Jeff Evans

NEW ORLEANS — Treatment of dangerously high blood pressure in the period immediately following an acute stroke was associated with significantly reduced 3-month mortality in the randomized, placebo-controlled Control of Hypertension and Hypotension Immediately Post-Stroke trial.

Patients in the CHHIPS pilot trial did not immediately benefit from antihypertensive medications because the trial's primary end point—the rate of death and dependency at 2 weeks after the stroke—was no different between treated and placebo patients, even though the patients who received antihypertensive drugs had significantly greater decline in systolic blood pressure (SBP) within the first 24 hours than did those who received placebo, Dr. John Potter reported at International Stroke Conference 2008.

“We know that elevated blood pressure levels are important in predicting primary and secondary [stroke] prevention, but we don't know much about the relationship in the acute situation,” said Dr. Potter of the University of East Anglia, Norwich, England.

Current guidelines on the early management of adult acute ischemic stroke patients advise the use of antihypertensive medications in patients who are eligible for tissue plasminogen activator when their blood pressure is greater than 185 mm Hg/110 mm Hg and in other patients when their blood pressure is above 220 mm Hg/120 mm Hg (Stroke 2007;38:1655–711).

To determine if antihypertensive treatment would benefit acute stroke patients with a SBP greater than 160 mm Hg, Dr. Potter and his colleagues randomized 179 patients to receive the β-blocker labetalol, the ACE inhibitor lisinopril, or placebo.

The investigators enrolled patients older than 18 years with a stroke onset within 36 hours and stroke symptoms lasting more than 60 minutes. The patients had not previously been taking antihypertensive medications and had undergone neuroimaging within 72 hours of stroke onset. They excluded any patients who were undergoing thrombolysis as well as those who had impaired consciousness, hypertensive encephalopathy, prestroke dependency (a modified Rankin score of more than 3), any coexisting cardiac or vascular emergencies, contraindications to the study medications, or a primary intracerebral hemorrhage with a SBP greater than 200 mm Hg and/or a diastolic blood pressure greater than 120 mm Hg.

CT scans revealed that about 60% of patients in all groups had an ischemic stroke and about 15% had a primary intracerebral hemorrhage. No relevant abnormality could be seen in the other 25%.

The patients in all groups had a mean National Institutes of Health Stroke Severity score of 11. More than 90% of the patients had no history of stroke or transient ischemic attack. Nearly half of the patients in all groups were dysphagic.

After randomization, patients who could swallow oral medications received 5 mg lisinopril, 50 mg labetalol, or oral placebo. If after 4 hours, their SBP had not dropped to a target range of 145–155 mm Hg or decreased by at least 15%, then the investigators gave another round of the same doses. This was repeated at 8 hours if necessary. During the next 13 days, patients received 5–15 mg lisinopril, 50–150 mg labetalol, or placebo.

For dysphagic patients, the investigators combined sublingual lisinopril with an intravenous placebo, oral labetalol with sublingual placebo, or sublingual and intravenous placebos. Between days 1 and 5, dysphagic patients were switched to oral medications or received their medications through a nasogastric or percutaneous endoscopic gastrostomy tube. Lisinopril is not approved for use as a sublingual preparation, Dr. Potter noted.

Although the active treatment groups had a significantly greater mean decline in SBP than did placebo-treated patients within the first 24 hours (21 mm Hg vs. 11 mm Hg) and at 2 weeks (31 mm Hg vs. 24 mm Hg), there was no difference between the treatment groups in the rate of death and dependency at 2 weeks (61% vs. 59%). Dependency was defined as a modified Rankin score of more than 3.

Patients who received labetalol or lisinopril reached the target SBP outcomes in significantly higher proportions than did placebo patients at 4 and 8 hours after stroke, but not at 24 hours. There were no differences in neurological status between groups at 72 hours post stroke.

However, patients who received placebo had a 2.2 times higher risk of dying by 3 months than did actively treated patients, based on 12 deaths in the placebo group and 11 deaths in the active treatment groups, Dr. Potter said at the conference, which was sponsored by the American Stroke Association.

NEW ORLEANS — Treatment of dangerously high blood pressure in the period immediately following an acute stroke was associated with significantly reduced 3-month mortality in the randomized, placebo-controlled Control of Hypertension and Hypotension Immediately Post-Stroke trial.

Patients in the CHHIPS pilot trial did not immediately benefit from antihypertensive medications because the trial's primary end point—the rate of death and dependency at 2 weeks after the stroke—was no different between treated and placebo patients, even though the patients who received antihypertensive drugs had significantly greater decline in systolic blood pressure (SBP) within the first 24 hours than did those who received placebo, Dr. John Potter reported at International Stroke Conference 2008.

“We know that elevated blood pressure levels are important in predicting primary and secondary [stroke] prevention, but we don't know much about the relationship in the acute situation,” said Dr. Potter of the University of East Anglia, Norwich, England.

Current guidelines on the early management of adult acute ischemic stroke patients advise the use of antihypertensive medications in patients who are eligible for tissue plasminogen activator when their blood pressure is greater than 185 mm Hg/110 mm Hg and in other patients when their blood pressure is above 220 mm Hg/120 mm Hg (Stroke 2007;38:1655–711).

To determine if antihypertensive treatment would benefit acute stroke patients with a SBP greater than 160 mm Hg, Dr. Potter and his colleagues randomized 179 patients to receive the β-blocker labetalol, the ACE inhibitor lisinopril, or placebo.

The investigators enrolled patients older than 18 years with a stroke onset within 36 hours and stroke symptoms lasting more than 60 minutes. The patients had not previously been taking antihypertensive medications and had undergone neuroimaging within 72 hours of stroke onset. They excluded any patients who were undergoing thrombolysis as well as those who had impaired consciousness, hypertensive encephalopathy, prestroke dependency (a modified Rankin score of more than 3), any coexisting cardiac or vascular emergencies, contraindications to the study medications, or a primary intracerebral hemorrhage with a SBP greater than 200 mm Hg and/or a diastolic blood pressure greater than 120 mm Hg.

CT scans revealed that about 60% of patients in all groups had an ischemic stroke and about 15% had a primary intracerebral hemorrhage. No relevant abnormality could be seen in the other 25%.

The patients in all groups had a mean National Institutes of Health Stroke Severity score of 11. More than 90% of the patients had no history of stroke or transient ischemic attack. Nearly half of the patients in all groups were dysphagic.

After randomization, patients who could swallow oral medications received 5 mg lisinopril, 50 mg labetalol, or oral placebo. If after 4 hours, their SBP had not dropped to a target range of 145–155 mm Hg or decreased by at least 15%, then the investigators gave another round of the same doses. This was repeated at 8 hours if necessary. During the next 13 days, patients received 5–15 mg lisinopril, 50–150 mg labetalol, or placebo.

For dysphagic patients, the investigators combined sublingual lisinopril with an intravenous placebo, oral labetalol with sublingual placebo, or sublingual and intravenous placebos. Between days 1 and 5, dysphagic patients were switched to oral medications or received their medications through a nasogastric or percutaneous endoscopic gastrostomy tube. Lisinopril is not approved for use as a sublingual preparation, Dr. Potter noted.

Although the active treatment groups had a significantly greater mean decline in SBP than did placebo-treated patients within the first 24 hours (21 mm Hg vs. 11 mm Hg) and at 2 weeks (31 mm Hg vs. 24 mm Hg), there was no difference between the treatment groups in the rate of death and dependency at 2 weeks (61% vs. 59%). Dependency was defined as a modified Rankin score of more than 3.

Patients who received labetalol or lisinopril reached the target SBP outcomes in significantly higher proportions than did placebo patients at 4 and 8 hours after stroke, but not at 24 hours. There were no differences in neurological status between groups at 72 hours post stroke.

However, patients who received placebo had a 2.2 times higher risk of dying by 3 months than did actively treated patients, based on 12 deaths in the placebo group and 11 deaths in the active treatment groups, Dr. Potter said at the conference, which was sponsored by the American Stroke Association.

NEW ORLEANS — Treatment of dangerously high blood pressure in the period immediately following an acute stroke was associated with significantly reduced 3-month mortality in the randomized, placebo-controlled Control of Hypertension and Hypotension Immediately Post-Stroke trial.

Patients in the CHHIPS pilot trial did not immediately benefit from antihypertensive medications because the trial's primary end point—the rate of death and dependency at 2 weeks after the stroke—was no different between treated and placebo patients, even though the patients who received antihypertensive drugs had significantly greater decline in systolic blood pressure (SBP) within the first 24 hours than did those who received placebo, Dr. John Potter reported at International Stroke Conference 2008.

“We know that elevated blood pressure levels are important in predicting primary and secondary [stroke] prevention, but we don't know much about the relationship in the acute situation,” said Dr. Potter of the University of East Anglia, Norwich, England.

Current guidelines on the early management of adult acute ischemic stroke patients advise the use of antihypertensive medications in patients who are eligible for tissue plasminogen activator when their blood pressure is greater than 185 mm Hg/110 mm Hg and in other patients when their blood pressure is above 220 mm Hg/120 mm Hg (Stroke 2007;38:1655–711).

To determine if antihypertensive treatment would benefit acute stroke patients with a SBP greater than 160 mm Hg, Dr. Potter and his colleagues randomized 179 patients to receive the β-blocker labetalol, the ACE inhibitor lisinopril, or placebo.

The investigators enrolled patients older than 18 years with a stroke onset within 36 hours and stroke symptoms lasting more than 60 minutes. The patients had not previously been taking antihypertensive medications and had undergone neuroimaging within 72 hours of stroke onset. They excluded any patients who were undergoing thrombolysis as well as those who had impaired consciousness, hypertensive encephalopathy, prestroke dependency (a modified Rankin score of more than 3), any coexisting cardiac or vascular emergencies, contraindications to the study medications, or a primary intracerebral hemorrhage with a SBP greater than 200 mm Hg and/or a diastolic blood pressure greater than 120 mm Hg.

CT scans revealed that about 60% of patients in all groups had an ischemic stroke and about 15% had a primary intracerebral hemorrhage. No relevant abnormality could be seen in the other 25%.

The patients in all groups had a mean National Institutes of Health Stroke Severity score of 11. More than 90% of the patients had no history of stroke or transient ischemic attack. Nearly half of the patients in all groups were dysphagic.

After randomization, patients who could swallow oral medications received 5 mg lisinopril, 50 mg labetalol, or oral placebo. If after 4 hours, their SBP had not dropped to a target range of 145–155 mm Hg or decreased by at least 15%, then the investigators gave another round of the same doses. This was repeated at 8 hours if necessary. During the next 13 days, patients received 5–15 mg lisinopril, 50–150 mg labetalol, or placebo.

For dysphagic patients, the investigators combined sublingual lisinopril with an intravenous placebo, oral labetalol with sublingual placebo, or sublingual and intravenous placebos. Between days 1 and 5, dysphagic patients were switched to oral medications or received their medications through a nasogastric or percutaneous endoscopic gastrostomy tube. Lisinopril is not approved for use as a sublingual preparation, Dr. Potter noted.

Although the active treatment groups had a significantly greater mean decline in SBP than did placebo-treated patients within the first 24 hours (21 mm Hg vs. 11 mm Hg) and at 2 weeks (31 mm Hg vs. 24 mm Hg), there was no difference between the treatment groups in the rate of death and dependency at 2 weeks (61% vs. 59%). Dependency was defined as a modified Rankin score of more than 3.

Patients who received labetalol or lisinopril reached the target SBP outcomes in significantly higher proportions than did placebo patients at 4 and 8 hours after stroke, but not at 24 hours. There were no differences in neurological status between groups at 72 hours post stroke.

However, patients who received placebo had a 2.2 times higher risk of dying by 3 months than did actively treated patients, based on 12 deaths in the placebo group and 11 deaths in the active treatment groups, Dr. Potter said at the conference, which was sponsored by the American Stroke Association.

NEW ORLEANS — Individuals with poststroke depression may respond best in the short term to a combination of a brief psychosocial and behavioral intervention and an antidepressant, Pamela H. Mitchell, Ph.D., reported at the International Stroke Conference 2008.

