Demographic and dietary risk factors in relation to urinary metabolites of organophosphate flame retardants in toddlers.

Organophosphate flame retardants (OPFRs), including Tris (1,3-dichloro-isopropyl) phosphate (TDCPP), triphenyl phosphate (TPP), and isopropylated triphenyl phosphate (ITP), are increasingly used in consumer products because of the recent phase out of polybrominated diphenyl ether (PBDE) flame retardants. OPFRs have been widely detected in adults and have been linked to reproductive and endocrine changes in adult males. Carcinogenicity and damage to immunologic, neurologic and developmental systems have been observed in human cell lines. Young children are especially vulnerable to OPFR exposure, but little is known about exposure levels or exposure risk factors in this population. We examined parent-reported demographic and dietary survey data in relation to OPFR urinary metabolite concentrations in 15- to 18-month old toddlers (n = 41). OPFR metabolites were detected in 100% of subjects. The metabolite of TPP, diphenyl phosphate (DPP) was detected most commonly (100%), with TDCPP metabolite, bis(1,3-dichloro-2-propyl) phosphate (BDCPP), detected in 85-95% of samples, and ITP metabolite, monoisopropylphenyl phenyl phosphate (ip-DPP), detected in 81% of samples (n = 21). Toddlers of mothers earning <$10,000 annually had geometric mean DPP concentrations 66% higher (p = 0.05) than toddlers of mothers earning >$10,000/year (7.8 ng/mL, 95% CI 5.03, 12.11 and 4.69 ng/mL, 95% CI 3.65-6.04, respectively). While no dietary factors were significantly associated with OPFR metabolite concentrations, results suggested meat and fish consumption may be associated with higher DPP and BDCPP levels while increased dairy and fresh food consumption may be associated with lower DPP, BDCPP, and ip-DPP levels. Research with larger sample sizes and more detailed dietary data is required to confirm these preliminary findings.

Parental optimism about childhood obesity-related disease risks.

OBJECTIVES: Most parents believe childhood obesity is a problem for society, but not for their own children. We sought to understand whether parents' risk assessment was skewed by optimism, the tendency to overestimate one's chances of experiencing positive events. METHODS: We administered a national web-based survey to 502 parents of 5-12-year-old children. Parents reported the chances that (a) their child and (b) 'a typical child in their community' would be overweight or obese, and develop hypertension, heart disease, type 2 diabetes and depression in adulthood. Respondents self-reported demographic and health information, and we obtained demographic and health information about the typical child using zip code-level census and lifestyle data. We used regression models with fixed effects to evaluate whether optimism bias was present in parent predictions of children's future health outcomes. RESULTS: Parents had 40 times lower adjusted odds (OR=0.025, P<0.001, 99% CI: 0.006, 0.100) of predicting that their child (versus a typical child) would be overweight or obese in adulthood. Of the 20% of parents who predicted their child would be overweight in adulthood, 93% predicted the typical child would also be overweight in adulthood. Controlling for health and demographic characteristics, parents estimated that their children's chances of developing obesity-related comorbidities would be 12-14 percentage points lower those that of a typical child. CONCLUSIONS: Parent risk assessment is skewed by optimism, among other characteristics. More accurate risk perception could motivate parents to engage in behavior change.

Overstimulation of newborn mice leads to behavioral differences and deficits in cognitive performance.

Observational studies in humans have found associations between overstimulation in infancy via excessive television viewing and subsequent deficits in cognition and attention. We developed and tested a mouse model of overstimulation whereby p10 mice were subjected to audio (70 db) and visual stimulation (flashing lights) for six hours per day for a total of 42 days. 10 days later cognition and behavior were tested using the following tests: Light Dark Latency, Elevated Plus Maze, Novel Object Recognition, and Barnes Maze. In all tests, overstimulated mice performed significantly worse compared to controls suggesting increased activity and risk taking, diminished short term memory, and decreased cognitive function. These findings suggest that excessive non-normative stimulation during critical periods of brain development can have demonstrable untoward effects on subsequent neurocognitive function.

The influence of types of decision support on physicians' decision making.

