Diane M. Comer

Treatment Services for Children With ADHD: A National Perspective

OBJECTIVE To summarize knowledge on treatment services for children and adolescents with attention-deficit hyperactivity disorder (ADHD), trends in services from 1989 to 1996, types of services provided, service mix, and barriers to care. METHOD A review of the literature and analyses from 2 national surveys of physician practices are presented. RESULTS Major shifts have occurred in stimulant prescriptions since 1989, with prescriptions now comprising three fourths of all visits to physicians by children with ADHD. Between 1989 and 1996, related services, such as health counseling, for children with ADHD increased 10-fold, and diagnostic services increased 3-fold. Provision of psychotherapy, however, decreased from 40% of pediatric visits to only 25% in the same time frame. Follow-up care also decreased from more than 90% of visits to only 75%. Family practitioners were more likely than either pediatricians or psychiatrists to prescribe stimulants and less likely to use diagnostic services, provide mental health counseling, or recommend follow-up care. About 50% of children with identified ADHD seen in real-world practice settings receive care that corresponds to guidelines of the American Academy of Child and Adolescent Psychiatry. Physicians reported significant barriers to service provision for these children, including lack of pediatric specialists, insurance obstacles, and lengthy waiting lists. CONCLUSIONS The trends in treatment services and physician variations in service delivery point to major gaps between the research base and clinical practice. Clinical variations may reflect training differences, unevenness in the availability of specialists and location of services, and changes in health care incentives.

Alcohol and drug use and related disorders : An underrecognized health issue among adolescents and young adults attending sexually transmitted disease clinics

Objectives: The objectives of this study were to describe patterns of alcohol and drug use disorders among young persons attending a public sexually transmitted disease (STD) clinic and to determine their associations with sexual risk behaviors and STDs. Study Design: Four hundred forty-eight men and women aged 15 to 24 who were attending an urban STD clinic completed an interviewer-administered questionnaire that assessed a broad range of substance use in general and for alcohol and marijuana use disorders. Results: Overall, 42.9% had an alcohol or marijuana use disorder (51.6% of males and 34.2% of females), whereas 30.6% had a confirmed STD. Participants with a substance use disorder were significantly more likely to have multiple sexual partners (odds ratio [OR] = 2.3; 95% confidence interval [CI] = 1.5–3.4), to be inconsistent condom users (OR = 3.1; 95% CI = 1.5–6.3), and to have an STD (OR = 1.7; 95% CI = 1.1–2.6). Conclusions: Among young STD clinic attendees, substance use disorders were more common than confirmed STDs. STD clinics may be an appropriate setting to screen for and address substance use disorders in young persons.

Home screening for sexually transmitted diseases in high-risk young women: randomised controlled trial

Objective: Home screening tests could eliminate several barriers to testing sexually transmitted diseases (STDs). Aim: To determine whether offering repeated home screening tests would increase the rate of testing for chlamydia and gonorrhoea in a high-risk sample of young women. Methods: In this randomised controlled trial, 403 young women (mean age 18.9 years, 70% black) with a recent STD or with STD-related risk factors were enrolled. Participants were recruited from clinics and high-prevalence neighbourhoods and then randomly assigned to receive either a home testing kit or an invitation to attend a medical clinic for testing at 6, 12 and 18 months after enrollment. Over 80% of women were followed for 2 years. The trial is registered with ClinicalTrials.gov, number NCT 00177437. Results: Of 197 women in the intervention group, 140 (71%) returned at least one home test and 25 of 249 (10%) home tests were positive. Women who received home screening tests completed significantly more STD tests overall (1.94 vs 1.41 tests per woman-year, p<0.001) and more STD tests in the absence of symptoms (1.18 vs 0.75 tests per woman-year, p<0.001). More women in the intervention group completed at least one test when asymptomatic (162 (82.2%) vs 117 (61.3%), p<0.001). The intervention was most effective among women recruited outside medical clinics. There was no significant difference in the overall rate of STDs detected. Conclusions: Home screening significantly increased the utilisation of chlamydia and gonorrhoea testing in this sample of high-risk young women, and thus represents a feasible strategy to facilitate STD testing in young women.

Pediatric mood and anxiety syndromes in primary care: who gets identified?.

