Doug Brunk

Major Finding: Mean venous thromboembolism risk-assessment scores significantly increased incrementally with body mass index (from 3.3 in the normal-weight group to 4.1 in the supermorbidly obese group), as did mean quality-of-life scores (from 20.3 in the normal-weight group to 29.0 in the supermorbidly obese group).

Data Source: An analysis of 7,227 National Venous Screening program participants.

Disclosures: Dr. Moore said that she had no relevant financial conflicts to disclose.

SAN DIEGO – The manifestations of chronic venous insufficiency increase with higher body mass index, results from a national screening program showed.

However, venous abnormalities on screening duplex ultrasound were not correlated with increasing BMI.

“We did not find an increase in obstruction or venous reflux in higher-BMI individuals, which leads us to believe that obesity in and of itself is a contributor to chronic venous disease in the absence of valvular insufficiency,” Dr. Colleen Moore said at the meeting.

To determine differences in venous disease across a spectrum of BMI, Dr. Moore and her associates analyzed results from the National Venous Screening program. The program, launched by the American Venous Forum in 2005, was designed to educate participants about venous thromboembolism (VTE) risk, varicose veins, and chronic venous insufficiency through screening, literature, promotional materials, and an interview with a venous expert.

“The program strives to identify those at risk for VTE, the presence of venous obstruction or reflux on a modified duplex ultrasound, and the presence of chronic venous insufficiency based on a quick leg inspection,” said Dr. Moore, of the vascular surgery department at Southern Illinois University, Springfield.

Dr. Moore and colleagues divided participants into six BMI categories and collected several data points for comparison, including demographic and health information, a VTE risk assessment, venous quality of life with the Chronic Venous Insufficiency Questionnaire 2 (CIVIQ2), and an abbreviated duplex ultrasound. Participants also underwent a lower-extremity inspection and were assigned a CEAP classification.

Dr. Moore presented findings from 7,227 people who have been screened since 2005. Of these, 1.3% were underweight (less than 18.5 kg/m

The prevalence of diabetes significantly increased incrementally with BMI (from 4.9% in the normal-weight group to 25.2% in the supermorbidly obese group), as did the prevalence of hypertension (from 22.9% to 54.3%, respectively).

Mean VTE risk-assessment scores significantly increased incrementally with BMI (from 3.3 in the normal-weight group to 4.1 in the supermorbidly obese group), as did mean quality-of-life scores (from 20.3 to 29.0, respectively). “We looked at social activities such as the ability to play sports or do housework,” Dr. Moore said. “As you become heavier those scores increase, indicating a worse quality of life, and are statistically significant compared with the normal-weight individuals.”

Mean CEAP scores significantly increased incrementally with BMI (from 1.4 in the normal-weight group to 1.9 in the supermorbidly obese group), as did mean venous clinical severity scores (from 2.6 to 4.3, respectively).

To watch a video interview from the meeting with Dr. Moore, scan this QR code using a smartphone.

Major Finding: Mean venous thromboembolism risk-assessment scores significantly increased incrementally with body mass index (from 3.3 in the normal-weight group to 4.1 in the supermorbidly obese group), as did mean quality-of-life scores (from 20.3 in the normal-weight group to 29.0 in the supermorbidly obese group).

Data Source: An analysis of 7,227 National Venous Screening program participants.

Disclosures: Dr. Moore said that she had no relevant financial conflicts to disclose.

SAN DIEGO – The manifestations of chronic venous insufficiency increase with higher body mass index, results from a national screening program showed.

However, venous abnormalities on screening duplex ultrasound were not correlated with increasing BMI.

“We did not find an increase in obstruction or venous reflux in higher-BMI individuals, which leads us to believe that obesity in and of itself is a contributor to chronic venous disease in the absence of valvular insufficiency,” Dr. Colleen Moore said at the meeting.

To determine differences in venous disease across a spectrum of BMI, Dr. Moore and her associates analyzed results from the National Venous Screening program. The program, launched by the American Venous Forum in 2005, was designed to educate participants about venous thromboembolism (VTE) risk, varicose veins, and chronic venous insufficiency through screening, literature, promotional materials, and an interview with a venous expert.

“The program strives to identify those at risk for VTE, the presence of venous obstruction or reflux on a modified duplex ultrasound, and the presence of chronic venous insufficiency based on a quick leg inspection,” said Dr. Moore, of the vascular surgery department at Southern Illinois University, Springfield.

Dr. Moore and colleagues divided participants into six BMI categories and collected several data points for comparison, including demographic and health information, a VTE risk assessment, venous quality of life with the Chronic Venous Insufficiency Questionnaire 2 (CIVIQ2), and an abbreviated duplex ultrasound. Participants also underwent a lower-extremity inspection and were assigned a CEAP classification.

Dr. Moore presented findings from 7,227 people who have been screened since 2005. Of these, 1.3% were underweight (less than 18.5 kg/m

The prevalence of diabetes significantly increased incrementally with BMI (from 4.9% in the normal-weight group to 25.2% in the supermorbidly obese group), as did the prevalence of hypertension (from 22.9% to 54.3%, respectively).

Mean VTE risk-assessment scores significantly increased incrementally with BMI (from 3.3 in the normal-weight group to 4.1 in the supermorbidly obese group), as did mean quality-of-life scores (from 20.3 to 29.0, respectively). “We looked at social activities such as the ability to play sports or do housework,” Dr. Moore said. “As you become heavier those scores increase, indicating a worse quality of life, and are statistically significant compared with the normal-weight individuals.”

Mean CEAP scores significantly increased incrementally with BMI (from 1.4 in the normal-weight group to 1.9 in the supermorbidly obese group), as did mean venous clinical severity scores (from 2.6 to 4.3, respectively).

To watch a video interview from the meeting with Dr. Moore, scan this QR code using a smartphone.

Major Finding: Mean venous thromboembolism risk-assessment scores significantly increased incrementally with body mass index (from 3.3 in the normal-weight group to 4.1 in the supermorbidly obese group), as did mean quality-of-life scores (from 20.3 in the normal-weight group to 29.0 in the supermorbidly obese group).

Data Source: An analysis of 7,227 National Venous Screening program participants.

Disclosures: Dr. Moore said that she had no relevant financial conflicts to disclose.

SAN DIEGO – The manifestations of chronic venous insufficiency increase with higher body mass index, results from a national screening program showed.

However, venous abnormalities on screening duplex ultrasound were not correlated with increasing BMI.

“We did not find an increase in obstruction or venous reflux in higher-BMI individuals, which leads us to believe that obesity in and of itself is a contributor to chronic venous disease in the absence of valvular insufficiency,” Dr. Colleen Moore said at the meeting.

To determine differences in venous disease across a spectrum of BMI, Dr. Moore and her associates analyzed results from the National Venous Screening program. The program, launched by the American Venous Forum in 2005, was designed to educate participants about venous thromboembolism (VTE) risk, varicose veins, and chronic venous insufficiency through screening, literature, promotional materials, and an interview with a venous expert.

“The program strives to identify those at risk for VTE, the presence of venous obstruction or reflux on a modified duplex ultrasound, and the presence of chronic venous insufficiency based on a quick leg inspection,” said Dr. Moore, of the vascular surgery department at Southern Illinois University, Springfield.

Dr. Moore and colleagues divided participants into six BMI categories and collected several data points for comparison, including demographic and health information, a VTE risk assessment, venous quality of life with the Chronic Venous Insufficiency Questionnaire 2 (CIVIQ2), and an abbreviated duplex ultrasound. Participants also underwent a lower-extremity inspection and were assigned a CEAP classification.

Dr. Moore presented findings from 7,227 people who have been screened since 2005. Of these, 1.3% were underweight (less than 18.5 kg/m

The prevalence of diabetes significantly increased incrementally with BMI (from 4.9% in the normal-weight group to 25.2% in the supermorbidly obese group), as did the prevalence of hypertension (from 22.9% to 54.3%, respectively).

Mean VTE risk-assessment scores significantly increased incrementally with BMI (from 3.3 in the normal-weight group to 4.1 in the supermorbidly obese group), as did mean quality-of-life scores (from 20.3 to 29.0, respectively). “We looked at social activities such as the ability to play sports or do housework,” Dr. Moore said. “As you become heavier those scores increase, indicating a worse quality of life, and are statistically significant compared with the normal-weight individuals.”

Mean CEAP scores significantly increased incrementally with BMI (from 1.4 in the normal-weight group to 1.9 in the supermorbidly obese group), as did mean venous clinical severity scores (from 2.6 to 4.3, respectively).

To watch a video interview from the meeting with Dr. Moore, scan this QR code using a smartphone.

Major Finding: Exercise and medication use significantly improved cognitive function in patients with Parkinson's disease based on results of the Stroop Color and Word Test. Exercise improved performance on the Brief Test of Attention and the Digit Span Forward and Backward Task when patients were off medication but not when they were on medication.

Data Source: An analysis of 48 Parkinson's disease patients who completed 6 months of a strengthening and balance exercise program under the guidance of a personal trainer.

Disclosures: The study was supported by an American Academy of Neurology Medical Student Summer Research Scholarship and by a grant from the National Institute of Neurological Disorders and Stroke.

HONOLULU – Patients with Parkinson's disease who participated in a 1-hour exercise program twice a week for 6 months experienced improvements in certain cognitive deficits, results from a single-center study showed.

“Exercise should be considered adjunct therapy in Parkinson's disease because it improves cognitive function in patients when not on medication,” lead study author Jeffrey R. Olech said in an interview during a poster session at the meeting.

Mr. Olech, a second-year student at the University of Illinois at Chicago, and his associates presented results from 48 Parkinson's disease patients who completed 6 months of a strengthening and balance exercise program under the guidance of a personal trainer. The researchers administered cognitive assessments when patients were “on” and “off” Parkinson's medication at baseline and at completion of the 6-month program.

Cognitive tests included the Stroop Color and Word Test, the Brief Test of Attention (BTA), and the Digit Span Forward and Backward Task. The researchers performed a two-way repeated measures analysis of variance on the cognitive measures with time (baseline vs. 6 months) and medication (on vs. off) as factors.

The mean age of patients was 59 years, and 58% were men. The mean baseline motor United Parkinson's Disease Rating Scale score was 34.6 among those off medication and 21.3 among those on medication.

At 6 months, exercise and medication use significantly improved cognitive function based on results of the Stroop Color and Word Test. A significant interaction was observed between exercise and medication use based on results of the BTA test and the Digit Span Forward and Backward Task. Exercise improved performance on both of these tests when patients were off medication, but not while they were on medication.

“It was surprising to us that cognitive function was improved without medication over different domains of cognitive assessments,” Mr. Olech said. “Previous research has demonstrated that Parkinson's patients on medication without exercise will maintain their level of cognitive performance over a 6-month period of time. Reasons improvement on cognitive outcomes off medication were observed could potentially be due to increased neural plasticity as a result of exercise, or an improvement in dopaminergic output during periods throughout the day that the drug's therapeutic benefit wanes.”

He and his associates plan to collect data in this cohort of patients at 18 and 24 months of follow-up to determine if the associations persist.

Mr. Olech acknowledged certain limitations of the study, including its lack of an intervention control group and its single-center design.

Major Finding: Exercise and medication use significantly improved cognitive function in patients with Parkinson's disease based on results of the Stroop Color and Word Test. Exercise improved performance on the Brief Test of Attention and the Digit Span Forward and Backward Task when patients were off medication but not when they were on medication.

Data Source: An analysis of 48 Parkinson's disease patients who completed 6 months of a strengthening and balance exercise program under the guidance of a personal trainer.

Disclosures: The study was supported by an American Academy of Neurology Medical Student Summer Research Scholarship and by a grant from the National Institute of Neurological Disorders and Stroke.

