Michele G. Sullivan

When Jennifer Swanberg, Ph.D., gave cameras to a group of sick children, she expected pictures describing their battles against debilitating illness.

What she got were pictures of kids being kids—and that, she said, was even more powerful.

Justin, 16, summed it up pretty succinctly, Dr. Swanberg said.

Justin died last year of cystic fibrosis; his photographs didn't dwell on his medications and limitations but on his activities and love of life instead.

“I wanted him to tell a story about dealing with his medical complications. I even pushed him a little, like, 'What about pictures of your appointments?' He said, 'Hey, I'm a kid first. Nothing else matters.'”

Justin's experience with photoexpression was the genesis for “I'm a Kid, Too,” a project Dr. Swanberg launched with the Lexington (Ky.) Arts and Cultural Council. The project supplied cameras and photojournalism mentoring to 15 children with debilitating illnesses.

In addition to being medically fragile, all the children faced another psychosocial hurdle: They were each adopted.

Dr. Swanberg of the College of Social Work at the University of Kentucky, Lexington, said the youngsters astounded her with their images. “They didn't even really know, consciously, what they were producing, but the results were profound.”

Tim, a boy confined to a wheelchair because of spina bifida, drew his inspiration from chalk art on the local playground asphalt. One of his photographs shows a chalk drawing of a bicycle. Because he shot it looking down from his wheelchair, the picture also includes his feet. Dr. Swanberg said, “When the kids saw it, they cheered, 'It's the closest Tim will ever get to riding a bike.'”

The project's most compelling message, Dr. Swanberg said, is that sick children are, first and foremost, children. “We can't view them as just a diagnosis. They are more than their illness.”

The 8-week program culminated with a public showing of the pictures, an event that filled the artists and their parents with pride. Often ostracized because of their illnesses, the children reveled in their accomplishments, Dr. Swanberg said.

So profoundly did the show affect the community that the university has decided to incorporate the project into its health care professions' curricula. Beginning next year, pediatric and psychology residents, as well as nursing and social work students, will be required to attend a 3-hour seminar about the psychosocial needs of children with significant medical conditions and about the foster care and adoptive systems they could encounter. The images of “I'm a Kid, Too” will be an important component of the course.

“It's a wonderful opportunity to educate students about the foster care system and the adoption process,” she said. “For instance, if a child is in foster care and needs medical attention, who makes that decision? It gets complicated and, when doctors are unaware of this issue, it can make treatment harder.”

In the meantime, Dr. Swanberg hopes to get additional funding to make the program available to larger numbers of children, perhaps by linking it with the local youth development center.

The 'I'm a Kid, Too' project in Lexington, Ky., enabled children with serious medical problems, who also were adopted, to express themselves successfully through photography. Courtesy Dr. Jennifer Swanberg

When Jennifer Swanberg, Ph.D., gave cameras to a group of sick children, she expected pictures describing their battles against debilitating illness.

What she got were pictures of kids being kids—and that, she said, was even more powerful.

Justin, 16, summed it up pretty succinctly, Dr. Swanberg said.

Justin died last year of cystic fibrosis; his photographs didn't dwell on his medications and limitations but on his activities and love of life instead.

“I wanted him to tell a story about dealing with his medical complications. I even pushed him a little, like, 'What about pictures of your appointments?' He said, 'Hey, I'm a kid first. Nothing else matters.'”

Justin's experience with photoexpression was the genesis for “I'm a Kid, Too,” a project Dr. Swanberg launched with the Lexington (Ky.) Arts and Cultural Council. The project supplied cameras and photojournalism mentoring to 15 children with debilitating illnesses.

In addition to being medically fragile, all the children faced another psychosocial hurdle: They were each adopted.

Dr. Swanberg of the College of Social Work at the University of Kentucky, Lexington, said the youngsters astounded her with their images. “They didn't even really know, consciously, what they were producing, but the results were profound.”

Tim, a boy confined to a wheelchair because of spina bifida, drew his inspiration from chalk art on the local playground asphalt. One of his photographs shows a chalk drawing of a bicycle. Because he shot it looking down from his wheelchair, the picture also includes his feet. Dr. Swanberg said, “When the kids saw it, they cheered, 'It's the closest Tim will ever get to riding a bike.'”

The project's most compelling message, Dr. Swanberg said, is that sick children are, first and foremost, children. “We can't view them as just a diagnosis. They are more than their illness.”

The 8-week program culminated with a public showing of the pictures, an event that filled the artists and their parents with pride. Often ostracized because of their illnesses, the children reveled in their accomplishments, Dr. Swanberg said.

So profoundly did the show affect the community that the university has decided to incorporate the project into its health care professions' curricula. Beginning next year, pediatric and psychology residents, as well as nursing and social work students, will be required to attend a 3-hour seminar about the psychosocial needs of children with significant medical conditions and about the foster care and adoptive systems they could encounter. The images of “I'm a Kid, Too” will be an important component of the course.

“It's a wonderful opportunity to educate students about the foster care system and the adoption process,” she said. “For instance, if a child is in foster care and needs medical attention, who makes that decision? It gets complicated and, when doctors are unaware of this issue, it can make treatment harder.”

In the meantime, Dr. Swanberg hopes to get additional funding to make the program available to larger numbers of children, perhaps by linking it with the local youth development center.

The 'I'm a Kid, Too' project in Lexington, Ky., enabled children with serious medical problems, who also were adopted, to express themselves successfully through photography. Courtesy Dr. Jennifer Swanberg

When Jennifer Swanberg, Ph.D., gave cameras to a group of sick children, she expected pictures describing their battles against debilitating illness.

What she got were pictures of kids being kids—and that, she said, was even more powerful.

Justin, 16, summed it up pretty succinctly, Dr. Swanberg said.

Justin died last year of cystic fibrosis; his photographs didn't dwell on his medications and limitations but on his activities and love of life instead.

“I wanted him to tell a story about dealing with his medical complications. I even pushed him a little, like, 'What about pictures of your appointments?' He said, 'Hey, I'm a kid first. Nothing else matters.'”

Justin's experience with photoexpression was the genesis for “I'm a Kid, Too,” a project Dr. Swanberg launched with the Lexington (Ky.) Arts and Cultural Council. The project supplied cameras and photojournalism mentoring to 15 children with debilitating illnesses.

In addition to being medically fragile, all the children faced another psychosocial hurdle: They were each adopted.

Dr. Swanberg of the College of Social Work at the University of Kentucky, Lexington, said the youngsters astounded her with their images. “They didn't even really know, consciously, what they were producing, but the results were profound.”

Tim, a boy confined to a wheelchair because of spina bifida, drew his inspiration from chalk art on the local playground asphalt. One of his photographs shows a chalk drawing of a bicycle. Because he shot it looking down from his wheelchair, the picture also includes his feet. Dr. Swanberg said, “When the kids saw it, they cheered, 'It's the closest Tim will ever get to riding a bike.'”

The project's most compelling message, Dr. Swanberg said, is that sick children are, first and foremost, children. “We can't view them as just a diagnosis. They are more than their illness.”

The 8-week program culminated with a public showing of the pictures, an event that filled the artists and their parents with pride. Often ostracized because of their illnesses, the children reveled in their accomplishments, Dr. Swanberg said.

So profoundly did the show affect the community that the university has decided to incorporate the project into its health care professions' curricula. Beginning next year, pediatric and psychology residents, as well as nursing and social work students, will be required to attend a 3-hour seminar about the psychosocial needs of children with significant medical conditions and about the foster care and adoptive systems they could encounter. The images of “I'm a Kid, Too” will be an important component of the course.

“It's a wonderful opportunity to educate students about the foster care system and the adoption process,” she said. “For instance, if a child is in foster care and needs medical attention, who makes that decision? It gets complicated and, when doctors are unaware of this issue, it can make treatment harder.”

In the meantime, Dr. Swanberg hopes to get additional funding to make the program available to larger numbers of children, perhaps by linking it with the local youth development center.

The 'I'm a Kid, Too' project in Lexington, Ky., enabled children with serious medical problems, who also were adopted, to express themselves successfully through photography. Courtesy Dr. Jennifer Swanberg

WASHINGTON — Recognizing and acting on areas of medical vulnerability can prevent secondary developmental disability in children with Down syndrome.

“For most parents, Down syndrome already implies that the child will not develop as they had expected,” William I. Cohen, M.D., said at the annual meeting of the American Academy of Pediatrics. “But it's possible to optimize their learning by early detection of issues that have developmental consequences.”

Problems with hearing, vision, sleep, and hypothyroidism are most likely to affect learning, said Dr. Cohen, director of the Down Syndrome Center of Western Pennsylvania, Pittsburgh.

The midfacial hypoplasia typically seen in Down syndrome is the root of many ear, nose, and throat problems, he said. “All the midfacial anatomy is smaller, and this contributes to the numerous ENT infections we see in these kids.”

Purulent nasopharyngitis and sinusitis are common, as are repeated otitis media infections. These problems can result in hearing loss if not aggressively managed, he said. “Hearing loss can be due to fluid in the middle ear getting trapped because of the really small eustachian tubes, which may also have an abnormal orientation.”