Patients with two alleles of a common polymorphism in the serotonin transporter gene (SERT) seemed to benefit most from the combination treatment, Dr. Mitchell said at the conference, sponsored by the American Stroke Association.

Recent meta-analyses of pooled data from clinical studies of poststroke depression have estimated that 33% of patients may be clinically depressed after having a stroke. Poststroke depression has been associated with poor rehabilitation and quality of life and may be a predictor of a subsequent stroke and death.

Very-short-duration clinical trials of selective serotonin reuptake inhibitors (SSRIs) have provided mixed results in terms of clinical response, and there is little evidence on the effectiveness of variants of cognitive-behavioral therapy or socially supportive interventions in treating poststroke depression. However, a variant of cognitive-behavioral therapy and pleasant events therapy, the “Seattle Protocols” was successful in reducing depression in Alzheimer's disease patients and in their caregivers, said Dr. Mitchell, of the school of public health and community medicine at the University of Washington, Seattle.

She and her colleagues randomized 101 patients to treatment with the Seattle Protocols intervention plus an SSRI prescribed by their own providers or to a control group of usual care (SSRI prescription with provider follow-up). Both groups recieved written materials from the American Stroke Association about stroke and depression. The subjects had a mean age of 57 years; about 70% had a history of depression before their stroke.

The nine-session, 8-week intervention is designed to increase the level of pleasant social events and activities and physical activity that may improve mood. Patients are taught behavioral strategies that reduce or prevent the behavioral and mood disturbances that are characteristic of stroke and depression. Patients and their caregivers (if present) also learn individualized problem-solving approaches.

At 9 weeks, 48 patients who received the intervention had significantly greater mean improvement on the Hamilton Depression Rating Scale (48%, from 20.4 at baseline to about 10.6) than did 53 control patients (19%, from 19 to about 15.4). More than half of those in the intervention group entered clinical remission (a score of 9 or less on the HDRS) by 1 year.

In 61 patients genotyped for polymorphisms in SERT, those with two “short” alleles for the 5-HTTLPR polymorphism of SERT were significantly more likely to respond to treatment in the intervention arm than if they had only one short allele or other versions of the polymorphism. The short allele seems to be associated with increased risk for depression and other mental disorders, she said. No such responses according to SERT genotype were seen in patients in the control arm.

Dr. Mitchell said she had no conflicts of interest to disclose.

NEW ORLEANS — Individuals with poststroke depression may respond best in the short term to a combination of a brief psychosocial and behavioral intervention and an antidepressant, Pamela H. Mitchell, Ph.D., reported at the International Stroke Conference 2008.

Patients with two alleles of a common polymorphism in the serotonin transporter gene (SERT) seemed to benefit most from the combination treatment, Dr. Mitchell said at the conference, sponsored by the American Stroke Association.

Recent meta-analyses of pooled data from clinical studies of poststroke depression have estimated that 33% of patients may be clinically depressed after having a stroke. Poststroke depression has been associated with poor rehabilitation and quality of life and may be a predictor of a subsequent stroke and death.

Very-short-duration clinical trials of selective serotonin reuptake inhibitors (SSRIs) have provided mixed results in terms of clinical response, and there is little evidence on the effectiveness of variants of cognitive-behavioral therapy or socially supportive interventions in treating poststroke depression. However, a variant of cognitive-behavioral therapy and pleasant events therapy, the “Seattle Protocols” was successful in reducing depression in Alzheimer's disease patients and in their caregivers, said Dr. Mitchell, of the school of public health and community medicine at the University of Washington, Seattle.

She and her colleagues randomized 101 patients to treatment with the Seattle Protocols intervention plus an SSRI prescribed by their own providers or to a control group of usual care (SSRI prescription with provider follow-up). Both groups recieved written materials from the American Stroke Association about stroke and depression. The subjects had a mean age of 57 years; about 70% had a history of depression before their stroke.

The nine-session, 8-week intervention is designed to increase the level of pleasant social events and activities and physical activity that may improve mood. Patients are taught behavioral strategies that reduce or prevent the behavioral and mood disturbances that are characteristic of stroke and depression. Patients and their caregivers (if present) also learn individualized problem-solving approaches.

At 9 weeks, 48 patients who received the intervention had significantly greater mean improvement on the Hamilton Depression Rating Scale (48%, from 20.4 at baseline to about 10.6) than did 53 control patients (19%, from 19 to about 15.4). More than half of those in the intervention group entered clinical remission (a score of 9 or less on the HDRS) by 1 year.

In 61 patients genotyped for polymorphisms in SERT, those with two “short” alleles for the 5-HTTLPR polymorphism of SERT were significantly more likely to respond to treatment in the intervention arm than if they had only one short allele or other versions of the polymorphism. The short allele seems to be associated with increased risk for depression and other mental disorders, she said. No such responses according to SERT genotype were seen in patients in the control arm.

Dr. Mitchell said she had no conflicts of interest to disclose.

NEW ORLEANS — Individuals with poststroke depression may respond best in the short term to a combination of a brief psychosocial and behavioral intervention and an antidepressant, Pamela H. Mitchell, Ph.D., reported at the International Stroke Conference 2008.

Patients with two alleles of a common polymorphism in the serotonin transporter gene (SERT) seemed to benefit most from the combination treatment, Dr. Mitchell said at the conference, sponsored by the American Stroke Association.

Recent meta-analyses of pooled data from clinical studies of poststroke depression have estimated that 33% of patients may be clinically depressed after having a stroke. Poststroke depression has been associated with poor rehabilitation and quality of life and may be a predictor of a subsequent stroke and death.

Very-short-duration clinical trials of selective serotonin reuptake inhibitors (SSRIs) have provided mixed results in terms of clinical response, and there is little evidence on the effectiveness of variants of cognitive-behavioral therapy or socially supportive interventions in treating poststroke depression. However, a variant of cognitive-behavioral therapy and pleasant events therapy, the “Seattle Protocols” was successful in reducing depression in Alzheimer's disease patients and in their caregivers, said Dr. Mitchell, of the school of public health and community medicine at the University of Washington, Seattle.

She and her colleagues randomized 101 patients to treatment with the Seattle Protocols intervention plus an SSRI prescribed by their own providers or to a control group of usual care (SSRI prescription with provider follow-up). Both groups recieved written materials from the American Stroke Association about stroke and depression. The subjects had a mean age of 57 years; about 70% had a history of depression before their stroke.

The nine-session, 8-week intervention is designed to increase the level of pleasant social events and activities and physical activity that may improve mood. Patients are taught behavioral strategies that reduce or prevent the behavioral and mood disturbances that are characteristic of stroke and depression. Patients and their caregivers (if present) also learn individualized problem-solving approaches.

At 9 weeks, 48 patients who received the intervention had significantly greater mean improvement on the Hamilton Depression Rating Scale (48%, from 20.4 at baseline to about 10.6) than did 53 control patients (19%, from 19 to about 15.4). More than half of those in the intervention group entered clinical remission (a score of 9 or less on the HDRS) by 1 year.

In 61 patients genotyped for polymorphisms in SERT, those with two “short” alleles for the 5-HTTLPR polymorphism of SERT were significantly more likely to respond to treatment in the intervention arm than if they had only one short allele or other versions of the polymorphism. The short allele seems to be associated with increased risk for depression and other mental disorders, she said. No such responses according to SERT genotype were seen in patients in the control arm.

Dr. Mitchell said she had no conflicts of interest to disclose.

NEW ORLEANS — Treatment of dangerously high blood pressure in the period immediately following an acute stroke was associated with significantly reduced 3-month mortality in the randomized, placebo-controlled Control of Hypertension and Hypotension Immediately Post-Stroke trial.

Patients in the CHHIPS pilot trial did not immediately benefit from antihypertensive medications because the trial's primary end point—the rate of death and dependency at 2 weeks after the stroke—was no different between treated and placebo patients, even though the patients who received antihypertensive drugs had significantly greater decline in systolic blood pressure (SBP) within the first 24 hours than did those who received placebo, Dr. John Potter reported at International Stroke Conference 2008.

“We know that elevated blood pressure levels are important in predicting primary and secondary [stroke] prevention, but we don't know much about the relationship in the acute situation,” said Dr. Potter of the University of East Anglia, Norwich, England.

Dr. Potter and his colleagues randomized 179 patients older than 18 years with a stroke onset within 36 hours and stroke symptoms lasting more than 60 minutes.

Patients who could swallow oral medications received 5 mg lisinopril, 50 mg labetalol, or oral placebo. If after 4 hours, their SBP had not dropped to a target range of 145–155 mm Hg or decreased by at least 15%, then the investigators gave another round of the same doses. If necessary, this was repeated at 8 hours if necessary. During the next 13 days, patients received 5–15 mg lisinopril, 50–150 mg labetalol, or placebo.

For dysphagic patients, the investigators combined sublingual lisinopril with an intravenous placebo, oral labetalol with sublingual placebo, or sublingual and intravenous placebos. Between days 1 and 5, dysphagic patients were switched to oral medications or received their medications through a nasogastric or percutaneous endoscopic gastrostomy tube.

Although the active treatment groups had a significantly greater mean decline in SBP than did placebo-treated patients within the first 24 hours (21 mm Hg vs. 11 mm Hg) and at 2 weeks (31 mm Hg vs. 24 mm Hg), there was no difference between the treatment groups in the rate of death and dependency at 2 weeks (61% vs. 59%).

Patients who received labetalol or lisinopril reached the target SBP outcomes in significantly higher proportions than did placebo-treated patients at 4 and 8 hours after stroke, but not at 24 hours. There were no differences in neurological status between the groups at 72 hours. However, patients who received placebo had a 2.2 times higher risk of dying by 3 months than did actively treated patients, Dr. Potter said at the conference, which was sponsored by the American Stroke Association.

NEW ORLEANS — Treatment of dangerously high blood pressure in the period immediately following an acute stroke was associated with significantly reduced 3-month mortality in the randomized, placebo-controlled Control of Hypertension and Hypotension Immediately Post-Stroke trial.

Patients in the CHHIPS pilot trial did not immediately benefit from antihypertensive medications because the trial's primary end point—the rate of death and dependency at 2 weeks after the stroke—was no different between treated and placebo patients, even though the patients who received antihypertensive drugs had significantly greater decline in systolic blood pressure (SBP) within the first 24 hours than did those who received placebo, Dr. John Potter reported at International Stroke Conference 2008.

“We know that elevated blood pressure levels are important in predicting primary and secondary [stroke] prevention, but we don't know much about the relationship in the acute situation,” said Dr. Potter of the University of East Anglia, Norwich, England.

Dr. Potter and his colleagues randomized 179 patients older than 18 years with a stroke onset within 36 hours and stroke symptoms lasting more than 60 minutes.

Patients who could swallow oral medications received 5 mg lisinopril, 50 mg labetalol, or oral placebo. If after 4 hours, their SBP had not dropped to a target range of 145–155 mm Hg or decreased by at least 15%, then the investigators gave another round of the same doses. If necessary, this was repeated at 8 hours if necessary. During the next 13 days, patients received 5–15 mg lisinopril, 50–150 mg labetalol, or placebo.

For dysphagic patients, the investigators combined sublingual lisinopril with an intravenous placebo, oral labetalol with sublingual placebo, or sublingual and intravenous placebos. Between days 1 and 5, dysphagic patients were switched to oral medications or received their medications through a nasogastric or percutaneous endoscopic gastrostomy tube.

Although the active treatment groups had a significantly greater mean decline in SBP than did placebo-treated patients within the first 24 hours (21 mm Hg vs. 11 mm Hg) and at 2 weeks (31 mm Hg vs. 24 mm Hg), there was no difference between the treatment groups in the rate of death and dependency at 2 weeks (61% vs. 59%).

Patients who received labetalol or lisinopril reached the target SBP outcomes in significantly higher proportions than did placebo-treated patients at 4 and 8 hours after stroke, but not at 24 hours. There were no differences in neurological status between the groups at 72 hours. However, patients who received placebo had a 2.2 times higher risk of dying by 3 months than did actively treated patients, Dr. Potter said at the conference, which was sponsored by the American Stroke Association.

