Controlled clinical trial of pediatric telephone protocols.

A randomized clinical trial of pediatric protocols administered by health assistants demonstrated an alternate method of handling telephone complaints in a large emergency room. The new system advised a higher medical examination rate than the current system in the emergency room probably bacause the current system has deficits with respect to collecting necessary information and making explicit decisions. This higher rate of recommended visits demonstrated in the emergency room was not confirmed in the two pediatric primary-care settings in which the protocol system was also tested. In addition to this use, the telephone protocols may also be useful in training medical and nursing students, in handling telephone complaints similar to a poison control center, in triaging problems in a rural or emergency medical service, and in providing a record of the telephone call.

Systematic utilization of data for analysis of a pediatric emergency-room experience.

This report describes the systematic use of emergency-room data to (1) define the experiences of a group of pediatric interns in their emergency-room rotation (especially as they relate to their role as future pediatric practitioners), (2) evaluate, supervise, and learn from their performance in this primary care setting, and (3) provide an ongoing weekly list of illnesses diagnosed in the emergency room as an epidemiological sentinel for the larger community. The future applications of this type of systematic approach, perhaps with computer technology, offer the opportunity for comparison of delivery, quality, and cost of health care between various sources of primary care (emergency-room facilities, private physicians' offices, neighborhood health centers, and health maintenance organizations.

Development and field testing of protocols for the management of pediatric telephone calls: protocols for pediatric telephone calls.

Although telephone calls comprise almost one fourth of all childhood patient-physician contacts, the content of telephone care is not emphasized in most educational and service programs. In response to the need to improve management of telephone calls to our pediatric emergency room, we developed 28 protocols to deal with the 25 most common complaints presented by phone. This paper describes the content of these protocols, the training of the health assistants who administered them, and the measures we took to assure their safety and general utility in pediatric practice settings. The study demonstrates the feasibility of an organized system for telephone care based on protocols which include: (1) basic data to be collected for each chief complaint category; (2) a range of appropriate dispositions; and (3) advice for home management when the patient does not require an immediate medical visit. Potential uses of these protocols for medical and nursing education and for clinical service needs are discussed.

Infants in a public school system: the indicators of early health and educational need.

The Brookline Early Education Project (BEEP) is a demonstration model in which a public school system in collaboration with a pediatric center has extended teaching and diagnostic services to the earliest days of life. In most cases, enrollment and data collection began three months before the children were born. A comprehensive diagnostic component including health, neurologic, sensory, developmental, and psychological assessments was performed periodically. The present study, the first of several reports, is an analysis of positive indicators of health and developmental need during the first six months of life. At the time of initial surveillance, age 2 weeks, a high yield of physical and demographic findings, along with perinatal stresses, was observed. It was noted that demographic, neurologic, physical, and perinatal stress factors appeared as independent variables. At the three- and six-month checkpoints, there were more overlapping findings between the categories of physical assessment, developmental examination, and neurologic evaluation. Over the six-month period, there was a tendency toward instability of findings: The group of youngsters thought to have special needs at the age of 2 weeks, 3 months, and 6 months differed in composition from each other. Likewise, there was significant flux in membership between the three- and six-month groups with needs. The study may have public policy implications, insofar as early education services should not be constructed to admit only "high-risk newborns" since this would exclude many children whose needs would become manifest later and would take in a number of children falsely identified as in need but with the resiliency to overcome this. The BEEP program has relevance for pediatric practice in demonstrating a component of health care with greater diagnostic and therapeutic responsibility for educational competence in young children.

High-risk youth and health: the case of excessive school absence.

Excessive school absence is a major educational and social problem in the United States, yet very little is known about its etiology or how to prevent or ameliorate it. This paper reports results from a series of related studies conducted in seven Boston middle schools (grades 6, 7, and 8) to test the hypotheses that health problems and unmet health needs are major characteristics distinguishing excessively absent students from regular attenders and that a health-oriented approach using medically mediated interventions is effective in reducing absences among excessively absent students. There were no significant differences between regular attenders and excessively absent students on multiple measures of student and family health status, health habits, and health service utilization patterns in a case-control study. The intervention program was not associated with a significant decrease in absence school-wide or for participating students. We conclude that demographic and educational characteristics of students exert a greater effect on their behavior in regard to absence from school than do health status or receipt of health services and that a health-oriented approach, such as the one used here, will not have a major impact on what remains one of the most profound educational and social problems involving children in the United States today.

