Diana Mahoney

The percentage of pediatric acute otitis media visits during which an antibiotic was not prescribed did not increase significantly in the 30 months after the dissemination in 2004 of the well-publicized clinical practice guideline that allowed for patient observation without initial antibiotic therapy, according to Dr. Andrew Coco of the Lancaster (Pa.) General Research Institute and his colleagues.

They analyzed data on 1,114 acute otitis media (AOM) patients aged 6 months to 12 years that was collected between 2002 and 2006 as part of the National Ambulatory Medical Care Survey, comparing the clinical management strategies during the 30-month periods before and after the publication of the 2004 American Academy of Pediatrics and American Academy of Family Physicians clinical practice guideline.

The primary study end point was the rate of AOM encounters with no reported antibiotic prescribing. Secondary end points were predictors of AOM encounters at which no antibiotic prescribing was reported and the rates of antibiotic prescribing and analgesic prescribing. Eighty-two percent of visits were with pediatricians, 14% were with family physicians, and 4% were with other physicians (Pediatrics 2010;125:214-20).

During the study overall, antibiotics were not prescribed in 13% of the visits, according to the analysis. In the 30 months prior to the publication of the clinical guideline, 11% of the AOM diagnoses were managed without an antibiotic, compared with 16% after the guideline publication, which does not represent a significant difference, they reported.

“It seems that, despite the guideline's endorsement, physicians have been reluctant to frequently use the observation option, perhaps because of perceptions of parental reluctance to accept this approach and barriers to follow-up,” they wrote

“It is encouraging that children who did not receive antibiotics were also less likely to present with symptoms of severe infection, such as fever or ear pain,” the authors wrote.

An unexpected finding, was the fact that amoxicillin/clavulanate prescribing, which the guideline recommends for the treatment of children with severe infection and those with treatment failure, decreased from 23% to 16%. This is, however, consistent with physicians' historical lack of enthusiasm for prescribing the combination treatment for severe infections, they wrote.

Physicians in the study “were choosing cefdinir as a second-line agent instead, perhaps because of a more convenient dosing schedule, a lower incidence of diarrhea, or more aggressive marketing,” the investigators wrote. Its use doubled from 7% to 14% of all antibiotics prescribed after publication of the guideline.

The proportion of visits at which amoxicillin was prescribed increased from 40% to 49%, which is consistent with the guideline.

The rate of analgesic prescribing also increased from 14% to 24%—an indication that pediatric providers “have accepted this strong recommendation to treat the pain that is often associated with AOM, which is a reversal of previous findings showing that treating otalgia is not prioritized by clinicians,” Dr. Coco and his associates wrote. “It would seem that physicians were more willing to adopt a recommendation from the guideline to add a treatment [analgesic agents] rather than to withhold one [antibiotics].”

The study authors reported having no conflicts of interest.

My Take

Watchful Waiting Is Uncomfortable

The finding that the 2004 AAP/AAFP guideline for AOM treatment has not substantially increased the proportion of the pediatric AOM cases being managed without antibiotics is not surprising.

Many physicians are uncomfortable with the watchful waiting recommendation because there is reasonable evidence that certain children benefit significantly from antibiotics. For example, the findings of a recent meta-analysis suggest that antibiotics are effective for the treatment of AOM in children younger than 2 years old who have bilateral disease and in children with both otorrhea and AOM (Lancet 2006;368:1429-35).

Additionally, the guideline calls for the use of antibiotics for the treatment of severe disease, which is a subjective characterization.

The gap between the guideline recommendations and clinical practice will likely widen further in the near future, with the upcoming publication of new studies linking watchful waiting with a greater proportion of children in whom the signs and symptoms of AOM last beyond 3 or 4 days.

Despite the guideline controversy, the reduction of antibiotic prescribing continues to be an important goal. To achieve it, we should focus on developing a vaccine that prevents viral and bacterial respiratory tract infections, practicing restraint in treating nonfocal upper respiratory tract infections with antibiotics, and establishing more accurate diagnostic criteria for AOM and sinusitis.

Another important goal should be the selection of appropriate antibiotics for the likely pathogens. Currently, the spectrum of antibiotics that are prescribed portray a lack of understanding of the effectiveness of various antibiotics against various pathogens.

For example, data on the increase in the use of azithromycin are problematic as it is a drug with a long half-life and is believed to promote the emergence of resistance to a greater extent than some other antibiotics. Even so, studies have shown that pediatricians choose azithromycin twice as often in children with recurrent AOM, which is backward, as it would be less likely to be effective in a recurrent episode than in a first. I think this confirms that selection of antibiotics is based more on convenience, taste, and possibly marketing than on an understanding of the activity and limitations of the antibiotic.

STEPHEN I. PELTON, M.D,. is director of pediatric infectious diseases at Boston Medical Center. He is a consultant for GlaxoSmithKline, Novartis, and Wyeth and is on the speakers bureau for MedImmune Inc. and Sanofi Pasteur Inc.

VITALS

The percentage of pediatric acute otitis media visits during which an antibiotic was not prescribed did not increase significantly in the 30 months after the dissemination in 2004 of the well-publicized clinical practice guideline that allowed for patient observation without initial antibiotic therapy, according to Dr. Andrew Coco of the Lancaster (Pa.) General Research Institute and his colleagues.

They analyzed data on 1,114 acute otitis media (AOM) patients aged 6 months to 12 years that was collected between 2002 and 2006 as part of the National Ambulatory Medical Care Survey, comparing the clinical management strategies during the 30-month periods before and after the publication of the 2004 American Academy of Pediatrics and American Academy of Family Physicians clinical practice guideline.

The primary study end point was the rate of AOM encounters with no reported antibiotic prescribing. Secondary end points were predictors of AOM encounters at which no antibiotic prescribing was reported and the rates of antibiotic prescribing and analgesic prescribing. Eighty-two percent of visits were with pediatricians, 14% were with family physicians, and 4% were with other physicians (Pediatrics 2010;125:214-20).

During the study overall, antibiotics were not prescribed in 13% of the visits, according to the analysis. In the 30 months prior to the publication of the clinical guideline, 11% of the AOM diagnoses were managed without an antibiotic, compared with 16% after the guideline publication, which does not represent a significant difference, they reported.

“It seems that, despite the guideline's endorsement, physicians have been reluctant to frequently use the observation option, perhaps because of perceptions of parental reluctance to accept this approach and barriers to follow-up,” they wrote

“It is encouraging that children who did not receive antibiotics were also less likely to present with symptoms of severe infection, such as fever or ear pain,” the authors wrote.

An unexpected finding, was the fact that amoxicillin/clavulanate prescribing, which the guideline recommends for the treatment of children with severe infection and those with treatment failure, decreased from 23% to 16%. This is, however, consistent with physicians' historical lack of enthusiasm for prescribing the combination treatment for severe infections, they wrote.

Physicians in the study “were choosing cefdinir as a second-line agent instead, perhaps because of a more convenient dosing schedule, a lower incidence of diarrhea, or more aggressive marketing,” the investigators wrote. Its use doubled from 7% to 14% of all antibiotics prescribed after publication of the guideline.

The proportion of visits at which amoxicillin was prescribed increased from 40% to 49%, which is consistent with the guideline.

The rate of analgesic prescribing also increased from 14% to 24%—an indication that pediatric providers “have accepted this strong recommendation to treat the pain that is often associated with AOM, which is a reversal of previous findings showing that treating otalgia is not prioritized by clinicians,” Dr. Coco and his associates wrote. “It would seem that physicians were more willing to adopt a recommendation from the guideline to add a treatment [analgesic agents] rather than to withhold one [antibiotics].”

The study authors reported having no conflicts of interest.

My Take

Watchful Waiting Is Uncomfortable

The finding that the 2004 AAP/AAFP guideline for AOM treatment has not substantially increased the proportion of the pediatric AOM cases being managed without antibiotics is not surprising.

Many physicians are uncomfortable with the watchful waiting recommendation because there is reasonable evidence that certain children benefit significantly from antibiotics. For example, the findings of a recent meta-analysis suggest that antibiotics are effective for the treatment of AOM in children younger than 2 years old who have bilateral disease and in children with both otorrhea and AOM (Lancet 2006;368:1429-35).

Additionally, the guideline calls for the use of antibiotics for the treatment of severe disease, which is a subjective characterization.

The gap between the guideline recommendations and clinical practice will likely widen further in the near future, with the upcoming publication of new studies linking watchful waiting with a greater proportion of children in whom the signs and symptoms of AOM last beyond 3 or 4 days.

Despite the guideline controversy, the reduction of antibiotic prescribing continues to be an important goal. To achieve it, we should focus on developing a vaccine that prevents viral and bacterial respiratory tract infections, practicing restraint in treating nonfocal upper respiratory tract infections with antibiotics, and establishing more accurate diagnostic criteria for AOM and sinusitis.

Another important goal should be the selection of appropriate antibiotics for the likely pathogens. Currently, the spectrum of antibiotics that are prescribed portray a lack of understanding of the effectiveness of various antibiotics against various pathogens.

For example, data on the increase in the use of azithromycin are problematic as it is a drug with a long half-life and is believed to promote the emergence of resistance to a greater extent than some other antibiotics. Even so, studies have shown that pediatricians choose azithromycin twice as often in children with recurrent AOM, which is backward, as it would be less likely to be effective in a recurrent episode than in a first. I think this confirms that selection of antibiotics is based more on convenience, taste, and possibly marketing than on an understanding of the activity and limitations of the antibiotic.

STEPHEN I. PELTON, M.D,. is director of pediatric infectious diseases at Boston Medical Center. He is a consultant for GlaxoSmithKline, Novartis, and Wyeth and is on the speakers bureau for MedImmune Inc. and Sanofi Pasteur Inc.

VITALS

The percentage of pediatric acute otitis media visits during which an antibiotic was not prescribed did not increase significantly in the 30 months after the dissemination in 2004 of the well-publicized clinical practice guideline that allowed for patient observation without initial antibiotic therapy, according to Dr. Andrew Coco of the Lancaster (Pa.) General Research Institute and his colleagues.

They analyzed data on 1,114 acute otitis media (AOM) patients aged 6 months to 12 years that was collected between 2002 and 2006 as part of the National Ambulatory Medical Care Survey, comparing the clinical management strategies during the 30-month periods before and after the publication of the 2004 American Academy of Pediatrics and American Academy of Family Physicians clinical practice guideline.

The primary study end point was the rate of AOM encounters with no reported antibiotic prescribing. Secondary end points were predictors of AOM encounters at which no antibiotic prescribing was reported and the rates of antibiotic prescribing and analgesic prescribing. Eighty-two percent of visits were with pediatricians, 14% were with family physicians, and 4% were with other physicians (Pediatrics 2010;125:214-20).

During the study overall, antibiotics were not prescribed in 13% of the visits, according to the analysis. In the 30 months prior to the publication of the clinical guideline, 11% of the AOM diagnoses were managed without an antibiotic, compared with 16% after the guideline publication, which does not represent a significant difference, they reported.

“It seems that, despite the guideline's endorsement, physicians have been reluctant to frequently use the observation option, perhaps because of perceptions of parental reluctance to accept this approach and barriers to follow-up,” they wrote

“It is encouraging that children who did not receive antibiotics were also less likely to present with symptoms of severe infection, such as fever or ear pain,” the authors wrote.

An unexpected finding, was the fact that amoxicillin/clavulanate prescribing, which the guideline recommends for the treatment of children with severe infection and those with treatment failure, decreased from 23% to 16%. This is, however, consistent with physicians' historical lack of enthusiasm for prescribing the combination treatment for severe infections, they wrote.

Physicians in the study “were choosing cefdinir as a second-line agent instead, perhaps because of a more convenient dosing schedule, a lower incidence of diarrhea, or more aggressive marketing,” the investigators wrote. Its use doubled from 7% to 14% of all antibiotics prescribed after publication of the guideline.

The proportion of visits at which amoxicillin was prescribed increased from 40% to 49%, which is consistent with the guideline.

The rate of analgesic prescribing also increased from 14% to 24%—an indication that pediatric providers “have accepted this strong recommendation to treat the pain that is often associated with AOM, which is a reversal of previous findings showing that treating otalgia is not prioritized by clinicians,” Dr. Coco and his associates wrote. “It would seem that physicians were more willing to adopt a recommendation from the guideline to add a treatment [analgesic agents] rather than to withhold one [antibiotics].”

The study authors reported having no conflicts of interest.

My Take

Watchful Waiting Is Uncomfortable

The finding that the 2004 AAP/AAFP guideline for AOM treatment has not substantially increased the proportion of the pediatric AOM cases being managed without antibiotics is not surprising.

Many physicians are uncomfortable with the watchful waiting recommendation because there is reasonable evidence that certain children benefit significantly from antibiotics. For example, the findings of a recent meta-analysis suggest that antibiotics are effective for the treatment of AOM in children younger than 2 years old who have bilateral disease and in children with both otorrhea and AOM (Lancet 2006;368:1429-35).

Additionally, the guideline calls for the use of antibiotics for the treatment of severe disease, which is a subjective characterization.

The gap between the guideline recommendations and clinical practice will likely widen further in the near future, with the upcoming publication of new studies linking watchful waiting with a greater proportion of children in whom the signs and symptoms of AOM last beyond 3 or 4 days.

Despite the guideline controversy, the reduction of antibiotic prescribing continues to be an important goal. To achieve it, we should focus on developing a vaccine that prevents viral and bacterial respiratory tract infections, practicing restraint in treating nonfocal upper respiratory tract infections with antibiotics, and establishing more accurate diagnostic criteria for AOM and sinusitis.

Another important goal should be the selection of appropriate antibiotics for the likely pathogens. Currently, the spectrum of antibiotics that are prescribed portray a lack of understanding of the effectiveness of various antibiotics against various pathogens.

For example, data on the increase in the use of azithromycin are problematic as it is a drug with a long half-life and is believed to promote the emergence of resistance to a greater extent than some other antibiotics. Even so, studies have shown that pediatricians choose azithromycin twice as often in children with recurrent AOM, which is backward, as it would be less likely to be effective in a recurrent episode than in a first. I think this confirms that selection of antibiotics is based more on convenience, taste, and possibly marketing than on an understanding of the activity and limitations of the antibiotic.

