J Periodontol • June 2009

The Potential Use of Gingival Crevicular

Blood for Measuring Glucose to Screen
for Diabetes: An Examination Based
on Characteristics of the Blood
Collection Site
Shiela M. Strauss,* Alla J. Wheeler,† Stefanie L. Russell,‡ Anya Brodsky,§ Robert M. Davidson,i
Rima Gluzman,‡ Lin Li,‡ Roberto Galao Malo,* Bram Salis,i Robert Schoor,i
and Krassimira Tzvetkova¶

Background: This study examined conditions under which

gingival crevicular blood (GCB) could be used to obtain a use-
ful glucose reading to screen for undiagnosed diabetes during
routine dental visits.
Methods: GCB and capillary finger-stick blood (CFB) glu-
cose readings obtained with a glucometer were compared
for 46 patients recruited from an urban university dental clinic.

R
ecent estimates indicate that 5.7
Study participants were divided into two groups based on million people with diabetes in the
probing depth or bleeding on probing (BOP) at the site of col- United States were undiagnosed in
lection of the GCB sample. Group 1 participants had blood col- 2007,1 with the number of undiagnosed
lected from sites with adequate BOP to obtain a sample individuals expected to increase dramat-
without touching the tooth or gingival margin, whereas group ically in the coming years.2 The issue
2 participants had blood collected from sites with little or no of undiagnosed diabetes is especially
bleeding. For each group, Pearson correlations were calcu- critical because early treatment and sec-
lated for glucose readings obtained using GCB and CFB sam- ondary prevention efforts may help to
ples, and the limits of agreement between the two samples prevent or delay the long-term compli-
were examined. cations of diabetes that are responsible
Results: For group 1 participants, correlations between for reduced quality of life and increased
CFB and GCB glucose readings were high (0.89), and the levels of morbidity and mortality among
limits of agreement were acceptable (-27.1 to 29.7). By con- these patients.3,4 These complications
trast, for participants in group 2, correlations between the glu- include damage to the heart, eyes, kid-
cose readings were lower (0.78), and limits of agreement were neys, nerves, or vascular system; altered
much broader (-25.1 to 80.5). wound healing; and periodontitis.5 Be-
Conclusion: GCB samples were suitable to screen for diabe- cause of the frequently mild or asymp-
tes in persons with sufficient BOP to obtain a sample without tomatic nature of diabetes in its early
touching the tooth or gingival margin (i.e., in patients having stages, many individuals with undiag-
the basic clinical signs of gingivitis or periodontal disease). nosed diabetes are likely to have had
J Periodontol 2009;80:907-914. diabetes for several years before being
diagnosed.6 As a result, by the time of
KEY WORDS
diagnosis in many of these individuals,
Diabetes; periodontitis; public health. beta cell function may have declined
substantially,7 and significant damage
may already have occurred. Thus, there
* College of Nursing, New York University, New York, NY.
† Dental Hygiene, College of Dentistry, New York University. is a critical need to increase opportunities
‡ Department of Epidemiology and Health Promotion, College of Dentistry, New York for diabetes screening and early diabetes
University.
§ College of Dentistry, New York University. detection, especially among those who
i Department of Periodontology and Implant Dentistry, College of Dentistry, New York
University.
¶ Cariology, College of Dentistry, New York University.
doi: 10.1902/jop.2009.080542

907
Diabetes Screening During the Periodontal Visit
may be at high risk for diabetes. Expanding the range
of venues to augment the conventional medical office
is one strategy to increase the likelihood of identifying
people with undiagnosed diabetes.
Research has explored the dental office as a strate-
gic venue of opportunity for glucose testing, examin-
ing the possibility of using gingival crevicular fluid
(GCF) for diabetes screening.8-10 Measuring glucose
in GCF is a promising approach, yielding moderate
to good correlations with capillary blood glucose mea-
sures.8-10 However, the need for special equipment
and the length of time necessary to collect a sufficient
sample for analysis suggest that such an approach
would have limited use and appeal in busy dental prac-
tices. The ability to collect gingival crevicular blood
(GCB) for glucose measurement using readily avail-
able glucometers that measure glucose in a few sec-
onds seems to offer a more practical alternative.
Because periodontal disease may predispose individuals
to incident diabetes,11 the dental visit offers a unique
opportunity to screen an especially at-risk population.
