Physician Withdrawal Checklist (PWC-20).

Anxiety disorders are the most common mental illnesses in the United States. Despite having a number of medication options readily available, benzodiazepines (BZs) and antidepressants have achieved remission rates of only 35% after 8 weeks of acute treatment. In the development of new anxiolytics, particularly those that affect the gamma-aminobutyric acid system, it is essential to assess the new compound's potential to cause discontinuation symptoms after stopping the medication as part of both short- and long-term treatment. This report describes the development of the 20-item Penn Physician Withdrawal Checklist (PWC), a smaller version of the original 35-item PWC, and examines its validity, internal consistency, test-retest and interrater reliability, and factor structure. The PWC scores, assessed at the peak of withdrawal severity, were selected from 143 of our patients for an orthogonal factor analysis. Our results suggest that the Penn Physician Withdrawal Checklist is a simple and accurate method to assess anxiolytic discontinuation symptoms.

Thyroid hypofunction in patients with rapid-cycling bipolar disorder after lithium challenge.

BACKGROUND: There is debate whether patients with rapid-cycling bipolar disorder (BD) are predisposed to thyroid axis abnormalities and whether this may contribute to development of rapid mood shifts. Using lithium carbonate as a challenge to the hypothalamic-pituitary-thyroid (HPT) system, we determined whether patients with rapid-cycling BD are sensitive to the "antithyroid" properties of lithium. METHODS: We studied the response to thyrotropin-releasing hormone (TRH) of HPT system hormones in 20 medication-free patients with rapid-cycling BD and compared these measurements with those of 20 healthy age- and gender-matched control subjects. The same measurements were repeated after both groups had received lithium carbonate for 4 weeks in sufficient doses to maintain blood levels between.7-1.2 mEq/L. RESULTS: At baseline, the results of thyroid function tests, including the TRH challenge test, did not differ between patients and control subjects. After treatment with lithium, serum concentrations of thyroxine significantly decreased, whereas basal thyrotropin (TSH) and DeltaTSH(max) significantly increased in both patients and control subjects; however, patients had significantly higher DeltaTSH(max) after TRH stimulation. More patients than control subjects developed laboratory evidence consistent with grade III hypothyroidism after lithium treatment. CONCLUSIONS: Rapid-cycling BD is associated with a latent hypofunction of the HPT system. This dysfunction becomes manifest with short-term lithium challenge.

Screening for risk of persistent posttraumatic stress in injured children and their parents.

CONTEXT: Injury, a leading health threat to children, is also a common cause of posttraumatic stress disorder (PTSD) in childhood. Most injured children with PTSD are not diagnosed or treated. OBJECTIVE: To develop a stand-alone screening tool for use by clinicians during acute trauma care to identify injured children and their parents who are at risk of significant, persistent posttraumatic stress symptoms. DESIGN: The Screening Tool for Early Predictors of PTSD (STEPP) was derived from a 50-item risk factor survey administered within 1 month of injury as part of a prospective cohort study of posttraumatic stress in injured children and their parents. Symptoms of PTSD were assessed at least 3 months after injury. SETTING: Urban, pediatric level I trauma center. PARTICIPANTS: A sample of 269 children aged 8 to 17 years admitted for treatment of traffic-related injuries between July 1999 and October 2001, and one parent per child, completed a risk factor survey assessing potential predictors of PTSD outcome. One hundred seventy-one families (63%) completed a follow-up assessment. MAIN OUTCOME MEASURES: The Clinician-Administered PTSD Scale for Children and Adolescents and the PTSD Checklist served as criterion standards for child and parent outcomes, respectively. Positive cases were defined as those meeting criteria for at least subsyndromal PTSD with continuing impairment ("persistent traumatic stress"). RESULTS: The STEPP contains 4 dichotomous questions asked of the child, 4 asked of one parent, and 4 items obtained easily from the emergency medical record. STEPP sensitivity in predicting posttraumatic stress was 0.88 for children and 0.96 for parents, with negative predictive values of 0.95 for children and 0.99 for parents. The odds ratio for prediction of persistent traumatic stress was 6.5 (95% confidence interval [CI], 1.8-22.8) in children and 26.6 (95% CI, 3.5-202.1) in parents. CONCLUSIONS: The STEPP represents a new method to guide clinicians in making evidence-based decisions for the allocation of scarce mental health resources for traumatic stress. Its brevity and simple scoring rule suggest that it can be easily administered in the acute care setting.

