Management of alcohol withdrawal syndrome in patients with alcohol-associated liver disease.

Alcohol-associated liver disease is a common and severe sequela of excessive alcohol use; effective treatment requires attention to both liver disease and underlying alcohol use disorder (AUD). Alcohol withdrawal syndrome (AWS) can be dangerous, is a common barrier to AUD recovery, and may complicate inpatient admissions for liver-related complications. Hepatologists can address these comorbid conditions by learning to accurately stage alcohol-associated liver disease, identify AUD using standardized screening tools (eg, Alcohol Use Disorder Identification Test), and assess risk for and symptoms of AWS. Depending on the severity, alcohol withdrawal often merits admission to a monitored setting, where symptom-triggered administration of benzodiazepines based on standardized scoring protocols is often the most effective approach to management. For patients with severe liver disease, selection of benzodiazepines with less dependence on hepatic metabolism (eg, lorazepam) is advisable. Severe alcohol withdrawal often requires a "front-loaded" approach with higher dosing, as well as intensive monitoring. Distinguishing between alcohol withdrawal delirium and HE is important, though it can be difficult, and can be guided by differentiating clinical characteristics, including time to onset and activity level. There is little data on the use of adjuvant medications, including anticonvulsants, dexmedetomidine, or propofol, in this patient population. Beyond the treatment of AWS, inpatient admission and outpatient hepatology visits offer opportunities to engage in planning for ongoing management of AUD, including initiation of medications for AUD and referral to additional recovery supports. Hepatologists trained to identify AUD, alcohol-associated liver disease, and risk for AWS can proactively address these issues, ensuring that patients' AWS is managed safely and effectively and supporting planning for long-term recovery.

Cost of talking parents, healthy teens: a worksite-based intervention to promote parent-adolescent sexual health communication.

PURPOSE: To examine the cost and cost-effectiveness of implementing Talking Parents, Healthy Teens, a worksite-based parenting program designed to help parents address sexual health with their adolescent children. METHODS: We enrolled 535 parents with adolescent children at 13 worksites in southern California in a randomized trial. We used time and wage data from employees involved in implementing the program to estimate fixed and variable costs. We determined cost-effectiveness with nonparametric bootstrap analysis. For the intervention, parents participated in eight weekly 1-hour teaching sessions at lunchtime. The program included games, discussions, role plays, and videotaped role plays to help parents learn to communicate with their children about sex-related topics, teach their children assertiveness and decision-making skills, and supervise and interact with their children more effectively. RESULTS: Implementing the program cost $543.03 (standard deviation, $289.98) per worksite in fixed costs, and $28.05 per parent (standard deviation, $4.08) in variable costs. At 9 months, this $28.05 investment per parent yielded improvements in number of sexual health topics discussed, condom teaching, and communication quality and openness. The cost-effectiveness was $7.42 per new topic discussed using parental responses and $9.18 using adolescent responses. Other efficacy outcomes also yielded favorable cost-effectiveness ratios. CONCLUSIONS: Talking Parents, Healthy Teens demonstrated the feasibility and cost-effectiveness of a worksite-based parenting program to promote parent-adolescent communication about sexual health. Its cost is reasonable and is unlikely to be a significant barrier to adoption and diffusion for most worksites considering its implementation.

Racial and ethnic health disparities among fifth-graders in three cities.

