Integrated care coordination by an interprofessional team reduces emergency department visits and hospitalisations at an academic health centre.

People with chronic behavioural and physical health conditions have higher healthcare costs and mortality rates than patients with chronic physical conditions alone. As a result, there has been promotion of integrated care for this group. It is important to train primary care residents to practice in integrated models of care with interprofessional teams and to evaluate the effectiveness of integrated care models to promote high-quality care for this at-risk group. We implemented an integrated, interprofessional care management programme for adults with chronic mental and physical health needs as part of a curriculum for family medicine and family medicine psychiatry residents. We then evaluated the clinical effectiveness of this programme by describing participants' healthcare utilisation patterns pre- and post-enrolment. Patients enrolled in the programme were approximately 60-70% less likely to utilise the emergency room and 50% less likely to be admitted to the hospital after enrolment in the programme compared to before enrolment. The odds of individual attendance at outpatient primary care and mental health visits improved after enrolment. In the context of the implementation of integrated behavioural and physical healthcare in primary care, this interprofessional care management programme reduced emergency department utilisation and hospitalisations while improving utilisation of primary care and psychiatry outpatient care. Further studies should focus on replication of this model to further discern the model's cost-savings and health promotion effects.

Comparison of patient preferences for fecal immunochemical test or colonoscopy using the analytic hierarchy process.

BACKGROUND: In average-risk individuals aged 50 to 75 years, there is no difference in life-years gained when comparing colonoscopy every 10 years vs. annual fecal immunochemical testing (FIT) for colorectal cancer screening. Little is known about the preferences of patients when they have experienced both tests. METHODS: The study was conducted with 954 patients from the University of Iowa Hospital and Clinics during 2010 to 2011. Patients scheduled for a colonoscopy were asked to complete a FIT before the colonoscopy preparation. Following both tests, patients completed a questionnaire which was based on an analytic hierarchy process (AHP) decision-making model. RESULTS: In the AHP analysis, the test accuracy was given the highest priority (0.457), followed by complications (0.321), and test preparation (0.223). Patients preferred colonoscopy (0.599) compared with FIT (0.401) when considering accuracy; preferred FIT (0.589) compared with colonoscopy (0.411) when considering avoiding complications; and preferred FIT (0.650) compared with colonoscopy (0.350) when considering test preparation. The overall aggregated priorities were 0.517 for FIT, and 0.483 for colonoscopy, indicating patients slightly preferred FIT over colonoscopy. Patients' preferences were significantly different before and after provision of detailed information on test features (p < 0.0001). CONCLUSIONS: AHP analysis showed that patients slightly preferred FIT over colonoscopy. The information provided to patients strongly affected patient preference. Patients' test preferences should be considered when ordering a colorectal cancer screening test.

Resident Remediation in Family Medicine Residency Programs: A CERA Survey of Program Directors.

BACKGROUND AND OBJECTIVES: Identifying underperforming residents and helping them become fully competent physicians is an important faculty responsibility. The process to identify and remediate these learners varies greatly between programs. The objective of this study was to evaluate the remediation landscape in family medicine residency programs by investigating resident remediation characteristics, tools to improve the process, and remediation challenges. METHODS: This study analyzed responses from the Council of Academic Family Medicine Educational Research Alliance (CERA) national survey of family medicine program directors in 2017. Survey questions included topics on faculty remediation training, remediation prevalence, tools for remediation, and barriers to remediation. RESULTS: Two hundred sixty-seven of 503 program directors completed our survey (53% response rate). Most residency programs (245/264, 93%) had at least one resident undergoing remediation in the last 3 years. A majority (242/265, 91%) of residents undergoing remediation were successful within 12 months. The three most important tools to improve remediation were an accessible remediation toolkit (50%), formal remediation recommendations from national family medicine organizations (20%), and on-site faculty development and training (19%). The top-two challenges to the remediation process were a lack of documented evaluations to trigger remediation and a lack of faculty knowledge and skills with effective remediation strategies. CONCLUSIONS: Residents needing remediation are common, but most were successfully remediated within 12 months. Program directors wanted access to a standardized toolkit to help guide the remediation process.

Point-of-Care Ultrasound in Family Medicine Residencies 5-Year Update: A CERA Study.