STEPHEN I. PELTON, M.D,. is director of pediatric infectious diseases at Boston Medical Center. He is a consultant for GlaxoSmithKline, Novartis, and Wyeth and is on the speakers bureau for MedImmune Inc. and Sanofi Pasteur Inc.

VITALS

Major Finding: The mean pain rating for non-Hispanic white and Hispanic white patients was 48.8 mm on the VAS, compared with 29.2 mm in the “cough-trick” group, indicating a 40% reduction in pain.

Data Source: A randomized controlled within-subject study of 68 prekindergarten and pre–junior high school children receiving scheduled immunizations.

Disclosures: The authors reported having no relevant financial disclosures. The study was supported in part by the Maternal and Child Health Bureau and by a grant from the Department of Health and Human Services' Administration on Developmental Disabilities.

Some children undergoing routine immunizations experienced less pain from the injection when they were asked to cough during the procedure.

However, Dustin P. Wallace, Ph.D., of the psychiatry department of the Mayo Clinic in Rochester, Minn., and his colleagues reported that the “cough trick,” which consists of a warm-up cough of moderate intensity, followed by second cough coinciding with the needle puncture of the actual immunization, was not universally effective among the study population, compared with usual treatment. They found that the strategy demonstrated statistically and clinically significant efficacy in post hoc analysis in children who identified themselves as Hispanic white or non-Hispanic white, but did not seem to be effective in children who identified themselves as non-Hispanic black (Pediatrics 2010;125: e367-73).

For the study, 68 children who were scheduled to receive either their prekindergarten (22) or pre–junior high (46) immunizations and their families were recruited from an outpatient pediatric clinic in a large public hospital. As per the within-study design, the children were assigned randomly to the cough trick for either their first or second immunization and usual treatment for the other one, the authors wrote. Immediately after each injection, the child, parent, and nurse independently rated the child's pain reaction on separate visual analog scales (VAS).

The average self-reported pain intensity was 42.6 mm on the VAS for injections in the control condition, compared with 37.1 mm for those given with the cough trick, which does not represent a statistically significant reduction in pain intensity, they wrote. However, post hoc analyses identified an interaction between treatment efficacy and self-reported race/ethnicity.

“The mean pain rating in the control condition [for non-Hispanic white and Hispanic white patients] was 48.8 mm, compared with 29.2 mm in the experimental condition, which indicated the cough trick was associated with a 40% reduction in pain,” the authors wrote. In contrast, a separate within-subject t-test to evaluate non-Hispanic black patients showed a nonsignificant increase in pain associated with the cough trick,” they noted.

It is possible that the pain assessment among the non-Hispanic black children was confounded by the fact that the participating nurses and the study research assistant were primarily non-Hispanic or Hispanic white, whereas almost half of the participants were black, the authors hypothesized. “These differences might have played a role in some participants' willingness to disclose pain or in their belief that this procedure could be of benefit,” they wrote, noting that future research should investigate the reliability and causes of the racial differences observed in this study.

Although the efficacy of the cough-trick strategy appeared to be moderated by race, it was not moderated by gender or age group, “which supports the potential utility of this strategy in a busy pediatric clinic setting,” the authors wrote.

Among the study's limitations are its small sample size and the use of the VAS for pain self-reporting, because the measure has not been validated for use with children younger than age 5 years.

Major Finding: The mean pain rating for non-Hispanic white and Hispanic white patients was 48.8 mm on the VAS, compared with 29.2 mm in the “cough-trick” group, indicating a 40% reduction in pain.

Data Source: A randomized controlled within-subject study of 68 prekindergarten and pre–junior high school children receiving scheduled immunizations.

Disclosures: The authors reported having no relevant financial disclosures. The study was supported in part by the Maternal and Child Health Bureau and by a grant from the Department of Health and Human Services' Administration on Developmental Disabilities.

Some children undergoing routine immunizations experienced less pain from the injection when they were asked to cough during the procedure.

However, Dustin P. Wallace, Ph.D., of the psychiatry department of the Mayo Clinic in Rochester, Minn., and his colleagues reported that the “cough trick,” which consists of a warm-up cough of moderate intensity, followed by second cough coinciding with the needle puncture of the actual immunization, was not universally effective among the study population, compared with usual treatment. They found that the strategy demonstrated statistically and clinically significant efficacy in post hoc analysis in children who identified themselves as Hispanic white or non-Hispanic white, but did not seem to be effective in children who identified themselves as non-Hispanic black (Pediatrics 2010;125: e367-73).

For the study, 68 children who were scheduled to receive either their prekindergarten (22) or pre–junior high (46) immunizations and their families were recruited from an outpatient pediatric clinic in a large public hospital. As per the within-study design, the children were assigned randomly to the cough trick for either their first or second immunization and usual treatment for the other one, the authors wrote. Immediately after each injection, the child, parent, and nurse independently rated the child's pain reaction on separate visual analog scales (VAS).

The average self-reported pain intensity was 42.6 mm on the VAS for injections in the control condition, compared with 37.1 mm for those given with the cough trick, which does not represent a statistically significant reduction in pain intensity, they wrote. However, post hoc analyses identified an interaction between treatment efficacy and self-reported race/ethnicity.

“The mean pain rating in the control condition [for non-Hispanic white and Hispanic white patients] was 48.8 mm, compared with 29.2 mm in the experimental condition, which indicated the cough trick was associated with a 40% reduction in pain,” the authors wrote. In contrast, a separate within-subject t-test to evaluate non-Hispanic black patients showed a nonsignificant increase in pain associated with the cough trick,” they noted.

It is possible that the pain assessment among the non-Hispanic black children was confounded by the fact that the participating nurses and the study research assistant were primarily non-Hispanic or Hispanic white, whereas almost half of the participants were black, the authors hypothesized. “These differences might have played a role in some participants' willingness to disclose pain or in their belief that this procedure could be of benefit,” they wrote, noting that future research should investigate the reliability and causes of the racial differences observed in this study.

Although the efficacy of the cough-trick strategy appeared to be moderated by race, it was not moderated by gender or age group, “which supports the potential utility of this strategy in a busy pediatric clinic setting,” the authors wrote.

Among the study's limitations are its small sample size and the use of the VAS for pain self-reporting, because the measure has not been validated for use with children younger than age 5 years.

Major Finding: The mean pain rating for non-Hispanic white and Hispanic white patients was 48.8 mm on the VAS, compared with 29.2 mm in the “cough-trick” group, indicating a 40% reduction in pain.

Data Source: A randomized controlled within-subject study of 68 prekindergarten and pre–junior high school children receiving scheduled immunizations.

Disclosures: The authors reported having no relevant financial disclosures. The study was supported in part by the Maternal and Child Health Bureau and by a grant from the Department of Health and Human Services' Administration on Developmental Disabilities.

Some children undergoing routine immunizations experienced less pain from the injection when they were asked to cough during the procedure.

However, Dustin P. Wallace, Ph.D., of the psychiatry department of the Mayo Clinic in Rochester, Minn., and his colleagues reported that the “cough trick,” which consists of a warm-up cough of moderate intensity, followed by second cough coinciding with the needle puncture of the actual immunization, was not universally effective among the study population, compared with usual treatment. They found that the strategy demonstrated statistically and clinically significant efficacy in post hoc analysis in children who identified themselves as Hispanic white or non-Hispanic white, but did not seem to be effective in children who identified themselves as non-Hispanic black (Pediatrics 2010;125: e367-73).

For the study, 68 children who were scheduled to receive either their prekindergarten (22) or pre–junior high (46) immunizations and their families were recruited from an outpatient pediatric clinic in a large public hospital. As per the within-study design, the children were assigned randomly to the cough trick for either their first or second immunization and usual treatment for the other one, the authors wrote. Immediately after each injection, the child, parent, and nurse independently rated the child's pain reaction on separate visual analog scales (VAS).

The average self-reported pain intensity was 42.6 mm on the VAS for injections in the control condition, compared with 37.1 mm for those given with the cough trick, which does not represent a statistically significant reduction in pain intensity, they wrote. However, post hoc analyses identified an interaction between treatment efficacy and self-reported race/ethnicity.

“The mean pain rating in the control condition [for non-Hispanic white and Hispanic white patients] was 48.8 mm, compared with 29.2 mm in the experimental condition, which indicated the cough trick was associated with a 40% reduction in pain,” the authors wrote. In contrast, a separate within-subject t-test to evaluate non-Hispanic black patients showed a nonsignificant increase in pain associated with the cough trick,” they noted.

It is possible that the pain assessment among the non-Hispanic black children was confounded by the fact that the participating nurses and the study research assistant were primarily non-Hispanic or Hispanic white, whereas almost half of the participants were black, the authors hypothesized. “These differences might have played a role in some participants' willingness to disclose pain or in their belief that this procedure could be of benefit,” they wrote, noting that future research should investigate the reliability and causes of the racial differences observed in this study.

Although the efficacy of the cough-trick strategy appeared to be moderated by race, it was not moderated by gender or age group, “which supports the potential utility of this strategy in a busy pediatric clinic setting,” the authors wrote.

Among the study's limitations are its small sample size and the use of the VAS for pain self-reporting, because the measure has not been validated for use with children younger than age 5 years.

NEW YORK – Geriatric patients presenting to the emergency department with behavioral emergencies are often referred to psychiatric services without having a basic medical work-up prior to transfer, according to the findings from a small retrospective.

“Despite the fact that it is well-known that many psychiatric emergencies in the geriatric population have an organic etiology, and the American College of Emergency Physicians [ACEP] policy recommends that these patients be evaluated for medical illness before being transferred for psychiatric care, the medical work-ups are frequently not happening,” said Dr. Kathleen C. Diller, of Temple University Hospital in Philadelphia.

In a retrospective study conducted in an urban university-based psychiatric emergency setting, Dr. Diller and Dr. Ruth M. Lamdan of Temple University School of Medicine reviewed the charts of 105 patients aged 65 years and older who were seen in the university hospital's psychiatric emergency service between April 1, 2004, and March 31, 2007, and compared their clinical presentations, diagnoses, work-ups, and outcomes with those of 105 gender- and race-matched 18- to 64-year-old controls.

Compared with the controls, the geriatric patients were significantly more likely to present disoriented and on an involuntary commitment, to have significantly more medical diagnoses, to be on more nonpsychiatric medications, to present with psychosis or with cognitive impairments, and to be admitted to a psychiatric facility, Dr. Diller said in a poster presentation at the American Psychiatric Association's Institute on Psychiatric Services.

Despite these differences, “the elderly patients were not more likely to be seen in the medical emergency department prior to or after presenting to the psychiatric emergency service, nor were they more likely to receive a medical work-up in the emergency department.”

Specifically, urinalysis was ordered for only 9.5% of the older group, and brain imaging was done in only 5.7% of them, Dr. Diller reported. “Documentation of complete cognitive evaluation was missing in 45.7% of the older adult examinations, and orientation evaluation was not done in 27.6% of them,” she said.

The geriatric patients included in the sample were more likely to receive some element of a medical work-up in the psychiatric emergency services, “but these were not guided by chief complaint of physical examination finding,” said Dr. Diller, who noted that ACEP recommends that medical evaluations be guided by patients' chief complaint.

Although limited by its retrospective design and by the possibility that older adults with significant medical comorbidities may have received a medical work-up in the emergency department and been admitted to medical facilities rather than referred to the psychiatric emergency service, the study findings suggest that many emergency clinicians were skipping even the most basic, inexpensive elements of the medical work-up, such as cognitive testing and urinalysis, Dr. Diller said.

Prospective comparisons are needed in order to make final recommendations for the emergency evaluation of the older adult who presents with psychiatric symptoms, but “specific protocols should be put in place to make sure all geriatric patients with psychiatric emergencies receive an adequate medical work-up,” Dr. Diller stated.

Toward this end, she recommended that geriatric screening protocols should be incorporated into residency training programs and that residents be reminded to have a heightened index of suspicion for medical illness as the cause of psychiatric symptoms in elderly patients.

In addition, she noted, “residents must be able to screen for delirium in all clinical settings, and psychiatric residents must be able to perform a directed medical work-up based on patient history.

Both Dr. Diller and Dr. Lamdan reported having no financial conflicts of interest with respect to this research.

NEW YORK – Geriatric patients presenting to the emergency department with behavioral emergencies are often referred to psychiatric services without having a basic medical work-up prior to transfer, according to the findings from a small retrospective.

“Despite the fact that it is well-known that many psychiatric emergencies in the geriatric population have an organic etiology, and the American College of Emergency Physicians [ACEP] policy recommends that these patients be evaluated for medical illness before being transferred for psychiatric care, the medical work-ups are frequently not happening,” said Dr. Kathleen C. Diller, of Temple University Hospital in Philadelphia.

In a retrospective study conducted in an urban university-based psychiatric emergency setting, Dr. Diller and Dr. Ruth M. Lamdan of Temple University School of Medicine reviewed the charts of 105 patients aged 65 years and older who were seen in the university hospital's psychiatric emergency service between April 1, 2004, and March 31, 2007, and compared their clinical presentations, diagnoses, work-ups, and outcomes with those of 105 gender- and race-matched 18- to 64-year-old controls.

Compared with the controls, the geriatric patients were significantly more likely to present disoriented and on an involuntary commitment, to have significantly more medical diagnoses, to be on more nonpsychiatric medications, to present with psychosis or with cognitive impairments, and to be admitted to a psychiatric facility, Dr. Diller said in a poster presentation at the American Psychiatric Association's Institute on Psychiatric Services.

Despite these differences, “the elderly patients were not more likely to be seen in the medical emergency department prior to or after presenting to the psychiatric emergency service, nor were they more likely to receive a medical work-up in the emergency department.”

Specifically, urinalysis was ordered for only 9.5% of the older group, and brain imaging was done in only 5.7% of them, Dr. Diller reported. “Documentation of complete cognitive evaluation was missing in 45.7% of the older adult examinations, and orientation evaluation was not done in 27.6% of them,” she said.

The geriatric patients included in the sample were more likely to receive some element of a medical work-up in the psychiatric emergency services, “but these were not guided by chief complaint of physical examination finding,” said Dr. Diller, who noted that ACEP recommends that medical evaluations be guided by patients' chief complaint.

