Fran Lowry

ATLANTA — Children with type 1 diabetes tend to get excellent, dedicated care from diabetologists who specialize in working with children and adolescents with juvenile diabetes.

But when it comes time to “graduate” to adult care, these kids may find themselves with no one to care for them, Dr. Leslie Plotnick said at the annual meeting of the American Academy of Pediatrics.

“I worry that we do not have enough endocrinologists to carry on with these kids when they leave our centers. Even though you are 18, it doesn't mean that you are an adult, and these kids can sometimes fall through the cracks through no fault of their own,” said Dr. Plotnick, a professor of pediatrics at Johns Hopkins Medical Institutions, Baltimore.

The transitioning of children with juvenile diabetes from the pediatric setting to adult endocrinologists is problematic for many reasons, Dr. Plotnick and Loretta Clark, R.N., a certified diabetes educator who works with Dr. Plotnick, said in a later interview.

One big obstacle to continuing on to good care is insurance. Unless a child is attending college full time, they may be dropped from their parents' insurance. Even a full-time job is no guarantee of health insurance.

“It's a big problem. If you work for a big company, or for a large institution, preexisting conditions may not eliminate you from health insurance. But if you are working in a small business, preexisting [medical conditions] can mean that you are not eligible to get health insurance, even if it might otherwise be offered,” Dr. Plotnick and Ms. Clark said.

This is true for all older children who have chronic medical conditions, Dr. Plotnick added. “Kids who have developmental delay may continue on their parents' insurance for a longer time, but this is not true for medical conditions. This problem goes way beyond diabetes and includes all pediatric chronic diseases.”

Children becoming young adults who see an adult endocrinologist may encounter other difficulties, because adult practice tends to differ considerably from the team approach to type 1 diabetes to which they have become accustomed.

“Here at Hopkins the kids usually see a nutritionist, a diabetes educator, and a physician. That isn't always true when [as young adults] they go to see an adult endocrinologist. And if they don't feel like there is a good match with the adult endocrinologist, they sometimes don't go back. And then they don't follow up. Sometimes a parent will call me and say their child went to see a particular doctor, didn't feel comfortable with that doctor, and hasn't been to see him again,” said Ms. Clark.

It would be ideal if there were enough pediatric endocrinologists to continue to see children well into their young adulthood.

“When kids finish high school, there are many changes in their lives. Having to change to a different physician as well is very tough,” added Ms. Clark.

Over the past year, Dr. Plotnick and her colleagues have started a program with an adult endocrinologist who has agreed to see their type 1 “grads.” So far, the program has been a success, she said.

ATLANTA — Children with type 1 diabetes tend to get excellent, dedicated care from diabetologists who specialize in working with children and adolescents with juvenile diabetes.

But when it comes time to “graduate” to adult care, these kids may find themselves with no one to care for them, Dr. Leslie Plotnick said at the annual meeting of the American Academy of Pediatrics.

“I worry that we do not have enough endocrinologists to carry on with these kids when they leave our centers. Even though you are 18, it doesn't mean that you are an adult, and these kids can sometimes fall through the cracks through no fault of their own,” said Dr. Plotnick, a professor of pediatrics at Johns Hopkins Medical Institutions, Baltimore.

The transitioning of children with juvenile diabetes from the pediatric setting to adult endocrinologists is problematic for many reasons, Dr. Plotnick and Loretta Clark, R.N., a certified diabetes educator who works with Dr. Plotnick, said in a later interview.

One big obstacle to continuing on to good care is insurance. Unless a child is attending college full time, they may be dropped from their parents' insurance. Even a full-time job is no guarantee of health insurance.

“It's a big problem. If you work for a big company, or for a large institution, preexisting conditions may not eliminate you from health insurance. But if you are working in a small business, preexisting [medical conditions] can mean that you are not eligible to get health insurance, even if it might otherwise be offered,” Dr. Plotnick and Ms. Clark said.

This is true for all older children who have chronic medical conditions, Dr. Plotnick added. “Kids who have developmental delay may continue on their parents' insurance for a longer time, but this is not true for medical conditions. This problem goes way beyond diabetes and includes all pediatric chronic diseases.”

Children becoming young adults who see an adult endocrinologist may encounter other difficulties, because adult practice tends to differ considerably from the team approach to type 1 diabetes to which they have become accustomed.

“Here at Hopkins the kids usually see a nutritionist, a diabetes educator, and a physician. That isn't always true when [as young adults] they go to see an adult endocrinologist. And if they don't feel like there is a good match with the adult endocrinologist, they sometimes don't go back. And then they don't follow up. Sometimes a parent will call me and say their child went to see a particular doctor, didn't feel comfortable with that doctor, and hasn't been to see him again,” said Ms. Clark.

It would be ideal if there were enough pediatric endocrinologists to continue to see children well into their young adulthood.

“When kids finish high school, there are many changes in their lives. Having to change to a different physician as well is very tough,” added Ms. Clark.

Over the past year, Dr. Plotnick and her colleagues have started a program with an adult endocrinologist who has agreed to see their type 1 “grads.” So far, the program has been a success, she said.

ATLANTA — Children with type 1 diabetes tend to get excellent, dedicated care from diabetologists who specialize in working with children and adolescents with juvenile diabetes.

But when it comes time to “graduate” to adult care, these kids may find themselves with no one to care for them, Dr. Leslie Plotnick said at the annual meeting of the American Academy of Pediatrics.

“I worry that we do not have enough endocrinologists to carry on with these kids when they leave our centers. Even though you are 18, it doesn't mean that you are an adult, and these kids can sometimes fall through the cracks through no fault of their own,” said Dr. Plotnick, a professor of pediatrics at Johns Hopkins Medical Institutions, Baltimore.

The transitioning of children with juvenile diabetes from the pediatric setting to adult endocrinologists is problematic for many reasons, Dr. Plotnick and Loretta Clark, R.N., a certified diabetes educator who works with Dr. Plotnick, said in a later interview.

One big obstacle to continuing on to good care is insurance. Unless a child is attending college full time, they may be dropped from their parents' insurance. Even a full-time job is no guarantee of health insurance.

“It's a big problem. If you work for a big company, or for a large institution, preexisting conditions may not eliminate you from health insurance. But if you are working in a small business, preexisting [medical conditions] can mean that you are not eligible to get health insurance, even if it might otherwise be offered,” Dr. Plotnick and Ms. Clark said.

This is true for all older children who have chronic medical conditions, Dr. Plotnick added. “Kids who have developmental delay may continue on their parents' insurance for a longer time, but this is not true for medical conditions. This problem goes way beyond diabetes and includes all pediatric chronic diseases.”

Children becoming young adults who see an adult endocrinologist may encounter other difficulties, because adult practice tends to differ considerably from the team approach to type 1 diabetes to which they have become accustomed.

“Here at Hopkins the kids usually see a nutritionist, a diabetes educator, and a physician. That isn't always true when [as young adults] they go to see an adult endocrinologist. And if they don't feel like there is a good match with the adult endocrinologist, they sometimes don't go back. And then they don't follow up. Sometimes a parent will call me and say their child went to see a particular doctor, didn't feel comfortable with that doctor, and hasn't been to see him again,” said Ms. Clark.

It would be ideal if there were enough pediatric endocrinologists to continue to see children well into their young adulthood.

“When kids finish high school, there are many changes in their lives. Having to change to a different physician as well is very tough,” added Ms. Clark.

Over the past year, Dr. Plotnick and her colleagues have started a program with an adult endocrinologist who has agreed to see their type 1 “grads.” So far, the program has been a success, she said.

ATLANTA — Delivering optimal well child care in the office depends on teamwork, teamwork, and more teamwork.

And the best way to determine how well your “medical home team” is working is to look at how you are doing with the help of an outside observer, Dr. Paula Duncan, professor of pediatrics at the University of Vermont, Burlington, said at the annual meeting of the American Academy of Pediatrics.

Dr. Duncan, cochairperson of the Bright Futures Pediatric Implementation Project, outlined some strategies that individual practices can use to improve the preventive and developmental services they offer their young patients and families.

First and foremost, each practice has to put itself under a microscope to see just how it actually functions, she said.

“Many of these strategies come from the Bright Futures Implementation Project and [from] Practicing Safety, spearheaded by Dr. Steven Kairys, chairman of pediatrics at Jersey Shore University Medical Center, Neptune, N.J. He has done outstanding work in this regard,” Dr. Duncan said.

