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Objective: To examine the relationship between the use and type of primary care and visits to the emergency department (ED) in early infancy by healthy infants who are Medicaid recipients. Design: A population-based cohort study using a database linking birth certificate data to Medicaid claims. Participants: A total of 151 464 full-term infants born in Ohio to mothers receiving Medicaid from July 1, 1991, through June 30, 1998. Main Outcome Measures: The primary outcome of interest was the occurrence of an ED visit within 91 days of the neonate's birth. Bivariate and multivariate analyses were performed to determine the effect of early linkage with primary care (within 21 days of birth) on ED use in early infancy. Results: Only 53% of the infants had a documented primary care visit within 21 days of birth. Twenty-eight percent of infants had at least 1 ED visit within 91 days of birth and 9% had more than 1 visit. The mean age of the neonate at the first ED visit was 39.7 days. Fifteen percent of primary care visits within 21 days of birth occurred at a hospital-based primary care clinic. After adjusting for maternal, infant, and residency characteristics and temporal differences, early primary care linkage was associated with a 16% increase in the likelihood of ED use. When the primary care visit occurred in a hospital-based primary care clinic, it was associated with a 27% increase in the likelihood of ED use. Conclusion: Contrary to our expectations, early primary care linkage did not result in a decreased risk of ED use.

Many medical residents need to be educated about the importance of vaccinating children. In a survey of 227 pediatric residents, only 57% made sure a child was completely vaccinated by the 15-month visit. Only 58% said they would vaccinate a child who was brought to the doctor because of illness and a fever. About one-fourth believed the parents would not return for well-child visits if the child was vaccinated during an illness. Others did not have the time to vaccinate or believed that vaccination during illness would cause discomfort for the child.

Physicians may need to be persuaded that immunizing sick children during doctor visits will not compromise routine well child visits. Researchers surveyed 174 pediatricians and family practice doctors at one children's medical center to determine their knowledge about vaccine contraindications and their actual immunization practices. Over two-thirds of doctors used sick child visits for immunization if children did not have a fever, but less than 30% immunized sick children with fevers. Just 11% of doctors immunized during the 15-month well baby visit. Only 15% of doctors could identify that a yeast allergy is a contraindication to the hepatitis B vaccine. Personal preference, rather than lack of knowledge, determined doctors' decisions about whether to immunize sick children.

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International medical graduates (IMGs) constitute approximately 25% of the US pediatric workforce. Their recruitment into US residency training raises concerns regarding their competence, although this has not been formally studied. Cincinnati Children's Hospital has systematically recruited IMGs over the past 16 years. This study evaluates perceptions of IMG performance by faculty and US graduate (USG) peers.

Objectives: To compare the content of after-hours medical triage and advice calls regarding private practice patients vs nonprivate practice patients and to assess caregiver compliance with advice resulting from these calls. Design: Survey of after-hours medical triage and advice calls during a 2-week period (September 1 through 15, 1996). Setting: Three private practices (serving approximately 24 000 patients) and 1 urban hospital-based, nonprivate practice (serving approximately 12 000 patients). Subjects: After-hours medical triage and advice calls from caregivers of patients receiving their primary care in these settings. Main Outcome Measure: Compliance with recommended emergency department (ED) or office visit referrals. Results: A total of 286 calls regarding private practice patients and 377 calls regarding nonprivate practice patients were received (P [is less than] .001). Eighty-one calls were referred by the nurse directly to the physician. Fifty-nine private practice patients and 59 nonprivate practice patients were referred to the ED. Caregivers of 94 private practice patients and 132 nonprivate practice patients were given home treatment advice. Appointments to be seen at their primary care source were given for 78 private practice patients and 160 nonprivate practice patients. Nonprivate practice patients were more likely to be referred for office care (P=.005); private practice patients were more likely to be referred to the ED (P=.01). Compliance with ED referrals was 42% for patients of nonprivate practice and 46% for private practice; for office visit referrals, compliance was 64% for nonprivate practice and 69% private practice patients (P=.71 for compliance with ED referrals and P=.40 for compliance with office referrals). Conclusions: Compliance with recommended physician encounters was not significantly different (and lower than expected) in both groups of patients. Private practice patients are more likely to be referred to the ED. Calls for nonprivate practice patients are more frequent and these patients are more likely to be referred to their primary care source. This difference may be due to caregivers of patients from nonprivate practices seeking advice for less serious conditions. Physicians should address telephone medicine with caregivers proactively during health maintenance visits. Arch Pediatr Adolesc Med. 1999;153:292-296, A nurse-staffed telephone triage system may effectively manage after-hours pediatric emergency care, but the advise is not always heeded. Researchers evaluated 663 calls from parents and caregivers to an emergency advice service. Most called because their child had respiratory trouble, an injury, gastrointestinal disturbances, fever, or rash. The nurse referred 81 calls to a physician. A physician-reviewer agreed with the nurse's advice 95% of the time. Only 46% of caregivers advised to seek immediate care in the emergency department complied with the advise. Two-thirds of caregivers advised to make an office appointment to see a doctor complied with the recommendation.