Although limited by its retrospective design and by the possibility that older adults with significant medical comorbidities may have received a medical work-up in the emergency department and been admitted to medical facilities rather than referred to the psychiatric emergency service, the study findings suggest that many emergency clinicians were skipping even the most basic, inexpensive elements of the medical work-up, such as cognitive testing and urinalysis, Dr. Diller said.

Prospective comparisons are needed in order to make final recommendations for the emergency evaluation of the older adult who presents with psychiatric symptoms, but “specific protocols should be put in place to make sure all geriatric patients with psychiatric emergencies receive an adequate medical work-up,” Dr. Diller stated.

Toward this end, she recommended that geriatric screening protocols should be incorporated into residency training programs and that residents be reminded to have a heightened index of suspicion for medical illness as the cause of psychiatric symptoms in elderly patients.

In addition, she noted, “residents must be able to screen for delirium in all clinical settings, and psychiatric residents must be able to perform a directed medical work-up based on patient history.

Both Dr. Diller and Dr. Lamdan reported having no financial conflicts of interest with respect to this research.

NEW YORK – Geriatric patients presenting to the emergency department with behavioral emergencies are often referred to psychiatric services without having a basic medical work-up prior to transfer, according to the findings from a small retrospective.

“Despite the fact that it is well-known that many psychiatric emergencies in the geriatric population have an organic etiology, and the American College of Emergency Physicians [ACEP] policy recommends that these patients be evaluated for medical illness before being transferred for psychiatric care, the medical work-ups are frequently not happening,” said Dr. Kathleen C. Diller, of Temple University Hospital in Philadelphia.

In a retrospective study conducted in an urban university-based psychiatric emergency setting, Dr. Diller and Dr. Ruth M. Lamdan of Temple University School of Medicine reviewed the charts of 105 patients aged 65 years and older who were seen in the university hospital's psychiatric emergency service between April 1, 2004, and March 31, 2007, and compared their clinical presentations, diagnoses, work-ups, and outcomes with those of 105 gender- and race-matched 18- to 64-year-old controls.

Compared with the controls, the geriatric patients were significantly more likely to present disoriented and on an involuntary commitment, to have significantly more medical diagnoses, to be on more nonpsychiatric medications, to present with psychosis or with cognitive impairments, and to be admitted to a psychiatric facility, Dr. Diller said in a poster presentation at the American Psychiatric Association's Institute on Psychiatric Services.

Despite these differences, “the elderly patients were not more likely to be seen in the medical emergency department prior to or after presenting to the psychiatric emergency service, nor were they more likely to receive a medical work-up in the emergency department.”

Specifically, urinalysis was ordered for only 9.5% of the older group, and brain imaging was done in only 5.7% of them, Dr. Diller reported. “Documentation of complete cognitive evaluation was missing in 45.7% of the older adult examinations, and orientation evaluation was not done in 27.6% of them,” she said.

The geriatric patients included in the sample were more likely to receive some element of a medical work-up in the psychiatric emergency services, “but these were not guided by chief complaint of physical examination finding,” said Dr. Diller, who noted that ACEP recommends that medical evaluations be guided by patients' chief complaint.

Although limited by its retrospective design and by the possibility that older adults with significant medical comorbidities may have received a medical work-up in the emergency department and been admitted to medical facilities rather than referred to the psychiatric emergency service, the study findings suggest that many emergency clinicians were skipping even the most basic, inexpensive elements of the medical work-up, such as cognitive testing and urinalysis, Dr. Diller said.

Prospective comparisons are needed in order to make final recommendations for the emergency evaluation of the older adult who presents with psychiatric symptoms, but “specific protocols should be put in place to make sure all geriatric patients with psychiatric emergencies receive an adequate medical work-up,” Dr. Diller stated.

Toward this end, she recommended that geriatric screening protocols should be incorporated into residency training programs and that residents be reminded to have a heightened index of suspicion for medical illness as the cause of psychiatric symptoms in elderly patients.

In addition, she noted, “residents must be able to screen for delirium in all clinical settings, and psychiatric residents must be able to perform a directed medical work-up based on patient history.

Both Dr. Diller and Dr. Lamdan reported having no financial conflicts of interest with respect to this research.

Major Finding: Motivational interviewing has the greatest impact on smoking cessation when it is delivered by a primary care physician, compared with delivery by counselors or nurses (relative risk 3.49 vs.1.23 and 1.27, respectively).

Data Source: Meta-analysis of 14 smoking cessation studies involving over 10,000 individuals in which motivational interviewing was used.

Disclosures: The authors reported no conflicts of interest.

Motivational interviewing can be an effective counseling technique for smoking cessation, particularly when it is delivered by a primary care physician, a review of intervention studies shows. However, the review results should be interpreted with caution, the authors wrote.

Dr. Douglas T.C. Lai, a family medicine physician affiliated with the Chinese University of Hong Kong, and his colleagues from that university and the University of Oxford (England), conducted a Cochrane Collaboration review of data from 14 studies involving more than 10,000 individuals and published between 1997 and 2008.

The review included randomized controlled trials, identified through the Cochrane Tobacco Addiction Group Specialized Register, in which motivational interviewing or its variants were used to assist in smoking cessation (Cochrane Database Syst. Rev. 2010 Jan. [doi: 10.1002/14651858.CD006936.pub2]).

Motivational interviewing (MI) is a nonconfrontational counseling technique designed to help people explore and resolve their uncertainties about behavior changes, the authors wrote. The brief psychotherpapeutic technique has been widely implemented as a smoking cessation technique and is recommended in smoking cessation guidelines.

However, little attempt has been made “to systematically review the evidence” about the intervention, Dr. Lai and his colleagues wrote.

In the current review, the investigators sought to include studies of interventions that made explicit reference to core MI principles as described by W. R. Miller and S. Rollnick in their book, “Motivational Interviewing: Preparing People to Change” (New York: Guilford Press, 2002).

The studies that were included had a monitoring element, such as the details of counselor training or measures to ensure the quality of MI sessions (videotaping sessions or use of an assessment scale and supervision, for example). The main outcome measure used in the review was abstinence from smoking after at least 6 months' follow-up, based on the most rigorous definition of abstinence in each trial and biochemically validated rates, where available.

All except two of the intervention studies reviewed took place in the United States, and the most commonly used MI approach was one in which the smoker received nonthreatening feedback designed to develop discrepancy between smoking and personal goals, the authors explained.

Dr. Lai and his colleagues noted that the interventions involved face-to-face sessions, except for three in which the counseling was telephone based.

Ten of the studies looked at single-session interventions, and the rest looked at three- and four-session interventions. Most of the studies compared the MI intervention with usual care or brief advice, often accompanied by self-help materials, the investigators reported.

The investigators conducted a conventional meta-analysis to estimate pooled treatment effects. They observed a modest but significant increase in smoking cessation among patients who underwent motivational interviewing, compared with those who received usual care.

With the strictest definition of abstinence and the longest follow-up, the overall effect across all 14 trials was a relative risk for smoking cessation in the treatment vs. usual care group of 1.27, the authors reported.

A slightly higher but similar effect (relative risk 1.37) was observed in a sensitivity analysis that excluded trials of participants who were already motivated to make a quit attempt, and a comparable relative risk (1.31) was noted in an analysis of findings from the nine trials in which the outcomes were validated biochemically, they said.

In a subgroup analysis by therapist type, the largest effect was observed in the interventions delivered by primary care physicians, followed by those with counselors and nurses, with respective relative risks of 3.49, 1.23, and 1.27, the authors reported.

Primary care doctors might be best suited to deliver this type of intervention because they are already familiar with the patients and, presumably, have an established rapport.

The authors point out that “this finding is based on two relatively small studies and should not be overstated.”

Despite the positive findings of the meta-analysis, “absolute quit rates were relatively low,” probably because most of the trials included smokers who were not motivated to quit, Dr. Lai and his colleagues reported.

The authors urged caution in interpreting results because of “variations in study quality, treatment fidelity, and the possibility of publication or selective reporting bias.” Future studies “should attempt to identify which core components of the motivational interviewing approach are effective,” they wrote.

The authors reported no conflicts of interest.

My Take

Efficacy of MI Is Fairly Consistent

Motivational interviewing has received a great deal of attention as a therapeutic modality for substance use disorders. As this article highlights, the efficacy of MI is fairly consistent across studies, but the effect size is modest. It might be that MI is most effective for individuals who have less severe illness and/or are at an earlier stage in the addiction process (i.e., “problem” drinkers). MI has also been used with success as an adjunct to help motivate and engage individuals in more intensive substance abuse treatment.

KATHLEEN T. BRADY, M.D., Ph.D., a psychiatrist and a pharmacologist, is professor at the Medical University of South Carolina, Charleston. She is director of the Southern Consortium of the National Institute on Drug Abuse's Clinical Trials Network. She serves as a consultant to or on the speakers bureaus of several pharmaceutical companies.

VITALS

Major Finding: Motivational interviewing has the greatest impact on smoking cessation when it is delivered by a primary care physician, compared with delivery by counselors or nurses (relative risk 3.49 vs.1.23 and 1.27, respectively).

Data Source: Meta-analysis of 14 smoking cessation studies involving over 10,000 individuals in which motivational interviewing was used.

Disclosures: The authors reported no conflicts of interest.

Motivational interviewing can be an effective counseling technique for smoking cessation, particularly when it is delivered by a primary care physician, a review of intervention studies shows. However, the review results should be interpreted with caution, the authors wrote.

Dr. Douglas T.C. Lai, a family medicine physician affiliated with the Chinese University of Hong Kong, and his colleagues from that university and the University of Oxford (England), conducted a Cochrane Collaboration review of data from 14 studies involving more than 10,000 individuals and published between 1997 and 2008.

The review included randomized controlled trials, identified through the Cochrane Tobacco Addiction Group Specialized Register, in which motivational interviewing or its variants were used to assist in smoking cessation (Cochrane Database Syst. Rev. 2010 Jan. [doi: 10.1002/14651858.CD006936.pub2]).

Motivational interviewing (MI) is a nonconfrontational counseling technique designed to help people explore and resolve their uncertainties about behavior changes, the authors wrote. The brief psychotherpapeutic technique has been widely implemented as a smoking cessation technique and is recommended in smoking cessation guidelines.

However, little attempt has been made “to systematically review the evidence” about the intervention, Dr. Lai and his colleagues wrote.

In the current review, the investigators sought to include studies of interventions that made explicit reference to core MI principles as described by W. R. Miller and S. Rollnick in their book, “Motivational Interviewing: Preparing People to Change” (New York: Guilford Press, 2002).

The studies that were included had a monitoring element, such as the details of counselor training or measures to ensure the quality of MI sessions (videotaping sessions or use of an assessment scale and supervision, for example). The main outcome measure used in the review was abstinence from smoking after at least 6 months' follow-up, based on the most rigorous definition of abstinence in each trial and biochemically validated rates, where available.

All except two of the intervention studies reviewed took place in the United States, and the most commonly used MI approach was one in which the smoker received nonthreatening feedback designed to develop discrepancy between smoking and personal goals, the authors explained.

Dr. Lai and his colleagues noted that the interventions involved face-to-face sessions, except for three in which the counseling was telephone based.

Ten of the studies looked at single-session interventions, and the rest looked at three- and four-session interventions. Most of the studies compared the MI intervention with usual care or brief advice, often accompanied by self-help materials, the investigators reported.

The investigators conducted a conventional meta-analysis to estimate pooled treatment effects. They observed a modest but significant increase in smoking cessation among patients who underwent motivational interviewing, compared with those who received usual care.

With the strictest definition of abstinence and the longest follow-up, the overall effect across all 14 trials was a relative risk for smoking cessation in the treatment vs. usual care group of 1.27, the authors reported.

A slightly higher but similar effect (relative risk 1.37) was observed in a sensitivity analysis that excluded trials of participants who were already motivated to make a quit attempt, and a comparable relative risk (1.31) was noted in an analysis of findings from the nine trials in which the outcomes were validated biochemically, they said.

In a subgroup analysis by therapist type, the largest effect was observed in the interventions delivered by primary care physicians, followed by those with counselors and nurses, with respective relative risks of 3.49, 1.23, and 1.27, the authors reported.

Primary care doctors might be best suited to deliver this type of intervention because they are already familiar with the patients and, presumably, have an established rapport.

The authors point out that “this finding is based on two relatively small studies and should not be overstated.”

Despite the positive findings of the meta-analysis, “absolute quit rates were relatively low,” probably because most of the trials included smokers who were not motivated to quit, Dr. Lai and his colleagues reported.

The authors urged caution in interpreting results because of “variations in study quality, treatment fidelity, and the possibility of publication or selective reporting bias.” Future studies “should attempt to identify which core components of the motivational interviewing approach are effective,” they wrote.

The authors reported no conflicts of interest.

My Take

Efficacy of MI Is Fairly Consistent

Motivational interviewing has received a great deal of attention as a therapeutic modality for substance use disorders. As this article highlights, the efficacy of MI is fairly consistent across studies, but the effect size is modest. It might be that MI is most effective for individuals who have less severe illness and/or are at an earlier stage in the addiction process (i.e., “problem” drinkers). MI has also been used with success as an adjunct to help motivate and engage individuals in more intensive substance abuse treatment.

KATHLEEN T. BRADY, M.D., Ph.D., a psychiatrist and a pharmacologist, is professor at the Medical University of South Carolina, Charleston. She is director of the Southern Consortium of the National Institute on Drug Abuse's Clinical Trials Network. She serves as a consultant to or on the speakers bureaus of several pharmaceutical companies.

VITALS

Major Finding: Motivational interviewing has the greatest impact on smoking cessation when it is delivered by a primary care physician, compared with delivery by counselors or nurses (relative risk 3.49 vs.1.23 and 1.27, respectively).

Data Source: Meta-analysis of 14 smoking cessation studies involving over 10,000 individuals in which motivational interviewing was used.

Disclosures: The authors reported no conflicts of interest.

Motivational interviewing can be an effective counseling technique for smoking cessation, particularly when it is delivered by a primary care physician, a review of intervention studies shows. However, the review results should be interpreted with caution, the authors wrote.

Dr. Douglas T.C. Lai, a family medicine physician affiliated with the Chinese University of Hong Kong, and his colleagues from that university and the University of Oxford (England), conducted a Cochrane Collaboration review of data from 14 studies involving more than 10,000 individuals and published between 1997 and 2008.

