Molecular cloning of a cDNA encoding interleukin 11, a stromal cell-derived lymphopoietic and hematopoietic cytokine

Hematopoiesis occurs in close association with a complex network of cells loosely termed the hematopoietic microenvironment. Analysis of the mechanisms of microenvironmental regulation of hematopoiesis has been hindered by the complexity of the microenvironment as well as the heterogeneity of hematopoietic stem cells and early progenitor cells. We have established immortalized primate bone marrow-derived stromal cell lines to facilitate analysis of the interactions of hematopoietic cells with the microenvironment in a large animal species. One such line, PU-34, was found to produce a variety of growth factors, including an activity that stimulates the proliferation of an interleukin 6-dependent murine plasmacytoma cell line. A cDNA encoding the plasmacytoma stimulatory activity was isolated through functional expression cloning in mammalian cells. The nucleotide sequence contained a single long reading frame of 597 nucleotides encoding a predicted 199-amino acid polypeptide. The amino acid sequence of this cytokine, designated interleukin 11 (IL-11), did not display significant similarity with any other sequence in the GenBank data base. Preliminary biological characterization indicates that in addition to stimulating plasmacytoma proliferation, IL-11 stimulates the T-cell-dependent development of immunoglobulin-producing B cells and synergizes with IL-3 in supporting murine megakaryocyte colony formation. These properties implicate IL-11 as an additional multifunctional regulator in the hematopoietic microenvironment.

Assessing the organizational social context (OSC) of mental health services: implications for research and practice

The organizational social context in which mental health services are provided is believed to affect the adoption and implementation of evidence-based practices (EBPs) as well as the quality and outcomes of the services. A fully developed science of implementation effectiveness requires conceptual models that include organizational social context and tools for assessing social context that have been tested in a broad cross-section of mental health systems. This paper describes the role of organizational social context in services and implementation research and evaluates a comprehensive contextual measure, labeled Organizational Social Context (OSC), designed to assess the key latent constructs of culture, climate and work attitudes. The psychometric properties of the OSC measure were assessed in a nationwide study of 1,154 clinicians in 100 mental health clinics with a second-order confirmatory factor analysis of clinician responses, estimates of scale reliabilities, and indices of within-clinic agreement and between-clinic differences among clinicians. Finally, the paper illustrates the use of nationwide norms in describing the OSC profiles of individual mental health clinics and examines the cross-level association of organizational-level culture and climate with clinician-level work attitudes.

Alcohol and drug disorders among physically abusive and neglectful parents in a community-based sample

OBJECTIVES

The purpose of this study was to compare the frequency of substance use disorders and symptoms between adults reporting child physical abuse or neglect and individually matched control subjects in a community sample.

METHODS

In a nested case-control study, 169 adults reporting physical abuse of a child and 209 adults reporting neglect of a child from 11,662 individuals successfully interviewed in a probabilistic survey in four communities were individually matched with control subjects drawn from the participants. Case subjects were compared with control subjects on the number of alcohol- or drug-related symptoms and disorder diagnoses as determined by symptoms from the Diagnostic Interview Schedule.

RESULTS

Respondents reporting either physical abuse or neglect of children were much more likely than their matched control subjects to report substance abuse or dependence. These differences persisted after potential confounding variables were controlled for.

CONCLUSIONS

Parental substance abuse and dependence, independent of confounding factors, are highly associated with child maltreatment. Inconsistent results in previous studies may have arisen from reliance on referred samples and unstandardized assessment methods. Agencies involved in the care of abused or neglected children and their families should consider incorporating routine substance abuse evaluations with treatment, or referral for treatment, where indicated.

