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Little is known about utilization of different evidence-based order sets within computerized physician order entry (CPOE) systems. We designed a retrospective study of resident and attending physician order set utilization to evaluate the use of three evidence-based computerized order sets (asthma, post-appendectomy care, and community-acquired pneumonia (CAP)), and examine patient and admission characteristics associated with order set utilization in pediatrics. We studied all 529 asthma patients, 277 appendectomy patients, and 210 CAP patients admitted between 1 November 2001 and 30 November 2003 during implementation of standardized order sets at a large, independent, not-for-profit pediatric institution. We analyzed order set utilization for the three order sets and tested the relationship between order set use and potential factors associated with utilization. Order set utilization varied by condition (X(2)=339.2, p<0.001), with the asthma order set use rate highest (88.1%), followed by appendectomy order set utilization (79.4%), and substantially lower CAP order set use (21.1%). We found that trends in order set utilization also varied by condition. Only the asthma order set showed a trend of increasing use after implementation (z= -3.02, p=0.002). In addition, factors associated with order set utilization varied. Uses of the asthma and post-appendectomy order sets were associated with factors such as admission unit and case complexity. CAP order set utilization was associated with case complexity but not admission source. We conclude that health services organizations looking to implement computerized order sets to reduce unnecessary practice variation while promoting best practices must consider the different factors that may influence the use of each order set rather than relying on a one-size-fits-all implementation strategy. Further, issues such as the level of physician involvement in order set development and consensus around order set content may be particularly important factors influencing order set utilization.
Condition-specific order sets within computerized physician order entry (CPOE) systems are designed to decrease unnecessary practice variation and to promote evidence-based practice. This study quantitatively assessed the relationship between use of a computerized order set and processes of care in inpatient pediatric asthma treatment, and qualitatively assessed user attitudes toward order set use. The study population included 790 patients with a primary diagnosis of asthma admitted to Columbus Children's Hospital between November 1, 2001 and November 30, 2003. Rates of systemic corticosteroid (SCS) use, metered-dose inhaler use, and pulse oximetry (PulseOx) were calculated for three patient groups: those admitted prior to order set implementation ('pre-set'); those admitted after implementation but without the order set used ('no set'); and those admitted after implementation with the order set used ('set'). Financial measures of length of stay, total charges, and pharmacy charges were also calculated. Focus groups exploring attitudes about order sets were held with physician users of order sets. Order set patients were significantly more likely to receive SCS and PulseOx than 'pre-set' and 'no set' patients. 'No set' patients did not differ significantly from 'pre-set' patients. No significant differences were found in financial measures. Results from focus groups suggested that order set use would be optimized by promoting order set awareness and maximizing order set quality. These results give further credence to policy-makers' calls for expanded use of CPOE systems with condition-specific order sets to facilitate provision of evidence-based care.
Seven different types of Slater type basis sets for the elements H (Z = 1) up to E118 (Z = 118), ranging from a double zeta valence quality up to a quadruple zeta valence quality, are tested in their performance in neutral atomic and diatomic oxide calculations. The exponents of the Slater type functions are optimized for the use in (scalar relativistic) zeroth-order regular approximated (ZORA) equations. Atomic tests reveal that, on average, the absolute basis set error of 0.03 kcal/mol in the density functional calculation of the valence spinor energies of the neutral atoms with the largest all electron basis set of quadruple zeta quality is lower than the average absolute difference of 0.16 kcal/mol in these valence spinor energies if one compares the results of ZORA equation with those of the fully relativistic Dirac equation. This average absolute basis set error increases to about 1 kcal/mol for the all electron basis sets of triple zeta valence quality, and to approximately 4 kcal/mol for the all electron basis sets of double zeta quality. The molecular tests reveal that, on average, the calculated atomization energies of 118 neutral diatomic oxides MO, where the nuclear charge Z of M ranges from Z = 1-118, with the all electron basis sets of triple zeta quality with two polarization functions added are within 1-2 kcal/mol of the benchmark results with the much larger all electron basis sets, which are of quadruple zeta valence quality with four polarization functions added. The accuracy is reduced to about 4-5 kcal/mol if only one polarization function is used in the triple zeta basis sets, and further reduced to approximately 20 kcal/mol if the all electron basis sets of double zeta quality are used. The inclusion of g-type STOs to the large benchmark basis sets had an effect of less than 1 kcal/mol in the calculation of the atomization energies of the group 2 and group 14 diatomic oxides. The basis sets that are optimized for calculations using the frozen core approximation (frozen core basis sets) have a restricted basis set in the core region compared to the all electron basis sets. On average, the use of these frozen core basis sets give atomic basis set errors that are approximately twice as large as the corresponding all electron basis set errors and molecular atomization energies that are close to the corresponding all electron results. Only if spin-orbit coupling is included in the frozen core calculations larger errors are found, especially for the heavier elements, due to the additional approximation that is made that the basis functions are orthogonalized on scalar relativistic core orbitals.