Sometimes the ear canal is so small that it's not possible to visualize the tympanic membrane. This warrants an immediate referral to an otolaryngologist.

“These children need aggressive medical management. If this fails, they may need ventilating tubes. It is common for children with DS to need tubes, and some require multiple sets. The risk of hearing loss is really increased because of the anatomy,” he said.

All Down syndrome children should have a behavioral hearing screen every 6 months until they are 3 years old, and annually thereafter.

A smaller oropharynx, with normal-sized adenoidal and tonsillar tissues, makes snoring and sleep apnea a problem as well; a tonsillectomy and adenoidectomy might be indicated. Sleep disturbances probably also arise from a decrease in REM sleep, which is common in children with Down syndrome.

The trachea and upper airway also are narrower in these children, predisposing them to croup. “Much of this is misdiagnosed, though, and is actually laryngeal inflammation caused by gastroesophageal reflux disease,” he said.

Down syndrome-related ocular problems also can impair learning, Dr. Cohen said. “All of these children could be referred for an ophthalmologic evaluation by the time they are 6 months old.”

The dense congenital cataracts sometimes seen in Down syndrome infants are obvious at birth, but other problems can be present as well. Strabismus is frequent, and refractive errors occur in up to 50% of these children.

Congenital hypothyroidism is about 27 times more common among Down syndrome children, though it is still rare. In general, 20% of children with DS may develop hypothyroidism. The etiology is usually autoimmune, most often Hashimoto's disease. Newborn screening will pick up congenital hypothyroidism, but children should have repeat measures of thyroid-stimulating hormone and free T₄ at their 6-month and 1-year checkups. The measures should be performed annually thereafter, he said.

Dr. Cohen also recommends using both normal and Down syndrome-specific growth charts for these children. “The Down syndrome charts will pick up growth problems, but since they're adjusted for weight and height, they might not pick up weight problems like a regular growth chart will.”

WASHINGTON — Recognizing and acting on areas of medical vulnerability can prevent secondary developmental disability in children with Down syndrome.

“For most parents, Down syndrome already implies that the child will not develop as they had expected,” William I. Cohen, M.D., said at the annual meeting of the American Academy of Pediatrics. “But it's possible to optimize their learning by early detection of issues that have developmental consequences.”

Problems with hearing, vision, sleep, and hypothyroidism are most likely to affect learning, said Dr. Cohen, director of the Down Syndrome Center of Western Pennsylvania, Pittsburgh.

The midfacial hypoplasia typically seen in Down syndrome is the root of many ear, nose, and throat problems, he said. “All the midfacial anatomy is smaller, and this contributes to the numerous ENT infections we see in these kids.”

Purulent nasopharyngitis and sinusitis are common, as are repeated otitis media infections. These problems can result in hearing loss if not aggressively managed, he said. “Hearing loss can be due to fluid in the middle ear getting trapped because of the really small eustachian tubes, which may also have an abnormal orientation.”

Sometimes the ear canal is so small that it's not possible to visualize the tympanic membrane. This warrants an immediate referral to an otolaryngologist.

“These children need aggressive medical management. If this fails, they may need ventilating tubes. It is common for children with DS to need tubes, and some require multiple sets. The risk of hearing loss is really increased because of the anatomy,” he said.

All Down syndrome children should have a behavioral hearing screen every 6 months until they are 3 years old, and annually thereafter.

A smaller oropharynx, with normal-sized adenoidal and tonsillar tissues, makes snoring and sleep apnea a problem as well; a tonsillectomy and adenoidectomy might be indicated. Sleep disturbances probably also arise from a decrease in REM sleep, which is common in children with Down syndrome.

The trachea and upper airway also are narrower in these children, predisposing them to croup. “Much of this is misdiagnosed, though, and is actually laryngeal inflammation caused by gastroesophageal reflux disease,” he said.

Down syndrome-related ocular problems also can impair learning, Dr. Cohen said. “All of these children could be referred for an ophthalmologic evaluation by the time they are 6 months old.”

The dense congenital cataracts sometimes seen in Down syndrome infants are obvious at birth, but other problems can be present as well. Strabismus is frequent, and refractive errors occur in up to 50% of these children.

Congenital hypothyroidism is about 27 times more common among Down syndrome children, though it is still rare. In general, 20% of children with DS may develop hypothyroidism. The etiology is usually autoimmune, most often Hashimoto's disease. Newborn screening will pick up congenital hypothyroidism, but children should have repeat measures of thyroid-stimulating hormone and free T₄ at their 6-month and 1-year checkups. The measures should be performed annually thereafter, he said.

Dr. Cohen also recommends using both normal and Down syndrome-specific growth charts for these children. “The Down syndrome charts will pick up growth problems, but since they're adjusted for weight and height, they might not pick up weight problems like a regular growth chart will.”

WASHINGTON — Recognizing and acting on areas of medical vulnerability can prevent secondary developmental disability in children with Down syndrome.

“For most parents, Down syndrome already implies that the child will not develop as they had expected,” William I. Cohen, M.D., said at the annual meeting of the American Academy of Pediatrics. “But it's possible to optimize their learning by early detection of issues that have developmental consequences.”

Problems with hearing, vision, sleep, and hypothyroidism are most likely to affect learning, said Dr. Cohen, director of the Down Syndrome Center of Western Pennsylvania, Pittsburgh.

The midfacial hypoplasia typically seen in Down syndrome is the root of many ear, nose, and throat problems, he said. “All the midfacial anatomy is smaller, and this contributes to the numerous ENT infections we see in these kids.”

Purulent nasopharyngitis and sinusitis are common, as are repeated otitis media infections. These problems can result in hearing loss if not aggressively managed, he said. “Hearing loss can be due to fluid in the middle ear getting trapped because of the really small eustachian tubes, which may also have an abnormal orientation.”

Sometimes the ear canal is so small that it's not possible to visualize the tympanic membrane. This warrants an immediate referral to an otolaryngologist.

“These children need aggressive medical management. If this fails, they may need ventilating tubes. It is common for children with DS to need tubes, and some require multiple sets. The risk of hearing loss is really increased because of the anatomy,” he said.

All Down syndrome children should have a behavioral hearing screen every 6 months until they are 3 years old, and annually thereafter.

A smaller oropharynx, with normal-sized adenoidal and tonsillar tissues, makes snoring and sleep apnea a problem as well; a tonsillectomy and adenoidectomy might be indicated. Sleep disturbances probably also arise from a decrease in REM sleep, which is common in children with Down syndrome.

The trachea and upper airway also are narrower in these children, predisposing them to croup. “Much of this is misdiagnosed, though, and is actually laryngeal inflammation caused by gastroesophageal reflux disease,” he said.

Down syndrome-related ocular problems also can impair learning, Dr. Cohen said. “All of these children could be referred for an ophthalmologic evaluation by the time they are 6 months old.”

The dense congenital cataracts sometimes seen in Down syndrome infants are obvious at birth, but other problems can be present as well. Strabismus is frequent, and refractive errors occur in up to 50% of these children.

Congenital hypothyroidism is about 27 times more common among Down syndrome children, though it is still rare. In general, 20% of children with DS may develop hypothyroidism. The etiology is usually autoimmune, most often Hashimoto's disease. Newborn screening will pick up congenital hypothyroidism, but children should have repeat measures of thyroid-stimulating hormone and free T₄ at their 6-month and 1-year checkups. The measures should be performed annually thereafter, he said.

Dr. Cohen also recommends using both normal and Down syndrome-specific growth charts for these children. “The Down syndrome charts will pick up growth problems, but since they're adjusted for weight and height, they might not pick up weight problems like a regular growth chart will.”

In people younger than 40 years, the combined rate of basal and squamous cell carcinomas increased by 74% from 1976 to 2003, Leslie J. Christenson, M.D., and colleagues have reported.

From 1976 to 1979, the combined incidence of basal and squamous cell carcinoma was 19/100,000. In 2000–2003, the rate had increased to 33/100,000.

The biggest increase occurred in basal cell carcinomas in women, wrote Dr. Christenson, a dermatologist at the Mayo Clinic, Rochester, Minn., and her associates. In 1976–1979, the incidence of basal cell carcinoma (BCC) in women was 13/100,000; by 2000–2003, it had risen to 31/100,000. Rates in men rose as well, but not as sharply (23/100,000 vs. 27/100,000) (JAMA 2005;294:681–90).

“These findings in young people really speak to the risk factors in this population,” study coauthor Randall K. Roenigk, M.D., said in an interview. “This is not due to people living longer and getting more sun exposure. These people are either getting more exposure, or the exposure they get is worse.”

The population-based study, which drew its data from the Rochester Epidemiology Project, wasn't able to draw associations between exposure and tumors. However, the study offered clues that seem to implicate tanning as one cause.

The head and neck are typically the most common sites of BCC and squamous cell carcinoma (SCC). Only about 60% of the tumors in this study occurred there—lower than the 80%–90% reported for the general population. Forty-one percent of the BCCs were located on the torso. “This change in location has been thought to support the etiologic factor of excessive outdoor tanning, use of tanning parlors, or both,” they wrote.