OBJECTIVE: To determine whether physicians' post-test probability estimates are influenced by receiving test characteristics and impact their subsequent clinical decisions. DESIGN: Questionnaire based randomised controlled trial. SETTING: Mailed survey with a vignette describing an infant whose pretest likelihood of pertussis was 30% and direct fluorescent-antibody (DFA) test was negative for pertussis. SUBJECTS: Nationally representative sample of US paediatricians (n = 1502). INTERVENTIONS: Random receipt of no additional information (controls), the DFA's sensitivity and specificity (TC group) or the test's sensitivity and specificity with their definitions (TCD group). MAIN OUTCOME MEASURES: Estimated post-test probability (PTP) of pertussis, PTP of 0.50, "nearly correct" PTP (+/-5%), intended erythromycin management and intended hospital disposition. ANALYSES: Chi2 and t tests. RESULTS: Despite the negative DFA result, 67% of the 635 (49.7%) participants who responded estimated a PTP higher than the pretest probability of 30%; the overall mean estimated PTP was 0.41 (SD 0.26) (correct answer: 0.18). The TCD group's mean PTP was significantly higher than controls' mean PTP (0.45 vs 0.38, p<0.001), while the TC and control groups' mean PTP did not differ significantly (0.41 vs 0.38, p = 0.16). With decision support significantly more TC and TCD participants compared to controls estimated the PTP as 0.50 (38% vs 17%, p<0.001; 41% vs 17%, p<0.001, respectively) and also estimated a nearly correct PTP more often (20% vs 13%, p = 0.06; 19% vs 13%, p = 0.08, respectively). The mean PTP of participants intending to discontinue erythromycin therapy or discharge the patient home was significantly lower than that of participants who intended continuing erythromycin or hospitalisation (0.20 vs 0.43, p<0.001; 0.40 vs 0.49, p = 0.005, respectively). CONCLUSIONS: Paediatricians differed in their response to information about test characteristics. For many, it increased errors in estimating post-test probability; for others, it reduced errors. Estimated post-test probability was logically associated with intended clinical management.

Validation of parent self reported home safety practices.

OBJECTIVES: To evaluate the validity of parents' self reported home safety practices concerning smoke detectors, bike helmets, car seats, and water heater temperature. SETTING: Parents of children 12 years old and under whose child had made at least one visit to a study clinic in the years 2000-2003. METHODS: As part of a randomized controlled trial to improve patient provider communication and preventive practices, parents' responses to telephone interview were compared with observations of safety practices during a home visit. Home visits were completed within nine weeks of the telephone interview. Parents were not told that the visit was part of a validation study and home visit observers were unaware of the interview responses. The authors calculated sensitivities, specificities, positive and negative predictive values, and their corresponding confidence intervals. RESULTS: Sensitivity (0.78 to 0.98) and positive predictive values (0.75 to 1.00) were high for all items. Specificities and negative predictive values were more variable and the highest estimates (specificity 0.95 to 1.00, negative predictive value 0.95 to 0.97) were for car seat types. CONCLUSIONS: The results suggest that parent self report practice of certain injury prevention behaviors (owning a car seat, hot water temperatures) is reliable, whereas self reports on other practices (working smoke detectors, properly fitting bike helmets) may be overstated.

Association of lower continuity of care with greater risk of emergency department use and hospitalization in children.

CONTEXT: The benefits of continuity of pediatric care remain controversial. OBJECTIVE: To determine whether there is an association between having a continuous relationship with a primary care pediatric provider and decreased risk of emergency department (ED) visitation and hospitalization. DESIGN: Retrospective cohort study. Setting and Population. We used claims data from 46 097 pediatric patients enrolled at Group Health Cooperative, a large staff-model health maintenance organization, between January 1, 1993, and December 31, 1998, for our analysis. To be eligible, patients had to have been continuously enrolled for at least a 2-year period or since birth and to have made at least 4 visits to one of the Group Health Cooperative clinics. MAIN EXPOSURE VARIABLE: A continuity of care (COC) index that quantifies the degree to which a patient has experienced continuous care with a provider. MAIN OUTCOME MEASURES: ED utilization and hospitalization. RESULTS: Compared with children with the highest COC, children with medium continuity were more likely to have visited the ED (hazard ratio [HR]: 1.28 [1.20-1.36]) and more likely to be hospitalized (HR: 1.22 [1.09-1.38]). Children with the lowest COC were even more likely to have visited the ED (HR: 1.58 [1.49-1.66]) and to be hospitalized (HR: 1.54 [1.33-1.75]). These risks were even greater for children on Medicaid and those with asthma. CONCLUSIONS: Lower continuity of primary care is associated with higher risk of ED utilization and hospitalization. Efforts to improve and maintain continuity may be warranted.

A randomized controlled trial of point-of-care evidence to improve the antibiotic prescribing practices for otitis media in children.