National young-driver survey: teen perspective and experience with factors that affect driving safety.

BACKGROUND: Motor vehicle crashes are the leading cause of fatality and acquired disability in adolescents. Young, inexperienced drivers are overrepresented in crashes. OBJECTIVE: Our goal was to explore the adolescent perspective on driving safety to provide a better understanding of factors that influence safety and teenagers' exposure to driving hazards. METHODS: Adolescents generated, prioritized, and explained their viewpoint by using the teen-centered method. These viewpoints were obtained from a school-based nationally representative survey of 9th-, 10th-, and 11th-graders (N = 5665) from 68 high schools, conducted in spring 2006, that included teen-generated items. The main outcome measures were rating of risk and prevalence of witnessing driving hazards. RESULTS: Drinking while driving was ranked as the greatest hazard (87% of the respondents reported that it made a lot of difference), although only 12% witnessed it often. Ranked next as dangers while driving were text-messaging, racing, impairment from marijuana, and road rage. Sixty percent viewed inexperience as a significant hazard, although only 15% reported seeing it often. Cell phone use was viewed as a significant hazard by 28%, although 57% witnessed it frequently. Only 10% viewed peer passengers as hazardous, but 64% frequently observed them. Distracting peer behaviors, among other distractions, were viewed as more dangerous. Subpopulations varied in the degree they perceived hazards. For example, black and Hispanic adolescents viewed substance use while driving as less hazardous than did white adolescents but witnessed it more frequently. CONCLUSIONS: Adolescents generally understand the danger of intoxicated driving. However, some groups need to better recognize this hazard. Distractions take teenagers' focus off the road, but not all are viewed as hazardous. Although inexperience is the key factor that interacts with other conditions to cause crashes, adolescents do not recognize what merits experience. Future research is needed to explore how to help teens become safer drivers and how to make clinicians, families, and communities more effective in setting, promoting, and monitoring safety standards.

A randomized, clinical trial of a home safety intervention based in an emergency department setting.

OBJECTIVE: To assess the effectiveness of an emergency department (ED)-based home safety intervention on caregivers' behaviors and practices related to home safety. METHODS: We conducted a randomized, clinical trial of 96 consecutive caregivers of children who were younger than 5 years and presented to an urban pediatric ED for evaluation of an acute unintentional injury sustained in the home. After completing a structured home safety questionnaire via face-to-face interview, caregivers were randomly assigned to receive either comprehensive home safety education and free safety devices or focused, injury-specific ED discharge instructions. Participants were contacted by telephone 2 months after the initial ED visit for repeat administration of the safety questionnaire. The pretest and posttest questionnaires were scored such that the accrual of points correlated with reporting of safer practices. Scores were then normalized to a 100-point scale. The overall safety score reflected performance on the entire questionnaire, and the 8 category safety scores reflected performance in single areas of home injury prevention (fire, burn, poison, near-drowning, aspiration, cuts/piercings, falls, and safety device use). The main outcome was degree of improvement in safety practices as assessed by improvement in safety scores. RESULTS: The intervention group demonstrated a significantly higher average overall safety score at follow-up than the control group (73.3% +/- 8.4% vs 66.8% +/-11.1) and significant improvements in poison, cut/piercing, and burns category scores. Caregivers in the intervention group also demonstrated greater improvement in reported use of the distributed safety devices. CONCLUSIONS: This educational and device disbursement intervention was effective in improving the home safety practices of caregivers of young children. Moreover, the ED was used effectively to disseminate home injury prevention information.

Imipramine and buspirone in patients with panic disorder who are discontinuing long-term benzodiazepine therapy.

Pretreatment with imipramine, buspirone, or placebo was compared in 40 patients meeting the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition criteria for panic disorder and in patients who were discontinuing long-term benzodiazepine use. The average duration of benzodiazepine use was 75 +/- 64 months, and the average benzodiazepine intake expressed as diazepam equivalents was 25.7 +/- 19 mg/d. We hypothesized that pretreatment with either imipramine or buspirone, in contrast to pretreatment with placebo, would lead to a significant decrease of symptoms of anxiety and depression before tapering benzodiazepines, thus making the taper process easier to complete. All 3 treatments (imipramine, buspirone, and placebo) caused a reduction in anxiety and depression symptoms as measured by changes in the Hamilton Anxiety Rating Scale and Hamilton Depression Rating Scale. Neither discontinuation severity nor taper-free status 12 weeks posttaper differed between the 3 treatment groups.