HONOLULU – Patients with Parkinson's disease who participated in a 1-hour exercise program twice a week for 6 months experienced improvements in certain cognitive deficits, results from a single-center study showed.

“Exercise should be considered adjunct therapy in Parkinson's disease because it improves cognitive function in patients when not on medication,” lead study author Jeffrey R. Olech said in an interview during a poster session at the meeting.

Mr. Olech, a second-year student at the University of Illinois at Chicago, and his associates presented results from 48 Parkinson's disease patients who completed 6 months of a strengthening and balance exercise program under the guidance of a personal trainer. The researchers administered cognitive assessments when patients were “on” and “off” Parkinson's medication at baseline and at completion of the 6-month program.

Cognitive tests included the Stroop Color and Word Test, the Brief Test of Attention (BTA), and the Digit Span Forward and Backward Task. The researchers performed a two-way repeated measures analysis of variance on the cognitive measures with time (baseline vs. 6 months) and medication (on vs. off) as factors.

The mean age of patients was 59 years, and 58% were men. The mean baseline motor United Parkinson's Disease Rating Scale score was 34.6 among those off medication and 21.3 among those on medication.

At 6 months, exercise and medication use significantly improved cognitive function based on results of the Stroop Color and Word Test. A significant interaction was observed between exercise and medication use based on results of the BTA test and the Digit Span Forward and Backward Task. Exercise improved performance on both of these tests when patients were off medication, but not while they were on medication.

“It was surprising to us that cognitive function was improved without medication over different domains of cognitive assessments,” Mr. Olech said. “Previous research has demonstrated that Parkinson's patients on medication without exercise will maintain their level of cognitive performance over a 6-month period of time. Reasons improvement on cognitive outcomes off medication were observed could potentially be due to increased neural plasticity as a result of exercise, or an improvement in dopaminergic output during periods throughout the day that the drug's therapeutic benefit wanes.”

He and his associates plan to collect data in this cohort of patients at 18 and 24 months of follow-up to determine if the associations persist.

Mr. Olech acknowledged certain limitations of the study, including its lack of an intervention control group and its single-center design.

Major Finding: Exercise and medication use significantly improved cognitive function in patients with Parkinson's disease based on results of the Stroop Color and Word Test. Exercise improved performance on the Brief Test of Attention and the Digit Span Forward and Backward Task when patients were off medication but not when they were on medication.

Data Source: An analysis of 48 Parkinson's disease patients who completed 6 months of a strengthening and balance exercise program under the guidance of a personal trainer.

Disclosures: The study was supported by an American Academy of Neurology Medical Student Summer Research Scholarship and by a grant from the National Institute of Neurological Disorders and Stroke.

HONOLULU – Patients with Parkinson's disease who participated in a 1-hour exercise program twice a week for 6 months experienced improvements in certain cognitive deficits, results from a single-center study showed.

“Exercise should be considered adjunct therapy in Parkinson's disease because it improves cognitive function in patients when not on medication,” lead study author Jeffrey R. Olech said in an interview during a poster session at the meeting.

Mr. Olech, a second-year student at the University of Illinois at Chicago, and his associates presented results from 48 Parkinson's disease patients who completed 6 months of a strengthening and balance exercise program under the guidance of a personal trainer. The researchers administered cognitive assessments when patients were “on” and “off” Parkinson's medication at baseline and at completion of the 6-month program.

Cognitive tests included the Stroop Color and Word Test, the Brief Test of Attention (BTA), and the Digit Span Forward and Backward Task. The researchers performed a two-way repeated measures analysis of variance on the cognitive measures with time (baseline vs. 6 months) and medication (on vs. off) as factors.

The mean age of patients was 59 years, and 58% were men. The mean baseline motor United Parkinson's Disease Rating Scale score was 34.6 among those off medication and 21.3 among those on medication.

At 6 months, exercise and medication use significantly improved cognitive function based on results of the Stroop Color and Word Test. A significant interaction was observed between exercise and medication use based on results of the BTA test and the Digit Span Forward and Backward Task. Exercise improved performance on both of these tests when patients were off medication, but not while they were on medication.

“It was surprising to us that cognitive function was improved without medication over different domains of cognitive assessments,” Mr. Olech said. “Previous research has demonstrated that Parkinson's patients on medication without exercise will maintain their level of cognitive performance over a 6-month period of time. Reasons improvement on cognitive outcomes off medication were observed could potentially be due to increased neural plasticity as a result of exercise, or an improvement in dopaminergic output during periods throughout the day that the drug's therapeutic benefit wanes.”

He and his associates plan to collect data in this cohort of patients at 18 and 24 months of follow-up to determine if the associations persist.

Mr. Olech acknowledged certain limitations of the study, including its lack of an intervention control group and its single-center design.

Major Finding: Women and blacks with Parkinson's disease both had 23% lower odds of receiving care from a neurologist than did men and whites, after adjustment for covariates.

Data Source: An analysis of more than 138,000 incident cases of Parkinson's disease from Medicare beneficiaries with outpatient or carrier file claims for Parkinson's disease in 2002.

Disclosures: Dr. Willis said she had no relevant financial disclosures.

HONOLULU – Women and minorities with Parkinson's disease obtained care from a neurologist less often than did white men, in a large national analysis of Medicare data.

In addition, Parkinson's patients who received care from a neurologist had significant improvement in certain clinical outcomes as well as better overall survival compared with patients who received care from physicians in other specialties.

“Neurological disorders are common,” Dr. Allison Wright Willis said at the meetingo “However, medical students and new physicians report feeling least secure in their ability to diagnose and manage neurologic disease. Unfortunately, primary care training programs may not be able to provide sufficient training in the management of complicated neurodegenerative diseases such as Parkinson's disease.”

Dr. Willis of the department of neurology at Washington University in St. Louis and her associates set out to determine if treatment of Parkinson's patients by a neurologist is associated with improved selected health outcomes, including hip fracture, skilled nursing facility placement, and survival. They evaluated more than 138,000 incident cases of Parkinson's disease from Medicare beneficiaries with outpatient or carrier file claims for Parkinson's disease in 2002.

For the period of 2002–2008, Dr. Willis and her colleagues used a Cox proportional hazards model to compare survival in patients with Parkinson's disease who were treated by either a neurologist or primary care physician. They included the variables of race, age, sex, comorbidity index, socioeconomic deprivation score, and physician specialty.

Dr. Willis reported that only 57% of newly diagnosed Parkinson's patients saw a neurologist at any time during the 48-month period in which neurologist encounter rates were calculated. Men and whites had the highest specialist treatment rates. Women and blacks both had 23% lower odds of receiving neurologist care than did men and whites, after adjustment for covariates.

Investigation of race and gender pairs revealed that white women, black men, black women, Hispanic women, and Asian women all had significantly lower odds, compared with white men, of receiving care from a neurologist after adjustment for age, comorbidity, and economic disparity. A sensitivity analysis performed using 469,000 prevalent cases of Parkinson's disease yielded similar findings.

In a subgroup analysis of nearly 130,000 Parkinson's patients without incident stroke or transient ischemic attack, patients cared for by a neurologist had 21% lower odds of being placed in a skilled nursing home, compared with patients treated by primary care physicians. Treatment by a neurologist also was associated with 14% lower odds of hip fracture than was treatment by primary care physicians.

The odds of survival over a 6-year period was 23% greater when patients received care from a neurologist rather than a primary care physician, with the greatest increase in survival seen in white men, white women, and black men.

“Should these results be confirmed using individual-level data, measures to lessen these disparities are vital,” Dr. Willis commented. “Furthermore, by demonstrating that neurologist treatment improves Parkinson's disease outcomes, our data highlight the need for health policy measures that support neurology practice and neurological education. However, the finding that fewer women and nonwhites received neurologist care may have broader implications for health care disparity and medical education.”

She went on to point out that in addition to what she described as “the clear social and policy implications of our research, these data are important to Parkinson's researchers. Parkinson's disease epidemiological studies and clinical trials typically rely on specialty centers or neurologist practices for case identification and recruitment. Our data suggest that this may produce a significant referral bias, [which is] critical when attempting to perform gene or environmental risk studies, and may result in a distortion of the Parkinson's disease risk literature or possibly confound clinical trial results. Additionally, the exclusive use of specialty center populations for recruitment may propagate a treatment bias resulting in fewer women and fewer minorities receiving state-of-the-art care.”

Dr. Willis acknowledged certain limitations of the study, including the fact that the Medicare data set analyzed does not provide information on severity of Parkinson's disease or physician diagnostic accuracy.

“As with any epidemiological study, unknown medical, social, economic, or cultural factors may remain that have influenced the observed health care patterns,” she noted. “Also, seeking neurologist care may be more likely in those who are health conscious and may correlate with other behaviors which would improve well-being, clinical course, or survival, such as medication use and exercise.”

Major Finding: Women and blacks with Parkinson's disease both had 23% lower odds of receiving care from a neurologist than did men and whites, after adjustment for covariates.

Data Source: An analysis of more than 138,000 incident cases of Parkinson's disease from Medicare beneficiaries with outpatient or carrier file claims for Parkinson's disease in 2002.

Disclosures: Dr. Willis said she had no relevant financial disclosures.

HONOLULU – Women and minorities with Parkinson's disease obtained care from a neurologist less often than did white men, in a large national analysis of Medicare data.

In addition, Parkinson's patients who received care from a neurologist had significant improvement in certain clinical outcomes as well as better overall survival compared with patients who received care from physicians in other specialties.

“Neurological disorders are common,” Dr. Allison Wright Willis said at the meetingo “However, medical students and new physicians report feeling least secure in their ability to diagnose and manage neurologic disease. Unfortunately, primary care training programs may not be able to provide sufficient training in the management of complicated neurodegenerative diseases such as Parkinson's disease.”

Dr. Willis of the department of neurology at Washington University in St. Louis and her associates set out to determine if treatment of Parkinson's patients by a neurologist is associated with improved selected health outcomes, including hip fracture, skilled nursing facility placement, and survival. They evaluated more than 138,000 incident cases of Parkinson's disease from Medicare beneficiaries with outpatient or carrier file claims for Parkinson's disease in 2002.

For the period of 2002–2008, Dr. Willis and her colleagues used a Cox proportional hazards model to compare survival in patients with Parkinson's disease who were treated by either a neurologist or primary care physician. They included the variables of race, age, sex, comorbidity index, socioeconomic deprivation score, and physician specialty.

Dr. Willis reported that only 57% of newly diagnosed Parkinson's patients saw a neurologist at any time during the 48-month period in which neurologist encounter rates were calculated. Men and whites had the highest specialist treatment rates. Women and blacks both had 23% lower odds of receiving neurologist care than did men and whites, after adjustment for covariates.

Investigation of race and gender pairs revealed that white women, black men, black women, Hispanic women, and Asian women all had significantly lower odds, compared with white men, of receiving care from a neurologist after adjustment for age, comorbidity, and economic disparity. A sensitivity analysis performed using 469,000 prevalent cases of Parkinson's disease yielded similar findings.

In a subgroup analysis of nearly 130,000 Parkinson's patients without incident stroke or transient ischemic attack, patients cared for by a neurologist had 21% lower odds of being placed in a skilled nursing home, compared with patients treated by primary care physicians. Treatment by a neurologist also was associated with 14% lower odds of hip fracture than was treatment by primary care physicians.

The odds of survival over a 6-year period was 23% greater when patients received care from a neurologist rather than a primary care physician, with the greatest increase in survival seen in white men, white women, and black men.

“Should these results be confirmed using individual-level data, measures to lessen these disparities are vital,” Dr. Willis commented. “Furthermore, by demonstrating that neurologist treatment improves Parkinson's disease outcomes, our data highlight the need for health policy measures that support neurology practice and neurological education. However, the finding that fewer women and nonwhites received neurologist care may have broader implications for health care disparity and medical education.”