Extensive review of the literature since 1884 on cleft-twin sets yielded 364 cleft-twin sets. Of these, 118 were monozygotic (MZ) and 246 dizygotic (DZ) sets. In addition, Danish material on cleft twins, like our Finnish material, reflects the total number of clefts and cleft twins on a well-defined population during a well-defined time interval. Both sets of material also contain slightly over 100 pairs of twins. The Danish material and the literature review were compared to the Finnish material. The hospital records of all Finnish patients with operated clefts who were born between 1948 and 1987 were reviewed. Information was gathered regarding each patient, his parents, the pregnancy, and his twin or triplet siblings and other siblings. This search produced 105 sets of twins and three sets of triplets with clefts, 15 sets of twins being concordant regarding clefting. This resulted in a total of 120 cleft siblings, and the corrected cleft incidence of 1.72 promille, close to the overall cleft incidence rate in Finland between 1948 and 1975. Twinning was found to be associated neither with an increased nor with a decreased risk of clefting, and clefting could not be seen to increase twinning. Zygosity could be verified in 88 sets of twins; the total number of MZ sets was 17, and of DZ was 71, a 19% MZ rate. Although a higher incidence of clefting in MZ-twin sets has been proposed, no such higher or lower incidence could be found in our material. Recognized syndromes were found in 15 sets (14%), slightly higher than found in a large Finnish study on cleft probands (8.4%). Of these, three sets were monozygotic (MZ), all of them cleft palate (CP) and male sets, whereas eight sets were dizygotic (DZ). All 15 sets were CP only, with no one set with cleft lip and palate [CL(P)]. In our total Finnish-twin material of 105 sets, we found the CL(P)/CP ratio to be 39/66 (37%/63%). In all of the 120 affected siblings, the ratio was 35%/65%. The very high rate of 63% of CP twins is about two to three times higher than that reported in the literature of 364 sets where the CP ratio is 23%; compared to the Danish material with a CP ratio of 17%, it is almost four-fold. The overall CP rate in all clefts (not restricted to twins) in Finland compared to the rate in our neighboring Scandinavian countries was very much in line with this very big difference seen in the CP rate in our twin material. The CL(P) incidence in our Finnish material is 0.61 promille and the CP incidence 1.11 promille. For MZCL(P), the incidence was 0.38 promille; for MZCP, 0.91 promille; for DZCL(P), 0.52 promille, and for DZCP, 0.99 promille. Compared to the Danish figures both the MZCP and DZCP incidence figures are nearly four-fold, with the MZCL(P) somewhat lower, and DZCL(P) less than half that number. The sex distribution of all cleft patients in our material was 44% male/56% female. Both in the Danish material and in the literature, it was the reverse. This difference is probably due mostly to the higher ratio of CP in the Finnish material. The CP group has a higher proportion of females in all these materials. The concordance (C) of the whole Finnish-twin material is 14%, compared to 16.5% reported in the literature and 8% for the Danish twins. The concordance for CL(P) in our material is many times lower (2.6%) than in the literature (17.1%) and in the Danish material (8%). In the Finnish twins, the C for CP is higher (17%) than that for the Danish (6%) and for the literature cleft-twin populations (14.3%). This is also true for the MZ and DZ subgroups. The heritability index (H) in CL(P) is lower for the Finns (17%) than for the Danish (45%) and for the literature materials (43%), and higher for CP (Finns 49%, Danish 33%, literature 36%). All of these data strongly suggest the quite different genetic behavior of both CL(P) and CP in Finland, with a much lower genetic component in the CL(P) and a higher in the CP.