As early as 1969, there were reports of dental profes-
sionals’ use of commercially available reagent strips to
screen for undiagnosed diabetes by assessing blood
glucose levels in the GCB of periodontal patients.12
Parker et al.’s13 study of patients with diabetes used
small plastic pipettes to transfer GCB to a glucose
self-monitoring instrument. The researchers compared
these glucose measures and those obtained from a
capillary finger-stick blood (CFB) sample to glucose
measured from a venous blood sample using labora-
tory measurements. Correlations were 0.97 and 0.98,
respectively, between laboratory measurements and
the GCB and CFB glucose readings from a glucometer
and 0.99 between GCB and CFB glucometer readings.
More recent analyses conducted by Beikler et al.14
and Khader et al.15 aimed to evaluate the usefulness
of readily available self-monitoring blood glucose de-
vices to conduct screenings for diabetes using GCB
glucose measures during routine periodontal exami-
nations. Their studies involved participants with and
without diabetes and correlated CFB and GCB glu-
cose measures. With correlations ‡0.98 between the
two blood glucose measures, these investigators con-
cluded that measuring periodontal patients’ blood
glucose using GCB is a quick, safe, and non-invasive
method to screen for diabetes during a regular peri-
odontal examination.
Müller and Behbehani16 examined 32 subjects with
gingivitis or less severe periodontitis than participants
in the Beikler et al.14 study and found a much lower
correlation (0.75) between CFB and GCB glucose
measures. In addition, they argued that the agreement
of the two glucose measures needs to be assessed,
rather than the correlation, if GCB readings are to
be used to measure blood glucose levels. In fact, the
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Volume 80 • Number 6
agreement between CFB and GCB glucose levels
among their sample of 32 participants was low, with
wide limits of agreement.
The purpose of the current study was to better un-
derstand variations in the results obtained by the re-
searchers who have examined the feasibility and
acceptability of using GCB as an alternative to CFB
samples to measure glucose levels. We hypothesized
that if oral blood was collected from sites with shallow
pockets or limited bleeding, where contact during
blood collection with the tooth surface or gingival sul-
cus was likely, the resulting contamination of the blood
sample would result in poor agreement between CFB
and GCB readings. Specifically, we hypothesized that
correlations of CFB and GCB would be lower and limits
of agreement would be wider among study partici-
pants with little or no bleeding on probing (BOP) com-
pared to those with adequate BOP to obtain a sample
without touching the tooth or the gingival margin.
MATERIALS AND METHODS
Participant Recruitment and Interview
Study participants were recruited during July and Au-
gust 2008 from the Periodontics and Implant Clinic,
New York University College of Dentistry. Persons
were excluded from the study if they required antibi-
otic prophylaxis prior to invasive dental care; there
was a history of a bleeding disorder; they took any
medication interfering with blood coagulation; or there
was a history of severe systemic disease, such as a car-
diovascular, renal, hepatic, or immunologic disorder,
that would preclude regular care by a dental provider.
After a member of the research team briefed the
potential participant on study procedures and the
study’s risks and benefits, patients gave their in-
formed written consent for participation. The file that
contained data collected from each study participant
identified each participant by a unique code number;
no names were used. All data were stored in locked
files. Participants were compensated $20 for their time.
The study received approval from the New York Uni-
versity School of Medicine Institutional Review Board.
Participation in the study involved the completion
of a brief (10-minute), self-administered question-
naire in the waiting area of the clinic. The question-
naire obtained demographic information (e.g., gender,
race/ethnicity, and years of education), height and
weight, date of most recent medical and dental visits,
past blood glucose testing, and history of diabetes. It
also contained a 10-question ‘‘knowledge quiz’’ that
assessed basic awareness about diabetes, including
its relationship to oral health.
Collection of GCB and CFB Samples
The periodontal examination included probing depth
(PD) and BOP using a disposable periodontal probe.
J Periodontol • June 2009
One site was chosen for collecting the GCB sample,
typically in the maxillary anterior sextant because this
area offered the best access for GCB sample collec-
tion. The area was isolated with cotton rolls to prevent
saliva contamination and dried with compressed air.
To obtain a clean sample, probing was repeated,
when necessary, until a sufficient quantity of blood
(;2 to 3 ml) was present to gather a sample. Espe-
cially for participants with PD ‡4 mm, collection of a
sufficient blood sample required no more probing
than is routine for the dental clinician to measure
pockets and attachment loss in a standard periodon-
tal examination. However, for participants with PD £3
mm, it was sometimes necessary to probe three or
more times at the site of data collection to obtain
the GCB sample.