Of those BCCs on the torso, 48% were superficial, 36% were nodular, and 7% were aggressive. In contrast, of those tumors on the head and neck, 4% were superficial, 49% were nodular, and 24% were aggressive.

Squamous cell carcinoma rates increased as well, rising from 1/100,000 in 1976–1979 to 4/100,000 in 2000–2003. There were no significant rate differences between men and women.

The study, which excluded anyone with a genetic predisposition for skin cancer, casts doubt on the assumption that some of the recent increase in skin cancers is the result of people living longer and thus, having more cumulative sun exposure, said Dr. Roenigk, chairman of the dermatology department at the Mayo Clinic. “These people are under 40—they don't have that cumulative risk. This is behavior driven.”

Stay alert to the possibility of skin cancers in younger patients, Dr. Roenigk advised. “The bottom line is, we're going to see it in younger populations, and this curve will probably continue to rise as these people age, unless they change their behavior drastically.”

In people younger than 40 years, the combined rate of basal and squamous cell carcinomas increased by 74% from 1976 to 2003, Leslie J. Christenson, M.D., and colleagues have reported.

From 1976 to 1979, the combined incidence of basal and squamous cell carcinoma was 19/100,000. In 2000–2003, the rate had increased to 33/100,000.

The biggest increase occurred in basal cell carcinomas in women, wrote Dr. Christenson, a dermatologist at the Mayo Clinic, Rochester, Minn., and her associates. In 1976–1979, the incidence of basal cell carcinoma (BCC) in women was 13/100,000; by 2000–2003, it had risen to 31/100,000. Rates in men rose as well, but not as sharply (23/100,000 vs. 27/100,000) (JAMA 2005;294:681–90).

“These findings in young people really speak to the risk factors in this population,” study coauthor Randall K. Roenigk, M.D., said in an interview. “This is not due to people living longer and getting more sun exposure. These people are either getting more exposure, or the exposure they get is worse.”

The population-based study, which drew its data from the Rochester Epidemiology Project, wasn't able to draw associations between exposure and tumors. However, the study offered clues that seem to implicate tanning as one cause.

The head and neck are typically the most common sites of BCC and squamous cell carcinoma (SCC). Only about 60% of the tumors in this study occurred there—lower than the 80%–90% reported for the general population. Forty-one percent of the BCCs were located on the torso. “This change in location has been thought to support the etiologic factor of excessive outdoor tanning, use of tanning parlors, or both,” they wrote.

Of those BCCs on the torso, 48% were superficial, 36% were nodular, and 7% were aggressive. In contrast, of those tumors on the head and neck, 4% were superficial, 49% were nodular, and 24% were aggressive.

Squamous cell carcinoma rates increased as well, rising from 1/100,000 in 1976–1979 to 4/100,000 in 2000–2003. There were no significant rate differences between men and women.

The study, which excluded anyone with a genetic predisposition for skin cancer, casts doubt on the assumption that some of the recent increase in skin cancers is the result of people living longer and thus, having more cumulative sun exposure, said Dr. Roenigk, chairman of the dermatology department at the Mayo Clinic. “These people are under 40—they don't have that cumulative risk. This is behavior driven.”

Stay alert to the possibility of skin cancers in younger patients, Dr. Roenigk advised. “The bottom line is, we're going to see it in younger populations, and this curve will probably continue to rise as these people age, unless they change their behavior drastically.”

In people younger than 40 years, the combined rate of basal and squamous cell carcinomas increased by 74% from 1976 to 2003, Leslie J. Christenson, M.D., and colleagues have reported.

From 1976 to 1979, the combined incidence of basal and squamous cell carcinoma was 19/100,000. In 2000–2003, the rate had increased to 33/100,000.

The biggest increase occurred in basal cell carcinomas in women, wrote Dr. Christenson, a dermatologist at the Mayo Clinic, Rochester, Minn., and her associates. In 1976–1979, the incidence of basal cell carcinoma (BCC) in women was 13/100,000; by 2000–2003, it had risen to 31/100,000. Rates in men rose as well, but not as sharply (23/100,000 vs. 27/100,000) (JAMA 2005;294:681–90).

“These findings in young people really speak to the risk factors in this population,” study coauthor Randall K. Roenigk, M.D., said in an interview. “This is not due to people living longer and getting more sun exposure. These people are either getting more exposure, or the exposure they get is worse.”

The population-based study, which drew its data from the Rochester Epidemiology Project, wasn't able to draw associations between exposure and tumors. However, the study offered clues that seem to implicate tanning as one cause.

The head and neck are typically the most common sites of BCC and squamous cell carcinoma (SCC). Only about 60% of the tumors in this study occurred there—lower than the 80%–90% reported for the general population. Forty-one percent of the BCCs were located on the torso. “This change in location has been thought to support the etiologic factor of excessive outdoor tanning, use of tanning parlors, or both,” they wrote.

Of those BCCs on the torso, 48% were superficial, 36% were nodular, and 7% were aggressive. In contrast, of those tumors on the head and neck, 4% were superficial, 49% were nodular, and 24% were aggressive.

Squamous cell carcinoma rates increased as well, rising from 1/100,000 in 1976–1979 to 4/100,000 in 2000–2003. There were no significant rate differences between men and women.

The study, which excluded anyone with a genetic predisposition for skin cancer, casts doubt on the assumption that some of the recent increase in skin cancers is the result of people living longer and thus, having more cumulative sun exposure, said Dr. Roenigk, chairman of the dermatology department at the Mayo Clinic. “These people are under 40—they don't have that cumulative risk. This is behavior driven.”

Stay alert to the possibility of skin cancers in younger patients, Dr. Roenigk advised. “The bottom line is, we're going to see it in younger populations, and this curve will probably continue to rise as these people age, unless they change their behavior drastically.”

The most effective way to prevent further confusion between Topamax and Toprol-XL—the brand names of topiramate and metoprolol succinate—would be to change one of their names, according to Michael R. Cohen, president of the Institute for Safe Medication Practices.

A complete name change would not be necessary, Mr. Cohen said in an interview; capital letters could be used to accentuate the differences between the two words.

“They have used capitals, but both companies used all capitals for the names,” which can actually detract from a visual recognition of the different letters in each name. “What they really need to do is identify with capitals the characters that are unique to each name—that would make the differences stand out more.”

However, a name change was not included among the suggested safety precautions in a “Dear Health Care Provider” letter sent out by Ortho-McNeil Pharmaceutical Inc., maker of Topamax.

Reports of mixups between Topamax and Toprol-XL (AstraZeneca) have been submitted to the Food and Drug Administration, the World Health Organization, and the U.S. Pharmacopeia, an Ortho-McNeil press release said. The reports document prescriptions that have been incorrectly written, labeled, and/or dispensed, resulting in some patients taking the incorrect drug.

Neither company would say how many medication errors have been reported, but the press release did say such errors can lead to “potentially serious health consequences associated with either unintended exposure to a medication or lack of a needed therapy.” Patients taking topiramate, an anticonvulsant, can experience a sudden increase in seizure activity, and those taking metoprolol succinate, a β-blocker, can experience increases in blood pressure, angina, or even myocardial infarction if therapy stops abruptly.

The errors have been traced not only to similarity in trade names, but also to the products' proximity on pharmacy shelves or computerized listings, and identical dose strengths in the tablet formulations.

Both drugs also recommend dosage titration, which could be another contributing factor, according to Ortho-McNeil's “Dear Health Care Provider” letter, which is part of the company's educational campaign targeted at physicians and pharmacists.

To help ensure that patients receive the correct medication, the campaign encourages physicians to:

▸ Be alert to the possibility of medication errors in patients prescribed Topamax or Toprol-XL.

▸ Be aware of the possibility of medication errors in patients presenting with unexpected signs or symptoms while on Topamax or Toprol-XL.

▸ Confirm the brand and generic names and dosage on written and oral prescriptions.

▸ Print legible prescriptions that include the brand and generic names, with indication.

▸ Counsel patients about the brand name, indication, and proper use of each drug.

Neither Ortho-McNeil nor AstraZeneca has announced plans to alter its drug's trade name in any way. In the absence of such changes, Mr. Cohen suggested that physicians take the initiative to explain the situation to patients and highlight the drug names in a way that makes the prescription very clear to the pharmacist.

Such an effort helps patients advocate for their own safety, he said. “Highlight the unique letter characters in each name, and take a few minutes to let their patients know that there have been some mistakes.”

Additionally, he said, pharmacists dispensing the medications can easily catch any errors with a few words to the person picking up the medication. “All they have to do when handing it out is to repeat the name of the drug to the patient and ask, in the case of Topamax, for example, 'Are you using this for seizures or migraines?'”

The most effective way to prevent further confusion between Topamax and Toprol-XL—the brand names of topiramate and metoprolol succinate—would be to change one of their names, according to Michael R. Cohen, president of the Institute for Safe Medication Practices.

A complete name change would not be necessary, Mr. Cohen said in an interview; capital letters could be used to accentuate the differences between the two words.

“They have used capitals, but both companies used all capitals for the names,” which can actually detract from a visual recognition of the different letters in each name. “What they really need to do is identify with capitals the characters that are unique to each name—that would make the differences stand out more.”