A well-trained outside facilitator can be extremely helpful, she added. Dr. Duncan gave the example of one practice that hired an observer to detail exactly how it operated.

“This practice was obviously interested in improvement. They were willing to look at how everyone in the practice—from the receptionist at the front desk, to the nurse practitioner, to the physicians—interacted with each other and with patients. The observer noted how patients were moved through the office, how work was actually done in this office, and how patients were treated. The results highlighted where improvements could be made and also showed what they were doing that was absolutely right,” she said.

As part of this process of looking inward, the practice also had meetings once a week. In addition to the personnel of the practice and the facilitator, the meetings included a parent. “I love having a parent as part of the team. The partnership between parents and the medical home is very important,” Dr. Duncan said.

It is essential to be able to learn what is on the parent's mind. The logical way to assess this is via questionnaires, but the practice team must be alert to those parents who may have difficulty filling out these questionnaires for one reason or another.

“One way to make sure we are getting this information is to have the nurse, or physician, or both, ask: 'What are you concerned about today?' Once we learn the parents' concerns, we then have to make sure we address them,” she said.

The aim of Bright Futures is to promote the best well child or preventive care, using certain strategies including:

▸ Use of recall and reminder systems, such as questionnaires.

▸ Development of a registry of children in the practice who have special health care needs.

▸ Use of a questionnaire at every visit to ask about parental and youths' concerns.

▸ Use of a confidentiality policy for adolescents.

▸ Use of a list to prompt essential preventive services.

▸ A referral follow-up system.

While Bright Futures may appear ambitious in scope, its goals can be achieved when the practice acts as an integrated team, Dr. Duncan said.

“For practices to be able to implement changes in well child care, or preventive services, they need to realize that everyone in the practice is important, and has something real to contribute. The way to make improvements is to get the whole office involved, and to get everybody working together,” she said.

ATLANTA — Delivering optimal well child care in the office depends on teamwork, teamwork, and more teamwork.

And the best way to determine how well your “medical home team” is working is to look at how you are doing with the help of an outside observer, Dr. Paula Duncan, professor of pediatrics at the University of Vermont, Burlington, said at the annual meeting of the American Academy of Pediatrics.

Dr. Duncan, cochairperson of the Bright Futures Pediatric Implementation Project, outlined some strategies that individual practices can use to improve the preventive and developmental services they offer their young patients and families.

First and foremost, each practice has to put itself under a microscope to see just how it actually functions, she said.

“Many of these strategies come from the Bright Futures Implementation Project and [from] Practicing Safety, spearheaded by Dr. Steven Kairys, chairman of pediatrics at Jersey Shore University Medical Center, Neptune, N.J. He has done outstanding work in this regard,” Dr. Duncan said.

A well-trained outside facilitator can be extremely helpful, she added. Dr. Duncan gave the example of one practice that hired an observer to detail exactly how it operated.

“This practice was obviously interested in improvement. They were willing to look at how everyone in the practice—from the receptionist at the front desk, to the nurse practitioner, to the physicians—interacted with each other and with patients. The observer noted how patients were moved through the office, how work was actually done in this office, and how patients were treated. The results highlighted where improvements could be made and also showed what they were doing that was absolutely right,” she said.

As part of this process of looking inward, the practice also had meetings once a week. In addition to the personnel of the practice and the facilitator, the meetings included a parent. “I love having a parent as part of the team. The partnership between parents and the medical home is very important,” Dr. Duncan said.

It is essential to be able to learn what is on the parent's mind. The logical way to assess this is via questionnaires, but the practice team must be alert to those parents who may have difficulty filling out these questionnaires for one reason or another.

“One way to make sure we are getting this information is to have the nurse, or physician, or both, ask: 'What are you concerned about today?' Once we learn the parents' concerns, we then have to make sure we address them,” she said.

The aim of Bright Futures is to promote the best well child or preventive care, using certain strategies including:

▸ Use of recall and reminder systems, such as questionnaires.

▸ Development of a registry of children in the practice who have special health care needs.

▸ Use of a questionnaire at every visit to ask about parental and youths' concerns.

▸ Use of a confidentiality policy for adolescents.

▸ Use of a list to prompt essential preventive services.

▸ A referral follow-up system.

While Bright Futures may appear ambitious in scope, its goals can be achieved when the practice acts as an integrated team, Dr. Duncan said.

“For practices to be able to implement changes in well child care, or preventive services, they need to realize that everyone in the practice is important, and has something real to contribute. The way to make improvements is to get the whole office involved, and to get everybody working together,” she said.

ATLANTA — Delivering optimal well child care in the office depends on teamwork, teamwork, and more teamwork.

And the best way to determine how well your “medical home team” is working is to look at how you are doing with the help of an outside observer, Dr. Paula Duncan, professor of pediatrics at the University of Vermont, Burlington, said at the annual meeting of the American Academy of Pediatrics.

Dr. Duncan, cochairperson of the Bright Futures Pediatric Implementation Project, outlined some strategies that individual practices can use to improve the preventive and developmental services they offer their young patients and families.

First and foremost, each practice has to put itself under a microscope to see just how it actually functions, she said.

“Many of these strategies come from the Bright Futures Implementation Project and [from] Practicing Safety, spearheaded by Dr. Steven Kairys, chairman of pediatrics at Jersey Shore University Medical Center, Neptune, N.J. He has done outstanding work in this regard,” Dr. Duncan said.

A well-trained outside facilitator can be extremely helpful, she added. Dr. Duncan gave the example of one practice that hired an observer to detail exactly how it operated.

“This practice was obviously interested in improvement. They were willing to look at how everyone in the practice—from the receptionist at the front desk, to the nurse practitioner, to the physicians—interacted with each other and with patients. The observer noted how patients were moved through the office, how work was actually done in this office, and how patients were treated. The results highlighted where improvements could be made and also showed what they were doing that was absolutely right,” she said.

As part of this process of looking inward, the practice also had meetings once a week. In addition to the personnel of the practice and the facilitator, the meetings included a parent. “I love having a parent as part of the team. The partnership between parents and the medical home is very important,” Dr. Duncan said.

It is essential to be able to learn what is on the parent's mind. The logical way to assess this is via questionnaires, but the practice team must be alert to those parents who may have difficulty filling out these questionnaires for one reason or another.

“One way to make sure we are getting this information is to have the nurse, or physician, or both, ask: 'What are you concerned about today?' Once we learn the parents' concerns, we then have to make sure we address them,” she said.

The aim of Bright Futures is to promote the best well child or preventive care, using certain strategies including:

▸ Use of recall and reminder systems, such as questionnaires.

▸ Development of a registry of children in the practice who have special health care needs.

▸ Use of a questionnaire at every visit to ask about parental and youths' concerns.

▸ Use of a confidentiality policy for adolescents.

▸ Use of a list to prompt essential preventive services.

▸ A referral follow-up system.

While Bright Futures may appear ambitious in scope, its goals can be achieved when the practice acts as an integrated team, Dr. Duncan said.

“For practices to be able to implement changes in well child care, or preventive services, they need to realize that everyone in the practice is important, and has something real to contribute. The way to make improvements is to get the whole office involved, and to get everybody working together,” she said.

TORONTO — College students are reluctant to get tested for HIV because they fear being judged by others, according to a poster presented at the 16th International AIDS Conference.

In a survey of 491 students at York University, Toronto, 49 (10%) reported having been tested for HIV. Two-thirds of them reported having had unprotected sex in the previous 6 months, although many were ignorant of their HIV status, said Trevor A. Hart, Ph.D., of the department of psychology at the university. “In Canada, where access to medical care and HIV testing are readily available and cost nothing, these results are quite troubling,” he said in interview.

There are 2,500 cases of new HIV infections in Canada a year. But in a 2003 survey of Canadians over age 15, only 27% reported ever having been tested for HIV (excluding testing for the purposes of insurance, blood donation, and participation in research), according to a 2005 report by Public Health Agency Canada. Dr. Hart and his colleagues decided to see if they could find out why the students weren't being tested.

They filled out a questionnaire in which they were asked about their sexual activities in the previous 6 months; their HIV testing histories and willingness to get tested; their concerns about being judged for getting an HIV test; and social anxiety. Most of the students (80%) were female; the mean age was 18 years, with a range of 17–24 years.