BACKGROUND AND OBJECTIVES: In 2014, family medicine residency programs began to integrate point-of-care ultrasound (POCUS) into training, although very few had an established POCUS curriculum. This study aimed to evaluate the resources, barriers, and scope of POCUS training in family medicine residencies 5 years after its inception. METHODS: Questions regarding current training and use of POCUS were included in the 2019 Council of Academic Family Medicine Educational Research Alliance (CERA) survey of family medicine residency program directors, and results compared to similar questions on the 2014 CERA survey. RESULTS: POCUS is becoming a core component of family medicine training programs, with 53% of program directors reporting establishing or an established core curriculum. Only 11% of program directors have no current plans to add POCUS training to their program, compared to 41% in 2014. Despite this increase in training, the reported clinical use of POCUS remains uncommon. Only 27% of programs use six of the eight surveyed POCUS modalities more than once per year. The top three barriers to including POCUS in residency training in 2019 have not changed since 2014, and are (1) a lack of trained faculty, (2) limited access to equipment, and (3) discomfort with interpreting images without radiologist review. CONCLUSIONS: Training in POCUS has increased in family medicine residencies over the last 5 years, although practical use of this technology in the clinical setting may be lagging behind. Further research should explore how POCUS can improve outcomes and reduce costs in the primary care setting to better inform training for this technology.

Trained lay observers can reliably assess medical students' communication skills.

CONTEXT: Our project investigated whether trained lay observers can reliably assess the communication skills of medical students by observing their patient encounters in an out-patient clinic. METHODS: During a paediatrics clerkship, trained lay observers (standardised observers [SOs]) assessed the communication skills of Year 3 medical students while the students interviewed patients. These observers accompanied students into examination rooms in an out-patient clinic and completed a 15-item communication skills checklist during the encounter. The reliability of the communication skills scores was calculated using generalisability analysis. Students rated the experience and the validity of the assessment. The communication skills scores recorded by the SOs in the clinic were correlated with communication skills scores on a paediatrics objective structured clinical examination (OSCE). RESULTS: Standardised observers accompanied a total of 51 medical students and watched 199 of their encounters with paediatric patients. The reliability of the communication skills scores from nine observed patient encounters was calculated to be 0.80. There was substantial correlation between the communication skills scores awarded by the clinic observers and students' communication skills scores on their OSCE cases (r = 0.53, P < 0.001). Following 83.8% of the encounters, students strongly agreed that the observer had not interfered with their interaction with the patient. After 95.8% of the encounters, students agreed or strongly agreed that the observers' scoring of their communication skills was valid. CONCLUSIONS: Standardised observers can reliably assess the communication skills of medical students during clinical encounters with patients and are well accepted by students.

Influence of patient characteristics on success of ambulatory blood pressure monitoring.

STUDY OBJECTIVE: To examine the influence of specific patient characteristics on the success of ambulatory blood pressure monitoring (ABPM). DESIGN: Retrospective analysis. SETTING: University-affiliated family care center. PATIENTS: Five hundred thirty patients (mean age 52.7 yrs, range 14-90 yrs) who were undergoing ABPM between January 1, 2001, and July 1, 2007. MEASUREMENT AND MAIN RESULTS: Specific patient characteristics were identified through an electronic medical record review and then examined for association with ABPM session success rate. These patient characteristics included age, sex, weight, height, body mass index (BMI), occupation, clinic blood pressure, travel distance to clinic, and presence of diabetes mellitus or renal disease. The percentage of valid readings obtained during an ABPM session was analyzed continuously (0-100%), whereas overall session success was analyzed dichotomously (0-79% or 80-100%). Univariate and multivariate regression analyses were performed to examine the influence of patient characteristics on the percentage of valid readings and the overall likelihood of achieving a successful session. In the 530 patients, the average percentage of valid readings was 90%, and a successful ABPM session (>or= 80% valid readings) was obtained in 84.7% (449 patients). A diagnosis of diabetes was found to negatively predict ABPM session success (continuous variable analysis, p=0.019; dichotomous variable analysis, odds ratio [OR] 0.45, 95% confidence interval [CI] 0.23-0.87, p=0.019), as did renal disease (continuous variable analysis, p=0.006; dichotomous variable analysis, OR 0.39, 95% CI 0.17-0.90, p=0.027) and increasing BMI (continuous variable analysis, p<0.001; dichotomous variable analysis, OR 0.78, 95% CI 0.65-0.93, p=0.005). Renal disease and BMI remained significant predictors in adjusted analyses. CONCLUSION: For most patients, ABPM was successful; however, elevated BMI and renal disease were associated with less complete ABPM session results. Adaptation and individualization of the ABPM process may be necessary to improve results in these patients.

How well does a shortened time interval characterize results of a full ambulatory blood pressure monitoring session?

