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BACKGROUND AND OBJECTIVES: In 2016, the American Board of Medical Specialties (ABMS) approved pediatric hospital medicine (PHM) as the newest pediatric subspecialty. To characterize development of the field, this article aims to: (1) describe the responsibilities and practice settings of US pediatricians self-identifying as hospitalists; and (2) determine how exclusive PHM practice, compared with PHM practice in combination with general or subspecialty care, was associated with professional development interests. METHODS: Pediatricians enrolling in the 2017-2018 American Board of Pediatrics (ABP) Maintenance of Certification program were offered a voluntary survey about their responsibilities, interests, and practice settings. Logistic regression was employed to characterize associations between exclusive PHM practice and: (1) interest in quality improvement (QI) leadership; (2) intention to take the PHM certifying exam; (3) satisfaction with allocation of professional time; and (4) intention to maintain more than one ABP certification. RESULTS: The survey response rate was 70.0%; 1662 (13.1%) self-reported PHM practice. Four-hundred ninety-one (29.5%) practiced PHM exclusively, 518 (31.1%) practiced PHM and general pediatrics, and 653 (39.3%) practiced PHM and one or more subspecialties. Respondents reporting exclusive PHM practice were significantly more likely to report interest in QI leadership or consultation (adjusted odds ratio [OR], 1.39; 95% CI, 1.09-1.79), PHM exam certification (adjusted OR, 7.10; 95% CI, 5.45-9.25), and maintenance of more than one ABP certification (adjusted OR, 2.64; 95% CI, 1.89-3.68). CONCLUSIONS: Hospitalists reported diverse clinical and nonclinical responsibilities. Those practicing PHM exclusively expressed high levels of interest in board certification and QI leadership. Ongoing monitoring of PHM responsibilities and practice settings will be important to support the professional development of the PHM workforce.

INTRODUCTION For decades, it has been recommended that children with sickle cell anemia (SCA) receive antibiotic prophylaxis to prevent serious infections and undergo transcranial Doppler (TCD) screening to identify those at highest risk of overt stroke. We assessed recent temporal trends in antibiotic prophylaxis prescription fills and TCD screening among children with SCA using validated quality measures. PROCEDURE Using validated claims-based definitions, we identified children with SCA who were enrolled in Michigan or New York State (NYS) Medicaid programs (2011-2018). Among recommended age groups, two outcomes were assessed yearly: (a) filling of ≥300 days of antibiotics, and (b) receipt of greater than or equal to one TCD. The proportion of children with each outcome was calculated by state. Temporal trends in each preventive service were assessed using generalized linear models. RESULTS A total of 1784 children were eligible for antibiotic prophylaxis (Michigan: 384; NYS: 1400), contributing 3322 person-years. Annual rates of filling ≥300 days of antibiotics ranged from 16% to 22% and were similar by state. There was no change in rates of antibiotic filling over time in Michigan (p-value: .10), but there was a decrease in NYS (p-value: .02). A total of 3439 children with SCA were eligible for TCD screening (Michigan: 710; NYS: 2729), contributing 10,012 person-years. Annual rates of TCD screening ranged from 39% to 45%, were similar by state, and did not change over time (p-values >.05). CONCLUSIONS Most children with SCA do not receive recommended antibiotic prophylaxis and/or TCD screening. New, sustainable, and coordinated interventions across preventive services are urgently needed.

OBJECTIVE: To develop, test, and validate the performance of ICD‐10‐CM claims‐based case definitions for identifying children with sickle cell anemia (SCA). DATA SOURCES: Medicaid administrative claims (2016) for children

Aim To determine (i) the proportion of different referral sources for new referrals to paediatric specialist outpatient clinics and (ii) any association of referral source with utilisation of additional health services. Methods Survey of parents presenting with their child at five paediatric specialist outpatient clinics at two Melbourne public hospitals. Results Just over half (52%) of the respondents were referred by a general practitioner (GP). The remainder were referred by a paediatrician (27%) at hospital discharge (16%) or from the ED (6%). Most respondents (71%) reported that their child also has a referral to see another specialist for the same health concern but had not yet had the consultation; 44% had consulted another doctor for the same health concern between receiving the referral and the appointment. Paediatrician referrals were more likely to see another specialist for the same health concern compared to other referral sources (P = 0.032). Conclusion Only half of the referrals of new patients to paediatric specialist outpatient clinics come from GPs. Future research should investigate whether multiple referral sources have a negative impact on the co-ordination and cost of paediatric health care.

