Kernicterus, thought to be due to severe hyperbilirubinemia, is an uncommon disorder with tragic consequences, especially when it affects healthy term and near-term infants. Early identification, prevention and treatment of severe hyperbilirubinemia should make kernicterus a preventable disease. However, national epidemiologic data are needed to monitor any preventive strategies. Recommendations are provided to obtain prospective data on the prevalence and incidence of severe hyperbilirubinemia and associate mortality and neurologic injury using standardized definitions, explore the clinical characteristics and root causes of kernicterus in children identified in the Kernicterus Pilot Registry, identify and test an indicator for population surveillance, validating systems-based approaches to the management of newborn jaundice, and explore the feasibility of using biologic or genetic markers to identify infants at risk for hyperbilirubinemia. Increased knowledge about the incidence and consequences of severe hyperbilirubinemia is essential to the planning, implementation and assessment of interventions to ensure that infants discharged as healthy from their birth hospitals have a safer transition to home, avoiding morbidity due to hyperbilirubinemia and other disorders.At a recent NIHCD-sponsored conference, key questions were raised about kernicterus and the need for additional strategies for its prevention. These questions and an approach to their answers form the basis of this report.

Background: Television viewing is associated with childhood obesity. Eating during viewing and eating highly advertised foods are 2 of the hypothesized mechanisms through which television is thought to affect children's weight.

Objectives: Our objectives were to describe the amounts and types of foods that children consume while watching television, compare those types with the types consumed at other times of the day, and examine the associations between children's body mass index (BMI) and the amounts and types of foods consumed during television viewing.

Design: Data were collected from 2 samples. The first sample consisted of ethnically diverse third-grade children, and the second consisted predominantly of Latino fifth-grade children. Three nonconsecutive 24-h dietary recalls were collected from each child. For each eating episode reported, children were asked whether they had been watching television. Height and weight were measured by using standard methods and were used to calculate BMI.

Results: On weekdays and weekend days, 17-18% and approximately 26% of total daily energy, respectively, were consumed during television viewing in the 2 samples. Although the fat content of the foods consumed during television viewing did not differ significantly from that of the foods consumed with the television off, less soda, fast food, fruit, and vegetables were consumed with the television on. The amount of food consumed during television viewing was not associated with children's BMI, but in the third-grade sample, the fat content of foods consumed during television viewing was associated with BMI.

Conclusions: A significant proportion of children's daily energy intake is consumed during television viewing, and the consumption of high-fat foods on weekends may be associated with BMI in younger children.

Objective: Hyperinsulinemia/insulin resistance is a risk factor for future type 2 diabetes. Fasting insulin and blood lipids serve as direct indicators of subsequent risk and as biochemical markers of metabolically significant adiposity. We examined the feasibility of obtaining fasting blood samples and report correlates of these biochemical markers in an understudied population sample.

Research Methods and Procedures: Fasting samples were requested from African-American girls, 8.00 to 10.99 years of age, for insulin, glucose, and lipid concentrations. Indices of insulin sensitivity and secretion were calculated and correlated with anthropometric, dietary, physical activity, and body composition data.

Results: Samples were obtained from 119 of 210 (57%) girls, varying from 5% to 86% across the four field centers. Glucose ranged from 71 to 104 mg/dL. Eleven percent had insulin concentrations >20 mU/liter. One girl had a triglyceride concentration >130 mg/dL. Thirteen percent had total cholesterol >200 mg/dL, whereas all subjects had high-density lipoprotein (HDL)-cholesterol of > or =35 mg/dL. Fourteen percent had low-density lipoprotein levels >130 mg/dL. Insulin concentrations showed consistently strong associations with measures of body weight (rs = 0.54 to 0.67); glucose, HDL, and LDL showed weaker correlations (rs = -0.11 to 0.22). Insulin concentration was highly correlated with indices of both insulin secretion and resistance (rs = 0.99).