Cytochrome P450c17 catalyzes the 17alpha-hydroxylase/17,20 lyase activity needed for sex steroid synthesis. We recently characterized the nuclear phosphoprotein SET as a novel transcriptional regulator that binds to the -447/-399 region of the rat P450c17 gene, along with the transcription factors COUP-TF II, NGF-IB, and SF-1. Gel shift studies localized SET binding to nucleotides -410/-402. We have shown that SET activates transcription of the rat P450c17 gene in neuronal precursor cells and now show that it also activates transcription from the -418/-399 region of the rat P450c17 gene in mouse Leydig MA-10 cells. Studying the ontogenic expression of SET and P450c17 in the rodent gonad, we found that SET expression preceded P450c17 expression in the embryonic genital ridge, suggesting that SET may be important for initiating P450c17 expression in this region. Expression of SET also preceded P450c17 expression in the testis and ovary, and its expression was much greater during embryogenesis than in the adult gonad. In the adult rat testis, P450c17 was expressed only in Leydig cells, while SET was expressed in Leydig cells and in spermatocytes. In the adult rat ovary, P450c17 was expressed only in theca cells, while SET was expressed in theca cells and also in oocytes. Because SET is expressed early in development in the genital ridge and in the testis and ovary, and because SET has many functions in addition to its activity as a transcription factor, we determined whether SET acts a transcription factor in oocytes. The SET protein was detected by Western blots in Xenopus oocytes from stages II through VI and in mature oocytes. Using extracts of Xenopus oocytes in gel shift assays, we detected a protein that bound to the -418/-399 region of the rat P450c17 gene, to which SET binds. Nuclear injection of either a -418/-399TK32LUC wildtype reporter construct or a construct containing a mutant SET site into Xenopus oocytes from stages III through VI resulted in activation of luciferase activity with the wildtype but not the mutant construct in all stages. These data suggest that Xenopus SET is able to bind to specific DNA sequences to activate transcription at all stages of Xenopus oogenesis. These data indicate that SET is an evolutionarily conserved transcription factor that participates in the early ontogenesis of the gonadal system, regulates P450c17 gene transcription in Leydig cells, and may also activate other genes expressed in immature oocytes, thus playing a role in oocyte development.
PURPOSE: To develop a computer-aided diagnosis (CAD) algorithm with setting-independent features and artificial neural networks to differentiate benign from malignant breast lesions. MATERIALS AND METHODS: Two sets of breast sonograms were evaluated. The first set contained 160 lesions and was stored directly on the magnetic optic disks from the ultrasonographic (US) system. Four different boundaries were delineated by four persons for each lesion in the first set. The second set comprised 111 lesions that were extracted from the hard-copy images. Seven morphologic features were used, five of which were newly developed. A multilayer feed-forward neural network was used as the classifier. Reliability, extendability, and robustness of the proposed CAD algorithm were evaluated. Results with the proposed algorithm were compared with those with two previous CAD algorithms. All performance comparisons were based on paired-samples t tests. RESULTS: The area under the receiver operating characteristic curve (A(z)) was 0.952 +/- 0.014 for the first set, 0.982 +/- 0.004 for the first set as the training set and the second set as the prediction set, 0.954 +/- 0.016 for the second set as the training set and the first set as the prediction set, and 0.950 +/- 0.005 for all 271 lesions. At the 5% significance level, the performance of the proposed CAD algorithm was shown to be extendible from one set of US images to the other set and robust for both small and large sample sizes. Moreover, the proposed CAD algorithm was shown to outperform the two previous CAD algorithms in terms of the A(z) value. CONCLUSION: The proposed CAD algorithm could effectively and reliably differentiate benign and malignant lesions. The proposed morphologic features were nearly setting independent and could tolerate reasonable variation in boundary delineation.