CONTEXT: Prescribing practices for otitis media are not consistent with current evidence-based recommendations. OBJECTIVE: To determine whether point-of-care evidence delivery regarding the use and duration of antibiotics for otitis media decreases the duration of therapy from 10 days and decreases the frequency of prescriptions written. DESIGN: Randomized, controlled trial. SETTING: Primary care pediatric clinic affiliated with university training program. Intervention. A point-of-care evidence-based message system presenting real time evidence to providers based on their prescribing practice for otitis media. MAIN OUTCOME MEASURES: Proportion of prescriptions for otitis media that were for <10 days and frequency with which antibiotics were prescribed. RESULTS: Intervention providers had a 34% greater reduction in the proportion of time they prescribed antibiotics for <10 days. Intervention providers were less likely to prescribe antibiotics than were control providers. CONCLUSIONS: A point-of-care information system integrated into outpatient pediatric care can significantly influence provider behavior for a common condition.

Methodologic issues in pediatric outcomes research.

Clinicians, health services researchers, and third-party payers, among others, are justifiably interested in the outcomes of pediatric medical care and are, therefore, supportive of research in this area. Pediatric populations pose some unique methodologic challenges for health services researchers. To date, however, many of the approaches, models, and techniques used in pediatric outcomes research have been imported uncritically from experience with adult populations. As a result, some of the most interesting and salient aspects of pediatric outcomes research have yet to be fully developed. These include the following: 1) the problems posed by the dynamics of childhood development, 2) an emphasis on health supervision, 3) the need to see children within the context of a family system and to appreciate the interrelatedness of child health domains, 4) the measurement of the effects of interventions that span sectors, and 5) the paucity of available data sources. This article reviews these problematic areas and argues for a broad conceptual definition of pediatric health, a systems approach to assessing outcomes, and increased interdisciplinary collaboration.

Continuity and quality of care for children with diabetes who are covered by medicaid.

BACKGROUND: Poor and minority children with Type 1 diabetes mellitus are at increased risk of severe adverse outcomes as a result of their disease. However, little is known about the quality of care that these children receive and which factors are associated with better quality of care. OBJECTIVES: Our objectives were as follows: 1) to describe the utilization of services associated with quality of care for children with Type 1 diabetes mellitus who are covered by Medicaid and 2) to test the hypothesis that increased continuity of primary care is associated with better care for these children. DESIGN: Retrospective cohort study. METHODS: Washington State Medicaid claims data for 1997 were used to determine what proportion of children with diabetes had 1) an inpatient or outpatient diagnosis of diabetic ketoacidosis (DKA), 2) a glycosylated hemoglobin (HgA1c) level that had been checked, 3) a retinal examination, and 4) thyroid function studies. Continuity of care was quantified using a pre-established index. RESULTS: Two hundred fifty-two eligible patients were identified. During the observation year, 20% had an outpatient diagnosis of DKA, 6% were admitted with DKA, 43% visited an ophthalmologist, 54% had their HgA1c checked, and 21% had their thyroid function assessed. Children with high continuity of care were less likely to have DKA as an outpatient (0.30 [0.13-0.71]). Children with medium continuity of care and high continuity of care were less likely to be hospitalized for DKA (0.22 [0.05-0.87] and 0.14 [0.03-0.67], respectively). For preventive services utilization, high continuity of care was associated only with an increased likelihood of visiting an ophthalmologist (2.80 [1.08-3.88]). CONCLUSIONS: The quality of care for Medicaid children with diabetes can be substantially improved. Low continuity of primary care is an identifiable risk factor for DKA.

Journal reading habits of internists.

We assessed the reading habits of internists with and without epidemiological training because such information may help guide medical journals as they make changes in how articles are edited and formatted. In a 1998 national self-administered mailed survey of 143 internists with fellowship training in epidemiology and study design and a random sample of 121 internists from the American Medical Association physician master file, we asked about the number of hours spent reading medical journals per week and the percentage of articles for which only the abstract is read. Respondents also were asked which of nine medical journals they subscribe to and read regularly. Of the 399 eligible participants, 264 returned surveys (response rate 66%). Respondents reported spending 4.4 hours per week reading medical journal articles and reported reading only the abstract for 63% of the articles; these findings were similar for internists with and without epidemiology training. Respondents admitted to a reliance on journal editors to provide rigorous and useful information, given the limited time available for critical reading. We conclude that internists, regardless of training in epidemiology, rely heavily on abstracts and prescreening of articles by editors.

Do physicians judge a study by its cover? An investigation of journal attribution bias.