Aim To assess a national sample of Australian parental confidence in general practitioner (GP) care for illness and injury for their children. Methods Cross-sectional, internet-based survey of a national, representative sample of parents of children birth – 17 years in Australia was used. Purposeful recruitment was used to achieve a national, representative sample of 2100 Australian parents, reflective of demographic and geographic distribution based on census data. Parents were asked to indicate their degree of confidence in a GP to handle medical problems as well as their preference for, and use of, paediatric speciality care for their children. Results Fewer than half of parents (44%) reported that they were completely confident in a GP to provide general care as defined as ‘can handle almost all general health issues for my child’. A slightly greater proportion of parents (56%) were completely confident in a GP to provide care for minor injuries, defined as injuries not requiring an X-ray. Greater confidence in general care was seen among parents >40 years of age and those whose GP is always bulk billed. Conclusions Parental confidence in GPs is an important issue. Our findings that fewer than half of parents are completely confident in their GP to provide general care to their child may be an influencing factor on current health-care utilisation trends. The potential implications of low parental confidence in GPs are greater numbers of emergency department presentations for children with lower urgency conditions and increased referrals of children for specialty care.

The aims of this study were to estimate the proportion of emergency department presentations attributable to children with cerebral palsy (CP), investigate the frequency of emergency department presentations in a CP cohort, and compare emergency department presentations among children with CP with those of other children.This was a retrospective cohort study. The Victorian Cerebral Palsy Register was linked to the Victorian Emergency Minimum Dataset. Data on emergency department presentations for the CP cohort occurring between 2007 and 2014 and population control data were obtained.The CP cohort (n=1748) had 7015 emergency department presentations during the 7-year period, accounting for 0.4% of the 1.69 million age-specific presentations during that time. The number of annual presentations per 1000 children rose with increasing CP severity. Compared with presentations among the general population, higher proportions of presentations among the CP cohort were preceded by ambulance arrivals (27% vs 8%), triaged as urgent (66% vs 32%), and required hospital admission (38% vs 12%).The marked differences in presentations between the CP cohort and the general population in the proportions that were urgent and required ambulance arrivals and hospital admissions was an important finding. Strategies to ensure appropriate use of services, including encouragement to seek earlier assistance from primary care providers, may prevent problems escalating to the need for urgent care.Children with cerebral palsy (CP) account for 0.4% of childhood emergency department presentations. More emergency department presentations among children with CP require ambulance arrival. More CP emergency department presentations are urgent and require hospital admission. Traditional emergency department triage scales seem less accurate for this group.

Aim The overall aim was to investigate the feasibility and utility of linking a cerebral palsy (CP) register to an administrative data set for health services research purposes. We sought to compare CP hospital admissions to general childhood population admissions, and identify factors associated with type and frequency of admissions in a CP cohort. Method The CP register for Victoria, Australia was linked to the state's hospital admissions database. Data pertaining to the admissions of a CP cohort (n=1748) that took place between 2007 and 2014 were extracted. Population data were also obtained. Results Overall, 80% of the CP cohort (n=1401) had at least admission between 2007 and 2014, accounting for 11 012 admissions or 1.5% of all admissions in their age group. Compared to general population admissions, CP admissions were more costly and more likely to be elective (66% vs 57%; p

