Reevaluation of the ambulatory pediatric patient whose blood culture is positive for Haemophilus influenzae type b.

We conducted a retrospective review of 60 patients with Haemophilus influenzae type b bacteremia initially treated as outpatients, to test the hypothesis that a subgroup of these patients is at low risk of continuing invasive infection and thus requires a less comprehensive reevaluation. These patients were 6% of the 975 patients with invasive H. influenzae type b infection identified by active surveillance in Dallas County, Texas, during a 6 1/2-year period. The clinical assessment of "ill" appearance and persistent fever (greater than or equal to 38.0 degrees C) on the return visit were the two most useful variables in identifying patients at risk of continuing infection. Among 25 (42%) patients who were considered "ill" (febrile or afebrile), 20 (80%) had continuing invasive infection and 14 (56%) had a subsequent culture that was positive for H. influenzae type b. Among 8 patients who were considered "well" but who remained febrile, 3 (38%) had continuing infection, including 1 (13%) patient with a second culture that was positive. By contrast, among 27 (45%) patients who were considered "well" and who were afebrile, continuing invasive infection was identified in only 2 (7%) patients, and all repeat cultures were negative. These results suggest that when patients return for reevaluation of H. influenzae type b bacteremia, clinical assessment by an experienced physician, together with the febrile status of the patient, can identify those at high versus low risk of continuing invasive infection and thus guide the extent of diagnostic reevaluation.

A student health HMO as a partnership model within an academic medical center.

The Department of Family Practice, College of Medicine, in partnership with the University of Illinois at Chicago, was responsible for the reorganization of the Student Health Service into a health maintenance organization (HMO), Campus Care. Historically, the two campuses of the University of Illinois at Chicago operated student health as an infirmary model. Reorganization of student health into the Campus Care HMO provided expanded health care services to students, preserved more health care dollars in the university system, and provided a nonincremental increase in the size and responsibility of the Department of Family Practice. One year's experience showed that while the capitation was low compared with standard HMOs, the variable and less frequent use of services by the student population resulted in a fiscally viable operation. Numerous transition difficulties were encountered, including the need for rapid systems conversion within a complex university system, reeducation of students as well as traditional university-based practitioners for operation in a managed care system, and the rapid expansion of a small family practice department. The positive experience of the University of Illinois at Chicago supports the notion that family practice is better suited to providing student health care than other primary care disciplines. Three issues are paramount to success: (1) approval, support, and protection by higher level administration from university territorialism, (2) a core family practice faculty with strong leadership and experience in high-volume clinical activity, and (3) a close examination of financial resources in light of expected utilization.

The development of cognitive knowledge in clinical clerkships.

As part of an attempt to match the seminar program in pediatrics to the increased level of sophistication that students during the latter half of their core clerkship year would possess compared with students who enter pediatrics early in the year, the faculty of the Department of Pediatrics at The University of Texas Medical Branch in Galveston developed a typical final examination (a 100-item, multiple-choice test) and administered it as a pretest to each section of the junior class as it entered pediatrics. Analysis of the data indicated the following. A substantial portion of the cognitive information required for success in the clinical years was acquired prior to entry to the clerkship; scores of students entering their last clerkship were almost the same in the pretest in pediatrics as were those of students who took the pretest 10 monts earlier; posttest scores were substantially higher than pretest scores for all groups of students. The paper includes some discussion of the reasons for the findings and a description of the steps being taken to remedy deficiencies in the educational and evaluation program revealed by the study.