Discussion: Fasting blood samples in young African-American girls were obtained with reasonable cooperation in three of the four field centers involved in this community-based study. Fasting insulin, glucose, LDL, and HDL concentrations may help evaluate future diabetes and cardiovascular risk in children of this age.

Objective: Television viewing has been associated with childhood obesity, although the mechanisms that link television viewing to higher BMI have not been established. Therefore, our objectives, in this report, were to describe the amount and types of foods that African-American girls consume while watching television and to examine the associations between African-American girls' BMI and the food they consume while watching television.

Research Methods and Procedures: Data were collected from 210 8- to 10-year-old African-American girls at four field centers by trained and certified nutritionists. Two nonconsecutive 24-hour dietary recalls were collected from each girl. For each eating episode reported, the girls were asked if they had been watching television while eating. Height and weight were collected using standard methods and used to calculate BMI.

Results: The data were analyzed separately by field center. The proportion of average daily energy intake that the girls consumed while watching television ranged from 26.9% to 35.0%. At all field centers, 40% to 50% of evening meals were consumed while watching television. None of the Spearman correlations between girls' BMI and the amount and type of foods consumed while watching television or at other times during the day were statistically significant (p > 0.05).

Discussion: This research revealed that a significant proportion of African-American girls' daily energy intake is consumed while watching television. Interventions that target reductions in food consumption while watching television or reducing television viewing may be effective strategies to decrease children's energy intakes. These results support a need for research to test the efficacy of these approaches.

Background: Improving asthma knowledge and self-management is a common focus of asthma educational programs, but most programs have had little influence on morbidity outcomes. We developed a novel multiple-component intervention that included the use of an asthma education video game intended to promote adoption of asthma self-management behaviors and appropriate asthma care.

Objective: To determine the effectiveness of an asthma education video game in reducing morbidity among high-risk, school-aged children with asthma.

Methods: We enrolled 119 children aged 5 to 12 years from low-income, urban areas in and around San Francisco, CA, and San Jose, CA. Children with moderate-to-severe asthma and parental reports of significant asthma health care utilization were randomized to participate in the disease management intervention or to receive their usual care (control group). Patients were evaluated for clinical and quality-of-life outcomes at weeks 8, 32, and 52 of the study.

Results: Compared with controls, the intervention group had significant improvements in the physical domain (P = .04 and P = .01 at 32 and 52 weeks, respectively) and social activity domain (P = .02 and P = .05 at 32 and 52 weeks, respectively) of asthma quality of life on the Child Health Survey for Asthma and child (P = .02 at 8 weeks) and parent (P = .04 and .004 at 32 and 52 weeks, respectively) asthma self-management knowledge. There were no significant differences between groups on clinical outcome variables.

Conclusions: A multicomponent educational, behavioral, and medical intervention targeted at high-risk, inner-city children with asthma can improve asthma knowledge and quality of life.

Adolescent smokers (N = 211) were randomized to 1 of 2 groups: (a) nicotine patch plus bupropion SR (sustained release; 150 mg per day) or (b) nicotine patch plus placebo. Group skills training sessions were conducted each week by research staff. Abstinence rates at Weeks 10 and 26 were as follows: (a) patch plus bupropion, 23% and 8%, (b) patch plus placebo, 28% and 7%. Despite the lack of a treatment effect, a large majority of adolescents in both treatment groups reduced their consumption to a few cigarettes per day or less and maintained this reduction over time. Similarly, an examination of survival curves revealed that by the end of treatment many had managed to avoid a return to daily smoking. These findings are encouraging and suggest new avenues for research. For example, treatments of the kind examined in this report, augmented by extended maintenance therapies, may yield higher long-term success rates.