She went on to point out that in addition to what she described as “the clear social and policy implications of our research, these data are important to Parkinson's researchers. Parkinson's disease epidemiological studies and clinical trials typically rely on specialty centers or neurologist practices for case identification and recruitment. Our data suggest that this may produce a significant referral bias, [which is] critical when attempting to perform gene or environmental risk studies, and may result in a distortion of the Parkinson's disease risk literature or possibly confound clinical trial results. Additionally, the exclusive use of specialty center populations for recruitment may propagate a treatment bias resulting in fewer women and fewer minorities receiving state-of-the-art care.”

Dr. Willis acknowledged certain limitations of the study, including the fact that the Medicare data set analyzed does not provide information on severity of Parkinson's disease or physician diagnostic accuracy.

“As with any epidemiological study, unknown medical, social, economic, or cultural factors may remain that have influenced the observed health care patterns,” she noted. “Also, seeking neurologist care may be more likely in those who are health conscious and may correlate with other behaviors which would improve well-being, clinical course, or survival, such as medication use and exercise.”

Major Finding: Women and blacks with Parkinson's disease both had 23% lower odds of receiving care from a neurologist than did men and whites, after adjustment for covariates.

Data Source: An analysis of more than 138,000 incident cases of Parkinson's disease from Medicare beneficiaries with outpatient or carrier file claims for Parkinson's disease in 2002.

Disclosures: Dr. Willis said she had no relevant financial disclosures.

HONOLULU – Women and minorities with Parkinson's disease obtained care from a neurologist less often than did white men, in a large national analysis of Medicare data.

In addition, Parkinson's patients who received care from a neurologist had significant improvement in certain clinical outcomes as well as better overall survival compared with patients who received care from physicians in other specialties.

“Neurological disorders are common,” Dr. Allison Wright Willis said at the meetingo “However, medical students and new physicians report feeling least secure in their ability to diagnose and manage neurologic disease. Unfortunately, primary care training programs may not be able to provide sufficient training in the management of complicated neurodegenerative diseases such as Parkinson's disease.”

Dr. Willis of the department of neurology at Washington University in St. Louis and her associates set out to determine if treatment of Parkinson's patients by a neurologist is associated with improved selected health outcomes, including hip fracture, skilled nursing facility placement, and survival. They evaluated more than 138,000 incident cases of Parkinson's disease from Medicare beneficiaries with outpatient or carrier file claims for Parkinson's disease in 2002.

For the period of 2002–2008, Dr. Willis and her colleagues used a Cox proportional hazards model to compare survival in patients with Parkinson's disease who were treated by either a neurologist or primary care physician. They included the variables of race, age, sex, comorbidity index, socioeconomic deprivation score, and physician specialty.

Dr. Willis reported that only 57% of newly diagnosed Parkinson's patients saw a neurologist at any time during the 48-month period in which neurologist encounter rates were calculated. Men and whites had the highest specialist treatment rates. Women and blacks both had 23% lower odds of receiving neurologist care than did men and whites, after adjustment for covariates.

Investigation of race and gender pairs revealed that white women, black men, black women, Hispanic women, and Asian women all had significantly lower odds, compared with white men, of receiving care from a neurologist after adjustment for age, comorbidity, and economic disparity. A sensitivity analysis performed using 469,000 prevalent cases of Parkinson's disease yielded similar findings.

In a subgroup analysis of nearly 130,000 Parkinson's patients without incident stroke or transient ischemic attack, patients cared for by a neurologist had 21% lower odds of being placed in a skilled nursing home, compared with patients treated by primary care physicians. Treatment by a neurologist also was associated with 14% lower odds of hip fracture than was treatment by primary care physicians.

The odds of survival over a 6-year period was 23% greater when patients received care from a neurologist rather than a primary care physician, with the greatest increase in survival seen in white men, white women, and black men.

“Should these results be confirmed using individual-level data, measures to lessen these disparities are vital,” Dr. Willis commented. “Furthermore, by demonstrating that neurologist treatment improves Parkinson's disease outcomes, our data highlight the need for health policy measures that support neurology practice and neurological education. However, the finding that fewer women and nonwhites received neurologist care may have broader implications for health care disparity and medical education.”

She went on to point out that in addition to what she described as “the clear social and policy implications of our research, these data are important to Parkinson's researchers. Parkinson's disease epidemiological studies and clinical trials typically rely on specialty centers or neurologist practices for case identification and recruitment. Our data suggest that this may produce a significant referral bias, [which is] critical when attempting to perform gene or environmental risk studies, and may result in a distortion of the Parkinson's disease risk literature or possibly confound clinical trial results. Additionally, the exclusive use of specialty center populations for recruitment may propagate a treatment bias resulting in fewer women and fewer minorities receiving state-of-the-art care.”

Dr. Willis acknowledged certain limitations of the study, including the fact that the Medicare data set analyzed does not provide information on severity of Parkinson's disease or physician diagnostic accuracy.

“As with any epidemiological study, unknown medical, social, economic, or cultural factors may remain that have influenced the observed health care patterns,” she noted. “Also, seeking neurologist care may be more likely in those who are health conscious and may correlate with other behaviors which would improve well-being, clinical course, or survival, such as medication use and exercise.”

Major Finding: IgG reactivity to fetal brain proteins at bands 37kDa and 73kDa was significantly associated with diagnosis of full autism; reactivity to proteins at bands 39kDa and 73kDa was significantly associated with diagnosis of the broader autism phenotype.

Data Source: Western blots against human fetal brain protein performed in 204 mothers of children diagnosed with autism, 71 mothers of children diagnosed with an autism spectrum disorder, and 183 mothers of typically developing children.

Disclosures: Dr. Van de Water has received personal compensation for activities with Pediatric Bioscience as a consultant, and holds stock and/or stock options in the company. She has also received royalty payments from the University of California, Davis.

HONOLULU – Certain maternal autoantibodies are associated with development of autism spectrum disorders, results from a large ongoing analysis demonstrate.

The finding lays the groundwork for an eventual diagnostic test for autism, said Judy Van de Water, Ph.D.

“Currently there is no biologic marker for autism,” said Dr. Van de Water, an immunologist at the University of California, Davis. “It's completely defined by behaviors.”

The maternal immune response in autism is of interest to researchers because of its role in neurodevelopment. “Maternal IgG isotype antibodies readily cross the placenta and are known to persist for up to 6 months postnatally in the child,” Dr. Van de Water said. “In addition, maternal antibodies have been shown to cause changes in fetal development in several known autoimmune disorders, such as SLE.”

In 2002, Dr. Van de Water and her associates began to collect blood samples from families as part of the Childhood Autism Risk from Genetics and the Environment (CHARGE) study.

They sampled the study population from three groups of children aged 2–5 years: children with autism (currently includes more than 800 families); typically developing children without autism or other developmental disabilities selected from the general population (currently 600 families enrolled); and children with developmental disabilities without autism (currently 220 families enrolled).

In the original experimental design, Western blots against human fetal brain protein were performed with 61 mothers of children with autism (36 regressive and 25 early onset), 40 mothers of children with developmental delay, and 62 mothers of typically developing children (Neurotoxicology 2008;29:226–31).

The investigators found that seven mothers of children with autism (12%) had IgG reactivity to fetal brain proteins at bands 37kDa and 73kDa. “We did not see this pattern in the typically developing controls or in the developmentally delayed population, so this seemed to be very specific for autism,” Dr. Van de Water said.

Analysis of autoantibody profiles of an additional 458 mothers – 204 mothers of children diagnosed with autism, 71 mothers of children diagnosed with an autism spectrum disorder, and 183 mothers of typically developing children – continues to yield highly significant associations between the presence of IgG reactivity to fetal brain proteins at bands 37kDa and 73kDa and a diagnosis of full autism.

Dr. Van de Water and her associates also discovered an association between the 39kDa and 73kDa bands and a diagnosis of the broader autism phenotype, “though this pattern is less frequent in the full autism group,” she said.

“We think we may have a very interesting biomarker, but is there a pathologic significance to these antibodies?” she asked. To find out, the researchers analyzed behavioral characteristics associated with maternal antibodies to fetal brain proteins.

Children of mothers who demonstrated reactivity at bands 37kDa and 73kDa had less expressive language. Similar results were seen in children of mothers who demonstrated reactivity at all three bands. In contrast, children of mothers who demonstrated reactivity at bands 39kDa and 73kDa had higher scores on the Aberrant Behavior Checklist irritability subscale.

A pilot study in monkeys conducted by Dr. Van de Water and her associates demonstrated behavioral changes in offspring following passive transfer of maternal IgG during the late first and early second trimesters (Brain Behav. Immun. 2008;22:806–16). Subsequent studies have confirmed that passive transfer of these antibodies into an animal model can recapitulate some behaviors characteristic of autism. More confirmatory studies are underway.

Major Finding: IgG reactivity to fetal brain proteins at bands 37kDa and 73kDa was significantly associated with diagnosis of full autism; reactivity to proteins at bands 39kDa and 73kDa was significantly associated with diagnosis of the broader autism phenotype.

Data Source: Western blots against human fetal brain protein performed in 204 mothers of children diagnosed with autism, 71 mothers of children diagnosed with an autism spectrum disorder, and 183 mothers of typically developing children.

Disclosures: Dr. Van de Water has received personal compensation for activities with Pediatric Bioscience as a consultant, and holds stock and/or stock options in the company. She has also received royalty payments from the University of California, Davis.

HONOLULU – Certain maternal autoantibodies are associated with development of autism spectrum disorders, results from a large ongoing analysis demonstrate.

The finding lays the groundwork for an eventual diagnostic test for autism, said Judy Van de Water, Ph.D.

“Currently there is no biologic marker for autism,” said Dr. Van de Water, an immunologist at the University of California, Davis. “It's completely defined by behaviors.”

The maternal immune response in autism is of interest to researchers because of its role in neurodevelopment. “Maternal IgG isotype antibodies readily cross the placenta and are known to persist for up to 6 months postnatally in the child,” Dr. Van de Water said. “In addition, maternal antibodies have been shown to cause changes in fetal development in several known autoimmune disorders, such as SLE.”

In 2002, Dr. Van de Water and her associates began to collect blood samples from families as part of the Childhood Autism Risk from Genetics and the Environment (CHARGE) study.

They sampled the study population from three groups of children aged 2–5 years: children with autism (currently includes more than 800 families); typically developing children without autism or other developmental disabilities selected from the general population (currently 600 families enrolled); and children with developmental disabilities without autism (currently 220 families enrolled).

In the original experimental design, Western blots against human fetal brain protein were performed with 61 mothers of children with autism (36 regressive and 25 early onset), 40 mothers of children with developmental delay, and 62 mothers of typically developing children (Neurotoxicology 2008;29:226–31).

The investigators found that seven mothers of children with autism (12%) had IgG reactivity to fetal brain proteins at bands 37kDa and 73kDa. “We did not see this pattern in the typically developing controls or in the developmentally delayed population, so this seemed to be very specific for autism,” Dr. Van de Water said.

Analysis of autoantibody profiles of an additional 458 mothers – 204 mothers of children diagnosed with autism, 71 mothers of children diagnosed with an autism spectrum disorder, and 183 mothers of typically developing children – continues to yield highly significant associations between the presence of IgG reactivity to fetal brain proteins at bands 37kDa and 73kDa and a diagnosis of full autism.

Dr. Van de Water and her associates also discovered an association between the 39kDa and 73kDa bands and a diagnosis of the broader autism phenotype, “though this pattern is less frequent in the full autism group,” she said.