Aim Over the last decade, there has been a dramatic increase in the number of referrals for paediatric subspecialty care and in overall appointments (new and review) to these doctors. We sought to determine the perspective of parents regarding their role in the initiation of referrals, their preferences for follow-up and the role of general practitioners (GPs) in care co-ordination. Methods Self-completed survey in outpatient paediatric clinics (general paediatrics and four subspecialties) at two children's hospitals in Victoria. Recruitment targets were 100 parents in each of the general paediatrics clinics and 50 parents in each subspecialty clinic, equally divided between new and review visits (total n = 600). Results A total of 606 parents provided responses, with a decline rate of 9%. Many (52%) new patients were referred by a GP with the remainder from a variety of other sources. With specific regard to providing general care to their child, only 45% were completely confident in a GP. Most (76%) agreed with the statement that a GP would give their child a referral to see a paediatrician whenever they ask. Approximately, a third of parents reported that a GP rarely or never co-ordinates the care of their child with other doctors. Conclusions Parents play an important role in both the initiation of paediatric specialty referrals and the patterns of follow-up care provided. Parent perspectives, preferences and motivations on both the referral process and the patterns for ongoing care are essential to develop policies that provide the best and most efficient care for children.

Aim In adult medicine, rates of investigation and prescribing appear to be increasing. Such information is lacking for paediatrics. We audited Australian paediatricians’ practices in 2013 to determine changes since 2008 in: (i) conditions seen; (ii) consultation duration; (iii) imaging and pathology ordered; and (iv) prescribing. Methods This is a patient-level prospective audit of paediatricians’ secondary care practice. Between November and December 2013, members of the Australian Paediatric Research Network were invited to complete standardised forms for 100 consecutive patients or all patients seen over 2 weeks, whichever was completed first. Main measures: diagnoses, consultation duration, pathology and/or imaging investigations ordered, rate of medication prescription. Analyses: hierarchical linear modelling clustered at the paediatrician level. Results One hundred and eighty paediatricians (48% of those eligible) contributed 7102 consultations. The proportion of developmental/behavioural conditions rose from 48% (SD 31%) to 60% (SD 30%) in new and 54% (SD 28%) to 66% (SD 28%) in review consultations in 2013 compared with 2008. More paediatricians reported diagnoses of autism spectrum disorder (39–56%, P = 0.002), attention-deficit/hyperactivity disorder (47–55%, P = 0.05) and intellectual disability (18–36%, P = 0.001) in first consultations. Mean consultation duration and pathology/imaging ordering rates were stable. Prescribing rates increased from 39 to 45% of consultations for the top 10 new diagnoses and from 57 to 68% of consultations for the top 10 review diagnoses. Conclusions Paediatricians are seeing more children with developmental–behavioural conditions, prescribing more and demonstrating wide variation in their practice. The latter suggests both over- and under-treatment.

Objectives Injuries are a significant proportion of lower urgency (triage category 4 or 5) child presentations to the EDs in metropolitan Melbourne. The purpose of the present study was to assess parental preferences and experiences regarding the treatment of lower urgency child injuries and the role of general practitioners (GPs) in such care. Methods A self-administered survey study of 1150 parents of children ≤9 years of age attending the ED at one of four Victorian hospitals triaged with a lower urgency condition (triage category 4 or 5) looked at whether children with lower urgency injuries are frequently referred by their GP to the ED and parent preferences for the care of lower urgency child injuries. Parents were recruited by time of day and weekday/weekend. Descriptive and bivariate analyses were performed. Results Fewer parents of injured children, compared with illness, attempted to make a GP appointment prior to attending ED (35% vs 46%; P

Aim The aim of the study was to investigate the patterns of medical service use in children with cerebral palsy (CP), taking into account child and family characteristics. Methods Nine hundred and one parents and carers of children registered with the Victorian CP Register were invited to complete a survey. Participants were asked about their child's appointments with general practitioners and public and private paediatric medical specialists over the preceding 12 months. Information on family characteristics and finances was also collected. Data on CP severity and complexity were extracted from the CP Register. Results Three hundred and fifty parents and carers (39%) participated. Of these, 83% reported that their child had ≥1 appointment with a general practitioner over the preceding 12 months, while 84% had ≥1 appointment with a public or private paediatric medical specialist. Overall, 58% of children saw 2–5 different paediatric medical specialists, while 9% had appointments with ≥6 clinicians. Children with severe and complex CP were more likely to have had ≥1 appointment with a publically funded paediatric medical specialist and had seen a greater number of different clinicians over the study period. Family characteristics were not associated with service use. Conclusions Children with CP are managed by a number of paediatric medical specialists, and they continue to see a range of specialists throughout adolescence. In Victoria, differences in service use are not based on family characteristics; instead the highest service users are those with severe and complex CP. For this group, care co-ordination and information sharing between treating clinicians are important, if gaps in care are to be avoided.