However, a name change was not included among the suggested safety precautions in a “Dear Health Care Provider” letter sent out by Ortho-McNeil Pharmaceutical Inc., maker of Topamax.

Reports of mixups between Topamax and Toprol-XL (AstraZeneca) have been submitted to the Food and Drug Administration, the World Health Organization, and the U.S. Pharmacopeia, an Ortho-McNeil press release said. The reports document prescriptions that have been incorrectly written, labeled, and/or dispensed, resulting in some patients taking the incorrect drug.

Neither company would say how many medication errors have been reported, but the press release did say such errors can lead to “potentially serious health consequences associated with either unintended exposure to a medication or lack of a needed therapy.” Patients taking topiramate, an anticonvulsant, can experience a sudden increase in seizure activity, and those taking metoprolol succinate, a β-blocker, can experience increases in blood pressure, angina, or even myocardial infarction if therapy stops abruptly.

The errors have been traced not only to similarity in trade names, but also to the products' proximity on pharmacy shelves or computerized listings, and identical dose strengths in the tablet formulations.

Both drugs also recommend dosage titration, which could be another contributing factor, according to Ortho-McNeil's “Dear Health Care Provider” letter, which is part of the company's educational campaign targeted at physicians and pharmacists.

To help ensure that patients receive the correct medication, the campaign encourages physicians to:

▸ Be alert to the possibility of medication errors in patients prescribed Topamax or Toprol-XL.

▸ Be aware of the possibility of medication errors in patients presenting with unexpected signs or symptoms while on Topamax or Toprol-XL.

▸ Confirm the brand and generic names and dosage on written and oral prescriptions.

▸ Print legible prescriptions that include the brand and generic names, with indication.

▸ Counsel patients about the brand name, indication, and proper use of each drug.

Neither Ortho-McNeil nor AstraZeneca has announced plans to alter its drug's trade name in any way. In the absence of such changes, Mr. Cohen suggested that physicians take the initiative to explain the situation to patients and highlight the drug names in a way that makes the prescription very clear to the pharmacist.

Such an effort helps patients advocate for their own safety, he said. “Highlight the unique letter characters in each name, and take a few minutes to let their patients know that there have been some mistakes.”

Additionally, he said, pharmacists dispensing the medications can easily catch any errors with a few words to the person picking up the medication. “All they have to do when handing it out is to repeat the name of the drug to the patient and ask, in the case of Topamax, for example, 'Are you using this for seizures or migraines?'”

The most effective way to prevent further confusion between Topamax and Toprol-XL—the brand names of topiramate and metoprolol succinate—would be to change one of their names, according to Michael R. Cohen, president of the Institute for Safe Medication Practices.

A complete name change would not be necessary, Mr. Cohen said in an interview; capital letters could be used to accentuate the differences between the two words.

“They have used capitals, but both companies used all capitals for the names,” which can actually detract from a visual recognition of the different letters in each name. “What they really need to do is identify with capitals the characters that are unique to each name—that would make the differences stand out more.”

However, a name change was not included among the suggested safety precautions in a “Dear Health Care Provider” letter sent out by Ortho-McNeil Pharmaceutical Inc., maker of Topamax.

Reports of mixups between Topamax and Toprol-XL (AstraZeneca) have been submitted to the Food and Drug Administration, the World Health Organization, and the U.S. Pharmacopeia, an Ortho-McNeil press release said. The reports document prescriptions that have been incorrectly written, labeled, and/or dispensed, resulting in some patients taking the incorrect drug.

Neither company would say how many medication errors have been reported, but the press release did say such errors can lead to “potentially serious health consequences associated with either unintended exposure to a medication or lack of a needed therapy.” Patients taking topiramate, an anticonvulsant, can experience a sudden increase in seizure activity, and those taking metoprolol succinate, a β-blocker, can experience increases in blood pressure, angina, or even myocardial infarction if therapy stops abruptly.

The errors have been traced not only to similarity in trade names, but also to the products' proximity on pharmacy shelves or computerized listings, and identical dose strengths in the tablet formulations.

Both drugs also recommend dosage titration, which could be another contributing factor, according to Ortho-McNeil's “Dear Health Care Provider” letter, which is part of the company's educational campaign targeted at physicians and pharmacists.

To help ensure that patients receive the correct medication, the campaign encourages physicians to:

▸ Be alert to the possibility of medication errors in patients prescribed Topamax or Toprol-XL.

▸ Be aware of the possibility of medication errors in patients presenting with unexpected signs or symptoms while on Topamax or Toprol-XL.

▸ Confirm the brand and generic names and dosage on written and oral prescriptions.

▸ Print legible prescriptions that include the brand and generic names, with indication.

▸ Counsel patients about the brand name, indication, and proper use of each drug.

Neither Ortho-McNeil nor AstraZeneca has announced plans to alter its drug's trade name in any way. In the absence of such changes, Mr. Cohen suggested that physicians take the initiative to explain the situation to patients and highlight the drug names in a way that makes the prescription very clear to the pharmacist.

Such an effort helps patients advocate for their own safety, he said. “Highlight the unique letter characters in each name, and take a few minutes to let their patients know that there have been some mistakes.”

Additionally, he said, pharmacists dispensing the medications can easily catch any errors with a few words to the person picking up the medication. “All they have to do when handing it out is to repeat the name of the drug to the patient and ask, in the case of Topamax, for example, 'Are you using this for seizures or migraines?'”

NASHVILLE, TENN. — Creatine monohydrate, in combination with resistance training, appears to increase strength and endurance in patients with Parkinson's disease more than resistance training alone.

The additional benefits may be related to creatine's ability to stimulate protein synthesis and reduce the depletion of adenosine triphosphate during exercise, Chris Hass, Ph.D., of Columbia University, New York, wrote in a poster at the annual meeting of the American College of Sports Medicine.

Creatine preserved dopaminergic neurons in a mouse model of Parkinson's (Exp. Neurol. 1999;157:142–9).

Dr. Hass randomized 20 patients with idiopathic Parkinson's disease to progressive resistance weight training plus placebo, or training plus daily creatine supplementation with 20 g/day for the first 5 days and 5 g/day thereafter. The patients' mean age was 62 years; their average functional Parkinson's evaluation score—using Hoehn and Yahr staging—was 2.2, which is considered mild to moderate Parkinson's disease.

All participants underwent 12 weeks of progressive resistance training on exercise machines, twice a week. The 11 exercises targeted arms, legs, chest, torso, and back. They performed one set of 8–12 repetitions, or to fatigue.

Both groups significantly improved the maximum amount of weight they could press, but the creatine group improved significantly more than controls in biceps curl (26% vs. 11%), with a trend toward significance in chest press (24% vs. 13%).

Muscular endurance improved in both groups but more in the creatine group (chest press endurance 38% vs. 33%; leg extension endurance 95% vs. 59%). Only the creatine group significantly increased in chair rise performance (12% vs. 5%).

NASHVILLE, TENN. — Creatine monohydrate, in combination with resistance training, appears to increase strength and endurance in patients with Parkinson's disease more than resistance training alone.

The additional benefits may be related to creatine's ability to stimulate protein synthesis and reduce the depletion of adenosine triphosphate during exercise, Chris Hass, Ph.D., of Columbia University, New York, wrote in a poster at the annual meeting of the American College of Sports Medicine.

Creatine preserved dopaminergic neurons in a mouse model of Parkinson's (Exp. Neurol. 1999;157:142–9).

Dr. Hass randomized 20 patients with idiopathic Parkinson's disease to progressive resistance weight training plus placebo, or training plus daily creatine supplementation with 20 g/day for the first 5 days and 5 g/day thereafter. The patients' mean age was 62 years; their average functional Parkinson's evaluation score—using Hoehn and Yahr staging—was 2.2, which is considered mild to moderate Parkinson's disease.

All participants underwent 12 weeks of progressive resistance training on exercise machines, twice a week. The 11 exercises targeted arms, legs, chest, torso, and back. They performed one set of 8–12 repetitions, or to fatigue.

Both groups significantly improved the maximum amount of weight they could press, but the creatine group improved significantly more than controls in biceps curl (26% vs. 11%), with a trend toward significance in chest press (24% vs. 13%).

Muscular endurance improved in both groups but more in the creatine group (chest press endurance 38% vs. 33%; leg extension endurance 95% vs. 59%). Only the creatine group significantly increased in chair rise performance (12% vs. 5%).

NASHVILLE, TENN. — Creatine monohydrate, in combination with resistance training, appears to increase strength and endurance in patients with Parkinson's disease more than resistance training alone.

The additional benefits may be related to creatine's ability to stimulate protein synthesis and reduce the depletion of adenosine triphosphate during exercise, Chris Hass, Ph.D., of Columbia University, New York, wrote in a poster at the annual meeting of the American College of Sports Medicine.

Creatine preserved dopaminergic neurons in a mouse model of Parkinson's (Exp. Neurol. 1999;157:142–9).