The review included randomized controlled trials, identified through the Cochrane Tobacco Addiction Group Specialized Register, in which motivational interviewing or its variants were used to assist in smoking cessation (Cochrane Database Syst. Rev. 2010 Jan. [doi: 10.1002/14651858.CD006936.pub2]).

Motivational interviewing (MI) is a nonconfrontational counseling technique designed to help people explore and resolve their uncertainties about behavior changes, the authors wrote. The brief psychotherpapeutic technique has been widely implemented as a smoking cessation technique and is recommended in smoking cessation guidelines.

However, little attempt has been made “to systematically review the evidence” about the intervention, Dr. Lai and his colleagues wrote.

In the current review, the investigators sought to include studies of interventions that made explicit reference to core MI principles as described by W. R. Miller and S. Rollnick in their book, “Motivational Interviewing: Preparing People to Change” (New York: Guilford Press, 2002).

The studies that were included had a monitoring element, such as the details of counselor training or measures to ensure the quality of MI sessions (videotaping sessions or use of an assessment scale and supervision, for example). The main outcome measure used in the review was abstinence from smoking after at least 6 months' follow-up, based on the most rigorous definition of abstinence in each trial and biochemically validated rates, where available.

All except two of the intervention studies reviewed took place in the United States, and the most commonly used MI approach was one in which the smoker received nonthreatening feedback designed to develop discrepancy between smoking and personal goals, the authors explained.

Dr. Lai and his colleagues noted that the interventions involved face-to-face sessions, except for three in which the counseling was telephone based.

Ten of the studies looked at single-session interventions, and the rest looked at three- and four-session interventions. Most of the studies compared the MI intervention with usual care or brief advice, often accompanied by self-help materials, the investigators reported.

The investigators conducted a conventional meta-analysis to estimate pooled treatment effects. They observed a modest but significant increase in smoking cessation among patients who underwent motivational interviewing, compared with those who received usual care.

With the strictest definition of abstinence and the longest follow-up, the overall effect across all 14 trials was a relative risk for smoking cessation in the treatment vs. usual care group of 1.27, the authors reported.

A slightly higher but similar effect (relative risk 1.37) was observed in a sensitivity analysis that excluded trials of participants who were already motivated to make a quit attempt, and a comparable relative risk (1.31) was noted in an analysis of findings from the nine trials in which the outcomes were validated biochemically, they said.

In a subgroup analysis by therapist type, the largest effect was observed in the interventions delivered by primary care physicians, followed by those with counselors and nurses, with respective relative risks of 3.49, 1.23, and 1.27, the authors reported.

Primary care doctors might be best suited to deliver this type of intervention because they are already familiar with the patients and, presumably, have an established rapport.

The authors point out that “this finding is based on two relatively small studies and should not be overstated.”

Despite the positive findings of the meta-analysis, “absolute quit rates were relatively low,” probably because most of the trials included smokers who were not motivated to quit, Dr. Lai and his colleagues reported.

The authors urged caution in interpreting results because of “variations in study quality, treatment fidelity, and the possibility of publication or selective reporting bias.” Future studies “should attempt to identify which core components of the motivational interviewing approach are effective,” they wrote.

The authors reported no conflicts of interest.

My Take

Efficacy of MI Is Fairly Consistent

Motivational interviewing has received a great deal of attention as a therapeutic modality for substance use disorders. As this article highlights, the efficacy of MI is fairly consistent across studies, but the effect size is modest. It might be that MI is most effective for individuals who have less severe illness and/or are at an earlier stage in the addiction process (i.e., “problem” drinkers). MI has also been used with success as an adjunct to help motivate and engage individuals in more intensive substance abuse treatment.

KATHLEEN T. BRADY, M.D., Ph.D., a psychiatrist and a pharmacologist, is professor at the Medical University of South Carolina, Charleston. She is director of the Southern Consortium of the National Institute on Drug Abuse's Clinical Trials Network. She serves as a consultant to or on the speakers bureaus of several pharmaceutical companies.

VITALS

BOSTON — Measuring urine neutrophil gelatinase–associated lipocalin upon hospital admission in patients with cirrhosis and renal failure can distinguish hepatorenal syndrome and acute kidney injury from other forms of kidney dysfunction and might help predict inpatient mortality, a study has shown.

If the findings are confirmed, a single measurement of neutrophil gelatinase–associated lipocalin (NGAL), an acute-phase protein, may help guide early, disease-specific therapy for patients with cirrhosis and renal failure, Dr. Elizabeth C. Verna said at the annual meeting of the American Association for the Study of Liver Diseases.

“Determining the etiology of acute renal failure in patients with cirrhosis, ascites, and edema remains an important clinical challenge, and it is particularly important in patients awaiting liver transplantation,” said Dr. Verna of Columbia University in New York.

Although urine NGAL has been shown to predict the onset or severity of acute kidney injury, and to predict clinical outcomes, “it has not been tested in the setting of cirrhosis or hepatorenal syndrome,” she noted.

Dr. Verna and her colleagues conducted a prospective cohort study of 115 adults admitted to the general medical service or ICU with either biopsy-proven cirrhosis or a combination of imaging, laboratory, and clinical data with documentation of cirrhosis. The study excluded patients with chronic end-stage renal disease on dialysis as well as those who were anuric on presentation with significant proteinuria, active urinary tract infection, HIV infection, or a previous solid organ transplant.

The primary outcomes included inpatient mortality and category of renal failure—normal renal function, stable chronic kidney disease, prerenal azotemia (PRA), hepatorenal syndrome (HRS), or acute kidney injury (AKI). Urine was collected from all patients within 24 hours of admission, and NGAL measurement was determined with Western blot and confirmed using ELISA, then corrected for urine creatinine for each case. The final adjudication of renal function was determined by an attending nephrologist who was blinded to both urine NGAL measures and clinical outcomes.

The mean age of the patients was 56 years, and 70% were men. Most had hepatitis C, alcohol dependence, or a combination of both. “Many of the patients had suffered previous consequences of cirrhosis, including ascites, variceal bleeding, and hepatocellular carcinoma,” she said. About 14% of the patients had previous transjugular intrahepatic portosystemic shunt and 18% had a history of at least stage 2 chronic kidney disease. The median model for end-stage liver disease (MELD) score on admission was 17, and median hospital stay was 6 days.

With respect to renal function category, 43% had normal kidney function, 11% had stable chronic kidney disease, 25% had PRA, 11% had HRS, and 9% had AKI, Urine NGAL was elevated in both AKI (1,000 mcg/g) and HRS patients (318 mcg/g), compared with PRA (111 mcg/g), while the admission values of creatinine were elevated only in AKI.

About 12% of the patients died while in the hospital, 22% required ICU admission, 17% had a nephrology consultation, and 10% underwent inpatient dialysis. “The majority of patients who died during admission were in the HRS or AKI groups,” Dr. Verna said. “The log transformation of urine NGAL was predictive of all of our other binary outcomes including inpatient mortality, dialysis, combination of dialysis and mortality, ICU admission, and renal consultation. This finding was strongest for inpatient mortality, where for every log increase in urine NGAL, the odds ratio for mortality was 1.9.”

In multiple logistic regression models, “a urine NGAL cutoff of 165 was significantly predictive of mortality and when controlling for creatinine at a cut point of 1.2, age, and [HRS],” she said. The strongest predictor of inpatient mortality was HRS as a diagnosis of acute renal failure; aadding the MELD [score] did not significantly change these relationships.

The study findings suggest that, in patients with cirrhosis, “a single urine NGAL measurement may distinguish HRS and AKI from PRA, and that HRS is a strong predictor of mortality in this setting,” Dr. Verna said. “Additional studies are required to understand why urine NGAL may be elevated in HRS. We think it perhaps is due to subtle and reversible tubular damage in these patients.”

If these findings are confirmed, Dr. Verna noted, “urine NGAL could be used clinically to discriminate HRS from PRA, which is usually a very difficult decision to make, and to direct early therapy.”

Disclosures: Dr. Verna reported having no relevant financial disclosures.

BOSTON — Measuring urine neutrophil gelatinase–associated lipocalin upon hospital admission in patients with cirrhosis and renal failure can distinguish hepatorenal syndrome and acute kidney injury from other forms of kidney dysfunction and might help predict inpatient mortality, a study has shown.

If the findings are confirmed, a single measurement of neutrophil gelatinase–associated lipocalin (NGAL), an acute-phase protein, may help guide early, disease-specific therapy for patients with cirrhosis and renal failure, Dr. Elizabeth C. Verna said at the annual meeting of the American Association for the Study of Liver Diseases.

“Determining the etiology of acute renal failure in patients with cirrhosis, ascites, and edema remains an important clinical challenge, and it is particularly important in patients awaiting liver transplantation,” said Dr. Verna of Columbia University in New York.

Although urine NGAL has been shown to predict the onset or severity of acute kidney injury, and to predict clinical outcomes, “it has not been tested in the setting of cirrhosis or hepatorenal syndrome,” she noted.

Dr. Verna and her colleagues conducted a prospective cohort study of 115 adults admitted to the general medical service or ICU with either biopsy-proven cirrhosis or a combination of imaging, laboratory, and clinical data with documentation of cirrhosis. The study excluded patients with chronic end-stage renal disease on dialysis as well as those who were anuric on presentation with significant proteinuria, active urinary tract infection, HIV infection, or a previous solid organ transplant.

The primary outcomes included inpatient mortality and category of renal failure—normal renal function, stable chronic kidney disease, prerenal azotemia (PRA), hepatorenal syndrome (HRS), or acute kidney injury (AKI). Urine was collected from all patients within 24 hours of admission, and NGAL measurement was determined with Western blot and confirmed using ELISA, then corrected for urine creatinine for each case. The final adjudication of renal function was determined by an attending nephrologist who was blinded to both urine NGAL measures and clinical outcomes.

The mean age of the patients was 56 years, and 70% were men. Most had hepatitis C, alcohol dependence, or a combination of both. “Many of the patients had suffered previous consequences of cirrhosis, including ascites, variceal bleeding, and hepatocellular carcinoma,” she said. About 14% of the patients had previous transjugular intrahepatic portosystemic shunt and 18% had a history of at least stage 2 chronic kidney disease. The median model for end-stage liver disease (MELD) score on admission was 17, and median hospital stay was 6 days.

With respect to renal function category, 43% had normal kidney function, 11% had stable chronic kidney disease, 25% had PRA, 11% had HRS, and 9% had AKI, Urine NGAL was elevated in both AKI (1,000 mcg/g) and HRS patients (318 mcg/g), compared with PRA (111 mcg/g), while the admission values of creatinine were elevated only in AKI.

About 12% of the patients died while in the hospital, 22% required ICU admission, 17% had a nephrology consultation, and 10% underwent inpatient dialysis. “The majority of patients who died during admission were in the HRS or AKI groups,” Dr. Verna said. “The log transformation of urine NGAL was predictive of all of our other binary outcomes including inpatient mortality, dialysis, combination of dialysis and mortality, ICU admission, and renal consultation. This finding was strongest for inpatient mortality, where for every log increase in urine NGAL, the odds ratio for mortality was 1.9.”

In multiple logistic regression models, “a urine NGAL cutoff of 165 was significantly predictive of mortality and when controlling for creatinine at a cut point of 1.2, age, and [HRS],” she said. The strongest predictor of inpatient mortality was HRS as a diagnosis of acute renal failure; aadding the MELD [score] did not significantly change these relationships.

The study findings suggest that, in patients with cirrhosis, “a single urine NGAL measurement may distinguish HRS and AKI from PRA, and that HRS is a strong predictor of mortality in this setting,” Dr. Verna said. “Additional studies are required to understand why urine NGAL may be elevated in HRS. We think it perhaps is due to subtle and reversible tubular damage in these patients.”

If these findings are confirmed, Dr. Verna noted, “urine NGAL could be used clinically to discriminate HRS from PRA, which is usually a very difficult decision to make, and to direct early therapy.”

Disclosures: Dr. Verna reported having no relevant financial disclosures.

BOSTON — Measuring urine neutrophil gelatinase–associated lipocalin upon hospital admission in patients with cirrhosis and renal failure can distinguish hepatorenal syndrome and acute kidney injury from other forms of kidney dysfunction and might help predict inpatient mortality, a study has shown.

If the findings are confirmed, a single measurement of neutrophil gelatinase–associated lipocalin (NGAL), an acute-phase protein, may help guide early, disease-specific therapy for patients with cirrhosis and renal failure, Dr. Elizabeth C. Verna said at the annual meeting of the American Association for the Study of Liver Diseases.

“Determining the etiology of acute renal failure in patients with cirrhosis, ascites, and edema remains an important clinical challenge, and it is particularly important in patients awaiting liver transplantation,” said Dr. Verna of Columbia University in New York.

Although urine NGAL has been shown to predict the onset or severity of acute kidney injury, and to predict clinical outcomes, “it has not been tested in the setting of cirrhosis or hepatorenal syndrome,” she noted.

Dr. Verna and her colleagues conducted a prospective cohort study of 115 adults admitted to the general medical service or ICU with either biopsy-proven cirrhosis or a combination of imaging, laboratory, and clinical data with documentation of cirrhosis. The study excluded patients with chronic end-stage renal disease on dialysis as well as those who were anuric on presentation with significant proteinuria, active urinary tract infection, HIV infection, or a previous solid organ transplant.

The primary outcomes included inpatient mortality and category of renal failure—normal renal function, stable chronic kidney disease, prerenal azotemia (PRA), hepatorenal syndrome (HRS), or acute kidney injury (AKI). Urine was collected from all patients within 24 hours of admission, and NGAL measurement was determined with Western blot and confirmed using ELISA, then corrected for urine creatinine for each case. The final adjudication of renal function was determined by an attending nephrologist who was blinded to both urine NGAL measures and clinical outcomes.

The mean age of the patients was 56 years, and 70% were men. Most had hepatitis C, alcohol dependence, or a combination of both. “Many of the patients had suffered previous consequences of cirrhosis, including ascites, variceal bleeding, and hepatocellular carcinoma,” she said. About 14% of the patients had previous transjugular intrahepatic portosystemic shunt and 18% had a history of at least stage 2 chronic kidney disease. The median model for end-stage liver disease (MELD) score on admission was 17, and median hospital stay was 6 days.