Infant mortality increase despite high access to tertiary care: an evolving relationship among infant mortality, health care, and socioeconomic change.

In this study, the determinants of an apparent increase in the infant mortality rate of an urban population with high access to tertiary neonatal care are reviewed. For a 4-year period (1980 to 1983), all infant deaths (n = 422) of the 32,329 births to residents of the City of Boston were analyzed through linked vital statistics data and a review of medical records. A significant increase in the infant mortality rate occurred in 1982 due to increases in three components of the infant mortality rate: the birth rate of very low birth weight infants (less than 1,500 g), the neonatal mortality rate of normal birth weight infants (greater than or equal to 2,500 g), and the mortality rate of infants dying during the postneonatal period (28 to 365 days). These increases were associated with inadequate levels of prenatal care. Although transient, the impact of the observed alterations in these infant mortality rate components was enhanced by a more long-standing phenomenon: the stabilization of mortality rates for low birth weight infants. This stabilization allowed the increases in other component rates to be expressed more fully than in previous years. In this report a mechanism is shown whereby fully regionalized neonatal care ultimately may confer to the infant mortality rate a heightened sensitivity to socioeconomic conditions and levels of adequate prenatal care.

Tuberculosis screening in Boston's homeless shelters.

From February 1984, through March 1985, a total of 26 cases of tuberculosis (TB) were verified in homeless persons in Boston. Fifteen cases were resistant to isoniazid (INH) and streptomycin (SM) and were most likely the result of a common source exposure to one or possibly two highly infectious persons. Five cases without multiple drug resistant organisms occurred in persons with previous positive tuberculin tests who had not received adequate therapy for prophylaxis of infection or treatment of disease. The remaining cases were in persons with a previous negative skin test or no history of ever receiving a skin test. A screening program using chest roentgenograms (CXR), skin tests, and sputum smears led to the identification of several cases. CXR, the most readily accepted test, was the mechanism by which all cases detected through screening were identified. Detection and therapy of TB in the homeless, a group at particular risk for disease, required intensive intervention and outreach efforts.

Effect of changing patterns of care and duration of survival on the cost of treating the acquired immunodeficiency syndrome (AIDS).

We performed a two-year cost of illness study of 240 AIDS patients (55 percent of all Massachusetts cases) diagnosed and treated at five hospitals from March 1984 through February 1986. Sociodemographic and clinical data as well as information on medical utilization were obtained from review of inpatient and outpatient hospital records. The yearly inpatient cost per patient decreased by 28 percent from $38,369 in year one to $27,714 in year two. These changes were related to shorter lengths of stay (from 20.6 days to 16.8 days per hospitalization, mean difference of 3.8 days, 95% CI of the difference -.2, 7.8), and less costly hospitalizations (from $12,463 to $9,957, mean difference of $2,506, 95% CI of the difference $135, $4,877). The probability of hospitalization, however, was similar in both years. These patterns of care were still evident after controlling for transmission category, race, site, mortality, insurance, age, gender, number and type of opportunistic diseases and time since diagnosis. Although the cost per patient per year decreased between years one and two, median survival increased by 70 percent (from 10 to 17 months). Hence overall estimated lifetime costs increased by 24 percent.

The value of MnDPDP enhancement during MR guided laser interstitial thermoablation of liver tumors.

Magnetic resonance (MR)-guided thermal ablation procedures are feasible in modern open low field strength MR scanners. The compromises for rapid imaging in this configuration worsen liver lesino conspicuity. To overcome this, we utilize liver-specific contrast Mangafodipir Trisodium (MnDPDP) to improve lesion recognition and targeting and allow a longer contrast-assisted window. Three observers assessed pre- and post-contrast MR scans of 14 liver ablation patients. They assessed the number of lesions, ease of puncture planning, conspicuity of lesions, gallbladder, vessels, and surrounding bowel. There was a significant improvement in lesion conspicuity and ease of puncture planning when MnDPDP was used. In two of the observers, there was also a significant improvement in the number of lesions seen and in bowel conspicuity. No significant difference was shown in the detection of the gallbladder or vessels. We conclude that the liver-specific contrast agent MnDPDP improves the overall accuracy and safety of MR-guided thermal ablation of liver tumors facilitating this procedure at lower field strengths. J. Magn. Reson. Imaging 2001;13:37-41.