For the collection of the GCB sample, we selected a
readily available glucometer# that had a compact de-
sign that facilitated intraoral collection, needed only a
small quantity of blood for an accurate reading (‡1 ml
according to the owner’s manual),17 and had a rapid
response (5 seconds). The device was introduced in-
traorally with the test strip in place, and the accumu-
lation of supragingival blood was allowed to flow onto
its reactive area. To the greatest extent possible, care
was taken to avoid having the test strip touch the tooth
or enter the sulcus. The study used two glucometers,
identical models from the same pharmaceutical com-
pany, and they were calibrated, according to the man-
ufacturer’s instructions, at the same time each week
for the duration of the data-collection period.
Immediately following the collection of the sample,
a CFB sample was drawn from one of the patient’s fin-
gers. The pad of the finger was wiped with alcohol, al-
lowed to dry, and then punctured with a sterile lancet.
A CFB sample was drawn onto the test strip preloaded
in the glucometer. GCB and CFB glucose readings
were recorded. Each study participant was provided
with literature concerning diabetes and oral health
at the conclusion of the dental visit. The participant
was also given a card on which a member of the re-
search team wrote the CFB glucose reading and the
date it was obtained, so that this information could
be shared with a medical provider. These CFB read-
ings were viewed as ‘‘casual’’ readings because they
were taken without regard to the time since the partic-
ipants last ate. Study participants with casual read-
ings that were elevated according to 2007 American
Diabetes Association guidelines18 were urged to visit
their primary care providers for medical evaluation.
Statistical and Graphical Analyses
Study participants were divided into two groups.
Group 1 participants had blood collected from sites
with adequate BOP to obtain a sample without touch-
ing the tooth or gingival margin (i.e., PD ‡4 mm and/
Strauss, Wheeler, Russell, et al.
or BOP at the site of GCB collection). Group 2 partic-
ipants had blood collected from sites with little or no
bleeding (i.e., PD £3 mm and/or limited BOP [i.e., £2
ml] at the data collection site). Descriptive statistics
(i.e., means and proportions) were used to summarize
study participants’ demographic, medical, and dental
care characteristics. Relationships between GCB and
CFB glucose readings within each of the two groups
were examined. First, correlations of GCB and CFB
glucose readings were computed for each group.
Consistent with the analyses conducted by Müller
and Behbehani,19 an analysis was then performed
comparing the two blood glucose readings using the
approach of Bland and Altman.20 In particular, limits
of agreement between the two readings were com-
puted to provide a range of values within which 95%
of the differences between the two readings were ex-
pected to fall. In addition, for each of the two groups
we created graphic displays, as suggested by Bland
and Altman,20 to assess the likelihood of bias and pos-
sible outliers. These displays include scatter plots of
GCB and CFB glucose measurements against each
other and plots of differences between GCB and
CFB glucose measures against the means of the
two measures. Although a paired t test analysis would
have enabled an examination of differences between
the GCB and CFB glucose measures, the Bland and
Altman approach was chosen for the current analyses
because the focus was on examining agreement be-
tween the two measures.
RESULTS
Fifty-four patients were asked to participate in the
study. Of these, three declined to participate, one
withdrew after completing the questionnaire, and four
had insufficient oral bleeding to obtain a GCB sample.
The remaining 46 participants constitute the study
sample. Sixty-five percent of these 46 study partici-
pants were female, and their mean age was 51 years
(SD = 15 years; range, 25 to 76 years). Thirty-six
percent were white, 56% were black, and 8% were dis-
tributed over several other races. With regard to their
ethnicity, 20% were Hispanic. Study participants had
completed an average of 15 years of education (SD =
2 years; range, 12 to 18 years). The average body
mass index (BMI) of participants was 27 kg/m2 (SD =
6 kg/m2; range, 18 to 54 kg/m2).
With regard to their dental care, 76% indicated that
they visited a dentist at least once a year and reported
that their last dental visit was 8 months earlier (SD =
23 months; range, 1 month to 10 years). The vast major-
ity (85%) reported that they had a primary care provider,
and the mean time since their last medical visit was
# OneTouch UltraMini Blood Glucose Monitoring System, LifeScan,
Milpitas, CA.