In vitro studies of parathyroid glands removed from dialysis patients with secondary hyperparathyroidism and hypercalcemia have demonstrated the presence of an increased set point of parathyroid hormone (PTH) stimulation by calcium (set point [PTHstim]), suggesting an intrinsic abnormality of the hyperplastic parathyroid cell. However, clinical studies on dialysis patients have not observed a correlation between the set point (PTHstim) and the magnitude of hyperparathyroidism. In the present study, 58 hemodialysis patients with moderate to severe hyperparathyroidism (mean PTH 780 +/- 377 pg/ml) were evaluated both before and after calcitriol treatment to establish the relationship among PTH, serum calcium, and the set point (PTHstim) and to determine whether changes in the serum calcium, as induced by calcitriol treatment, modified these relationships. Calcitriol treatment decreased serum PTH levels and increased the serum calcium and the setpoint (PTHstim); however, the increase in serum calcium was greater than the increase in the setpoint (PTHstim). Before treatment with calcitriol, the correlation between the set point (PTHstim) and the serum calcium was r = 0.82, p < 0.001, and between the set point (PTHstim) and PTH was r = 0.39, p = 0.002. After treatment with calcitriol, the correlation between the set point (PTHstim) and the serum calcium remained significant (r = 0.70, p < 0.001), but the correlation between the set point (PTHstim) and PTH was no longer significant (r = 0.09); moreover, a significant correlation was present between the change in the set point (PTHstim) and the change in serum calcium that resulted from calcitriol treatment (r = 0.73, p < 0.001). The correlation between the residual values (deviation from the regression line) of the set point (PTHstim), derived from the correlation between PTH and the set point (PTHstim), and serum calcium was r = 0.77, p < 0.001 before calcitriol and r = 0.72, p < 0.001 after calcitriol. In conclusion, the set point (PTHstim) increased after a sustained increase in the serum calcium, suggesting an adaptation of the set point to the existing serum calcium; the increase in serum calcium resulting from calcitriol treatment was greater than the increase in the set point (PTHstim); the set point (PTHstim) was greater in hemodialysis patients with higher serum PTH levels; and the correlation between PTH and the set point (PTHstim) may be obscured because the serum calcium directly modifies the set point (PTHstim).
PURPOSE: To compare computed tomographic (CT) window settings selected by radiologists with those determined by using two alternative approaches for depiction of pulmonary emboli (PE). MATERIALS AND METHODS: Institutional review board approval was obtained; informed consent was not required. This study was compliant with the Health Insurance Portability and Accountability Act. Twenty-five clinical chest CT studies were obtained with a standardized PE protocol and retrospectively evaluated by five chest and two body CT radiologists. Of these studies, 13 were positive for PE, and 12 were negative. At the main pulmonary artery (PA), mean attenuations (MPA) and standard deviations (SDPA) were measured. Initially, images were displayed with a standard mediastinal window setting (window width, W = 400 HU; window center, C = 30 HU), and each observer adjusted the setting to a personally preferred setting (eg, "personal") for PE detection. Images displayed at this setting were compared in a side-by-side fashion with the "modified" (W = MPA + 2 . SDPA, C = W/2) and "double-half" (W = 2 . MPA, C = MPA/2) window setting. Each observer rated images from 1 (ie, most preferred) to 3 (ie, least preferred). For quantitative analysis, window width and center value of each setting were divided by corresponding MPA to compute a width ratio and a center ratio. Window settings and ratings were compared with repeated-measures analysis of variance, paired t tests, and Wilcoxon signed-rank tests. RESULTS: Ratings for all three types of window settings were significantly different (P < .001). Observers preferred their personal settings the most and the modified settings the least. Mean ratios for the seven observers were 1.68 +/- 0.20 for window width and 0.47 +/- 0.08 for window center. Window width ratios for all settings were significantly different from each other (P < .001). Window center ratios were significantly higher for the modified setting than for the double-half setting (P = .013). Values for mean PA attenuation were correlated with window width ratios for six (86%) observers (mean r2 value = 0.29 +/- 0.19, P < or = .03) and with window center ratios for four (57%) observers (mean r2 value = 0.16 +/- 0.14, P < or = .02), thus indicating a trend of setting window width and window center higher when contrast enhancement is lower and vice versa. CONCLUSION: On average, observers selected CT window settings for PE detection at a window width of slightly less than twice the mean PA attenuation and at a window center of about half the mean PA attenuation. Observers tended to use larger window widths and centers as the degree of PA enhancement was lower.