A genetic selection for isolating cDNAs encoding secreted proteins

We describe a simple, rapid technique for simultaneously isolating large numbers of cDNAs encoding secreted proteins. The technique makes use of a facile genetic selection performed in a strain of Saccharomyces cerevisiae deleted for its endogenous invertase gene. A cDNA cloning vector which carries a modified invertase gene lacking its leader sequence is used in conjunction with this strain. Heterologous secreted genes fused appropriately upstream of this defective invertase provide the necessary signals to restore secretion, allowing the yeast to grow on sugars such as sucrose or raffinose. This microbial growth selection facilitates scanning cDNA libraries containing millions of clones, enabling the wholesale identification of novel secreted proteins without the need for specific bioassays. The technique is similar to one previously described (Klein et al. (1996) Proc. Natl. Acad. Sci. USA 93, 7108-7113). We describe results using a cDNA library derived from activated human peripheral blood mononuclear cells (PBMC). Genes identified from this library encoded signal sequences of proteins of diverse structure, function, and cellular location such as cytokines, type 1 and type 2 transmembrane proteins, and proteins found in intracellular organelles. In addition, a number of novel secreted proteins were identified, including a chemokine and a novel G-protein-coupled receptor. Since signal sequences possess features conserved throughout evolution, the procedure can be used to isolate genes encoding secreted proteins from both eukaryotes and prokaryotes.

Onset of physical abuse and neglect: psychiatric, substance abuse, and social risk factors from prospective community data

Studies of psychiatric and social risk factors for child maltreatment have been limited by retrospective methodologies and reliance on officially reported or identified samples. Using data from both Waves I and II of the National Institute for Mental Health's Epidemiologic Catchment Area survey, 7,103 parents from a probabilistic community sample who did not self-report physical abuse or neglect of their children at Wave I were followed to determine the risk factors associated with the onset of self-reported physical abuse or neglect identified at Wave II. Social factors considered included age, socioeconomic status, social support, education, household size, and gender. In addition, several psychiatric disorders, including substance abuse disorders and depression were examined. Risk models were developed using hierarchical logistic regression. Physical abuse and neglect were found to have distinct sets of risk factors, with minimal overlap between the groups. Social and demographic variables were found to be limited predictors of maltreatment, while substance abuse disorders were strongly associated with the onset of both abuse and neglect (relative risks = 2.90 and 3.24 respectively). Depression was found to be a strong risk factor for physical abuse (relative risk = 3.45). Implications of the findings are discussed in terms of major causal models of maltreatment.

Cassini Radar Views the Surface of Titan

The Cassini Titan Radar Mapper imaged about 1% of Titan's surface at a resolution of approximately 0.5 kilometer, and larger areas of the globe in lower resolution modes. The images reveal a complex surface, with areas of low relief and a variety of geologic features suggestive of dome-like volcanic constructs, flows, and sinuous channels. The surface appears to be young, with few impact craters. Scattering and dielectric properties are consistent with porous ice or organics. Dark patches in the radar images show high brightness temperatures and high emissivity and are consistent with frozen hydrocarbons.

Health utilization and cost impact of childhood constipation in the United States

OBJECTIVE

To estimate the total health care utilization and costs for children with constipation in the United States.

STUDY DESIGN

We analyzed data from 2 consecutive years (2003 and 2004) of the Medical Expenditure Panel Survey (MEPS), a nationally representative household survey. We identified children who either had been reported as constipated by their parents or had received a prescription for laxatives in a given year. Outcome measures were service utilization and expenditures.

RESULTS

The MEPS database included a total of 21 778 children age 0 to 18 years, representing 158 million children nationally. An estimated 1.7 million US children (1.1%) reported constipation in the 2-year period. No differences with respect to age, sex, race, and socioeconomic status were found between the children with constipation and those without constipation. The children with constipation used more health services than children without constipation, resulting in significantly higher costs: $3430/year vs $1099/year. This amounts to an additional cost for children with constipation of $3.9 billion/year.

CONCLUSIONS

This study demonstrates that childhood constipation has a significant impact on the use and cost of medical care services. The estimated cost per year is 3 times than that in children without constipation, which likely is an underestimate of the actual burden of childhood constipation.

The adolescent child health and illness profile. A population-based measure of health

This study was designed to test the reliability and validity of an instrument to assess adolescent health status. Reliability and validity were examined by administration to adolescents (ages 11-17 years) in eight schools in two urban areas, one area in Appalachia, and one area in the rural South. Integrity of the domains and subdomains and construct validity were tested in all areas. Test/retest stability, criterion validity, and convergent and discriminant validity were tested in the two urban areas. Iterative testing has resulted in the final form of the CHIP-AE (Child Health and Illness Profile-Adolescent Edition) having 6 domains with 20 subdomains. The domains are Discomfort, Disorders, Satisfaction with Health, Achievement (of age-appropriate social roles), Risks, and Resilience. Tested aspects of reliability and validity have achieved acceptable levels for all retained subdomains. The CHIP-AE in its current form is suitable for assessing the health status of populations and subpopulations of adolescents. Evidence from test-retest stability analyses suggests that the CHIP-AE also can be used to assess changes occurring over time or in response to health services interventions targeted at groups of adolescents.