909
Diabetes Screening During the Periodontal Visit Volume 80 • Number 6

4 months (SD = 4 months; range, 1 to 18 months). the differences between the GCB and CFB values –
Seventy-six percent reported having been tested for 1.96 times the standard deviation of these differences,
blood glucose, with a mean time since this last glu- or -27.1 and 29.7. In the Bland-Altman plot (Fig. 2),
cose test of 16 months (SD = 32 months; range, differences between GCB and CFB measurements are
1 month to 11 years). Although only 9% reported that plotted against the average of the two measures, with
they had been told they had diabetes, 33% of the study lines marking the limits of agreement (note that the
participants indicated that they had a first-degree rel- mean of the differences [1.3] is close to zero). With
ative with diabetes. GCB readings from the 46 partic- 21 degrees of freedom and t = 2.080, we determined
ipants ranged from 68 to 234 mg/dl, and CFB samples the 95% confidence intervals (CIs) of the lower and up-
ranged from 71 to 203 mg/dl. Study participants re- per limits of agreement to be -38.2 to -16.0 and 18.6
ported having last eaten an average of 5 hours previ- to 40.8, respectively.
ously (SD = 4 hours; range, 10 minutes to 15 hours). Group 2 participants. The 24 study participants in
There were no statistically significant differences be- group 2 had PD £3 mm at the site of GCB collection.
tween the study participants in groups 1 and 2 with re- Although there was sufficient blood for a GCB reading
gard to demographic information, BMI, the medical according to the glucometer’s owner’s manual (i.e.,
and dental care data that we collected, their average
glucose readings, or the time since they last ate.
Correlation of GCB and CFB Glucose Readings Table 1.
Group 1 participants. For the 22 study participants in Analysis of Repeatability/Agreement of
group 1, GCB samples were obtained from intraoral Measurements of Blood Glucose Levels
sites with PD between 4 and 10 mm (mean, 6.2 –
(mg/dl) in CFB and GCB Samples
1.9 mm) or from sites that had sufficient gingival
bleeding to enable avoidance of touching the tooth
Group 1 Group 2
or the sulcus. The Pearson correlation between these
Measures (n = 22) (n = 24)
GCB and CFB samples was 0.89 (P <0.001). The cor-
respondence between the GCB and CFB readings is Minimum difference -24 -20
shown in Figure 1, together with the line of equality;
Maximum difference 32 83
it suggests no systematic bias in GCB and CFB com-
parisons. Mean difference – SD 1.3 – 14.5 28.2 – 27.2
We also performed an analysis of agreement that
Coefficient95% of agreement 28.4 53.3
compared the two readings for each study participant
in group 1. Table 1 lists the differences between GCB Limits95% of agreement -27.1 to 29.7 -25.1 to 80.5
and CFB values, which ranged from -24 to 32 mg/dl
95% CI of lower limit -38.2 to -16 -45 to -5.2
(mean, 1.3 – 14.5 mg/dl). The 95% coefficient of
agreement (defined as 1.96 times the standard devi- 95% CI of upper limit 18.6 to 40.8 60.6 to 100.4
ation of differences in the readings) was 28.4. If the
differences follow a normal distribution, 95% of the
differences are expected to lie between the mean of

Figure 2.
Means of CFB and GCB glucose readings and differences in GCB
and CFB glucose readings, with lines representing the upper
Figure 1. and lower 95% limits of agreement for group 1 participants.
CFB and GCB glucose readings with line of equality for group 1 The mean difference in GCB and CFB glucose readings is 1.3 mg/dl
participants. (close to 0).

910
J Periodontol • June 2009
‡1 ml),17 the amount of blood collected (generally no
more than 2 ml) was, in actual practice, not adequate
to ensure that the test strip did not make contact with
the tooth or the sulcus. The Pearson correlation was
0.78 between GCB and CFB samples for group 2
study participants (P <0.001); Figure 3 shows the cor-
respondence between GCB and CFB readings, to-
gether with the line of equality for group 2. For this
group, GCB readings were typically higher than
CFB measures. The difference between GCB and
CFB readings ranged from -20 to 83 mg/dl (mean,
28.2 – 27.2 mg/dl), and the 95% coefficient of agree-
ment was 53.3 (Table 1). If the differences follow a
normal distribution, 95% of them are expected to lie
between the limits of agreement (-25.1 to 80.5), with
95% CIs for the lower and upper limits of agreement
of -45 to -5.2 and 60.6 to 100.4, respectively. In Figure
4, differences between GCB and CFB measurements
Figure 3.
