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Penfold R.B.,Harvard University | Kelleher K.J.,Center for Innovation in Pediatric Practice | Wang W.,Center for Innovation in Pediatric Practice | Pajer K.,Nationwide Childrens Hospital
Pediatrics | Year: 2010

OBJECTIVE: The uptake of new antipsychotic medications among children has not been studied adequately. Although ziprasidone received Food and Drug Administration approval for the treatment of psychotic disorders among children in June 2009, it first became available for off-label use by children in 2001 and presented an excellent case study for off-label market entry. The objective of this study was to determine the pattern of initiation and switching for off-label use of ziprasidone among Michigan children who were insured by Medicaid in the first year that ziprasidone was available. METHODS: We conducted a retrospective study by using Michigan Medicaid data for patients who were aged <21 years and had 2 years of continuous enrollment and at least 1 prescription for ziprasidone in the first year the medication was available. The main outcome measures were proportion of children prescribed ziprasidone as their first antipsychotic, with evidence of treatment resistance, and by a psychiatrist. RESULTS: In the first year, 292 individuals who met criteria were prescribed ziprasidone. Approximately 53% had a diagnosis of psychosis. Explosive personality disorder and oppositional defiant disorder were the next most common diagnoses. For 33% of individuals, this was the first antipsychotic medication. Only 12% of individuals showed evidence of treatment resistance to other antipsychotic medications before switching to ziprasidone. CONCLUSIONS: During the period when ziprasidone had no approved pediatric usages, a small percentage of patients who were prescribed ziprasidone showed evidence of treatment resistance, the primary expected indication. Some prescribing for ziprasidone in the first year in this population could be considered inappropriate considering what was known about the safety and efficacy of ziprasidone in children and adolescents at the time. "Fail first" and prior authorization policies may be appropriate in the first year a medication is available so as to protect children from potential serious harm. Copyright © 2010 by the American Academy of Pediatrics. Source

Eneli I.U.,Center for Healthy Weight and Nutrition | Wang W.,Center for Innovation in Pediatric Practice
Obesity | Year: 2013

Objective To examine identification and counseling for obesity at pediatric office visits associated with psychotropic medications. Design and Methods Analysis of ambulatory care visits by children 2-17 years in the National Ambulatory Medical Care Surveys and outpatient component of the National Hospital Ambulatory Medical Care Surveys from 2005 to 2008. Physician identification of obesity was determined using ICD-9 CM diagnostic codes. Results In 2005-2008, there were 38,539 pediatric ambulatory care visits weighted to represent 600 million pediatric visits nationally. Psychotropic medications were associated with 5.2% of visits. The prevalence of overweight/obesity (BMI ≥ 85th%tile) was 15.9% for visits without psychotropic medication, 19.4% and 16.8% for visits associated with nonobesogenic and obesogenic psychotropic medications, respectively. Controlling for age, gender, and BMI, obesity was more likely to be identified at visits associated with psychotropic medications (OR 5.2, 95% CI 3-8.8), among females (OR 1.6, 95% CI 1.1-2.3) and non-Hispanics (OR 1.5, 95% CI 1.0-2.4). At visits with psychotropic medications, dietary counseling was provided at 11.4%, while blood pressure and cholesterol screening were obtained at 6.9% and 6.8% of these visits, respectively. Conclusions Our results indicate suboptimal identification and counseling for obesity children who are prescribed psychotropic medications, despite their increased risk for weight gain. Copyright © 2013 The Obesity Society. Source

Mieczkowski B.P.,Ohio State University | Oduguwa A.,Ohio State University | Kowatch R.A.,Ohio State University | Kowatch R.A.,Center for Innovation in Pediatric Practice | Splaingard M.,Sleep Disorder Center
Journal of Affective Disorders | Year: 2014