“We think we may have a very interesting biomarker, but is there a pathologic significance to these antibodies?” she asked. To find out, the researchers analyzed behavioral characteristics associated with maternal antibodies to fetal brain proteins.

Children of mothers who demonstrated reactivity at bands 37kDa and 73kDa had less expressive language. Similar results were seen in children of mothers who demonstrated reactivity at all three bands. In contrast, children of mothers who demonstrated reactivity at bands 39kDa and 73kDa had higher scores on the Aberrant Behavior Checklist irritability subscale.

A pilot study in monkeys conducted by Dr. Van de Water and her associates demonstrated behavioral changes in offspring following passive transfer of maternal IgG during the late first and early second trimesters (Brain Behav. Immun. 2008;22:806–16). Subsequent studies have confirmed that passive transfer of these antibodies into an animal model can recapitulate some behaviors characteristic of autism. More confirmatory studies are underway.

Major Finding: IgG reactivity to fetal brain proteins at bands 37kDa and 73kDa was significantly associated with diagnosis of full autism; reactivity to proteins at bands 39kDa and 73kDa was significantly associated with diagnosis of the broader autism phenotype.

Data Source: Western blots against human fetal brain protein performed in 204 mothers of children diagnosed with autism, 71 mothers of children diagnosed with an autism spectrum disorder, and 183 mothers of typically developing children.

Disclosures: Dr. Van de Water has received personal compensation for activities with Pediatric Bioscience as a consultant, and holds stock and/or stock options in the company. She has also received royalty payments from the University of California, Davis.

HONOLULU – Certain maternal autoantibodies are associated with development of autism spectrum disorders, results from a large ongoing analysis demonstrate.

The finding lays the groundwork for an eventual diagnostic test for autism, said Judy Van de Water, Ph.D.

“Currently there is no biologic marker for autism,” said Dr. Van de Water, an immunologist at the University of California, Davis. “It's completely defined by behaviors.”

The maternal immune response in autism is of interest to researchers because of its role in neurodevelopment. “Maternal IgG isotype antibodies readily cross the placenta and are known to persist for up to 6 months postnatally in the child,” Dr. Van de Water said. “In addition, maternal antibodies have been shown to cause changes in fetal development in several known autoimmune disorders, such as SLE.”

In 2002, Dr. Van de Water and her associates began to collect blood samples from families as part of the Childhood Autism Risk from Genetics and the Environment (CHARGE) study.

They sampled the study population from three groups of children aged 2–5 years: children with autism (currently includes more than 800 families); typically developing children without autism or other developmental disabilities selected from the general population (currently 600 families enrolled); and children with developmental disabilities without autism (currently 220 families enrolled).

In the original experimental design, Western blots against human fetal brain protein were performed with 61 mothers of children with autism (36 regressive and 25 early onset), 40 mothers of children with developmental delay, and 62 mothers of typically developing children (Neurotoxicology 2008;29:226–31).

The investigators found that seven mothers of children with autism (12%) had IgG reactivity to fetal brain proteins at bands 37kDa and 73kDa. “We did not see this pattern in the typically developing controls or in the developmentally delayed population, so this seemed to be very specific for autism,” Dr. Van de Water said.

Analysis of autoantibody profiles of an additional 458 mothers – 204 mothers of children diagnosed with autism, 71 mothers of children diagnosed with an autism spectrum disorder, and 183 mothers of typically developing children – continues to yield highly significant associations between the presence of IgG reactivity to fetal brain proteins at bands 37kDa and 73kDa and a diagnosis of full autism.

Dr. Van de Water and her associates also discovered an association between the 39kDa and 73kDa bands and a diagnosis of the broader autism phenotype, “though this pattern is less frequent in the full autism group,” she said.

“We think we may have a very interesting biomarker, but is there a pathologic significance to these antibodies?” she asked. To find out, the researchers analyzed behavioral characteristics associated with maternal antibodies to fetal brain proteins.

Children of mothers who demonstrated reactivity at bands 37kDa and 73kDa had less expressive language. Similar results were seen in children of mothers who demonstrated reactivity at all three bands. In contrast, children of mothers who demonstrated reactivity at bands 39kDa and 73kDa had higher scores on the Aberrant Behavior Checklist irritability subscale.

A pilot study in monkeys conducted by Dr. Van de Water and her associates demonstrated behavioral changes in offspring following passive transfer of maternal IgG during the late first and early second trimesters (Brain Behav. Immun. 2008;22:806–16). Subsequent studies have confirmed that passive transfer of these antibodies into an animal model can recapitulate some behaviors characteristic of autism. More confirmatory studies are underway.

SAN DIEGO – Pain management alternatives to opioids continue to evolve, said Joseph F. Dasta, M.Sc. (Pharm.).

New options include intravenous ibuprofen, approved in June 2009; nasal ketorolac (May 2010); and intravenous acetaminophen, (November 2010).

Nonopioid alternatives are needed because data “suggest that opioids as well as untreated pain are associated with development of postoperative delirium,” said Mr. Dasta, a health care consultant who is also with the College of Pharmacy at the University of Texas, Austin.

Most of the available agents for pain management are short acting, “which can be good and bad,” Mr. Dasta said. In addition, many of the currently approved agents for pain management require intravenous administration and may cause adverse drug reactions.

Intravenous diclofenac is currently being investigated as another possible therapy, he said, as are the cyclo-oxygenase-2 selective inhibitors etoricoxib and parecoxib, and the NSAID lornoxicam.

New studies of bupivacaine, an anesthetic drug that lasts for 6–10 hours, are also underway. “Several formulations are being developed whereby bupivacaine would be instilled into the surgical site, to the operative area, and last for several days,” said Mr. Dasta, who is a paid consultant for Cadence, Hospira, and Pacira Pharmaceuticals.

SAN DIEGO – Pain management alternatives to opioids continue to evolve, said Joseph F. Dasta, M.Sc. (Pharm.).

New options include intravenous ibuprofen, approved in June 2009; nasal ketorolac (May 2010); and intravenous acetaminophen, (November 2010).

Nonopioid alternatives are needed because data “suggest that opioids as well as untreated pain are associated with development of postoperative delirium,” said Mr. Dasta, a health care consultant who is also with the College of Pharmacy at the University of Texas, Austin.

Most of the available agents for pain management are short acting, “which can be good and bad,” Mr. Dasta said. In addition, many of the currently approved agents for pain management require intravenous administration and may cause adverse drug reactions.

Intravenous diclofenac is currently being investigated as another possible therapy, he said, as are the cyclo-oxygenase-2 selective inhibitors etoricoxib and parecoxib, and the NSAID lornoxicam.

New studies of bupivacaine, an anesthetic drug that lasts for 6–10 hours, are also underway. “Several formulations are being developed whereby bupivacaine would be instilled into the surgical site, to the operative area, and last for several days,” said Mr. Dasta, who is a paid consultant for Cadence, Hospira, and Pacira Pharmaceuticals.

SAN DIEGO – Pain management alternatives to opioids continue to evolve, said Joseph F. Dasta, M.Sc. (Pharm.).

New options include intravenous ibuprofen, approved in June 2009; nasal ketorolac (May 2010); and intravenous acetaminophen, (November 2010).

Nonopioid alternatives are needed because data “suggest that opioids as well as untreated pain are associated with development of postoperative delirium,” said Mr. Dasta, a health care consultant who is also with the College of Pharmacy at the University of Texas, Austin.

Most of the available agents for pain management are short acting, “which can be good and bad,” Mr. Dasta said. In addition, many of the currently approved agents for pain management require intravenous administration and may cause adverse drug reactions.

Intravenous diclofenac is currently being investigated as another possible therapy, he said, as are the cyclo-oxygenase-2 selective inhibitors etoricoxib and parecoxib, and the NSAID lornoxicam.

New studies of bupivacaine, an anesthetic drug that lasts for 6–10 hours, are also underway. “Several formulations are being developed whereby bupivacaine would be instilled into the surgical site, to the operative area, and last for several days,” said Mr. Dasta, who is a paid consultant for Cadence, Hospira, and Pacira Pharmaceuticals.

Major Finding: During their hospital stay for influenza, children previously exposed to secondhand smoke were significantly more likely to require ICU admission (31% vs. 10% for children with no exposure) and mechanical ventilation (13% vs. 2%, respectively).

Data Source: A chart review of 113 patients aged 0–15 years discharged from Golisano Children's Hospital in Rochester, N.Y., with a diagnosis of influenza between 2002 and 2009.

Disclosures: Dr. Wilson disclosed that she is on the speakers bureau for the American Academy of Pediatrics Julius B. Richmond Center of Excellence, with funding from the Flight Attendant Medical Research Institute, National Research Service Award T32, Strong Children's Research Center Summer Research Program, and the Child Health Corporation of America through a grant to the Pediatric Research in Inpatient Settings Network.

DENVER – Children exposed to secondhand tobacco smoke who are admitted to the hospital for influenza are more likely to require admission to the intensive care unit and have a longer hospital stay than their peers who are not exposed to secondhand smoke.

These effects are even greater for children with chronic illnesses who are exposed to secondhand smoke, Dr. Karen M. Wilson reported.

An estimated 18% of children aged 3–11 years are regularly exposed to secondhand tobacco smoke inside the home, said Dr. Wilson, assistant professor of pediatrics at the University of Rochester (N.Y.).

Although secondhand smoke exposure is associated with worse outcomes for children's illnesses, including respiratory syncytial virus and asthma, “the effect of secondhand smoke exposure on influenza severity in children is unclear,” she noted. “More than 40% of preschool children experience influenza at some point. In adults, tobacco smoke increases the risk of influenza infection and the risk of complications.”

To determine if children hospitalized with influenza who are exposed to secondhand smoke have more severe illness, Dr. Wilson and her associates conducted a review of 169 medical charts at Golisano Children's Hospital in Rochester. They generated a list of patients aged 0–15 years with a discharge diagnosis of influenza between 2002 and 2009. The influenza diagnosis was verified by laboratory review.

Measures of severity included intensive care unit admission, defined as admission or transfer to the ICU at any time during the stay; need for mechanical ventilation, defined as any documentation of endotracheal intubation during the stay; and length of stay.

Exposure to secondhand smoke was assessed by any documentation of presence or absence of secondhand smoke exposure by any provider. “Any documentation of exposure was considered exposed; documentation of no exposure was considered not exposed,” Dr. Wilson said.

She reported findings from 113 children who were included in the final analysis. Of these, 46 (41%) were exposed to secondhand smoke and 67 (59%) were not. The average age of the 113 children was 4 years, and 50% were male. Of the 113 children, 58% were white, 22% were black, 8% were Hispanic, and 3.5% were Asian; race/ethnicity was unknown in the remaining 8.5%. Fewer than half of the children (44%) had public health insurance. More than three-quarters of the children (78%) had influenza A. In addition, 25% had asthma, 25% had an underlying chronic condition, 14% had documentation of prematurity, 19% required ICU care, and 6% required mechanical ventilation.

None of the potential covariates – including asthma, prematurity, and chronic conditions – were significantly associated with secondhand smoke exposure. However, children exposed to secondhand smoke were significantly more likely to require ICU admission (31% vs. 10% for children with no exposure) and mechanical ventilation (13% vs. 2%, respectively).

The mean length of stay was 2.1 days for children who had no chronic condition or exposure to secondhand smoke, 2.5 days for children who had no chronic condition but had exposure to secondhand smoke, 3.5 days for children who had a chronic condition but no exposure to secondhand smoke, and 11 days for children who had a chronic condition and were exposed to secondhand smoke.

In a logistic regression model controlling for age, gender, race, and type of insurance, exposure to secondhand smoke was significantly associated with ICU admission but chronic conditions were not.

In a logistic regression model limited to exposure to secondhand smoke and chronic conditions, chronic conditions were associated with the need for mechanical ventilation but exposure to secondhand smoke was not.