CFB and GCB glucose readings with line of equality for group 2
participants.
Figure 4.
Means of CFB and GCB glucose readings and differences in GCB and
CFB glucose readings, with lines representing the upper and lower
95% limits of agreement and the mean of the differences for group 2
participants. The mean difference in GCB and CFB glucose readings is
28.2 mg/dl.
Strauss, Wheeler, Russell, et al.
are plotted against the average of the two measures,
with lines marking the average of the differences and
the limits of agreement.
DISCUSSION
In view of the growing number of people with undiag-
nosed diabetes and the increased risk for periodontal
patients, diabetes screening at the time of the peri-
odontal visit seems to offer a promising approach.
The usefulness of this approach is limited without con-
fidence in the accuracy of glucose readings taken
from GCB samples. Our study supports such confi-
dence in GCB glucose testing for patients with ade-
quate BOP to obtain a sample without touching the
tooth or gingival margin (our group 1). When this
was the case, we found a correlation of 0.89 between
GCB and CFB glucose readings. Although this corre-
lation was lower than that obtained in the studies of
Beikler et al.14 and Khader et al.,15 it is highly signif-
icant. Moreover, the 95% limits of agreement interval
for our group 1 study participants was similar to that
obtained from a subgroup (n = 17) of participants in
the Müller and Behbehani study19 who had CFB sam-
ples collected and compared from their right and left
hands. Screening using CFB samples is generally per-
formed without regard to the specific finger from
which blood is collected and glucose measured.
Therefore, it can be argued that differences between
CFB and GCB readings in persons in whom sampling
was from a site with adequate BOP to obtain a sample
without touching the tooth or gingival margin are no
greater than would be obtained if repeat CFB testing
were performed on different fingers of the hands. In
fact, it seems as though some variation in CFB glu-
cose readings using readily available glucometers is
to be expected. For example, the owner’s manual
for the glucometer used in our study indicates that
the glucose value is considered accurate when it is
within –20% of the laboratory test measurement.17
Conversely, our results suggest that diabetes
screening using GCB samples in patients with little
or no BOP at the site of collection of the blood sample
(patients in group 2 in our study) may often give false
high glucose readings, perhaps as a result of contam-
ination from touching the sulcus or the tooth at the
testing site. With regard to the GCB and CFB glucose
correlation (0.78) and the broad width of the 95%
limits of agreement interval, our group 2 results were
similar to those obtained by Müller and Behbehani.19
Thus, our analyses do not support the use of GCB
samples for glucose testing for patients such as those
in our group 2.
GCB glucose testing is not the only way that pa-
tients can be screened for diabetes in the dental
venue. Dental professionals can collect CFB blood
at the time of the dental visit, such as is being
911
Diabetes Screening During the Periodontal Visit
performed in a demonstration project spearheaded by
Delta Dental of Minnesota (a dental insurance pro-
vider).21 Arguably, however, the use of GCB to mea-
sure glucose is likely to be more acceptable to the
dental professional and the patient because providers
and patients anticipate oral intervention in the dental
office. Notably, in surveys of dentists and dental hy-
gienists, 85% of dentists and 78% of dental hygienists
in New York State reported providing annual oral can-
cer examinations to their patients aged 40 years and
older,22 whereas 92% of Illinois dentists indicated that
they performed oral cancer screenings on asymptom-
atic patients.23 However, perhaps because they are
likely to be less comfortable performing extraoral as-
sessments,24 a much smaller proportion of dentists
and dental hygienists assess blood pressure25-27 or pro-
vide tobacco- or alcohol-cessation counseling.28-32
Because the measurement of glucose through GCB
involves a quick and simple intraoral procedure with
minimal cost, dental professionals may be motivated
to implement diabetes screening using a GCB sample
and feel comfortable and confident in doing so.