NEW ORLEANS — Treatment of dangerously high blood pressure in the period immediately following an acute stroke was associated with significantly reduced 3-month mortality in the randomized, placebo-controlled Control of Hypertension and Hypotension Immediately Post-Stroke trial.

Patients in the CHHIPS pilot trial did not immediately benefit from antihypertensive medications because the trial's primary end point—the rate of death and dependency at 2 weeks after the stroke—was no different between treated and placebo patients, even though the patients who received antihypertensive drugs had significantly greater decline in systolic blood pressure (SBP) within the first 24 hours than did those who received placebo, Dr. John Potter reported at International Stroke Conference 2008.

“We know that elevated blood pressure levels are important in predicting primary and secondary [stroke] prevention, but we don't know much about the relationship in the acute situation,” said Dr. Potter of the University of East Anglia, Norwich, England.

Dr. Potter and his colleagues randomized 179 patients older than 18 years with a stroke onset within 36 hours and stroke symptoms lasting more than 60 minutes.

Patients who could swallow oral medications received 5 mg lisinopril, 50 mg labetalol, or oral placebo. If after 4 hours, their SBP had not dropped to a target range of 145–155 mm Hg or decreased by at least 15%, then the investigators gave another round of the same doses. If necessary, this was repeated at 8 hours if necessary. During the next 13 days, patients received 5–15 mg lisinopril, 50–150 mg labetalol, or placebo.

For dysphagic patients, the investigators combined sublingual lisinopril with an intravenous placebo, oral labetalol with sublingual placebo, or sublingual and intravenous placebos. Between days 1 and 5, dysphagic patients were switched to oral medications or received their medications through a nasogastric or percutaneous endoscopic gastrostomy tube.

Although the active treatment groups had a significantly greater mean decline in SBP than did placebo-treated patients within the first 24 hours (21 mm Hg vs. 11 mm Hg) and at 2 weeks (31 mm Hg vs. 24 mm Hg), there was no difference between the treatment groups in the rate of death and dependency at 2 weeks (61% vs. 59%).

Patients who received labetalol or lisinopril reached the target SBP outcomes in significantly higher proportions than did placebo-treated patients at 4 and 8 hours after stroke, but not at 24 hours. There were no differences in neurological status between the groups at 72 hours. However, patients who received placebo had a 2.2 times higher risk of dying by 3 months than did actively treated patients, Dr. Potter said at the conference, which was sponsored by the American Stroke Association.

CINCINNATI — Quality improvement programs at hospitals might report significantly different rates of risk-adjusted comorbidities and outcomes for surgical patients, according to a retrospective analysis of two programs within one health system.

The risk-adjusted mortalities calculated by the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) and the University HealthSystem Consortium (UHC) for the general and vascular surgery services in the Ohio State University health system were different for “pretty much the same patient population over the same time period,” Dr. Steven M. Steinberg said at the annual meeting of the Central Surgical Association.

Dr. Steinberg, chief of the division of critical care, trauma, and burn in the department of surgery at Ohio State, and his coinvestigators compared the NSQIP records of 120 consecutive general and vascular surgery inpatients with their matching records, which were submitted to UHC from January to June 2006.

NSQIP provides a prospective database of 30-day, risk-adjusted surgical outcome data on inpatients and outpatients from participating hospitals.

UHC's membership of 101 academic medical centers and 170 of their affiliated hospitals includes about 90% of nonprofit academic medical centers. UHC uses the Centers for Medicare and Medicaid Services' system for classifying the severity of illness, the All Patient Refined Diagnosis Related Groups.

“From our point of view, [UHC's methodology] is somewhat more complex than the NSQIP methodology,” Dr. Steinberg said.

According to NSQIP, Ohio State's ratio of observed to expected mortality was 0.76, placing it in the top quartile. But UHC calculated a ratio of 1.45, putting it in the bottom quartile. A ratio less than 1 indicates that the hospital is performing better than expected given the complexity of its patient population and surgical case complexity.

Overall, NSQIP tallied significantly fewer comorbidities per person after risk adjustment than did UHC (1.38 vs. 2.85). These included discordant results between NSQIP and UHC for the rates of hypertension (47% vs. 43%, respectively) and diabetes (11% vs. 14%), as well as cardiac (10% vs. 12%) and pulmonary comorbidities (18% vs. 23%).

Significant discordance also occurred between NSQIP and UHC results for all complications combined (28% vs. 11%).

“Clearly, not all risk adjustment is the same. Both NSQIP and the University HealthSystem Consortium risk adjustment of data cannot be kept at our institution because they are so different,” Dr. Steinberg said. “From my point of view, NSQIP has more face validity than the UHC system, not just because we did better [on NSQIP] but because it's something that I can understand, whereas I have great difficulty in being able to understand the UHC process.”

Several audience members thought that the results illustrate the problems with using retrospective analyses of administrative data sets to evaluate outcomes, rather than prospective databases that are maintained by a trained and dedicated nurse, as is the case with NSQIP.

The difference in the ratio of observed to expected mortality between these quality improvement programs could be attributable to a number of factors:

PIProblems with documentation and coding (although this is unlikely, according to Dr. Steinberg).

PIDifferences in the participation of medical centers in each quality improvement program (although 56 centers participate in both NSQIP and UHC).

PIPossible incorrect classification—for example, UHC defines a service line by ICD-9 codes, not whether a patient was ever actually on a service.

PIDifferences in the programs' risk-adjustment methodologies.

'Clearly, not all risk adjustment is the same.' DR. STEINBERG

CINCINNATI — Quality improvement programs at hospitals might report significantly different rates of risk-adjusted comorbidities and outcomes for surgical patients, according to a retrospective analysis of two programs within one health system.

The risk-adjusted mortalities calculated by the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) and the University HealthSystem Consortium (UHC) for the general and vascular surgery services in the Ohio State University health system were different for “pretty much the same patient population over the same time period,” Dr. Steven M. Steinberg said at the annual meeting of the Central Surgical Association.

Dr. Steinberg, chief of the division of critical care, trauma, and burn in the department of surgery at Ohio State, and his coinvestigators compared the NSQIP records of 120 consecutive general and vascular surgery inpatients with their matching records, which were submitted to UHC from January to June 2006.

NSQIP provides a prospective database of 30-day, risk-adjusted surgical outcome data on inpatients and outpatients from participating hospitals.

UHC's membership of 101 academic medical centers and 170 of their affiliated hospitals includes about 90% of nonprofit academic medical centers. UHC uses the Centers for Medicare and Medicaid Services' system for classifying the severity of illness, the All Patient Refined Diagnosis Related Groups.

“From our point of view, [UHC's methodology] is somewhat more complex than the NSQIP methodology,” Dr. Steinberg said.

According to NSQIP, Ohio State's ratio of observed to expected mortality was 0.76, placing it in the top quartile. But UHC calculated a ratio of 1.45, putting it in the bottom quartile. A ratio less than 1 indicates that the hospital is performing better than expected given the complexity of its patient population and surgical case complexity.

Overall, NSQIP tallied significantly fewer comorbidities per person after risk adjustment than did UHC (1.38 vs. 2.85). These included discordant results between NSQIP and UHC for the rates of hypertension (47% vs. 43%, respectively) and diabetes (11% vs. 14%), as well as cardiac (10% vs. 12%) and pulmonary comorbidities (18% vs. 23%).

Significant discordance also occurred between NSQIP and UHC results for all complications combined (28% vs. 11%).

“Clearly, not all risk adjustment is the same. Both NSQIP and the University HealthSystem Consortium risk adjustment of data cannot be kept at our institution because they are so different,” Dr. Steinberg said. “From my point of view, NSQIP has more face validity than the UHC system, not just because we did better [on NSQIP] but because it's something that I can understand, whereas I have great difficulty in being able to understand the UHC process.”

Several audience members thought that the results illustrate the problems with using retrospective analyses of administrative data sets to evaluate outcomes, rather than prospective databases that are maintained by a trained and dedicated nurse, as is the case with NSQIP.

The difference in the ratio of observed to expected mortality between these quality improvement programs could be attributable to a number of factors:

PIProblems with documentation and coding (although this is unlikely, according to Dr. Steinberg).

PIDifferences in the participation of medical centers in each quality improvement program (although 56 centers participate in both NSQIP and UHC).

PIPossible incorrect classification—for example, UHC defines a service line by ICD-9 codes, not whether a patient was ever actually on a service.

PIDifferences in the programs' risk-adjustment methodologies.

'Clearly, not all risk adjustment is the same.' DR. STEINBERG

CINCINNATI — Quality improvement programs at hospitals might report significantly different rates of risk-adjusted comorbidities and outcomes for surgical patients, according to a retrospective analysis of two programs within one health system.

The risk-adjusted mortalities calculated by the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) and the University HealthSystem Consortium (UHC) for the general and vascular surgery services in the Ohio State University health system were different for “pretty much the same patient population over the same time period,” Dr. Steven M. Steinberg said at the annual meeting of the Central Surgical Association.

Dr. Steinberg, chief of the division of critical care, trauma, and burn in the department of surgery at Ohio State, and his coinvestigators compared the NSQIP records of 120 consecutive general and vascular surgery inpatients with their matching records, which were submitted to UHC from January to June 2006.

NSQIP provides a prospective database of 30-day, risk-adjusted surgical outcome data on inpatients and outpatients from participating hospitals.

UHC's membership of 101 academic medical centers and 170 of their affiliated hospitals includes about 90% of nonprofit academic medical centers. UHC uses the Centers for Medicare and Medicaid Services' system for classifying the severity of illness, the All Patient Refined Diagnosis Related Groups.

“From our point of view, [UHC's methodology] is somewhat more complex than the NSQIP methodology,” Dr. Steinberg said.

According to NSQIP, Ohio State's ratio of observed to expected mortality was 0.76, placing it in the top quartile. But UHC calculated a ratio of 1.45, putting it in the bottom quartile. A ratio less than 1 indicates that the hospital is performing better than expected given the complexity of its patient population and surgical case complexity.

Overall, NSQIP tallied significantly fewer comorbidities per person after risk adjustment than did UHC (1.38 vs. 2.85). These included discordant results between NSQIP and UHC for the rates of hypertension (47% vs. 43%, respectively) and diabetes (11% vs. 14%), as well as cardiac (10% vs. 12%) and pulmonary comorbidities (18% vs. 23%).

Significant discordance also occurred between NSQIP and UHC results for all complications combined (28% vs. 11%).

“Clearly, not all risk adjustment is the same. Both NSQIP and the University HealthSystem Consortium risk adjustment of data cannot be kept at our institution because they are so different,” Dr. Steinberg said. “From my point of view, NSQIP has more face validity than the UHC system, not just because we did better [on NSQIP] but because it's something that I can understand, whereas I have great difficulty in being able to understand the UHC process.”

Several audience members thought that the results illustrate the problems with using retrospective analyses of administrative data sets to evaluate outcomes, rather than prospective databases that are maintained by a trained and dedicated nurse, as is the case with NSQIP.

The difference in the ratio of observed to expected mortality between these quality improvement programs could be attributable to a number of factors:

PIProblems with documentation and coding (although this is unlikely, according to Dr. Steinberg).

PIDifferences in the participation of medical centers in each quality improvement program (although 56 centers participate in both NSQIP and UHC).

PIPossible incorrect classification—for example, UHC defines a service line by ICD-9 codes, not whether a patient was ever actually on a service.

PIDifferences in the programs' risk-adjustment methodologies.

'Clearly, not all risk adjustment is the same.' DR. STEINBERG

BALTIMORE — The increasing need for wound care centers in the United States may present an opportunity for dermatologists to wed their interests in both medical and surgical dermatology, according to Dr. Robert S. Kirsner.

"Wound care is at the junction of surgical and medical dermatology. To somebody with broad interests, it may be attractive because there are certain wound problems that require the internist in you and some wound problems that require the surgeon in you," said Dr. Kirsner, director of the Wound CURE (Cutaneous Ulcer Rehabilitation and Education) Center at the University of Miami.

