The challenge of tetradic relationships in medically interpreted pediatric primary care visits: A descriptive study of communication practices.

OBJECTIVE: To examine spoken interactions between pediatricians and community-based interpreters speaking with adolescents and parents with Limited English proficiency (LEP) in primary care to identify the challenges of interpreting in a four-person or tetradic visit, its sources of co-constructed errors, and specific practices for educational intervention. METHODS: As part of a larger study of vaccine decision-making at six clinical sites in two states, this descriptive study used discourse analysis to examine 20 routine primary care visits in a Latino Clinic in interactions between adolescents, parents, community-based interpreters, and pediatricians. Specific patterns of communication practices were identified that contributed to inaccuracies in medical interpretation RESULTS: Practices needing improvement were tallied for simple frequencies and included: omissions; false fluency; substitutions; editorializing; added clarification, information, or questions; medical terminology; extra explanation to mother; and, cultural additions. Of these speaking practices, omissions were the most common (123 out of 292 total) and the most affected by pediatricians. CONCLUSION: The dynamics of both pediatricians and interpreters contributed to identification of areas for improvement, with more adolescent participation in bilingual than monolingual visits. PRACTICE IMPLICATIONS: These observations provide opportunities for mapping a communication skills training intervention based on observations for future testing of an evidence-based curriculum.

Pneumococcal bacteremia in Charleston County, South Carolina. A decade later.

Since nationwide surveillance for pneumococcal bacteremia in the United States is not done, community-based studies are useful alternative methods to monitor trends in this disease. Data on the incidence of pneumococcal bacteremia in Charleston County, South Carolina, from 1974 to 1976, have been used to support cost-effective pneumococcal vaccine programs for the elderly. We reevaluated the incidence of pneumococcal bacteremia in Charleston County in 1986 and 1987 to assess whether earlier estimates remained valid given changes in medical practice. During 1986 and 1987, overall annual incidence of pneumococcal bacteremia in Charleston County was 18.7 per 100,000 (95% confidence limits, 13.7 to 23.6 per 100,000), which represents a 2.3-fold increase over the earlier rate. The increase coincided with a 2.2-fold increase in the annual number of blood cultures processed at four Charleston County hospital laboratories from 1975 to 1987 despite only a 1.1-fold increase in the number of patients discharged from these hospitals. Annualized rates increased 2.3-fold for adults more than or equal to 65 years old to 53 per 100,000 and 4.6-fold for children less than 2 years old to 162 per 100,000. The case-fatality rate of bacteremic patients was 18%, compared with 21% in the earlier study. The case-fatality rate for adults more than or equal to 65 years of age was 44%. Ninety-one percent of adults 19 to 64 years old with bacteremia had underlying medical conditions for which pneumococcal vaccine is recommended; all persons 55 to 64 years old had at least one underlying condition. The marked increases in pneumococcal bacteremia rates detected are likely due to more routine culturing of blood from symptomatic patients with pneumococcal disease. These findings emphasize the need for effective programs promoting use of pneumococcal vaccine in high-risk groups, particularly those more than or equal to 65 years old, and the development of a more immunogenic vaccine for children less than 2 years old.

Effectiveness of computer-generated appointment reminders.

Previous studies of appointment reminders among general pediatric patients have been done exclusively among low socioeconomic populations in clinics with low continuity of care and using block scheduling methods. This study of mailed computer-generated appointment reminders took place in a setting with patient demographics and practice techniques similar to those of many private pediatric practices. During a 6-month period, 901 appointments that were made more than 7 days prior to the scheduled date were randomly assigned to receive reminder postcards or to serve as controls. The overall broken appointment (no-show) rate was reduced from 19% in the control group to 10% in the reminder group, representing a 48% reduction (P = .0002). The magnitude of reduction of no-shows was similar for appointments scheduled more than 14 days prior to the appointment time (39%) as well as those scheduled more recently (58%). Equivalent results were seen with well-child appointments (47%) as with other visits (50%). Both lower and higher socioeconomic groups demonstrated similar results. The mailed postcards cost $0.20 each and were highly cost effective, generating an estimated $7.50 for each $1 spent during the study. With reductions similar to those found in this study, computer-generated appointment reminders are likely to be cost effective in other practices if current no-show rates are greater than 2% to 4%.

