among 15- to 24-year-olds, especially among those belonging to minorities, noted Dr. Caples, who is a behavioral health scientist at Texas Tech University Health Sciences Center at the Permian Basin, in Odessa, Tex.

However, pediatric screening rates have been low historically. Both parental attitudes about screening and the knowledge behind those attitudes are potential barriers.

"We wanted to see what parents thought about having their children screened, particularly in our community, for two reasons," she explained. "We have the highest teenage pregnancy rate in the state. But we are also still considered a very conservative community, almost like the Bible Belt."

Dr. Caples and her coinvestigator, Dr. Jamal Islam, gave two questionnaires to adults walking into an academic community-based clinic who had a child between the ages of 10 and 24. One questionnaire asked about sociodemographic factors and attitudes about HIV screening. The other, the 18-item HIV Knowledge Questionnaire (HIV-KQ-18), tested their knowledge.

Initial survey results, reported in a poster session at the meeting, showed that the 78 parents who returned questionnaires were 38 years old, on average, and 93% were female. Most were Hispanic (58%). Two-thirds had three or more children. The majority (57%) had themselves been screened for HIV.

When asked if they would be willing to screen their child for HIV, 23% of parents indicated they would strongly agree, and 34% indicated that they would agree, Dr. Caples reported. Another 23% did not have an opinion one way or another. Only 14% disagreed, and 6% strongly disagreed.

"That 23%, that is kind of in the neutral zone; if their doctor suggested it, they would probably agree to it," she commented. "I think it will be important to identify, for the 20% who do not want their children screened, why not."

The majority of parents believed that pediatric screening should start between ages 11 and 15 years (44%) or at age 16 or older (20%).

As for HIV knowledge, the percentage of parents answering correctly ranged from 43% to 97% for individual statements on the HIV-KQ-18. It was less than 80% for five statements: the female condom prevents HIV (43% answered correctly), deep kissing with an HIV-positive person can transmit HIV (62% answered correctly), all HIV-positive pregnant women will have an HIV-positive baby (71% answered correctly), coughing and sneezing do not spread HIV (73% answered correctly), and sharing a glass can spread HIV (76% answered correctly).

"Age and race of the parent had no effect on their willingness to screen, which is really encouraging," Dr. Caples said. Similarly, HIV knowledge had minimal influence on this outcome. But parents were more likely to be willing to screen if they feared that their child would contract HIV or thought that their child was specifically at risk. The role of level of education is still being assessed.

Most survey participants were mothers, so fathers’ attitudes regarding HIV screening remain unknown, she acknowledged. Also, the findings may not be generalizable to other populations.

"Once we finish [the study] and really get a good grasp on what the parental attitudes are or potential barriers, I think maybe moving a screening into an annual evaluation for children may be the way to go here," Dr. Caples commented.

Additionally, educating the community on the fact that not only are their children at risk for HIV, but also that their own risk is rising again will be important "because it has kind of lost a lot of the steam as far as people paying attention to it," she said.

Dr. Caples reported that she did not have any relevant conflicts of interest.

SEATTLE – More than half of parents reported they would be willing to have their child screened for HIV, according to a survey conducted in an academic community-based clinic in west Texas.

"Our outcome is very encouraging that a good majority of parents do see the need for [screening]," Stephanie Caples, Ph.D., said in an interview. "I was going into [the study] speculating that nobody would want their child screened because we are such a conservative little part of Texas, even though Medicine is saying very differently – the girls are coming in very young with [sexually transmitted infections] STIs and pregnancies."

Of the 78 parents polled, all of whom had children aged 10-24 years, more than half strongly agreed or agreed that they would be willing to have their child screened, researchers reported at the annual meeting of the North American Primary Care Research Group.

Additionally, when asked what the appropriate age for screening to begin is, 44% thought it should start between ages 11 and 15.

In addition to agreeing that they would be willing to screen their child, the parents "were able to hit the average age right on the money ... as far as what we are seeing in the clinic, children who are coming through and reporting that they are sexually active," she added.