Dr. Wilson acknowledged certain limitations of the study, including its single-center design “and the potential for errors in documentation and abstraction,” she said. “The exposure measure was reliant on provider documentation … but provider documentation is more likely to underestimate secondhand smoke exposure in children, so we probably misclassified some children as being non–smoke exposed.”

In addition, “there may be other covariates that we were not able to measure because we don't have documentation in the chart,” she said.

Despite such limitations, Dr. Wilson said that the findings support the notion of considering secondhand smoke exposure in risk stratification for children admitted with influenza. “Greater efforts are needed to help parents eliminate their children's exposure to secondhand smoke,” she said. “Parents of children with chronic illness should be aware of the risk of secondhand smoke exposure, and children exposed to secondhand smoke should be a priority group for influenza immunization.”

'Children exposed to secondhand smoke should be a priority group for influenza immunization.'

Source DR. WILSON

Major Finding: During their hospital stay for influenza, children previously exposed to secondhand smoke were significantly more likely to require ICU admission (31% vs. 10% for children with no exposure) and mechanical ventilation (13% vs. 2%, respectively).

Data Source: A chart review of 113 patients aged 0–15 years discharged from Golisano Children's Hospital in Rochester, N.Y., with a diagnosis of influenza between 2002 and 2009.

Disclosures: Dr. Wilson disclosed that she is on the speakers bureau for the American Academy of Pediatrics Julius B. Richmond Center of Excellence, with funding from the Flight Attendant Medical Research Institute, National Research Service Award T32, Strong Children's Research Center Summer Research Program, and the Child Health Corporation of America through a grant to the Pediatric Research in Inpatient Settings Network.

DENVER – Children exposed to secondhand tobacco smoke who are admitted to the hospital for influenza are more likely to require admission to the intensive care unit and have a longer hospital stay than their peers who are not exposed to secondhand smoke.

These effects are even greater for children with chronic illnesses who are exposed to secondhand smoke, Dr. Karen M. Wilson reported.

An estimated 18% of children aged 3–11 years are regularly exposed to secondhand tobacco smoke inside the home, said Dr. Wilson, assistant professor of pediatrics at the University of Rochester (N.Y.).

Although secondhand smoke exposure is associated with worse outcomes for children's illnesses, including respiratory syncytial virus and asthma, “the effect of secondhand smoke exposure on influenza severity in children is unclear,” she noted. “More than 40% of preschool children experience influenza at some point. In adults, tobacco smoke increases the risk of influenza infection and the risk of complications.”

To determine if children hospitalized with influenza who are exposed to secondhand smoke have more severe illness, Dr. Wilson and her associates conducted a review of 169 medical charts at Golisano Children's Hospital in Rochester. They generated a list of patients aged 0–15 years with a discharge diagnosis of influenza between 2002 and 2009. The influenza diagnosis was verified by laboratory review.

Measures of severity included intensive care unit admission, defined as admission or transfer to the ICU at any time during the stay; need for mechanical ventilation, defined as any documentation of endotracheal intubation during the stay; and length of stay.

Exposure to secondhand smoke was assessed by any documentation of presence or absence of secondhand smoke exposure by any provider. “Any documentation of exposure was considered exposed; documentation of no exposure was considered not exposed,” Dr. Wilson said.

She reported findings from 113 children who were included in the final analysis. Of these, 46 (41%) were exposed to secondhand smoke and 67 (59%) were not. The average age of the 113 children was 4 years, and 50% were male. Of the 113 children, 58% were white, 22% were black, 8% were Hispanic, and 3.5% were Asian; race/ethnicity was unknown in the remaining 8.5%. Fewer than half of the children (44%) had public health insurance. More than three-quarters of the children (78%) had influenza A. In addition, 25% had asthma, 25% had an underlying chronic condition, 14% had documentation of prematurity, 19% required ICU care, and 6% required mechanical ventilation.

None of the potential covariates – including asthma, prematurity, and chronic conditions – were significantly associated with secondhand smoke exposure. However, children exposed to secondhand smoke were significantly more likely to require ICU admission (31% vs. 10% for children with no exposure) and mechanical ventilation (13% vs. 2%, respectively).

The mean length of stay was 2.1 days for children who had no chronic condition or exposure to secondhand smoke, 2.5 days for children who had no chronic condition but had exposure to secondhand smoke, 3.5 days for children who had a chronic condition but no exposure to secondhand smoke, and 11 days for children who had a chronic condition and were exposed to secondhand smoke.

In a logistic regression model controlling for age, gender, race, and type of insurance, exposure to secondhand smoke was significantly associated with ICU admission but chronic conditions were not.

In a logistic regression model limited to exposure to secondhand smoke and chronic conditions, chronic conditions were associated with the need for mechanical ventilation but exposure to secondhand smoke was not.

Dr. Wilson acknowledged certain limitations of the study, including its single-center design “and the potential for errors in documentation and abstraction,” she said. “The exposure measure was reliant on provider documentation … but provider documentation is more likely to underestimate secondhand smoke exposure in children, so we probably misclassified some children as being non–smoke exposed.”

In addition, “there may be other covariates that we were not able to measure because we don't have documentation in the chart,” she said.

Despite such limitations, Dr. Wilson said that the findings support the notion of considering secondhand smoke exposure in risk stratification for children admitted with influenza. “Greater efforts are needed to help parents eliminate their children's exposure to secondhand smoke,” she said. “Parents of children with chronic illness should be aware of the risk of secondhand smoke exposure, and children exposed to secondhand smoke should be a priority group for influenza immunization.”

'Children exposed to secondhand smoke should be a priority group for influenza immunization.'

Source DR. WILSON

Major Finding: During their hospital stay for influenza, children previously exposed to secondhand smoke were significantly more likely to require ICU admission (31% vs. 10% for children with no exposure) and mechanical ventilation (13% vs. 2%, respectively).

Data Source: A chart review of 113 patients aged 0–15 years discharged from Golisano Children's Hospital in Rochester, N.Y., with a diagnosis of influenza between 2002 and 2009.

Disclosures: Dr. Wilson disclosed that she is on the speakers bureau for the American Academy of Pediatrics Julius B. Richmond Center of Excellence, with funding from the Flight Attendant Medical Research Institute, National Research Service Award T32, Strong Children's Research Center Summer Research Program, and the Child Health Corporation of America through a grant to the Pediatric Research in Inpatient Settings Network.

DENVER – Children exposed to secondhand tobacco smoke who are admitted to the hospital for influenza are more likely to require admission to the intensive care unit and have a longer hospital stay than their peers who are not exposed to secondhand smoke.

These effects are even greater for children with chronic illnesses who are exposed to secondhand smoke, Dr. Karen M. Wilson reported.

An estimated 18% of children aged 3–11 years are regularly exposed to secondhand tobacco smoke inside the home, said Dr. Wilson, assistant professor of pediatrics at the University of Rochester (N.Y.).

Although secondhand smoke exposure is associated with worse outcomes for children's illnesses, including respiratory syncytial virus and asthma, “the effect of secondhand smoke exposure on influenza severity in children is unclear,” she noted. “More than 40% of preschool children experience influenza at some point. In adults, tobacco smoke increases the risk of influenza infection and the risk of complications.”

To determine if children hospitalized with influenza who are exposed to secondhand smoke have more severe illness, Dr. Wilson and her associates conducted a review of 169 medical charts at Golisano Children's Hospital in Rochester. They generated a list of patients aged 0–15 years with a discharge diagnosis of influenza between 2002 and 2009. The influenza diagnosis was verified by laboratory review.

Measures of severity included intensive care unit admission, defined as admission or transfer to the ICU at any time during the stay; need for mechanical ventilation, defined as any documentation of endotracheal intubation during the stay; and length of stay.

Exposure to secondhand smoke was assessed by any documentation of presence or absence of secondhand smoke exposure by any provider. “Any documentation of exposure was considered exposed; documentation of no exposure was considered not exposed,” Dr. Wilson said.

She reported findings from 113 children who were included in the final analysis. Of these, 46 (41%) were exposed to secondhand smoke and 67 (59%) were not. The average age of the 113 children was 4 years, and 50% were male. Of the 113 children, 58% were white, 22% were black, 8% were Hispanic, and 3.5% were Asian; race/ethnicity was unknown in the remaining 8.5%. Fewer than half of the children (44%) had public health insurance. More than three-quarters of the children (78%) had influenza A. In addition, 25% had asthma, 25% had an underlying chronic condition, 14% had documentation of prematurity, 19% required ICU care, and 6% required mechanical ventilation.

None of the potential covariates – including asthma, prematurity, and chronic conditions – were significantly associated with secondhand smoke exposure. However, children exposed to secondhand smoke were significantly more likely to require ICU admission (31% vs. 10% for children with no exposure) and mechanical ventilation (13% vs. 2%, respectively).

The mean length of stay was 2.1 days for children who had no chronic condition or exposure to secondhand smoke, 2.5 days for children who had no chronic condition but had exposure to secondhand smoke, 3.5 days for children who had a chronic condition but no exposure to secondhand smoke, and 11 days for children who had a chronic condition and were exposed to secondhand smoke.

In a logistic regression model controlling for age, gender, race, and type of insurance, exposure to secondhand smoke was significantly associated with ICU admission but chronic conditions were not.

In a logistic regression model limited to exposure to secondhand smoke and chronic conditions, chronic conditions were associated with the need for mechanical ventilation but exposure to secondhand smoke was not.

Dr. Wilson acknowledged certain limitations of the study, including its single-center design “and the potential for errors in documentation and abstraction,” she said. “The exposure measure was reliant on provider documentation … but provider documentation is more likely to underestimate secondhand smoke exposure in children, so we probably misclassified some children as being non–smoke exposed.”

In addition, “there may be other covariates that we were not able to measure because we don't have documentation in the chart,” she said.

Despite such limitations, Dr. Wilson said that the findings support the notion of considering secondhand smoke exposure in risk stratification for children admitted with influenza. “Greater efforts are needed to help parents eliminate their children's exposure to secondhand smoke,” she said. “Parents of children with chronic illness should be aware of the risk of secondhand smoke exposure, and children exposed to secondhand smoke should be a priority group for influenza immunization.”

'Children exposed to secondhand smoke should be a priority group for influenza immunization.'

Source DR. WILSON

Major Finding: The probability of HPV vaccination occurring is 2.6 times higher for adolescents who receive a provider recommendation than it is for adolescents who do not receive a provider recommendation.

Data Source: Results from 18,228 females aged 13–17 years who participated in the National Immunization Survey–Teen 2008–2009.

Disclosures: Dr. Dorell said that she had no relevant financial disclosures.

DENVER – Provider recommendation is strongly associated with initiation of the human papillomavirus vaccine in teenage females, results from a national survey demonstrated.

“It's important for providers to take the time to counsel and recommend the HPV vaccine and communicate the benefits and the risks of the vaccination, as well as the risk of getting HPV disease as teenagers,” Dr. Christina G. Dorell said in an interview during a poster session at the meeting.

Dr. Dorell of the immunization services division at the Centers for Disease Control and Prevention, Atlanta, presented findings from the 2008–2009 National Immunization Survey–Teen (NIS-Teen), which was analyzed to determine human papillomavirus (HPV) vaccination coverage among females aged 13–17 years. The NIS-Teen is composed of two parts: a random-digit-dialed telephone survey of parents or guardians of adolescents aged 13–17 years, and a mailed survey to all vaccination providers identified by the parent and for which consent was granted.

The researchers evaluated associations of select socioeconomic characteristics, intention to vaccinate, and HPV status. They used multivariable logistic regression to examine associations while controlling for other factors, including state of residence.

