Comparison of two cohorts of medically at-risk adolescents engaging in substance use (cancer survivors and asthmatics): Clinical predictors for monitoring care.

BACKGROUND AND PURPOSE: Medically at-risk adolescents differ in their perception of severity and are vulnerable to substance use because of effects on their medical regimen. The intent in comparing two cohorts, adolescent survivors of cancer and teens with asthma, is to provide clinical predictors to help in monitoring those needing help with substance use decision making. METHODS: Baseline data were obtained from two randomized controlled trials for a decision-making program of research for medically at-risk adolescents. Multivariate analyses were used to identify clinical predictors for poor decision making as well as lifetime and current substance use (smoking, alcohol use, and marijuana use). CONCLUSIONS: Predictors for both cohorts for lifetime and current substance use were increasing age and risk motivation. A significant predictor for both cohorts for poor decision making related to substance use was risk motivation, measured as a more positive attitude for engaging in substance use. Negative modeling by peers and family members had an impact on teen survivors' decision making; but, this was not clear for teens with asthma. IMPLICATIONS FOR PRACTICE: Research is needed comparing other medically at-risk adolescents to determine which cohorts on the substance use spectrum are less resilient to peer and parent modeling, have unrealistic views of their decision-making skills, and need close monitoring and guidance.

A Health-Related Quality of Life Measure for Older Adolescents With Asthma: Child Health Survey for Asthma-T (Teen Version).

BACKGROUND: Although adolescent substance use can have direct effects on asthma symptoms and interact with medications used to treat asthma, no validated health-related quality of life (HRQL) instrument exists for adolescents 17 to 19 years of age with asthma. PURPOSE: The American Academy of Pediatric's HRQL instrument, the Child Health Survey for Asthma (CHSA)-Child version, was modified with a substance use subscale to address outcomes specific to adolescents ages 17 to 19 years with asthma. METHODS: Two cohorts (N = 70) were recruited for instrument testing at pediatric primary care practices and two university clinics. A small methodological study with 24 adolescents was conducted to obtain initial support of the psychometric properties for the CHSA-Teen version at baseline, day 14, and day 16. A follow-up study included 46 teens to provide further support. RESULTS: The psychometric properties of the CHSA-Teen version were good and comparable with the CHSA-Child version for feasibility, reliability, and validity. CONCLUSIONS: Health care providers need to be aware of each adolescent's substance use to personalize counseling related to asthma medications.

SUPPORTING PHYSICIANS' PRACTICE-BASED LEARNING AND IMPROVEMENT (PBLI) AND QUALITY IMPROVEMENT THROUGH EXPLORATION OF POPULATION-BASED MEDICAL DATA.

Participating in self-assessment activities may stimulate improvement in practice behaviors. However, it is unclear how best to support the development of self-assessment skills, particularly in the health care domain. Exploration of population-based data is one method to enable health care providers to identify deficiencies in overall practice behavior that can motivate quality improvement initiatives. At the University of Virginia, we are developing a decision support tool to integrate and present population-based patient data to health care providers related to both clinical outcomes and non-clinical measures (e.g., demographic information). By enabling users to separate their direct impact on clinical outcomes from other factors out of their control, we may enhance the self-assessment process.

A review of the Journal of Pediatrics: the first 75 years.

OBJECTIVE: To assess changes in the format and content of articles published in The Journal of Pediatrics to aid in understanding the current state of pediatric research and to anticipate what to expect in the coming years. STUDY DESIGN: We conducted a retrospective review of case reports, research articles, and review articles published in volume 150 of The Journal. We noted components of study authorship, content, and design and compared these data with those in earlier volumes. RESULTS: The numbers of authors and grants per article and the proportion of studies with international authorship have all increased. Print circulation has dropped, but The Journal is now available in electronic format. Research topics shifted, with fewer articles devoted to infectious disease and general pediatrics. An increase in articles about endocrinology reflects a surge of interest in pediatric obesity. Most articles contain original research, reporting analyses from observational studies with few clinical trials. CONCLUSIONS: Recent trends suggest that readers of The Journal should expect more research articles with observational designs and increasing international authorship. The Journal's electronic presence will likely increase and provide greater readership globally.

Statistical literacy for readers of Pediatrics: a moving target.