In a study designed to distinguish between parallel and serial models of performance on Sternberg's item recognition task, Krueger (1975) presented subjects with a memory set (the "added" set) followed by a second ("core") set, a probe to the core set, and finally a probe to the added set. Response latency (RT) to both the core- and added-set probes initially increased with the size of the extraneous set. Over successive blocks of trials, the effect of the size of the extraneous set diminished. In Experiment 1 of the present study, Krueger's basic procedures were replicated with results similar to those he reported for early trials. Experiment 2 was a variation on the added-set procedure. Rather than the memory sets' being drawn from different categories (letters and digits), both sets consisted of digits. On half of the negative trials for both the core and the added tasks, the probe was drawn from the extraneous set, forcing the subjects to separate the two sets. Although RT on the core task did not increase with the size of the added set, there was an increase in RT to the added set with increases in core-set size, a finding inconsistent with the serial search model.
The Scientific Working Group on DNA Analysis Methods (SWGDAM) mitochondrial DNA (mtDNA) population data set is used to infer the relative rarity of mtDNA profiles obtained from evidence samples and of profiles used to identify missing persons. In this study, the East Asian haplogroup patterns in the SWGDAM data sets were analyzed in a phylogenetic context to determine relevant single nucleotide polymorphisms (SNPs) and to describe haplogroup distributions for Asians (n = 753; with a breakdown of individuals from China n = 356, Korea n = 182, Japan n = 163, and Thailand n = 52). We focus on the patterns observed in the SWGDAM Chinese data set and refer to interesting differences in the smaller subgroup data sets for the other East Asian populations (Japanese, Korean, and Thai). A total of 218 SNPs were observed in the data set, including 37 observed positions not previously reported. In the largest of the East Asian SWGDAM data sets (Chinese), these SNPs ranged from having 1 to 29 changes in the phylogenetic tree, with site 16519 being the most variable. On average there were 4.5 changes for a character on the tree. The most variable sites (with 14 or more changes each listed from fastest to slowest) observed were 16519 (L = 29), 16311 (L = 27), 152 (L = 24), 146 (L = 21), 16172 (L = 17), 16189 (L = 17), 195 (L = 16), 16362 (L = 15), 16093 (L = 14), 16129 (L = 14) and 150 (L = 14). These rapidly changing sites are consistent with other published analyses. Only 28 SNPs are needed to identify all clusters containing 1% (n = 7) or more individuals in the East Asian data set. All 36 haplogroups previously observed in East Asian populations were also seen in the SWGDAM data sets and include: A, B, B4, B4a, B4b, B5a, B5b, C, D, D4, D4a, D4b, D5, D5a, F, F1, F1a, F1b, F1c, F2a, G2, G2a, M, M7a1, M7b, M7b1, M7b2, M7c, M8a, M9, M10, N9a, R, R9a, Y, and Z. Haplogroups A, B4a, D4, and F1a were the most commonly observed clusters in the Chinese data set (the largest of the data sets) with each of these occurring in more than 6% of the samples in the data set. The next most common haplogroups in the Chinese data set include the clusters C, M7b1, and N9a with each observed at frequencies greater than or equal to 4%. European Caucasian, and African haplogroups were rarely observed within the East Asian data sets. The various analyses revealed that the data set was similar to published East Asian data sets such as those from Han Chinese.