The Centers for Disease Control and Prevention favors routine, voluntary HIV screening for adolescents because the HIV rate is rising among 15- to 24-year-olds, especially among those belonging to minorities, noted Dr. Caples, who is a behavioral health scientist at Texas Tech University Health Sciences Center at the Permian Basin, in Odessa, Tex.

However, pediatric screening rates have been low historically. Both parental attitudes about screening and the knowledge behind those attitudes are potential barriers.

"We wanted to see what parents thought about having their children screened, particularly in our community, for two reasons," she explained. "We have the highest teenage pregnancy rate in the state. But we are also still considered a very conservative community, almost like the Bible Belt."

Dr. Caples and her coinvestigator, Dr. Jamal Islam, gave two questionnaires to adults walking into an academic community-based clinic who had a child between the ages of 10 and 24. One questionnaire asked about sociodemographic factors and attitudes about HIV screening. The other, the 18-item HIV Knowledge Questionnaire (HIV-KQ-18), tested their knowledge.

Initial survey results, reported in a poster session at the meeting, showed that the 78 parents who returned questionnaires were 38 years old, on average, and 93% were female. Most were Hispanic (58%). Two-thirds had three or more children. The majority (57%) had themselves been screened for HIV.

When asked if they would be willing to screen their child for HIV, 23% of parents indicated they would strongly agree, and 34% indicated that they would agree, Dr. Caples reported. Another 23% did not have an opinion one way or another. Only 14% disagreed, and 6% strongly disagreed.

"That 23%, that is kind of in the neutral zone; if their doctor suggested it, they would probably agree to it," she commented. "I think it will be important to identify, for the 20% who do not want their children screened, why not."

The majority of parents believed that pediatric screening should start between ages 11 and 15 years (44%) or at age 16 or older (20%).

As for HIV knowledge, the percentage of parents answering correctly ranged from 43% to 97% for individual statements on the HIV-KQ-18. It was less than 80% for five statements: the female condom prevents HIV (43% answered correctly), deep kissing with an HIV-positive person can transmit HIV (62% answered correctly), all HIV-positive pregnant women will have an HIV-positive baby (71% answered correctly), coughing and sneezing do not spread HIV (73% answered correctly), and sharing a glass can spread HIV (76% answered correctly).

"Age and race of the parent had no effect on their willingness to screen, which is really encouraging," Dr. Caples said. Similarly, HIV knowledge had minimal influence on this outcome. But parents were more likely to be willing to screen if they feared that their child would contract HIV or thought that their child was specifically at risk. The role of level of education is still being assessed.

Most survey participants were mothers, so fathers’ attitudes regarding HIV screening remain unknown, she acknowledged. Also, the findings may not be generalizable to other populations.

"Once we finish [the study] and really get a good grasp on what the parental attitudes are or potential barriers, I think maybe moving a screening into an annual evaluation for children may be the way to go here," Dr. Caples commented.

Additionally, educating the community on the fact that not only are their children at risk for HIV, but also that their own risk is rising again will be important "because it has kind of lost a lot of the steam as far as people paying attention to it," she said.

Dr. Caples reported that she did not have any relevant conflicts of interest.

SEATTLE – More than half of parents reported they would be willing to have their child screened for HIV, according to a survey conducted in an academic community-based clinic in west Texas.

"Our outcome is very encouraging that a good majority of parents do see the need for [screening]," Stephanie Caples, Ph.D., said in an interview. "I was going into [the study] speculating that nobody would want their child screened because we are such a conservative little part of Texas, even though Medicine is saying very differently – the girls are coming in very young with [sexually transmitted infections] STIs and pregnancies."

Of the 78 parents polled, all of whom had children aged 10-24 years, more than half strongly agreed or agreed that they would be willing to have their child screened, researchers reported at the annual meeting of the North American Primary Care Research Group.