Furthermore, especially among older persons (a
population at greater risk for diabetes), PD ‡4 mm
and/or excess BOP is common and increases with
age,33 even exceeding 50% in some samples.34-38
Thus, like the group 1 participants in the present
study, our results suggest that many at-risk older
(and younger) persons can be reliably screened for di-
abetes by measuring glucose in a GCB sample. In ad-
dition, for the group 1 participants in the present
study, the procedure involving probing and GCB
blood collection took only ;2 minutes (including
preparation time) and did not seem to increase patient
discomfort (no patients complained about any dis-
comfort during the probing or while the sample was
being drawn). Unlike screening for diabetes in the
dental setting using a CFB sample, diabetes screening
using a GCB sample can occur simultaneously while
the dental provider probes to gather the necessary
data for the diagnosis of periodontal disease. Such a
screening makes use of a blood sample that would
generally be swabbed away. Although care must be
taken when gathering the sample, such care in pa-
tients like those in group 1 of the present study is
not any greater than would be expended when the sul-
cus or pocket is probed during a thorough oral exam-
ination.
We acknowledge a number of limitations to the re-
search. First, as was true of the studies by Beikler
et al.,14 Khader et al.,15 and Müller and Behbehani,16
we did not collect venous blood samples to use as a
gold standard with which to measure glucose in the
laboratory, nor did we collect duplicate GCB and
CFB samples, as was done in the study by Parker
et al.13 However, when using the mean of duplicate
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Volume 80 • Number 6
measures of GCB and CFB glucose readings, Parker
et al.13 determined that it was not better than a single
measurement in determining the correlation, bias,
precision, and prediction error of the GCB and CFB
glucose measures. Another limitation concerns the
possible bias in the use of self-reported data provided
in response to survey questions. However, because
study participants were identified by a study-assigned
number rather than by name, the self-report bias is
likely to be minimized. In addition, as in the studies
of Beikler et al.,14 Khader et al.,15 and Müller and
Behbehani,16 we did not differentiate between patients
with and without diabetes in participant recruitment.
Notably, glucose measures in persons with well-con-
trolled diabetes might not differ from those in persons
without diabetes. In addition, we did not differentiate
between patients with and without diabetes in the
analyses of data regarding the correlation and agree-
ment between GCB and CFB measures (the focus
of our analyses) because the literature does not sug-
gest that this correlation and agreement would be
dependent on diabetes status. Also, as was the case
with the studies by Beikler et al.14 and Müller and
Behbehani,16 our participants were not fasting, nor
were the results adjusted based on the time since
the participants last ate. Notably, although some re-
search39,40 found that concurrence of glucose mea-
sures from CFB and from alternate testing sites is
diminished in the postprandial period, other stud-
ies41,42 failed to find that the length of time since last
food intake affects this concurrence. Because there
were no statistically significant differences between
groups 1 and 2 with regard to the length of time since
study participants had last eaten, the time since last
food intake should not have affected one group more
than the other in terms of the agreement between CFB
and GCB glucose readings. Finally, we note that salic-
ylates have a hypoglycemic effect, with aspirin and
salsalate reducing blood glucose in persons with dia-
betes.43-45 Nonetheless, we did not exclude persons
from the study if they used anti-inflammatory drugs
because there is no research to suggest that the use
of these drugs would differentially affect the CFB
and GCB measures.
CONCLUSIONS
Despite these limitations, this study sheds light on the
types of individuals for whom screening for diabetes
using GCB blood samples may be encouraged. Al-
though not a test to diagnose diabetes, such screening
is an important first step in identifying those for whom
follow-up tests regarding possible diabetes are war-
ranted. Furthermore, the costs associated with the
purchase of a readily available glucometer and indi-
vidual test strips are extremely modest. In addition,
once the dental provider has measured PD and
J Periodontol • June 2009
attachment loss in a standard periodontal examina-
tion and a sufficient amount of bleeding is generated
to enable blood glucose measurement with the gluc-
ometer, only 5 seconds are needed to obtain a glucose
reading. Thus, with minimal cost and a limited invest-
ment of time for patients and clinicians, dental profes-
sionals can play a critical role in supporting their
patients’ overall health.
ACKNOWLEDGMENTS
The authors gratefully acknowledge financial support
for the project from the New York University College of
Dentistry’s Office of Research. We also thank the
study participants and the staff at the New York Uni-
versity Periodontics and Implant Clinic for their sup-
port of our project. The authors report no conflicts
of interest related to this study.
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Correspondence: Dr. Shiela M. Strauss, New York Univer-
sity College of Nursing, 246 Greene St., Room 616E, New
York, NY 10003. Fax: 212/995-4359; e-mail: ss4313@
nyu.edu.
Submitted October 22, 2008; accepted for publication
February 4, 2009.