The results revealed that social anxiety and fear of being judged prevented the young adults from getting tested for HIV and learning about their status. Those who were more socially anxious were more likely to be concerned about being judged about HIV testing by their siblings. They were also inhibited by friends, their family doctor, grandparents, coworkers, and God. Family doctors should ask patients if they are sexually active, and if so, ask if they know their HIV status. “It's like knowing your blood type, or when last you got a tetanus shot,” he said.

Knowing your HIV status should be 'like knowing your blood type, or when last you got a tetanus shot.' DR. HART

TORONTO — College students are reluctant to get tested for HIV because they fear being judged by others, according to a poster presented at the 16th International AIDS Conference.

In a survey of 491 students at York University, Toronto, 49 (10%) reported having been tested for HIV. Two-thirds of them reported having had unprotected sex in the previous 6 months, although many were ignorant of their HIV status, said Trevor A. Hart, Ph.D., of the department of psychology at the university. “In Canada, where access to medical care and HIV testing are readily available and cost nothing, these results are quite troubling,” he said in interview.

There are 2,500 cases of new HIV infections in Canada a year. But in a 2003 survey of Canadians over age 15, only 27% reported ever having been tested for HIV (excluding testing for the purposes of insurance, blood donation, and participation in research), according to a 2005 report by Public Health Agency Canada. Dr. Hart and his colleagues decided to see if they could find out why the students weren't being tested.

They filled out a questionnaire in which they were asked about their sexual activities in the previous 6 months; their HIV testing histories and willingness to get tested; their concerns about being judged for getting an HIV test; and social anxiety. Most of the students (80%) were female; the mean age was 18 years, with a range of 17–24 years.

The results revealed that social anxiety and fear of being judged prevented the young adults from getting tested for HIV and learning about their status. Those who were more socially anxious were more likely to be concerned about being judged about HIV testing by their siblings. They were also inhibited by friends, their family doctor, grandparents, coworkers, and God. Family doctors should ask patients if they are sexually active, and if so, ask if they know their HIV status. “It's like knowing your blood type, or when last you got a tetanus shot,” he said.

Knowing your HIV status should be 'like knowing your blood type, or when last you got a tetanus shot.' DR. HART

TORONTO — College students are reluctant to get tested for HIV because they fear being judged by others, according to a poster presented at the 16th International AIDS Conference.

In a survey of 491 students at York University, Toronto, 49 (10%) reported having been tested for HIV. Two-thirds of them reported having had unprotected sex in the previous 6 months, although many were ignorant of their HIV status, said Trevor A. Hart, Ph.D., of the department of psychology at the university. “In Canada, where access to medical care and HIV testing are readily available and cost nothing, these results are quite troubling,” he said in interview.

There are 2,500 cases of new HIV infections in Canada a year. But in a 2003 survey of Canadians over age 15, only 27% reported ever having been tested for HIV (excluding testing for the purposes of insurance, blood donation, and participation in research), according to a 2005 report by Public Health Agency Canada. Dr. Hart and his colleagues decided to see if they could find out why the students weren't being tested.

They filled out a questionnaire in which they were asked about their sexual activities in the previous 6 months; their HIV testing histories and willingness to get tested; their concerns about being judged for getting an HIV test; and social anxiety. Most of the students (80%) were female; the mean age was 18 years, with a range of 17–24 years.

The results revealed that social anxiety and fear of being judged prevented the young adults from getting tested for HIV and learning about their status. Those who were more socially anxious were more likely to be concerned about being judged about HIV testing by their siblings. They were also inhibited by friends, their family doctor, grandparents, coworkers, and God. Family doctors should ask patients if they are sexually active, and if so, ask if they know their HIV status. “It's like knowing your blood type, or when last you got a tetanus shot,” he said.

Knowing your HIV status should be 'like knowing your blood type, or when last you got a tetanus shot.' DR. HART

When it comes to rating the severity of their illness and assessing its effect on their quality of life, teens with juvenile idiopathic arthritis may not see eye to eye with their parents, reported K.L. Shaw, Ph.D., of the Institute of Child Health, University of Birmingham (England), and associates.

Perceptions between parent and teen are particularly discordant when the disease is of medium severity, but these become more in sync at either end of the disease spectrum, the researchers said (Arthritis Rheum. 2006;55:189–98).

Patients often are asked for their subjective assessment of their function, pain, and health-related quality of life (HRQOL). Adolescents are particularly well suited to self-assessment; their cognitive development is usually up to the task and self-assessment lets teens maintain their autonomy and privacy.

Parents of teens who are not able or willing to self-report are asked to report on these subjective aspects of their child's disease, acting as a proxy for the adolescent. The unanswered question has been to what extent the findings from teen self-assessment and parent's assessment of the teen's health overlap, Dr. Shaw and associates said.

They examined agreement about pain, physical health, functional ability, and HRQOL between adolescents with juvenile idiopathic arthritis (JIA) and their parents using the Childhood Health Assessment Questionnaire with visual analog scales for pain and general well-being, and the Juvenile Arthritis Quality of Life Questionnaire. Agreement was determined using the Bland and Altman method.

The study population consisted of 303 adolescent-parent dyads. The children were divided into groups aged 11, 14, and 17 years, to reflect the various stages of adolescent development, Dr. Shaw and associates wrote.

They found a wide variation in agreement for the variables studied.

For pain, agreement between the adolescents and parents was better when the mean rating for pain was either low or high, and most discordant when the mean pain rating was somewhere in the middle of the scale.

Also, adolescents who showed agreement with their parents had statistically significant lower disease activity, fewer active or limited joints, lower pain, better general well-being, lower disability, and better HRQOL, when compared with the other groups. The findings were similar for general well-being, functional disability, and HRQOL.

The investigators concluded that consideration of both adolescent and parent-proxy reports is important and that reliance on parental reports alone “will only partly inform the clinician.”

When it comes to rating the severity of their illness and assessing its effect on their quality of life, teens with juvenile idiopathic arthritis may not see eye to eye with their parents, reported K.L. Shaw, Ph.D., of the Institute of Child Health, University of Birmingham (England), and associates.

Perceptions between parent and teen are particularly discordant when the disease is of medium severity, but these become more in sync at either end of the disease spectrum, the researchers said (Arthritis Rheum. 2006;55:189–98).

Patients often are asked for their subjective assessment of their function, pain, and health-related quality of life (HRQOL). Adolescents are particularly well suited to self-assessment; their cognitive development is usually up to the task and self-assessment lets teens maintain their autonomy and privacy.

Parents of teens who are not able or willing to self-report are asked to report on these subjective aspects of their child's disease, acting as a proxy for the adolescent. The unanswered question has been to what extent the findings from teen self-assessment and parent's assessment of the teen's health overlap, Dr. Shaw and associates said.

They examined agreement about pain, physical health, functional ability, and HRQOL between adolescents with juvenile idiopathic arthritis (JIA) and their parents using the Childhood Health Assessment Questionnaire with visual analog scales for pain and general well-being, and the Juvenile Arthritis Quality of Life Questionnaire. Agreement was determined using the Bland and Altman method.

The study population consisted of 303 adolescent-parent dyads. The children were divided into groups aged 11, 14, and 17 years, to reflect the various stages of adolescent development, Dr. Shaw and associates wrote.

They found a wide variation in agreement for the variables studied.

For pain, agreement between the adolescents and parents was better when the mean rating for pain was either low or high, and most discordant when the mean pain rating was somewhere in the middle of the scale.

Also, adolescents who showed agreement with their parents had statistically significant lower disease activity, fewer active or limited joints, lower pain, better general well-being, lower disability, and better HRQOL, when compared with the other groups. The findings were similar for general well-being, functional disability, and HRQOL.

The investigators concluded that consideration of both adolescent and parent-proxy reports is important and that reliance on parental reports alone “will only partly inform the clinician.”

When it comes to rating the severity of their illness and assessing its effect on their quality of life, teens with juvenile idiopathic arthritis may not see eye to eye with their parents, reported K.L. Shaw, Ph.D., of the Institute of Child Health, University of Birmingham (England), and associates.

Perceptions between parent and teen are particularly discordant when the disease is of medium severity, but these become more in sync at either end of the disease spectrum, the researchers said (Arthritis Rheum. 2006;55:189–98).