Psychometric properties and U.S. National norms of the Evidence-Based Practice Attitude Scale (EBPAS)

The Evidence-Based Practice Attitude Scale (EBPAS) assesses mental health and social service provider attitudes toward adopting evidence-based practices. Scores on the EBPAS derive from 4 subscales (i.e., Appeal, Requirements, Openness, and Divergence) as well as the total scale, and preliminary studies have linked EBPAS scores to clinic structure and policies, organizational culture and climate, and first-level leadership. EBPAS scores are also related to service provider characteristics, including age, education level, and level of professional development. The present study examined the factor structure, reliability, and norms of EBPAS scores in a sample of 1,089 mental health service providers from a nationwide sample drawn from 100 service institutions in 26 states in the United States. The study also examined associations of provider demographic characteristics with EBPAS subscale and total scores. Confirmatory factor analysis supported a second-order factor model, and reliability coefficients for the subscales ranged from .91 to .67 (total scale = .74). The study establishes national norms for the EBPAS so that comparisons can be drawn for U.S. local as well as international studies of attitudes toward evidence-based practices. The results suggest that the factor structure and reliability are likely generalizable to a variety of service provider contexts and different service settings and that the EBPAS subscales are associated with provider characteristics. Directions for future research are discussed.

Therapist turnover and new program sustainability in mental health clinics as a function of organizational culture, climate, and service structure

The present study incorporates organizational theory and organizational characteristics in examining issues related to the successful implementation of mental health services. Following the theoretical foundations of socio-technical and cultural models of organizational effectiveness, organizational climate, culture, legal and service structures, and workforce characteristics are examined as correlates of therapist turnover and new program sustainability in a nationwide sample of mental health clinics. Results of General Linear Modeling (GLM) with the organization as the unit of analysis revealed that organizations with the best climates as measured by the Organizational Social Context (OSC) profiling system, had annual turnover rates (10%) that were less than half the rates found in organizations with the worst climates (22%). In addition, organizations with the best culture profiles sustained new treatment or service programs over twice as long (50 vs. 24 months) as organizations with the worst cultures. Finally, clinics with separate children's services units had higher turnover rates than clinics that served adults and children within the same unit. The findings suggest that strategies to support the implementation of new mental health treatments and services should attend to organizational culture and climate, and to the compatibility of organizational service structures with the demand characteristics of treatments.

The organizational social context of mental health services and clinician attitudes toward evidence-based practice: a United States national study

ABSTBACKGROUND: Evidence-based practices have not been routinely adopted in community mental health organizations despite the support of scientific evidence and in some cases even legislative or regulatory action. We examined the association of clinician attitudes toward evidence-based practice with organizational culture, climate, and other characteristics in a nationally representative sample of mental health organizations in the United States.

METHODS

In-person, group-administered surveys were conducted with a sample of 1,112 mental health service providers in a nationwide sample of 100 mental health service institutions in 26 states in the United States. The study examines these associations with a two-level Hierarchical Linear Modeling (HLM) analysis of responses to the Evidence-Based Practice Attitude Scale (EBPAS) at the individual clinician level as a function of the Organizational Social Context (OSC) measure at the organizational level, controlling for other organization and clinician characteristics.

RESULTS

We found that more proficient organizational cultures and more engaged and less stressful organizational climates were associated with positive clinician attitudes toward adopting evidence-based practice.

CONCLUSIONS

The findings suggest that organizational intervention strategies for improving the organizational social context of mental health services may contribute to the success of evidence-based practice dissemination and implementation efforts by influencing clinician attitudes.

Primary care referral of children with psychosocial problems

OBJECTIVES

To examine primary care provider referral patterns for patients with psychosocial problems and to understand the factors that influence whether a mental health referral is made.

DESIGN

Secondary analysis of the Child Behavior Study data collected during 1994-1997 from background survey of providers, visit survey of providers and parents, and follow-up survey of parents.

SETTING

Two hundred six primary care offices in the United States, Canada, and Puerto Rico.

PATIENTS

Four thousand twelve of 21 150 patients aged 4 to 15 years in the Child Behavior Study with a clinician-identified psychosocial problem.

