Klaus J. Roghmann

Child Health and the Community

This update of a 1975 case study of the service and research program of the University of Rochesters department of pediatrics picks up 20 years later, examining demographic, economic, and health system changes in the community, utilization patterns and evaluating old and new programs.

Chronic illness and its consequences:Observations based on three epidemiologic surveys†

The findings of three epidemiologic surveys relating to the psychological and social consequences of chronic physical disorders are presented. The prevalence of the categories of disorder considered and the over-all prevalence of them are estimated. Comparisons of the chronically ill with healthy control subjects in two of the studies permit the conclusion that the only demographic characteristic distinguishing the groups is the higher ratio of boys among the chronically ill. The children with chronic physical disorders are subdivided by type, duration, and severity of illness, and these characteristics are related to the frequency of secondary handicaps in the areas of educational achievement, behavior, and psychologic maladjustment. In each of these areas the chronically ill fare significantly less well. The need for more effective comprehensive services to prevent secondary handicaps is highlighted by these findings.

Variation in severity of respiratory syncytial virus infections with subtype

Two major subtypes of respiratory syncytial virus have been identified. This study assessed the hypothesis that A-subtype infections were more severe than B-subtype infections among the 157 infants hospitalized in two hospitals in Rochester, N.Y., during two winters. Severity was measured both by specific clinical observations and by a severity index that was derived empirically. Among all subjects, several clinical observations suggested that A-subtype infections were more severe. For example, mechanical ventilation was required in 12.6% of those with A-subtype compared with 1.6% of those with B-subtype infection (relative risk = 7.88; p = 0.01). Among high-risk infants (infants with underlying conditions or age 3 months or less at admission), carbon dioxide tension greater than 45 mm Hg was found in 37.0% of those with A-subtype compared with 12.0% of those with B-subtype infection (relative risk = 3.08; p = 0.04). In discrete multivariate (logit) analysis, effects of subtype (odds ratio = 6.59; p less than 0.01) on severity remained after adjustment for other statistically significant effects of age less than 3 months, underlying condition, and premature birth. The finding that A-subtype infections were more severe might have important implications for vaccine development, studies of the virulence of respiratory syncytial virus, clinical management (e.g., selection for antiviral therapy), and long-term prognosis.

Satisfaction with medical care: its measurement and relation to utilization.

Both the conceptualization and the measurement of satisfaction have been of major concern in medical care research. Some scholars used satisfaction as a determinant of utilization, others as a consequence of utilization. Measures of satisfaction are largely content oriented. Reliabilities are reported, but validity is usually assumed (face validity) or assessed through correlations with a criterion variable like “wish to change providers.” Using multidimensional scaling techniques, this study identifies several components in the construct “satisfaction” and relates them to the utilization of services. A general satisfaction measure provides us with an assessment of physicians and the medical care delivered, a specific satisfaction measure assesses past experience with the regular source of the care. Both of these can be divided into a positive and negative subcluster. Regressions were computed predicting satisfaction from utilization, and utilization from satisfaction, each time controlling in a preceding step for sociodemographic factors. The relationships varied strongly by provider; as a rule, a larger proportion of the variance could be explained analyzing for one provider at a time than for all providers combined. Analyzing one provider at a time showed that satisfaction substantially increased the proportion of explained variance in utilization in hierarchical regression, but utilization did not increase the explained variance in satisfaction.

Adverse and beneficial effects of immediate treatment of Group A beta-hemolytic streptococcal pharyngitis with penicillin.

