Demographics and anthropometrics impact benefits of health intervention: data from the Reduce Obesity and Diabetes Project.

OBJECTIVE: To determine the efficacy of a 4-month school-based health, nutrition and exercise intervention on body fatness and examine possible effects of demographic and anthropometric covariates. METHODS: Height, weight, waist circumference and body composition were measured in a diverse population of 644 NYC middle school students (mean ± SD age 12.7 ± 0.9 years; 46% male; 38% Hispanic, 17% East Asian, 15% South Asian, 13.5% African American, 8.5% Caucasian, 8% other) during the fall and spring semesters. Year 1 participants (n = 322) were controls. Experimental participants (year 2, n = 469) received a 12-session classroom-based health and nutrition educational programme with an optional exercise intervention. RESULTS: Groups were demographically and anthropometrically similar. The intervention resulted in significant reductions in indices of adiposity (ΔBMI z-scores [-0.035 ± 0.014; p = 0.01], Δ% body fat [-0.5 ± 0.2; p < 0.0001] and Δwaist circumference [-0.73 ± 0.30 cm; p < 0.0001]). Intervention effects were greater (p = 0.01) in men (ΔBMI z-score = -0.052 ± 0.015) versus women (0.022 ± 0.018), participants who were obese (ΔBMI z-score -0.083 ± 0.022 kg m-2) versus lean (-0.0097 ± 0.020 kg m-2) and South Asians (Δ% body fat -1.03 ± 0.35) versus total (-0.49 ± 0.20%) participants (p = 0.005). CONCLUSION: A 4-month school-based health intervention was effective in decreasing measures of adiposity in middle school students, particularly in men, participants who were obese and South Asians.

The "Culture OSCE"--introducing a formative assessment into a postgraduate program.

BACKGROUND: There is a growing need for appropriate training models in the area of cultural competence. An Objective Structured Clinical Exam (OSCE) format is ideal for this endeavor, since it allows for skills practice and feedback. As a result, we designed the first formative Culture OSCE at Maimonides Medical Center and have been implementing it since 1999. PROGRAM DEVELOPMENT: An interdisciplinary committee developed the OSCE as a formative assessment. Stations were designed based on a review of the literature and real situations experienced in the hospital. A two-hour workshop introducing the concept of cultural competence precedes the OSCE. The emphasis is on skills that are generalizable to encounters with any culture. Standardized patients are recruited from the relevant cultural groups or are trained to understand specific cultural issues. Costumes and props are utilized to enhance the authenticity of the encounter. Faculty, recruited and trained to observe encounters, gives constructive feedback, thus enhancing faculty development in this area as well. A rating scale was developed which incorporates communication and cultural skills as two separate dimensions of the encounter. PROGRAM EVALUATION: Written feedback is obtained from residents, the trained faculty observers and the standardized patients. Resident feedback has demonstrated good face validity. A post-OSCE debriefing session allows residents an opportunity to consolidate learning and give oral feedback. CONCLUSION: The Maimonides Medical Center Pediatrics Department designed the first Culture OSCE. This is deemed to be a valuable training tool, and serves to highlight the importance of cultural competence within the Department.

The use of media to impact on legislation.

There clearly are a large number of opportunities to use the media to influence legislation and legislative initiatives. There are a number of examples of legislation or laws that now exist as a result of pediatricians using the media effectively. National requirements for child auto restraints, Consumer Product Safety Commission regulations on children's toys, safety caps on medications, bicycle helmet laws, and increasing restrictions on guns can all be traced, in part, to the timely and appropriate use of the media. North Carolina safe gun laws to protect children resulted from pediatricians using some unfortunate and tragic incidents to dramatize the need for gun control. Highlighting the inappropriate care for children in emergency situations in New Jersey contributed to the movement to enact pediatric emergency care guidelines for that state. Finally, the effective use of the media by the AAP has brought a number of serious, child-related issues to the legislative forefront resulting in improved conditions for children. It is not easy, though. To use the media effectively takes persistence, thoughtful attention to developing relationships with the professionals in the media, and careful follow-up. It's important that pediatricians speak out on behalf of children and children's needs. The media, when used properly and knowledgeably, can be a powerful ally and contributor to a better outcome.