Patients often are asked for their subjective assessment of their function, pain, and health-related quality of life (HRQOL). Adolescents are particularly well suited to self-assessment; their cognitive development is usually up to the task and self-assessment lets teens maintain their autonomy and privacy.

Parents of teens who are not able or willing to self-report are asked to report on these subjective aspects of their child's disease, acting as a proxy for the adolescent. The unanswered question has been to what extent the findings from teen self-assessment and parent's assessment of the teen's health overlap, Dr. Shaw and associates said.

They examined agreement about pain, physical health, functional ability, and HRQOL between adolescents with juvenile idiopathic arthritis (JIA) and their parents using the Childhood Health Assessment Questionnaire with visual analog scales for pain and general well-being, and the Juvenile Arthritis Quality of Life Questionnaire. Agreement was determined using the Bland and Altman method.

The study population consisted of 303 adolescent-parent dyads. The children were divided into groups aged 11, 14, and 17 years, to reflect the various stages of adolescent development, Dr. Shaw and associates wrote.

They found a wide variation in agreement for the variables studied.

For pain, agreement between the adolescents and parents was better when the mean rating for pain was either low or high, and most discordant when the mean pain rating was somewhere in the middle of the scale.

Also, adolescents who showed agreement with their parents had statistically significant lower disease activity, fewer active or limited joints, lower pain, better general well-being, lower disability, and better HRQOL, when compared with the other groups. The findings were similar for general well-being, functional disability, and HRQOL.

The investigators concluded that consideration of both adolescent and parent-proxy reports is important and that reliance on parental reports alone “will only partly inform the clinician.”

ORLANDO – When opioids are prescribed for chronic pain patients, following the five-step VIGIL system can lessen the threat of being scrutinized by the Drug Enforcement Agency.

The acronym stands for verification, identification, generalization, interpretation, and legalization, said its developer, David B. Brushwood, at the annual clinical meeting of the American Academy of Pain Management.

“The old advice that says doctors will be okay as long they practice good medicine and document their actions thoroughly is wrong. I don't agree with it. These things may get you out of trouble once you are in it, but I want to teach you how to stay out of trouble in the first place,” said Mr. Brushwood, who is a professor of pharmacy health care administration at the University of Florida, Gainesville.

▸ Verification. This is the first step in staying out of legal trouble, and this step involves one of three options, according to Mr. Brushwood. Verify use of schedule II opioids with a previous prescriber; start the patient out on a nonopioid to see how he or she deals with the medication; or call a trusted colleague.

▸ Identification. “Ask for government-issued photo ID of anyone being prescribed or picking up a prescription for opioids for hydrocodone/acetaminophen, including someone who says he is coming in to pick up his mom's OxyContin,” said Mr. Brushwood, a Mayday Scholar with the American Society of Law, Medicine, and Ethics.

▸ Generalization. “Keep all controlled substances under lock and key; use only one pharmacy for your controlled substance drugs; and work closely with your pharmacist,” he advised.

▸ Interpretation. This fourth step involves using brief questionnaires, such as the Drug Abuse Screening Test (DAST) and the Screener and Opioid Assessment for Patients with Pain (SOAPP) tests.

“When you interpret the results of these tests, you can ask yourself whether you now feel comfortable allowing the patient to have controlled substances,” Mr. Brushwood said.

This step also will help to differentiate between the chronic pain patients and the “fakers and liars.”

▸ Legalization. This final step “means staying squeaky clean with regard to meeting your legal requirements,” he said. Follow state and federal laws for controlled substances, and make no exceptions.

The first step in staying out of legal trouble is patient verification. MR. BRUSHWOOD

ORLANDO – When opioids are prescribed for chronic pain patients, following the five-step VIGIL system can lessen the threat of being scrutinized by the Drug Enforcement Agency.

The acronym stands for verification, identification, generalization, interpretation, and legalization, said its developer, David B. Brushwood, at the annual clinical meeting of the American Academy of Pain Management.

“The old advice that says doctors will be okay as long they practice good medicine and document their actions thoroughly is wrong. I don't agree with it. These things may get you out of trouble once you are in it, but I want to teach you how to stay out of trouble in the first place,” said Mr. Brushwood, who is a professor of pharmacy health care administration at the University of Florida, Gainesville.

▸ Verification. This is the first step in staying out of legal trouble, and this step involves one of three options, according to Mr. Brushwood. Verify use of schedule II opioids with a previous prescriber; start the patient out on a nonopioid to see how he or she deals with the medication; or call a trusted colleague.

▸ Identification. “Ask for government-issued photo ID of anyone being prescribed or picking up a prescription for opioids for hydrocodone/acetaminophen, including someone who says he is coming in to pick up his mom's OxyContin,” said Mr. Brushwood, a Mayday Scholar with the American Society of Law, Medicine, and Ethics.

▸ Generalization. “Keep all controlled substances under lock and key; use only one pharmacy for your controlled substance drugs; and work closely with your pharmacist,” he advised.

▸ Interpretation. This fourth step involves using brief questionnaires, such as the Drug Abuse Screening Test (DAST) and the Screener and Opioid Assessment for Patients with Pain (SOAPP) tests.

“When you interpret the results of these tests, you can ask yourself whether you now feel comfortable allowing the patient to have controlled substances,” Mr. Brushwood said.

This step also will help to differentiate between the chronic pain patients and the “fakers and liars.”

▸ Legalization. This final step “means staying squeaky clean with regard to meeting your legal requirements,” he said. Follow state and federal laws for controlled substances, and make no exceptions.

The first step in staying out of legal trouble is patient verification. MR. BRUSHWOOD

ORLANDO – When opioids are prescribed for chronic pain patients, following the five-step VIGIL system can lessen the threat of being scrutinized by the Drug Enforcement Agency.

The acronym stands for verification, identification, generalization, interpretation, and legalization, said its developer, David B. Brushwood, at the annual clinical meeting of the American Academy of Pain Management.

“The old advice that says doctors will be okay as long they practice good medicine and document their actions thoroughly is wrong. I don't agree with it. These things may get you out of trouble once you are in it, but I want to teach you how to stay out of trouble in the first place,” said Mr. Brushwood, who is a professor of pharmacy health care administration at the University of Florida, Gainesville.

▸ Verification. This is the first step in staying out of legal trouble, and this step involves one of three options, according to Mr. Brushwood. Verify use of schedule II opioids with a previous prescriber; start the patient out on a nonopioid to see how he or she deals with the medication; or call a trusted colleague.

▸ Identification. “Ask for government-issued photo ID of anyone being prescribed or picking up a prescription for opioids for hydrocodone/acetaminophen, including someone who says he is coming in to pick up his mom's OxyContin,” said Mr. Brushwood, a Mayday Scholar with the American Society of Law, Medicine, and Ethics.

▸ Generalization. “Keep all controlled substances under lock and key; use only one pharmacy for your controlled substance drugs; and work closely with your pharmacist,” he advised.

▸ Interpretation. This fourth step involves using brief questionnaires, such as the Drug Abuse Screening Test (DAST) and the Screener and Opioid Assessment for Patients with Pain (SOAPP) tests.

“When you interpret the results of these tests, you can ask yourself whether you now feel comfortable allowing the patient to have controlled substances,” Mr. Brushwood said.

This step also will help to differentiate between the chronic pain patients and the “fakers and liars.”

▸ Legalization. This final step “means staying squeaky clean with regard to meeting your legal requirements,” he said. Follow state and federal laws for controlled substances, and make no exceptions.

The first step in staying out of legal trouble is patient verification. MR. BRUSHWOOD

ORLANDO – Do not confuse addiction with physical dependence when prescribing opioids for your chronic pain patients, Dr. Jennifer P. Schneider advised at the annual clinical meeting of the American Academy of Pain Management.

Trust patients to tell the truth when they complain of pain and counsel them about the side effects of opioids.

Dr. Schneider, an internist whose Tucson, Ariz., practice focuses on addiction medicine and pain management, stressed that the patient's word is the gold standard when it comes to judging his or her own pain. However, she said, “Doctors are uncomfortable with this.”

The field of chronic pain management is full of misconceptions, she added. For example, cancer pain is more likely to get treated than noncancer pain, because practitioners falsely believe patients will become addicted to their pain medications; some physicians may not be concerned about the risk for addiction in this population because they perceive these patients as being close to death.