Ambulatory blood pressure monitoring (ABPM) is useful in evaluating cardiovascular risk but requires significant time. The authors examined how closely shortened time intervals correlate with the systolic blood pressure (BP) determined from a full 24-hour ABPM session in 1004 ABPM recordings. After excluding the first hour, Pearson correlations performed for the mean systolic BP of the subsequent 3-, 5-, and 7-hour periods (4, 6, and 8 hours total) with the entire, and remainder of the session, demonstrated greatest improvement in correlation when the session is increased from 4 to 6 hours. Bland-Altman analysis of the 6-hour time period revealed a mean difference of 5.41 mm Hg compared with the full session mean. The authors conclude that 6-hour ABPM can approximate the overall mean BP obtained from full 24-hour ABPM. However, shortened sessions do not characterize the influence of circadian variation on the 24-hour mean BP and may overestimate the 24-hour BP levels.

A cluster randomized trial to evaluate physician/pharmacist collaboration to improve blood pressure control.

This was a prospective, cluster randomized controlled trial in patients with uncontrolled hypertension aged 21 to 85 years (mean, 61 years). Pharmacists made recommendations to physicians for patients in the intervention clinics (n=101) but not patients in the control clinics (n=78). The mean adjusted difference in systolic blood pressure (BP) between the control and intervention groups was 8.7 mm Hg (95% confidence interval [CI], 4.4-12.9), while the difference in diastolic BP was 5.4 mm Hg (CI, 2.8-8.0) at 9 months. The 24-hour BP levels showed similar effects, with a mean systolic BP level that was 8.8 mm Hg lower (CI, 5.0-12.6) and a mean diastolic BP level that was 4.6 mm Hg (CI, 2.4-6.8) lower in the intervention group. BP was controlled in 89.1% of patients in the intervention group and 52.9% in the control group (adjusted odds ratio, 8.9; CI, 3.8-20.7; P<.001). Physician/pharmacist collaboration achieved significantly better mean BP values and overall BP control rates, primarily by intensification of medication therapy and improving patient adherence.

The influence of irrelevant anchors on the judgments and choices of doctors and patients.

BACKGROUND: Little research has examined how anchor numbers affect choice, despite several decades of research showing that judgments typically and robustly assimilate toward irrelevant anchors. METHODS: In one experiment, HIV-positive patients (N = 99) judged the chances that sexual partners would become infected with HIV after sex using a defective condom and then indicated their choices of remedial action. In a second experiment, Iowa physicians (N =191) rated the chances that hypothetical patients had a pulmonary embolism and then formulated a treatment plan. RESULTS: Irrelevant anchor numbers dramatically affected judgments by HIV-infected patients of the chances of HIV infection after a condom broke during sex (43% v. 64% in the low- and high-anchor conditions, respectively) and judgments by doctors of the chances of pulmonary embolism (23% v. 53%, respectively). Despite large anchoring effects in judgement, treatment choices did not differ between low-and high-anchor conditions. Accountability did not reduce the anchoring bias in the doctors' judgments. DISCUSSION: The practical implications of anchoring for risk judgments are potentially large, but the bias may be less relevant to treatment choices. The findings suggest that the theoretical underpinnings of the anchoring bias may be more complex than previously thought.

Explicit and implicit evaluation of physician adherence to hypertension guidelines.

This study evaluated physician adherence to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) hypertension guidelines in 6 community-based clinics. Explicit review of retrospective medical record data for patients with uncontrolled hypertension measured guideline adherence using 22 criteria. Mean overall guideline adherence was 53.5% and did not improve significantly over time. Random-effects models demonstrated significant associations between guideline adherence and various demographic and medical predictors, including age, minority status, comorbid conditions, and number of medications. A subsequent implicit review evaluated the degree to which nonadherence was justifiable and identified factors that might have affected adherence. Nonadherence was rated as justifiable for only 6.6% of the failed explicit criteria. In general, adherence to the JNC 7 guidelines was modest even when barriers that might have affected adherence were taken into consideration.

Email teleconsultations: well formulated clinical referrals reduce the need for clinic consultation.