Dermatologists can offer their expertise in wound care by directing or even opening up their own wound care clinic or by practicing or consulting part-time with a center, he said.

Some wound centers have a dermatologist who works there a half or full day per week, but typically a dermatologist is a consultant to a wound center and sees patients with dermatologic conditions such as pyoderma gangrenosum, vasculitis, or immunobullous disease, Dr. Kirsner said in an interview.

Wound care centers that include a physician may be run from a solo or group practice or based in an ambulatory center or at a hospital. Hospital-based centers may be the more "economically savvy way of doing it," Dr. Robert D. Galiano said at the annual meeting of the American Society of Plastic Surgeons.

A center can be established independently by a physician, fully staffed by an outside company, set up by an outside company that the physician then runs, or formed by a mix of these approaches. Regardless of the type of wound care center, about 35% of all hospitals now have some sort of formal wound care center, "and I think this number is only going to increase," said Dr. Galiano, who is in the process of establishing a wound care center at Northwestern Memorial Hospital in Chicago, where he is a plastic surgeon.

To determine the best course to take for Northwestern's wound care center, Dr. Galiano visited a wound care clinic at an academic medical center, a research-intensive podiatry-based center within an academic medical center, a small university-based center that was affiliated with a wound management company, and a wound care center at a large state academic medical center that also was affiliated with a management company.

During his visits, Dr. Galiano learned that most wound care centers "will be met with a high rate of skepticism. There's a feeling out there that wound centers are loss leaders and certainly not profitable." The success of centers at large academic institutions will depend on the costs of the facility, rent, and personnel; the types of wounds treated; and the role of research as an adjunct to revenue.

All of the centers that Dr. Galiano visited were well established and profitable. Such centers were also very labor intensive and left little time for other clinical activities.

Facility costs need to be shared with or underwritten by the hospital since the costs of running a center will probably not be covered by the revenues that the center itself brings in for ambulatory visits. "You have to incorporate downstream revenue," Dr. Galiano advised.

The costs of durable medical equipment and goods, such as the best dressings, need to be controlled in some way because most academic medical centers are nonprofit and will not allow physicians to bill for the best, most expensive dressings. Arrangements could be made with another provider not affiliated with the hospital to provide those materials on-site and then bill the patient directly for them, he suggested.

The most successful centers that Dr. Galiano visited had a large volume of inpatients with chronic wounds that consisted mostly of diabetic foot ulcers, which are associated with the highest-paying diagnosis-related groups.

Dr. David L. Steed, a vascular surgeon who is director of the wound healing/limb preservation clinic at the University of Pittsburgh, handles about 4,000 patient visits per year with his colleagues. The clinic cares for venous stasis ulcers (41%), diabetic neuropathy foot ulcers (27%), ischemic ulcers (13%), pressure ulcers (10%), and other types of chronic wounds (9%).

Dr. Steed's clinic, which is not hospital based, handles all charges itself, and must break even. The clinic employs a nurse practitioner, research nurse, patient care technician, diabetes educator, and podiatrist and has one student (medical or nursing) or resident (surgery or dermatology) present at a time. Plastic and orthopedic surgeons, as well as dermatologists and diabetologists, frequently consult on cases.

"We break even in the clinic, but all the things I send to the hospital make money," he said at the meeting.

At a wound care center, it is reasonable to expect about 40% of patients to be new to the hospital and that 15% on their first visit will require hospital admission, ambulatory surgery, or angiography, Dr. Steed said. Nearly all wound center patients use radiology and laboratory services.

In another presentation, Dr. David Hurley said that he initially balked at the idea of opening a comprehensive wound care center at the hospital in which he worked as a general plastic surgeon and vice president. After the hospital opened a center without his support, he was later offered the opportunity to become its medical director.

He learned that his skepticism of wound care treatments, such as hyperbaric oxygen therapy, was unfounded. "They sent me off to a couple courses, and what I learned was that my understanding of comprehensive wound care had really stopped back with my residency training. It had not been a focus of my training," he said.

"One of the things driving the interest in the development of comprehensive wound care centers is the fact that we now have a much better understanding of the biochemistry and physiology of problem wounds," he said.

Dr. Hurley spent more and more time at the center and began looking at it as a possible exit strategy from his plastic surgery practice. Three years ago, he left his medical practice to become the chief medical officer of the management company that had helped to set up the center. That company, Diversified Clinical Services, Jacksonville, Fla., partners with hospitals to manage, operate, and develop comprehensive wound care centers.

Dermatologists can offer their expertise in wound care by directing or even opening up their own clinic. DR. KIRSNER

BALTIMORE — The increasing need for wound care centers in the United States may present an opportunity for dermatologists to wed their interests in both medical and surgical dermatology, according to Dr. Robert S. Kirsner.

"Wound care is at the junction of surgical and medical dermatology. To somebody with broad interests, it may be attractive because there are certain wound problems that require the internist in you and some wound problems that require the surgeon in you," said Dr. Kirsner, director of the Wound CURE (Cutaneous Ulcer Rehabilitation and Education) Center at the University of Miami.

Dermatologists can offer their expertise in wound care by directing or even opening up their own wound care clinic or by practicing or consulting part-time with a center, he said.

Some wound centers have a dermatologist who works there a half or full day per week, but typically a dermatologist is a consultant to a wound center and sees patients with dermatologic conditions such as pyoderma gangrenosum, vasculitis, or immunobullous disease, Dr. Kirsner said in an interview.

Wound care centers that include a physician may be run from a solo or group practice or based in an ambulatory center or at a hospital. Hospital-based centers may be the more "economically savvy way of doing it," Dr. Robert D. Galiano said at the annual meeting of the American Society of Plastic Surgeons.

A center can be established independently by a physician, fully staffed by an outside company, set up by an outside company that the physician then runs, or formed by a mix of these approaches. Regardless of the type of wound care center, about 35% of all hospitals now have some sort of formal wound care center, "and I think this number is only going to increase," said Dr. Galiano, who is in the process of establishing a wound care center at Northwestern Memorial Hospital in Chicago, where he is a plastic surgeon.

To determine the best course to take for Northwestern's wound care center, Dr. Galiano visited a wound care clinic at an academic medical center, a research-intensive podiatry-based center within an academic medical center, a small university-based center that was affiliated with a wound management company, and a wound care center at a large state academic medical center that also was affiliated with a management company.

During his visits, Dr. Galiano learned that most wound care centers "will be met with a high rate of skepticism. There's a feeling out there that wound centers are loss leaders and certainly not profitable." The success of centers at large academic institutions will depend on the costs of the facility, rent, and personnel; the types of wounds treated; and the role of research as an adjunct to revenue.

All of the centers that Dr. Galiano visited were well established and profitable. Such centers were also very labor intensive and left little time for other clinical activities.

Facility costs need to be shared with or underwritten by the hospital since the costs of running a center will probably not be covered by the revenues that the center itself brings in for ambulatory visits. "You have to incorporate downstream revenue," Dr. Galiano advised.

The costs of durable medical equipment and goods, such as the best dressings, need to be controlled in some way because most academic medical centers are nonprofit and will not allow physicians to bill for the best, most expensive dressings. Arrangements could be made with another provider not affiliated with the hospital to provide those materials on-site and then bill the patient directly for them, he suggested.

The most successful centers that Dr. Galiano visited had a large volume of inpatients with chronic wounds that consisted mostly of diabetic foot ulcers, which are associated with the highest-paying diagnosis-related groups.

Dr. David L. Steed, a vascular surgeon who is director of the wound healing/limb preservation clinic at the University of Pittsburgh, handles about 4,000 patient visits per year with his colleagues. The clinic cares for venous stasis ulcers (41%), diabetic neuropathy foot ulcers (27%), ischemic ulcers (13%), pressure ulcers (10%), and other types of chronic wounds (9%).

Dr. Steed's clinic, which is not hospital based, handles all charges itself, and must break even. The clinic employs a nurse practitioner, research nurse, patient care technician, diabetes educator, and podiatrist and has one student (medical or nursing) or resident (surgery or dermatology) present at a time. Plastic and orthopedic surgeons, as well as dermatologists and diabetologists, frequently consult on cases.

"We break even in the clinic, but all the things I send to the hospital make money," he said at the meeting.

At a wound care center, it is reasonable to expect about 40% of patients to be new to the hospital and that 15% on their first visit will require hospital admission, ambulatory surgery, or angiography, Dr. Steed said. Nearly all wound center patients use radiology and laboratory services.

In another presentation, Dr. David Hurley said that he initially balked at the idea of opening a comprehensive wound care center at the hospital in which he worked as a general plastic surgeon and vice president. After the hospital opened a center without his support, he was later offered the opportunity to become its medical director.

He learned that his skepticism of wound care treatments, such as hyperbaric oxygen therapy, was unfounded. "They sent me off to a couple courses, and what I learned was that my understanding of comprehensive wound care had really stopped back with my residency training. It had not been a focus of my training," he said.

"One of the things driving the interest in the development of comprehensive wound care centers is the fact that we now have a much better understanding of the biochemistry and physiology of problem wounds," he said.

Dr. Hurley spent more and more time at the center and began looking at it as a possible exit strategy from his plastic surgery practice. Three years ago, he left his medical practice to become the chief medical officer of the management company that had helped to set up the center. That company, Diversified Clinical Services, Jacksonville, Fla., partners with hospitals to manage, operate, and develop comprehensive wound care centers.

Dermatologists can offer their expertise in wound care by directing or even opening up their own clinic. DR. KIRSNER

BALTIMORE — The increasing need for wound care centers in the United States may present an opportunity for dermatologists to wed their interests in both medical and surgical dermatology, according to Dr. Robert S. Kirsner.

"Wound care is at the junction of surgical and medical dermatology. To somebody with broad interests, it may be attractive because there are certain wound problems that require the internist in you and some wound problems that require the surgeon in you," said Dr. Kirsner, director of the Wound CURE (Cutaneous Ulcer Rehabilitation and Education) Center at the University of Miami.

Dermatologists can offer their expertise in wound care by directing or even opening up their own wound care clinic or by practicing or consulting part-time with a center, he said.

Some wound centers have a dermatologist who works there a half or full day per week, but typically a dermatologist is a consultant to a wound center and sees patients with dermatologic conditions such as pyoderma gangrenosum, vasculitis, or immunobullous disease, Dr. Kirsner said in an interview.

Wound care centers that include a physician may be run from a solo or group practice or based in an ambulatory center or at a hospital. Hospital-based centers may be the more "economically savvy way of doing it," Dr. Robert D. Galiano said at the annual meeting of the American Society of Plastic Surgeons.

A center can be established independently by a physician, fully staffed by an outside company, set up by an outside company that the physician then runs, or formed by a mix of these approaches. Regardless of the type of wound care center, about 35% of all hospitals now have some sort of formal wound care center, "and I think this number is only going to increase," said Dr. Galiano, who is in the process of establishing a wound care center at Northwestern Memorial Hospital in Chicago, where he is a plastic surgeon.

To determine the best course to take for Northwestern's wound care center, Dr. Galiano visited a wound care clinic at an academic medical center, a research-intensive podiatry-based center within an academic medical center, a small university-based center that was affiliated with a wound management company, and a wound care center at a large state academic medical center that also was affiliated with a management company.

During his visits, Dr. Galiano learned that most wound care centers "will be met with a high rate of skepticism. There's a feeling out there that wound centers are loss leaders and certainly not profitable." The success of centers at large academic institutions will depend on the costs of the facility, rent, and personnel; the types of wounds treated; and the role of research as an adjunct to revenue.

All of the centers that Dr. Galiano visited were well established and profitable. Such centers were also very labor intensive and left little time for other clinical activities.

Facility costs need to be shared with or underwritten by the hospital since the costs of running a center will probably not be covered by the revenues that the center itself brings in for ambulatory visits. "You have to incorporate downstream revenue," Dr. Galiano advised.

The costs of durable medical equipment and goods, such as the best dressings, need to be controlled in some way because most academic medical centers are nonprofit and will not allow physicians to bill for the best, most expensive dressings. Arrangements could be made with another provider not affiliated with the hospital to provide those materials on-site and then bill the patient directly for them, he suggested.