MAIN OUTCOME MEASURES

Referral for psychosocial problem at index visit and reported follow-up with mental health care provider within 6 months.

RESULTS

Six hundred fifty (16%) of 4012 patients with psychosocial problems were referred at the initial visit. In multivariate analysis, significant factors associated with likelihood of referral included patient factors (severity, type of problem, academic difficulties, prior mental health service use) and family factors (mental health referral of parent); however, none of the provider factors were significant. Clinicians reported frequent barriers to referral and mental health services in the general background survey; however, these factors were rarely reported as influences on individual management decisions. Only 61% of referred families reported that their child saw a mental health care provider in the 6-month period after the initial primary care referral.

CONCLUSIONS

Most psychosocial problems are initially managed in primary care without referral. However, referral is an important component of care for patients with severe problems, and many families are not effectively engaged in mental health services, even after a referral is made.

Assignment of genes encoding a unique cytokine (IL12) composed of two unrelated subunits to chromosomes 3 and 5

IL12 (formerly NKSF or CLMF) is a unique cytokine composed of two unrelated disulfide-linked subunits. The larger 40-kDa subunit (p40) is a member of the cytokine receptor family, and the smaller 35-kDa subunit (p35) is related to IL6 and GCSF. The chromosomal localization of these two subunits was determined by PCR analysis of DNA from rodent-human hybrids. More refined mapping was obtained by PCR analysis of hybrids containing translocation chromosomes and for p40, by analysis of radiation hybrids. The subunits map to different chromosomes: p40 (IL12B) to 5q31-q33 and p35 (IL12A) to 3p12-3q13.2.

Nonfatal injuries among US children with disabling conditions

OBJECTIVES

We investigated the risk of nonfatal injury in US children with disabilities. Disability was defined as a long-term reduction in the ability to conduct social role activities, such as school or play, because of a chronic physical or mental condition.

METHODS

Among 57 909 children aged 5-17 years who participated in the 2000-2002 National Health Interview Survey, we identified 312 children with vision/hearing disabilities, 711 with mental retardation, 603 with attention-deficit/hyperactivity disorder (ADD/HD), and 403 with chronic asthma. We compared nonfatal injuries in the past 3 months between children with disabling conditions and those without using injury rates and logistic regression analyses.

RESULTS

Compared with children without a disability, a higher percentage of children with disabilities reported nonfatal injuries (4.2% for vision disability, 3.2% for mental retardation, 4.5% for attention-deficit/hyperactivity disorder, and 5.7% for asthma vs 2.5% for healthy children). After we controlled for confounding effects of sociodemographic variables, children with disabilities, with the exception of mental retardation, had a statistically significantly higher injury risk than those without disabling conditions.

CONCLUSIONS

Children with a disabling condition from vision/hearing disability, ADD/HD, or chronic asthma had a significantly higher risk for nonfatal injuries compared with children without a disabling condition. These data underscore the need to promote injury control and prevention programs targeting children with disabilities.

Cloning and expression of eukaryotic initiation factor 4B cDNA: sequence determination identifies a common RNA recognition motif

Eukaryotic protein synthesis initiation factor 4B (eIF-4B) is an 80,000 dalton polypeptide which is essential for the binding of mRNA to ribosomes. A highly purified preparation of eIF-4B from HeLa cells was subjected to enzymatic cleavage and amino-terminal amino acid sequence analysis. Degenerate oligonucleotide probes were used to isolate a 3851 bp cDNA encoding eIF-4B from a human cDNA library. The DNA encodes a protein comprising 611 residues with a mass of 69,843 daltons. The amino-terminal domain of eIF-4B contains a consensus RNA binding domain present in a number of other RNA binding proteins. Expression of eIF-4B in transfected COS-1 cells yielded a polypeptide which reacted with anti-eIF-4B antiserum and comigrated with purified eIF-4B. Expression of eIF-4B in COS-1 cells resulted in a general inhibition of translation, possibly due to a 50-fold eIF-4B overproduction.