We examined how well primary-care physicians formulated their clinical referrals when asking for help with patient-related clinical problems using an email-based teleconsultation service. Over 100 family physicians made use of the service. The specialists were medical school faculty members. The service was initiated in May 1996 with 19 specialists and expanded to 34 specialties over the next five years. A total of 1618 patient-related clinical questions were analysed, the outcome for the analysis being whether specialists recommended a clinic consultation. Specialists recommended a clinic consultation in response to 10% of their clinical questions about patients. There was a strong association between how family physicians formulated their clinical questions and whether the specialist recommended a clinic consultation. When the family physicians specified a clinical task (P < 0.001), intervention (P = 0.004) and outcome (P < 0.001) in their questions, specialists were less likely to recommend a clinic consultation. This influence was independent of the amount of clinical information included with the question (P > 0.05). About 5% of the questions that included all three question components resulted in the recommendation for a clinic consultation, compared with nearly 30% of the questions containing none of these components. How family physicians formulate their clinical questions influences whether specialists request a clinic consultation.

Association of amoxicillin use during early childhood with developmental tooth enamel defects.

BACKGROUND: It has been speculated that amoxicillin use could be associated with dental enamel defects. OBJECTIVE: To assess the association between dental fluorosis, one of the most common developmental tooth enamel defects, and amoxicillin use during early childhood. DESIGN, SETTING, AND PARTICIPANTS: As participants in the Iowa Fluoride Study, subjects were followed up from birth to 32 months using questionnaires every 3 to 4 months to gather information on fluoride intake and amoxicillin use. METHODS: Early-erupting permanent teeth of 579 subjects were assessed for fluorosis using the Fluorosis Risk Index at approximately the age of 9 years. Relationships between fluorosis and amoxicillin use were assessed using relative risk (RR), Mantel-Haenszel stratified analyses, and multivariable logistic regression. RESULTS: Amoxicillin use was reported by 75% of subjects by 12 months and 91% by 32 months. Overall, 24% had fluorosis on both maxillary central incisors. Amoxicillin use from 3 to 6 months significantly increased the risk of fluorosis on the maxillary central incisors (RR = 2.04; 95% confidence interval [CI], 1.49-2.78). After adjusting for fluoride intake and otitis media, the risk of fluorosis on the maxillary central incisors from amoxicillin use during 3 to 6 months (Mantel-Haenszel RR = 1.85; 95% CI, 1.20-2.78) was still statistically significant. Multivariable logistic regression analyses confirmed the increased risk of fluorosis from amoxicillin use during 3 to 6 months (odds ratio = 2.50; 95% CI, 1.21-5.15); fluoride intake was also statistically significant. CONCLUSION: The findings from this study suggest a link between amoxicillin use during infancy and developmental enamel defects of permanent teeth; however, further research is needed.

Women's quality of life is decreased by acute cystitis and antibiotic adverse effects associated with treatment.

BACKGROUND: Although acute cystitis is a common infection in women, the impact of this infection and its treatment on women's quality of life (QOL) has not been previously described. OBJECTIVES: To evaluate QOL in women treated for acute cystitis, and describe the relationship between QOL, clinical outcome and adverse events of each of the interventions used in the study. DESIGN: Randomized, open-label, multicenter, treatment study. SETTING: Two family medicine outpatient clinics in Iowa. PATIENTS: One-hundred-fifty-seven women with clinical signs and symptoms of acute uncomplicated cystitis. INTERVENTION: Fifty-two patients received trimethoprim/sulfamethoxazole 1 double-strength tablet twice daily for 3 days, 54 patients received ciprofloxacin 250 mg twice daily for 3 days and 51 patients received nitrofurantoin 100 mg twice daily for 7 days. MEASUREMENTS: QOL was assessed at the time of enrollment and at 3, 7, 14 and 28 days after the initial visit. QOL was measured using a modified Quality of Well-Being scale, a validated, multi-attribute health scale. Clinical outcome was assessed by telephone interview on days 3, 7, 14 and 28 using a standardized questionnaire to assess resolution of symptoms, compliance with the prescribed regimen, and occurrence of adverse events. RESULTS: Patients experiencing a clinical cure had significantly better QOL at days 3 (p = 0.03), 7 (p < 0.001), and 14 (p = 0.02) compared to patients who failed treatment. While there was no difference in QOL by treatment assignment, patients experiencing an adverse event had lower QOL throughout the study period. Patients treated with ciprofloxacin appeared to experience adverse events at a higher rate (62%) compared to those treated with TMP/SMX (45%) and nitrofurantoin (49%), however the difference was not statistically significant (p = 0.2). CONCLUSION: Patients experiencing cystitis have an increase in their QOL with treatment. Those experiencing clinical cure have greater improvement in QOL compared to patients fail therapy. While QOL is improved by treatment, those reporting adverse events have lower overall QOL compared to those who do not experience adverse events. This study is important in that it suggests that both cystitis and antibiotic treatment can affect QOL in a measurable way.