Of the 18,288 females surveyed, 41% received at least one HPV dose. Of those, 53% completed the three-dose series.

The probability of HPV vaccination occurring is 2.6 times higher for adolescents who receive a provider recommendation than for adolescents who do not receive a provider recommendation. Other factors independently associated with HPV vaccine initiation were older age, having a preventive visit at age 11 or 12 years, being eligible for state Children's Health Insurance Program (CHIP) or Vaccines for Children (VFC) program, having a mother younger than age 34 years, having a mother who never married, and not receiving all vaccines at public facilities.

More than half of white females (60%) completed the vaccination series, compared with 46% of blacks and 40% of Hispanics. Other factors independently associated with completing the vaccination series were having a mother aged 45 or older, being knowledgeable about HPV disease, and not receiving all vaccines at public facilities.

The main reported reasons parents do not intend for their daughters to receive the HPV vaccination in the next 12 months were lack of knowledge (19%), considering it not needed or not necessary (19%), the fact that their daughters were not sexually active (18%), and that they did not receive a provider recommendation (13%).

Dr. Dorell acknowledged certain limitations of the study, including the fact that the telephone portion of the survey was using land line phones only, thus contributing to a noncoverage bias of wireless-only households. It's also possible that some of the provider data or vaccination histories may be incomplete, she said. However, she pointed out that one of the main strengths of the NIS-Teen “is that it is the only nationally representative survey that reports vaccination coverage estimates from provider-reported data, which is the gold standard for measuring vaccination coverage.”

Major Finding: The probability of HPV vaccination occurring is 2.6 times higher for adolescents who receive a provider recommendation than it is for adolescents who do not receive a provider recommendation.

Data Source: Results from 18,228 females aged 13–17 years who participated in the National Immunization Survey–Teen 2008–2009.

Disclosures: Dr. Dorell said that she had no relevant financial disclosures.

DENVER – Provider recommendation is strongly associated with initiation of the human papillomavirus vaccine in teenage females, results from a national survey demonstrated.

“It's important for providers to take the time to counsel and recommend the HPV vaccine and communicate the benefits and the risks of the vaccination, as well as the risk of getting HPV disease as teenagers,” Dr. Christina G. Dorell said in an interview during a poster session at the meeting.

Dr. Dorell of the immunization services division at the Centers for Disease Control and Prevention, Atlanta, presented findings from the 2008–2009 National Immunization Survey–Teen (NIS-Teen), which was analyzed to determine human papillomavirus (HPV) vaccination coverage among females aged 13–17 years. The NIS-Teen is composed of two parts: a random-digit-dialed telephone survey of parents or guardians of adolescents aged 13–17 years, and a mailed survey to all vaccination providers identified by the parent and for which consent was granted.

The researchers evaluated associations of select socioeconomic characteristics, intention to vaccinate, and HPV status. They used multivariable logistic regression to examine associations while controlling for other factors, including state of residence.

Of the 18,288 females surveyed, 41% received at least one HPV dose. Of those, 53% completed the three-dose series.

The probability of HPV vaccination occurring is 2.6 times higher for adolescents who receive a provider recommendation than for adolescents who do not receive a provider recommendation. Other factors independently associated with HPV vaccine initiation were older age, having a preventive visit at age 11 or 12 years, being eligible for state Children's Health Insurance Program (CHIP) or Vaccines for Children (VFC) program, having a mother younger than age 34 years, having a mother who never married, and not receiving all vaccines at public facilities.

More than half of white females (60%) completed the vaccination series, compared with 46% of blacks and 40% of Hispanics. Other factors independently associated with completing the vaccination series were having a mother aged 45 or older, being knowledgeable about HPV disease, and not receiving all vaccines at public facilities.

The main reported reasons parents do not intend for their daughters to receive the HPV vaccination in the next 12 months were lack of knowledge (19%), considering it not needed or not necessary (19%), the fact that their daughters were not sexually active (18%), and that they did not receive a provider recommendation (13%).

Dr. Dorell acknowledged certain limitations of the study, including the fact that the telephone portion of the survey was using land line phones only, thus contributing to a noncoverage bias of wireless-only households. It's also possible that some of the provider data or vaccination histories may be incomplete, she said. However, she pointed out that one of the main strengths of the NIS-Teen “is that it is the only nationally representative survey that reports vaccination coverage estimates from provider-reported data, which is the gold standard for measuring vaccination coverage.”

Major Finding: The probability of HPV vaccination occurring is 2.6 times higher for adolescents who receive a provider recommendation than it is for adolescents who do not receive a provider recommendation.

Data Source: Results from 18,228 females aged 13–17 years who participated in the National Immunization Survey–Teen 2008–2009.

Disclosures: Dr. Dorell said that she had no relevant financial disclosures.

DENVER – Provider recommendation is strongly associated with initiation of the human papillomavirus vaccine in teenage females, results from a national survey demonstrated.

“It's important for providers to take the time to counsel and recommend the HPV vaccine and communicate the benefits and the risks of the vaccination, as well as the risk of getting HPV disease as teenagers,” Dr. Christina G. Dorell said in an interview during a poster session at the meeting.

Dr. Dorell of the immunization services division at the Centers for Disease Control and Prevention, Atlanta, presented findings from the 2008–2009 National Immunization Survey–Teen (NIS-Teen), which was analyzed to determine human papillomavirus (HPV) vaccination coverage among females aged 13–17 years. The NIS-Teen is composed of two parts: a random-digit-dialed telephone survey of parents or guardians of adolescents aged 13–17 years, and a mailed survey to all vaccination providers identified by the parent and for which consent was granted.

The researchers evaluated associations of select socioeconomic characteristics, intention to vaccinate, and HPV status. They used multivariable logistic regression to examine associations while controlling for other factors, including state of residence.

Of the 18,288 females surveyed, 41% received at least one HPV dose. Of those, 53% completed the three-dose series.

The probability of HPV vaccination occurring is 2.6 times higher for adolescents who receive a provider recommendation than for adolescents who do not receive a provider recommendation. Other factors independently associated with HPV vaccine initiation were older age, having a preventive visit at age 11 or 12 years, being eligible for state Children's Health Insurance Program (CHIP) or Vaccines for Children (VFC) program, having a mother younger than age 34 years, having a mother who never married, and not receiving all vaccines at public facilities.

More than half of white females (60%) completed the vaccination series, compared with 46% of blacks and 40% of Hispanics. Other factors independently associated with completing the vaccination series were having a mother aged 45 or older, being knowledgeable about HPV disease, and not receiving all vaccines at public facilities.

The main reported reasons parents do not intend for their daughters to receive the HPV vaccination in the next 12 months were lack of knowledge (19%), considering it not needed or not necessary (19%), the fact that their daughters were not sexually active (18%), and that they did not receive a provider recommendation (13%).

Dr. Dorell acknowledged certain limitations of the study, including the fact that the telephone portion of the survey was using land line phones only, thus contributing to a noncoverage bias of wireless-only households. It's also possible that some of the provider data or vaccination histories may be incomplete, she said. However, she pointed out that one of the main strengths of the NIS-Teen “is that it is the only nationally representative survey that reports vaccination coverage estimates from provider-reported data, which is the gold standard for measuring vaccination coverage.”

DENVER – Provider recommendation is strongly associated with initiation of the human papillomavirus vaccine in teenage females, results from a national survey demonstrated.

"It’s important for providers to take the time to counsel and recommend the HPV vaccine and communicate the benefits and the risks of the vaccination, as well as the risk of getting HPV disease as teenagers," Dr. Christina G. Dorell said in an interview during a poster session at the annual meeting of the Pediatric Academic Societies.

Dr. Dorell of the immunization services division at the Centers for Disease Control and Prevention, Atlanta, presented findings from the 2008-2009 National Immunization Survey Teen (NIS-Teen), which was analyzed to determine human papillomavirus (HPV) vaccination coverage among females aged 13-17 years. The NIS-Teen is composed of two parts: a random-digit–dialed telephone survey of parents or guardians of adolescents aged 13-17 years, and a mailed survey to all vaccination providers identified by the parent and for which consent was granted.

The researchers evaluated associations of select socioeconomic characteristics, intention to vaccinate, and HPV status. They used multivariable logistic regression to examine associations while controlling for other factors, including state of residence.

Of the 18,288 females surveyed, 41% received at least one HPV dose. Of those, 53% completed the three-dose series.

The probability of HPV vaccination occurring is 2.6 times higher for adolescents who receive a provider recommendation than for adolescents who do not receive a provider recommendation. Other factors independently associated with HPV vaccine initiation were older age, having a preventive visit at age 11 or 12 years, being eligible for state Children’s Health Insurance Program (CHIP) or Vaccines for Children (VFC) program, having a mother younger than age 34 years, having a mother who never married, and not receiving all vaccines at public facilities.

More than half of white females (60%) completed the vaccination series, compared with 46% of blacks and 40% of Hispanics. Other factors independently associated with completing the vaccination series were having a mother aged 45 or older, being knowledgeable about HPV disease, and not receiving all vaccines at public facilities.

The main reported reasons parents do not intend for their daughters to receive the HPV vaccination in the next 12 months were lack of knowledge (19%), considering it not needed or not necessary (19%), the fact that their daughters were not sexually active (18%), and that they did not receive a provider recommendation (13%).

Dr. Dorell acknowledged certain limitations of the study, including the fact that the telephone portion of the survey was using land line phones only, thus contributing to a noncoverage bias of wireless-only households. It’s also possible that some of the provider data or vaccination histories may be incomplete, she said. However, she pointed out that one of the main strengths of the NIS-Teen "is that it is the only nationally representative survey that reports vaccination coverage estimates from provider-reported data, which is the gold standard for measuring vaccination coverage."

Dr. Dorell said that she had no relevant financial disclosures.

DENVER – Provider recommendation is strongly associated with initiation of the human papillomavirus vaccine in teenage females, results from a national survey demonstrated.

"It’s important for providers to take the time to counsel and recommend the HPV vaccine and communicate the benefits and the risks of the vaccination, as well as the risk of getting HPV disease as teenagers," Dr. Christina G. Dorell said in an interview during a poster session at the annual meeting of the Pediatric Academic Societies.

Dr. Dorell of the immunization services division at the Centers for Disease Control and Prevention, Atlanta, presented findings from the 2008-2009 National Immunization Survey Teen (NIS-Teen), which was analyzed to determine human papillomavirus (HPV) vaccination coverage among females aged 13-17 years. The NIS-Teen is composed of two parts: a random-digit–dialed telephone survey of parents or guardians of adolescents aged 13-17 years, and a mailed survey to all vaccination providers identified by the parent and for which consent was granted.

The researchers evaluated associations of select socioeconomic characteristics, intention to vaccinate, and HPV status. They used multivariable logistic regression to examine associations while controlling for other factors, including state of residence.

Of the 18,288 females surveyed, 41% received at least one HPV dose. Of those, 53% completed the three-dose series.

The probability of HPV vaccination occurring is 2.6 times higher for adolescents who receive a provider recommendation than for adolescents who do not receive a provider recommendation. Other factors independently associated with HPV vaccine initiation were older age, having a preventive visit at age 11 or 12 years, being eligible for state Children’s Health Insurance Program (CHIP) or Vaccines for Children (VFC) program, having a mother younger than age 34 years, having a mother who never married, and not receiving all vaccines at public facilities.

More than half of white females (60%) completed the vaccination series, compared with 46% of blacks and 40% of Hispanics. Other factors independently associated with completing the vaccination series were having a mother aged 45 or older, being knowledgeable about HPV disease, and not receiving all vaccines at public facilities.

The main reported reasons parents do not intend for their daughters to receive the HPV vaccination in the next 12 months were lack of knowledge (19%), considering it not needed or not necessary (19%), the fact that their daughters were not sexually active (18%), and that they did not receive a provider recommendation (13%).

