Update in adolescent dermatology.

This dermatology article serves as a quick reference for the physician treating adolescents. We first review the diagnostic approach to a dermatologic problem: configuration, color, pattern, and distribution. The next section discusses diagnosis and management of the most common clinical situations encountered in everyday practice, including skin infections, infestations, dermatitis, hypersensitivity reactions, and papulosquamous disorders. The following section covers conditions that should be managed with the help of a dermatologist, including difficult acute situations such as Stevens-Johnson syndrome, toxic epidermal necrolysis, and necrotizing fasciitis; other chronic situations, including refractory common conditions such as acne and psoriasis, are also considered. We then discuss conditions that should be managed exclusively by a dermatologist, including malignancies, bullous disorders, and less common types of ichthyosis. The final section alerts the physician to dermatologic conditions that may be manifestations of other disorders, necessitating appropriate referral to a different specialist. Examples are immunologic and endocrine disorders, inflammatory bowel disease, collagen vascular disease, and malignancies.

Bleeding at circumcision: patient or operator issue?

OBJECTIVE: The goal of this study is to define precisely bleeding after circumcision and to determine whether patient-related variables or experience of the operator is associated with subsequent bleeding. METHODS: This is a prospective cohort study of 537 consecutive Gomco circumcisions. The authors defined bleeding and operator experience, both current and long term, and sought to correlate them. They selected patient variables (age, weight, gestational age, APGAR scores, and demographic data) to determine if there were associations with subsequent bleeding. RESULTS: There were 24 bleeds out of 537 Gomco procedures (4.47%). In comparing bleeders with nonbleeders, there was no significant association between long-term operator experience and subsequent bleeding (P = .609). However, bleeding was significantly associated with less current operator experience (P = .014). The authors were unable to detect any patient-related variables or demographics associated with subsequent bleeding. CONCLUSIONS: Regarding postcircumcision bleeding, current operator experience appears to be a more important factor than long-term experience or patient-related variables.

Gastrointestinal care of children and adolescents with developmental disabilities.

This article discusses nutrition in and specific conditions affecting children and adolescents who have disabilities. It is geared toward the practitioner of pediatrics to provide education regarding nutritional needs and how to meet them in these patients. The article reviews common problems in diagnosis and management, with particular emphasis on day-to-day issues that are in the purview of the primary care physician, and presents some recent developments in these topics.

Blood lead screening.

To evaluate local procedures for and barriers to testing Medicaid patients for lead toxicity, a retrospective review of 675 charts of Medicaid patients' age 12 to 36 months form the 7 practices who serve the vast majority of Medicaid children in Kalamazoo, Michigan was undertaken. We identified and tested a model for barriers to patients and physicians obtaining blood lead levels. Only 27.6% had blood lead levels substantially lower than the universal testing mandated by the Centers for Medicare and Medicaid Services. Physicians overestimated the number of children having blood lead tests, even with adjusting for patient non-compliance. Practices varied sharply in their approach to screening. Of 489 patients without findable lead test results, 139 (28.4%) were attributable to previous screening, 98 (20.0%) to patient failure, 181 (37.0%) to physician failure, 52 (10.6%) to patient + physician failure and 19 (3.9%) were indeterminate. There is need for improvement, standardization and unification of lead screening guidelines. Understanding barriers to blood lead testing is also necessary to develop credible data to promote shifts in public policy regarding lead abatement. Further studies should be done, such as interviews and questionnaires to determine why physicians fail to order blood lead tests, and patients fail to appear for a test that has been ordered.

A 1999 quality improvement initiative-reassessment in 2004.

We obtained a longitudinal overview of physician compliance with the American Academy of Pediatrics Policy RE9539 regarding early newborn discharge between 1999 and 2004. In previous studies we reported the results of a Quality Improvement/Feedback (QI/F) initiative at one community hospital (intervention) in 1999, during which time physician education occurred at a grand rounds and the hospital QI department reviewed all newborn charts for a 1-year period, notifying physicians of any deviations from the policy. We also assessed the very same physicians at another community hospital (control), which did not have this initiative and found significant changes in physician behavior only at the intervention hospital. In this study we reassessed the same physicians in the year 2004 and compared their performance with that in 2000, after the intervention was well established, once again at both the intervention and control hospitals. Physicians caring for newborns at the intervention hospital continued to demonstrate improvement in compliance with the Early Newborn Discharge Policy (p = 0.0036), whereas there was no significant change in physician performance over time at the control hospital (p = 0.6874). We conclude, similarly to the first study, that improvement in physician practice continued, but there was still no overall change in physician culture.