Background We present a fold-over technique for total and subtotal glossectomy reconstruction utilizing the ALT flap with the goal of increasing soft tissue bulk. Methods Retrospective review of total and subtotal glossectomy patients undergoing ALT fold-over flap reconstruction from January 2007 to December 2012. Results Eight patients fit inclusion criteria. Average length of follow-up was 35 months. There were no flap failures. At last follow-up, no patients were tracheostomy dependent. Six out of 8 patients (75%) did not require a g-tube and were able to maintain their weight. Speech intelligibility was good in 6/8 patients (75%). Conclusions The ALT fold-over flap technique provides sufficient bulk to allow decannulation and airway protection as well as PO intake in most patients. Given the minimal donor site morbidity, it is our technique of choice for total and subtotal glossectomy defects. © 2016 Wiley Periodicals, Inc. Microsurgery, 2016.

Objective The age band with, by far, the greatest number of ED presentations is children 0-4 years, with other paediatric age bands also among the highest. As the majority of these presentations are for lower urgency conditions, we sought to determine why parents seek ED care for their child for lower urgency conditions. Methods A survey study of 1150 parents or guardians of children with lower urgency conditions (triage category 4 or 5) presenting to the EDs of three public general and one paediatric specialty hospital in metropolitan Melbourne. Results Fewer than half of parents (43%) attempted to make an appointment with a general practitioner (GP) for their child prior to presenting to the ED. Two-thirds of those who did contact a GP were instructed by their GP to go to the ED for their lower urgency condition. Few attempted to contact a nurse telephone triage service or after-hours GP service. Conclusions The current magnitude and the growth of lower urgency paediatric ED presentations is a strain on the health care system. Efforts to educate parents regarding the suitability and availability of GP appointments can be the cornerstone of an initial strategy to address this issue. However, efforts to address the high rates of GP referral to EDs for low urgency presentations will be more vexing to develop, yet no less important. They will require addressing fundamental issues in both current GP care for children and the training of GP registrars.

Aim The aim of this paper was to study the prevalence of a regular source of primary care for Victorian children attending one of four emergency departments (EDs) and to determine associated characteristics, including ED use. Methods Responses were collected via an electronic survey from parents attending EDs with their child (≤9 years of age) for a lower-urgency condition. Single, multiple choice, and Likert scale responses were analysed using bivariate and logistic regression tests. Results Of the 1146 parents who provided responses, 80% stated their child has a regular source of primary care. Of these, care is mostly received by a general practitioner (GP) (95%) in GP group practices (71%). Approximately 20% have changed where their child receives primary care in the last year. No associations were observed between having a regular source of primary care and frequency of ED attendance in the past 12 months, although parents whose child did not have a regular source of primary care were more likely to view the ED as a more convenient place to receive care than the primary care provider (39% without regular source vs. 18% with regular source; P < 0.0001). Children were less likely to have a regular source of primary care if their parents were younger, had a lower household income, lower education, and were visiting a hospital in a lower socio-economic indexes for areas rank. Conclusions Policy options to improve continuity of care for children may require investigation. Increasing the prevalence of regular source of primary care for children may in turn reduce ED visits.