“This is such faulty thinking. Addiction is not the same as physical dependence or tolerance. We've got to get that message across to clinicians,” she said.

Sometimes physicians get suspicious when patients complain that their original dose either relieves pain less effectively than before or has stopped altogether, Dr. Schneider said. “When this happens, ask patients about their function. Maybe they are having more pain because they are no longer just sitting on the sofa, like they used to. If they are now able to get up and walk the dog or do gardening, they will need more medication. So don't just assume it's tolerance, or worse, that they are drug seeking. If you don't want them to get back to lying on the sofa, prescribe more.”

Long-acting opioids are preferable over shorter-acting agents, because they produce even blood levels and more stable pain relief. Short-acting drugs are more likely to cause a “buzz” as they get taken up by the brain. Patients also have to get up in the middle of the night to take short-acting opioids to keep their blood levels constant.

Short-acting drugs are useful for acute pain, however, and can also be used for rescue dosing, Dr. Schneider said.

There is no evidence for major organ toxicity with opioids. However, constipation is a problem for virtually all patients, and they should be aware of the importance of adequate hydration to minimize this. A stool softener also may be of benefit, she said.

Opioids lower testosterone levels in men, which can put them at risk for osteoporosis. Dr. Schneider advised replacing the testosterone to prevent the loss of bone and to give men more energy and muscle strength.

The “big bugaboo” of opioid prescribing is diversion. “Are patients selling their drugs on the street? We all worry about this,” she said. To help guard against diversion, Dr. Schneider recommended doing routine drug screening with an additional screen for any special drugs that patients may be taking.

“A regular urine drug screen will pick up codeine, morphine, and heroin only, but not methadone, fentanyl, oxycodone, or hydrocodone. So when you use a urine drug screen, make sure you test for other drugs, if you suspect the patient is taking other substances.”

A drug screen is also good to make sure patients are using the drugs as prescribed, she added.

Dr. Schneider reported that she also has her patients sign a contract with her, in which they attest they will not engage in illegal or diversional activity and will take their medication in a responsible manner.

“If you do all these things and are victimized by someone who is a drug seeker, at least you have documented your efforts and have done everything you can do,” she said.

ORLANDO – Do not confuse addiction with physical dependence when prescribing opioids for your chronic pain patients, Dr. Jennifer P. Schneider advised at the annual clinical meeting of the American Academy of Pain Management.

Trust patients to tell the truth when they complain of pain and counsel them about the side effects of opioids.

Dr. Schneider, an internist whose Tucson, Ariz., practice focuses on addiction medicine and pain management, stressed that the patient's word is the gold standard when it comes to judging his or her own pain. However, she said, “Doctors are uncomfortable with this.”

The field of chronic pain management is full of misconceptions, she added. For example, cancer pain is more likely to get treated than noncancer pain, because practitioners falsely believe patients will become addicted to their pain medications; some physicians may not be concerned about the risk for addiction in this population because they perceive these patients as being close to death.

“This is such faulty thinking. Addiction is not the same as physical dependence or tolerance. We've got to get that message across to clinicians,” she said.

Sometimes physicians get suspicious when patients complain that their original dose either relieves pain less effectively than before or has stopped altogether, Dr. Schneider said. “When this happens, ask patients about their function. Maybe they are having more pain because they are no longer just sitting on the sofa, like they used to. If they are now able to get up and walk the dog or do gardening, they will need more medication. So don't just assume it's tolerance, or worse, that they are drug seeking. If you don't want them to get back to lying on the sofa, prescribe more.”

Long-acting opioids are preferable over shorter-acting agents, because they produce even blood levels and more stable pain relief. Short-acting drugs are more likely to cause a “buzz” as they get taken up by the brain. Patients also have to get up in the middle of the night to take short-acting opioids to keep their blood levels constant.

Short-acting drugs are useful for acute pain, however, and can also be used for rescue dosing, Dr. Schneider said.

There is no evidence for major organ toxicity with opioids. However, constipation is a problem for virtually all patients, and they should be aware of the importance of adequate hydration to minimize this. A stool softener also may be of benefit, she said.

Opioids lower testosterone levels in men, which can put them at risk for osteoporosis. Dr. Schneider advised replacing the testosterone to prevent the loss of bone and to give men more energy and muscle strength.

The “big bugaboo” of opioid prescribing is diversion. “Are patients selling their drugs on the street? We all worry about this,” she said. To help guard against diversion, Dr. Schneider recommended doing routine drug screening with an additional screen for any special drugs that patients may be taking.

“A regular urine drug screen will pick up codeine, morphine, and heroin only, but not methadone, fentanyl, oxycodone, or hydrocodone. So when you use a urine drug screen, make sure you test for other drugs, if you suspect the patient is taking other substances.”

A drug screen is also good to make sure patients are using the drugs as prescribed, she added.

Dr. Schneider reported that she also has her patients sign a contract with her, in which they attest they will not engage in illegal or diversional activity and will take their medication in a responsible manner.

“If you do all these things and are victimized by someone who is a drug seeker, at least you have documented your efforts and have done everything you can do,” she said.

ORLANDO – Do not confuse addiction with physical dependence when prescribing opioids for your chronic pain patients, Dr. Jennifer P. Schneider advised at the annual clinical meeting of the American Academy of Pain Management.

Trust patients to tell the truth when they complain of pain and counsel them about the side effects of opioids.

Dr. Schneider, an internist whose Tucson, Ariz., practice focuses on addiction medicine and pain management, stressed that the patient's word is the gold standard when it comes to judging his or her own pain. However, she said, “Doctors are uncomfortable with this.”

The field of chronic pain management is full of misconceptions, she added. For example, cancer pain is more likely to get treated than noncancer pain, because practitioners falsely believe patients will become addicted to their pain medications; some physicians may not be concerned about the risk for addiction in this population because they perceive these patients as being close to death.

“This is such faulty thinking. Addiction is not the same as physical dependence or tolerance. We've got to get that message across to clinicians,” she said.

Sometimes physicians get suspicious when patients complain that their original dose either relieves pain less effectively than before or has stopped altogether, Dr. Schneider said. “When this happens, ask patients about their function. Maybe they are having more pain because they are no longer just sitting on the sofa, like they used to. If they are now able to get up and walk the dog or do gardening, they will need more medication. So don't just assume it's tolerance, or worse, that they are drug seeking. If you don't want them to get back to lying on the sofa, prescribe more.”

Long-acting opioids are preferable over shorter-acting agents, because they produce even blood levels and more stable pain relief. Short-acting drugs are more likely to cause a “buzz” as they get taken up by the brain. Patients also have to get up in the middle of the night to take short-acting opioids to keep their blood levels constant.

Short-acting drugs are useful for acute pain, however, and can also be used for rescue dosing, Dr. Schneider said.

There is no evidence for major organ toxicity with opioids. However, constipation is a problem for virtually all patients, and they should be aware of the importance of adequate hydration to minimize this. A stool softener also may be of benefit, she said.

Opioids lower testosterone levels in men, which can put them at risk for osteoporosis. Dr. Schneider advised replacing the testosterone to prevent the loss of bone and to give men more energy and muscle strength.

The “big bugaboo” of opioid prescribing is diversion. “Are patients selling their drugs on the street? We all worry about this,” she said. To help guard against diversion, Dr. Schneider recommended doing routine drug screening with an additional screen for any special drugs that patients may be taking.

“A regular urine drug screen will pick up codeine, morphine, and heroin only, but not methadone, fentanyl, oxycodone, or hydrocodone. So when you use a urine drug screen, make sure you test for other drugs, if you suspect the patient is taking other substances.”

A drug screen is also good to make sure patients are using the drugs as prescribed, she added.

Dr. Schneider reported that she also has her patients sign a contract with her, in which they attest they will not engage in illegal or diversional activity and will take their medication in a responsible manner.

“If you do all these things and are victimized by someone who is a drug seeker, at least you have documented your efforts and have done everything you can do,” she said.

GENEVA — Giving HIV-infected patients a holiday from their drugs may safely reduce the side effects and costs of treatment, according to results from the Staccato study, a prospective, open-label, randomized trial done in Thailand, Switzerland, and Australia.

Interruption of treatment with highly active antiretroviral therapy (HAART) according to a subject's CD4+ cell count led to substantial drug savings and reduced the side effects of treatment but did not raise the risk of increased immune suppression or emergence of resistance (Lancet 2006;368:459–65).