With respect to renal function category, 43% had normal kidney function, 11% had stable chronic kidney disease, 25% had PRA, 11% had HRS, and 9% had AKI, Urine NGAL was elevated in both AKI (1,000 mcg/g) and HRS patients (318 mcg/g), compared with PRA (111 mcg/g), while the admission values of creatinine were elevated only in AKI.

About 12% of the patients died while in the hospital, 22% required ICU admission, 17% had a nephrology consultation, and 10% underwent inpatient dialysis. “The majority of patients who died during admission were in the HRS or AKI groups,” Dr. Verna said. “The log transformation of urine NGAL was predictive of all of our other binary outcomes including inpatient mortality, dialysis, combination of dialysis and mortality, ICU admission, and renal consultation. This finding was strongest for inpatient mortality, where for every log increase in urine NGAL, the odds ratio for mortality was 1.9.”

In multiple logistic regression models, “a urine NGAL cutoff of 165 was significantly predictive of mortality and when controlling for creatinine at a cut point of 1.2, age, and [HRS],” she said. The strongest predictor of inpatient mortality was HRS as a diagnosis of acute renal failure; aadding the MELD [score] did not significantly change these relationships.

The study findings suggest that, in patients with cirrhosis, “a single urine NGAL measurement may distinguish HRS and AKI from PRA, and that HRS is a strong predictor of mortality in this setting,” Dr. Verna said. “Additional studies are required to understand why urine NGAL may be elevated in HRS. We think it perhaps is due to subtle and reversible tubular damage in these patients.”

If these findings are confirmed, Dr. Verna noted, “urine NGAL could be used clinically to discriminate HRS from PRA, which is usually a very difficult decision to make, and to direct early therapy.”

Disclosures: Dr. Verna reported having no relevant financial disclosures.

The future of noninvasive body sculpting appears promising, as a growing number of external body-contouring technologies are awaiting approval or have recently received approval for use in the United States.

While the mechanisms by which the various technologies attack fat are different, the ultimate goal is the same: improving the appearance of problem areas such as the thighs and lower abdomen without invasive surgery, Dr. Mark G. Rubin said at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation.

Among the devices receiving attention are the LipoSonix (Medicis) and UltraShape Contour I ultrasound-based systems, both of which have completed Food and Drug Administration trials and are awaiting an approval decision, and the Zerona low-level laser device (Erchonia), which has been approved for use, according to Dr. Rubin, a dermatologist in private practice in Beverly Hills, Calif.

The LipoSonix system, which is cleared for use in Europe and Canada, uses high-intensity, focused ultrasound to disrupt subcutaneous adipose tissue in the anterior abdomen without damaging the skin or underlying tissues and organs, according to Dr. Rubin. A transducer delivers the high intensity ultrasound at precise depths in the targeted subcutaneous adipose tissue, causing thermal coagulation of the adipose tissue, he said, noting that the damaged tissue and lipids are then transported via macrophage cells through the lymphatic system to the liver. The damaged tissue is ultimately reabsorbed over several months.

In controlled clinical studies sponsored by the manufacturer, a single, 1-hour LipoSonix treatment resulted in an average 2.8-cm reduction in waistline circumference at 8-12 weeks, although individual results vary by patient, according to Dr. Rubin.

The UltraShape Contour I system, which has also been approved for use in Europe and Canada, uses nonthermal, selective, focused ultrasound for fat reduction and body contouring, and employs an optical tracking and guidance system to help ensure the treatment is only delivered to the targeted area, Dr. Rubin explained. While the LipoSonix system achieves targeted fat cell reduction by thermal necrosis, the Ultrashape Contour I relies on initial cavitation followed by the mechanical destruction of cells.

In a multicenter, controlled, clinical study of the UltraShape Contour I system, 137 patients received a single treatment to the abdomen, flanks, or thighs. The mean circumference reduction, evaluated at 12 weeks was 2 cm, Dr. Rubin reported, noting that the majority of the effect was achieved within 2 weeks and maintained out to 12 weeks. The mean reduction in skin-fat thickness was 2.9 mm (Plast. Reconstr. Surg. 2007;120:779-89.)

"The benefits of the ultrasound devices are that they appear to have permanent fat reduction," Dr. Rubin said in an interview. In contrast, the Zerona low-level laser causes fat cells to shrink and deflate without heating the skin or causing any surrounding tissue damage, but the fat reduction is most likely temporary, he said. "The external ultrasound devices destroy fat cells, while the low-level laser drains the fat cell but it survives and can 're-inflate' again."

The reported clinical efficacy of Zerona, which requires multiple 40-minute sessions over 2 weeks, is variable. Data from a company sponsored, multisite, randomized, placebo-controlled study showed that the mean reduction of combined waist-hip-thigh circumference of patients in the treatment group was 3-4 inches, compared with a half inch in the placebo group (Lasers Surg. Med. 2009;41:799-809).

Dr. Rubin's own clinical experience with Zerona has yielded a smaller reduction. "In our experience with 41 patients, the average circumferential loss for waist, hips, and both thighs combined is 2.91 inches," he said. "There is some data suggesting laser head positioning may affect clinical results."

An advantage of Zerona is it does not create pain, inflammation, or swelling, said Dr. Rubin. It is, however, associated with more uncertainties. For example, although it consistently emulsifies the fat that it targets, "not all of the patients can successfully mobilize and degrade the fatty debris," he said. "It is believed that certain individuals, based on their lymphatic vessel structure, are unable to deliver the fat away from the interstitial space in a timely manner," which means the results will be minimal. Studies are currently underway to try to identify who the best Zerona candidates are, "but at this time the answer remains unknown," he said.

None of the devices are as effective as liposuction for fat reduction and circumferential reduction of body areas, he said. However, the devices are appealing to patients "because they are noninvasive, requiring no incisions or needles."

^{Photo Courtesy Dr. Mark G. Rubin}

Dr. Rubin is a consultant for Medicis and Zerona. SDEF and this news organization are owned by Elsevier.

The future of noninvasive body sculpting appears promising, as a growing number of external body-contouring technologies are awaiting approval or have recently received approval for use in the United States.

While the mechanisms by which the various technologies attack fat are different, the ultimate goal is the same: improving the appearance of problem areas such as the thighs and lower abdomen without invasive surgery, Dr. Mark G. Rubin said at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation.

Among the devices receiving attention are the LipoSonix (Medicis) and UltraShape Contour I ultrasound-based systems, both of which have completed Food and Drug Administration trials and are awaiting an approval decision, and the Zerona low-level laser device (Erchonia), which has been approved for use, according to Dr. Rubin, a dermatologist in private practice in Beverly Hills, Calif.

The LipoSonix system, which is cleared for use in Europe and Canada, uses high-intensity, focused ultrasound to disrupt subcutaneous adipose tissue in the anterior abdomen without damaging the skin or underlying tissues and organs, according to Dr. Rubin. A transducer delivers the high intensity ultrasound at precise depths in the targeted subcutaneous adipose tissue, causing thermal coagulation of the adipose tissue, he said, noting that the damaged tissue and lipids are then transported via macrophage cells through the lymphatic system to the liver. The damaged tissue is ultimately reabsorbed over several months.

In controlled clinical studies sponsored by the manufacturer, a single, 1-hour LipoSonix treatment resulted in an average 2.8-cm reduction in waistline circumference at 8-12 weeks, although individual results vary by patient, according to Dr. Rubin.

The UltraShape Contour I system, which has also been approved for use in Europe and Canada, uses nonthermal, selective, focused ultrasound for fat reduction and body contouring, and employs an optical tracking and guidance system to help ensure the treatment is only delivered to the targeted area, Dr. Rubin explained. While the LipoSonix system achieves targeted fat cell reduction by thermal necrosis, the Ultrashape Contour I relies on initial cavitation followed by the mechanical destruction of cells.

In a multicenter, controlled, clinical study of the UltraShape Contour I system, 137 patients received a single treatment to the abdomen, flanks, or thighs. The mean circumference reduction, evaluated at 12 weeks was 2 cm, Dr. Rubin reported, noting that the majority of the effect was achieved within 2 weeks and maintained out to 12 weeks. The mean reduction in skin-fat thickness was 2.9 mm (Plast. Reconstr. Surg. 2007;120:779-89.)

"The benefits of the ultrasound devices are that they appear to have permanent fat reduction," Dr. Rubin said in an interview. In contrast, the Zerona low-level laser causes fat cells to shrink and deflate without heating the skin or causing any surrounding tissue damage, but the fat reduction is most likely temporary, he said. "The external ultrasound devices destroy fat cells, while the low-level laser drains the fat cell but it survives and can 're-inflate' again."

The reported clinical efficacy of Zerona, which requires multiple 40-minute sessions over 2 weeks, is variable. Data from a company sponsored, multisite, randomized, placebo-controlled study showed that the mean reduction of combined waist-hip-thigh circumference of patients in the treatment group was 3-4 inches, compared with a half inch in the placebo group (Lasers Surg. Med. 2009;41:799-809).

Dr. Rubin's own clinical experience with Zerona has yielded a smaller reduction. "In our experience with 41 patients, the average circumferential loss for waist, hips, and both thighs combined is 2.91 inches," he said. "There is some data suggesting laser head positioning may affect clinical results."

An advantage of Zerona is it does not create pain, inflammation, or swelling, said Dr. Rubin. It is, however, associated with more uncertainties. For example, although it consistently emulsifies the fat that it targets, "not all of the patients can successfully mobilize and degrade the fatty debris," he said. "It is believed that certain individuals, based on their lymphatic vessel structure, are unable to deliver the fat away from the interstitial space in a timely manner," which means the results will be minimal. Studies are currently underway to try to identify who the best Zerona candidates are, "but at this time the answer remains unknown," he said.

None of the devices are as effective as liposuction for fat reduction and circumferential reduction of body areas, he said. However, the devices are appealing to patients "because they are noninvasive, requiring no incisions or needles."

^{Photo Courtesy Dr. Mark G. Rubin}

Dr. Rubin is a consultant for Medicis and Zerona. SDEF and this news organization are owned by Elsevier.

The future of noninvasive body sculpting appears promising, as a growing number of external body-contouring technologies are awaiting approval or have recently received approval for use in the United States.

While the mechanisms by which the various technologies attack fat are different, the ultimate goal is the same: improving the appearance of problem areas such as the thighs and lower abdomen without invasive surgery, Dr. Mark G. Rubin said at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation.

Among the devices receiving attention are the LipoSonix (Medicis) and UltraShape Contour I ultrasound-based systems, both of which have completed Food and Drug Administration trials and are awaiting an approval decision, and the Zerona low-level laser device (Erchonia), which has been approved for use, according to Dr. Rubin, a dermatologist in private practice in Beverly Hills, Calif.

The LipoSonix system, which is cleared for use in Europe and Canada, uses high-intensity, focused ultrasound to disrupt subcutaneous adipose tissue in the anterior abdomen without damaging the skin or underlying tissues and organs, according to Dr. Rubin. A transducer delivers the high intensity ultrasound at precise depths in the targeted subcutaneous adipose tissue, causing thermal coagulation of the adipose tissue, he said, noting that the damaged tissue and lipids are then transported via macrophage cells through the lymphatic system to the liver. The damaged tissue is ultimately reabsorbed over several months.

In controlled clinical studies sponsored by the manufacturer, a single, 1-hour LipoSonix treatment resulted in an average 2.8-cm reduction in waistline circumference at 8-12 weeks, although individual results vary by patient, according to Dr. Rubin.

The UltraShape Contour I system, which has also been approved for use in Europe and Canada, uses nonthermal, selective, focused ultrasound for fat reduction and body contouring, and employs an optical tracking and guidance system to help ensure the treatment is only delivered to the targeted area, Dr. Rubin explained. While the LipoSonix system achieves targeted fat cell reduction by thermal necrosis, the Ultrashape Contour I relies on initial cavitation followed by the mechanical destruction of cells.

In a multicenter, controlled, clinical study of the UltraShape Contour I system, 137 patients received a single treatment to the abdomen, flanks, or thighs. The mean circumference reduction, evaluated at 12 weeks was 2 cm, Dr. Rubin reported, noting that the majority of the effect was achieved within 2 weeks and maintained out to 12 weeks. The mean reduction in skin-fat thickness was 2.9 mm (Plast. Reconstr. Surg. 2007;120:779-89.)

"The benefits of the ultrasound devices are that they appear to have permanent fat reduction," Dr. Rubin said in an interview. In contrast, the Zerona low-level laser causes fat cells to shrink and deflate without heating the skin or causing any surrounding tissue damage, but the fat reduction is most likely temporary, he said. "The external ultrasound devices destroy fat cells, while the low-level laser drains the fat cell but it survives and can 're-inflate' again."

The reported clinical efficacy of Zerona, which requires multiple 40-minute sessions over 2 weeks, is variable. Data from a company sponsored, multisite, randomized, placebo-controlled study showed that the mean reduction of combined waist-hip-thigh circumference of patients in the treatment group was 3-4 inches, compared with a half inch in the placebo group (Lasers Surg. Med. 2009;41:799-809).

Dr. Rubin's own clinical experience with Zerona has yielded a smaller reduction. "In our experience with 41 patients, the average circumferential loss for waist, hips, and both thighs combined is 2.91 inches," he said. "There is some data suggesting laser head positioning may affect clinical results."

An advantage of Zerona is it does not create pain, inflammation, or swelling, said Dr. Rubin. It is, however, associated with more uncertainties. For example, although it consistently emulsifies the fat that it targets, "not all of the patients can successfully mobilize and degrade the fatty debris," he said. "It is believed that certain individuals, based on their lymphatic vessel structure, are unable to deliver the fat away from the interstitial space in a timely manner," which means the results will be minimal. Studies are currently underway to try to identify who the best Zerona candidates are, "but at this time the answer remains unknown," he said.

None of the devices are as effective as liposuction for fat reduction and circumferential reduction of body areas, he said. However, the devices are appealing to patients "because they are noninvasive, requiring no incisions or needles."

^{Photo Courtesy Dr. Mark G. Rubin}

Dr. Rubin is a consultant for Medicis and Zerona. SDEF and this news organization are owned by Elsevier.