Objective The Victorian Nurse-On-Call (NOC) service has been in use for over 8 years, though little research has been conducted investigating the service. The present study aimed to explore whether parents in Victoria presenting with their child to the ED for lower urgency conditions use the NOC before ED arrival and whether the advice given impacts their decision to attend the ED. Methods A survey study of 1150 parents attending one of four EDs in Victoria, Australia for their child's lower urgency condition. Results Few parents (20%) contacted the service before attending. Of those who did contact the service, 70% were instructed to attend the ED. Parents reported that they did not contact the service due to lack of awareness (16%) and because they perceive the service to not be helpful (53%). Conclusions The findings of our study show that use and awareness of NOC is low in parents attending the ED for their child's lower urgency condition. The success of NOC in the goal of deferring non-urgent conditions from presenting to the ED appears limited. Telenursing triage services in Australia should consider assessment of their algorithms to increase the likelihood that where appropriate, lower urgency conditions are directed to primary care services rather than the ED.

Objective To determine the accuracy and reliability of triage of children in public hospital EDs using the Australasian Triage Scale (ATS). This is the first study to examine these issues in paediatric triage following the 2007 development of the Emergency Triage Education Kit (ETEK) to foster accurate and consistent application of the ATS. Methods A convenience sample of 167 triage nurses working at three general hospitals and one speciality paediatric hospital in greater metropolitan Melbourne assigned triage ratings for nine paediatric clinical scenarios using the ATS. Scenarios were derived from the ETEK or from other published sources. Kappa was used to assess interrater reliability within and between hospitals. Results Triage nurses correctly assigned triage scores to an average of 5.3 of nine paediatric clinical scenarios. Accuracy in specific hospitals ranged from a low of 15% on one scenario, to 100% accuracy on a different scenario at a different hospital. Interrater reliability within and across the EDs studied was found to be kappa = 0.27. Both accuracy and interrater reliability were marginally higher at the speciality paediatric hospital. Conclusions Our findings demonstrate inconsistencies in the accuracy and reliability in which sick children presenting to EDs receive triage scores both within and across hospitals. These results suggest the need for improvements either in current triage nurse training or training resources. Use of the ETEK alone has not resulted in high levels of paediatric triage accuracy or reliability.

Background Many previous studies that have investigated hospital admissions in children and young people with cerebral palsy lack information on cerebral palsy severity and complexity. Consequently, little is known about factors associated with the frequency and type of hospital admissions in this population. This study used hospital admission data available for all children and young people known to a population-based cerebral palsy register to describe the patterns of use of tertiary paediatric hospital services over a 5-year period. Methods This was a retrospective cohort analysis of routinely collected admission data from the two tertiary paediatric hospitals in the Australian state of Victoria. Data on admissions of individuals born between 1993 and 2008 registered on the Victorian Cerebral Palsy Register were analysed (n = 2183). Results Between 2008 and 2012, 53% of the cohort (n = 1160) had at least one same-day admission, and 46% (n = 996) had one or more multi-day admissions. Those with a moderate to severe motor impairment and those with a co-diagnosis of epilepsy had more admissions, and for multi-day admissions, longer lengths of stay, P

Aims The aim of this study was to describe the pattern of tertiary paediatric emergency department (ED) use in children and young people with cerebral palsy (CP). Methods A retrospective analysis of ED data routinely collected at the two tertiary paediatric hospitals in Victoria, Australia, cross-matched with the Victorian Cerebral Palsy Register. Data pertaining to the ED presentations of 2183 registered individuals born 1993–2008 were obtained. Results Between 2008 and 2012, 37% (n = 814) of the CP cohort had 3631 tertiary paediatric ED presentations. Overall, 40% (n = 332) of presenters were residing in inner metropolitan Melbourne; 44% (n = 356) in outer Melbourne; and 13% (n = 108) in regional Victoria. Presenters were more likely than non-presenters to be younger, non-ambulant and have epilepsy. In total, 71% of presentations were triaged as Australasian Triage Scale 1–3 (urgent), and 44% resulted in a hospital admission. Disorders of the respiratory, neurological and gastrointestinal systems, and medical device problems were responsible for 72% of presentations. Conclusion Many of the tertiary paediatric ED presentations in this group were appropriate based on the high admission rate and the large proportion triaged as urgent. However, there is evidence that some families are bypassing local services and travelling long distances to attend the tertiary paediatric ED, even for less urgent complaints that do not require hospital admission. Alternative pathways of care delivery, and strategies to promote the management of common problems experienced by children and young people with CP in non-paediatric EDs or primary care settings, may go some way towards reducing unnecessary tertiary paediatric ED use in this group.