Background While studies have suggested an increased prevalence of Obstructive Sleep Apnea (OSA) in adults with Bipolar Disorder (BPD), little is published about children with BPD. Behavioral difficulties including emotional liability, depression and poor school performance are commonly reported in children with either BPD or OSA. Comorbid medical disorders may exacerbate the course of BPD. We reviewed demographic and polysomnogram characteristics of children with BPD to help outpatient identification of OSA. Methods A single center retrospective chart review of children with BPD referred for a polysomnogram (PSG) over a ten-year period was conducted. There were 27 children identified whose diagnosis of BPD was independently verified by a child psychiatrist using DSM-IV standard criteria. Results Six (22%) children had OSA with a median apnea-hyponea index of 7.5 events per hour. Variables that were significantly different between the OSA and non-OSA groups were: median BMI (47 vs 30 kg/m2, p=0.001); sleep efficiency (78.2% vs 91%, p=0.009); and oxygen saturation nadir (82% vs 92%, p=0.0003). There was no difference found in snoring percentage on PSG between the two groups. Limitations The retrospective design from a single tertiary center limited the cohort size. Only secondary verification of the diagnosis of BPD from the available medical record was possible. Conclusions Our findings suggest that extreme obesity (BMI >40 kg/m2), oxygen desaturation during sleep and frequent nocturnal awakenings are associated with OSA in children with BPD. Traditional clinical parameters for obesity and snoring, per se, are poor predictors of OSA in children with BPD. © 2014 Elsevier B.V. Source

Das A.,Prince Sultan University | Sarkar M.,Center for Innovation in Pediatric Practice
Yale Journal of Biology and Medicine | Year: 2014

Results: The data were coded manually and emerging themes included pregnancy-related knowledge and misconceptions and personal, societal, and structural barriers, as well as risk perceptions and self-efficacy. Lack of access to health care and pregnancy-related health information led participants to rely heavily on information and misconceptions about pregnancy gleaned from elder women, friends, and mothers-in-law and husbands. Doctors and para-medical staff were only consulted during complications. All women faced personal, societal, and structural level barriers, including feelings of shame and embarrassment, fear of repercussion for discussing their pregnancies with their doctors, and inadequate time with their doctors.Conclusion: Lack of access and adequate health care information were of primary concern to pregnant women and their families. Policy Implications: Our study can help inform policies and multi-sectoral approaches that are being taken by the Indian government to reduce maternal and child morbidity and burdens.Objectives: Understanding health information-seeking behaviors and barriers to care and access among pregnant women can potentially moderate the consistent negative associations between poverty, low levels of literacy, and negative maternal and child health outcomes in India. Our seminal study explores health information needs, health information-seeking behaviors, and perceived information support of low-income pregnant women in rural India.Methods: Using the Wilson Model of health information-seeking framework, we designed a culturally tailored guided interview to assess information-seeking behaviors and barriers to information seeking among pregnant women. We used a local informant and health care worker to recruit 14 expectant women for two focus group interviews lasting 45 minutes to an hour each. Thirteen other related individuals including husbands, mothers, mothers-in-law, and health care providers were also recruited by hospital counselors for in-depth interviews regarding their pregnant wives/daughters and daughters-in-law. Interviews were transcribed and analyzed by coding the data into thematic categories. © 2014 Yale Journal of Biology and Medicine Inc. All rights reserved. Source

Erwin E.A.,Center for Innovation in Pediatric Practice | Woodfolk J.A.,University of Virginia | James H.R.,University of Virginia | Satinover S.M.,University of Virginia | Platts-Mills T.A.E.,University of Virginia
Annals of Allergy, Asthma and Immunology | Year: 2014

Background Current understanding of the effects of reducing exposure to cat allergens is limited. It has also become clear that there are different forms of immune response to cat allergens. Objective To investigate changes in skin tests and cat specific IgG and IgE antibodies when students from a home with a cat move to a college dormitory. Methods Ninety-seven college students participated in a prospective study that consisted of allergy skin prick testing and serum measurement of IgE and IgG antibodies to cat at the beginning and end of one academic year in college. A subgroup returned for follow-up at the end of 2 years. Results Among 97 students, 33% had IgG antibodies to Fel d 1 but no evidence of sensitization, 25% had positive skin test results and/or serum IgE antibodies, and 42% had negative skin test results and no detectable serum antibodies. Among the non-cat sensitized students with IgG antibodies, the titers decreased during 8 months (P =.002). Titers of IgG4 to Fel d 1 also decreased (P <.001). Among the sensitized students, no change in IgE antibodies to cat occurred in 8 months (P =.20), whereas Fel d 1 specific IgG antibodies decreased (P <.001). Thus, ratios of IgG to IgE decreased highly significantly (P =.007). Among the students with negative skin test results who returned for follow-up (n = 56), none developed positive skin test results or serum IgE antibodies. Conclusion Under conditions of marked decrease in exposure, no participants developed new-onset sensitization. Among the individuals sensitized at study entry, there were major decreases in the ratio of IgG to IgE. © 2014 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved. Source

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