Objective: To seek clues to the enhancement of primary care management by (i) Determining how often and in whom primary care clinicians in the United States, Puerto Rico, and Canada identify pediatric mood or anxiety syndromes; (ii) Determining which clinical and demographic features predict higher rates of identification; (iii) Describing assessment methods used. Methods: This report uses the database of the multi-site Child Behavior Study. This cross-sectional study involved 206 primary care practices in the United States, Puerto Rico, and Canada; 395 clinicians and 20,861 primary care attenders aged 4–15 years. Clinicians completed a visit questionnaire addressing presence and type of psychosocial problems and how assessed. Parents completed a questionnaire addressing family demographics, child symptoms (Pediatric Symptom Checklist) and functioning, and child service use. Results: Clinicians identified psychosocial problems on 17.9% of visits, but mood or anxiety syndromes on only 3.3%, most commonly in children judged to have co-morbid behavioral syndromes, of whom the majority (66.7%) already had contact with specialized mental health. Neither parental concerns about mood and anxiety symptoms nor clinician familiarity with the patient were major predictors of identification. When making a diagnosis of a pure internalizing syndrome (i.e., without a co-morbid behavioral syndrome) clinicians rarely used standardized tools or school reports. Conclusions: Neither screening for nor diagnosis of mood and anxiety syndromes is a routine part of primary care of children and adolescents. Efforts to improve care must include practical, validated screening procedures to enhance assessment for mood and anxiety syndromes, particularly among children in whom primary care clinicians identify psychosocial problems.

Prospective study of displaced children's symptoms in wartime Bosnia

Background: This study examines the psychological symptoms of Bosnian children exposed to war and trauma, and detects changes in these symptoms over time. Method: A total of 147 displaced children residing in refugee centers in Bosnia completed self-report assessments of anxiety, depressive, and posttraumatic stress symptoms at two time points. Results: Symptoms of posttraumatic stress, anxiety, and depression showed a greater decrease in boys relative to girls over time. Conclusion: Gender may be an important factor in the natural course of trauma-related symptoms among war traumatized children. Further research is needed to better understand the psychological effects of war trauma on children, and the natural course of posttraumatic symptoms, so as to improve interventions targeted to this vulnerable population.

Racial/ethnic disparities in contraceptive use: Variation by age and women's reproductive experiences

OBJECTIVE Disparities in unintended pregnancy in the United States are related, in part, to black and Hispanic women being overall less likely to use effective contraceptive methods. However, the fact that these same groups are more likely to use female sterilization, a highly effective method, suggests there may be variability in disparities in contraceptive use across a womans life course. We sought to assess the relationship between race/ethnicity and contraceptive use in a nationally representative sample and to approximate a life course perspective by examining effect modification on these disparities by womens age, parity, and history of unintended pregnancy. STUDY DESIGN We conducted an analysis of the 2006 through 2010 National Survey of Family Growth to determine the association between race/ethnicity and: (1) use of any method; (2) use of a highly or moderately effective method among women using contraception; and (3) use of a highly effective method among women using contraception. We then performed analyses to assess interactions between race/ethnicity and age, parity, and history of unintended pregnancy. RESULTS Our sample included 7214 females aged 15-44 years. Compared to whites, blacks were less likely to use any contraceptive method (adjusted odds ratio, 0.65); and blacks and Hispanics were less likely to use a highly or moderately effective method (adjusted odds ratio, 0.49 and 0.57, respectively). Interaction analyses revealed that racial/ethnic disparities in contraceptive use varied by womens age, with younger women having more prominent disparities. CONCLUSION Interventions designed to address disparities in unintended pregnancy should focus on improving contraceptive use among younger women.

Evaluation of urine biomarkers of kidney injury in polycystic kidney disease

Progressive disruption of renal tubular integrity in the setting of increased cellular proliferation and apoptosis is a feature of ADPKD. Here we evaluated the effect of these processes on the expression of NGAL and IL-18, markers of tubular injury, in rodent models and in the cyst fluid and urine of patients with ADPKD. Two mouse models where Pkd2 was inactivated which resulted in early or adult onset cysts, were used to evaluate NGAL levels. Further, the Han:SPRD rat model of polycystic disease was used to study IL-18 levels. In four annual serial urine samples from 107 patients with ADPKD in the Consortium for Radiologic Imaging for the Study of Polycystic Kidney Disease (CRISP) study, NGAL and IL-18 excretion rates were determined in conjunction with measures of total kidney volume and estimated GFR (eGFR) by the MDRD equation. Kidneys from affected mice and rats showed prominent expression of NGAL and IL-18/IL-18R, respectively, in epithelial cells lining kidney cysts. In human ADPKD cyst fluid, both NGAL and IL-18 were elevated. In CRISP patients, the mean percentage increase in total kidney volume was 5.4 /year and the mean decline in eGFR 2.4 mL/min/year. The trend of increased mean urine NGAL and IL-18 over three years was statistically significant; however, there was no association of tertiles of IL-18 or quartiles of NGAL and the change in total kidney volume or eGFR over this period. Thus, urinary NGAL and IL-18 excretion are mildly and stably elevated in ADPKD, but do not correlate with changes in total kidney volume or kidney function. This may be due, in part, to the lack of communication between individual cysts and the urinary collecting system in this disorder.