The limited effect of screening for depressive symptoms with the PHQ-9 in rural family practices.

CONTEXT: Previous studies have found that routine screening for depression does not improve patient outcome unless it is combined with case management. However, these studies were conducted before the widespread use of SSRIs or in settings other than traditional primary care. PURPOSE: This study investigated whether screening for depressive symptoms improves outcomes for depressed patients seen in rural fee-for-service primary care offices. METHODS: Depression screening was conducted at 2 private rural clinics in Iowa using the PHQ-9. Patients with depressive symptoms were randomized to the control group or the intervention group, where providers were given completed PHQ-9 questionnaires at the baseline visit. The outcome PHQ-9 scores were assessed by telephone at 4, 10, and 24 weeks after the index visit. FINDINGS: A total of 861 patients were screened for depressive symptoms; 51 subjects enrolled in the trial. The intervention and control groups did not significantly differ with respect to changes in PHQ-9 scores at any of the 3 follow-up times. They also did not differ with respect to the proportion of subjects who were actively managed with medication or by referral to a mental health specialist: 46% vs 33% (P = .38) for all subjects and 50% vs 50% (P = .96) for subjects with major depression at baseline. CONCLUSIONS: Screening for depressive symptoms with the PHQ-9 in 2 rural medical clinics did not significantly increase physicians' active management of depression or lead to improved patient outcomes.

Family medicine residents do not ask better-formulated clinical questions as they advance in their training.

OBJECTIVE: We investigated whether family medicine residents demonstrated increased skill in formulating clinical questions over their 3 years of training. METHODS: We conducted an analysis of 454 questions asked by 49 family physician residents engaged in informal consultation with subspecialists using an e-mail-based system. Clinical question formulation was measured on a scale of 0 to 2 by awarding 1 point each for the presence of a proposed intervention and a desired outcome. Changes in question formulation as residents progressed in their training were assessed using cross-sectional and repeated measures. FINDINGS: The mean question quality was scored at 1.10, and there was no significant change over the 3 years. Thirteen residents used the e-mail service over their entire 3-year training period. The individual residents showed substantial differences in how well they formulated clinical questions, with their mean question quality scores ranging from 0.38 to 1.45. There was, however, no evidence that the quality of their questions changed as they progressed in their medical training. CONCLUSIONS: Resident physicians asked moderately well-formulated clinical questions, but question formulation did not improve as they progressed in clinical training. Further training in formulating clinical questions may be helpful.

Noninvasive 24-hour ambulatory blood pressure monitoring: overview of technology and clinical applications.

During the last 25 years, 24-hour noninvasive ambulatory blood pressure monitoring (ABPM) has evolved from a research tool of limited clinical use into an important tool for stratifying cardiovascular risk and guiding therapeutic decisions. Until recently, clinical use of ABPM focused on identifying patients with white-coat hypertension, but accumulated evidence now points to greater prognostic significance of ABPM in determining risk for target-organ damage compared with that of office blood pressure measurements. Clinicians involved in the care of patients with hypertension should familiarize themselves with the role of this technology and how to use it in an appropriate and cost-effective manner.

Medically administered antibiotics, dietary habits, fluoride intake and dental caries experience in the primary dentition.

OBJECTIVES: Dental caries continues to be a major public health problem in the US and other nations, particularly among younger children. Unfortunately, understanding of factors contributing to caries in this age group is incomplete and further studies are necessary. The purpose of this study was to assess factors related to extensive caries experience among children aged 4-7 years, including antibiotic use, dietary patterns, fluoride intakes, and tooth brushing habits. METHODS: The case-control study was nested within a longitudinal cohort study of children's oral health. The larger cohort study collected data on fluoride intakes and behavioral factors, including antibiotic use and dietary patterns of children periodically from birth. A single dental examination was completed for each child at a time between the ages of 4-7 years. A case-control design was used to compare children with severe caries experience (6 or greater dmfs) to those with no caries experience. Cases (n = 39) included all who met the criteria and had sufficient longitudinal data (n = 39) while a control group was selected to have comparable mean age, exam dates, and an equal number of boys and girls. RESULTS: Backward elimination logistic regression controlling for demographic variables showed severe caries experience to be related to greater regular pop/other sugared beverage intake, greater frequency of starch foods, and greater frequency of eating occasions. Mother's education and fluoride intake from water were inversely related to severe caries experience. Antibiotic use was generally higher in the control group, but was not significantly different than in the severe caries group. CONCLUSIONS: Although we cannot rule out the possibility that antibiotics may be associated with increased or decreased caries risk, our data suggest that they play only a minor role in caries prevention compared to fluoride. Dietary sugar continues to be a significant risk factor for caries in the primary dentition.