Lifelong treatment with HAART is extremely effective in controlling HIV and has significantly improved AIDS-free survival since its introduction in 1996. However, HAART is expensive and also can lead to troublesome side effects.

To evaluate the safety of interrupting HAART, the Staccato investigators randomized 430 patients who had CD4 counts greater than 350 cells/microliter and HIV RNA less than 50 copies/milliliter for at least 3 months prior to study entry to either continued therapy (n = 146) or scheduled treatment interruptions (n = 284) for a median of 21.9 months (range 16.4–25.3 months).

Initially, the Staccato trial attempted to assess the safety of interruption therapy of 1 week on/1 week off. However, an interim analysis of this strategy found an unacceptably high rate of failure, and this arm was discontinued, wrote senior author Dr. Bernard Hirschel, chief of the HIV/AIDS division, Geneva University Hospital, Geneva, and his associates.

All patients were monitored for CD4 count, viral load, adverse events, and HIV disease progression. Patients in the scheduled treatment interruption group began the trial by discontinuing HAART. If their CD4 count dropped below 350 cells/microliter on two consecutive measures, they resumed HAART for at least 12 weeks. They stopped again if their CD4 count rose above 350 cells/microliter.

Results at the end of the study showed that HIV control was similar in both groups, with 90.5% of patients in the interrupted group and 91.8% of patients in the continuous treatment group achieving HIV RNA less than 50 copies/milliliter.

Patients in the interruption group had more oral and genital candidiasis, but they also had a moderate decrease in such treatment-related adverse events as diarrhea and lipodystrophy, the researchers wrote.

“The results provide reassurance about the one risk that was feared—development of resistance and loss of efficacy of treatment,” Dr. Hirschel said in a statement. “Scheduled treatment interruptions, lasting many months, with substantial drug savings, can be anticipated, particularly in patients whose immune systems were never damaged by HIV.”

GENEVA — Giving HIV-infected patients a holiday from their drugs may safely reduce the side effects and costs of treatment, according to results from the Staccato study, a prospective, open-label, randomized trial done in Thailand, Switzerland, and Australia.

Interruption of treatment with highly active antiretroviral therapy (HAART) according to a subject's CD4+ cell count led to substantial drug savings and reduced the side effects of treatment but did not raise the risk of increased immune suppression or emergence of resistance (Lancet 2006;368:459–65).

Lifelong treatment with HAART is extremely effective in controlling HIV and has significantly improved AIDS-free survival since its introduction in 1996. However, HAART is expensive and also can lead to troublesome side effects.

To evaluate the safety of interrupting HAART, the Staccato investigators randomized 430 patients who had CD4 counts greater than 350 cells/microliter and HIV RNA less than 50 copies/milliliter for at least 3 months prior to study entry to either continued therapy (n = 146) or scheduled treatment interruptions (n = 284) for a median of 21.9 months (range 16.4–25.3 months).

Initially, the Staccato trial attempted to assess the safety of interruption therapy of 1 week on/1 week off. However, an interim analysis of this strategy found an unacceptably high rate of failure, and this arm was discontinued, wrote senior author Dr. Bernard Hirschel, chief of the HIV/AIDS division, Geneva University Hospital, Geneva, and his associates.

All patients were monitored for CD4 count, viral load, adverse events, and HIV disease progression. Patients in the scheduled treatment interruption group began the trial by discontinuing HAART. If their CD4 count dropped below 350 cells/microliter on two consecutive measures, they resumed HAART for at least 12 weeks. They stopped again if their CD4 count rose above 350 cells/microliter.

Results at the end of the study showed that HIV control was similar in both groups, with 90.5% of patients in the interrupted group and 91.8% of patients in the continuous treatment group achieving HIV RNA less than 50 copies/milliliter.

Patients in the interruption group had more oral and genital candidiasis, but they also had a moderate decrease in such treatment-related adverse events as diarrhea and lipodystrophy, the researchers wrote.

“The results provide reassurance about the one risk that was feared—development of resistance and loss of efficacy of treatment,” Dr. Hirschel said in a statement. “Scheduled treatment interruptions, lasting many months, with substantial drug savings, can be anticipated, particularly in patients whose immune systems were never damaged by HIV.”

GENEVA — Giving HIV-infected patients a holiday from their drugs may safely reduce the side effects and costs of treatment, according to results from the Staccato study, a prospective, open-label, randomized trial done in Thailand, Switzerland, and Australia.

Interruption of treatment with highly active antiretroviral therapy (HAART) according to a subject's CD4+ cell count led to substantial drug savings and reduced the side effects of treatment but did not raise the risk of increased immune suppression or emergence of resistance (Lancet 2006;368:459–65).

Lifelong treatment with HAART is extremely effective in controlling HIV and has significantly improved AIDS-free survival since its introduction in 1996. However, HAART is expensive and also can lead to troublesome side effects.

To evaluate the safety of interrupting HAART, the Staccato investigators randomized 430 patients who had CD4 counts greater than 350 cells/microliter and HIV RNA less than 50 copies/milliliter for at least 3 months prior to study entry to either continued therapy (n = 146) or scheduled treatment interruptions (n = 284) for a median of 21.9 months (range 16.4–25.3 months).

Initially, the Staccato trial attempted to assess the safety of interruption therapy of 1 week on/1 week off. However, an interim analysis of this strategy found an unacceptably high rate of failure, and this arm was discontinued, wrote senior author Dr. Bernard Hirschel, chief of the HIV/AIDS division, Geneva University Hospital, Geneva, and his associates.

All patients were monitored for CD4 count, viral load, adverse events, and HIV disease progression. Patients in the scheduled treatment interruption group began the trial by discontinuing HAART. If their CD4 count dropped below 350 cells/microliter on two consecutive measures, they resumed HAART for at least 12 weeks. They stopped again if their CD4 count rose above 350 cells/microliter.

Results at the end of the study showed that HIV control was similar in both groups, with 90.5% of patients in the interrupted group and 91.8% of patients in the continuous treatment group achieving HIV RNA less than 50 copies/milliliter.

Patients in the interruption group had more oral and genital candidiasis, but they also had a moderate decrease in such treatment-related adverse events as diarrhea and lipodystrophy, the researchers wrote.

“The results provide reassurance about the one risk that was feared—development of resistance and loss of efficacy of treatment,” Dr. Hirschel said in a statement. “Scheduled treatment interruptions, lasting many months, with substantial drug savings, can be anticipated, particularly in patients whose immune systems were never damaged by HIV.”

TORONTO — College students are reluctant to get tested for HIV because they fear being judged by others, according to a poster presented at the 16th International AIDS Conference.

In a survey of 491 students at York University, Toronto, 49 (10%) reported having been tested for HIV.

Two-thirds of the students reported having had unprotected sex in the previous 6 months, even though many were ignorant of their HIV status, said Trevor A. Hart, Ph.D., of the department of psychology at the university.

“In a country such as Canada, where access to medical care and HIV testing are readily available and cost nothing, these results are quite troubling,” Dr. Hart said in an interview.

The number of new HIV infections in Canada is high, about 2,500 new cases a year. But in a 2003 survey of Canadians over age 15, only 27% reported ever having been tested for HIV (excluding testing for the purposes of insurance, blood donation, and participation in research), according to a 2005 report by Public Health Agency Canada.

Dr. Hart and his colleagues decided to see if they could find out why their population of students was not being tested.

The students filled out a questionnaire in which they were asked about their sexual activities in the previous 6 months; their HIV testing histories and willingness to get tested; their concerns about being judged for getting an HIV test; and social anxiety.

Most of the students (80%) were female, and the mean age was 18 years, with a range of 17–24 years.

The results of the survey revealed that social anxiety and fear of being judged prevented the young adults from getting tested for HIV and learning what their HIV status was.

Surprisingly, students who were more socially anxious were more likely to be concerned about being judged about HIV testing by their siblings. They were also inhibited by friends, their physician, grandparents, coworkers, and God, Dr. Hart reported.

He added that primary care doctors have an important role to play in helping make sure that more youngsters know their HIV status.

To encourage HIV testing, physicians should ask patients if they are sexually active, and if so, ask if they know their HIV status. Physicians can explain that it's common for people to get tested for HIV and that being tested doesn't mean that the person did anything wrong. “It's like knowing your blood type, or when you got your last tetanus shot,” Dr. Hart said.