Dr. Hass randomized 20 patients with idiopathic Parkinson's disease to progressive resistance weight training plus placebo, or training plus daily creatine supplementation with 20 g/day for the first 5 days and 5 g/day thereafter. The patients' mean age was 62 years; their average functional Parkinson's evaluation score—using Hoehn and Yahr staging—was 2.2, which is considered mild to moderate Parkinson's disease.

All participants underwent 12 weeks of progressive resistance training on exercise machines, twice a week. The 11 exercises targeted arms, legs, chest, torso, and back. They performed one set of 8–12 repetitions, or to fatigue.

Both groups significantly improved the maximum amount of weight they could press, but the creatine group improved significantly more than controls in biceps curl (26% vs. 11%), with a trend toward significance in chest press (24% vs. 13%).

Muscular endurance improved in both groups but more in the creatine group (chest press endurance 38% vs. 33%; leg extension endurance 95% vs. 59%). Only the creatine group significantly increased in chair rise performance (12% vs. 5%).

CAMBRIDGE, MD. — Two existing medications—an antibiotic and a hypoglycemic agent—may add some strength to the poorly outfitted armamentarium for hepatic encephalopathy, Steve Solga, M.D., said at a hepatobiliary update sponsored by Johns Hopkins University.

The altered brain function of hepatic encephalopathy appears to be related to increased ammonia levels in the blood, although controversy remains on this issue. Intestinal dysmotility, common in cirrhosis, causes an overgrowth of urease-positive bacteria and increased nitrogen absorption. The impaired liver is unable to process this extra load, so ammonia levels increase.

Generally, treatment is aimed at decreasing ammonia production and absorption; neomycin and lactulose are the most common therapies. Neomycin directly decreases the gut flora, whereas lactulose decreases gut bacteria load by promoting elimination and tilts the bacterial balance toward nonammoniagenic types.

The problem, Dr. Solga said, is that while lactulose is safe, it is not as effective in resolving symptoms as is neomycin. But neomycin may not be safe for many patients.

“Some literature suggests that long-term use is associated with irreversible ototoxicity and nephrotoxicity, and that it shouldn't be given for longer than 2 weeks for hepatic encephalopathy in patients with preexisting renal impairment.”

Importantly, neither treatment has been adequately studied in well-designed randomized trials, he added.

Rifaximin, another poorly absorbed antibiotic often used for “traveler's diarrhea,” is being studied for use in hepatic encephalopathy.

“Most of the trials indicate that safety is relatively well established, but we don't have solid efficacy data yet for hepatic encephalopathy,” he said.

However, according to a 2005 review of 15 studies, rifaximin was at least as effective as lactulose and neomycin in improving neurologic symptoms and reducing blood ammonia levels (Rev. Gastroenterol. Disord. 2005;5[suppl. 1]:10–8).

The hypoglycemic agent acarbose might have some benefit for hepatic encephalopathy patients who are diabetic, he added. The drug promotes the growth of saccrolytic bacteria.

An Italian study of 107 patients found that acarbose significantly decreased blood ammonia and improved intellectual function, while controlling blood sugar (Clin. Gastroenterol. Hepatol. 2005;3:184–91).

Finally, gut flora therapy, in the form of either prebiotics or probiotics, has potential. However, this treatment is still in its infancy. There are also regulatory issues to contend with, inasmuch as it remains unclear whether probiotics are drugs or supplements.

CAMBRIDGE, MD. — Two existing medications—an antibiotic and a hypoglycemic agent—may add some strength to the poorly outfitted armamentarium for hepatic encephalopathy, Steve Solga, M.D., said at a hepatobiliary update sponsored by Johns Hopkins University.

The altered brain function of hepatic encephalopathy appears to be related to increased ammonia levels in the blood, although controversy remains on this issue. Intestinal dysmotility, common in cirrhosis, causes an overgrowth of urease-positive bacteria and increased nitrogen absorption. The impaired liver is unable to process this extra load, so ammonia levels increase.

Generally, treatment is aimed at decreasing ammonia production and absorption; neomycin and lactulose are the most common therapies. Neomycin directly decreases the gut flora, whereas lactulose decreases gut bacteria load by promoting elimination and tilts the bacterial balance toward nonammoniagenic types.

The problem, Dr. Solga said, is that while lactulose is safe, it is not as effective in resolving symptoms as is neomycin. But neomycin may not be safe for many patients.

“Some literature suggests that long-term use is associated with irreversible ototoxicity and nephrotoxicity, and that it shouldn't be given for longer than 2 weeks for hepatic encephalopathy in patients with preexisting renal impairment.”

Importantly, neither treatment has been adequately studied in well-designed randomized trials, he added.

Rifaximin, another poorly absorbed antibiotic often used for “traveler's diarrhea,” is being studied for use in hepatic encephalopathy.

“Most of the trials indicate that safety is relatively well established, but we don't have solid efficacy data yet for hepatic encephalopathy,” he said.

However, according to a 2005 review of 15 studies, rifaximin was at least as effective as lactulose and neomycin in improving neurologic symptoms and reducing blood ammonia levels (Rev. Gastroenterol. Disord. 2005;5[suppl. 1]:10–8).

The hypoglycemic agent acarbose might have some benefit for hepatic encephalopathy patients who are diabetic, he added. The drug promotes the growth of saccrolytic bacteria.

An Italian study of 107 patients found that acarbose significantly decreased blood ammonia and improved intellectual function, while controlling blood sugar (Clin. Gastroenterol. Hepatol. 2005;3:184–91).

Finally, gut flora therapy, in the form of either prebiotics or probiotics, has potential. However, this treatment is still in its infancy. There are also regulatory issues to contend with, inasmuch as it remains unclear whether probiotics are drugs or supplements.

CAMBRIDGE, MD. — Two existing medications—an antibiotic and a hypoglycemic agent—may add some strength to the poorly outfitted armamentarium for hepatic encephalopathy, Steve Solga, M.D., said at a hepatobiliary update sponsored by Johns Hopkins University.

The altered brain function of hepatic encephalopathy appears to be related to increased ammonia levels in the blood, although controversy remains on this issue. Intestinal dysmotility, common in cirrhosis, causes an overgrowth of urease-positive bacteria and increased nitrogen absorption. The impaired liver is unable to process this extra load, so ammonia levels increase.

Generally, treatment is aimed at decreasing ammonia production and absorption; neomycin and lactulose are the most common therapies. Neomycin directly decreases the gut flora, whereas lactulose decreases gut bacteria load by promoting elimination and tilts the bacterial balance toward nonammoniagenic types.

The problem, Dr. Solga said, is that while lactulose is safe, it is not as effective in resolving symptoms as is neomycin. But neomycin may not be safe for many patients.

“Some literature suggests that long-term use is associated with irreversible ototoxicity and nephrotoxicity, and that it shouldn't be given for longer than 2 weeks for hepatic encephalopathy in patients with preexisting renal impairment.”

Importantly, neither treatment has been adequately studied in well-designed randomized trials, he added.

Rifaximin, another poorly absorbed antibiotic often used for “traveler's diarrhea,” is being studied for use in hepatic encephalopathy.

“Most of the trials indicate that safety is relatively well established, but we don't have solid efficacy data yet for hepatic encephalopathy,” he said.

However, according to a 2005 review of 15 studies, rifaximin was at least as effective as lactulose and neomycin in improving neurologic symptoms and reducing blood ammonia levels (Rev. Gastroenterol. Disord. 2005;5[suppl. 1]:10–8).

The hypoglycemic agent acarbose might have some benefit for hepatic encephalopathy patients who are diabetic, he added. The drug promotes the growth of saccrolytic bacteria.

An Italian study of 107 patients found that acarbose significantly decreased blood ammonia and improved intellectual function, while controlling blood sugar (Clin. Gastroenterol. Hepatol. 2005;3:184–91).

Finally, gut flora therapy, in the form of either prebiotics or probiotics, has potential. However, this treatment is still in its infancy. There are also regulatory issues to contend with, inasmuch as it remains unclear whether probiotics are drugs or supplements.

A home visit program designed to identify early childhood language delays not only failed to spot most delayed children, but also failed to refer the vast majority of identified children for further evaluation or intervention.

The results suggest the home visitors didn't get enough training to properly screen children and that the visitors lacked the skills to communicate concerns about developmental delays to parents, according to Tracy M. King, M.D., and colleagues (J. Dev. Behav. Pediatr. 2005;26:293–303).

“This study argues for prudence in the ongoing proliferation of home visiting programs and for caution in setting expectations regarding child development outcomes,” said Dr. King of Johns Hopkins University School of Medicine, Baltimore, and her coinvestigators.

The researchers compared language delay identification rates for children enrolled in the Hawaii Healthy Start Program (304) with rates in a group of control children (209). All of the children were at high risk of developmental delay, child abuse, or neglect.

The Hawaii Healthy Start Program (HHSP) provides a regular home visitor, who teaches parents about child development, models good parental behavior, and links parents to a medical provider. The visitor also performs childhood developmental testing—including language testing—when the child is 3 years old. The control group did not receive any home visitation services.

The home visitors identified only 24% of children with severe language delay. Parents and primary care providers in the HHSP group each identified 31% of such children, while parents in the control group identified almost twice as many (56%).