The effect of a journal's prestige on readers' impressions of an article is unknown. Two hypotheses were tested: first, that attribution of a study to a "high" prestige journal would be associated with improved impressions and attribution to a "low" prestige journal would be associated with diminished impressions; and second, that formal training in epidemiology and biostatistics would mitigate the effects of this journal attribution bias. The study was designed as a trial among a random sample of 264 internists. Participants were asked to read an article and an abstract from either the Southern Medical Journal (SMJ) or the New England Journal of Medicine (NEJM). Questionnaires were constructed that either attributed the article or abstract to its source or presented it as unattributed. After each article or abstract, respondents were asked to rate the quality of the study, the appropriateness of the methodology employed, the significance of the findings, and its likely effects on their practice. A 20-point impression score was created based on responses to these statements. The effect of attribution to a specific journal and formal epidemiology training on impression scores were assessed using linear regression. Of the 399 eligible participants, 264 questionnaires were returned (response rate 66%). Differences in impression scores associated with attribution of an article or abstract to the NEJM were.71 [95% C.I. (-.44-1.87)] and.50 [95% C.I. (-.87-1.87)] respectively; differences in impression scores associated with attribution of an article or abstract to the SMJ were -.12 [95% C.I. (-1.53-1.30)] and -.95 [95% C.I. (-2.41-.52)]. A stratified analysis demonstrated that epidemiology training did not meaningfully alter the effect of journal attribution on participants' impression scores. If journal attribution bias exists, it is likely to exert small and clinically insignificant effects when physicians read articles carefully. Formal training in epidemiology and biostatistics does not appear to alter these results.

A systematic review of treatments for infant colic.

OBJECTIVE: To conduct a systematic review of rigorously evaluated treatments for infant colic. METHODS: Online bibliographic databases were searched for the term "colic" in articles classified as clinical trials or randomized controlled trials and conducted in infants. Reference lists from review articles, meta-analyses, and the selected articles were also reviewed for potential studies. The abstracts or full-text articles of 57 relevant studies were examined, of which 22 met the selection criteria. The methodology and findings of all retrieved articles were critically evaluated. Data were extracted from each article regarding study methods, intervention studied, outcomes measured, and results. RESULTS: Four of the interventions studied had data of adequate quality and statistically significant numbers needed to treat (NNT): hypoallergenic diet (NNT = 6), soy formula (NNT = 2), reduced stimulation (NNT = 2), and herbal tea (NNT = 3). CONCLUSIONS: There are some effective therapies for infant colic, but additional rigorous studies of existing and alternative therapies are needed.

Pediatric deaths attributable to complex chronic conditions: a population-based study of Washington State, 1980-1997.

OBJECTIVES: Advances in medical technology and public health are changing the causes and patterns of pediatric mortality. To better inform health care planning for dying children, we sought to determine if an increasing proportion of pediatric deaths were attributable to an underlying complex chronic condition (CCC), what the typical age of CCC-associated deaths was, and whether this age was increasing. DESIGN: Population-based retrospective cohort from 1980 to 1997, compiled from Washington State annual censuses and death certificates of children 0 to 18 years old. MAIN OUTCOME MEASURES: For each of 9 categories of CCCs, the counts of death, mortality rates, and ages of death. RESULTS: Nearly one-quarter of the 21 617 child deaths during this period were attributable to a CCC. Death rates for the sudden infant death syndrome (SIDS), CCCs, and all other causes each declined, but less so for CCCs. Among infants who died because of causes other than injury or SIDS, 31% of the remaining deaths were attributable to a CCC in 1980 and 41% by 1997; for deaths in children 1 year of age and older, CCCs were cited in 53% in 1980, versus 58% in 1997. The median age of death for all CCCs was 4 months 9 days, with substantial differences among CCCs. No overall change in the age of death between 1980 to 1997 was found (nonparametric trend test). CONCLUSIONS: CCCs account for an increasing proportion of child deaths. The majority of these deaths occur during infancy, but the typical age varies by cause. These findings should help shape the design of support care services offered to children dying with chronic conditions and their families.

The association between greater continuity of care and timely measles-mumps-rubella vaccination.

OBJECTIVES: This study assessed whether greater continuity of care is associated with timely administration of measles-mumps-rubella (MMR) vaccination. METHODS: We studied 11,233 patients continuously enrolled in Group Health Cooperative (GHC) from birth to 15 months. We used a preestablished index to quantify continuity of care based on the number of primary care providers in relation to the number of clinic visits. MMR vaccination status at 15 months was assessed with automated immunization data systems at GHC. RESULTS: In a logistic regression model, both medium continuity (odds ratio [OR] = 1.20, 95% confidence interval [CI] = 1.08, 1.33) and high continuity (OR = 1.36, 95% CI = 1.22, 1.52) were associated with increased likelihood of being immunized by 15 months compared with patients in the lowest tercile of continuity of care. CONCLUSION: Greater continuity of care is associated with more timely immunization.