Doctors might also consider putting up posters or having pamphlets about HIV in their waiting rooms to normalize and destigmatize HIV testing, he added.

TORONTO — College students are reluctant to get tested for HIV because they fear being judged by others, according to a poster presented at the 16th International AIDS Conference.

In a survey of 491 students at York University, Toronto, 49 (10%) reported having been tested for HIV.

Two-thirds of the students reported having had unprotected sex in the previous 6 months, even though many were ignorant of their HIV status, said Trevor A. Hart, Ph.D., of the department of psychology at the university.

“In a country such as Canada, where access to medical care and HIV testing are readily available and cost nothing, these results are quite troubling,” Dr. Hart said in an interview.

The number of new HIV infections in Canada is high, about 2,500 new cases a year. But in a 2003 survey of Canadians over age 15, only 27% reported ever having been tested for HIV (excluding testing for the purposes of insurance, blood donation, and participation in research), according to a 2005 report by Public Health Agency Canada.

Dr. Hart and his colleagues decided to see if they could find out why their population of students was not being tested.

The students filled out a questionnaire in which they were asked about their sexual activities in the previous 6 months; their HIV testing histories and willingness to get tested; their concerns about being judged for getting an HIV test; and social anxiety.

Most of the students (80%) were female, and the mean age was 18 years, with a range of 17–24 years.

The results of the survey revealed that social anxiety and fear of being judged prevented the young adults from getting tested for HIV and learning what their HIV status was.

Surprisingly, students who were more socially anxious were more likely to be concerned about being judged about HIV testing by their siblings. They were also inhibited by friends, their physician, grandparents, coworkers, and God, Dr. Hart reported.

He added that primary care doctors have an important role to play in helping make sure that more youngsters know their HIV status.

To encourage HIV testing, physicians should ask patients if they are sexually active, and if so, ask if they know their HIV status. Physicians can explain that it's common for people to get tested for HIV and that being tested doesn't mean that the person did anything wrong. “It's like knowing your blood type, or when you got your last tetanus shot,” Dr. Hart said.

Doctors might also consider putting up posters or having pamphlets about HIV in their waiting rooms to normalize and destigmatize HIV testing, he added.

TORONTO — College students are reluctant to get tested for HIV because they fear being judged by others, according to a poster presented at the 16th International AIDS Conference.

In a survey of 491 students at York University, Toronto, 49 (10%) reported having been tested for HIV.

Two-thirds of the students reported having had unprotected sex in the previous 6 months, even though many were ignorant of their HIV status, said Trevor A. Hart, Ph.D., of the department of psychology at the university.

“In a country such as Canada, where access to medical care and HIV testing are readily available and cost nothing, these results are quite troubling,” Dr. Hart said in an interview.

The number of new HIV infections in Canada is high, about 2,500 new cases a year. But in a 2003 survey of Canadians over age 15, only 27% reported ever having been tested for HIV (excluding testing for the purposes of insurance, blood donation, and participation in research), according to a 2005 report by Public Health Agency Canada.

Dr. Hart and his colleagues decided to see if they could find out why their population of students was not being tested.

The students filled out a questionnaire in which they were asked about their sexual activities in the previous 6 months; their HIV testing histories and willingness to get tested; their concerns about being judged for getting an HIV test; and social anxiety.

Most of the students (80%) were female, and the mean age was 18 years, with a range of 17–24 years.

The results of the survey revealed that social anxiety and fear of being judged prevented the young adults from getting tested for HIV and learning what their HIV status was.

Surprisingly, students who were more socially anxious were more likely to be concerned about being judged about HIV testing by their siblings. They were also inhibited by friends, their physician, grandparents, coworkers, and God, Dr. Hart reported.

He added that primary care doctors have an important role to play in helping make sure that more youngsters know their HIV status.

To encourage HIV testing, physicians should ask patients if they are sexually active, and if so, ask if they know their HIV status. Physicians can explain that it's common for people to get tested for HIV and that being tested doesn't mean that the person did anything wrong. “It's like knowing your blood type, or when you got your last tetanus shot,” Dr. Hart said.

Doctors might also consider putting up posters or having pamphlets about HIV in their waiting rooms to normalize and destigmatize HIV testing, he added.

TORONTO — Men who have sex with men are engaging in unsafe sex under the false belief that highly active antiretroviral therapy will protect them from transmitting or getting infected with HIV, according to a poster presented at the 16th International AIDS Conference.

Men who were positive for HIV and who were taking highly active antiretroviral therapy admitted in a questionnaire that they believed that their HIV medications made it much harder to transmit the virus and were more likely to have unprotected sex with men who were not HIV positive, said Trevor A. Hart, Ph.D., of the department of psychology at York University, Toronto.

Similarly, men who were negative for HIV were much more likely to have unprotected sex with HIV-positive partners who were taking HAART because of their optimistic beliefs about the therapy.

In addition to the belief that HIV is harder to transmit sexually because of HAART, the men were more likely to believe that HIV is a less-serious disease because of HAART, Dr. Hart said.

He and his colleagues examined the relation between HAART beliefs and risky sexual behaviors among 554 men who have sex with men who were recruited for the study from the 2005 Toronto Gay Pride Festival.

It is true that HIV medications reduce viral load and improve individuals' health, but if people are having more unprotected sex as a result, their risk of transmitting or getting the infection still is increased, Dr. Hart said in an interview.

“We need to pass on the message that, even though the medications are quite useful, they don't make HIV into a pleasant disease to have, and they do not ensure that you can't ever get HIV. True, there is some reduction of risk, but if you then go and compensate by having risky sex, that really won't be helpful.” Getting this message across is important for protecting gay and bisexual patients, he said.

Similar concerns about the dangers of HIV transmission and reinfection also were voiced by Julie Overbaugh, Ph.D., of the human biology division at the Fred Hutchinson Cancer Research Center, Seattle.

Speaking about “serosorting”—a practice in which HIV-positive individuals seek out sexual partners with the same HIV status—Dr. Overbaugh said evidence is emerging about the danger of reinfection from this practice.

“In the case of patients who continue to engage in a lot of high-risk behavior with other HIV partners, there should be a little caution that they may be getting reinfected. At this point, there are very little data, but [the patients] should be told that their chance of getting reinfected is there, and that it could have clinical consequences,” she said.

Although HAART may be somewhat protective against being reinfected, there is still a danger, she added.

In a survey, men who have sex with men said they believed HIV was a less serious disease because of HAART. DR. HART

TORONTO — Men who have sex with men are engaging in unsafe sex under the false belief that highly active antiretroviral therapy will protect them from transmitting or getting infected with HIV, according to a poster presented at the 16th International AIDS Conference.

Men who were positive for HIV and who were taking highly active antiretroviral therapy admitted in a questionnaire that they believed that their HIV medications made it much harder to transmit the virus and were more likely to have unprotected sex with men who were not HIV positive, said Trevor A. Hart, Ph.D., of the department of psychology at York University, Toronto.

Similarly, men who were negative for HIV were much more likely to have unprotected sex with HIV-positive partners who were taking HAART because of their optimistic beliefs about the therapy.

In addition to the belief that HIV is harder to transmit sexually because of HAART, the men were more likely to believe that HIV is a less-serious disease because of HAART, Dr. Hart said.

He and his colleagues examined the relation between HAART beliefs and risky sexual behaviors among 554 men who have sex with men who were recruited for the study from the 2005 Toronto Gay Pride Festival.

It is true that HIV medications reduce viral load and improve individuals' health, but if people are having more unprotected sex as a result, their risk of transmitting or getting the infection still is increased, Dr. Hart said in an interview.

“We need to pass on the message that, even though the medications are quite useful, they don't make HIV into a pleasant disease to have, and they do not ensure that you can't ever get HIV. True, there is some reduction of risk, but if you then go and compensate by having risky sex, that really won't be helpful.” Getting this message across is important for protecting gay and bisexual patients, he said.

Similar concerns about the dangers of HIV transmission and reinfection also were voiced by Julie Overbaugh, Ph.D., of the human biology division at the Fred Hutchinson Cancer Research Center, Seattle.

Speaking about “serosorting”—a practice in which HIV-positive individuals seek out sexual partners with the same HIV status—Dr. Overbaugh said evidence is emerging about the danger of reinfection from this practice.