The fact that parents in the control group had an increased identification rate raises the concern that the home visitors actually interfered with identification. This could be because they lack sufficient training and are giving parents false reassurance of the child's language development.

Among children with any language delay, home visits identified 17%. Parents and primary care providers also did poorly in this group, identifying 26% and 24%, respectively. Parents in the control group identified 20% of children with any language delay and primary care providers, 25%.

Particularly concerning were the low referral rates after children were identified, the investigators said. Among the 72 children identified as having delays, only 2 were referred to their primary care provider, and none were referred to local early intervention programs.

Poor parental identification rates could be related to the high-risk communities in which the families lived, the investigators said. “It may be that language delays have become so prevalent in certain at-risk communities that it is no longer possible for parents to make accurate assessments of their child's development based on comparisons with the child's peers.”

Poor home visitor and medical provider identification rates probably are due to inadequate training in child development, they said.

In an accompanying editorial, Shirley Russ, M.D., and Neal Halfon, M.D., said identification rates could be improved by using trained nurses as home visitors. Similar programs employing nurses have higher family retention rates and much better identification and referral rates (J. Dev. Behav. Pediatr. 2005;26:304–5).

“Professional nurses would be more likely to have knowledge of early childhood systems and resources in the community and would also have had more training in communicating about health and development issues to parents,” said Dr. Russ and Dr. Halfon of the University of California, Los Angeles.

Dr. King and colleagues replied in a second commentary that unfortunately visiting nurse programs are costly and difficult to staff in areas such as Hawaii, which is experiencing a serious nursing shortage (J. Dev. Behav. Pediatr. 2005;26:307).

A home visit program designed to identify early childhood language delays not only failed to spot most delayed children, but also failed to refer the vast majority of identified children for further evaluation or intervention.

The results suggest the home visitors didn't get enough training to properly screen children and that the visitors lacked the skills to communicate concerns about developmental delays to parents, according to Tracy M. King, M.D., and colleagues (J. Dev. Behav. Pediatr. 2005;26:293–303).

“This study argues for prudence in the ongoing proliferation of home visiting programs and for caution in setting expectations regarding child development outcomes,” said Dr. King of Johns Hopkins University School of Medicine, Baltimore, and her coinvestigators.

The researchers compared language delay identification rates for children enrolled in the Hawaii Healthy Start Program (304) with rates in a group of control children (209). All of the children were at high risk of developmental delay, child abuse, or neglect.

The Hawaii Healthy Start Program (HHSP) provides a regular home visitor, who teaches parents about child development, models good parental behavior, and links parents to a medical provider. The visitor also performs childhood developmental testing—including language testing—when the child is 3 years old. The control group did not receive any home visitation services.

The home visitors identified only 24% of children with severe language delay. Parents and primary care providers in the HHSP group each identified 31% of such children, while parents in the control group identified almost twice as many (56%).

The fact that parents in the control group had an increased identification rate raises the concern that the home visitors actually interfered with identification. This could be because they lack sufficient training and are giving parents false reassurance of the child's language development.

Among children with any language delay, home visits identified 17%. Parents and primary care providers also did poorly in this group, identifying 26% and 24%, respectively. Parents in the control group identified 20% of children with any language delay and primary care providers, 25%.

Particularly concerning were the low referral rates after children were identified, the investigators said. Among the 72 children identified as having delays, only 2 were referred to their primary care provider, and none were referred to local early intervention programs.

Poor parental identification rates could be related to the high-risk communities in which the families lived, the investigators said. “It may be that language delays have become so prevalent in certain at-risk communities that it is no longer possible for parents to make accurate assessments of their child's development based on comparisons with the child's peers.”

Poor home visitor and medical provider identification rates probably are due to inadequate training in child development, they said.

In an accompanying editorial, Shirley Russ, M.D., and Neal Halfon, M.D., said identification rates could be improved by using trained nurses as home visitors. Similar programs employing nurses have higher family retention rates and much better identification and referral rates (J. Dev. Behav. Pediatr. 2005;26:304–5).

“Professional nurses would be more likely to have knowledge of early childhood systems and resources in the community and would also have had more training in communicating about health and development issues to parents,” said Dr. Russ and Dr. Halfon of the University of California, Los Angeles.

Dr. King and colleagues replied in a second commentary that unfortunately visiting nurse programs are costly and difficult to staff in areas such as Hawaii, which is experiencing a serious nursing shortage (J. Dev. Behav. Pediatr. 2005;26:307).

A home visit program designed to identify early childhood language delays not only failed to spot most delayed children, but also failed to refer the vast majority of identified children for further evaluation or intervention.

The results suggest the home visitors didn't get enough training to properly screen children and that the visitors lacked the skills to communicate concerns about developmental delays to parents, according to Tracy M. King, M.D., and colleagues (J. Dev. Behav. Pediatr. 2005;26:293–303).

“This study argues for prudence in the ongoing proliferation of home visiting programs and for caution in setting expectations regarding child development outcomes,” said Dr. King of Johns Hopkins University School of Medicine, Baltimore, and her coinvestigators.

The researchers compared language delay identification rates for children enrolled in the Hawaii Healthy Start Program (304) with rates in a group of control children (209). All of the children were at high risk of developmental delay, child abuse, or neglect.

The Hawaii Healthy Start Program (HHSP) provides a regular home visitor, who teaches parents about child development, models good parental behavior, and links parents to a medical provider. The visitor also performs childhood developmental testing—including language testing—when the child is 3 years old. The control group did not receive any home visitation services.

The home visitors identified only 24% of children with severe language delay. Parents and primary care providers in the HHSP group each identified 31% of such children, while parents in the control group identified almost twice as many (56%).

The fact that parents in the control group had an increased identification rate raises the concern that the home visitors actually interfered with identification. This could be because they lack sufficient training and are giving parents false reassurance of the child's language development.

Among children with any language delay, home visits identified 17%. Parents and primary care providers also did poorly in this group, identifying 26% and 24%, respectively. Parents in the control group identified 20% of children with any language delay and primary care providers, 25%.

Particularly concerning were the low referral rates after children were identified, the investigators said. Among the 72 children identified as having delays, only 2 were referred to their primary care provider, and none were referred to local early intervention programs.

Poor parental identification rates could be related to the high-risk communities in which the families lived, the investigators said. “It may be that language delays have become so prevalent in certain at-risk communities that it is no longer possible for parents to make accurate assessments of their child's development based on comparisons with the child's peers.”

Poor home visitor and medical provider identification rates probably are due to inadequate training in child development, they said.

In an accompanying editorial, Shirley Russ, M.D., and Neal Halfon, M.D., said identification rates could be improved by using trained nurses as home visitors. Similar programs employing nurses have higher family retention rates and much better identification and referral rates (J. Dev. Behav. Pediatr. 2005;26:304–5).

“Professional nurses would be more likely to have knowledge of early childhood systems and resources in the community and would also have had more training in communicating about health and development issues to parents,” said Dr. Russ and Dr. Halfon of the University of California, Los Angeles.

Dr. King and colleagues replied in a second commentary that unfortunately visiting nurse programs are costly and difficult to staff in areas such as Hawaii, which is experiencing a serious nursing shortage (J. Dev. Behav. Pediatr. 2005;26:307).

Combing wet hair with conditioner and a fine-tooth comb is four times more effective at curing pediculosis than water-based, over-the-counter pediculicide shampoos, Nigel Hill, Ph.D., and colleagues reported.

The study contradicts others that have found pediculicides more effective than wet combing—possibly because the lice examined in the new study appeared to have developed resistance to permethrin, one of the most common active ingredients in the shampoos, said Dr. Hill, head science officer of the London School of Hygiene and Tropical Medicine, and his associates (BMJ 2005;331:384–7).

The researchers randomized 133 children aged 2–15 years with head lice to either the “Bug Buster” wet-combing kit or to a water-based, over-the-counter pediculicide containing either malathion or permethrin.

The Bug Buster kit, developed by the United Kingdom charity organization Community Hygiene Concern, includes a fine-tooth comb and conditioner. Treatment consists of four sequential combings of wet, conditioned hair with 3 days between each combing. The cure rates were 17% for malathion shampoo, 10% for permethrin, and 57% for the Bug Buster kit.

Several factors could account for the difference, the investigators said. The most recent Bug Buster kit has an improved comb. Also, only one dose of the pediculicide shampoo was used, while many physicians tell their patients to use two doses.

Combing wet hair with conditioner and a fine-tooth comb is four times more effective at curing pediculosis than water-based, over-the-counter pediculicide shampoos, Nigel Hill, Ph.D., and colleagues reported.

The study contradicts others that have found pediculicides more effective than wet combing—possibly because the lice examined in the new study appeared to have developed resistance to permethrin, one of the most common active ingredients in the shampoos, said Dr. Hill, head science officer of the London School of Hygiene and Tropical Medicine, and his associates (BMJ 2005;331:384–7).

The researchers randomized 133 children aged 2–15 years with head lice to either the “Bug Buster” wet-combing kit or to a water-based, over-the-counter pediculicide containing either malathion or permethrin.