Dr. Dorell acknowledged certain limitations of the study, including the fact that the telephone portion of the survey was using land line phones only, thus contributing to a noncoverage bias of wireless-only households. It’s also possible that some of the provider data or vaccination histories may be incomplete, she said. However, she pointed out that one of the main strengths of the NIS-Teen "is that it is the only nationally representative survey that reports vaccination coverage estimates from provider-reported data, which is the gold standard for measuring vaccination coverage."

Dr. Dorell said that she had no relevant financial disclosures.

DENVER – Provider recommendation is strongly associated with initiation of the human papillomavirus vaccine in teenage females, results from a national survey demonstrated.

"It’s important for providers to take the time to counsel and recommend the HPV vaccine and communicate the benefits and the risks of the vaccination, as well as the risk of getting HPV disease as teenagers," Dr. Christina G. Dorell said in an interview during a poster session at the annual meeting of the Pediatric Academic Societies.

Dr. Dorell of the immunization services division at the Centers for Disease Control and Prevention, Atlanta, presented findings from the 2008-2009 National Immunization Survey Teen (NIS-Teen), which was analyzed to determine human papillomavirus (HPV) vaccination coverage among females aged 13-17 years. The NIS-Teen is composed of two parts: a random-digit–dialed telephone survey of parents or guardians of adolescents aged 13-17 years, and a mailed survey to all vaccination providers identified by the parent and for which consent was granted.

The researchers evaluated associations of select socioeconomic characteristics, intention to vaccinate, and HPV status. They used multivariable logistic regression to examine associations while controlling for other factors, including state of residence.

Of the 18,288 females surveyed, 41% received at least one HPV dose. Of those, 53% completed the three-dose series.

The probability of HPV vaccination occurring is 2.6 times higher for adolescents who receive a provider recommendation than for adolescents who do not receive a provider recommendation. Other factors independently associated with HPV vaccine initiation were older age, having a preventive visit at age 11 or 12 years, being eligible for state Children’s Health Insurance Program (CHIP) or Vaccines for Children (VFC) program, having a mother younger than age 34 years, having a mother who never married, and not receiving all vaccines at public facilities.

More than half of white females (60%) completed the vaccination series, compared with 46% of blacks and 40% of Hispanics. Other factors independently associated with completing the vaccination series were having a mother aged 45 or older, being knowledgeable about HPV disease, and not receiving all vaccines at public facilities.

The main reported reasons parents do not intend for their daughters to receive the HPV vaccination in the next 12 months were lack of knowledge (19%), considering it not needed or not necessary (19%), the fact that their daughters were not sexually active (18%), and that they did not receive a provider recommendation (13%).

Dr. Dorell acknowledged certain limitations of the study, including the fact that the telephone portion of the survey was using land line phones only, thus contributing to a noncoverage bias of wireless-only households. It’s also possible that some of the provider data or vaccination histories may be incomplete, she said. However, she pointed out that one of the main strengths of the NIS-Teen "is that it is the only nationally representative survey that reports vaccination coverage estimates from provider-reported data, which is the gold standard for measuring vaccination coverage."

Dr. Dorell said that she had no relevant financial disclosures.

DENVER – The ratio of controller to total asthma medication fills predicts the risk of exacerbations in pediatric patients with persistent asthma, results from a large study demonstrated.

"The occurrence of asthma exacerbations requiring medical attention is a key health outcome, and may be an indicator of the quality of asthma care," Dr. Louis Vernacchio reported at the annual meeting of the Pediatric Academic Societies. "Exacerbations that are cared for in the office setting may be more common than hospital admissions or ED visits, but there is currently no standard methodology for defining exacerbations cared for in the office setting. It would be nice to develop process measures that relate to asthma outcomes, particularly to exacerbations," he said.

Dr. Vernacchio, of the Pediatric Physicians’ Organization at Children’s (PPOC) and the general pediatrics division at Children’s Hospital Boston, and his associate, Jennifer M. Muto, set out to assess the accuracy of claims-based definitions of asthma exacerbations cared for in the office setting and to evaluate potential risk factors for asthma exacerbations that could serve as process measures for quality improvement. They analyzed medical claims from a large not-for-profit insurer for patients of the PPOC, a large independent practice association affiliated with Children’s Hospital Boston. The study population included 19,469 patients aged 5-17 years who were continuously enrolled in 2008 and 19,779 patients aged 5-17 years who were continuously enrolled in 2009. Of these, 530 (2.7%) met Healthcare Effectiveness Data and Information Set (HEDIS) criteria for persistent asthma in 2008 and 507 (2.6%) did so in 2009.

Proposed definitions of asthma exacerbations cared for in an office setting included office visits for asthma with oral steroid prescription filled the day of or the day after a visit (definition 1); office visits for asthma with oral steroid prescription filled the day of or the day after a visit or with nebulizer treatment given in the office (definition 2); office visits for asthma with oral steroid prescription filled the day of or the day after a visit or with oral steroid prescription filled the day of or the day after a visit or with nebulizer treatment given in the office, or coded as "with status asthmaticus" or "with acute exacerbation" (definition 3).

The researchers compared each of those three definitions to a chart review, which was considered the gold standard. Two clinicians independently reviewed 144 asthma visits and evaluated three elements in each chart: history of present illness, physical examination, and assessment. "If they found evidence of exacerbation in two of those three areas, we counted the visit as an exacerbation visit," Dr. Vernacchio said.

Receiver operating characteristic curve analysis revealed that definition 1 had a sensitivity of 24.7% and a specificity of 90.5%, definition 2 had a sensitivity of 56.8% and a specificity of 76.2%, and definition 3 had a sensitivity of 95.1% and a specificity of 68.3%. "The overall area under the curve is best with the third definition, but there’s a tradeoff in sensitivity and specificity," he said.

Logistic regression analysis of associations with exacerbations revealed that the ratio of controller to total asthma prescription fills was the process measure that correlated most closely to the risk of asthma exacerbations, with risk ratios near 2.0 for those in the third and fourth quartiles of controller to total asthma prescription fills ratio (corresponding to ratios of 0.5-0.8 and less than 0.5, respectively).

"This ratio can serve as the basis for quality improvement projects in pediatric asthma," Dr. Vernacchio said. He noted that the proposed 2012 HEDIS measure uses a cutoff value of 0.5, "which is well below what appears optimal in our data."

Dr. Vernacchio said that he had no relevant financial conflicts to disclose.

DENVER – The ratio of controller to total asthma medication fills predicts the risk of exacerbations in pediatric patients with persistent asthma, results from a large study demonstrated.

"The occurrence of asthma exacerbations requiring medical attention is a key health outcome, and may be an indicator of the quality of asthma care," Dr. Louis Vernacchio reported at the annual meeting of the Pediatric Academic Societies. "Exacerbations that are cared for in the office setting may be more common than hospital admissions or ED visits, but there is currently no standard methodology for defining exacerbations cared for in the office setting. It would be nice to develop process measures that relate to asthma outcomes, particularly to exacerbations," he said.

Dr. Vernacchio, of the Pediatric Physicians’ Organization at Children’s (PPOC) and the general pediatrics division at Children’s Hospital Boston, and his associate, Jennifer M. Muto, set out to assess the accuracy of claims-based definitions of asthma exacerbations cared for in the office setting and to evaluate potential risk factors for asthma exacerbations that could serve as process measures for quality improvement. They analyzed medical claims from a large not-for-profit insurer for patients of the PPOC, a large independent practice association affiliated with Children’s Hospital Boston. The study population included 19,469 patients aged 5-17 years who were continuously enrolled in 2008 and 19,779 patients aged 5-17 years who were continuously enrolled in 2009. Of these, 530 (2.7%) met Healthcare Effectiveness Data and Information Set (HEDIS) criteria for persistent asthma in 2008 and 507 (2.6%) did so in 2009.

Proposed definitions of asthma exacerbations cared for in an office setting included office visits for asthma with oral steroid prescription filled the day of or the day after a visit (definition 1); office visits for asthma with oral steroid prescription filled the day of or the day after a visit or with nebulizer treatment given in the office (definition 2); office visits for asthma with oral steroid prescription filled the day of or the day after a visit or with oral steroid prescription filled the day of or the day after a visit or with nebulizer treatment given in the office, or coded as "with status asthmaticus" or "with acute exacerbation" (definition 3).

The researchers compared each of those three definitions to a chart review, which was considered the gold standard. Two clinicians independently reviewed 144 asthma visits and evaluated three elements in each chart: history of present illness, physical examination, and assessment. "If they found evidence of exacerbation in two of those three areas, we counted the visit as an exacerbation visit," Dr. Vernacchio said.

Receiver operating characteristic curve analysis revealed that definition 1 had a sensitivity of 24.7% and a specificity of 90.5%, definition 2 had a sensitivity of 56.8% and a specificity of 76.2%, and definition 3 had a sensitivity of 95.1% and a specificity of 68.3%. "The overall area under the curve is best with the third definition, but there’s a tradeoff in sensitivity and specificity," he said.

Logistic regression analysis of associations with exacerbations revealed that the ratio of controller to total asthma prescription fills was the process measure that correlated most closely to the risk of asthma exacerbations, with risk ratios near 2.0 for those in the third and fourth quartiles of controller to total asthma prescription fills ratio (corresponding to ratios of 0.5-0.8 and less than 0.5, respectively).

"This ratio can serve as the basis for quality improvement projects in pediatric asthma," Dr. Vernacchio said. He noted that the proposed 2012 HEDIS measure uses a cutoff value of 0.5, "which is well below what appears optimal in our data."

Dr. Vernacchio said that he had no relevant financial conflicts to disclose.

DENVER – The ratio of controller to total asthma medication fills predicts the risk of exacerbations in pediatric patients with persistent asthma, results from a large study demonstrated.

"The occurrence of asthma exacerbations requiring medical attention is a key health outcome, and may be an indicator of the quality of asthma care," Dr. Louis Vernacchio reported at the annual meeting of the Pediatric Academic Societies. "Exacerbations that are cared for in the office setting may be more common than hospital admissions or ED visits, but there is currently no standard methodology for defining exacerbations cared for in the office setting. It would be nice to develop process measures that relate to asthma outcomes, particularly to exacerbations," he said.

Dr. Vernacchio, of the Pediatric Physicians’ Organization at Children’s (PPOC) and the general pediatrics division at Children’s Hospital Boston, and his associate, Jennifer M. Muto, set out to assess the accuracy of claims-based definitions of asthma exacerbations cared for in the office setting and to evaluate potential risk factors for asthma exacerbations that could serve as process measures for quality improvement. They analyzed medical claims from a large not-for-profit insurer for patients of the PPOC, a large independent practice association affiliated with Children’s Hospital Boston. The study population included 19,469 patients aged 5-17 years who were continuously enrolled in 2008 and 19,779 patients aged 5-17 years who were continuously enrolled in 2009. Of these, 530 (2.7%) met Healthcare Effectiveness Data and Information Set (HEDIS) criteria for persistent asthma in 2008 and 507 (2.6%) did so in 2009.

Proposed definitions of asthma exacerbations cared for in an office setting included office visits for asthma with oral steroid prescription filled the day of or the day after a visit (definition 1); office visits for asthma with oral steroid prescription filled the day of or the day after a visit or with nebulizer treatment given in the office (definition 2); office visits for asthma with oral steroid prescription filled the day of or the day after a visit or with oral steroid prescription filled the day of or the day after a visit or with nebulizer treatment given in the office, or coded as "with status asthmaticus" or "with acute exacerbation" (definition 3).