In-training examinations as predictors of resident clinical performance.

Previous attempts to predict resident clinical performance based solely on measures of cognitive skills have been uniformly unsuccessful. For the past 8 years, a formative residency evaluation system has been used that includes yearly comprehensive oral in-training examinations (OITEs) assessing each resident's performance in the three areas of professional competence: cognitive, psychomotor, and affective. The results of these examinations and scores received on the written in-training examination (WITE) given by the American Board of Pediatrics were compared with faculty ratings received during the subsequent year of residency. No significant correlation was found at any level of training between WITE scores and clinical performance. Analysis based on clinical setting did not improve these results. Oral in-training examination scores, however, were highly correlated with clinical performance ratings. In addition, with oral in-training examination scores, the "problem" interns--those whose clinical performance rating placed them in the lower 10% of interns--were predicted with a high degree of significance, sensitivity, and specificity. Predictions based on WITEs were not significant. Simultaneous evaluation of all three areas of professional competence should be done when predictions of resident performance are attempted. The OITE is a powerful formative evaluation tool, providing valuable learning experiences as residents are objectively assessed while they perform patient-centered tasks that represent critical skills in the practice of medicine. It allows early detection and possible amelioration of future problems in the clinical performance of a resident.

Effect of topical adrenergic decongestants on middle ear pressure in infants with common colds.

BACKGROUND: Otitis media is frequently a complication of the common cold. Obstruction of the eustachian tube ostia by nasopharyngeal edema has been suggested as a cause of this complication. OBJECTIVE: To determine the effect of a topical adrenergic decongestant on middle ear pressure in infants with common cold symptoms. METHODS: The study was conducted with a randomized, double blinded, placebo-controlled design. Middle ear pressure was determined in infants 6 to 18 months old who had common cold symptoms. Infants with abnormal middle ear pressure (< or = -100 mm H2O) in either ear were treated with intranasal phenylephrine drops or placebo. The effect of the treatment on middle ear pressure in ears with abnormal pressure at baseline was determined 1 h later. RESULTS: Twenty-three of 44 infants with abnormal middle ear pressures received intranasal phenylephrine drops and 21 received placebo. Middle ear pressure remained abnormal after treatment with phenylephrine in 29 of 33 (88%) ears and after treatment with placebo in 26 of 34 (76%). The mean change in middle ear pressure after treatment was +23 mm H2O in the active group and +40 mm H2O in the placebo group. CONCLUSIONS: Treatment of nasal obstruction with topical adrenergic decongestants does not improve abnormal middle ear pressures during the common cold.

Who needs an immunization in a pediatric subspecialty clinic?

BACKGROUND: The Standards for Pediatric Immunization Practices recommends that subspecialty clinics screen children's immunization status and ensure the receipt of needed immunizations. OBJECTIVES: To determine the proportion of children presenting to a pediatric subspecialty clinic in whom immunization status can be assessed, and which of those assessed are due an immunization (eligible to receive an immunization on the day of clinic visit). DESIGN: Standardized survey of 196 patients or accompanying children presenting to a pediatric cardiology clinic. Need for immunizations was determined by the Advisory Committee on Immunization Practices recommendations. RESULTS: The reason for visit included 58% return (enrolled in the clinic), 25% initial, and 17% accompanying another patient. Usual immunization provider included 51% health department, 42% primary care physician, and 7% military. We could assess the immunization status of 79 (40%) of 196, and 19 (24%) of these 79 were due an immunization. Logistic regression analysis revealed that children enrolled in the clinic were more likely to be due for immunization than those presenting for initial visits (38% vs 8%; adjusted odds ratio, 7.42; 95% confidence interval, 1.43 to 38.55). CONCLUSIONS: We could not assess the immunization status of most children presenting to this pediatric clinic. Patients enrolled in the clinic were at increased risk for being due immunization. Having a primary care physician as a provider of immunizations did not ensure the receipt of immunizations. Pediatric subspecialists should assess the immunization status of their patients and make sure that they receive needed immunizations.

Methodological issues in determining rates of childhood immunization in office practice. A study from pediatric research in office settings (PROS).