The Bug Buster kit, developed by the United Kingdom charity organization Community Hygiene Concern, includes a fine-tooth comb and conditioner. Treatment consists of four sequential combings of wet, conditioned hair with 3 days between each combing. The cure rates were 17% for malathion shampoo, 10% for permethrin, and 57% for the Bug Buster kit.

Several factors could account for the difference, the investigators said. The most recent Bug Buster kit has an improved comb. Also, only one dose of the pediculicide shampoo was used, while many physicians tell their patients to use two doses.

Combing wet hair with conditioner and a fine-tooth comb is four times more effective at curing pediculosis than water-based, over-the-counter pediculicide shampoos, Nigel Hill, Ph.D., and colleagues reported.

The study contradicts others that have found pediculicides more effective than wet combing—possibly because the lice examined in the new study appeared to have developed resistance to permethrin, one of the most common active ingredients in the shampoos, said Dr. Hill, head science officer of the London School of Hygiene and Tropical Medicine, and his associates (BMJ 2005;331:384–7).

The researchers randomized 133 children aged 2–15 years with head lice to either the “Bug Buster” wet-combing kit or to a water-based, over-the-counter pediculicide containing either malathion or permethrin.

The Bug Buster kit, developed by the United Kingdom charity organization Community Hygiene Concern, includes a fine-tooth comb and conditioner. Treatment consists of four sequential combings of wet, conditioned hair with 3 days between each combing. The cure rates were 17% for malathion shampoo, 10% for permethrin, and 57% for the Bug Buster kit.

Several factors could account for the difference, the investigators said. The most recent Bug Buster kit has an improved comb. Also, only one dose of the pediculicide shampoo was used, while many physicians tell their patients to use two doses.

Bacterial vaginosis, high-density group B streptococcus colonization, and the use of hormonal contraceptives each is independently associated with an increased risk of genital tract shedding of herpes simplex virus type 2, Thomas L. Cherpes, M.D., and his colleagues at the University of Pittsburgh reported.

These increased risks could be key factors in HSV-2 transmission.

“Because hormonal contraceptives are used by more than 100 million women worldwide, and because bacterial vaginosis and vaginal GBS colonization are two of the most common genital tract conditions present among women of reproductive age, even modest associations between these variables and genital tract shedding of HSV-2 would result in substantial attributable risks for transmission of the virus,” Dr. Cherpes and his colleagues reported (Clin. Infect. Dis. 2005;40:1422–8).

The researchers followed 330 HSV-2-positive women for a year. The women were aged 18–30 years; 65% were black.

Every 4 months, the investigators collected behavioral data, vaginal swabs and smears, and a blood sample from each woman.

In the multivariate analysis, genital tract shedding was associated with recent HSV-2 seroconversion (OR 3), high-density group B streptococcus colonization (OR 2.2), bacterial vaginosis (OR 1.9), and the use of either depomedroxyprogesterone acetate or oral contraceptives (OR 1.8).

Genital tract shedding was not associated with vaginal intercourse, new sexual partner, or douching.

The association with bacterial vaginosis and high-density GBS colonization was somewhat of a surprise, the researchers said.

“A number of recent studies have demonstrated that [bacterial vaginosis] is associated with significant alterations in the concentrations of several immunomodulatory cytokines, compared with the concentrations of these cytokines associated with normal vaginal flora,” they reported.

Oral contraceptives may influence shedding by different means, the researchers said.

Suppression of estrogen and progesterone may alter the T cell-mediated immune response, and thereby increase shedding.

Additionally, women who use oral contraceptives can have larger areas of cervical ectopy.

“This extension of the single-layered columnar epithelium onto the ectocervix may facilitate genital tract shedding,” the researchers said.

However, since the increased risk was the same for both oral and injectable hormonal contraceptives, and cervical ectopy is more commonly associated with the oral form, it may not be the predominate mechanism responsible for increased viral shedding, they said.

Previous studies on the subject have reached varying conclusions, Katherine LaGuardia, M.D., medical affairs director for Ortho Women's Health, Ortho-McNeil Pharmaceutical, Inc., said in an interview.

“This study really doesn't shed any new light on this issue,” she said. “The definitive study, which would control for both sexual behavior and hormonal contraception, has yet to be done.”

However, she said, it's important to continue stressing to women that no hormonal contraceptive method protects against sexually transmitted infection. “Although safe and effective when used as labeled, these methods don't protect against infection,” Dr. LaGuardia said. “Using a condom along with hormonal methods offers the best protection against both pregnancy and STIs, including HIV.”

Bacterial vaginosis, high-density group B streptococcus colonization, and the use of hormonal contraceptives each is independently associated with an increased risk of genital tract shedding of herpes simplex virus type 2, Thomas L. Cherpes, M.D., and his colleagues at the University of Pittsburgh reported.

These increased risks could be key factors in HSV-2 transmission.

“Because hormonal contraceptives are used by more than 100 million women worldwide, and because bacterial vaginosis and vaginal GBS colonization are two of the most common genital tract conditions present among women of reproductive age, even modest associations between these variables and genital tract shedding of HSV-2 would result in substantial attributable risks for transmission of the virus,” Dr. Cherpes and his colleagues reported (Clin. Infect. Dis. 2005;40:1422–8).

The researchers followed 330 HSV-2-positive women for a year. The women were aged 18–30 years; 65% were black.

Every 4 months, the investigators collected behavioral data, vaginal swabs and smears, and a blood sample from each woman.

In the multivariate analysis, genital tract shedding was associated with recent HSV-2 seroconversion (OR 3), high-density group B streptococcus colonization (OR 2.2), bacterial vaginosis (OR 1.9), and the use of either depomedroxyprogesterone acetate or oral contraceptives (OR 1.8).

Genital tract shedding was not associated with vaginal intercourse, new sexual partner, or douching.

The association with bacterial vaginosis and high-density GBS colonization was somewhat of a surprise, the researchers said.

“A number of recent studies have demonstrated that [bacterial vaginosis] is associated with significant alterations in the concentrations of several immunomodulatory cytokines, compared with the concentrations of these cytokines associated with normal vaginal flora,” they reported.

Oral contraceptives may influence shedding by different means, the researchers said.

Suppression of estrogen and progesterone may alter the T cell-mediated immune response, and thereby increase shedding.

Additionally, women who use oral contraceptives can have larger areas of cervical ectopy.

“This extension of the single-layered columnar epithelium onto the ectocervix may facilitate genital tract shedding,” the researchers said.

However, since the increased risk was the same for both oral and injectable hormonal contraceptives, and cervical ectopy is more commonly associated with the oral form, it may not be the predominate mechanism responsible for increased viral shedding, they said.

Previous studies on the subject have reached varying conclusions, Katherine LaGuardia, M.D., medical affairs director for Ortho Women's Health, Ortho-McNeil Pharmaceutical, Inc., said in an interview.

“This study really doesn't shed any new light on this issue,” she said. “The definitive study, which would control for both sexual behavior and hormonal contraception, has yet to be done.”

However, she said, it's important to continue stressing to women that no hormonal contraceptive method protects against sexually transmitted infection. “Although safe and effective when used as labeled, these methods don't protect against infection,” Dr. LaGuardia said. “Using a condom along with hormonal methods offers the best protection against both pregnancy and STIs, including HIV.”

Bacterial vaginosis, high-density group B streptococcus colonization, and the use of hormonal contraceptives each is independently associated with an increased risk of genital tract shedding of herpes simplex virus type 2, Thomas L. Cherpes, M.D., and his colleagues at the University of Pittsburgh reported.

These increased risks could be key factors in HSV-2 transmission.

“Because hormonal contraceptives are used by more than 100 million women worldwide, and because bacterial vaginosis and vaginal GBS colonization are two of the most common genital tract conditions present among women of reproductive age, even modest associations between these variables and genital tract shedding of HSV-2 would result in substantial attributable risks for transmission of the virus,” Dr. Cherpes and his colleagues reported (Clin. Infect. Dis. 2005;40:1422–8).

The researchers followed 330 HSV-2-positive women for a year. The women were aged 18–30 years; 65% were black.

Every 4 months, the investigators collected behavioral data, vaginal swabs and smears, and a blood sample from each woman.

In the multivariate analysis, genital tract shedding was associated with recent HSV-2 seroconversion (OR 3), high-density group B streptococcus colonization (OR 2.2), bacterial vaginosis (OR 1.9), and the use of either depomedroxyprogesterone acetate or oral contraceptives (OR 1.8).

Genital tract shedding was not associated with vaginal intercourse, new sexual partner, or douching.

The association with bacterial vaginosis and high-density GBS colonization was somewhat of a surprise, the researchers said.

“A number of recent studies have demonstrated that [bacterial vaginosis] is associated with significant alterations in the concentrations of several immunomodulatory cytokines, compared with the concentrations of these cytokines associated with normal vaginal flora,” they reported.

Oral contraceptives may influence shedding by different means, the researchers said.

Suppression of estrogen and progesterone may alter the T cell-mediated immune response, and thereby increase shedding.

Additionally, women who use oral contraceptives can have larger areas of cervical ectopy.

“This extension of the single-layered columnar epithelium onto the ectocervix may facilitate genital tract shedding,” the researchers said.