Motivational interviewing can be an effective counseling technique for smoking cessation, particularly when it is delivered by a primary care physician, a review of intervention studies shows. However, the review results should be interpreted with caution, the authors wrote.

Dr. Douglas T.C. Lai, a family physician affiliated with the Chinese University of Hong Kong, and his colleagues from that university and the University of Oxford (England), conducted a Cochrane Collaboration review of data from 14 studies involving over 10,000 individuals and published between 1997 and 2008. The review included randomized controlled trials, identified through the Cochrane Tobacco Addiction Group Specialized Register, in which motivational interviewing or its variants were used to assist in smoking cessation (Cochrane Database Syst. Rev. 2010 Jan. [doi:10.1002/14651858.CD006936.pub2

Motivational interviewing (MI) is a nonconfrontational counseling technique designed to help people explore and resolve their uncertainties about behavior changes, the authors wrote. The brief intervention has been widely implemented as a smoking cessation technique and is recommended in smoking cessation guidelines. However, little attempt has been made “to systematically review the evidence” about the intervention.

In the current review, the researchers sought to include studies of interventions making explicit reference to core MI principles as described by W. R. Miller and S. Rollnick in their book, “Motivational Interviewing: Preparing People to Change” (New York: Guilford Press, 2002).

The studies had to include a monitoring element, such as the details of counselor training or measures to ensure the quality of MI sessions (videotaping sessions or use of an assessment scale and supervision, for example). The main outcome measure used in the review was abstinence from smoking after at least 6 months' follow-up, based on the most rigorous definition of abstinence in each trial and biochemically validated rates, where available.

All except two of the intervention studies included in the review took place in the United States, and the most commonly used MI approach was one in which the smoker received nonthreatening feedback designed to develop discrepancy between smoking and personal goals, the authors explained.

Dr. Lai and his colleagues noted that the interventions involved face-to-face sessions, except for three in which the counseling was telephone based. Ten of the studies looked at single-session interventions, and the rest looked at three- and four-session interventions. Most of the studies compared the MI intervention with usual care or brief advice, often accompanied by self-help materials, they said.

The investigators conducted a conventional meta-analysis to estimate pooled treatment effects.

They observed a modest but significant increase in smoking cessation among patients who underwent MI, compared with those who received usual care. With the strictest definition of abstinence and the longest follow-up, the overall effect across all 14 trials was a relative risk for smoking cessation in the treatment vs. usual care group of 1.27, the authors reported.

A slightly higher but similar effect (relative risk 1.37) was observed in a sensitivity analysis that excluded trials of participants who were already motivated to make a quit attempt, and a comparable relative risk (1.31) was noted in an analysis of findings from the nine trials in which the outcomes were validated biochemically, they said.

In a subgroup analysis by therapist type, the largest effect was observed in the interventions delivered by primary care physicians, followed by those with counselors and nurses, the authors reported. It is possible that primary care doctors are best suited to deliver this type of intervention because they are already familiar with the patients and, presumably, have an established rapport. The author pointed out that “this finding is based on two relatively small studies and should not be overstated.”

The authors reported no conflicts of interest.

My Take

Be Realistic

The systematic review by Dr. Lai and his colleagues affirms the general notion that interventions for tobacco cessation provided by clinicians increase abstinence rates, but also goes further to suggest that primary care physicians may be more effective than other clinicians.

This conclusion must be interpreted with caution because it is based upon two small studies. Even if the authors' conclusion are true, motivational interviewing is an incredibly powerful tool—but one with limited ability to be disseminated into primary care practices. The “crush of the practice” in primary care leaves only the optimistic and detached remaining hopeful that providers will be able to apply these skills with their patients who use tobacco.

A more realistic model is the AAR model in which busy clinicians Ask-Advise-Refer. The ideal role of motivational interviewing in primary care may be to overcome patient barriers to accepting referral to a tobacco treatment specialist or to picking up the phone and calling the tobacco quit line (800-QUITNOW).

Motivational interviewing can be an effective counseling technique for smoking cessation, particularly when it is delivered by a primary care physician, a review of intervention studies shows. However, the review results should be interpreted with caution, the authors wrote.

Dr. Douglas T.C. Lai, a family physician affiliated with the Chinese University of Hong Kong, and his colleagues from that university and the University of Oxford (England), conducted a Cochrane Collaboration review of data from 14 studies involving over 10,000 individuals and published between 1997 and 2008. The review included randomized controlled trials, identified through the Cochrane Tobacco Addiction Group Specialized Register, in which motivational interviewing or its variants were used to assist in smoking cessation (Cochrane Database Syst. Rev. 2010 Jan. [doi:10.1002/14651858.CD006936.pub2

Motivational interviewing (MI) is a nonconfrontational counseling technique designed to help people explore and resolve their uncertainties about behavior changes, the authors wrote. The brief intervention has been widely implemented as a smoking cessation technique and is recommended in smoking cessation guidelines. However, little attempt has been made “to systematically review the evidence” about the intervention.

In the current review, the researchers sought to include studies of interventions making explicit reference to core MI principles as described by W. R. Miller and S. Rollnick in their book, “Motivational Interviewing: Preparing People to Change” (New York: Guilford Press, 2002).

The studies had to include a monitoring element, such as the details of counselor training or measures to ensure the quality of MI sessions (videotaping sessions or use of an assessment scale and supervision, for example). The main outcome measure used in the review was abstinence from smoking after at least 6 months' follow-up, based on the most rigorous definition of abstinence in each trial and biochemically validated rates, where available.

All except two of the intervention studies included in the review took place in the United States, and the most commonly used MI approach was one in which the smoker received nonthreatening feedback designed to develop discrepancy between smoking and personal goals, the authors explained.

Dr. Lai and his colleagues noted that the interventions involved face-to-face sessions, except for three in which the counseling was telephone based. Ten of the studies looked at single-session interventions, and the rest looked at three- and four-session interventions. Most of the studies compared the MI intervention with usual care or brief advice, often accompanied by self-help materials, they said.

The investigators conducted a conventional meta-analysis to estimate pooled treatment effects.

They observed a modest but significant increase in smoking cessation among patients who underwent MI, compared with those who received usual care. With the strictest definition of abstinence and the longest follow-up, the overall effect across all 14 trials was a relative risk for smoking cessation in the treatment vs. usual care group of 1.27, the authors reported.

A slightly higher but similar effect (relative risk 1.37) was observed in a sensitivity analysis that excluded trials of participants who were already motivated to make a quit attempt, and a comparable relative risk (1.31) was noted in an analysis of findings from the nine trials in which the outcomes were validated biochemically, they said.

In a subgroup analysis by therapist type, the largest effect was observed in the interventions delivered by primary care physicians, followed by those with counselors and nurses, the authors reported. It is possible that primary care doctors are best suited to deliver this type of intervention because they are already familiar with the patients and, presumably, have an established rapport. The author pointed out that “this finding is based on two relatively small studies and should not be overstated.”

The authors reported no conflicts of interest.

My Take

Be Realistic

The systematic review by Dr. Lai and his colleagues affirms the general notion that interventions for tobacco cessation provided by clinicians increase abstinence rates, but also goes further to suggest that primary care physicians may be more effective than other clinicians.

This conclusion must be interpreted with caution because it is based upon two small studies. Even if the authors' conclusion are true, motivational interviewing is an incredibly powerful tool—but one with limited ability to be disseminated into primary care practices. The “crush of the practice” in primary care leaves only the optimistic and detached remaining hopeful that providers will be able to apply these skills with their patients who use tobacco.

A more realistic model is the AAR model in which busy clinicians Ask-Advise-Refer. The ideal role of motivational interviewing in primary care may be to overcome patient barriers to accepting referral to a tobacco treatment specialist or to picking up the phone and calling the tobacco quit line (800-QUITNOW).

Motivational interviewing can be an effective counseling technique for smoking cessation, particularly when it is delivered by a primary care physician, a review of intervention studies shows. However, the review results should be interpreted with caution, the authors wrote.

Dr. Douglas T.C. Lai, a family physician affiliated with the Chinese University of Hong Kong, and his colleagues from that university and the University of Oxford (England), conducted a Cochrane Collaboration review of data from 14 studies involving over 10,000 individuals and published between 1997 and 2008. The review included randomized controlled trials, identified through the Cochrane Tobacco Addiction Group Specialized Register, in which motivational interviewing or its variants were used to assist in smoking cessation (Cochrane Database Syst. Rev. 2010 Jan. [doi:10.1002/14651858.CD006936.pub2

Motivational interviewing (MI) is a nonconfrontational counseling technique designed to help people explore and resolve their uncertainties about behavior changes, the authors wrote. The brief intervention has been widely implemented as a smoking cessation technique and is recommended in smoking cessation guidelines. However, little attempt has been made “to systematically review the evidence” about the intervention.

In the current review, the researchers sought to include studies of interventions making explicit reference to core MI principles as described by W. R. Miller and S. Rollnick in their book, “Motivational Interviewing: Preparing People to Change” (New York: Guilford Press, 2002).

The studies had to include a monitoring element, such as the details of counselor training or measures to ensure the quality of MI sessions (videotaping sessions or use of an assessment scale and supervision, for example). The main outcome measure used in the review was abstinence from smoking after at least 6 months' follow-up, based on the most rigorous definition of abstinence in each trial and biochemically validated rates, where available.

All except two of the intervention studies included in the review took place in the United States, and the most commonly used MI approach was one in which the smoker received nonthreatening feedback designed to develop discrepancy between smoking and personal goals, the authors explained.

Dr. Lai and his colleagues noted that the interventions involved face-to-face sessions, except for three in which the counseling was telephone based. Ten of the studies looked at single-session interventions, and the rest looked at three- and four-session interventions. Most of the studies compared the MI intervention with usual care or brief advice, often accompanied by self-help materials, they said.

The investigators conducted a conventional meta-analysis to estimate pooled treatment effects.

They observed a modest but significant increase in smoking cessation among patients who underwent MI, compared with those who received usual care. With the strictest definition of abstinence and the longest follow-up, the overall effect across all 14 trials was a relative risk for smoking cessation in the treatment vs. usual care group of 1.27, the authors reported.

A slightly higher but similar effect (relative risk 1.37) was observed in a sensitivity analysis that excluded trials of participants who were already motivated to make a quit attempt, and a comparable relative risk (1.31) was noted in an analysis of findings from the nine trials in which the outcomes were validated biochemically, they said.

In a subgroup analysis by therapist type, the largest effect was observed in the interventions delivered by primary care physicians, followed by those with counselors and nurses, the authors reported. It is possible that primary care doctors are best suited to deliver this type of intervention because they are already familiar with the patients and, presumably, have an established rapport. The author pointed out that “this finding is based on two relatively small studies and should not be overstated.”

The authors reported no conflicts of interest.

My Take

Be Realistic

The systematic review by Dr. Lai and his colleagues affirms the general notion that interventions for tobacco cessation provided by clinicians increase abstinence rates, but also goes further to suggest that primary care physicians may be more effective than other clinicians.

This conclusion must be interpreted with caution because it is based upon two small studies. Even if the authors' conclusion are true, motivational interviewing is an incredibly powerful tool—but one with limited ability to be disseminated into primary care practices. The “crush of the practice” in primary care leaves only the optimistic and detached remaining hopeful that providers will be able to apply these skills with their patients who use tobacco.

A more realistic model is the AAR model in which busy clinicians Ask-Advise-Refer. The ideal role of motivational interviewing in primary care may be to overcome patient barriers to accepting referral to a tobacco treatment specialist or to picking up the phone and calling the tobacco quit line (800-QUITNOW).

Major Finding: Motivational interviewing had more impact on smoking cessation when delivered by a primary care physician, compared with delivery by counselors or nurses (relative risk 3.9 vs.1.23 and 1.27).

Data Source: Meta-analysis of 14 smoking cessation studies involving more than 10,000 individuals in which motivational interviewing was utilized.

Disclosures: The authors reported having no conflicts of interest.

Motivational interviewing can be an effective counseling technique for smoking cessation, particularly when it is delivered by a primary care physician, a review of intervention studies shows. However, the review results should be interpreted with caution, the authors wrote.

Dr. Douglas T.C. Lai, of the Chinese University of Hong Kong, and his colleagues from that university and the University of Oxford (England), conducted a Cochrane Collaboration review of data from 14 studies involving more than 10,000 individuals and published between 1997 and 2008. The review included randomized controlled trials, identified through the Cochrane Tobacco Addiction Group Specialized Register, in which motivational interviewing or its variants were used to assist in smoking cessation (Cochrane Database Syst. Rev. 2010 Jan. [doi:10.1002/14651858.CD006936.pub2

Motivational interviewing is a nonconfrontational counseling technique designed to help people explore and resolve their uncertainties about behavior changes, the authors wrote. The brief psychotherapeutic intervention has been widely implemented as a smoking cessation technique and is recommended in smoking cessation guidelines. However, little attempt has been made “to systematically review the evidence” about the intervention, they wrote.

In the current review, the investigators sought to include studies of interventions that made explicit reference to core principles as described by W. R. Miller and S. Rollnick in their book, “Motivational Interviewing: Preparing People to Change” (New York: Guilford Press, 2002).

The studies had to include a monitoring element, such as the details of counselor training or measures to ensure the quality of interview sessions (videotaping sessions or use of an assessment scale and supervision, for example). The main outcome measure used in the review was abstinence from smoking after at least 6 months' follow-up, based on the most rigorous definition of abstinence in each trial and biochemically validated rates, where available.

All except two of the intervention studies included in the review took place in the United States, and the most commonly used interview approach was one in which the smoker received nonthreatening feedback designed to develop discrepancy between smoking and personal goals, the authors explained. Dr. Lai and his colleagues noted that the interventions involved face-to-face sessions, except for three in which the counseling was telephone based. Ten of the studies looked at single-session interventions, and the rest looked at three- and four-session interventions. Most of the studies compared the intervention with usual care or brief advice, often accompanied by self-help materials, they said.

The investigators conducted a conventional meta-analysis to estimate pooled treatment effects. They observed a modest but significant increase in smoking cessation among patients who underwent motivational interviewing, compared with those who received usual care. With the strictest definition of abstinence and the longest follow-up, the overall effect across all 14 trials was a relative risk for smoking cessation in the treatment vs. usual care group of 1.27, the authors reported.