AbstractBackgroundThe importance and benefits of direct observation in residency training have been underscored by a number of studies. Yet, implementing direct observation in an effective and sustainable way is hampered by demands on physicians' time and shrinking resources for educational innovation.ObjectiveTo describe the development and pilot implementation of a direct observation tool to assess the history and physical examination skills of interns in a pediatric emergency department rotation.MethodsA task force developed specific history and physical examination checklists for a range of common conditions. For the pilot implementation, 10 pediatric emergency medicine faculty attendings conducted the initial observations of 34 interns during the course of 1 academic year. At the conclusion of the pilot, the faculty observers and interns were interviewed to assess the feasibility and benefits of the process.ResultsA total of 33 of the 34 interns were observed during their rotation, with 26 of the observations conducted when the faculty observer was off shift, and it took approximately 20 minutes to complete each observation. In terms of learning benefits, interns and faculty observers reported that it facilitated clear and useful feedback and revealed gaps that would not have otherwise been identified. Faculty observers also mentioned that it helped them focus their teaching effort, built empathy with learners, and gave them a way to demonstrate a true concern for their learning.ConclusionOur results offer evidence for the feasibility and benefits of the direct observation checklists. The description of the implementation, challenges, and response to those challenges may help others avoid some of the common problems faced when implementing direct observation methods.

Many pediatric residency programs struggle to incorporate injury prevention training into their curricula.

To determine the characteristics of nonurgent emergency department (ED) visits in the first 3 months of life.

Abstract. Objective: To compare the patient compliances and time analyses of two methods of assigning primary care providers (PCPs) to ED patients who are without a PCP: phone interview vs face‐to‐face interaction. Methods: Prospective observational cohort study following an intervention, performed in a pediatric ED, serving a population of 1.7 million, with a census of 80,000 pediatric ED visits per year. Over one year, a consecutive sampling of 1,062 patients evaluated in the ED and without a PCP were approached to participate in our study (536 enrolled, 526 declined). Patients enrolled were addressed by a nurse practitioner/social worker (NP/SW) who arranged an appointment with a PCP, either in person (in ED) or by phone after discharge. The primary outcome measure was compliance with the arranged appointment. Secondarily, the authors analyzed the time necessary for each approach in person‐hours. Results: Of the 536 enrolled, 81 were excluded because data collection was incomplete at the time of the study's completion, leaving 455 study patients. Seventy‐six percent of the study patients were between the ages of 1 month and 12 years. Contact was made by phone for 151 (33%) patients and face‐to‐face for 304 (67%). Sixty‐two percent of the phone patients kept their appointments, compared with 52% of face‐to‐face patients (p = 0.048, RR = 1.20, 1.02 < RR < 1.41). Phone interaction was also more time effective. Conclusions: Linking ED patients without a medical provider to PCPs via phone is as effective as a face‐to‐face interaction.

