Sex differences in nevirapine rash.

Nevirapine is a nonnucleoside reverse transcriptase inhibitor (NNRTI) that has the most common treatment limiting side effect of rash. Severe rash has been observed in 3% of patients taking nevirapine in clinical trials, 85% of whom were men. In a multicenter, retrospective cohort study of all patients who received nevirapine over a 5-year period, severe rash was noted in 9 of 95 women and 3 of 263 men (risk ratio [RR], 8.31; 95% confidence interval [CI], 2.3-30.0; P=.005). Women were more likely to discontinue nevirapine therapy because of rash (RR, 4.5; 95% CI, 1. 9-10.5; P=.0005). After adjusting for age and baseline CD4 cell count in multivariate analysis, women had a 7-fold increase in risk for severe rash and were 3.5 times more likely to discontinue nevirapine therapy. In women of reproductive age for whom contraception may occur, nevirapine remains the NNRTI of choice. Recognition of sex differences in this severe adverse event will be important in prescribing nevirapine.

Neonatal bilirubin testing practices: reports from 312 laboratories enrolled in the Colege of American Pathologists Excel Proficiency Testing Program.

OBJECTIVE: To characterize laboratory practices for neonatal bilirubin testing and to identify opportunities for improvement. DESIGN: A voluntary self-assessment questionnaire was used to assess the laboratory practices of 312 laboratories subscribing to the College of American Pathologists (CAP) Excel Chemistry Proficiency Testing Program. RESULTS: A range of preanalytic and analytic practices were reported. The most notable problems identified were the use of overly long capillary puncture devices (17.8%), failure to protect the specimen from light prior to analysis (3.4%), failure to use a control containing >171 micromol/L bilirubin (26.1%), use of single-level control (4.2%), and lack of established linearity limits (7.0%). CONCLUSION: Opportunities exist to improve specimen collection, processing, and analysis for some physician-office and small-hospital laboratories.

Computer instruction in learning concepts of streptococcal pharyngitis.

OBJECTIVE: To evaluate a computer-assisted instruction unit covering the basic concepts of streptococcal pharyngitis for effectiveness as a learning tool. DESIGN: Randomized control trial. SETTING: A medical school associated with a tertiary care hospital. PARTICIPANTS: Third-year medical students on a pediatric clerkship from December 1, 1992, to October 31, 1993. INTERVENTION: Students were randomized into a study or a control group and given a pretest on streptococcal pharyngitis. The study group then completed the computer-assisted instruction unit. No attempt was made to distinguish among the clinical experiences of the two groups during the next 4 weeks, after which a second test on streptococcal pharyngitis was given to both groups. MAIN OUTCOME MEASURES: Outcome was measured by scores (percentage correct) from tests given at day 1 and week 4 of the clerkship. RESULTS: The posttest scores of the study group increased by an average of 12.1 above the pretest scores, but the scores of the control group were only 3.4 points higher. The difference between these increases is statistically significant (P < .01, Student's t test). CONCLUSION: Short, well-designed computer-assisted instruction units can be effective tools in medical education.

Physician office laboratory education and training in primary care residency programs.

OBJECTIVE: To assess the status of office laboratory residency education and training in family practice, internal medicine, obstetrics and gynecology, and pediatric residency programs. DESIGN: A single mailed survey to 1299 residency programs from December 1992 to February 1993. PARTICIPANTS: Primary care residency directors from 507 (39%) of 1299 programs. INTERVENTIONS: A 27-item survey of residency-based office laboratory practices, education, training, and resources. MAIN OUTCOME MEASURES: Differences between specialties in provision and quantity of office laboratory education and training, presence of a residency-based office laboratory, laboratory classification under the Clinical Laboratory Improvement Amendments, and available laboratory tests. RESULTS: Of those responding, office laboratories were present in 89% of family practice, 19% of internal medicine, 29% of obstetrics and gynecology, and 24% of pediatrics residency programs. Laboratory training was available at 60% of family practice, 16% of internal medicine, 15% of obstetrics and gynecology, and 30% of pediatrics programs. The median number of hours of formal skills training was 10 hours for family practice residency programs but less than 2 hours for the other specialties. Only 25% of the programs reported educational assistance from pathologists. Merely 4% of the programs had postassessment examinations and 2% awarded certificates of achievement. A majority of family practice programs performed waivered tests and physician-performed microscopy tests, but moderately complex tests were performed in less than 50% of family practice programs. CONCLUSIONS: Family practice residency programs provide more office laboratory training for residents than other specialties. There is a need for improved residency training in the basics of office laboratory practice.