However, since the increased risk was the same for both oral and injectable hormonal contraceptives, and cervical ectopy is more commonly associated with the oral form, it may not be the predominate mechanism responsible for increased viral shedding, they said.

Previous studies on the subject have reached varying conclusions, Katherine LaGuardia, M.D., medical affairs director for Ortho Women's Health, Ortho-McNeil Pharmaceutical, Inc., said in an interview.

“This study really doesn't shed any new light on this issue,” she said. “The definitive study, which would control for both sexual behavior and hormonal contraception, has yet to be done.”

However, she said, it's important to continue stressing to women that no hormonal contraceptive method protects against sexually transmitted infection. “Although safe and effective when used as labeled, these methods don't protect against infection,” Dr. LaGuardia said. “Using a condom along with hormonal methods offers the best protection against both pregnancy and STIs, including HIV.”

When Jennifer Swanberg, Ph.D., gave cameras to a group of sick children, she expected pictures describing their battle against debilitating illness.

What she got were pictures of kids being kids–and that, she said, was even more powerful.

Justin, 16, summed it up pretty succinctly, Dr. Swanberg said.

Justin died last year of cystic fibrosis; his photographs didn't dwell on his medications and limitations but on his activities and love of life instead.

“I wanted him to tell a story about dealing with his medical complications. I even pushed him a little, like, 'What about pictures of your appointments?' He said, 'Hey, I'm a kid first. Nothing else matters.' ”

Justin's experience with photoexpression was the genesis for “I'm a Kid, Too,” a project Dr. Swanberg launched with the Lexington (Kentucky) Arts and Cultural Council. The project supplied cameras and photojournalism mentoring to 15 children with debilitating illnesses. In addition to being medically fragile, all the children faced another psychosocial hurdle: They were each adopted.

Dr. Swanberg of the College of Social Work at the University of Kentucky, Lexington, said the youngsters astounded her with their images. “They didn't even really know, consciously, what they were producing, but the results were profound.”

Tim, a boy confined to a wheelchair because of spina bifida, drew his inspiration from chalk art on the local playground asphalt. One of his photographs shows a chalk drawing of a bicycle.

Because he shot it looking down from his wheelchair, the picture also includes his feet. “When the kids saw it, they cheered, 'It's the closest Tim will ever get to riding a bike,'” Dr. Swanberg said.

The project's most compelling message, Dr. Swanberg said, is that sick children are, first and foremost, children. “We can't view them as just a diagnosis. They are more than their illness.”

The 8-week program culminated with a public showing of the pictures, an event that filled the artists and their parents with pride. Often ostracized because of their illnesses, the children reveled in their accomplishments, Dr. Swanberg said.

So profoundly did the show affect the community that the university has decided to incorporate the project into its health care professions' curricula.

Beginning next year, pediatric and psychology residents, as well as nursing and social work students, will be required to attend a 3-hour seminar about the psychosocial needs of children with significant medical conditions and about the foster care and adoptive systems they could encounter. The images of “I'm a Kid, Too” will be an important component of the course.

“It's a wonderful opportunity to educate students about the foster care system and the adoption process,” she said. “For instance, if a child is in foster care and needs medical attention, who makes that decision? It gets complicated and, when doctors are unaware of this issue, it can make treatment harder.”

In the meantime, Dr. Swanberg said she hopes to secure additional funding to make the program available to larger numbers of children, perhaps by linking it with the local youth-development center. “It gave them such a feeling of self-efficacy and boosted their self-image,” she said. “I'd like others to be able to experience that as well.”

The “I'm a Kid, Too” project urges children with debilitating illness to express themselves through photography. Courtesy Dr. Jennifer Swanberg

When Jennifer Swanberg, Ph.D., gave cameras to a group of sick children, she expected pictures describing their battle against debilitating illness.

What she got were pictures of kids being kids–and that, she said, was even more powerful.

Justin, 16, summed it up pretty succinctly, Dr. Swanberg said.

Justin died last year of cystic fibrosis; his photographs didn't dwell on his medications and limitations but on his activities and love of life instead.

“I wanted him to tell a story about dealing with his medical complications. I even pushed him a little, like, 'What about pictures of your appointments?' He said, 'Hey, I'm a kid first. Nothing else matters.' ”

Justin's experience with photoexpression was the genesis for “I'm a Kid, Too,” a project Dr. Swanberg launched with the Lexington (Kentucky) Arts and Cultural Council. The project supplied cameras and photojournalism mentoring to 15 children with debilitating illnesses. In addition to being medically fragile, all the children faced another psychosocial hurdle: They were each adopted.

Dr. Swanberg of the College of Social Work at the University of Kentucky, Lexington, said the youngsters astounded her with their images. “They didn't even really know, consciously, what they were producing, but the results were profound.”

Tim, a boy confined to a wheelchair because of spina bifida, drew his inspiration from chalk art on the local playground asphalt. One of his photographs shows a chalk drawing of a bicycle.

Because he shot it looking down from his wheelchair, the picture also includes his feet. “When the kids saw it, they cheered, 'It's the closest Tim will ever get to riding a bike,'” Dr. Swanberg said.

The project's most compelling message, Dr. Swanberg said, is that sick children are, first and foremost, children. “We can't view them as just a diagnosis. They are more than their illness.”

The 8-week program culminated with a public showing of the pictures, an event that filled the artists and their parents with pride. Often ostracized because of their illnesses, the children reveled in their accomplishments, Dr. Swanberg said.

So profoundly did the show affect the community that the university has decided to incorporate the project into its health care professions' curricula.

Beginning next year, pediatric and psychology residents, as well as nursing and social work students, will be required to attend a 3-hour seminar about the psychosocial needs of children with significant medical conditions and about the foster care and adoptive systems they could encounter. The images of “I'm a Kid, Too” will be an important component of the course.

“It's a wonderful opportunity to educate students about the foster care system and the adoption process,” she said. “For instance, if a child is in foster care and needs medical attention, who makes that decision? It gets complicated and, when doctors are unaware of this issue, it can make treatment harder.”

In the meantime, Dr. Swanberg said she hopes to secure additional funding to make the program available to larger numbers of children, perhaps by linking it with the local youth-development center. “It gave them such a feeling of self-efficacy and boosted their self-image,” she said. “I'd like others to be able to experience that as well.”

The “I'm a Kid, Too” project urges children with debilitating illness to express themselves through photography. Courtesy Dr. Jennifer Swanberg

When Jennifer Swanberg, Ph.D., gave cameras to a group of sick children, she expected pictures describing their battle against debilitating illness.

What she got were pictures of kids being kids–and that, she said, was even more powerful.

Justin, 16, summed it up pretty succinctly, Dr. Swanberg said.

Justin died last year of cystic fibrosis; his photographs didn't dwell on his medications and limitations but on his activities and love of life instead.

“I wanted him to tell a story about dealing with his medical complications. I even pushed him a little, like, 'What about pictures of your appointments?' He said, 'Hey, I'm a kid first. Nothing else matters.' ”

Justin's experience with photoexpression was the genesis for “I'm a Kid, Too,” a project Dr. Swanberg launched with the Lexington (Kentucky) Arts and Cultural Council. The project supplied cameras and photojournalism mentoring to 15 children with debilitating illnesses. In addition to being medically fragile, all the children faced another psychosocial hurdle: They were each adopted.

Dr. Swanberg of the College of Social Work at the University of Kentucky, Lexington, said the youngsters astounded her with their images. “They didn't even really know, consciously, what they were producing, but the results were profound.”

Tim, a boy confined to a wheelchair because of spina bifida, drew his inspiration from chalk art on the local playground asphalt. One of his photographs shows a chalk drawing of a bicycle.

Because he shot it looking down from his wheelchair, the picture also includes his feet. “When the kids saw it, they cheered, 'It's the closest Tim will ever get to riding a bike,'” Dr. Swanberg said.

The project's most compelling message, Dr. Swanberg said, is that sick children are, first and foremost, children. “We can't view them as just a diagnosis. They are more than their illness.”

The 8-week program culminated with a public showing of the pictures, an event that filled the artists and their parents with pride. Often ostracized because of their illnesses, the children reveled in their accomplishments, Dr. Swanberg said.

So profoundly did the show affect the community that the university has decided to incorporate the project into its health care professions' curricula.

Beginning next year, pediatric and psychology residents, as well as nursing and social work students, will be required to attend a 3-hour seminar about the psychosocial needs of children with significant medical conditions and about the foster care and adoptive systems they could encounter. The images of “I'm a Kid, Too” will be an important component of the course.

“It's a wonderful opportunity to educate students about the foster care system and the adoption process,” she said. “For instance, if a child is in foster care and needs medical attention, who makes that decision? It gets complicated and, when doctors are unaware of this issue, it can make treatment harder.”

In the meantime, Dr. Swanberg said she hopes to secure additional funding to make the program available to larger numbers of children, perhaps by linking it with the local youth-development center. “It gave them such a feeling of self-efficacy and boosted their self-image,” she said. “I'd like others to be able to experience that as well.”

The “I'm a Kid, Too” project urges children with debilitating illness to express themselves through photography. Courtesy Dr. Jennifer Swanberg