Additionally, when asked what the appropriate age for screening to begin is, 44% thought it should start between ages 11 and 15.

In addition to agreeing that they would be willing to screen their child, the parents "were able to hit the average age right on the money ... as far as what we are seeing in the clinic, children who are coming through and reporting that they are sexually active," she added.

The Centers for Disease Control and Prevention favors routine, voluntary HIV screening for adolescents because the HIV rate is rising among 15- to 24-year-olds, especially among those belonging to minorities, noted Dr. Caples, who is a behavioral health scientist at Texas Tech University Health Sciences Center at the Permian Basin, in Odessa, Tex.

However, pediatric screening rates have been low historically. Both parental attitudes about screening and the knowledge behind those attitudes are potential barriers.

"We wanted to see what parents thought about having their children screened, particularly in our community, for two reasons," she explained. "We have the highest teenage pregnancy rate in the state. But we are also still considered a very conservative community, almost like the Bible Belt."

Dr. Caples and her coinvestigator, Dr. Jamal Islam, gave two questionnaires to adults walking into an academic community-based clinic who had a child between the ages of 10 and 24. One questionnaire asked about sociodemographic factors and attitudes about HIV screening. The other, the 18-item HIV Knowledge Questionnaire (HIV-KQ-18), tested their knowledge.

Initial survey results, reported in a poster session at the meeting, showed that the 78 parents who returned questionnaires were 38 years old, on average, and 93% were female. Most were Hispanic (58%). Two-thirds had three or more children. The majority (57%) had themselves been screened for HIV.

When asked if they would be willing to screen their child for HIV, 23% of parents indicated they would strongly agree, and 34% indicated that they would agree, Dr. Caples reported. Another 23% did not have an opinion one way or another. Only 14% disagreed, and 6% strongly disagreed.

"That 23%, that is kind of in the neutral zone; if their doctor suggested it, they would probably agree to it," she commented. "I think it will be important to identify, for the 20% who do not want their children screened, why not."

The majority of parents believed that pediatric screening should start between ages 11 and 15 years (44%) or at age 16 or older (20%).

As for HIV knowledge, the percentage of parents answering correctly ranged from 43% to 97% for individual statements on the HIV-KQ-18. It was less than 80% for five statements: the female condom prevents HIV (43% answered correctly), deep kissing with an HIV-positive person can transmit HIV (62% answered correctly), all HIV-positive pregnant women will have an HIV-positive baby (71% answered correctly), coughing and sneezing do not spread HIV (73% answered correctly), and sharing a glass can spread HIV (76% answered correctly).

"Age and race of the parent had no effect on their willingness to screen, which is really encouraging," Dr. Caples said. Similarly, HIV knowledge had minimal influence on this outcome. But parents were more likely to be willing to screen if they feared that their child would contract HIV or thought that their child was specifically at risk. The role of level of education is still being assessed.

Most survey participants were mothers, so fathers’ attitudes regarding HIV screening remain unknown, she acknowledged. Also, the findings may not be generalizable to other populations.

"Once we finish [the study] and really get a good grasp on what the parental attitudes are or potential barriers, I think maybe moving a screening into an annual evaluation for children may be the way to go here," Dr. Caples commented.

Additionally, educating the community on the fact that not only are their children at risk for HIV, but also that their own risk is rising again will be important "because it has kind of lost a lot of the steam as far as people paying attention to it," she said.

Dr. Caples reported that she did not have any relevant conflicts of interest.

SEATTLE - More than half of parents reported they would be willing to have their child screened for HIV, according to a survey conducted in an academic community-based clinic in west Texas.

"Our outcome is very encouraging that a good majority of parents do see the need for [screening]," Stephanie Caples, Ph.D., said in an interview. "I was going into [the study] speculating that nobody would want their child screened because we are such a conservative little part of Texas, even though Medicine is saying very differently – the girls are coming in very young with [sexually transmitted infections] and pregnancies."