Cultures for sexually transmitted diseases (STDs) are frequently obtained as part of an evaluation for alleged sexual abuse, but the prevalence of STDs in abused children is very low. Furthermore, STDs in children may not be identified if the clinician does not maintain a high index of suspicion in the symptomatic child. A retrospective review was done to study the symptoms and presenting complaints of girls under 12 with gonorrhea and chlamydia infections and to examine the prevalence of STDs in asymptomatic girls. The charts of 622 patients were reviewed. All patients were females under 12, Tanner I or II, who were initially seen for evaluation of sexual abuse or who were diagnosed with an STD. During the study period, 28 girls were found to have STDs. Twenty-two of these girls had vaginal gonorrhea; vaginal chlamydia was diagnosed in eight. Twenty-three of the 28 girls (82) with an STD were initially seen and cultured for a chief complaint of vaginal discharge. Of the 581 patients who were cultured for evaluation of abuse, only five STDs were diagnosed (0.7). All 22 girls with gonorrhea had a vaginal discharge on examination. Of the eight girls with chlamydia, two also had vaginal gonorrhea. Of the six who had chlamydia without gonorrhea, asymptomatic infection was common; four gave histories of discharge but only one had a discharge on examination. Our review indicates that girls under 12 who present for evaluation of vaginal discharge may have an STD and should be cultured for gonorrhea and chlamydia whether or not sexual abuse is suspected. In girls alleging sexual abuse and who are asymptomatic, vaginal gonorrhea and chlamydia infection are uncommon.

An enzyme immunoassay (EIA, ELISA) using microwells coated with a flagellin-enriched fraction of B. burgdorferi and absorbent-containing sample diluent for the quantitative determination of Lyme disease (LD) IgG and IgM antibodies in human serum samples was described. This LD EIA required three 15-minute incubations at room temperature, followed by a 1-step normalization of photometer readings to EIA units (EU/ml). Compared with tests using the whole bacterial extract as antigens and a sample diluent containing 6% BSA, this new LD EIA revealed lower values for 20 syphilis (SS) and 21 normal serum samples (NS) but about the same for 21 Lyme disease (LD) samples, allowing lower cut-off points which would place almost all these SS and NS samples below while almost all LD samples above the positive cut-off point. The LD EIA results of larger numbers (67 to 291) of mixed samples correlated with results of four reference EIA. However, the LD EIA gave lower (2 to 4 fold) reactivities (index values) with SS and NS samples but higher values with positive serum samples than reference EIA. Thus, this LD EIA showed improvements in both specificity and sensitivity over other tests compared.

Two rapid and simple enzyme immunoasskys (EIA) for antibodies to E. histolytica, the protozoa causing ambiasis, are described. In the rapid dot EIA, a qualitative procedure, antigens were dried as a small dot (3 mm in diameter) on a thin white opaque polystyrene strip and serum samples were assayed undiluted. The assay required 3 incubation periods, 1 to 3 minutes each, and was completed in 9 minutes, with a positive reaction revealed as a blue color (precipitate) on the antigen dot and negative as colorless. The developed color is stable for permanent record. In the Microwell EIA, a quantitative procedure, antigens were dried in the Microwells. The assay also consisted 3 incubation periods of 15 minutes each, and was completed in 50 minutes. The results in absorbance values were normalized to EIA units (EU). Both tests had good reproducibility, sensitivity and specificity; and highly correlated with 3 other serologic tests. Their reagents can be stored for more than a year. Both tests could be suitable for small and physicians' office laboratories, especially in developing countries.