Does making newborn follow-up appointments from the hospital improve compliance?

OBJECTIVE: To test a system of arranging the first newborn follow-up appointments made from the hospital prior to discharge. METHODS: Prospective randomized study of 328 term healthy newborns divided into control and intervention groups. As there were multiple practices, we checked for clustering in the two groups and then compared them for patient compliance with the first newborn appointment. We also compared the control and intervention groups for compliance with regard to insurance status. RESULTS: There was difference between the control and intervention group in timeliness for the first appointment (control, 84.9%, intervention group, 94.2%, p=0.0062). There was also improvement in privately insured patients (control 89.1%, intervention 96.5%, p=0.0263), as well as in Medicaid+noninsured patients (control 64.7%, intervention 90.2%, p=0.0245). DISCUSSION: We conclude that arranging for follow-up appointments from the hospital is a worthwhile inexpensive intervention that could significantly improve patient compliance with the first newborn visit.

Patient compliance with the first newborn visit appointment.

OBJECTIVE: To analyze patient compliance regarding the first newborn visit after hospital discharge. STUDY DESIGN: We selected at random 640 charts over a 1-year period from two community hospitals of healthy term newborns who were cared for by four practices in Kalamazoo, MI. We collected demographic data from the hospital chart and recorded the discharge order for time of posthospital follow-up. We then accessed the individual clinics' appointment logs to determine when the patient came for the first visit. Lateness was defined as appearance for appointment >24 hours after the time stated on the hospital discharge order. We studied patient lateness with respect to the clinic, maternal age, insurance status, and distance from the patient's home to the medical facility, using both univariate and multivariate analyses. RESULTS: We demonstrated a significant difference in lateness of the first appointment between Medicaid and non-Medicaid patients in both the univariate (p<0.001) and multivariate (p=0.0003) analyses. We also demonstrated significant differences in the univariate analysis in patient lateness among the different practices (p<0.001) as well as lateness with regard to maternal age (p=0.0009). We did not attain significance in either analysis for patient lateness with regard to distance of home from the medical facility, or the hospital in which the baby was born. CONCLUSION: We demonstrated a need to improve upon newborn follow-up from the hospital and suggest strategies for other communities to analyze the process and improve upon patient and practice compliance with that first appointment.

Syncope in the adolescent.

Syncope in the adolescent is a common dilemma and can be frightening to patients, families, and physicians. An evidence-based approach to the evaluation of syncope in the adolescent is presented, with the emphasis on neurally mediated syncope (NMS). NMS does not actually lead to the youth's death; however, leaving such adolescents in unprotected situations (e.g., swimming or driving) can lead to considerable danger. Also, recurrent episodes of NMS have been shown to be associated with diverse psychosocial difficulties, either as a cause or a consequence of them.

Early newborn discharge: a tale of two hospitals.

This study reviews physician documentation of compliance with The American Academy of Pediatrics (AAP) policy RE9539 regarding early newborn hospital discharge and follow-up. All pediatricians in Kalamazoo, MI, were educated at a grand rounds regarding the AAP early newborn discharge policy. Newborns are seen at 2 community hospitals. One of them simultaneously instituted a Quality Improvement/Feedback (QI/F) program regarding early newborn discharge, (intervention) and the other 1 did not (control). This is a retrospective chart analysis that compares performance of 4 pediatric practices seeing newborns at each hospital. Each practice was compared at each hospital for appropriateness of discharge orders before and after the educational grand rounds and the QI/F initiative. Statistical analysis was done using the chi square test and the Breslow-Day test for homogeneity, and the Fisher's Exact Test. Odds ratios with a 95% confidence interval based on Taylor's approximation were used. There were no significant differences between the pediatric practices' performance before and after the educational initiative at the control hospital. There were significant differences before and after the educational initiative in the intervention hospital with the QI/F initiative. There was a significant reduction in variation among the practices after the QI/F initiative at the intervention hospital. When both hospitals were compared after the educational initiative, there was a significant difference between compliance among the same practices at each hospital, with better compliance at the intervention hospital with the QI/F initiative. There were significant differences in physicians' performance at the intervention hospital before and after the educational and QI/F initiatives. However, it was noted that the very same physicians did not comply as well in the control hospital without the QI/F initiative, thus still raising questions as to whether QI measures alter physician "culture." It is possible that the driving force for change in physician behavior was more intragroup peer pressure than an external QI/F initiative.