Favorable patient acceptance of ambulatory blood pressure monitoring in a primary care setting in the United States: a cross-sectional survey.

BACKGROUND: The use of ambulatory blood pressure monitoring (ABPM) in the diagnosis and management of hypertension in primary care settings in the United States is increasing. Insufficient information is available describing patients' experiences and acceptance of this technology in the United States, where medical insurance coverage of the procedure is often limited. The objective of this study was to describe patient satisfaction with ABPM performed in a primary care office in the United States, using modern ABPM technology. METHODS: Cross-sectional survey performed on consecutive patients referred to the ABPM service of the Family Care Center, University of Iowa Hospitals and Clinics, Iowa City, Iowa from January 2001 to July 2003. Measures of patient satisfaction and acceptance with the device, comfort, and overall session were assessed via a 9-question, Likert-scale response survey. RESULTS: Since its inception two and a half years ago, 245 total ABPM sessions have been conducted in 235 unique patients. Of the 235 eligible respondents, 177 returned completed surveys, yielding a 75% response rate. Three-fourths (75%) of patients believed that undergoing the test was worthwhile considering the time and monetary cost involved, while most (90%) reported they thought the information provided by the test would be helpful to their physician in making treatment decisions. Patients reporting that their physician had clearly explained the benefit of undergoing the testing were more likely to report that they thought the results of the test would be more helpful in making treatment decisions. Few patients (20%) found that wearing the monitor was uncomfortable. CONCLUSIONS: When clinically indicated, clinicians should not hesitate to order ABPM testing for fear of subjecting patients to an uncomfortable test, or an uncovered insurance benefit. When ordering ABPM, they should be sure to educate the patient about the potential benefits of undergoing the testing. Most patients believe the test will provide useful information in making treatment decisions, despite probable lack of insurance coverage, and appear willing to experience some discomfort for the overall gain of the results obtained from undergoing the session.

Malpractice liability for informal consultations.

BACKGROUND: Informal ("curbside") consults are widely used by primary care physicians. These interactions occur in person, by telephone, or even by e-mail. Exposure to malpractice liability is a frequent concern of subspecialty physicians and influences their willingness to engage in this activity. To assess this risk, we reviewed reported judicial opinions involving informal consultation by physicians. METHODS: A search of the existing medical literature, and of the Westlaw national database was undertaken to identify reported judicial opinions involving informal physician consults that address whether informal consultations create a legal relationship between consulting specialist physicians and patients that gives rise to a legal duty of care owed by the consulting specialist to the patient. CONCLUSIONS: Courts have consistently ruled that no physician-patient relationship exists between a consultant and the patient who is the focus of the informal consultation. In the absence of such a relationship, the courts have found no grounds for a claim of malpractice. Malpractice risks associated with informal consultation appear to be minimal, regardless of the method of communication. While "informal consultation" is not a term used by the courts, the courts have applied a consistent set of criteria that help define the legal parameters of this activity.

Primary tooth fluorosis and amoxicillin use during infancy.

OBJECTIVE: It has been speculated that amoxicillin use could be associated with enamel defects, but there have been few studies of this possible relationship. This study assessed the association between amoxicillin use during the first year of life and primary tooth fluorosis. METHODS: Subjects (n = 490) were recruited at birth and followed prospectively with a series of questionnaires to gather information on fluoride intake and amoxicillin use. Primary tooth fluorosis was assessed by calibrated examiners at approximately 5 years of age. RESULTS: Amoxicillin use for 6 weeks to 3 months and 3 months to 6 months significantly increased the risk for fluorosis of primary second molars in bivariate analyses. However, after controlling for fluoride intake, the adjusted risks of fluorosis were not significant for amoxicillin use. No other antibiotics were significantly associated with fluorosis in the bivariate analyses. In multivariate analyses with logistic regressions, only fluoride intake was statistically significantly related to fluorosis. CONCLUSION: Fluoride exposure was the sole predictor of primary tooth fluorosis in a multivariate model. However, bivariate results suggest that amoxicillin could play a contributing role in the development of primary tooth fluorosis, especially for children exposed to lower levels of fluoride. An investigation of the relationship between amoxicillin intake and fluorosis of permanent teeth is warranted.