Objectives To describe patterns of ED utilisation over time, by patient age group and triage classification. Methods Secondary analysis of data from all patients presenting to EDs in Victoria utilising the Victorian Emergency Minimum Dataset (VEMD) for the years 2002–2013. The VEMD includes all hospitals in Victoria with 24 h EDs. Results The absolute number of presentations to EDs in Victoria has grown by over 52% in the last 11 years. The triage categories of highest urgency (1–3) grew by 89% whereas the categories of lowest urgency (4–5) grew by 33%. Over this period, the 5 year age band with the greatest number of ED presentations has consistently been, by far, children 0–4 years of age. This age group has seen an increase of 29% in ED presentations overall with a >55% increase in Triage 1–3, and an increase of 16% in triage 4–5. For all age groups, there has been little change in the number of triage category 4–5 presentations since 2007/2008. However, for triage categories 1–3, there have been consistent increases in presentations across all age groups. Conclusion The age range with the greatest absolute number of ED presentations in Victoria is children 0–4 years of age. This finding is consistent over time and across all triage classifications. The age range with the second highest absolute number of ED presentations is comprised of those 20–24 years of age. This is in contrast to the frequent public attention placed on the volume of ED presentations by the elderly.

OBJECTIVE In 2005, we conducted a study of the prevalence of board certification requirements for hospital privileging and found that one-third of hospitals did not require pediatricians to be board certified. In 2010, the American Board of Pediatrics implemented the Maintenance of Certification (MOC) program. To examine changes in the policies of hospitals regarding requirements for board certification, we surveyed privileging personnel at hospitals across the country. STUDY DESIGN Telephone survey between April 2010 and June 2010 of privileging personnel at a random sample of 220 hospitals. RESULTS Of the 220 hospitals, 23 were ineligible because they had no pediatricians on staff, and 26 hospitals refused to participate. The remaining 154 hospitals completed the survey, resulting in a 78% participation rate. Compared with our findings in 2005, in 2010 a greater proportion of hospitals now require board certification for general pediatricians (80% vs 67%, P = 0.141) and pediatric subspecialists (86% vs 71%, P = 0.048). Among these hospitals, a larger proportion (24% vs 4%) now requires board certification for all pediatricians at the point of initial privileging. However, a greater proportion of hospitals reported that they make exceptions to their board certification policies (99% vs 41%). CONCLUSION In the 5 years since our previous study, a larger proportion of hospitals now require pediatricians to be board certified, although the proportion of hospitals that make exceptions to this policy has increased twofold. Hospitals appear to be incorporating the MOC program into their privileging policies. Journal of Hospital Medicine 2013;8:298–303. © 2013 Society of Hospital Medicine

Aim To determine if the duration of general practitioner (GP) consultations, or the proportional distribution of item numbers associated with longer consultations, with children has changed in association with the demographic changes in Australia. Method Secondary data analysis of Medicare claims from 1996 to 2010, which were stratified by patient age and visit type as designated by billing item number, and of the Bettering the Evaluation of Care and Health (BEACH) database was conducted. The Medicare data that were analysed were changes in overall proportion and absolute numbers of longer consultations for children from 1996 to 2010, while the BEACH data that were analysed were changes in the average duration of visits for children and the proportion of visits by children for chronic conditions. Results Despite the increase in the population of children, and the increasing numbers of children with chronic illness, the absolute number of longer consultations for children has decreased over the time period studied. Further, the proportion of all longer consultations that are being provided to children has diminished. For those consultations that do occur, the GPs are not spending any more time with children in 2010 than they did in consultations in 2000. Conclusions There have been significant changes in the patterns of longer consultations provided to children by GPs. Efforts to ensure that children receive primary care for chronic conditions and preventive care must now take on a greater urgency for the health-care system.