A slightly higher but similar effect (relative risk 1.37) was observed in a sensitivity analysis that excluded trials of participants who were already motivated to make a quit attempt, and a comparable relative risk (1.31) was noted in an analysis of findings from the nine trials in which the outcomes were validated biochemically, they said.

In a subgroup analysis by therapist type, the largest effect was observed in the interventions delivered by primary care physicians, followed by those with counselors and nurses, with respective relative risks of 3.49, 1.23, and 1.27, the authors reported. It is possible that primary care doctors are best suited to deliver this type of intervention because they are already familiar with the patients and, presumably, have an established rapport. The author point out that “this finding is based on two relatively small studies and should not be overstated.”

Despite the positive findings of the meta-analysis, “absolute quit rates were relatively low,” probably because most of the trials included smokers who were not motivated to quit, the authors wrote.

The authors urged caution in interpreting the results because of “variations in study quality, treatment fidelity, and the possibility of publication or selective reporting bias.” Future studies, they noted, “should attempt to identify which core components of the motivational interviewing approach are effective, and whether modifying them enhances or reduces their effectiveness.”

My Take

Referral Might Be More Realistic

The systematic review by Dr. Lai and his colleagues affirms the general notion that interventions for tobacco cessation provided by clinicians increase abstinence rates, but also goes further to suggest that primary care physicians may be more effective than other clinicians.

As the authors point out, this conclusion must be interpreted with caution because it is based on two small studies. Even if the authors' conclusion are true, motivational interviewing is an incredibly powerful tool—but one with limited ability to be disseminated into primary care practices. The “crush of the practice” in primary care leaves only the optimistic and detached remaining hopeful that providers will be able to apply these skills with their patients who use tobacco.

A more realistic model is the AAR model in which busy clinicians Ask-Advise-Refer. The ideal role of motivational interviewing in primary care may be to overcome patient barriers to accepting referral to a tobacco treatment specialist or to picking up the phone and calling the tobacco quit line (800-QUITNOW).

Major Finding: Motivational interviewing had more impact on smoking cessation when delivered by a primary care physician, compared with delivery by counselors or nurses (relative risk 3.9 vs.1.23 and 1.27).

Data Source: Meta-analysis of 14 smoking cessation studies involving more than 10,000 individuals in which motivational interviewing was utilized.

Disclosures: The authors reported having no conflicts of interest.

Motivational interviewing can be an effective counseling technique for smoking cessation, particularly when it is delivered by a primary care physician, a review of intervention studies shows. However, the review results should be interpreted with caution, the authors wrote.

Dr. Douglas T.C. Lai, of the Chinese University of Hong Kong, and his colleagues from that university and the University of Oxford (England), conducted a Cochrane Collaboration review of data from 14 studies involving more than 10,000 individuals and published between 1997 and 2008. The review included randomized controlled trials, identified through the Cochrane Tobacco Addiction Group Specialized Register, in which motivational interviewing or its variants were used to assist in smoking cessation (Cochrane Database Syst. Rev. 2010 Jan. [doi:10.1002/14651858.CD006936.pub2

Motivational interviewing is a nonconfrontational counseling technique designed to help people explore and resolve their uncertainties about behavior changes, the authors wrote. The brief psychotherapeutic intervention has been widely implemented as a smoking cessation technique and is recommended in smoking cessation guidelines. However, little attempt has been made “to systematically review the evidence” about the intervention, they wrote.

In the current review, the investigators sought to include studies of interventions that made explicit reference to core principles as described by W. R. Miller and S. Rollnick in their book, “Motivational Interviewing: Preparing People to Change” (New York: Guilford Press, 2002).

The studies had to include a monitoring element, such as the details of counselor training or measures to ensure the quality of interview sessions (videotaping sessions or use of an assessment scale and supervision, for example). The main outcome measure used in the review was abstinence from smoking after at least 6 months' follow-up, based on the most rigorous definition of abstinence in each trial and biochemically validated rates, where available.

All except two of the intervention studies included in the review took place in the United States, and the most commonly used interview approach was one in which the smoker received nonthreatening feedback designed to develop discrepancy between smoking and personal goals, the authors explained. Dr. Lai and his colleagues noted that the interventions involved face-to-face sessions, except for three in which the counseling was telephone based. Ten of the studies looked at single-session interventions, and the rest looked at three- and four-session interventions. Most of the studies compared the intervention with usual care or brief advice, often accompanied by self-help materials, they said.

The investigators conducted a conventional meta-analysis to estimate pooled treatment effects. They observed a modest but significant increase in smoking cessation among patients who underwent motivational interviewing, compared with those who received usual care. With the strictest definition of abstinence and the longest follow-up, the overall effect across all 14 trials was a relative risk for smoking cessation in the treatment vs. usual care group of 1.27, the authors reported.

A slightly higher but similar effect (relative risk 1.37) was observed in a sensitivity analysis that excluded trials of participants who were already motivated to make a quit attempt, and a comparable relative risk (1.31) was noted in an analysis of findings from the nine trials in which the outcomes were validated biochemically, they said.

In a subgroup analysis by therapist type, the largest effect was observed in the interventions delivered by primary care physicians, followed by those with counselors and nurses, with respective relative risks of 3.49, 1.23, and 1.27, the authors reported. It is possible that primary care doctors are best suited to deliver this type of intervention because they are already familiar with the patients and, presumably, have an established rapport. The author point out that “this finding is based on two relatively small studies and should not be overstated.”

Despite the positive findings of the meta-analysis, “absolute quit rates were relatively low,” probably because most of the trials included smokers who were not motivated to quit, the authors wrote.

The authors urged caution in interpreting the results because of “variations in study quality, treatment fidelity, and the possibility of publication or selective reporting bias.” Future studies, they noted, “should attempt to identify which core components of the motivational interviewing approach are effective, and whether modifying them enhances or reduces their effectiveness.”

My Take

Referral Might Be More Realistic

The systematic review by Dr. Lai and his colleagues affirms the general notion that interventions for tobacco cessation provided by clinicians increase abstinence rates, but also goes further to suggest that primary care physicians may be more effective than other clinicians.

As the authors point out, this conclusion must be interpreted with caution because it is based on two small studies. Even if the authors' conclusion are true, motivational interviewing is an incredibly powerful tool—but one with limited ability to be disseminated into primary care practices. The “crush of the practice” in primary care leaves only the optimistic and detached remaining hopeful that providers will be able to apply these skills with their patients who use tobacco.

A more realistic model is the AAR model in which busy clinicians Ask-Advise-Refer. The ideal role of motivational interviewing in primary care may be to overcome patient barriers to accepting referral to a tobacco treatment specialist or to picking up the phone and calling the tobacco quit line (800-QUITNOW).

Major Finding: Motivational interviewing had more impact on smoking cessation when delivered by a primary care physician, compared with delivery by counselors or nurses (relative risk 3.9 vs.1.23 and 1.27).

Data Source: Meta-analysis of 14 smoking cessation studies involving more than 10,000 individuals in which motivational interviewing was utilized.

Disclosures: The authors reported having no conflicts of interest.

Motivational interviewing can be an effective counseling technique for smoking cessation, particularly when it is delivered by a primary care physician, a review of intervention studies shows. However, the review results should be interpreted with caution, the authors wrote.

Dr. Douglas T.C. Lai, of the Chinese University of Hong Kong, and his colleagues from that university and the University of Oxford (England), conducted a Cochrane Collaboration review of data from 14 studies involving more than 10,000 individuals and published between 1997 and 2008. The review included randomized controlled trials, identified through the Cochrane Tobacco Addiction Group Specialized Register, in which motivational interviewing or its variants were used to assist in smoking cessation (Cochrane Database Syst. Rev. 2010 Jan. [doi:10.1002/14651858.CD006936.pub2

Motivational interviewing is a nonconfrontational counseling technique designed to help people explore and resolve their uncertainties about behavior changes, the authors wrote. The brief psychotherapeutic intervention has been widely implemented as a smoking cessation technique and is recommended in smoking cessation guidelines. However, little attempt has been made “to systematically review the evidence” about the intervention, they wrote.

In the current review, the investigators sought to include studies of interventions that made explicit reference to core principles as described by W. R. Miller and S. Rollnick in their book, “Motivational Interviewing: Preparing People to Change” (New York: Guilford Press, 2002).

The studies had to include a monitoring element, such as the details of counselor training or measures to ensure the quality of interview sessions (videotaping sessions or use of an assessment scale and supervision, for example). The main outcome measure used in the review was abstinence from smoking after at least 6 months' follow-up, based on the most rigorous definition of abstinence in each trial and biochemically validated rates, where available.

All except two of the intervention studies included in the review took place in the United States, and the most commonly used interview approach was one in which the smoker received nonthreatening feedback designed to develop discrepancy between smoking and personal goals, the authors explained. Dr. Lai and his colleagues noted that the interventions involved face-to-face sessions, except for three in which the counseling was telephone based. Ten of the studies looked at single-session interventions, and the rest looked at three- and four-session interventions. Most of the studies compared the intervention with usual care or brief advice, often accompanied by self-help materials, they said.

The investigators conducted a conventional meta-analysis to estimate pooled treatment effects. They observed a modest but significant increase in smoking cessation among patients who underwent motivational interviewing, compared with those who received usual care. With the strictest definition of abstinence and the longest follow-up, the overall effect across all 14 trials was a relative risk for smoking cessation in the treatment vs. usual care group of 1.27, the authors reported.

A slightly higher but similar effect (relative risk 1.37) was observed in a sensitivity analysis that excluded trials of participants who were already motivated to make a quit attempt, and a comparable relative risk (1.31) was noted in an analysis of findings from the nine trials in which the outcomes were validated biochemically, they said.

In a subgroup analysis by therapist type, the largest effect was observed in the interventions delivered by primary care physicians, followed by those with counselors and nurses, with respective relative risks of 3.49, 1.23, and 1.27, the authors reported. It is possible that primary care doctors are best suited to deliver this type of intervention because they are already familiar with the patients and, presumably, have an established rapport. The author point out that “this finding is based on two relatively small studies and should not be overstated.”

Despite the positive findings of the meta-analysis, “absolute quit rates were relatively low,” probably because most of the trials included smokers who were not motivated to quit, the authors wrote.

The authors urged caution in interpreting the results because of “variations in study quality, treatment fidelity, and the possibility of publication or selective reporting bias.” Future studies, they noted, “should attempt to identify which core components of the motivational interviewing approach are effective, and whether modifying them enhances or reduces their effectiveness.”

My Take

Referral Might Be More Realistic

The systematic review by Dr. Lai and his colleagues affirms the general notion that interventions for tobacco cessation provided by clinicians increase abstinence rates, but also goes further to suggest that primary care physicians may be more effective than other clinicians.

As the authors point out, this conclusion must be interpreted with caution because it is based on two small studies. Even if the authors' conclusion are true, motivational interviewing is an incredibly powerful tool—but one with limited ability to be disseminated into primary care practices. The “crush of the practice” in primary care leaves only the optimistic and detached remaining hopeful that providers will be able to apply these skills with their patients who use tobacco.

A more realistic model is the AAR model in which busy clinicians Ask-Advise-Refer. The ideal role of motivational interviewing in primary care may be to overcome patient barriers to accepting referral to a tobacco treatment specialist or to picking up the phone and calling the tobacco quit line (800-QUITNOW).

Revised recommendations for human papillomavirus vaccination—including a permissive recommendation for young men—are part of the newly issued 2010 adult immunization schedule from the Advisory Committee on Immunization Practices at the Centers for Disease Control and Prevention.

The schedule, approved by the American College of Obstetricians and Gynecologists, includes these changes:

▸ For human papillomavirus (HPV), a bivalent vaccine (HPV2) has been licensed for use in females. Therefore, either the bivalent or quadrivalent (HPV4) vaccination can be used for women between 19 and 26 years. In addition, HPV4 may be given to males aged 9-25 years “to reduce their likelihood of acquiring genital warts,” according to the revised schedule.

▸ For influenza vaccination, the term “seasonal” has been added to distinguish between seasonal and pandemic influenza vaccines.

▸ For measles, mumps, rubella (MMR) vaccination, most adults born after 1957 do not require repeat vaccination if they have documentation of having received at least one dose of the vaccine. Women without documentation of rubella vaccination should receive a dose of the MMR vaccine.

Health care workers, college students, international travelers, and individuals who have been exposed to measles or mumps in an outbreak setting should receive two doses of MMR. When a second MMR dose is indicated, it should be administered 4 weeks after the first dose.

During an outbreak, MMR vaccination is recommended for unvaccinated health care workers born before 1957 who do not have evidence of immunity or disease.

▸ For hepatitis A, vaccination is recommended for unvaccinated individuals who anticipate close personal contact with an international adoptee from a country with intermediate or high endemicity to hepatitis A. The first dose should be given at least 2 weeks before the arrival of the adoptee.

▸ For the three-dose hepatitis B vaccine, the second dose should be administered 1 month after the first dose, and the third dose should be administered at least 2 months after the second. If using the combined hepatitis A and B vaccine, three doses should be administered at 0, 1, and 6 months. Alternatively, a four-dose schedule, administered on days 0, 7, 21, and 30, followed by a 12-month booster, may be used.

▸ For meningococcal vaccination, the conjugate vaccine (MCV4) is preferred for adults aged 55 years or younger, while the polysaccharide vaccine (MPSV4) is recommended for adults older than 55 years. Revaccination with MCV4 after 5 years is recommended for individuals who continue to be at risk for infection, such as adults with anatomic or functional asplenia. However, it is not recommended for individuals whose only risk factor is continued on-campus residence.

▸ For Haemophilus influenzae type B (Hib) vaccination, there is no recommendation for individuals older than age 5 years. One dose of the vaccine may be given to certain high-risk unvaccinated patients (Ann. Intern. Med. 2010;152:36-9).

“Deaths from vaccine-preventable illnesses still occur in the United States,” noted Dr. Robert H. Hopkins Jr. and Dr. Keyur S. Vyas of the University of Arkansas, Little Rock, in an accompanying editorial.

Clinicians' “challenge is to change this perception and to make immunizations integral to each encounter for physicians who care for adults in primary and specialty care settings,” they added.