Measurement of provider adherence to a guideline-based decision support system (DSS) presents a number of important challenges. Establishing a causal relationship between the DSS and change in concordance requires consideration of both the primary intention of the guideline and different ways providers attempt to satisfy the guideline. During our work with a guideline-based decision support system for hypertension, ATHENA DSS, we document a number of subtle deviations from the strict hypertension guideline recommendations that ultimately demonstrate provider adherence. We believe that understanding these complexities is crucial to any valid evaluation of provider adherence. We also describe the development of an advisory evaluation engine that automates the interpretation of clinician adherence with the DSS on multiple levels, facilitating the high volume of complex data analysis that is created in a clinical trial of a guideline-based DSS.

The success of clinical decision-support systems requires that they are seamlessly integrated into clinical workflow. In the SAGE project, which aims to create the technological infra-structure for implementing computable clinical practice guide-lines in enterprise settings, we created a deployment-driven methodology for developing guideline knowledge bases. It involves (1) identification of usage scenarios of guideline-based care in clinical workflow, (2) distillation and disambiguation of guideline knowledge relevant to these usage scenarios, (3) formalization of data elements and vocabulary used in the guideline, and (4) encoding of usage scenarios and guideline knowledge using an executable guideline model. This methodology makes explicit the points in the care process where guideline-based decision aids are appropriate and the roles of clinicians for whom the guideline-based assistance is intended. We have evaluated the methodology by simulating the deployment of an immunization guideline in a real clinical information system and by reconstructing the workflow context of a deployed decision-support system for guideline-based care. We discuss the implication of deployment-driven guideline encoding for sharability of executable guidelines.

STUDY OBJECTIVES: Patients with pulmonary arterial hypertension (PAH) often present with dyspnea and severe functional limitations, but their health-related quality of life (HRQOL) has not been studied extensively. This study describes HRQOL in a cohort of patients with PAH.

DESIGN: Cross-sectional study.

SETTING: A tertiary care, university hospital-based, pulmonary hypertension (PH) clinic.

PARTICIPANTS: We studied HRQOL in 53 patients with PAH (mean age, 47 years; median duration of disease, 559 days). Eighty-three percent were women, 53% received epoprostenol, and 72% reported moderate-to-severe functional limitations with a New York Heart Association class 3 or 4 at enrollment.

MEASUREMENTS AND RESULTS: We examined HRQOL by administering the Nottingham Health Profile, Congestive Heart Failure Questionnaire, and Hospital Anxiety and Depression Scale. We used the Visual Analog Scale and standard gamble (SG) techniques to measure preferences for current health (utilities). Compared with population norms, participants reported moderate-to-severe impairment in multiple domains of HRQOL, including physical mobility, emotional reaction, pain, energy, sleep, and social isolation. Mean SG utilities were 0.71, suggesting that, on average, participants were willing to accept a 29% risk of death in order to be cured of PH.

CONCLUSIONS: PAH is a devastating condition that affects predominately young women in the prime of their life. Understanding HRQOL and preferences are important in the care and management of these patients. Compared with population norms, patients with PAH have substantial functional and emotional limitations that adversely affect their HRQOL.

The traditional focus of disability research has been on the elderly, with good reason. Chronic disability is much more prevalent among the elderly, and it has a more direct impact on the demand for medical care. It is also important to understand trends in disability among the young, however, particularly if these trends diverge from those among the elderly. These trends could have serious implications for future health care spending because more disability at younger ages almost certainly translates into more disability among tomorrow's elderly, and disability is a key predictor of health care spending. Using data from the Medicare Current Beneficiary Survey (MCBS) and the National Health Interview Study (NHIS), we forecast that per-capita Medicare costs will decline for the next fifteen to twenty years, in accordance with recent projections of declining disability among the elderly. By 2020, however, the trend reverses. Per-capita costs begin to rise due to growth in disability among the younger elderly. Total costs may well remain relatively flat until 2010 and then begin to rise because per-capita costs will cease to decline rapidly enough to offset the influx of new elderly people. Overall, cost forecasts for the elderly that incorporate information about disability among today's younger generations yield more pessimistic scenarios than those based solely on elderly data sets, and this information should be incorporated into official Medicare forecasts.