To characterize tissue-specific differences in insulin signaling, we compared the mechanisms of mitogen-activated protein (MAP) kinase activation by insulin in the mitogenically active 3T3-L1 fibroblasts with the metabolically active 3T3-L1 adipocytes. In both cell lines, insulin significantly increased p21ras·GTP loading (1.5-2-fold) and MAP kinase activity (5-8-fold). Inhibition of Ras farnesylation with lovastatin blocked activation of p21rasand Raf-1 kinase in both 3T3-L1 fibroblasts and 3T3-L1 adipocytes. In 3T3-L1 fibroblasts, this was accompanied by an inhibition of the stimulatory effect of insulin on MAP kinase. In contrast, in 3T3-L1 adipocytes, despite an inhibition of activation of p21rasand Raf-1 by lovastatin, insulin continued to stimulate MAP kinase activity. Fractionation of the cell lysates on the FPLC Mono-Q column revealed that lovastatin inhibited insulin stimulation of ERK2 (and, to a lesser extent, ERK1) in 3T3-L1 fibroblasts and had no effect on the insulin-stimulated ERK2 in 3T3-L1 adipocytes. These results demonstrate an important distinction between the mechanism of insulin signaling in the metabolically and mitogenically active cells. Insulin activates MAP kinase by the Ras-dependent pathway in the 3T3-L1 fibroblasts and by the Ras-independent pathway in the 3T3-L1 adipocytes.

Sirolimus is an immunosuppressive agent approved for prophylaxis of acute rejection in renal transplant patients aged 13 years or older. A retrospective review of pericardial effusion coincident with sirolimus therapy was conducted from key clinical trials and spontaneous reporting sources. A significantly higher rate of pericardial effusion occurred with sirolimus versus azathioprine treatment in a cardiac transplantation trial (28.6% versus 9.3%, respectively). Cases of pericardial effusion were also observed in the sirolimus treatment arms of three de novo renal transplant studies (rates 0.5 to 1.9%). Although most of the pericardial effusions occurred in cardiac transplantation, sirolimus is not approved for this use. As of January 31, 2007, the Wyeth safety database (which includes clinical trial data and spontaneous reports) contained reports of pericardial effusion in 56 sirolimus-treated patients, 31 of whom required pericardial drainage. These data suggest that pericardial effusion should be considered in the differential diagnosis of a clinical deterioration in posttransplant patients treated with sirolimus. The adverse reaction of pericardial effusion has been added to product labeling.

Residency is a high-risk period for physician burnout. We aimed to determine the short-term stability of factors associated with burnout, application of these data to previous conceptual models, and the relationship of these factors over 3 months. Physician wellness questionnaire results were analyzed at 2 time points 3 months apart. Associations among variables within and across time points were analyzed. Logistic regression was used to predict burnout and compassionate care. A total of 74% of residents completed surveys. Over 3 months, burnout (P= .005) and empathy (P= .04) worsened. The most significant cross-sectional relationship was between stress and emotional exhaustion (time 1 r= 0.61, time 2 r= 0.68). Resilience was predictive of increased compassionate care and decreased burnout (P< .05). Mindfulness was predictive of decreased burnout (P< .05). Mitigating stress and fostering mindfulness and resilience longitudinally may be key areas of focus for improved wellness in pediatric residents. Larger studies are needed to better develop targeted wellness interventions.

The article presents the poem "A Fountain," by Charles Schubert. First Line: The air is thin at the top of the mountain. Last Line: overshadowing the view of the life as fountain.

An 11-week-old infant experienced toxicity following the intranasal instillation of a four percent cocaine solution in preparation for an examination to rule out choanal stenosis. The child recovered fully but required the use of anticonvulsants and admission to the hospital. To our knowledge, this is the first case report where cocaine toxicity was experienced following this routine practice. We present our case and a review of the literature involving other instances where there have been complications with the use of topical cocaine. This report should alert the medical community to the potential complications of using topical cocaine for its anesthetic properties.

The article presents the poem "By Midmorning," by Charles Schubert. First Line: half the street has been torn apart, apartments; Last Line: into smoke if they tried a little harder.

The article presents the poem "By the Time Winter Comes," by Charles Schubert. First Line: I would like to train elephants in my sleep, teach; Last Line: through the grass as they crashed downhill, uneaten.