Patterns of blood donations among individuals at risk for AIDS, 1984.

Of 978 respondents to an anonymous questionnaire targeted to reach homosexuals in Boston during October 1984, 88 (9 per cent) reported recent blood donation. When compared to non-recent donors, high-risk respondents who were recent blood donors were younger, less open about their sexual preference, and more likely to obtain their information about AIDS (acquired immunodeficiency syndrome) from television and newspapers. These results suggest that particular subgroups of the population at risk for AIDS would benefit from expanded educational programs.

Corroboration of sexual histories among male homosexual couples.

Using data from a study of human immunodeficiency virus transmission among homosexual male partners from Boston, Massachusetts, the authors compared self-reported sexual histories among 155 index-partner pairs during 1985-1988. Overall, high levels of agreement were observed for all reported sexual activities. Agreement on anal sex was very high (Spearman's r = 0.78-0.79, p less than or equal to 0.001; kappa = 0.76-0.88, p less than or equal to 0.001). Level of agreement did vary significantly by a couple's drug and alcohol use; the heavier substance user generally reported fewer sexual encounters than the lighter user. These results have important implications in sexual behavior research and show that among homosexual men, self-reports of sexual behavior may be reasonably valid.

Medical care costs of AIDS in Massachusetts.

Previous investigation has suggested that the direct cost of medical care for the 24,011 reported patients with acquired immunodeficiency syndrome (AIDS) may be as high as $147,000 per patient. To evaluate the use and cost of medical services for patients with AIDS in Massachusetts, we performed a one-year cost of illness study of 45 AIDS patients. Sociodemographic and clinical data as well as information on medical utilization were obtained from review of outpatient and hospital records. Patients with AIDS required a mean of 3.3 (+/- 3.2) hospitalizations per year and 18.4 (+/- 21.8) ambulatory visits per year. Overall, medical costs averaged $46,505 +/- $38,720 per patient per year, with 91% of these expenditures related to use of inpatient services. These results suggest that the cost of medical care for AIDS patients may be substantially less than previously estimated.

The relation between nitrite inhalants, unprotected receptive anal intercourse, and the risk of human immunodeficiency virus infection.

The role of nitrite was evaluated between 1985 and 1988 in a study of sexual transmission of the human immunodeficiency virus (HIV) among homosexual male couples in Boston, Massachusetts. Initial enrollment data suggested that a history of unprotected receptive anal intercourse (odds ratio (OR) = 2.3, 95% confidence interval (CI) 1.4-3.6) and a history of nitrite use (OR = 1.7, 95% CI 1.1-2.5) were independent risk factors for HIV infection. In addition, interaction between nitrite use and unprotected receptive anal intercourse was observed (OR = 5.5, 95% CI 2.8-11.1) after controlling for number of unprotected receptive anal sex partners and history of sexually transmitted diseases. Since it was felt that nitrite use might be a marker for unprotected receptive anal sexual activity, a supplemental questionnaire was administered to obtain information on simultaneous nitrite use and unprotected receptive anal intercourse. The supplemental data suggested a strong interaction between nitrite use and unprotected receptive anal intercourse in increasing the risk of HIV infection. In the adjusted analyses, the odds ratio for HIV infection was considerably greater among men who always used nitrites during unprotected receptive anal intercourse (OR = 31.8, 95% CI 12.9-76.7) compared with men who sometimes (OR = 7.1, 95% CI 2.1-23.6) or never (OR = 9.0, 95% CI 2.5-32.1) used them. These findings have preventive public health implications and may add insight into our understanding of the mechanism by which HIV infection spread rapidly among homosexual men in the early 1980s.

Factors associated with excessive school absence.

Excessive school absence is a major educational and social problem in the United States which is most pronounced in urban school systems. A case control study of excessively absent inner-city middle-school students and regular attenders failed to demonstrate any differences between groups in terms of health status, health-related behaviors, or utilization of health services. These results contrast dramatically with the findings of a previous study which identified a number of educational and demographic characteristics which clearly distinguish excessively absent students from regular attenders. It is concluded that educational and demographic factors are far more important in influencing excessive absence behavior than are health-related factors. The implications of these findings for the pediatrician are discussed.