The need to prepare pediatric transplant recipients for the transfer to adult-centered transplant care has received increased attention. This study aimed to determine adolescent and young adult LTR and parent perceptions and attitudes about the transition process. LTR and their parents completed a survey assessing level of prior thought and interest in learning about transferring care, knowledge of the transition process, perceived importance of self-management skills, concerns about moving to the adult clinic, and responsibility for health management tasks. Responses were analyzed by age, gender, and time since transplantation. Participants included 46 LTR (mean age = 16.6 yr; range 12-21), and 31 parents. Recipients and parents reported moderate concern about transition, with leaving pediatric providers being a primary worry. LTR ≥16 yr reported greater health care responsibility and increased thought, interest, and knowledge about transition. There were significant differences between parent and LTR perceptions of health care responsibility, indicating that LTR perceive having more independence than what their parents report. Overall, results suggest that adolescent and young adult LTR and their parents perceive the importance of transitional care, but demonstrate poor knowledge of the process. There remains a need for improved transition planning for both adolescents and parents.

To examine transition readiness, adherence, and health out- comes in pediatric liver transplant recipients using a clinically admin- istered screening measure. Seventy-one pediatric liver transplant recipients (11-20 yr) and 58 parents completed a clinic-based TRS measuring perceived and demonstrated self-management skills, AoR for health-related tasks, regimen knowledge, and psychosocial adjustment. Adherence was measured using s.d. of immunosuppressants, proportion of immunosuppressant blood levels out of target range, and clinic attendance. Health outcomes included liver test panels, biopsies, rejec- tion episodes, and hospitalizations. Results indicate that all domains of transition readiness, with the exception of demonstrated skills, and non- adherence were positively correlated with age. Proportion of immuno- suppressant blood levels below target range was positively correlated with self-management skills and increased responsibility for medication tasks. Parent regimen knowledge was associated with clinic attendance. Health outcomes were significantly related to medication non-adher- ence, but not to transition readiness domains. Medication adherence is considered to be a key factor in the transition from pediatric to adult- centered transplant care. Non-adherence is associated with an increased risk for medical complications and is potentially modifiable. Interven- tions to promote self-management skills and adherence should be an essential component of transition planning.

OBJECTIVE: To explore the structure, components, and training goals of pediatric hospitalist fellowship programs in North America. DESIGN: We constructed a 17-item structured questionnaire to be administered by phone. Questionnaire items focused on documenting goals, training, requirements, and clinical duties of pediatric hospitalist training programs. From February through June 2007, research staff contacted directors of the programs. Responses were analyzed to determine program characteristics, including goals, formal training requirements, clinical rotations, and participation in hospital administrative activities. RESULTS: All 8 training programs completed the survey. There appear to be 2 distinct tracks for pediatric hospitalist training programs: clinical or academic specialization. Currently there are no standards or requirements for fellowship training from an external accrediting body and the curriculum for these programs is likely driven by service requirements and speculation on the needs of a future generation of pediatric hospitalists. The stated goals of the programs were quite similar. Seven reported that the provision of advanced training in the clinical care of hospitalized patients, quality improvement (QI), and hospital administration are central goals of their training program. Six reported training in the education of medical students and residents to be a primary goal, while 5 indicated training in health services research as a primary goal. CONCLUSIONS: Pediatric hospitalist fellowships are in the very early stages of their development. In time, greater structure across institutions will need to be put in place if they are to succeed in becoming a necessary prerequisite to the practice of hospital medicine. Journal of Hospital Medicine 2009;4:157–163. © 2009 Society of Hospital Medicine.

