Long QT syndrome: how effective therapy in a single patient favorably influenced the long-term clinical course and genetic understanding of this hereditary disorder.

The story of the long QT syndrome involved a chance interaction that took place in 1957 when Dr. Moss was shown a unique series of ECGs with a prolonged QT interval in a young deaf boy whose recurrent syncope culminated in sudden death. Who could have predicted that this clinical experience would lead to innovative and effective new therapy for a patient with the long QT syndrome several years later and the subsequent formation of the International Long QT Registry? This Registry has stimulated interactions among and between patients and physicians and has enhanced collaborations involving clinical, genetic, and basic-science investigators. The net result has been a significant improvement in the diagnosis, treatment, and outcome of patients with the long QT syndrome and an overall advancement in the science of medicine - two of the many satisfactions that physicians can experience in the clinical practice of medicine.

Acute physiologic effects of secondhand smoke exposure in children.

INTRODUCTION: We investigated the hypothesis that exhaled carbon monoxide (eCO), heart rate (HR), and blood pressure (BP) would increase acutely in exposed but not in unexposed children. METHODS: In a nonrandomized controlled design, parent-child dyads were assigned to groups based on exposure: child subjects, 7-18 years of age, exposed to smoking daily in the home (exposed) or with no household exposure (unexposed control). HR, BP, and eCO were measured before and after exposure to a parent smoking 1 cigarette (exposed) or a time-lapse equivalent (control). The primary analysis compared mean acute changes in physiological measures following intervention or control procedure. RESULTS: Forty-one dyads were enrolled. At baseline, no differences in child gender, race, ethnicity, HR, BP, lipids, or fasting glucose were noted between exposure groups. Following experimental or control procedures, the median change in eCO was similar between groups (-0.1 ppm exposed vs. 0.0 ppm unexposed, p = .27). Acute hemodynamic changes were also similar between exposed and unexposed children, respectively: (HR change 4.2 vs. 2.6 beats per minute, p = .62; systolic blood pressure change 0.08 vs. 0.41 mm Hg, p = .91; diastolic blood pressure 0.08 vs. 2.27 mm Hg, p = .37). DISCUSSION: This is the first study to report on acute physiologic changes of secondhand smoke exposure in children in a naturalistic setting. A single acute dose of passive smoke exposure in children did not alter the physiologic variables of HR or BP. Further in-home study using continuous monitoring is needed. Demonstration of acute effects may serve as clinical feedback to motivate parents to quit smoking.

Targeting pregnant and parental smokers: long-term outcomes of a practice-based intervention.

INTRODUCTION: This study aimed to assess the change in obstetric and pediatric provider smoking cessation practices following implementation of a practice guideline-driven office-based program. METHODS: This pre-post evaluation took place between May 2003 and August 2006 in 1 pediatric and 1 obstetric hospital-based clinic. The intervention involved provider training combined with office system supports. A total of 1,080 exit interviews were collected to measure outcomes of clinic practices at baseline and at 1 month, 6 months, 1 year (obstetric), and 2 years (pediatric) after implementation. Trend analysis was used to assess change in practice rates over time. RESULTS: Following program implementation, pediatric provider "Ask" rates increased (49% before to 86% 2 years after, p < .0001); changes in pediatric "Advise" and "Assist" rates were not significant: 44%-59% (p = .19) and 18%-28% (p = .26), respectively. In the obstetric clinic, whereas no significant changes were detected in provider "Ask" (59%-65% 1 year after, p = .17) or "Advise" (72%-85%, p = .27) rates, "Assist" rates rose from 28% to 62% (p = .0075) 1 year after program implementation. DISCUSSION: Implementation of the office-based program achieved significantly improved trends in pediatric provider "Ask" rates and obstetric provider "Assist" rates over time. Further research is needed on office strategies to create long-term provider behavior changes in smoking cessation practices.

An examination of attitudes, knowledge, and clinical practices among Pennsylvania pediatricians regarding breastfeeding and smoking.

BACKGROUND AND OBJECTIVE: The most recent American Academy of Pediatrics policy statement clearly supports breastfeeding for smoking mothers. The impact of this recommendation on pediatricians' counseling and prescribing practices is unclear. This study describes Pennsylvania pediatricians' attitudes, knowledge, and practices regarding breastfeeding, maternal smoking, and smoking cessation. METHODS: A descriptive study was conducted using a web-based, anonymous survey. The survey consisted of three clinical vignettes followed by knowledge and attitude questions. RESULTS: Among 296 respondents, more than half reported one or more conversations about breastfeeding and smoking in the past year. Most were comfortable counseling on breastfeeding, but few were comfortable counseling about smoking and breastfeeding. Respondents scored poorly on five knowledge items; 27% answered zero items correctly, and only 21% answered four or five items correctly. Less than half reported breastfeeding was safe for smoking mothers. Compared to pediatricians with high knowledge scores, those with a low score were less likely to tell a smoking mother that breastfeeding is safe (38% vs. 69%, p < 0.01) and more likely to recommend formula feeding (19% vs. 3%, p < 0.01). Most pediatricians were uncertain about the safety of nicotine replacement therapy and bupropion (Zyban, GalxoSmithKline, Research Triangle Park, NC) with breastfeeding. CONCLUSIONS: Pennsylvania pediatricians lack knowledge and comfort related to the topic of breastfeeding and maternal smoking. Additional efforts to inform and educate pediatricians on the subjects of breastfeeding, maternal tobacco use, and smoking cessation products are needed.

What do mothers think about concurrent breast-feeding and smoking?

OBJECTIVE: According to newer policies of the American Academy of Pediatrics, smoking is not contraindicated with breast-feeding, yet smokers initiate and maintain breast-feeding less often than nonsmokers. We sought to describe maternal knowledge and attitudes regarding concurrent breast-feeding and smoking or nicotine replacement therapy (NRT) and to evaluate the association between maternal smoking and infant feeding practices. METHODS: Mothers bringing children <13 months old for an appointment completed a 24-item anonymous survey that addressed knowledge, attitudes, and practices about concurrent breast-feeding and smoking/NRT. RESULTS: Among 204 survey completers, 63% were African American, 52% had never breast-fed, and 54% had never smoked. Regardless of smoking status, 19% were aware of the recommendation to smoke after breast-feeding; most did not know that nicotine gum (42%) or patch (40%) transfers less or about the same amount of nicotine into breast milk than smoking a pack per day. Most mothers (80%) believed that women should not smoke any cigarettes if breast-feeding; current smokers (25%) were more likely than former (10%) or never smokers (11%) to find it acceptable to smoke one or more cigarettes per day (P = .03). Only 2% found it acceptable to use NRT while breast-feeding. Among ever breast-feeders, 10% stopped breast-feeding because of smoking. Over half of recent or current smokers reported that smoking affected their infant feeding decision. CONCLUSIONS: Mothers in this sample believe that women who smoke or take NRT should not breast-feed. Smoking status affected women's infant feeding practices. Correction of misinformation could increase breast-feeding rates.