The most successful centers that Dr. Galiano visited had a large volume of inpatients with chronic wounds that consisted mostly of diabetic foot ulcers, which are associated with the highest-paying diagnosis-related groups.

Dr. David L. Steed, a vascular surgeon who is director of the wound healing/limb preservation clinic at the University of Pittsburgh, handles about 4,000 patient visits per year with his colleagues. The clinic cares for venous stasis ulcers (41%), diabetic neuropathy foot ulcers (27%), ischemic ulcers (13%), pressure ulcers (10%), and other types of chronic wounds (9%).

Dr. Steed's clinic, which is not hospital based, handles all charges itself, and must break even. The clinic employs a nurse practitioner, research nurse, patient care technician, diabetes educator, and podiatrist and has one student (medical or nursing) or resident (surgery or dermatology) present at a time. Plastic and orthopedic surgeons, as well as dermatologists and diabetologists, frequently consult on cases.

"We break even in the clinic, but all the things I send to the hospital make money," he said at the meeting.

At a wound care center, it is reasonable to expect about 40% of patients to be new to the hospital and that 15% on their first visit will require hospital admission, ambulatory surgery, or angiography, Dr. Steed said. Nearly all wound center patients use radiology and laboratory services.

In another presentation, Dr. David Hurley said that he initially balked at the idea of opening a comprehensive wound care center at the hospital in which he worked as a general plastic surgeon and vice president. After the hospital opened a center without his support, he was later offered the opportunity to become its medical director.

He learned that his skepticism of wound care treatments, such as hyperbaric oxygen therapy, was unfounded. "They sent me off to a couple courses, and what I learned was that my understanding of comprehensive wound care had really stopped back with my residency training. It had not been a focus of my training," he said.

"One of the things driving the interest in the development of comprehensive wound care centers is the fact that we now have a much better understanding of the biochemistry and physiology of problem wounds," he said.

Dr. Hurley spent more and more time at the center and began looking at it as a possible exit strategy from his plastic surgery practice. Three years ago, he left his medical practice to become the chief medical officer of the management company that had helped to set up the center. That company, Diversified Clinical Services, Jacksonville, Fla., partners with hospitals to manage, operate, and develop comprehensive wound care centers.

Dermatologists can offer their expertise in wound care by directing or even opening up their own clinic. DR. KIRSNER

The medical and nonmedical costs of group A streptococcal pharyngitis in American children and adolescents add up to an estimated $205 per case, or between $224 million and $539 million annually across the country, according to results of the first study to collect empiric data of this type for the illness.

The results of the study suggest that not only might routine vaccination of school-aged children with a group A streptococcal (GAS) vaccine prevent pharyngitis, but it also could reduce unnecessary antibiotic use and the transmission of GAS infection within the community, reported Elizabeth Pfoh of Harvard Medical School, Boston, and her associates (Pediatrics 2008;121:229–34).

Ms. Pfoh and her colleagues conducted a survey over the telephone with one parent from 135 (57%) of the 236 eligible families with at least one episode of GAS pharyngitis who presented to two pediatric practice sites in the Boston metropolitan area during 2005–2006.

Children who presented to the practices were ill with symptoms associated with GAS pharyngitis for a mean of 4.5 days. In 29% of the cases, at least one other family member developed GAS pharyngitis after the index case. These transmissions led to a mean of 2.6 sick family members other than the index case in households where transmission occurred. Within families, the overall mean secondary attack rate was 20%.

The children who had GAS pharyngitis missed an average of 1.9 days of school or day care, whereas 57 of the 135 parents who were surveyed missed an average of 1.8 workdays to care for their child. A second parent or caregiver missed a mean of 1.5 workdays in 14% of the families. A little more than half of the survey respondents also said that they missed an average of 0.3 days of personal time during their child's illness.

Most of the children with GAS pharyngitis required only one outpatient visit (87%). None of the children required hospitalization for complications associated with the condition.

The investigators extrapolated from their findings to the U.S. population with various national estimates for health service utilization data, costs of services, and values of work and personal time lost to calculate the total costs in 2006 dollars.

Although the combined mean medical ($118) and nonmedical ($87) costs for each case of GAS pharyngitis were less than what has been reported for otitis media in children ($262) or pertussis in adolescents ($397), the fact that GAS pharyngitis occurs more frequently than these other infections means that there potentially could be significant economic benefits in preventing GAS pharyngitis, according to Ms. Pfoh and her coinvestigators.

The medical costs associated with GAS pharyngitis were attributable to outpatient visits (52%), followed by antibiotic treatment (24%), diagnostic testing (17%), and emergency department visits (7%). Nonmedical costs comprised time costs (46%), child care expenses (16%), transportation (15%), deductibles or copayments (15%), and over-the-counter medications (8%).

The investigators suggested that their study was limited in its generalizability because of its small sample size and its largely middle-class, English-speaking participants. They tried to limit recall bias by surveying parents between 2 and 6 weeks after the illness episode.

Any inclusion of GAS carriers who did not have true acute infections may have been balanced by the fact that the investigators did not include costs incurred by sick family members, costs of missed school days, and costs of complications.

ELSEVIER GLOBAL MEDICAL NEWS

The medical and nonmedical costs of group A streptococcal pharyngitis in American children and adolescents add up to an estimated $205 per case, or between $224 million and $539 million annually across the country, according to results of the first study to collect empiric data of this type for the illness.

The results of the study suggest that not only might routine vaccination of school-aged children with a group A streptococcal (GAS) vaccine prevent pharyngitis, but it also could reduce unnecessary antibiotic use and the transmission of GAS infection within the community, reported Elizabeth Pfoh of Harvard Medical School, Boston, and her associates (Pediatrics 2008;121:229–34).

Ms. Pfoh and her colleagues conducted a survey over the telephone with one parent from 135 (57%) of the 236 eligible families with at least one episode of GAS pharyngitis who presented to two pediatric practice sites in the Boston metropolitan area during 2005–2006.

Children who presented to the practices were ill with symptoms associated with GAS pharyngitis for a mean of 4.5 days. In 29% of the cases, at least one other family member developed GAS pharyngitis after the index case. These transmissions led to a mean of 2.6 sick family members other than the index case in households where transmission occurred. Within families, the overall mean secondary attack rate was 20%.

The children who had GAS pharyngitis missed an average of 1.9 days of school or day care, whereas 57 of the 135 parents who were surveyed missed an average of 1.8 workdays to care for their child. A second parent or caregiver missed a mean of 1.5 workdays in 14% of the families. A little more than half of the survey respondents also said that they missed an average of 0.3 days of personal time during their child's illness.

Most of the children with GAS pharyngitis required only one outpatient visit (87%). None of the children required hospitalization for complications associated with the condition.

The investigators extrapolated from their findings to the U.S. population with various national estimates for health service utilization data, costs of services, and values of work and personal time lost to calculate the total costs in 2006 dollars.

Although the combined mean medical ($118) and nonmedical ($87) costs for each case of GAS pharyngitis were less than what has been reported for otitis media in children ($262) or pertussis in adolescents ($397), the fact that GAS pharyngitis occurs more frequently than these other infections means that there potentially could be significant economic benefits in preventing GAS pharyngitis, according to Ms. Pfoh and her coinvestigators.

The medical costs associated with GAS pharyngitis were attributable to outpatient visits (52%), followed by antibiotic treatment (24%), diagnostic testing (17%), and emergency department visits (7%). Nonmedical costs comprised time costs (46%), child care expenses (16%), transportation (15%), deductibles or copayments (15%), and over-the-counter medications (8%).

The investigators suggested that their study was limited in its generalizability because of its small sample size and its largely middle-class, English-speaking participants. They tried to limit recall bias by surveying parents between 2 and 6 weeks after the illness episode.

Any inclusion of GAS carriers who did not have true acute infections may have been balanced by the fact that the investigators did not include costs incurred by sick family members, costs of missed school days, and costs of complications.

ELSEVIER GLOBAL MEDICAL NEWS

The medical and nonmedical costs of group A streptococcal pharyngitis in American children and adolescents add up to an estimated $205 per case, or between $224 million and $539 million annually across the country, according to results of the first study to collect empiric data of this type for the illness.

The results of the study suggest that not only might routine vaccination of school-aged children with a group A streptococcal (GAS) vaccine prevent pharyngitis, but it also could reduce unnecessary antibiotic use and the transmission of GAS infection within the community, reported Elizabeth Pfoh of Harvard Medical School, Boston, and her associates (Pediatrics 2008;121:229–34).

Ms. Pfoh and her colleagues conducted a survey over the telephone with one parent from 135 (57%) of the 236 eligible families with at least one episode of GAS pharyngitis who presented to two pediatric practice sites in the Boston metropolitan area during 2005–2006.

Children who presented to the practices were ill with symptoms associated with GAS pharyngitis for a mean of 4.5 days. In 29% of the cases, at least one other family member developed GAS pharyngitis after the index case. These transmissions led to a mean of 2.6 sick family members other than the index case in households where transmission occurred. Within families, the overall mean secondary attack rate was 20%.

The children who had GAS pharyngitis missed an average of 1.9 days of school or day care, whereas 57 of the 135 parents who were surveyed missed an average of 1.8 workdays to care for their child. A second parent or caregiver missed a mean of 1.5 workdays in 14% of the families. A little more than half of the survey respondents also said that they missed an average of 0.3 days of personal time during their child's illness.

Most of the children with GAS pharyngitis required only one outpatient visit (87%). None of the children required hospitalization for complications associated with the condition.

The investigators extrapolated from their findings to the U.S. population with various national estimates for health service utilization data, costs of services, and values of work and personal time lost to calculate the total costs in 2006 dollars.

Although the combined mean medical ($118) and nonmedical ($87) costs for each case of GAS pharyngitis were less than what has been reported for otitis media in children ($262) or pertussis in adolescents ($397), the fact that GAS pharyngitis occurs more frequently than these other infections means that there potentially could be significant economic benefits in preventing GAS pharyngitis, according to Ms. Pfoh and her coinvestigators.

The medical costs associated with GAS pharyngitis were attributable to outpatient visits (52%), followed by antibiotic treatment (24%), diagnostic testing (17%), and emergency department visits (7%). Nonmedical costs comprised time costs (46%), child care expenses (16%), transportation (15%), deductibles or copayments (15%), and over-the-counter medications (8%).

The investigators suggested that their study was limited in its generalizability because of its small sample size and its largely middle-class, English-speaking participants. They tried to limit recall bias by surveying parents between 2 and 6 weeks after the illness episode.

Any inclusion of GAS carriers who did not have true acute infections may have been balanced by the fact that the investigators did not include costs incurred by sick family members, costs of missed school days, and costs of complications.

ELSEVIER GLOBAL MEDICAL NEWS

An educational program for anticipating and managing ear pain, presented by nurses to parents at the 15-month well-child visit, significantly cut health care costs over the following year, especially for emergency department visits.

Parents and physicians alike gave high marks to the program, which reduced visits to the emergency department (ED) for acute otitis media (AOM) by 80% and yielded a net savings of about $50 per child, Dr. Deborah B. McWilliams and her colleagues at the Mayo Clinic, Rochester, Minn., wrote (Arch. Pediatr. Adolesc. Med. 2008;162:151–6).

In an editorial in the same issue, Dr. Stephen Berman of the Children's Hospital, Denver, wrote that the program “demonstrates one of the small steps that can be taken to shift our emphasis to parental empowerment and shared decision making” to improve performance in pediatric practice while also reducing costs to maximize the value of health care services (Arch. Pediatr. Adolesc. Med. 2008;162:186–8).

In the controlled study that was conducted during a 3-month period in 2003, nurses gave 5- to 10-minute structured PowerPoint presentations to the parents of 191 children who were being seen for their 15-month well-child visit. The investigators also recruited a control cohort of 133 children at any of the other Mayo Clinic practices at the time of the interventions. Children with tympanostomy tubes were not allowed into the study.

The presentation reviewed how to recognize ear pain, how to safely relieve pain (including the use of antipyrine-benzocaine analgesic ear drops as well as dosing instructions for ibuprofen and acetaminophen), and how to recognize the danger signs that require urgent medical attention. The nurses also explained why it would be beneficial to schedule an appointment with the child's pediatrician on the following day for possible AOM, rather than going to the ED after hours.