The nucleotide sequence encoding the hamster 78-kDa glucose-regulated protein (GRP78) and its conservation between hamster and rat

The complete nucleotide (nt) sequence encoding the hamster 78-kDa glucose-regulated protein has been determined using a cDNA plasmid p3C5. Comparison of the nucleotide sequences from rat and hamster showed a strong conservation in the coding region as well as 5'- and 3'-untranslated regions (UTRs). The relatively long (206 nt for rat) 5'UTR shares 72% sequence homology between rat and hamster in the 142 nt upstream from the ATG start codon. This conserved region contained an imperfect inverted-repeat sequence. The long 5'UTR region is capable of forming stable dyad structures. The homology within the rat and hamster protein-coding region is 93.7%, with most of the differences resulting in silent site mutations. Out of the 654 amino acids, only four changes are detected, two of which are located in the signal peptide. While the sizes of the 3'UTR are different between the two species compared, strong sequence homologies (95%) were observed throughout the entire UTRs. Also, the 3'UTR was not rich in A + T residues as found in other eukaryotic mRNAs.

Titan Radar Mapper observations from Cassini's T3 fly-by

Cassini's Titan Radar Mapper imaged the surface of Saturn's moon Titan on its February 2005 fly-by (denoted T3), collecting high-resolution synthetic-aperture radar and larger-scale radiometry and scatterometry data. These data provide the first definitive identification of impact craters on the surface of Titan, networks of fluvial channels and surficial dark streaks that may be longitudinal dunes. Here we describe this great diversity of landforms. We conclude that much of the surface thus far imaged by radar of the haze-shrouded Titan is very young, with persistent geologic activity.

The lakes of Titan

The surface of Saturn's haze-shrouded moon Titan has long been proposed to have oceans or lakes, on the basis of the stability of liquid methane at the surface. Initial visible and radar imaging failed to find any evidence of an ocean, although abundant evidence was found that flowing liquids have existed on the surface. Here we provide definitive evidence for the presence of lakes on the surface of Titan, obtained during the Cassini Radar flyby of Titan on 22 July 2006 (T16). The radar imaging polewards of 70 degrees north shows more than 75 circular to irregular radar-dark patches, in a region where liquid methane and ethane are expected to be abundant and stable on the surface. The radar-dark patches are interpreted as lakes on the basis of their very low radar reflectivity and morphological similarities to lakes, including associated channels and location in topographic depressions. Some of the lakes do not completely fill the depressions in which they lie, and apparently dry depressions are present. We interpret this to indicate that lakes are present in a number of states, including partly dry and liquid-filled. These northern-hemisphere lakes constitute the strongest evidence yet that a condensable-liquid hydrological cycle is active in Titan's surface and atmosphere, in which the lakes are filled through rainfall and/or intersection with the subsurface 'liquid methane' table.

Somatic symptoms of depression in elderly patients with medical comorbidities

OBJECTIVE

Somatic symptoms of depression such as fatigue create a diagnostic dilemma when assessing an older patient with medical comorbidities, since chronic medical illnesses may produce similar symptoms. Alternatively, somatic symptoms attributed to medical illness may actually be caused by depression. These analyses were designed to determine if somatic symptoms in older patients are more strongly associated with chronic physical problems or with depression.

DESIGN

Reanalysis of data from an observational study of depression in primary care and a randomized trial of paroxetine and nortriptyline for the treatment of major depression. Patients were evaluated with a structured diagnostic interview and a battery of psychiatric, physical, and psychosocial measures.

PARTICIPANTS

Two hundred and forty eight primary care and psychiatric patients aged >or= 60 years.

METHODS

Associations among depression, somatization, and chronic physical problems were examined using correlations and regression modeling.

RESULTS

Two somatization measures, the Asberg Side Effects Rating Scale and the Utvalg for Kliniske Undersogelser (UKU), were significantly associated with psychological symptoms of depression (r = 0.73 and r = 0.76, p < 0.0001) but not with medical comorbidities (r = 0.02, p = 0.16 and r = 0.10, p = 0.78). In multiple regression models, psychological symptoms of depression remained significant predictors of somatization (p < 0.0001) after controlling for age, gender, and medical comorbidities.

CONCLUSIONS

In older patients with medical disorders and multiple somatic complaints, clinicians should consider the possibility of depression. Rating scales emphasizing somatic symptoms associated with depression may provide a more accurate measure of depression severity than those excluding such symptoms.