OBJECTIVE: Pediatric residents are expected to study research design and statistical methods to enable them to critically appraise the pediatric literature and apply the findings to patient care. However, it is not clear how best to teach these skills or even which statistical concepts are most important. An earlier study demonstrated that the statistical complexity of articles published in Pediatrics increased from 1952 to 1982. The goals of our study were to assess whether this trend has continued and to determine the statistical measures and procedures most commonly encountered in Pediatrics. METHODS: We reviewed the print research articles published in Pediatrics, volume 115, 2005, and recorded the statistical measures and procedures reported in each article to determine how many articles used statistics or statistical procedures and what statistical procedures were encountered most commonly. RESULTS: The proportion of articles that used any inferential statistics increased from 48% in 1982 to 89% in 2005. The mean number of inferential procedures per article increased from 2.5 in 1982 to 3.9 in 2005. The most commonly encountered statistical procedures or measures were descriptive statistics, tests of proportions, measures of risk, logistic regression, t tests, nonparametric tests, analysis of variance, multiple linear regression, sample size and power calculation, and tests of correlation. However, a reader who is familiar with only these concepts can understand the analyses used in only 47% of articles. CONCLUSIONS: Our results confirm a trend toward the use of new and increasingly complex statistical techniques in Pediatrics. Educational efforts might most profitably focus on the principles underlying statistical analysis rather than on specific statistical tests. Authors, reviewers, and journal editors have a greater responsibility for ensuring that statistical procedures are used appropriately, as it may be increasingly unrealistic to expect readers to fully understand the statistical analyses used in journal articles.

Safe at school: a Virginia experience.

OBJECTIVE: The Commonwealth of Virginia passed legislation in 1999 requiring nonmedical school personnel to assist students with the management of type 1 diabetes when school nurses were unavailable. This study was designed to determine which school personnel in Virginia currently assist type 1 diabetic students with insulin administration and management of hypoglycemia and to determine if these students are being cared for in a safe manner. RESEARCH DESIGN AND METHODS: Parents of children with type 1 diabetes who attended public school in Virginia during the previous year and who were receiving their diabetes care at the University of Virginia diabetes clinics were asked to participate in an anonymous survey. The survey asked parents which school personnel were responsible for their child's diabetes care while at school and which persons helped with specific care tasks including blood glucose monitoring, insulin administration, and assistance with treatment of hypoglycemia. Questions were asked regarding the occurrence and treatment of hypoglycemia and any adverse effects of such treatment. RESULTS: A total of 185 parents whose children attended 153 different schools responded, 69% of whom reported that a full-time school nurse was assigned to their child's school. In other schools, teachers, administrators, coaches, and cafeteria workers supplemented part-time nurses in assisting students with diabetes management tasks. Although hypoglycemia was not a rare event (75% of students experienced a median of five episodes per year), only one severe event requiring the use of glucagon was reported. In that case, glucagon was administered appropriately by a part-time school nurse, and the student experienced no adverse effects related to the treatment. CONCLUSIONS: Students with type 1 diabetes can be cared for safely during the school day by a variety of trained medical and nonmedical personnel. The occurrence of one severe hypoglycemic event among 185 students suggests that as many as 3% of students could experience severe hypoglycemia in a given school year. Legislation that permits nonmedical school personnel to assist students with their diabetes management could make the diabetic children's school day safer and improve their overall glucose control.

Case-control confusion.

OBJECTIVE: Critical analysis of journal articles by using principles of evidence-based medicine is important for clinicians applying research results in their practice and is a valuable component of pediatric residency training. Appraisal of an article's methodological rigor is often tailored to a particular type of study design, so that misclassification of study design can confuse the appraisal. The goal of this study was to determine how often pediatric research articles that are self-declared as case-control studies conform to a standard definition for this study design. METHODS: A Medline search identified articles published in two pediatric journals from January 1996 through August 2004 with the phrase "case-control study" in the title or abstract. Articles that were self-declared as case-control studies were analyzed to determine whether they satisfied a standard definition of a case-control study. RESULTS: Of the 91 purported case-control studies, only 68 (75%) met the standard definition for at least the most important analysis. The remaining 23 articles could be classified as cross-sectional studies (N = 16) or prospective cohort studies (N = 7). CONCLUSIONS: Ambiguity in the definition of a case-control study can cause confusion in the critical appraisal of published clinical research.