In addition, the importance of immunization should be imparted to students and residents early in their training, as an essential component of the comprehensive care of adults in ambulatory and inpatient settings, they said (Ann. Intern. Med. 2010;152:59-60).

The complete 2010 Adult Immunization Schedule will be available at www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm

Disclosures: Members of ACIP disclosed relationships with MedImmune, Sanofi Pasteur, Novartis, and Wyeth. According to the report, members with conflicts are not permitted to vote if the conflict involves the vaccine or agent being considered. Dr. Hopkins and Dr. Vyas reported no potential conflicts of interest.

Revised recommendations for human papillomavirus vaccination—including a permissive recommendation for young men—are part of the newly issued 2010 adult immunization schedule from the Advisory Committee on Immunization Practices at the Centers for Disease Control and Prevention.

The schedule, approved by the American College of Obstetricians and Gynecologists, includes these changes:

▸ For human papillomavirus (HPV), a bivalent vaccine (HPV2) has been licensed for use in females. Therefore, either the bivalent or quadrivalent (HPV4) vaccination can be used for women between 19 and 26 years. In addition, HPV4 may be given to males aged 9-25 years “to reduce their likelihood of acquiring genital warts,” according to the revised schedule.

▸ For influenza vaccination, the term “seasonal” has been added to distinguish between seasonal and pandemic influenza vaccines.

▸ For measles, mumps, rubella (MMR) vaccination, most adults born after 1957 do not require repeat vaccination if they have documentation of having received at least one dose of the vaccine. Women without documentation of rubella vaccination should receive a dose of the MMR vaccine.

Health care workers, college students, international travelers, and individuals who have been exposed to measles or mumps in an outbreak setting should receive two doses of MMR. When a second MMR dose is indicated, it should be administered 4 weeks after the first dose.

During an outbreak, MMR vaccination is recommended for unvaccinated health care workers born before 1957 who do not have evidence of immunity or disease.

▸ For hepatitis A, vaccination is recommended for unvaccinated individuals who anticipate close personal contact with an international adoptee from a country with intermediate or high endemicity to hepatitis A. The first dose should be given at least 2 weeks before the arrival of the adoptee.

▸ For the three-dose hepatitis B vaccine, the second dose should be administered 1 month after the first dose, and the third dose should be administered at least 2 months after the second. If using the combined hepatitis A and B vaccine, three doses should be administered at 0, 1, and 6 months. Alternatively, a four-dose schedule, administered on days 0, 7, 21, and 30, followed by a 12-month booster, may be used.

▸ For meningococcal vaccination, the conjugate vaccine (MCV4) is preferred for adults aged 55 years or younger, while the polysaccharide vaccine (MPSV4) is recommended for adults older than 55 years. Revaccination with MCV4 after 5 years is recommended for individuals who continue to be at risk for infection, such as adults with anatomic or functional asplenia. However, it is not recommended for individuals whose only risk factor is continued on-campus residence.

▸ For Haemophilus influenzae type B (Hib) vaccination, there is no recommendation for individuals older than age 5 years. One dose of the vaccine may be given to certain high-risk unvaccinated patients (Ann. Intern. Med. 2010;152:36-9).

“Deaths from vaccine-preventable illnesses still occur in the United States,” noted Dr. Robert H. Hopkins Jr. and Dr. Keyur S. Vyas of the University of Arkansas, Little Rock, in an accompanying editorial.

Clinicians' “challenge is to change this perception and to make immunizations integral to each encounter for physicians who care for adults in primary and specialty care settings,” they added.

In addition, the importance of immunization should be imparted to students and residents early in their training, as an essential component of the comprehensive care of adults in ambulatory and inpatient settings, they said (Ann. Intern. Med. 2010;152:59-60).

The complete 2010 Adult Immunization Schedule will be available at www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm

Disclosures: Members of ACIP disclosed relationships with MedImmune, Sanofi Pasteur, Novartis, and Wyeth. According to the report, members with conflicts are not permitted to vote if the conflict involves the vaccine or agent being considered. Dr. Hopkins and Dr. Vyas reported no potential conflicts of interest.

Revised recommendations for human papillomavirus vaccination—including a permissive recommendation for young men—are part of the newly issued 2010 adult immunization schedule from the Advisory Committee on Immunization Practices at the Centers for Disease Control and Prevention.

The schedule, approved by the American College of Obstetricians and Gynecologists, includes these changes:

▸ For human papillomavirus (HPV), a bivalent vaccine (HPV2) has been licensed for use in females. Therefore, either the bivalent or quadrivalent (HPV4) vaccination can be used for women between 19 and 26 years. In addition, HPV4 may be given to males aged 9-25 years “to reduce their likelihood of acquiring genital warts,” according to the revised schedule.

▸ For influenza vaccination, the term “seasonal” has been added to distinguish between seasonal and pandemic influenza vaccines.

▸ For measles, mumps, rubella (MMR) vaccination, most adults born after 1957 do not require repeat vaccination if they have documentation of having received at least one dose of the vaccine. Women without documentation of rubella vaccination should receive a dose of the MMR vaccine.

Health care workers, college students, international travelers, and individuals who have been exposed to measles or mumps in an outbreak setting should receive two doses of MMR. When a second MMR dose is indicated, it should be administered 4 weeks after the first dose.

During an outbreak, MMR vaccination is recommended for unvaccinated health care workers born before 1957 who do not have evidence of immunity or disease.

▸ For hepatitis A, vaccination is recommended for unvaccinated individuals who anticipate close personal contact with an international adoptee from a country with intermediate or high endemicity to hepatitis A. The first dose should be given at least 2 weeks before the arrival of the adoptee.

▸ For the three-dose hepatitis B vaccine, the second dose should be administered 1 month after the first dose, and the third dose should be administered at least 2 months after the second. If using the combined hepatitis A and B vaccine, three doses should be administered at 0, 1, and 6 months. Alternatively, a four-dose schedule, administered on days 0, 7, 21, and 30, followed by a 12-month booster, may be used.

▸ For meningococcal vaccination, the conjugate vaccine (MCV4) is preferred for adults aged 55 years or younger, while the polysaccharide vaccine (MPSV4) is recommended for adults older than 55 years. Revaccination with MCV4 after 5 years is recommended for individuals who continue to be at risk for infection, such as adults with anatomic or functional asplenia. However, it is not recommended for individuals whose only risk factor is continued on-campus residence.

▸ For Haemophilus influenzae type B (Hib) vaccination, there is no recommendation for individuals older than age 5 years. One dose of the vaccine may be given to certain high-risk unvaccinated patients (Ann. Intern. Med. 2010;152:36-9).

“Deaths from vaccine-preventable illnesses still occur in the United States,” noted Dr. Robert H. Hopkins Jr. and Dr. Keyur S. Vyas of the University of Arkansas, Little Rock, in an accompanying editorial.

Clinicians' “challenge is to change this perception and to make immunizations integral to each encounter for physicians who care for adults in primary and specialty care settings,” they added.

In addition, the importance of immunization should be imparted to students and residents early in their training, as an essential component of the comprehensive care of adults in ambulatory and inpatient settings, they said (Ann. Intern. Med. 2010;152:59-60).

The complete 2010 Adult Immunization Schedule will be available at www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm

Disclosures: Members of ACIP disclosed relationships with MedImmune, Sanofi Pasteur, Novartis, and Wyeth. According to the report, members with conflicts are not permitted to vote if the conflict involves the vaccine or agent being considered. Dr. Hopkins and Dr. Vyas reported no potential conflicts of interest.

BOSTON — Children with benign focal epilepsy with centro-temporal spikes had a higher incidence of psychiatric illnesses, attention-deficit/hyperactivity disorder (ADHD), and developmental delay compared with the estimated incidence in the general population, based on a retrospective study of electroencephalogram findings.

Children with benign focal epilepsy “are not sufficiently screened for psychological and other cognitive problems. The nocturnal seizures are often missed, unless the child generalizes; and most institutions don't have a good neuropsychiatry division to assess for learning difficulties. Subtle learning difficulties often go undetected,” Dr. Shalaka Indulkar reported in a poster presentation at the annual meeting of the American Epilepsy Society.

Dr. Indulkar and colleagues reviewed consecutive routine EEGs from 1995 through 2004 for pediatric patients with benign focal epileptiform discharges. They identified 117 whose seizures were consistent with benign focal epilepsy with centro-temporal spikes (BECTS). These features included either typical brief hemifacial seizures associated with speech arrest, drooling, and preservation of consciousness; gurgling or grunting noises with loss of consciousness and terminating in vomiting; or nocturnal secondarily generalized seizures.

Data also included general demographics and neurologic, behavioral, and psychiatric disorders and used descriptive data and the Fisher's exact test for analysis.

Of the 117 patients in the analysis, 51 were girls and 66 were boys. Mean age at initial diagnosis of EEG abnormality was 6.8 years, said Dr. Indulkar, a neurology resident at Cleveland Clinic.

The prevalence of co-existing psychiatric problems, including anxiety, schizophrenia, obsessive compulsive disorder, and depression in the study population was 9.4%, she reported, noting that this rate is substantially higher than the estimated 1%–4% seen in the general pediatric population.

ADHD was observed in 11% of the seizure population, compared with an estimated prevalence rate of 3%–7% in school-aged children in the United States. In addition, developmental delay, including pervasive developmental disorder, language disorder, and autism, was found in 10.2% of the seizure population, and tics were noted in 5.1%. “We also found a high incidence of children with migraine and headaches in the study population,” Dr. Indulkar said.

In an interview, she said that “children with typical [BECTS] do not necessarily have abnormal EEGs in sleep, but they still may have learning difficulties, so the mechanism [for the CNS-related comorbidities] remains elusive.”

Dr. Indulkar reported no relevant disclosures and said no specific funding was used to conduct the study.

BOSTON — Children with benign focal epilepsy with centro-temporal spikes had a higher incidence of psychiatric illnesses, attention-deficit/hyperactivity disorder (ADHD), and developmental delay compared with the estimated incidence in the general population, based on a retrospective study of electroencephalogram findings.

Children with benign focal epilepsy “are not sufficiently screened for psychological and other cognitive problems. The nocturnal seizures are often missed, unless the child generalizes; and most institutions don't have a good neuropsychiatry division to assess for learning difficulties. Subtle learning difficulties often go undetected,” Dr. Shalaka Indulkar reported in a poster presentation at the annual meeting of the American Epilepsy Society.

Dr. Indulkar and colleagues reviewed consecutive routine EEGs from 1995 through 2004 for pediatric patients with benign focal epileptiform discharges. They identified 117 whose seizures were consistent with benign focal epilepsy with centro-temporal spikes (BECTS). These features included either typical brief hemifacial seizures associated with speech arrest, drooling, and preservation of consciousness; gurgling or grunting noises with loss of consciousness and terminating in vomiting; or nocturnal secondarily generalized seizures.

Data also included general demographics and neurologic, behavioral, and psychiatric disorders and used descriptive data and the Fisher's exact test for analysis.

Of the 117 patients in the analysis, 51 were girls and 66 were boys. Mean age at initial diagnosis of EEG abnormality was 6.8 years, said Dr. Indulkar, a neurology resident at Cleveland Clinic.

The prevalence of co-existing psychiatric problems, including anxiety, schizophrenia, obsessive compulsive disorder, and depression in the study population was 9.4%, she reported, noting that this rate is substantially higher than the estimated 1%–4% seen in the general pediatric population.

ADHD was observed in 11% of the seizure population, compared with an estimated prevalence rate of 3%–7% in school-aged children in the United States. In addition, developmental delay, including pervasive developmental disorder, language disorder, and autism, was found in 10.2% of the seizure population, and tics were noted in 5.1%. “We also found a high incidence of children with migraine and headaches in the study population,” Dr. Indulkar said.

In an interview, she said that “children with typical [BECTS] do not necessarily have abnormal EEGs in sleep, but they still may have learning difficulties, so the mechanism [for the CNS-related comorbidities] remains elusive.”

Dr. Indulkar reported no relevant disclosures and said no specific funding was used to conduct the study.

BOSTON — Children with benign focal epilepsy with centro-temporal spikes had a higher incidence of psychiatric illnesses, attention-deficit/hyperactivity disorder (ADHD), and developmental delay compared with the estimated incidence in the general population, based on a retrospective study of electroencephalogram findings.

Children with benign focal epilepsy “are not sufficiently screened for psychological and other cognitive problems. The nocturnal seizures are often missed, unless the child generalizes; and most institutions don't have a good neuropsychiatry division to assess for learning difficulties. Subtle learning difficulties often go undetected,” Dr. Shalaka Indulkar reported in a poster presentation at the annual meeting of the American Epilepsy Society.

Dr. Indulkar and colleagues reviewed consecutive routine EEGs from 1995 through 2004 for pediatric patients with benign focal epileptiform discharges. They identified 117 whose seizures were consistent with benign focal epilepsy with centro-temporal spikes (BECTS). These features included either typical brief hemifacial seizures associated with speech arrest, drooling, and preservation of consciousness; gurgling or grunting noises with loss of consciousness and terminating in vomiting; or nocturnal secondarily generalized seizures.

Data also included general demographics and neurologic, behavioral, and psychiatric disorders and used descriptive data and the Fisher's exact test for analysis.

Of the 117 patients in the analysis, 51 were girls and 66 were boys. Mean age at initial diagnosis of EEG abnormality was 6.8 years, said Dr. Indulkar, a neurology resident at Cleveland Clinic.

The prevalence of co-existing psychiatric problems, including anxiety, schizophrenia, obsessive compulsive disorder, and depression in the study population was 9.4%, she reported, noting that this rate is substantially higher than the estimated 1%–4% seen in the general pediatric population.

ADHD was observed in 11% of the seizure population, compared with an estimated prevalence rate of 3%–7% in school-aged children in the United States. In addition, developmental delay, including pervasive developmental disorder, language disorder, and autism, was found in 10.2% of the seizure population, and tics were noted in 5.1%. “We also found a high incidence of children with migraine and headaches in the study population,” Dr. Indulkar said.

In an interview, she said that “children with typical [BECTS] do not necessarily have abnormal EEGs in sleep, but they still may have learning difficulties, so the mechanism [for the CNS-related comorbidities] remains elusive.”

Dr. Indulkar reported no relevant disclosures and said no specific funding was used to conduct the study.