Compared with the previous year, ED visits declined by 80%, urgent care visits dropped by 40%, and regular-hours primary care office visits decreased by 28% in the intervention group. The control arm saw no significant decrease in visits to these venues.

Of 88 parent responses to survey questions at the 24-month well-child visit, 42% said that their child had experienced ear pain since the 15-month well-child visit. In that subgroup of parents, 86% thought that the educational program had helped them to avoid an ED or after-hours visit. Nearly 90% of these respondents thought that the prescription for antipyrine-benzocaine otic drops that each parent was given at the 15-month well-child visit also had helped them to avoid an ED or after-hours visit.

“Because total visits for ear pain also decreased significantly, there must have been not only a potential shift from after-hours visits to primary care but also a realization by parents that much of the ear pain is controllable and transient, not always requiring a medical appointment,” Dr. Berman wrote.

Parental support for the intervention was very high among the 97 survey respondents at the 15-month well-child visit, and also among the 88 respondents at the 24-month visit.

A 3-year review of medical records since the intervention revealed no cases of mastoiditis or otolaryngologic, ED, or hospital visits that could be attributed to a delay in medical attention or antibiotic therapy.

The estimated costs of the project would have totaled $12,040 per 1,000 patients, saving at least $65,779 per 1,000 patients based on the cost of ED, urgent care center, and regular hours primary care visits at the Mayo Clinic. This translated into a net savings of about $50 per child.

Other than an absence of randomization, the study was limited by a reliance on control data from other local clinic sites, a lack of information on parent education levels in the groups, and a lack of data on how many patients used or filled the prescription.

An educational program for anticipating and managing ear pain, presented by nurses to parents at the 15-month well-child visit, significantly cut health care costs over the following year, especially for emergency department visits.

Parents and physicians alike gave high marks to the program, which reduced visits to the emergency department (ED) for acute otitis media (AOM) by 80% and yielded a net savings of about $50 per child, Dr. Deborah B. McWilliams and her colleagues at the Mayo Clinic, Rochester, Minn., wrote (Arch. Pediatr. Adolesc. Med. 2008;162:151–6).

In an editorial in the same issue, Dr. Stephen Berman of the Children's Hospital, Denver, wrote that the program “demonstrates one of the small steps that can be taken to shift our emphasis to parental empowerment and shared decision making” to improve performance in pediatric practice while also reducing costs to maximize the value of health care services (Arch. Pediatr. Adolesc. Med. 2008;162:186–8).

In the controlled study that was conducted during a 3-month period in 2003, nurses gave 5- to 10-minute structured PowerPoint presentations to the parents of 191 children who were being seen for their 15-month well-child visit. The investigators also recruited a control cohort of 133 children at any of the other Mayo Clinic practices at the time of the interventions. Children with tympanostomy tubes were not allowed into the study.

The presentation reviewed how to recognize ear pain, how to safely relieve pain (including the use of antipyrine-benzocaine analgesic ear drops as well as dosing instructions for ibuprofen and acetaminophen), and how to recognize the danger signs that require urgent medical attention. The nurses also explained why it would be beneficial to schedule an appointment with the child's pediatrician on the following day for possible AOM, rather than going to the ED after hours.

Compared with the previous year, ED visits declined by 80%, urgent care visits dropped by 40%, and regular-hours primary care office visits decreased by 28% in the intervention group. The control arm saw no significant decrease in visits to these venues.

Of 88 parent responses to survey questions at the 24-month well-child visit, 42% said that their child had experienced ear pain since the 15-month well-child visit. In that subgroup of parents, 86% thought that the educational program had helped them to avoid an ED or after-hours visit. Nearly 90% of these respondents thought that the prescription for antipyrine-benzocaine otic drops that each parent was given at the 15-month well-child visit also had helped them to avoid an ED or after-hours visit.

“Because total visits for ear pain also decreased significantly, there must have been not only a potential shift from after-hours visits to primary care but also a realization by parents that much of the ear pain is controllable and transient, not always requiring a medical appointment,” Dr. Berman wrote.

Parental support for the intervention was very high among the 97 survey respondents at the 15-month well-child visit, and also among the 88 respondents at the 24-month visit.

A 3-year review of medical records since the intervention revealed no cases of mastoiditis or otolaryngologic, ED, or hospital visits that could be attributed to a delay in medical attention or antibiotic therapy.

The estimated costs of the project would have totaled $12,040 per 1,000 patients, saving at least $65,779 per 1,000 patients based on the cost of ED, urgent care center, and regular hours primary care visits at the Mayo Clinic. This translated into a net savings of about $50 per child.

Other than an absence of randomization, the study was limited by a reliance on control data from other local clinic sites, a lack of information on parent education levels in the groups, and a lack of data on how many patients used or filled the prescription.

An educational program for anticipating and managing ear pain, presented by nurses to parents at the 15-month well-child visit, significantly cut health care costs over the following year, especially for emergency department visits.

Parents and physicians alike gave high marks to the program, which reduced visits to the emergency department (ED) for acute otitis media (AOM) by 80% and yielded a net savings of about $50 per child, Dr. Deborah B. McWilliams and her colleagues at the Mayo Clinic, Rochester, Minn., wrote (Arch. Pediatr. Adolesc. Med. 2008;162:151–6).

In an editorial in the same issue, Dr. Stephen Berman of the Children's Hospital, Denver, wrote that the program “demonstrates one of the small steps that can be taken to shift our emphasis to parental empowerment and shared decision making” to improve performance in pediatric practice while also reducing costs to maximize the value of health care services (Arch. Pediatr. Adolesc. Med. 2008;162:186–8).

In the controlled study that was conducted during a 3-month period in 2003, nurses gave 5- to 10-minute structured PowerPoint presentations to the parents of 191 children who were being seen for their 15-month well-child visit. The investigators also recruited a control cohort of 133 children at any of the other Mayo Clinic practices at the time of the interventions. Children with tympanostomy tubes were not allowed into the study.

The presentation reviewed how to recognize ear pain, how to safely relieve pain (including the use of antipyrine-benzocaine analgesic ear drops as well as dosing instructions for ibuprofen and acetaminophen), and how to recognize the danger signs that require urgent medical attention. The nurses also explained why it would be beneficial to schedule an appointment with the child's pediatrician on the following day for possible AOM, rather than going to the ED after hours.

Compared with the previous year, ED visits declined by 80%, urgent care visits dropped by 40%, and regular-hours primary care office visits decreased by 28% in the intervention group. The control arm saw no significant decrease in visits to these venues.

Of 88 parent responses to survey questions at the 24-month well-child visit, 42% said that their child had experienced ear pain since the 15-month well-child visit. In that subgroup of parents, 86% thought that the educational program had helped them to avoid an ED or after-hours visit. Nearly 90% of these respondents thought that the prescription for antipyrine-benzocaine otic drops that each parent was given at the 15-month well-child visit also had helped them to avoid an ED or after-hours visit.

“Because total visits for ear pain also decreased significantly, there must have been not only a potential shift from after-hours visits to primary care but also a realization by parents that much of the ear pain is controllable and transient, not always requiring a medical appointment,” Dr. Berman wrote.

Parental support for the intervention was very high among the 97 survey respondents at the 15-month well-child visit, and also among the 88 respondents at the 24-month visit.

A 3-year review of medical records since the intervention revealed no cases of mastoiditis or otolaryngologic, ED, or hospital visits that could be attributed to a delay in medical attention or antibiotic therapy.

The estimated costs of the project would have totaled $12,040 per 1,000 patients, saving at least $65,779 per 1,000 patients based on the cost of ED, urgent care center, and regular hours primary care visits at the Mayo Clinic. This translated into a net savings of about $50 per child.

Other than an absence of randomization, the study was limited by a reliance on control data from other local clinic sites, a lack of information on parent education levels in the groups, and a lack of data on how many patients used or filled the prescription.

Use of social networking Web sites poses no greater risk of sexual solicitation and harassment of children than do other online behaviors, according to the results of an e-mail survey of 1,588 preteens and teens.

“Our findings suggest that online interpersonal victimizations do not seem to occur to any greater degree and, in fact, seem to occur to a lesser degree in social networking sites than other places online where youth communicate with others,” wrote Michele L. Ybarra, Ph.D., of Internet Solutions for Kids Inc., Santa Ana, Calif., and Kimberly J. Mitchell, Ph.D., of the Crimes Against Children Research Center at the University of New Hampshire, Durham (Pediatrics 2008;121:e350–7).

Despite the lack of any objective study on the risk of sexual solicitation or harassment of children or young adolescents on social networking Web sites, legislators have made calls in recent years for laws to restrict minors' access to these sites, according to Dr. Ybarra and Dr. Mitchell.

To determine whether such sites do pose a higher than normal risk for a child's being sexually solicited or harassed, the investigators sent e-mails about the survey to adults with children or adolescents aged 10–15 years who had opted to become members of Harris Poll Online.

A total of 1,588 preteens and teens participated in the online study after an adult finished a brief survey, yielding a response rate of 26%, which is “within the expected range of well-conducted online surveys,” the investigators observed.

When the preteens and teens were asked the two activities at which they spent most of their time online, visiting social networking sites was reported as one of the two activities by 17% of the respondents; 47% reported playing games and 23% reported instant messaging as one of the two activities.

In the study, 15% of all subjects reported being targeted by unwanted sexual solicitation within the last year. Having unwanted sexual solicitation was defined as having experienced at least one episode in which someone tried to get them to talk about sex online when they did not want to, asked them to give sexual information about themselves when they did not want to, or asked them to do something sexual when they were online that they did not want to do. But only 4% of all the preteens and teens said they had been targeted in this way on a social networking site specifically.

A total of 34% of the subjects had experienced harassment within the last year in the form of a rude, mean, threatening, or aggressive comment made to them online, or the spreading of false rumors about them online. But again, only 9% of all preteens and teens reported being harassed while on a social networking site specifically.

Some of the online behaviors–such as visiting chat rooms, during which the greatest percentage of respondents reported experiencing either sexual solicitation or harassment–were among the activities in which subjects reported spending the least amount of time online.

Preteens and teens who received unwanted sexual solicitations on social networking sites were significantly more likely to be female than were those who were solicited elsewhere online (80% versus 53%). Victims of harassment on social networking sites were also more likely to be female than were those who had such experiences elsewhere online (66% versus 48%).

The investigators weighted the data (including all percentages) to reflect the U.S. population of adults with children or adolescents in the 10- to 15-year-old age group, and the propensity of the children or teens to be online.

“Time and money spent on proposed legislation and legal action aimed at these sites may have a greater impact if they are focused on other areas of prevention, such as funding for online youth outreach programs, school antibullying programs, and online mental health services,” the researchers wrote.

They encouraged physicians to educate parents and children about what behaviors do and do not increase the likehood of interpersonal victimization. In addition, the authors said, physicians should help parents understand that the child's psychosocial profile and general outline behaviors are more likely to influence the likelihood of the child's online victimization than the actual technology.

Use of social networking Web sites poses no greater risk of sexual solicitation and harassment of children than do other online behaviors, according to the results of an e-mail survey of 1,588 preteens and teens.

“Our findings suggest that online interpersonal victimizations do not seem to occur to any greater degree and, in fact, seem to occur to a lesser degree in social networking sites than other places online where youth communicate with others,” wrote Michele L. Ybarra, Ph.D., of Internet Solutions for Kids Inc., Santa Ana, Calif., and Kimberly J. Mitchell, Ph.D., of the Crimes Against Children Research Center at the University of New Hampshire, Durham (Pediatrics 2008;121:e350–7).

Despite the lack of any objective study on the risk of sexual solicitation or harassment of children or young adolescents on social networking Web sites, legislators have made calls in recent years for laws to restrict minors' access to these sites, according to Dr. Ybarra and Dr. Mitchell.

To determine whether such sites do pose a higher than normal risk for a child's being sexually solicited or harassed, the investigators sent e-mails about the survey to adults with children or adolescents aged 10–15 years who had opted to become members of Harris Poll Online.