STATEMENT OF PROBLEM: Setting of irreversible hydrocolloid impression materials is based on the ionic reaction between carboxylic groups and calcium ions and may, therefore, be affected by ionic species present in the mixing water. The impact of this phenomenon on the clinical performance of these materials has not been well documented. PURPOSE: The purpose of this study was to compare the setting behavior of irreversible hydrocolloid impression materials when mixed with tap and distilled water, and to determine the impact of typical cations present in tap water and their concentrations on the setting process. MATERIAL AND METHODS: Six brands of irreversible hydrocolloid impression materials (Kromopan 100, Xantalgin Select FS, Alginoplast, Elastic Plus, Ypeen, and Ypeen Premium) were mixed with tap and distilled water (control) according to manufacturers' recommendations. Elastic Plus was also mixed with aqueous solutions containing various concentrations of NaCl, CaCl(2), and AlCl(3) to determine the role of typical cations on setting. Using a controlled shear stress oscillatory rheometer, time changes of storage (G') and loss (G'') moduli during setting were measured at 23 degrees C and used to determine the working and setting times and rigidity of set impression materials. The sample size (n=3) for each material/mixing system was increased to 8 to increase reliability of measurements in systems where the effect of mixing water was low or variance of results was high. The data were analyzed (alpha=.05) using a t test (tap water), a 1-way ANOVA, a Tukey post hoc test (shear stress), and a nested ANOVA and Fisher Least Significant Difference post hoc analysis (cation and cation concentration). RESULTS: Statistical analysis showed significant (P<.001) acceleration in the setting rate for Kromopan 100, the working time of which was shorter with tap water by 23.4 seconds and the setting time, by 32.8 seconds. Similar significant reductions (in seconds) in both working and setting times, respectively, were found with Xantalgin Select FS (12.0, P<.001 and 23.6, P<.002), Alginoplast (24.3, P<.001 and 44.7, P<.005), and Elastic Plus (23.0, P<.001 and 22.0, P<.002), when compared with the same materials mixed with distilled water. At the same time, the rigidity of the set impression materials mixed with tap water increased by approximately 10%. With Ypeen Premium, the setting time decreased significantly by 20.0 seconds (P<.001) with tap water, while the working time and rigidity did not change. The setting behavior of Ypeen was not significantly affected by water quality. Acceleration of the setting reactions and increase in impression rigidity depended (P<.001) primarily on concentration and valency of cations present in mixing water. CONCLUSION: Setting of irreversible hydrocolloid impression materials can be significantly accelerated when tap water with high water hardness is used for mixing or when the mixing water contains higher concentrations of cations such as Na(+), Ca(2+), and Al(3+).
To explore the feasibility of parsimony analysis for large data sets, we conducted heuristic parsimony searches and bootstrap analyses on separate and combined DNA data sets for 190 angiosperms and three outgroups. Separate data sets of 18S rDNA (1,855 bp), rbcL (1,428 bp), and atpB (1,450 bp) sequences were combined into a single matrix 4,733 bp in length. Analyses of the combined data set show great improvements in computer run times compared to those of the separate data sets and of the data sets combined in pairs. Six searches of the 18S rDNA + rbcL + atpB data set were conducted; in all cases TBR branch swapping was completed, generally within a few days. In contrast, TBR branch swapping was not completed for any of the three separate data sets, or for the pairwise combined data sets. These results illustrate that it is possible to conduct a thorough search of tree space with large data sets, given sufficient signal. In this case, and probably most others, sufficient signal for a large number of taxa can only be obtained by combining data sets. The combined data sets also have higher internal support for clades than the separate data sets, and more clades receive bootstrap support of > or = 50% in the combined analysis than in analyses of the separate data sets. These data suggest that one solution to the computational and analytical dilemmas posed by large data sets is the addition of nucleotides, as well as taxa.
OBJECTIVE: Methylphenidate (MPH), the most commonly prescribed drug for attention-deficit/hyperactivity disorder (ADHD), has a short half-life, which necessitates multiple daily doses. The need for multiple doses produces problems with medication administration during school and after-school hours, and therefore with compliance. Previous long-acting stimulants and preparations have shown effects equivalent to twice-daily dosing of MPH. This study tests the efficacy and duration of action, in natural and laboratory settings, of an extended-release MPH preparation designed to last 12 hours and therefore be equivalent to 3-times-daily dosing. METHODS: Sixty-eight children with ADHD, 6 to 12 years old, participated in a within-subject, double-blind comparison of placebo, immediate-release (IR) MPH 3 times a day (tid), and Concerta, a once-daily MPH formulation. Three dosing levels of medication were used: 5 mg IR MPH tid/18 mg Concerta once a day (qd); 10 mg IR MPH tid/36 mg Concerta qd; and 15 mg IR MPH tid/54 mg Concerta qd. All children were currently medicated with MPH at enrollment, and each child's dose level was based on that child's MPH dosing before the study. The doses of Concerta were selected to be comparable to the daily doses of MPH that each child received. To achieve the ascending rate of MPH delivery determined by initial investigations to provide the necessary continuous coverage, Concerta doses were 20% higher