“In the case of patients who continue to engage in a lot of high-risk behavior with other HIV partners, there should be a little caution that they may be getting reinfected. At this point, there are very little data, but [the patients] should be told that their chance of getting reinfected is there, and that it could have clinical consequences,” she said.

Although HAART may be somewhat protective against being reinfected, there is still a danger, she added.

In a survey, men who have sex with men said they believed HIV was a less serious disease because of HAART. DR. HART

TORONTO — Men who have sex with men are engaging in unsafe sex under the false belief that highly active antiretroviral therapy will protect them from transmitting or getting infected with HIV, according to a poster presented at the 16th International AIDS Conference.

Men who were positive for HIV and who were taking highly active antiretroviral therapy admitted in a questionnaire that they believed that their HIV medications made it much harder to transmit the virus and were more likely to have unprotected sex with men who were not HIV positive, said Trevor A. Hart, Ph.D., of the department of psychology at York University, Toronto.

Similarly, men who were negative for HIV were much more likely to have unprotected sex with HIV-positive partners who were taking HAART because of their optimistic beliefs about the therapy.

In addition to the belief that HIV is harder to transmit sexually because of HAART, the men were more likely to believe that HIV is a less-serious disease because of HAART, Dr. Hart said.

He and his colleagues examined the relation between HAART beliefs and risky sexual behaviors among 554 men who have sex with men who were recruited for the study from the 2005 Toronto Gay Pride Festival.

It is true that HIV medications reduce viral load and improve individuals' health, but if people are having more unprotected sex as a result, their risk of transmitting or getting the infection still is increased, Dr. Hart said in an interview.

“We need to pass on the message that, even though the medications are quite useful, they don't make HIV into a pleasant disease to have, and they do not ensure that you can't ever get HIV. True, there is some reduction of risk, but if you then go and compensate by having risky sex, that really won't be helpful.” Getting this message across is important for protecting gay and bisexual patients, he said.

Similar concerns about the dangers of HIV transmission and reinfection also were voiced by Julie Overbaugh, Ph.D., of the human biology division at the Fred Hutchinson Cancer Research Center, Seattle.

Speaking about “serosorting”—a practice in which HIV-positive individuals seek out sexual partners with the same HIV status—Dr. Overbaugh said evidence is emerging about the danger of reinfection from this practice.

“In the case of patients who continue to engage in a lot of high-risk behavior with other HIV partners, there should be a little caution that they may be getting reinfected. At this point, there are very little data, but [the patients] should be told that their chance of getting reinfected is there, and that it could have clinical consequences,” she said.

Although HAART may be somewhat protective against being reinfected, there is still a danger, she added.

In a survey, men who have sex with men said they believed HIV was a less serious disease because of HAART. DR. HART

ATLANTA — Women with a new or a recurrent episode of hematuria are significantly less likely to be referred to a specialist for follow-up than are men with the same condition, researchers said at the annual meeting of the American Urological Association.

This delay in referral may be putting women at greater risk of death from bladder cancer, said Dr. Cheryl T. Lee, director of the Bladder Cancer Research Program at the University of Michigan in Ann Arbor.

Using insurance records from a nonprofit health plan, Dr. Lee and her colleagues performed a retrospective cohort study of 926 patients (60% men, 40% women) aged 18 years and older, who had new diagnosis codes for hematuria.

The investigators reported that 402 of 559 men (72%) were referred for urologic evaluation of hematuria, compared with 102 of 367 women (28%) over follow-up periods of 27 and 26 months, respectively. This gender disparity in referral was greatest in women over the age of 60, in whom bladder cancer is more common. “This unequal access to specialty evaluation of hematuria could potentially contribute to the delay in diagnosis of bladder cancer we so frequently see in women,” she said.

Men were significantly more likely to be referred to a specialist upon first presentation to a general practitioner with hematuria, compared with women, who were not referred until their second or third episode. This bias was stronger as patients aged, with men being referred at higher rates than women in the 50- to 59-year-old age category and the over-60 age category.

Ultimately, an adjusted multivariate analysis showed that men were 65% more likely to undergo urologic evaluation of hematuria than were women, Dr. Lee said.

Blood in the urine from urinary tract infections occurs more commonly in women than in men but generally in women under the age of 40, she commented. “I would argue that women in their 50s are at risk for bladder cancer, but certainly there is no argument about the increasing risk for women over the age of 60. An alarm should really go off when you see these women in your practice,” she said in an interview.

She conceded that the low prevalence of bladder cancer overall makes it difficult for the primary care physician to know when to refer.

The gender disparity in referral was greatest in women over the age of 60. DR. LEE

ATLANTA — Women with a new or a recurrent episode of hematuria are significantly less likely to be referred to a specialist for follow-up than are men with the same condition, researchers said at the annual meeting of the American Urological Association.

This delay in referral may be putting women at greater risk of death from bladder cancer, said Dr. Cheryl T. Lee, director of the Bladder Cancer Research Program at the University of Michigan in Ann Arbor.

Using insurance records from a nonprofit health plan, Dr. Lee and her colleagues performed a retrospective cohort study of 926 patients (60% men, 40% women) aged 18 years and older, who had new diagnosis codes for hematuria.

The investigators reported that 402 of 559 men (72%) were referred for urologic evaluation of hematuria, compared with 102 of 367 women (28%) over follow-up periods of 27 and 26 months, respectively. This gender disparity in referral was greatest in women over the age of 60, in whom bladder cancer is more common. “This unequal access to specialty evaluation of hematuria could potentially contribute to the delay in diagnosis of bladder cancer we so frequently see in women,” she said.

Men were significantly more likely to be referred to a specialist upon first presentation to a general practitioner with hematuria, compared with women, who were not referred until their second or third episode. This bias was stronger as patients aged, with men being referred at higher rates than women in the 50- to 59-year-old age category and the over-60 age category.

Ultimately, an adjusted multivariate analysis showed that men were 65% more likely to undergo urologic evaluation of hematuria than were women, Dr. Lee said.

Blood in the urine from urinary tract infections occurs more commonly in women than in men but generally in women under the age of 40, she commented. “I would argue that women in their 50s are at risk for bladder cancer, but certainly there is no argument about the increasing risk for women over the age of 60. An alarm should really go off when you see these women in your practice,” she said in an interview.

She conceded that the low prevalence of bladder cancer overall makes it difficult for the primary care physician to know when to refer.

The gender disparity in referral was greatest in women over the age of 60. DR. LEE

ATLANTA — Women with a new or a recurrent episode of hematuria are significantly less likely to be referred to a specialist for follow-up than are men with the same condition, researchers said at the annual meeting of the American Urological Association.

This delay in referral may be putting women at greater risk of death from bladder cancer, said Dr. Cheryl T. Lee, director of the Bladder Cancer Research Program at the University of Michigan in Ann Arbor.

Using insurance records from a nonprofit health plan, Dr. Lee and her colleagues performed a retrospective cohort study of 926 patients (60% men, 40% women) aged 18 years and older, who had new diagnosis codes for hematuria.

The investigators reported that 402 of 559 men (72%) were referred for urologic evaluation of hematuria, compared with 102 of 367 women (28%) over follow-up periods of 27 and 26 months, respectively. This gender disparity in referral was greatest in women over the age of 60, in whom bladder cancer is more common. “This unequal access to specialty evaluation of hematuria could potentially contribute to the delay in diagnosis of bladder cancer we so frequently see in women,” she said.

Men were significantly more likely to be referred to a specialist upon first presentation to a general practitioner with hematuria, compared with women, who were not referred until their second or third episode. This bias was stronger as patients aged, with men being referred at higher rates than women in the 50- to 59-year-old age category and the over-60 age category.

Ultimately, an adjusted multivariate analysis showed that men were 65% more likely to undergo urologic evaluation of hematuria than were women, Dr. Lee said.

Blood in the urine from urinary tract infections occurs more commonly in women than in men but generally in women under the age of 40, she commented. “I would argue that women in their 50s are at risk for bladder cancer, but certainly there is no argument about the increasing risk for women over the age of 60. An alarm should really go off when you see these women in your practice,” she said in an interview.

She conceded that the low prevalence of bladder cancer overall makes it difficult for the primary care physician to know when to refer.

The gender disparity in referral was greatest in women over the age of 60. DR. LEE