The impact of an AIDS symposium on attitudes of providers of pediatric health care.

Following reports of concern among health-care workers regarding the occupational risk of infection with the human immunodeficiency virus (HIV), a symposium was designed in 1987 to demonstrate to health-care providers at three hospitals in The Bronx, New York, the low risk of occupational HIV infection and techniques for avoiding infection. After the symposium, 103 of the health-care providers who had attended it completed a questionnaire assessing the impact of the symposium on their attitudes; the responses from 100 of these providers were used in this study. Twenty-nine of the responding providers reported that the symposium had increased their concerns regarding their risk of HIV infection; this group was composed of seven of the 15 medical students who responded, 12 of the 36 housestaff, seven of the 28 faculty, and three of the 21 other medical staff. The findings of the present study suggest that a symposium designed to decrease concerns of occupational HIV infection among health-care workers may have the opposite effect on some of those who attend it, especially medical students. Education alone may be inadequate to reassure some providers. The authors recommend small-group sessions addressing the emotional aspects of health-care providers' concerns.

Needle injuries among pediatric housestaff physicians in New York City.

Concerns regarding accidental needle puncture wounds, needle injuries among house officers have increased following reports of human immunodeficiency virus (HIV) transmission via this route. Pediatric house officers training in areas with large numbers of children infected with HIV may face a significant risk of occupational HIV infection via needle injury. The cumulative incidence of needle injury among pediatric house officers in New York who completed at least 1 year of training was ascertained. A questionnaire designed to elicit retrospective information regarding needle injuries was completed by 294 house officers in medical school-affiliated pediatric training programs. A total of 205 (69.7%) had stuck themselves or been stuck with a needle contaminated with a patient's blood, and 48 (17%) reported a needle injury involving a needle contaminated with the blood of a patient with suspected HIV infection. Only 11 of the 48 had received counselling or HIV testing following their possible HIV exposure. These data indicate that needle injury among pediatric house officers in New York is common. Reducing occupational risk is an especially compelling policy issue for pediatric training programs in areas where HIV is endemic.

Concerns of medical and pediatric house officers about acquiring AIDS from their patients.

To assess the degree of house officers' concerns about acquiring AIDS (acquired immunodeficiency syndrome) from their patients, we surveyed 263 medical and pediatric interns and residents in four housestaff training programs affiliated with seven New York City hospitals with large AIDS patient populations; 258 questionnaires (98 per cent) were returned. Thirty-six per cent of medical and 17 per cent of pediatric house officers reported percutaneous exposures to needles contaminated with blood of AIDS patients. Forty-eight per cent of medical and 30 per cent of pediatric house officers reported a moderate to major concern about acquiring AIDS from their patients. Greater concern about personal risk was noted in those house officers who were earlier in their residency training, who reported having treated a greater number of AIDS patients, and who were in medicine rather than pediatrics programs. Twenty-five per cent of all respondents reported that they would not continue to care for AIDS patients if given a choice. The results demonstrate a substantial degree of concern about acquiring AIDS among house officers caring for AIDS patients and suggest the need for housestaff program administrators for formally address these concerns.

Blood leukotriene levels during the acute asthma attack in children.

Leukotrienes (LT) have been proposed to be important mediators in the etiology of the acute asthma attack (AAA). We therefore studied blood LT levels in 18 children having AAA. Heparinized blood samples were obtained before and after treatment with epinephrine injections and/or metaproterenol inhalations in the emergency room. The samples were acidified and subjected to Sep-pak chromatography. Reverse phase high performance liquid chromatography (RP-HPLC), ultraviolet (UV) spectroscopy and bioassay on guinea pig ileum were used to identify the LT based on comparison to data produced by standard synthetic LT samples. Radioimmunoassay (RIA) was used to further confirm the presence of LT. LT C, D and E were detected in the plasma of children having AAA. Only LT C levels were significantly elevated over control values. The mean blood LT C level of control patients was 1.6 +/- 1.2 nanograms per milliliter (ng/ml, mean +/- SEM) while that of the asthma patients was 73.8 +/- 18.2 ng/ml prior to treatment. After emergency room treatment the asthma patients had a mean blood LT C level of 22.5 +/- 11.7 ng/ml. Lowered levels of LT C accompanied improved clinical condition of the patients. This finding indicates that the AAA in children is associated with elevated blood levels of LT C.