Effect of institutional prestige on reviewers' recommendations and editorial decisions.

OBJECTIVE: To determine whether manuscripts from institutions with greater prestige are more likely to be recommended for publication by reviewers and to be accepted for publication. DESIGN: Retrospective study of reviewers' recommendations and editorial decisions for manuscripts from the United States received at the Journal of Pediatrics between January 1 and July 31, 1992. Manuscripts were classified as major papers or as brief reports. Institutions were ranked in quintiles according to the monetary value of grants funded by the National Institutes of Health. Reviewers' recommendations were classified as reject, reconsider, or accept, and editorial decisions as accept or reject, without regard to qualifying recommendations. RESULTS: For the 147 brief reports, lower institutional rank was associated with lower rates of recommendation for acceptance and of selection for publication. For the 258 major papers, however, there was no significant relationship between institutional rank and either the reviewers' recommendations or the acceptance rate. Similar results were found when the manuscripts were divided into five numerically equal groups according to institutional rank. CONCLUSIONS: Major manuscripts from institutions with greater prestige were no more likely to be recommended or accepted for publication than those from institutions with lesser prestige. In contrast, the likelihood of recommendation for acceptance and of selection for publication of brief reports appeared to correlate with the prestige of the institution.

Problems identified by secondary review of accepted manuscripts.

To test the hypothesis that no important deficits would be identified on further review of accepted manuscripts, and that such manuscripts would be recommended for publication on rereview, we sent manuscripts that had been accepted for publication, after review and revision, for rereview by new referees who were unaware of the status of the manuscripts. Each review was evaluated independently by two assistant editors to determine whether substantive criticisms were identified by the new reviewers. The majority of manuscripts were thought by the new reviewers to have defects that warranted further revision, but the problems noted were often dissimilar. However, 80% of the manuscripts were recommended for publication and others were judged suitable for publication, although not at a high priority. The assistant editors frequently differed in their judgments whether a given criticism of a reviewer warranted further revision; nevertheless, there was infrequent disagreement regarding the basic decision for acceptance or rejection.

Effect of acceptance or rejection on the author's evaluation of peer review of medical manuscripts.

To determine whether authors of rejected manuscripts would evaluate the editorial review process less favorably than would authors of manuscripts accepted for publication, a questionnaire was sent to solicit evaluations of the quality of the reviews that had led to the rejection or acceptance of manuscripts submitted to the Journal of Pediatrics. Similar evaluations of the editor's letter were also sought. Authors were more likely to respond to the questionnaire if their manuscripts had been accepted and were more likely to complete the questionnaire thoroughly. Authors of accepted manuscripts evaluated the editor's communication more favorably than did the authors of manuscripts not accepted for publication, but the evaluations of the reviews were not significantly different. Most authors utilized the reviews to modify their manuscripts before submitting them to another journal.

Kimura's disease: report of a pediatric case in the United States.

A 14-year-old male adolescent is described with a 6-year history of active lymphadenopathy, skin rash, peripheral blood eosinophilia, and markedly elevated serum-IgE level. Complete histopathologic and immunologic evaluations established the diagnosis of Kimura's disease as first described in Japan. Because of its relative infrequency and varied features, this disorder can be difficult to diagnose when it is encountered in the United States.