OBJECTIVE: To compare 3 methods for measuring pediatric office immunization rates. DESIGN: Retrospective and prospective cross-sectional surveys. PATIENTS: Children 2 and 3 years old from 15 pediatric practices in 11 states. METHODS: Immunization rates were determined for each practice using 3 methods. The Consecutive method used data from the practice's medical records of patients seen consecutively in the office; the Chart method used data from randomly selected practice medical records; and the Active method (reference standard) used a combination of medical record data with a telephone interview to collect additional immunization data and current patient status, using data only on current patients. Analyses were based on a mean of 57, 62, and 51 (Consecutive, Chart, and Active method, respectively) patients per practice. Patients were considered fully immunized if they had received 4 doses of DTP/DT vaccine, 3 doses of OPV/IPV, and 1 dose of MMR vaccine by their second birthday Comparisons were made using the paired t test. RESULTS: The mean immunization rate by method was Consecutive, 81.5% (range, 51%-97%); Chart, 71.6% (range, 42%-94%); and Active, 79.6% (range, 53%-96%). Within a given practice, the differences between methods varied considerably (0 to 28 percentage points). The mean difference from the reference standard Active method was 8 percentage points (P < .001) for the Chart method and -1.9 percentage points (P = .36) for the Consecutive method. The largest difference was between the Consecutive and Chart methods (mean difference, 9.9 percentage points; P = .003). Practitioners uniformly found the Consecutive method easiest to implement. CONCLUSIONS: Practice-specific immunization rates are one of the few objective measures of the quality of preventive pediatric care. Pediatric practices monitoring their immunization rates should consider using the Consecutive method, a simple, acceptable, and valid measure of practice immunization rate.

Teaching dietary counseling skills to residents: patient and physician outcomes. The CADRE Study Group.

Our objective was to determine whether an educational intervention and prompting intervention for physicians improved dietary counseling of patients with high blood cholesterol and resulted in beneficial changes in patients' diets and cholesterol levels. We instituted a factorial design, multicenter, randomized, placebo-controlled trial to test two interventions. We tested the trial at continuity care clinics of internal medicine residents at seven community and university medical centers in the northern and eastern United States. Our participants were 130 internal medicine residents and 254 adult outpatients with blood cholesterol levels of 240-300 mg/dL. Interventions included an educational program for resident physicians designed to improve their skills and confidence in dietary counseling (two one-hour sessions with specially prepared printed materials for use in counseling) and a prompting intervention, which was a fingerstick blood cholesterol determination prior to the patient's clinic visit. Resident physicians' knowledge, attitudes, and self-reported behaviors were assessed prior to the intervention and 10 months later using chart audits and questionnaires. Residents' behaviors were also assessed by exit interviews with patients. Patients' knowledge, attitudes, behaviors, and fingerstick blood cholesterol levels were measured at baseline and 10 months later. The educational program increased the percentage of physicians who were confident in providing effective dietary counseling (baseline of 26% to 67%-78%; P < .01). The prompting intervention approximately doubled the frequency of physician counseling (P = .0005) and increased the likelihood that patients would try to change their diets. When both interventions were combined, most outcomes were better, although not statistically significant. Cholesterol levels, however, decreased only marginally and were no different among groups at 10-month follow-up. Despite success in changing physicians' attitudes and behaviors and increasing patients' willingness to change their diets, there was no significant change in patients' cholesterol levels. Medical Subject Headings (MeSH): randomized controlled trial; cholesterol; patient education; behavior therapy; education, medical; diet.

Randomized multicenter trial documenting the efficacy and safety of a lactose-free and a lactose-containing formula for term infants.

OBJECTIVE: To evaluate the efficacy and safety of a new lactose-free infant formula. DESIGN: Randomized, prospective, double-blind, controlled, outpatient, multicenter, parallel 12-week trial. SETTING: Ambulatory-care facilities of the participating centers. SUBJECTS: 137 healthy term infants (approximately 7 days old at the time of study enrollment). INTERVENTION: Healthy term infants, whose mothers had decided not to breast-feed, were randomly assigned 1 of the 2 study formulas. MAIN OUTCOME MEASURES: Weight, length, and occipitofrontal circumference measurements were obtained at baseline and when the infant was 2, 4, 8, and 12 weeks old. Formula acceptance and tolerance were also assessed at weeks 2, 4, 8, and 12. Serum albumin concentration, creatirune level, and blood urea nitrogen were determined at baseline and week 12. Adverse events were assessed throughout the study. STATISTICAL ANALYSES PERFORMED: Each baseline anthropometric and laboratory variable was analyzed for comparability between groups using the Student t test and was also analyzed using a repeated-measures analysis of variance method. Covariance analysis was applied to the final laboratory data using the respective baseline data as covariates. Decisions about equality of mean responses to formula effects were based on the .05 level of significance in all cases. RESULTS: One hundred four infants completed the study. No significant differences between the 2 formula groups were noted for any of the growth and blood parameters. APPLICATIONS: This new formula is an effective and safe lactose-free nutrition alternative for infants who require such a diet.