BACKGROUND: For many health-related behaviors and outcomes, racial and ethnic disparities among adolescents are well documented, but less is known about health-related disparities during preadolescence. METHODS: We studied 5119 randomly selected public-school fifth-graders and their parents in three metropolitan areas in the United States. We examined differences among black, Latino, and white children on 16 measures, including witnessing of violence, peer victimization, perpetration of aggression, seat-belt use, bike-helmet use, substance use, discrimination, terrorism worries, vigorous exercise, obesity, and self-rated health status and psychological and physical quality of life. We tested potential mediators of racial and ethnic disparities (i.e., sociodemographic characteristics and the child's school) using partially adjusted models. RESULTS: There were significant differences between black children and white children for all 16 measures and between Latino children and white children for 12 of 16 measures, although adjusted analyses reduced many of these disparities. For example, in unadjusted analysis, the rate of witnessing a threat or injury with a gun was higher among blacks (20%) and Latinos (11%) than among whites (5%), and the number of days per week on which the student performed vigorous exercise was lower among blacks (3.56 days) and Latinos (3.77 days) than among whites (4.33 days) (P<0.001 for all comparisons). After statistical adjustment, these differences were reduced by about half between blacks and whites and were eliminated between Latinos and whites. Household income, household highest education level, and the child's school were the most substantial mediators of racial and ethnic disparities. CONCLUSIONS: We found that harmful health behaviors, experiences, and outcomes were more common among black children and Latino children than among white children. Adjustment for socioeconomic status and the child's school substantially reduced most of these differences. Interventions that address potentially detrimental consequences of low socioeconomic status and adverse school environments may help reduce racial and ethnic differences in child health. (Funded by the Centers for Disease Control and Prevention.).

The patient-centered medical home, practice patterns, and functional outcomes for children with attention deficit/hyperactivity disorder.

OBJECTIVE: To determine whether children with attention deficit/hyperactivity disorder (ADHD) receive care in a patient-centered medical home (PCMH) and how that relates to their ADHD treatment and functional outcomes. METHODS: Cross-sectional analysis of the 2007 National Survey for Children's Health, a nationally representative survey of 91,642 parents. This analysis covers 5169 children with parent-reported ADHD ages 6-17. The independent variable is receiving care in a PCMH. Main outcome measures are receiving ADHD medication, mental health specialist involvement, and functional outcomes (difficulties with participation in activities, attending school, making friends; having problem behaviors; missed school days; and number of times parents contacted by school). RESULTS: Only 44% of children with ADHD received care in a PCMH. Children with ADHD receiving care in a PCMH compared with those who did not were more likely to receive medication for ADHD (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.1-1.9); less likely to have mental health specialist involvement (OR, 0.6; 95% CI, 0.4-0.7); less likely to have difficulties participating in activities (OR, 0.6; 95% CI 0.4-0.8), making friends (OR, 0.6; 95% CI, 0.5-0.9), and attending school (OR, 0.4; 95% CI, 0.3-06); less likely to have problem behaviors (OR 0.6; 95% CI 0.5-0.9); had fewer missed school days (ß = -1.5, 95% CI -2.4 to -0.5); and parents were contacted by school less frequently (ß = -0.2, 95% CI -0.3 to -0.1). CONCLUSIONS: For children with ADHD, receiving care in a PCMH is associated with practice pattern change and better outcomes. The PCMH may represent a promising opportunity to improve quality of care and outcomes for children with ADHD.

Factors influencing the enrollment of eligible extremely-low-birth-weight children in the part C early intervention program.

OBJECTIVE: To determine whether eligible extremely-low-birth-weight children (<1000 g) were enrolled in the federally enacted, state-coordinated Early Intervention (EI) program intended to help children with developmental delay or disability regardless of parental income, and the factors associated with enrollment. METHODS: Retrospective analysis of 884 EI-eligible ELBW children born in South Carolina with birth weight 401 to 999 g, gestation > or =24 weeks, and survival for the first 120 days of life. We created a linked data set with data from Early Intervention (1996-2001), Vital Records (1996-1998), death certificates, and Medicaid. Each child was followed from birth to 3 years old, the program eligibility period. RESULTS: A total of 54% of ELBW children were enrolled in EI at any time from birth to 36 months. Even among children ever enrolled in Medicaid (83% of all ELBW children), only 63% were enrolled in EI. Being born in a multiple gestational birth, having heavier birth weight (750 to 999 g), and having ever enrolled in Medicaid were positively associated with EI enrollment. Among Medicaid patients for whom perinatal data were available, additional risk adjustment showed that EI enrollment was more likely with birth in level 3 hospitals, birth weight 750 to 999 g, Neonatal Medical Index severity level V (most severe), and longer initial length of hospital stay. CONCLUSIONS: Only about half of eligible ELBW children in South Carolina were enrolled-much lower than reported elsewhere. Efforts are needed to understand why eligible infants are not being enrolled and to develop strategies to remedy the situation.