The usefulness of chest radiographs in first asthma attacks.

To assess the value of routine chest radiography during acute first attacks of asthma, we studied 371 consecutive children over one year of age who presented with an initial episode of wheezing. Three hundred fifty children (94.3 per cent) had radiographic findings that were compatible with uncomplicated asthma and were considered negative. Twenty-one (5.7 per cent) had positive findings: atelectasis and pneumonia were noted in seven, segmental atelectasis in six, pneumonia in five, multiple areas of subsegmental atelectasis in two, and pneumomediastinum in one. The patients with positive films were more likely to have a respiratory rate above 60 or a pulse rate above 160 (P less than 0.001), localized rales or localized decreased breath sounds before treatment (P less than 0.01), and localized rales (P less than 0.005) and localized wheezing (P less than 0.02) after treatment; also, these patients were admitted to the hospital more often (P less than 0.001). Ninety-five per cent (20 of 21) of the children with positive films could be identified before treatment on the basis of a combination of tachypnea, tachycardia, fever, and localized rales or localized decreased breath sounds. Most first-time wheezers will not have positive radiographs; careful clinical evaluation should reveal which patients will have abnormal radiographs and will therefore benefit from the procedure.

Febrile infants: predictors of bacteremia.

One hundred and seventy-five infants less than 8 weeks of age, presenting to the pediatric emergency room of the Bronx Municipal Hospital Center with rectal temperature greater than or equal to 38 degrees C (100.4 degrees F), were studied. House officers recorded their impressions of the infants on a number of variables prior to performing a lumbar puncture and obtaining laboratory data. All infants were admitted for parenteral antibiotic therapy pending culture results. Culture-positive bacterial infections occurred in 6.3% (n = 11); the incidence of bacteremia was 3.4% (n = 6). Of special concern were the 134 infants who had no visible source for their fever during the first examination. A major goal was to determine whether there were any early predictors of bacteremia in this group. The individual variables of white blood cell count greater than or equal to 15,000/mm3, band count greater than or equal to 500/mm3, temperature, impression of irritability, tone, cry, and activity level were not related to the presence of bacteremia. An erythrocyte sedimentation rate greater than or equal to 30 and the examiner's impression of sepsis were significantly associated with bacteremia but did not correctly identify all cases. However, the combination of impression of sepsis, white blood count greater than or equal to 15,000/mm3, and erythrocyte sedimentation rate greater than or equal to 30 identified all infants with bacteremia and excluded 82% of the infants who were eventually shown not to have bacteremia.

Parental perceptions of enuresis. A collaborative study.

Of 1,379 children 4 years of age and older who were patients in nine medical centers across the country, 346 (25.1%) were found to be enuretic. Their parents considered heavy sleeping and emotional problems as the main causes of enuresis in children; physical causes rarely were believed to be important. "Waking up the child" from sleep to urinate and "talking about the problem" were the main methods that parents used to treat enuresis. Very few used medication. Parents with a grade school level of education punish bed-wetting children at twice the rate of high school- and college-educated parents. Physicians need to be more aware that enuresis is an important problem for parents and that there are many widely held beliefs about cause and management.

Enuresis: a contrast of attitudes of parents and physicians.

Questionnaires were used to survey 1,435 parents and 446 physicians in order to determine and compare attitudes and beliefs about enuresis. Although both groups thought that bed-wetting is a maturational problem, the parent group thought emotional causes were important and were less likely to accept small bladder size as an etiology. Parents thought that children should be dry at a much younger age than did the physicians (2.75 vs 5.13 years, respectively). Only 63% of parents thought that medical intervention is a good way to deal with a child's bed-wetting, yet 87% of the physicians suggested medical evaluation. A comparison of the various methods used to stop bed-wetting indicated that parents use waking the child, reassurance and talking with the child, restricting fluids, and punishment significantly more often than physicians. Although many physicians prescribe medication, only 6.6% of the parents thought that medicines are a "very good way" to treat enuresis. When developing a treatment plan for a child with enuresis, the physician should recognize the wide differences between parental and physician attitudes toward this common problem of childhood.