Effect of Vitamin D3 Supplementation in Black and in White Children: A Randomized, Placebo-Controlled Trial

CONTEXT Dosages of vitamin D necessary to prevent or treat vitamin D deficiency in children remain to be clarified. OBJECTIVE To determine the effects of vitamin D3 1000 IU/d on serum 25-hydroxyvitamin D [25(OH)D], PTH, and markers of bone turnover (osteocalcin and collagen type 1 cross-linked C-telopeptide) in black children and white children, and to explore whether there is a threshold level of 25(OH)D associated with maximal suppression of serum PTH concentration. DESIGN Healthy 8- to 14-year-old Pittsburgh-area black (n = 84) and white (n = 73) children not receiving vitamin supplements, enrolled from October through March from 2008 through 2011, were randomized to vitamin D3 1000 IU or placebo daily for 6 months. RESULTS The mean baseline concentration of 25(OH)D was <20 ng/mL in both the vitamin D-supplemented group and the placebo group (19.8 ± 7.6 and 18.8 ± 6.9 ng/mL, respectively). The mean concentration was higher in the supplemented group than in the placebo group at 2 months (26.4 ± 8.1 vs 18.9 ± 8.1 ng/mL; P < .0001) and also at 6 months (26.7 ± 7.6 vs 22.4 ± 7.3; P = .003), after adjusting for baseline 25(OH)D, race, gender, pubertal status, dietary vitamin D intake, body mass index, and sunlight exposure. Increases were only significant in black children, when examined by race. The association between 25(OH)D and PTH concentrations was inverse and linear, without evidence of a plateau. Overall, vitamin D supplementation had no effect on PTH and bone turnover. CONCLUSIONS Vitamin D3 supplementation with 1000 IU/d in children with mean baseline 25(OH)D concentration <20 ng/mL effectively raised their mean 25(OH)D concentration to ≥20 ng/mL but failed to reach 30 ng/mL. Vitamin D supplementation had no effect on PTH concentrations.

A Randomized Controlled Trial of Aspirin and Exertional Heat Stress Activation of Platelets in Firefighters during Exertion in Thermal Protective Clothing

Abstract Purpose. Platelet aggregation is enhanced in firefighters following short bouts of work in thermal protective clothing (TPC). We sought to determine if aspirin therapy before and/or following exertion in TPC prevents platelet activation. Methods. In a double-blind, placebo-controlled study, 102 firefighters were randomized to receive daily therapy (81 mg aspirin or placebo) for 14 days before and a single dose (325 mg aspirin or placebo) following exercise in TPC resulting in four potential assignments: aspirin before and after exercise (AA), placebo before and after exercise (PP), aspirin before and placebo after exercise (AP), and placebo before and aspirin after exercise (PA). Platelet closure time (PCT) was measured with a platelet function analyzer before the 2-week treatment, after the 2 week treatment period, immediately after exercise, and 30, 60, and 90 minutes later. Results. Baseline PCT did not differ between groups. PCT changed over time in all four groups (p < 0.001) rising to a median of >300 seconds [IQR 99, 300] in AA and >300 [92, 300] in AP prior to exercise. Following exercise, median PCT decreased to in all groups. Median PCT returned to >300 seconds 30 minutes later in AA and AP and rose to 300 seconds in PA 60 minutes after exercise. Conclusions. Daily aspirin therapy blunts platelet activation during exertional heat stress and single-dose aspirin therapy following exertional heat stress reduces platelet activation within 60 minutes. Key words: firefighter; uncompensable heat stress; thermoregulation; emergency incident rehabilitation

Outcomes after listing with a requirement for a prospective crossmatch in pediatric heart transplantation

BACKGROUND Allosensitization is associated with inferior waitlist outcomes in pediatric heart transplant candidates, presumably because of the requirement for a negative prospective crossmatch. However, there are no reports of heart transplant candidate outcomes according to prospective crossmatch requirements. METHODS We analyzed data on all children listed for isolated heart transplantation from 1995 to 2009 in the USA according to prospective crossmatch requirement (PXMR). Primary objectives were to describe the prevalence of PXMR at and during listing and to compare waitlist and post-transplant survival for patients based on PXMR. Patients with a PXMR during listing include those with a PXMR at the time of listing as well as those who were designated by the listing center as needing a prospective crossmatch at some point after being placed onto the waitlist. RESULTS Among 6,343 listed children, 7.7% had a requirement for a prospective crossmatch at the time of listing and 11.8% had a requirement for a prospective crossmatch during listing. After controlling for risk factors associated with inferior survival, PXMR at listing was associated with increased waitlist mortality (HR 1.32, 95% CI 1.10 to 1.56; p = 0.003). Recipients with a PXMR during listing more commonly had a positive DSXM (22.1% vs 10.3%, p < 0.0001), as did recipients who carried a PXMR throughout listing (21.7% vs 11.3%, p = 0.004). However, there was no significant difference in post-transplant survival on the basis of a PXMR during listing (HR 1.04, 95% CI 0.87 to 1.25; p = 0.67). Nearly 30% of recipients with a PXMR during listing had a peak pre-transplant PRA ≤ 10%. CONCLUSIONS PXMR increases the likelihood of death while awaiting, but not after, pediatric heart transplantation. Further study is necessary to understand how PXMR is applied, and changes, after listing for pediatric heart transplantation.