The researchers compared each of those three definitions to a chart review, which was considered the gold standard. Two clinicians independently reviewed 144 asthma visits and evaluated three elements in each chart: history of present illness, physical examination, and assessment. "If they found evidence of exacerbation in two of those three areas, we counted the visit as an exacerbation visit," Dr. Vernacchio said.

Receiver operating characteristic curve analysis revealed that definition 1 had a sensitivity of 24.7% and a specificity of 90.5%, definition 2 had a sensitivity of 56.8% and a specificity of 76.2%, and definition 3 had a sensitivity of 95.1% and a specificity of 68.3%. "The overall area under the curve is best with the third definition, but there’s a tradeoff in sensitivity and specificity," he said.

Logistic regression analysis of associations with exacerbations revealed that the ratio of controller to total asthma prescription fills was the process measure that correlated most closely to the risk of asthma exacerbations, with risk ratios near 2.0 for those in the third and fourth quartiles of controller to total asthma prescription fills ratio (corresponding to ratios of 0.5-0.8 and less than 0.5, respectively).

"This ratio can serve as the basis for quality improvement projects in pediatric asthma," Dr. Vernacchio said. He noted that the proposed 2012 HEDIS measure uses a cutoff value of 0.5, "which is well below what appears optimal in our data."

Dr. Vernacchio said that he had no relevant financial conflicts to disclose.

Patients with rheumatoid arthritis who received 3 months of treatment with the investigational Janus kinase inhibitor tofacitinib had clinically significant improvements in patient-reported outcomes, compared with those who were given placebo, according to Dr. Vibeke Strand, who reported the 3-month results of a 6-month, phase III trial on May 26.

"I see this drug as being everything that a biologic is. ...There are a lot of places where biologics are not very accessible. ... The data look quite comparable to biologics," Dr. Strand said in an interview.

The study marks the first of five pivotal, phase III, randomized, placebo-controlled trials planned for tofacitinib (CP-690-550), Dr. Strand said in an interview. She described tofacitinib as "the first of several Janus kinase and Syk kinase inhibitors that are promising oral disease-modifying antirheumatic drugs with onset of effect that is rapid and magnitude of effect similar to anti–[tumor necrosis factor] therapies," said Dr. Strand of the division of immunology/rheumatology at Stanford (Calif.) University. Tofacitinib "has been studied vs. monotherapy adalimumab in phase II."

For the current 6-month trial, 610 rheumatoid arthritis (RA) patients were randomized to one of three treatments: tofacitinib 5 mg b.i.d., tofacitinib 10 mg b.i.d., or placebo, all as monotherapy. Patients on placebo were advanced to either tofacitinib 5 mg b.i.d. or tofacitinib 10 mg b.i.d. after month 3. The mean age of the patients was 51 years, and 87% were women.

In her presentation, Dr. Strand reported change-from-baseline results on several patient-reported outcomes at 3 months, including Patient Global Assessment of disease activity on a visual analog scale, pain on a visual analog scale, physical function by the HAQ-DI (Health Assessment Questionnaire–Disability Index), and health-related quality of life by the MOS SF-36 (Medical Outcomes Study 36-item Short Form Health Survey).

Improvements were reported as least square means of changes from baseline. At 3 months, treatment with tofacitinib monotherapy resulted in statistically significant and clinically meaningful improvements, compared with placebo, in all patient-reported outcomes except sleep improvement in the tofacitinib 5-mg group.

Mean Patient Global Assessment scores achieved a minimally clinically important difference (MCID) relative to baseline in 73% of the patients taking 5 mg (number needed to treat, 4), in 75% of patients taking10 mg (NNT, 3.8), and in 48% of the placebo group.

Patients’ pain scores showed an MCID relative to baseline in 70% of the patients on 5 mg (NNT, 4.6), in 77% of the patients on 10 mg (NNT, 3.5), and in 48% of the patients on placebo.

Physical function scores on the HAQ-DI showed an MCID relative to baseline in 61% of the patients on 5 mg (NNT, 5.7), in 68% in patients taking 10 mg (NNT, 4), and in 43% of those on placebo.

The physical component scores on the MOS SF-36 were 2.63, 6.97, and 8.55, respectively. Physical component scores on the MOS SF-36 showed an MCID relative to baseline in 68% of the patients on 5 mg (NNT, 4.2), in 75% of the group on 10 mg (NNT, 3.2), and in 44% of those on placebo.

"Randomized, controlled trial data don’t always reflect what we see in the clinic, but this product has a large phase II database, and these findings are consistent with those data," Dr. Strand said. "Patients clearly have derived early and clinically meaningful benefit from treatment – in pain, fatigue, physical function, and ‘multidimensional function’ [as shown] in the SF-36 – which reflects improvements in those parameters, and not just physical and emotional well-being but also in social functioning and mental health."

Dr. Strand disclosed that she is a paid consultant to Pfizer but said that she received no support for preparation of the abstract or presentation.

Patients with rheumatoid arthritis who received 3 months of treatment with the investigational Janus kinase inhibitor tofacitinib had clinically significant improvements in patient-reported outcomes, compared with those who were given placebo, according to Dr. Vibeke Strand, who reported the 3-month results of a 6-month, phase III trial on May 26.

"I see this drug as being everything that a biologic is. ...There are a lot of places where biologics are not very accessible. ... The data look quite comparable to biologics," Dr. Strand said in an interview.

The study marks the first of five pivotal, phase III, randomized, placebo-controlled trials planned for tofacitinib (CP-690-550), Dr. Strand said in an interview. She described tofacitinib as "the first of several Janus kinase and Syk kinase inhibitors that are promising oral disease-modifying antirheumatic drugs with onset of effect that is rapid and magnitude of effect similar to anti–[tumor necrosis factor] therapies," said Dr. Strand of the division of immunology/rheumatology at Stanford (Calif.) University. Tofacitinib "has been studied vs. monotherapy adalimumab in phase II."

For the current 6-month trial, 610 rheumatoid arthritis (RA) patients were randomized to one of three treatments: tofacitinib 5 mg b.i.d., tofacitinib 10 mg b.i.d., or placebo, all as monotherapy. Patients on placebo were advanced to either tofacitinib 5 mg b.i.d. or tofacitinib 10 mg b.i.d. after month 3. The mean age of the patients was 51 years, and 87% were women.

In her presentation, Dr. Strand reported change-from-baseline results on several patient-reported outcomes at 3 months, including Patient Global Assessment of disease activity on a visual analog scale, pain on a visual analog scale, physical function by the HAQ-DI (Health Assessment Questionnaire–Disability Index), and health-related quality of life by the MOS SF-36 (Medical Outcomes Study 36-item Short Form Health Survey).

Improvements were reported as least square means of changes from baseline. At 3 months, treatment with tofacitinib monotherapy resulted in statistically significant and clinically meaningful improvements, compared with placebo, in all patient-reported outcomes except sleep improvement in the tofacitinib 5-mg group.

Mean Patient Global Assessment scores achieved a minimally clinically important difference (MCID) relative to baseline in 73% of the patients taking 5 mg (number needed to treat, 4), in 75% of patients taking10 mg (NNT, 3.8), and in 48% of the placebo group.

Patients’ pain scores showed an MCID relative to baseline in 70% of the patients on 5 mg (NNT, 4.6), in 77% of the patients on 10 mg (NNT, 3.5), and in 48% of the patients on placebo.

Physical function scores on the HAQ-DI showed an MCID relative to baseline in 61% of the patients on 5 mg (NNT, 5.7), in 68% in patients taking 10 mg (NNT, 4), and in 43% of those on placebo.

The physical component scores on the MOS SF-36 were 2.63, 6.97, and 8.55, respectively. Physical component scores on the MOS SF-36 showed an MCID relative to baseline in 68% of the patients on 5 mg (NNT, 4.2), in 75% of the group on 10 mg (NNT, 3.2), and in 44% of those on placebo.

"Randomized, controlled trial data don’t always reflect what we see in the clinic, but this product has a large phase II database, and these findings are consistent with those data," Dr. Strand said. "Patients clearly have derived early and clinically meaningful benefit from treatment – in pain, fatigue, physical function, and ‘multidimensional function’ [as shown] in the SF-36 – which reflects improvements in those parameters, and not just physical and emotional well-being but also in social functioning and mental health."

Dr. Strand disclosed that she is a paid consultant to Pfizer but said that she received no support for preparation of the abstract or presentation.

Patients with rheumatoid arthritis who received 3 months of treatment with the investigational Janus kinase inhibitor tofacitinib had clinically significant improvements in patient-reported outcomes, compared with those who were given placebo, according to Dr. Vibeke Strand, who reported the 3-month results of a 6-month, phase III trial on May 26.

"I see this drug as being everything that a biologic is. ...There are a lot of places where biologics are not very accessible. ... The data look quite comparable to biologics," Dr. Strand said in an interview.

The study marks the first of five pivotal, phase III, randomized, placebo-controlled trials planned for tofacitinib (CP-690-550), Dr. Strand said in an interview. She described tofacitinib as "the first of several Janus kinase and Syk kinase inhibitors that are promising oral disease-modifying antirheumatic drugs with onset of effect that is rapid and magnitude of effect similar to anti–[tumor necrosis factor] therapies," said Dr. Strand of the division of immunology/rheumatology at Stanford (Calif.) University. Tofacitinib "has been studied vs. monotherapy adalimumab in phase II."

For the current 6-month trial, 610 rheumatoid arthritis (RA) patients were randomized to one of three treatments: tofacitinib 5 mg b.i.d., tofacitinib 10 mg b.i.d., or placebo, all as monotherapy. Patients on placebo were advanced to either tofacitinib 5 mg b.i.d. or tofacitinib 10 mg b.i.d. after month 3. The mean age of the patients was 51 years, and 87% were women.

In her presentation, Dr. Strand reported change-from-baseline results on several patient-reported outcomes at 3 months, including Patient Global Assessment of disease activity on a visual analog scale, pain on a visual analog scale, physical function by the HAQ-DI (Health Assessment Questionnaire–Disability Index), and health-related quality of life by the MOS SF-36 (Medical Outcomes Study 36-item Short Form Health Survey).

Improvements were reported as least square means of changes from baseline. At 3 months, treatment with tofacitinib monotherapy resulted in statistically significant and clinically meaningful improvements, compared with placebo, in all patient-reported outcomes except sleep improvement in the tofacitinib 5-mg group.

Mean Patient Global Assessment scores achieved a minimally clinically important difference (MCID) relative to baseline in 73% of the patients taking 5 mg (number needed to treat, 4), in 75% of patients taking10 mg (NNT, 3.8), and in 48% of the placebo group.

Patients’ pain scores showed an MCID relative to baseline in 70% of the patients on 5 mg (NNT, 4.6), in 77% of the patients on 10 mg (NNT, 3.5), and in 48% of the patients on placebo.

Physical function scores on the HAQ-DI showed an MCID relative to baseline in 61% of the patients on 5 mg (NNT, 5.7), in 68% in patients taking 10 mg (NNT, 4), and in 43% of those on placebo.

The physical component scores on the MOS SF-36 were 2.63, 6.97, and 8.55, respectively. Physical component scores on the MOS SF-36 showed an MCID relative to baseline in 68% of the patients on 5 mg (NNT, 4.2), in 75% of the group on 10 mg (NNT, 3.2), and in 44% of those on placebo.

"Randomized, controlled trial data don’t always reflect what we see in the clinic, but this product has a large phase II database, and these findings are consistent with those data," Dr. Strand said. "Patients clearly have derived early and clinically meaningful benefit from treatment – in pain, fatigue, physical function, and ‘multidimensional function’ [as shown] in the SF-36 – which reflects improvements in those parameters, and not just physical and emotional well-being but also in social functioning and mental health."

Dr. Strand disclosed that she is a paid consultant to Pfizer but said that she received no support for preparation of the abstract or presentation.