A total of 1,588 preteens and teens participated in the online study after an adult finished a brief survey, yielding a response rate of 26%, which is “within the expected range of well-conducted online surveys,” the investigators observed.

When the preteens and teens were asked the two activities at which they spent most of their time online, visiting social networking sites was reported as one of the two activities by 17% of the respondents; 47% reported playing games and 23% reported instant messaging as one of the two activities.

In the study, 15% of all subjects reported being targeted by unwanted sexual solicitation within the last year. Having unwanted sexual solicitation was defined as having experienced at least one episode in which someone tried to get them to talk about sex online when they did not want to, asked them to give sexual information about themselves when they did not want to, or asked them to do something sexual when they were online that they did not want to do. But only 4% of all the preteens and teens said they had been targeted in this way on a social networking site specifically.

A total of 34% of the subjects had experienced harassment within the last year in the form of a rude, mean, threatening, or aggressive comment made to them online, or the spreading of false rumors about them online. But again, only 9% of all preteens and teens reported being harassed while on a social networking site specifically.

Some of the online behaviors–such as visiting chat rooms, during which the greatest percentage of respondents reported experiencing either sexual solicitation or harassment–were among the activities in which subjects reported spending the least amount of time online.

Preteens and teens who received unwanted sexual solicitations on social networking sites were significantly more likely to be female than were those who were solicited elsewhere online (80% versus 53%). Victims of harassment on social networking sites were also more likely to be female than were those who had such experiences elsewhere online (66% versus 48%).

The investigators weighted the data (including all percentages) to reflect the U.S. population of adults with children or adolescents in the 10- to 15-year-old age group, and the propensity of the children or teens to be online.

“Time and money spent on proposed legislation and legal action aimed at these sites may have a greater impact if they are focused on other areas of prevention, such as funding for online youth outreach programs, school antibullying programs, and online mental health services,” the researchers wrote.

They encouraged physicians to educate parents and children about what behaviors do and do not increase the likehood of interpersonal victimization. In addition, the authors said, physicians should help parents understand that the child's psychosocial profile and general outline behaviors are more likely to influence the likelihood of the child's online victimization than the actual technology.

Use of social networking Web sites poses no greater risk of sexual solicitation and harassment of children than do other online behaviors, according to the results of an e-mail survey of 1,588 preteens and teens.

“Our findings suggest that online interpersonal victimizations do not seem to occur to any greater degree and, in fact, seem to occur to a lesser degree in social networking sites than other places online where youth communicate with others,” wrote Michele L. Ybarra, Ph.D., of Internet Solutions for Kids Inc., Santa Ana, Calif., and Kimberly J. Mitchell, Ph.D., of the Crimes Against Children Research Center at the University of New Hampshire, Durham (Pediatrics 2008;121:e350–7).

Despite the lack of any objective study on the risk of sexual solicitation or harassment of children or young adolescents on social networking Web sites, legislators have made calls in recent years for laws to restrict minors' access to these sites, according to Dr. Ybarra and Dr. Mitchell.

To determine whether such sites do pose a higher than normal risk for a child's being sexually solicited or harassed, the investigators sent e-mails about the survey to adults with children or adolescents aged 10–15 years who had opted to become members of Harris Poll Online.

A total of 1,588 preteens and teens participated in the online study after an adult finished a brief survey, yielding a response rate of 26%, which is “within the expected range of well-conducted online surveys,” the investigators observed.

When the preteens and teens were asked the two activities at which they spent most of their time online, visiting social networking sites was reported as one of the two activities by 17% of the respondents; 47% reported playing games and 23% reported instant messaging as one of the two activities.

In the study, 15% of all subjects reported being targeted by unwanted sexual solicitation within the last year. Having unwanted sexual solicitation was defined as having experienced at least one episode in which someone tried to get them to talk about sex online when they did not want to, asked them to give sexual information about themselves when they did not want to, or asked them to do something sexual when they were online that they did not want to do. But only 4% of all the preteens and teens said they had been targeted in this way on a social networking site specifically.

A total of 34% of the subjects had experienced harassment within the last year in the form of a rude, mean, threatening, or aggressive comment made to them online, or the spreading of false rumors about them online. But again, only 9% of all preteens and teens reported being harassed while on a social networking site specifically.

Some of the online behaviors–such as visiting chat rooms, during which the greatest percentage of respondents reported experiencing either sexual solicitation or harassment–were among the activities in which subjects reported spending the least amount of time online.

Preteens and teens who received unwanted sexual solicitations on social networking sites were significantly more likely to be female than were those who were solicited elsewhere online (80% versus 53%). Victims of harassment on social networking sites were also more likely to be female than were those who had such experiences elsewhere online (66% versus 48%).

The investigators weighted the data (including all percentages) to reflect the U.S. population of adults with children or adolescents in the 10- to 15-year-old age group, and the propensity of the children or teens to be online.

“Time and money spent on proposed legislation and legal action aimed at these sites may have a greater impact if they are focused on other areas of prevention, such as funding for online youth outreach programs, school antibullying programs, and online mental health services,” the researchers wrote.

They encouraged physicians to educate parents and children about what behaviors do and do not increase the likehood of interpersonal victimization. In addition, the authors said, physicians should help parents understand that the child's psychosocial profile and general outline behaviors are more likely to influence the likelihood of the child's online victimization than the actual technology.

BALTIMORE – Veterans who screen positive for posttraumatic stress disorder but are not clinically diagnosed with the condition have significantly different presentation from that of clinically diagnosed veterans, Kathryn M. Magruder, Ph.D., reported at the annual meeting of the International Society for Traumatic Stress Studies.

In one of the only two studies that have reported the percentage of veterans correctly diagnosed with PTSD in primary care clinics, Dr. Magruder of the department of psychiatry and behavioral sciences, Medical University of South Carolina, and her colleagues at the Ralph H. Johnson Veterans Affairs Medical Center, both in Charleston, previously found that primary care physicians correctly identified PTSD in 47% of veterans who had the condition (Gen. Hosp. Psychiatry 2005;27:169-79).

The other study, an Israeli national sample of primary care providers, reported a “pretty dismal rate of recognition” of PTSD of only 2% (Psychol. Med. 2001;31:555-60).

Dr. Magruder and her associates wanted to determine why primary care clinicians frequently miss PTSD diagnoses, so they randomly selected 819 primary care patients from four VA medical centers to participate. Of 98 (12%) patients who screened positive for PTSD on the Clinician-Administered PTSD Scale, only 42 (43%) were correctly recognized as having PTSD (defined as an ICD-9 diagnosis of PTSD).

Many researchers have suggested that somatic symptoms, such as pain, might divert the attention of primary care physicians so that they pursue a medical diagnosis rather than a psychiatric one. But previous studies have had conflicting results, with pain symptoms found both to make physicians more apt to miss a psychiatric diagnosis and to increase the likelihood they will make a correct psychiatric diagnosis, Dr. Magruder said.

In this study, veterans aged 65 years and older who tested positive for PTSD on the Clinician-Administered PTSD Scale were significantly more likely to have their PTSD go unrecognized by a primary care clinician (67%, 12 of 18 patients) than to have it diagnosed (33%, 6 of 18). Veterans without war zone service who screened positive also had significantly higher rates of unrecognized PTSD (75%, 21 of 28) than rates of diagnosed PTSD (25%, 7 of 28).

Patients who had worse functioning on the role-emotional subscale of the Short Form-36 quality of life questionnaire were more likely to be recognized as having PTSD. Mental health and pain subscales on the SF-36 did not show significant differences between patients according to their PTSD recognition status.

Patients who had an ICD-9 musculoskeletal pain diagnosis were 3.5 times more likely to be recognized as having PTSD than were those who did not have such a diagnosis, after adjusting for age, race, gender, and war zone service.

In addition, patients with substance use disorders were nearly 10 times more likely to be recognized as having PTSD than were patients without substance use problems.

“This study argues that we really ought to pay better attention to screening results” and that physicians should receive additional training in nonclassic PTSD presentations, Dr. Magruder said at the meeting, which was also sponsored by Boston University.

In the study, “providers may have picked up on more of the obvious presentations of PTSD,” such as poor emotional functioning, persistent reexperiencing, and increased arousal.

One limitation of the study is that the data were collected prior to Operation Enduring Freedom and Operation Iraqi Freedom. The younger group of patients in those conflicts could have “sensitized clinicians to look more closely at presentations in younger patients,” Dr. Magruder suggested.

The study also did not take into account provider-level factors and problems in the scheduling or duration of clinical visits.

BALTIMORE – Veterans who screen positive for posttraumatic stress disorder but are not clinically diagnosed with the condition have significantly different presentation from that of clinically diagnosed veterans, Kathryn M. Magruder, Ph.D., reported at the annual meeting of the International Society for Traumatic Stress Studies.

In one of the only two studies that have reported the percentage of veterans correctly diagnosed with PTSD in primary care clinics, Dr. Magruder of the department of psychiatry and behavioral sciences, Medical University of South Carolina, and her colleagues at the Ralph H. Johnson Veterans Affairs Medical Center, both in Charleston, previously found that primary care physicians correctly identified PTSD in 47% of veterans who had the condition (Gen. Hosp. Psychiatry 2005;27:169-79).

The other study, an Israeli national sample of primary care providers, reported a “pretty dismal rate of recognition” of PTSD of only 2% (Psychol. Med. 2001;31:555-60).

Dr. Magruder and her associates wanted to determine why primary care clinicians frequently miss PTSD diagnoses, so they randomly selected 819 primary care patients from four VA medical centers to participate. Of 98 (12%) patients who screened positive for PTSD on the Clinician-Administered PTSD Scale, only 42 (43%) were correctly recognized as having PTSD (defined as an ICD-9 diagnosis of PTSD).

Many researchers have suggested that somatic symptoms, such as pain, might divert the attention of primary care physicians so that they pursue a medical diagnosis rather than a psychiatric one. But previous studies have had conflicting results, with pain symptoms found both to make physicians more apt to miss a psychiatric diagnosis and to increase the likelihood they will make a correct psychiatric diagnosis, Dr. Magruder said.

In this study, veterans aged 65 years and older who tested positive for PTSD on the Clinician-Administered PTSD Scale were significantly more likely to have their PTSD go unrecognized by a primary care clinician (67%, 12 of 18 patients) than to have it diagnosed (33%, 6 of 18). Veterans without war zone service who screened positive also had significantly higher rates of unrecognized PTSD (75%, 21 of 28) than rates of diagnosed PTSD (25%, 7 of 28).

Patients who had worse functioning on the role-emotional subscale of the Short Form-36 quality of life questionnaire were more likely to be recognized as having PTSD. Mental health and pain subscales on the SF-36 did not show significant differences between patients according to their PTSD recognition status.

Patients who had an ICD-9 musculoskeletal pain diagnosis were 3.5 times more likely to be recognized as having PTSD than were those who did not have such a diagnosis, after adjusting for age, race, gender, and war zone service.

In addition, patients with substance use disorders were nearly 10 times more likely to be recognized as having PTSD than were patients without substance use problems.

“This study argues that we really ought to pay better attention to screening results” and that physicians should receive additional training in nonclassic PTSD presentations, Dr. Magruder said at the meeting, which was also sponsored by Boston University.

In the study, “providers may have picked up on more of the obvious presentations of PTSD,” such as poor emotional functioning, persistent reexperiencing, and increased arousal.

One limitation of the study is that the data were collected prior to Operation Enduring Freedom and Operation Iraqi Freedom. The younger group of patients in those conflicts could have “sensitized clinicians to look more closely at presentations in younger patients,” Dr. Magruder suggested.

The study also did not take into account provider-level factors and problems in the scheduling or duration of clinical visits.

BALTIMORE – Veterans who screen positive for posttraumatic stress disorder but are not clinically diagnosed with the condition have significantly different presentation from that of clinically diagnosed veterans, Kathryn M. Magruder, Ph.D., reported at the annual meeting of the International Society for Traumatic Stress Studies.