on a daily basis than a comparable tid regimen of IR MPH. Children received each medication condition for 7 days. The investigation was conducted in the context of a background clinical behavioral intervention in both the natural environment and the laboratory setting. Parents received behavioral parent training and teachers were taught to establish a school-home daily report card (DRC). A DRC is a list of individual target behaviors that represent a child's most salient areas of impairment. Teachers set daily goals for each child's impairment targets, and parents provided rewards at home for goal attainment. Each weekday, teachers completed the DRC, and it was used as a dependent measure of individualized medication response. Teachers and parents also completed weekly standardized ratings of behavior and treatment effectiveness. To evaluate the time course of medication effects, children spent 12 hours in a laboratory setting on Saturdays and medication effects were measured using procedures and methods adapted from our summer treatment program. Measures of classroom behavior and academic productivity/accuracy were taken in a laboratory classroom setting during which children completed independent math and reading worksheets. Measures of social behavior were taken in structured, small-group board game settings and unstructured recess settings. Measures included behavior frequency counts, academic problems completed and accuracy, independent observations, teacher and counselor ratings, and individualized behavioral target goals. Reports of adverse events, sleep quality, and appetite were collected. RESULTS: On virtually all measures in all settings, both drug conditions were significantly different from placebo, and the 2 drugs were not different from each other. In children's regular school settings, both medications improved behavior as measured by teacher ratings and individualized target behaviors (the DRC); these effects were seen into the evening as measured by parent ratings. In the laboratory setting, effects of Concerta were equivalent to tid MPH and lasted at least through 12 hours after dosing. Concerta was significantly superior to tid MPH on 2 parent rating scores, and when asked, more parents preferred Concerta than preferred tid IR MPH or placebo. Side effects on children's sleep and appetite were similar for the 2 preparations. In the lab setting, both medications improved productivity and accuracy on arithmetic seatwork assignments, disruptive and on-task behavior, and classroom rule following. Both medications improved children's rule following and negative behavior in small group board games, as well as in unstructured recess settings. Individual target behaviors also showed significant improvement with medication across domains in the laboratory setting. Children's behavior across settings deteriorated across the laboratory day, and the primary effect of medication was to prevent this deterioration as the day wore on. Results support the use of background behavioral treatment in clinical trials of stimulant medication, and illustrate the utility of a measure of individualized daily target goals (ie, the DRC) as an objective measure of medication response in both the laboratory and natural school settings. CONCLUSION: This investigation clearly supports the efficacy of the Concerta long-acting formulation of MPH for parents who desire to have medication benefits for their child throughout the day and early evening. (ABSTRACT TRUNCATED)
OBJECTIVE: Estimate effectiveness of goal setting for nutrition and physical activity behavior change, review the effect of goal-setting characteristics on behavior change, and investigate effectiveness of interventions containing goal setting. DATA SOURCE: For this review, a literature search was conducted for the period January 1977 through December 2003 that included a Current Contents, Biosis Previews, Medline, PubMed, PsycINFO, and ERIC search of databases and a reference list search. Key words were goal, goal setting, nutrition, diet, dietary, physical activity, exercise, behavior change, interventions, and fitness. STUDY INCLUSION AND EXCLUSION CRITERIA: The search identified 144 studies, of which 28 met inclusion criteria for being published in a peer reviewed journal and using goal setting in an intervention to modify dietary or physical activity behaviors. Excluded from this review were those studies that (1) evaluated goal setting cross-sectionally without an intervention; (2) used goal setting for behavioral disorders, to improve academic achievement, or in sports performance; (3) were reviews. DATA EXTRACTION AND SYNTHESIS: The articles were categorized by target audience and secondarily by research focus. Data extracted included outcome measure, research rating, purpose, sample, sample description, assignment, findings, and goal-setting support. RESULTS: Thirteen of the 23 adult studies used a goal-setting effectiveness study design and eight produced positive results supporting goal setting. No adolescent or child studies used this design. The results were inconclusive for the studies investigating goal-setting characteristics (n = 7). Four adult and four child intervention evaluation studies showed positive outcomes. No studies reported power calculations, and only 32% of the studies were rated as fully supporting goal setting. CONCLUSIONS: Goal setting has shown some promise in promoting dietary and physical activity behavior change among adults, but methodological issues still need to be resolved. The literature with adolescents and children is limited, and the authors are not aware of any published studies with this audience investigating the independent effect of goal setting on dietary or physical activity behavior. Although, goal setting is widely used with children and adolescents in nutrition interventions, its effectiveness has yet to be reported.