Adolescent medicine in pediatric practice: a survey of practice and training.

This study was designed to assess the relation between training in adolescent medicine, during and after residency, and self-reported practice of adolescent medicine. This is a cross-sectional study. A questionnaire was mailed to all members of the South Carolina Chapter of the American Academy of Pediatrics. After 2 mailings, 198 (83%) questionnaires were returned. Adolescent medicine training in residency was associated with more adolescent patients enrolled in a practice (P < 0.01) and more adolescent patient visits (P < 0.01) but not with an increase in perceived competence in the practice of adolescent medicine. Adolescent medicine continuing medical education was associated with seeing more adolescent patients and with increased competence in many areas, including contraceptives, suicide, and school problems (P < 0.05). training in adolescent medicine during and after residency is associated with treating more adolescent patients. Continuing medical education also is associated with increased perceived competence in areas related to adolescents.

Recent changes in residency requirements for pediatrics: who agrees?

The purposes of this study were to determine the opinion of private and academic pediatricians about changes in pediatric residency requirements proposed by the Residency Review Committee (RRC) in October 1994 and to compare the results with the requirements finalized in February 1996 and implemented in February 1997. Surveys were mailed to all Fellows of the American Academy of Pediatrics in South Carolina. Those surveyed were asked to agree or disagree with 57 proposed changes. The level of agreement among all groups of pediatricians was very high; however there were significant differences between groups of pediatricians. Many controversial items were modified or deleted in the final version.

Children's immunizations: the gap between parents and providers.

Children's immunizations have been a part of our health care practice for many years. While immunizations have reached record highs in recent years, there is a fear that complacency may cause a drop in immunization rates and thus increases in disease rates. This study explored immunizations from two perspectives. First, focus groups with parents examined immunization information acquisition, practices, and barriers. Next, a physician survey examined immunization provider perceptions of parents' information acquisition, barriers and immunization practices. Several gaps were discovered between these two groups controlling the immunization of our children. Suggestions are made as to possible paths to begin addressing these gaps in order to increase immunization rates.

Predicting resident clinical performance with in-training examinations.

Yearly oral in-training examinations that assess resident performance in the three domains of professional competence (cognitive, psychomotor, and affective) given over a seven year period correlated highly with subsequent resident clinical performance and also predicted with a high degree of significance, sensitivity, and specificity those "problem" interns whose clinical performance placed them in the lower 10% of interns. Scores received on written in-training examinations were not significantly correlated with clinical performance and did not identify "problem" residents.

The effects of genetics and age on expression of MHC class II and CD4 antigens on rat cardiac interstitial dendritic cells.

Interstitial dendritic cells (IDC) in normal hearts of inbred rat strains and congenic and congenic recombinant lines were identified and quantitated by immunohistologic methods, on the basis of cellular reactivity with MRC-OX6, a monoclonal antibody (MAb) directed against MHC class II determinants, and with W3/25, a MAb directed against a CD4 epitope. In all strains and lines examined, the W3/25+ IDC frequency was uniformly high with little interstrain variation. In contrast, all rat strains and lines examined showed either high or low OX6+ IDC frequency. Double staining by two color immunofluorescence indicated that strains with a low OX6+ IDC frequency were characterized by a high frequency of W3/25+ OX6- IDC and a low frequency of W3/25+ OX6+ IDC. In strains with high OX6+ IDC frequency, the majority of IDC coexpressed both markers. Comparative analysis of (i) MHC identical background disparate strains and lines, (ii) MHC disparate background identical strains and lines, and (iii) F2 segregation analysis of intercrosses and backcrosses derived from an original cross between high and low frequency OX6+ IDC strains, all indicated that OX6+ IDC frequency is dependent upon both MHC- and non-MHC-linked genetic factors. It is suggested that rat cardiac OX6+ IDC frequency is influenced by a minimum of two autosomal genes, one of which is MHC linked. The frequencies of both W3/25+ IDC frequency reached adult levels by 10 days of age; adult levels of OX6+ IDC were not attained until Day 21. It is postulated that in the rat heart, W3/25+ OX6- IDC are potential precursors of W3/25+ OX6+ IDC, and that the cellular frequency of coexpression in the adult is under genetic influence. Whether these genetic factors modify constitutive or physiologic levels of class II-inducing lymphokine activity, or influence cellular susceptibility of IDC to induced class II expression is unclear.