Improving access to care and clinical outcome for pediatric behavioral problems: a randomized trial of a nurse-administered intervention in primary care

OBJECTIVE

To determine the effectiveness of an on-site modular intervention in improving access to mental health services and outcomes for children with behavioral problems in primary care relative to enhanced usual care. The study includes boys and girls from six primary care offices in metropolitan Pittsburgh, PA.

METHODS

One hundred sixty-three clinically referred children who met a modest clinical cutoff (75th percentile) on the externalizing behavior scale of the Pediatric Symptom Checklist-17 were randomized to a protocol for on-site, nurse-administered intervention or to enhanced usual care. Protocol for on-site, nurse-administered intervention applied treatment modules from an evidence-based specialty mental health treatment for children with disruptive behavior disorders that were adapted for delivery in the primary care setting; enhanced usual care offered diagnostic assessment, recommendations, and facilitated referral to a specialty mental health provider in the community. The main outcome measures such as standardized rating scales, including the Pediatric Symptom Checklist-17, individualized target behavior ratings, treatment termination reports, and diagnostic interviews were collected.

RESULTS

Protocol for on-site, nurse-administered intervention cases were significantly more likely to receive and complete mental health services, reported fewer service barriers and more consumer satisfaction, and showed greater, albeit modest, improvements on just a few clinical outcomes that included remission for categorical behavioral disorders at 1-year follow-up. Both conditions also reported several significant improvements on several clinical outcomes over time.

CONCLUSIONS

A psychosocial intervention for behavior problems that was delivered by nurses in the primary care setting is feasible, improves access to mental health services, and has some clinical efficacy. Options for enhancing clinical outcome include the use of multifaceted collaborative care interventions in the pediatric practice.

Building bridges to evidence-based practice: the MacArthur Foundation Child System and Treatment Enhancement Projects (Child STEPs)

The papers in this special issue describe research undertaken by the MacArthur Foundation-funded Research Network on Youth Mental Health. The project is designed to understand the challenges of implementing evidence-based treatments in community-based mental health practices. This Introduction and the following articles describe the impetus and conceptual framework underlying one cluster of the Network's activity-i.e., the Clinic Systems Project (CSP). The CSP studies examined the organizational and service system environments in a large national sample of community mental health and affiliated organizations that provide services to children. The main goal is to identify leverage points for, and barriers to, the adoption and implementation of evidence-based practices for children.

Intensive short course chemotherapy for tuberculous meningitis

This nonrandomized, open clinical investigation of tuberculous meningitis evaluated 53 children with Stage I (n = 8), Stage II (n = 29) and Stage III (n = 16) disease. The overall mortality was 20.8% (11 of 53) with a rate of sequelae of 35.7% (15 of 42) in survivors reflecting the advanced stages of children at diagnosis. Various combinations of standard antituberculous drugs including isoniazid, rifampin, pyrazinamide, streptomycin and ethambutol were given. Three treatment durations used during various time periods were evaluated: 12, 9 and 6 months with only the 6-month regimen receiving pyrazinamide (PZA). This prospective evaluation demonstrated that: (1) severe disease at presentation is highly associated with early mortality (P less than 0.05), regardless of drug regimen; and (2) intensive short course chemotherapy (6 months) with PZA, regardless of stage of disease at presentation, is more efficacious than longer course therapy (9 or 12 months) without PZA in preventing total negative outcomes and sequelae (P less than 0.05). This study demonstrates that a 6-month regimen containing PZA can be used in treating children with tuberculous meningitis.

Doctor-office collaborative care for pediatric behavioral problems: a preliminary clinical trial

OBJECTIVES

To evaluate the feasibility and clinical benefits of an integrated mental health intervention (doctor-office collaborative care [DOCC]) vs enhanced usual care (EUC) for children with behavioral problems.

DESIGN

Cases were assigned to DOCC and EUC using a 2:1 randomization schedule that resulted in 55 DOCC and 23 EUC cases.

SETTING

Preassessment was conducted in 4 pediatric primary care practices. Postassessment was conducted in the pediatric or research office. Doctor-office collaborative care was provided in the practice; EUC was initiated in the office but involved a facilitated referral to a local mental health specialist.

PARTICIPANTS

Of 125 referrals (age range, 5-12 years), 78 children participated.

INTERVENTIONS

Children and their parents were assigned to receive DOCC or EUC.