Of the 78 parents polled, all of whom had children aged 10-24 years, more than half strongly agreed or agreed that they would be willing to have their child screened, researchers reported at the annual meeting of the North American Primary Care Research Group.

Additionally, when asked what the appropriate age for screening to begin is, 44% thought it should start between ages 11 and 15.

In addition to agreeing that they would be willing to screen their child, the parents "were able to hit the average age right on the money ... as far as what we are seeing in the clinic, children who are coming through and reporting that they are sexually active," she added.

The Centers for Disease Control and Prevention favors routine, voluntary HIV screening for adolescents because the HIV rate is rising among 15- to 24-year-olds, especially among those belonging to minorities, noted Dr. Caples, who is a behavioral health scientist at Texas Tech University Health Sciences Center at the Permian Basin, in Odessa, Tex.

However, pediatric screening rates have been low historically. Both parental attitudes about screening and the knowledge behind those attitudes are potential barriers.

"We wanted to see what parents thought about having their children screened, particularly in our community, for two reasons," she explained. "We have the highest teenage pregnancy rate in the state. But we are also still considered a very conservative community, almost like the Bible Belt."

Dr. Caples and her coinvestigator, Dr. Jamal Islam, gave two questionnaires to adults walking into an academic community-based clinic who had a child between the ages of 10 and 24. One questionnaire asked about sociodemographic factors and attitudes about HIV screening. The other, the 18-item HIV Knowledge Questionnaire (HIV-KQ-18), tested their knowledge.

Initial survey results, reported in a poster session at the meeting, showed that the 78 parents who returned questionnaires were 38 years old, on average, and 93% were female. Most were Hispanic (58%). Two-thirds had three or more children. The majority (57%) had themselves been screened for HIV.

When asked if they would be willing to screen their child for HIV, 23% of parents indicated they would strongly agree, and 34% indicated that they would agree, Dr. Caples reported. Another 23% did not have an opinion one way or another. Only 14% disagreed, and 6% strongly disagreed.

"That 23%, that is kind of in the neutral zone; if their doctor suggested it, they would probably agree to it," she commented. "I think it will be important to identify, for the 20% who do not want their children screened, why not."

The majority of parents believed that pediatric screening should start between ages 11 and 15 years (44%) or at age 16 or older (20%).

As for HIV knowledge, the percentage of parents answering correctly ranged from 43% to 97% for individual statements on the HIV-KQ-18. It was less than 80% for five statements: the female condom prevents HIV (43% answered correctly), deep kissing with an HIV-positive person can transmit HIV (62% answered correctly), all HIV-positive pregnant women will have an HIV-positive baby (71% answered correctly), coughing and sneezing do not spread HIV (73% answered correctly), and sharing a glass can spread HIV (76% answered correctly).

"Age and race of the parent had no effect on their willingness to screen, which is really encouraging," Dr. Caples said. Similarly, HIV knowledge had minimal influence on this outcome. But parents were more likely to be willing to screen if they feared that their child would contract HIV or thought that their child was specifically at risk. The role of level of education is still being assessed.

Most survey participants were mothers, so fathers' attitudes regarding HIV screening remain unknown, she acknowledged. Also, the findings may not be generalizable to other populations.

"Once we finish [the study] and really get a good grasp on what the parental attitudes are or potential barriers, I think maybe moving a screening into an annual evaluation for children may be the way to go here," Dr. Caples commented.

Additionally, educating the community on the fact that not only are their children at risk for HIV, but also that their own risk is rising again will be important "because it has kind of lost a lot of the steam as far as people paying attention to it," she said.

Dr. Caples reported that she did not have any relevant conflicts of interest.

SEATTLE - More than half of parents reported they would be willing to have their child screened for HIV, according to a survey conducted in an academic community-based clinic in west Texas.

"Our outcome is very encouraging that a good majority of parents do see the need for [screening]," Stephanie Caples, Ph.D., said in an interview. "I was going into [the study] speculating that nobody would want their child screened because we are such a conservative little part of Texas, even though Medicine is saying very differently – the girls are coming in very young with [sexually transmitted infections] and pregnancies."