In one of the only two studies that have reported the percentage of veterans correctly diagnosed with PTSD in primary care clinics, Dr. Magruder of the department of psychiatry and behavioral sciences, Medical University of South Carolina, and her colleagues at the Ralph H. Johnson Veterans Affairs Medical Center, both in Charleston, previously found that primary care physicians correctly identified PTSD in 47% of veterans who had the condition (Gen. Hosp. Psychiatry 2005;27:169-79).

The other study, an Israeli national sample of primary care providers, reported a “pretty dismal rate of recognition” of PTSD of only 2% (Psychol. Med. 2001;31:555-60).

Dr. Magruder and her associates wanted to determine why primary care clinicians frequently miss PTSD diagnoses, so they randomly selected 819 primary care patients from four VA medical centers to participate. Of 98 (12%) patients who screened positive for PTSD on the Clinician-Administered PTSD Scale, only 42 (43%) were correctly recognized as having PTSD (defined as an ICD-9 diagnosis of PTSD).

Many researchers have suggested that somatic symptoms, such as pain, might divert the attention of primary care physicians so that they pursue a medical diagnosis rather than a psychiatric one. But previous studies have had conflicting results, with pain symptoms found both to make physicians more apt to miss a psychiatric diagnosis and to increase the likelihood they will make a correct psychiatric diagnosis, Dr. Magruder said.

In this study, veterans aged 65 years and older who tested positive for PTSD on the Clinician-Administered PTSD Scale were significantly more likely to have their PTSD go unrecognized by a primary care clinician (67%, 12 of 18 patients) than to have it diagnosed (33%, 6 of 18). Veterans without war zone service who screened positive also had significantly higher rates of unrecognized PTSD (75%, 21 of 28) than rates of diagnosed PTSD (25%, 7 of 28).

Patients who had worse functioning on the role-emotional subscale of the Short Form-36 quality of life questionnaire were more likely to be recognized as having PTSD. Mental health and pain subscales on the SF-36 did not show significant differences between patients according to their PTSD recognition status.

Patients who had an ICD-9 musculoskeletal pain diagnosis were 3.5 times more likely to be recognized as having PTSD than were those who did not have such a diagnosis, after adjusting for age, race, gender, and war zone service.

In addition, patients with substance use disorders were nearly 10 times more likely to be recognized as having PTSD than were patients without substance use problems.

“This study argues that we really ought to pay better attention to screening results” and that physicians should receive additional training in nonclassic PTSD presentations, Dr. Magruder said at the meeting, which was also sponsored by Boston University.

In the study, “providers may have picked up on more of the obvious presentations of PTSD,” such as poor emotional functioning, persistent reexperiencing, and increased arousal.

One limitation of the study is that the data were collected prior to Operation Enduring Freedom and Operation Iraqi Freedom. The younger group of patients in those conflicts could have “sensitized clinicians to look more closely at presentations in younger patients,” Dr. Magruder suggested.

The study also did not take into account provider-level factors and problems in the scheduling or duration of clinical visits.

WASHINGTON — The few studies that have examined the effectiveness of incentivized pay-for-performance programs have found a mix of moderate to no improvement in quality measures, which, in some instances, have led to unintended consequences, according to Dr. Daniel B. Mark.

More than 100 reward or incentive programs have been started in the private U.S. health care sector under the control of employer groups or managed care organizations, said Dr. Mark, but congressionally authorized programs by the Centers for Medicare and Medicaid Services have received the most attention.

It is important to examine the evidence base that pay-for-performance programs actually improve quality because “people are making this association,” said Dr. Mark, director of the Outcomes Research and Assessment Group at the Duke (University) Clinical Research Institute, Durham, N.C.

During the last 20 years, incentivized performance programs have shown that “what you measure generally improves and what gets measured is generally what's easiest to measure. But the ease of measurement does not necessarily define the importance of the measurement.”

Little, if anything, is known about whether these initiatives are cost effective for the health care system at large, Dr. Mark noted at the annual meeting of the Heart Failure Society of America.

A systematic overview of 17 studies published during 1980–2005 on pay-for-performance programs found that 1 of 2 studies on system-level incentives had a positive result in which all performance measures improved. In nine studies of incentive programs aimed at the provider group level, seven had partially positive or fully positive results but had “quite small” effect sizes. Positive or partially positive results were seen in five of six programs at the physician level (Ann. Int. Med. 2006;145:265–72).

Nine of the studies were randomized and controlled, but eight of these had a sample size of fewer than 100 physicians or groups; the other study had fewer than 200 groups.

Programs in four studies appeared to have created unintended consequences, including “gaming the baseline level of illness,” avoiding sicker patients, and an improvement in documentation without any actual change in care. The studies did not include any information on the optimal duration of these programs or whether their effect persisted after the program was terminated. Only one study had a preliminary examination of cost-effectiveness.

Another study compared patients with acute non-ST-elevation myocardial infarction in 57 hospitals that participated in CMS Hospital Quality Incentive Demonstration and 113 control hospitals that did not participate to determine if a pay-for-performance strategy produced better quality of care. There was “very little evidence that there was any intervention effect,” Dr. Mark said. Measures that were not incentivized by CMS also did not appear to change (JAMA 2007;297:2373–80).

In the United Kingdom, family practice physicians participated in a pay-for-performance program in 2004 that focused on 146 quality indicators for 10 chronic diseases. The National Health Service substantially increased its deficit that year because the funds allocated for the project were used up by greater than predicted success in achieving the quality indicators. This led to an average increase in the physicians' pay of about $40,000 that year (N. Engl. J. Med. 2006;355:375–84).

Other investigators noted that in the 1998–2003 period prior to the NHS project, all of the quality indicators had already been improving, “so it's not clear how much the program's achievements can actually be attributed to the program itself,” he said (N. Engl. J. Med. 2007;357:181–90).

Another study showed that public reporting of quality measures alone could improve a set of quality indicators by the same magnitude as a pay-for performance program that included public reporting (N. Engl. J. Med. 2007;356:486–96).

Little, if anything, is known about whether these initiatives are cost effective for the health care system at large. DR. MARK

WASHINGTON — The few studies that have examined the effectiveness of incentivized pay-for-performance programs have found a mix of moderate to no improvement in quality measures, which, in some instances, have led to unintended consequences, according to Dr. Daniel B. Mark.

More than 100 reward or incentive programs have been started in the private U.S. health care sector under the control of employer groups or managed care organizations, said Dr. Mark, but congressionally authorized programs by the Centers for Medicare and Medicaid Services have received the most attention.

It is important to examine the evidence base that pay-for-performance programs actually improve quality because “people are making this association,” said Dr. Mark, director of the Outcomes Research and Assessment Group at the Duke (University) Clinical Research Institute, Durham, N.C.

During the last 20 years, incentivized performance programs have shown that “what you measure generally improves and what gets measured is generally what's easiest to measure. But the ease of measurement does not necessarily define the importance of the measurement.”

Little, if anything, is known about whether these initiatives are cost effective for the health care system at large, Dr. Mark noted at the annual meeting of the Heart Failure Society of America.

A systematic overview of 17 studies published during 1980–2005 on pay-for-performance programs found that 1 of 2 studies on system-level incentives had a positive result in which all performance measures improved. In nine studies of incentive programs aimed at the provider group level, seven had partially positive or fully positive results but had “quite small” effect sizes. Positive or partially positive results were seen in five of six programs at the physician level (Ann. Int. Med. 2006;145:265–72).

Nine of the studies were randomized and controlled, but eight of these had a sample size of fewer than 100 physicians or groups; the other study had fewer than 200 groups.

Programs in four studies appeared to have created unintended consequences, including “gaming the baseline level of illness,” avoiding sicker patients, and an improvement in documentation without any actual change in care. The studies did not include any information on the optimal duration of these programs or whether their effect persisted after the program was terminated. Only one study had a preliminary examination of cost-effectiveness.

Another study compared patients with acute non-ST-elevation myocardial infarction in 57 hospitals that participated in CMS Hospital Quality Incentive Demonstration and 113 control hospitals that did not participate to determine if a pay-for-performance strategy produced better quality of care. There was “very little evidence that there was any intervention effect,” Dr. Mark said. Measures that were not incentivized by CMS also did not appear to change (JAMA 2007;297:2373–80).

In the United Kingdom, family practice physicians participated in a pay-for-performance program in 2004 that focused on 146 quality indicators for 10 chronic diseases. The National Health Service substantially increased its deficit that year because the funds allocated for the project were used up by greater than predicted success in achieving the quality indicators. This led to an average increase in the physicians' pay of about $40,000 that year (N. Engl. J. Med. 2006;355:375–84).

Other investigators noted that in the 1998–2003 period prior to the NHS project, all of the quality indicators had already been improving, “so it's not clear how much the program's achievements can actually be attributed to the program itself,” he said (N. Engl. J. Med. 2007;357:181–90).

Another study showed that public reporting of quality measures alone could improve a set of quality indicators by the same magnitude as a pay-for performance program that included public reporting (N. Engl. J. Med. 2007;356:486–96).

Little, if anything, is known about whether these initiatives are cost effective for the health care system at large. DR. MARK

WASHINGTON — The few studies that have examined the effectiveness of incentivized pay-for-performance programs have found a mix of moderate to no improvement in quality measures, which, in some instances, have led to unintended consequences, according to Dr. Daniel B. Mark.

More than 100 reward or incentive programs have been started in the private U.S. health care sector under the control of employer groups or managed care organizations, said Dr. Mark, but congressionally authorized programs by the Centers for Medicare and Medicaid Services have received the most attention.

It is important to examine the evidence base that pay-for-performance programs actually improve quality because “people are making this association,” said Dr. Mark, director of the Outcomes Research and Assessment Group at the Duke (University) Clinical Research Institute, Durham, N.C.

During the last 20 years, incentivized performance programs have shown that “what you measure generally improves and what gets measured is generally what's easiest to measure. But the ease of measurement does not necessarily define the importance of the measurement.”

Little, if anything, is known about whether these initiatives are cost effective for the health care system at large, Dr. Mark noted at the annual meeting of the Heart Failure Society of America.

A systematic overview of 17 studies published during 1980–2005 on pay-for-performance programs found that 1 of 2 studies on system-level incentives had a positive result in which all performance measures improved. In nine studies of incentive programs aimed at the provider group level, seven had partially positive or fully positive results but had “quite small” effect sizes. Positive or partially positive results were seen in five of six programs at the physician level (Ann. Int. Med. 2006;145:265–72).

Nine of the studies were randomized and controlled, but eight of these had a sample size of fewer than 100 physicians or groups; the other study had fewer than 200 groups.

Programs in four studies appeared to have created unintended consequences, including “gaming the baseline level of illness,” avoiding sicker patients, and an improvement in documentation without any actual change in care. The studies did not include any information on the optimal duration of these programs or whether their effect persisted after the program was terminated. Only one study had a preliminary examination of cost-effectiveness.

Another study compared patients with acute non-ST-elevation myocardial infarction in 57 hospitals that participated in CMS Hospital Quality Incentive Demonstration and 113 control hospitals that did not participate to determine if a pay-for-performance strategy produced better quality of care. There was “very little evidence that there was any intervention effect,” Dr. Mark said. Measures that were not incentivized by CMS also did not appear to change (JAMA 2007;297:2373–80).

In the United Kingdom, family practice physicians participated in a pay-for-performance program in 2004 that focused on 146 quality indicators for 10 chronic diseases. The National Health Service substantially increased its deficit that year because the funds allocated for the project were used up by greater than predicted success in achieving the quality indicators. This led to an average increase in the physicians' pay of about $40,000 that year (N. Engl. J. Med. 2006;355:375–84).

Other investigators noted that in the 1998–2003 period prior to the NHS project, all of the quality indicators had already been improving, “so it's not clear how much the program's achievements can actually be attributed to the program itself,” he said (N. Engl. J. Med. 2007;357:181–90).

Another study showed that public reporting of quality measures alone could improve a set of quality indicators by the same magnitude as a pay-for performance program that included public reporting (N. Engl. J. Med. 2007;356:486–96).

Little, if anything, is known about whether these initiatives are cost effective for the health care system at large. DR. MARK