MAIN OUTCOME MEASURES

Preassessment diagnostic status was evaluated using the Schedule for Affective Disorders and Schizophrenia for School-aged Children. Preassessment and 6-month postassessment ratings of behavioral and emotional problems were collected from parents using the Vanderbilt Attention-Deficit/Hyperactivity Disorder Diagnostic Parent Rating Scale, as well as individualized goal achievement ratings forms. At discharge, care managers and a diagnostic evaluator completed the Clinical Global Impression Scale, and pediatricians and parents completed satisfaction and study feedback measures.

RESULTS

Group comparisons found significant improvements for DOCC over EUC in service use and completion, behavioral and emotional problems, individualized behavioral goals, and overall clinical response. Pediatricians and parents were highly satisfied with DOCC.

CONCLUSION

The feasibility and clinical benefits of DOCC for behavioral problems support the integration of collaborative mental health services for common mental disorders in primary care.

Skiing- and Snowboarding-Related Injuries Treated in U.S. Emergency Departments, 2002

BACKGROUND

This study aims to describe the characteristics of skiing- and snowboarding-related injuries treated in U.S. emergency departments (EDs).

METHODS

Skiing- and snowboarding-related injuries collected by the National Electronic Injury Surveillance System in 2002 were analyzed. Data regarding skiing and snowboarding participation were used to calculate injury rates by age group and activity (skiing versus snowboarding).

RESULTS

An estimated 77,300 (95% CI = 11,600-143,000) skiing- and 62,000 (95% CI = 32,800-91,200) snowboarding-related injuries were treated in U.S. hospital EDs in 2002. Wrist injuries (17.9%) and arm injuries (16.6%) among snowboarders and knee injuries (22.7%) among skiers were the most common injuries. The age groups that have the highest skiing-related injury rates were the 55-64 years (29.0 per 1,000 participants), the 65+ years (21.7 per 1,000 participants), and the 45-54 years (15.5 per 1,000 participants). The age groups that have the highest snowboarding-related injuries were the 10-13 years (15.9 per 1,000 participants), the 14-17 years (15.0 per 1,000 participants), and the 18-24 years (13.5 per 1,000 participants). Traumatic brain injury (TBI) rates were higher among older skiers, 55-64 years (2.15 per 1,000 participants), and younger skiers, 10-13 years (1.69 per 1,000 participants).

CONCLUSIONS

Our study is the first to demonstrate that older skiers are at highest risk for injury. Adolescents are at highest risk for snowboarding-related injury. Prevention of TBI should be a top injury control priority among skiers and snowboarders.

Multi-Institutional Sharing of Electronic Health Record Data to Assess Childhood Obesity

OBJECTIVE

To evaluate the validity of multi-institutional electronic health record (EHR) data sharing for surveillance and study of childhood obesity.

METHODS

We conducted a non-concurrent cohort study of 528,340 children with outpatient visits to six pediatric academic medical centers during 2007-08, with sufficient data in the EHR for body mass index (BMI) assessment. EHR data were compared with data from the 2007-08 National Health and Nutrition Examination Survey (NHANES).

RESULTS

Among children 2-17 years, BMI was evaluable for 1,398,655 visits (56%). The EHR dataset contained over 6,000 BMI measurements per month of age up to 16 years, yielding precise estimates of BMI. In the EHR dataset, 18% of children were obese versus 18% in NHANES, while 35% were obese or overweight versus 34% in NHANES. BMI for an individual was highly reliable over time (intraclass correlation coefficient 0.90 for obese children and 0.97 for all children). Only 14% of visits with measured obesity (BMI ≥95%) had a diagnosis of obesity recorded, and only 20% of children with measured obesity had the diagnosis documented during the study period. Obese children had higher primary care (4.8 versus 4.0 visits, p<0.001) and specialty care (3.7 versus 2.7 visits, p<0.001) utilization than non-obese counterparts, and higher prevalence of diverse co-morbidities. The cohort size in the EHR dataset permitted detection of associations with rare diagnoses. Data sharing did not require investment of extensive institutional resources, yet yielded high data quality.

CONCLUSIONS

Multi-institutional EHR data sharing is a promising, feasible, and valid approach for population health surveillance. It provides a valuable complement to more resource-intensive national surveys, particularly for iterative surveillance and quality improvement. Low rates of obesity diagnosis present a significant obstacle to surveillance and quality improvement for care of children with obesity.