Introduction: A long-term goal of our group is to develop proteomic-based approaches to the detection and use of protein biomarkers for improvement in diagnosis, prognosis, and tailoring of treatment for head and neck squamous cell cancer (HNSCC). We have previously demonstrated that protein expression profiling of serum can identify multiple protein biomarker events that can serve as molecular fingerprints for the assessment of HNSCC disease state and prognosis. Methods: An automated Bruker Daltonics (Billerica, MA) ClinProt matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometer was used. Magnetic chemical affinity beads were used to differentially capture serum proteins prior to MALDI-TOF analysis. The resulting spectra were analyzed using postprocessing software and a pattern recognition genetic algorithm (ClinProt 2.0). An HNSCC cohort of 48 sera samples from 24 patients consisting of matched pretreatment and 6 to 12 month posttreatment samples was used for further analysis. Low-mass differentially expressed peptides were identified using MALDI-TOF/TOF. Results: In the working mass range of 1,000 to 10,000 m/z, approximately 200 peaks were resolved for ionic bead capture approaches. For spectra generated from weak cation bead capture, a k-nearest neighbor genetic algorithm was able to correctly classify 94% normal from pretreatment HNSCC samples, 80% of pretreatment from posttreatment samples, and 87% of normal from posttreatment samples. These peptides were then analyzed by MALDI-TOF/TOF mass spectometry for sequence identification directly from serum processed with the same magnetic bead chemistry or alternatively after gel electrophoresis separation of the captured proteins. We were able to compare this with similar studies using surface-enhanced laser desorption ionization (SELDI)-TOF to show this method as a valid tool for this process with some improvement in the identification of our groups. Conclusions: This initial study using new high-resolution MALDI-TOF mass spectrometry coupled with bead fractionation is suitable for automated protein profiling and has the capability to simultaneously identify potential biomarker proteins for HNSCC. In addition, we were able to show improvement with the MALDI-TOF in identifying groups with HNSCC when compared with our prior data using SELDI-TOF. Using this MALDI-TOF technology as a discovery platform, we anticipate generating biomarker panels for use in more accurate prediction of prognosis and treatment efficacies for HNSCC.

We describe a case of laryngeal stenosis secondary to an etiology not previously described. A patient with Erdheim-Chester disease presented with airway obstruction and was found to have subglottic stenosis. Biopsy results confirmed Erdheim-Chester nodules as the cause of the obstruction. This case illustrates the need for biopsy to rule out malignancy and less common etiologies of subglottic stenosis.

We applaud the Pediatric Hospital Medicine fellowship directors for their collaboration in the development of core competencies that can be applied to all pediatric hospitalist programs. We found wide variability in the structure and requirements of the programs and believe that the establishment of core competencies will likely be of benefit in bringing greater uniformity and structure to curricula in the training programs. Regarding the findings of the survey undertaken by Dr. Manicone, we believe a few issues deserve clarification and may lead to different conclusions. First, Dr. Manicone asked program directors to try to determine which of the deidentified programs in our tables were most likely to be their own program. We are unable, as is he, to infer how many, if any, were able to guess correctly. If a program director guessed incorrectly, undoubtedly they would, by definition, feel their program was not represented accurately. Second, our study was conducted in early 2007, and his 2 years later. It is possible, even likely, that some of these programs have modified their training during that time period. This may be one reason a program director might believe the description of their program is inaccurate at this time. Third, Dr. Manicone notes that he was not the program director of the Children’s National Medical Center at the time of the survey and was not interviewed by our research team. It is certainly possible that the program directors of several other medical centers may have also changed since the time of our study. If that is the case, it would not be surprising that new program directors might characterize specific components of their training programs in different ways than the program directors we interviewed. Finally, and perhaps most importantly, due to the newness and small size of the fellowship programs in our study, many directors reported that some requirements (especially for administration and research training) are made uniquely on a fellow-by-fellow basis. Allowing a trainee to tailor a program to fit his or her specific needs creates a unique and hopefully ideal learning experience for the fellows. However, this does not translate into specific fellowship requirements or opportunities as a whole. Hopefully, the core competencies can address these discrepancies, to the benefit of future trainees. We believe this final point is illustrated clearly by the results of the survey conducted by Dr. Manicone. The program attributes in the article rated as most accurately depicted in his study were the assigned clinical duties and billing independence. These were often the only clearly proscribed requirements articulated by a program director during our interviews. In contrast, other program requirements, including formal research training, often were identified as being determined on a case-by-case basis, according to the needs of the fellow, without firm expectations or requirements.