Of the 78 parents polled, all of whom had children aged 10-24 years, more than half strongly agreed or agreed that they would be willing to have their child screened, researchers reported at the annual meeting of the North American Primary Care Research Group.

Additionally, when asked what the appropriate age for screening to begin is, 44% thought it should start between ages 11 and 15.

In addition to agreeing that they would be willing to screen their child, the parents "were able to hit the average age right on the money ... as far as what we are seeing in the clinic, children who are coming through and reporting that they are sexually active," she added.

The Centers for Disease Control and Prevention favors routine, voluntary HIV screening for adolescents because the HIV rate is rising among 15- to 24-year-olds, especially among those belonging to minorities, noted Dr. Caples, who is a behavioral health scientist at Texas Tech University Health Sciences Center at the Permian Basin, in Odessa, Tex.

However, pediatric screening rates have been low historically. Both parental attitudes about screening and the knowledge behind those attitudes are potential barriers.

"We wanted to see what parents thought about having their children screened, particularly in our community, for two reasons," she explained. "We have the highest teenage pregnancy rate in the state. But we are also still considered a very conservative community, almost like the Bible Belt."

Dr. Caples and her coinvestigator, Dr. Jamal Islam, gave two questionnaires to adults walking into an academic community-based clinic who had a child between the ages of 10 and 24. One questionnaire asked about sociodemographic factors and attitudes about HIV screening. The other, the 18-item HIV Knowledge Questionnaire (HIV-KQ-18), tested their knowledge.

Initial survey results, reported in a poster session at the meeting, showed that the 78 parents who returned questionnaires were 38 years old, on average, and 93% were female. Most were Hispanic (58%). Two-thirds had three or more children. The majority (57%) had themselves been screened for HIV.

When asked if they would be willing to screen their child for HIV, 23% of parents indicated they would strongly agree, and 34% indicated that they would agree, Dr. Caples reported. Another 23% did not have an opinion one way or another. Only 14% disagreed, and 6% strongly disagreed.

"That 23%, that is kind of in the neutral zone; if their doctor suggested it, they would probably agree to it," she commented. "I think it will be important to identify, for the 20% who do not want their children screened, why not."

The majority of parents believed that pediatric screening should start between ages 11 and 15 years (44%) or at age 16 or older (20%).

As for HIV knowledge, the percentage of parents answering correctly ranged from 43% to 97% for individual statements on the HIV-KQ-18. It was less than 80% for five statements: the female condom prevents HIV (43% answered correctly), deep kissing with an HIV-positive person can transmit HIV (62% answered correctly), all HIV-positive pregnant women will have an HIV-positive baby (71% answered correctly), coughing and sneezing do not spread HIV (73% answered correctly), and sharing a glass can spread HIV (76% answered correctly).

"Age and race of the parent had no effect on their willingness to screen, which is really encouraging," Dr. Caples said. Similarly, HIV knowledge had minimal influence on this outcome. But parents were more likely to be willing to screen if they feared that their child would contract HIV or thought that their child was specifically at risk. The role of level of education is still being assessed.

Most survey participants were mothers, so fathers' attitudes regarding HIV screening remain unknown, she acknowledged. Also, the findings may not be generalizable to other populations.

"Once we finish [the study] and really get a good grasp on what the parental attitudes are or potential barriers, I think maybe moving a screening into an annual evaluation for children may be the way to go here," Dr. Caples commented.

Additionally, educating the community on the fact that not only are their children at risk for HIV, but also that their own risk is rising again will be important "because it has kind of lost a lot of the steam as far as people paying attention to it," she said.

Dr. Caples reported that she did not have any relevant conflicts of interest.

SEATTLE - More than half of parents reported they would be willing to have their child screened for HIV, according to a survey conducted in an academic community-based clinic in west Texas.