Comparison of continuity in a resident versus private practice.

BACKGROUND: There is widespread agreement among pediatric educators that continuity (following a panel of patients on a first contact basis for all their health care) is an important part of the education of pediatricians. OBJECTIVE: To measure continuity in a pediatric residency practice and to compare this continuity with 2 nearby private general pediatric group practices. We also examined measures of continuity suggested in the literature. DESIGN: Visit data were obtained from the practice billing system for a resident continuity practice and 2 nearby private practices for the 3-year period from July 1, 1992, to June 30, 1995. Visit data used were restricted to patients seen in the office of the practices during regular office hours. Continuity was measured using 5 different indices: 1) the usual provider of care index, visits by the usual clinician/total visits, 2) continuity for patient, the average proportion of visits that an individual patient was seen by his or her own physician, 3) continuity for physician (PHY), the average proportion of visits that an individual physician saw his or her own patients, 4) Continuity of Care Index (COC), and 5) the Modified, Modified Continuity Index. During the period examined, pediatric residents were present in the continuity practice for 1 half-day each week. The resident continuity practice (RCP) had 57 residents and saw 3386 patients for 18 955 visits. Private practice 1 (PP1) had 4 pediatricians who saw 4968 patients for 33 537 visits. Private practice 2 (PP2) had 5 pediatricians who saw 11 953 patients for 75 778 visits. RESULTS: For all visit types, continuity in the RCP was not as high as in the private practices, PHY-RCP versus PP1, PP2; 53% versus 70%, 77%. However, continuity in RCP was greater than 50% for all measures except the COC index, which precipitously decreases as the number of clinicians seen increases. Examining continuity for health maintenance visits (PHY-RCP, PP2 vs PP1; 96%, 96% vs 82%) RCP was equal to the best of the private practices. The percentage of patients not seen for a health maintenance visit during the study period was lowest in the resident practice (RCP/PP1/PP2, 15/22/30). CONCLUSIONS: Although continuity for all visits in this RCP was less than in private practice, it was surprisingly high, considering the limited time residents spend in clinic. In a particularly important area for continuity, health maintenance visits, continuity was identical to one and superior to the other private practice.

Comparison of cefuroxime axetil, cefaclor, and amoxicillin-clavulanate potassium suspensions in acute otitis media in infants and children.

In this randomized, blinded, multicenter comparison study, 377 infants and children with acute otitis media (AOM) received a 10-day course of an oral suspension of one of the following: cefuroxime axetil (CAE), 30 mg/kg/day; cefaclor (CEC), 40 mg/kg/day; or amoxicillin-clavulanate potassium (AMX-CL), 40 mg/kg/day. Clinical efficacy was determined by pneumatic otoscopy and tympanometric testing 3 to 5, 11 to 14, and 22 to 26 days after the initiation of therapy. There was a statistically significant difference among the three treatment groups with respect to clinical outcome; more patients in the CAE group (62%) than in the CEC group (46%) or the AMX-CL group (52%) had complete resolution of signs and symptoms of AOM (including effusion). Paired comparisons revealed a significant difference in efficacy between CAE and CEC and a nearly significant difference between AMX-CL and CEC. Taste acceptability was highest for CEC and lowest for this formulation of CAE. Significantly more patients in the AMX-CL group than in the CAE or CEC group had a side effect, primarily diarrhea, vomiting, or diaper rash. We conclude that CAE suspension has greater clinical efficacy than CEC and fewer side effects than AMX-CL.