"Our outcome is very encouraging that a good majority of parents do see the need for [screening]," Stephanie Caples, Ph.D., said in an interview. "I was going into [the study] speculating that nobody would want their child screened because we are such a conservative little part of Texas, even though Medicine is saying very differently – the girls are coming in very young with [sexually transmitted infections] and pregnancies."

Of the 78 parents polled, all of whom had children aged 10-24 years, more than half strongly agreed or agreed that they would be willing to have their child screened, researchers reported at the annual meeting of the North American Primary Care Research Group.

Additionally, when asked what the appropriate age for screening to begin is, 44% thought it should start between ages 11 and 15.

In addition to agreeing that they would be willing to screen their child, the parents "were able to hit the average age right on the money ... as far as what we are seeing in the clinic, children who are coming through and reporting that they are sexually active," she added.

The Centers for Disease Control and Prevention favors routine, voluntary HIV screening for adolescents because the HIV rate is rising among 15- to 24-year-olds, especially among those belonging to minorities, noted Dr. Caples, who is a behavioral health scientist at Texas Tech University Health Sciences Center at the Permian Basin, in Odessa, Tex.

However, pediatric screening rates have been low historically. Both parental attitudes about screening and the knowledge behind those attitudes are potential barriers.

"We wanted to see what parents thought about having their children screened, particularly in our community, for two reasons," she explained. "We have the highest teenage pregnancy rate in the state. But we are also still considered a very conservative community, almost like the Bible Belt."

Dr. Caples and her coinvestigator, Dr. Jamal Islam, gave two questionnaires to adults walking into an academic community-based clinic who had a child between the ages of 10 and 24. One questionnaire asked about sociodemographic factors and attitudes about HIV screening. The other, the 18-item HIV Knowledge Questionnaire (HIV-KQ-18), tested their knowledge.

Initial survey results, reported in a poster session at the meeting, showed that the 78 parents who returned questionnaires were 38 years old, on average, and 93% were female. Most were Hispanic (58%). Two-thirds had three or more children. The majority (57%) had themselves been screened for HIV.

When asked if they would be willing to screen their child for HIV, 23% of parents indicated they would strongly agree, and 34% indicated that they would agree, Dr. Caples reported. Another 23% did not have an opinion one way or another. Only 14% disagreed, and 6% strongly disagreed.

"That 23%, that is kind of in the neutral zone; if their doctor suggested it, they would probably agree to it," she commented. "I think it will be important to identify, for the 20% who do not want their children screened, why not."

The majority of parents believed that pediatric screening should start between ages 11 and 15 years (44%) or at age 16 or older (20%).

As for HIV knowledge, the percentage of parents answering correctly ranged from 43% to 97% for individual statements on the HIV-KQ-18. It was less than 80% for five statements: the female condom prevents HIV (43% answered correctly), deep kissing with an HIV-positive person can transmit HIV (62% answered correctly), all HIV-positive pregnant women will have an HIV-positive baby (71% answered correctly), coughing and sneezing do not spread HIV (73% answered correctly), and sharing a glass can spread HIV (76% answered correctly).

"Age and race of the parent had no effect on their willingness to screen, which is really encouraging," Dr. Caples said. Similarly, HIV knowledge had minimal influence on this outcome. But parents were more likely to be willing to screen if they feared that their child would contract HIV or thought that their child was specifically at risk. The role of level of education is still being assessed.

Most survey participants were mothers, so fathers' attitudes regarding HIV screening remain unknown, she acknowledged. Also, the findings may not be generalizable to other populations.

"Once we finish [the study] and really get a good grasp on what the parental attitudes are or potential barriers, I think maybe moving a screening into an annual evaluation for children may be the way to go here," Dr. Caples commented.

Additionally, educating the community on the fact that not only are their children at risk for HIV, but also that their own risk is rising again will be important "because it has kind of lost a lot of the steam as far as people paying attention to it," she said.

Dr. Caples reported that she did not have any relevant conflicts of interest.