One hundred forty-two children with presumed Group A beta-hemolytic streptococcal (GABHS) pharyngitis were enrolled in a randomized double blind prospective study comparing the consequences of immediate penicillin treatment with treatment delayed for 48 to 56 hours. One hundred fourteen of the enrolled patients were culture-positive. An adverse impact of early antibiotic therapy was noted; the incidence of subsequent infections with GABHS was significantly greater in those treated at the initial office visit with penicillin. In the month following documented evaluation of GABHS, a recurrence occurred 2 times more frequently in those treated with penicillin immediately compared with those for whom treatment was delayed 48 to 56 hours. Late recurrences (beyond 1 month but in the same streptococcal season) occurred 8 times more frequently (P less than 0.035). Delay in penicillin treatment did not increase GABHS intrafamilial spread. Symptoms of both groups were assessed for 2 days following the initiation of treatment. Both placebo-treated and penicillin-treated groups used aspirin or acetaminophen ad libitum. Penicillin was shown to reduce fever and relieve sore throat, dysphagia, headache, abdominal pain, lethargy and anorexia significantly beyond that achieved with aspirin or acetaminophen alone. Penicillin had no effect on culture-negative cases.

Risk factors for nosocomial pneumonia in the elderly

PURPOSE Pneumonia is now the second most frequent hospital-acquired infection in acute-care facilities, and recent studies indicate that the incidence rate for nosocomial pneumonia in long-term-care facilities is of similar magnitude. The mortality rate is high, especially in the elderly. With prevention of this complication as an overall priority, this study was designed to determine the risk factors associated with nosocomial pneumonia in the elderly in both acute-care and long-term-care settings. PATIENTS AND METHODS An epidemiologic case-control study was undertaken to compare patients or residents who developed radiographically confirmed pneumonia with control subjects who did not have and did not develop respiratory infection. Thirty-three cases were identified in the acute-care setting during the 18-week period, and 27 cases were identified in the long-term-care setting. Two matched controls were chosen for each case. Data collection involved review of the medical record and verification by medical personnel while the cases or controls were still institutionalized. Risk factor variables were analyzed using an odds ratio and 95% confidence interval calculation for matched triplets, and chi-square analysis. Selected risk factors were entered into a backward stepwise logistic regression to determine the best combination of risk factors for each setting. RESULTS In the acute-care setting, current neurologic disease, current renal disease, deteriorating health, altered level of consciousness, disorientation, dependent bathing, dependent bowel function, dependent feeding, aspiration, difficulty with oropharyngeal secretions, and presence of a nasogastric tube were significant risk factors. In the long-term-care setting, deteriorating health, malnourishment, recent weight change, altered level of consciousness, disorientation, aspiration, difficulty with oropharyngeal secretions, suctioning, presence of a nasogastric or gastric tube, upper respiratory infection, inhalation therapy, increased confusion, and increased agitation were determined to be significant. Current pulmonary disease, previous infection, and antibiotic therapy were found not to be associated with the onset of nosocomial pneumonia. Through logistic regression, the best models for prediction of nosocomial pneumonia in the elderly were identified. In the acute-care setting, difficulty with oropharyngeal secretions and presence of a nasogastric tube were the best predictors. In the long-term-care setting, difficulty with oropharyngeal secretions, deteriorating health, and occurrence of an unusual event were the best combination of predictors. CONCLUSION These data confirm prior findi

Early closure of the patent ductus arteriosus in very low-birth-weight infants: A controlled trial

A controlled clinical trial comparing early closure (mean = 48.8 hours) of the patent ductus arteriosus using indomethacin to conventional medical management, with intervention only after cardiopulmonary decompensation (mean = 167.4 hours), was undertaken in 24 preterm infants with severe respiratory distress syndrome and evidence of PDA. An interval analysis of one-half the projected sample revealed that infants undergoing early closure of the PDA had significantly reduced occurrence of BPD or mortality by 6 months of age. A comparison of birth weight, Apgar scores, gestational age, age of initial PDA diagnosis, and fluid therapy during the first seven days of life showed no significant differences between early intervention and control groups. At the time of the interval analysis, there were no differences between the groups in duration of intermittent mandatory ventilation or oxygen exposure. Studies will be required to determine whether these and other variables can be altered by early closure of the PDA.

The diary as a research instrument in the study of health and illness behavior: experiences with a random sample of young families.

A health calendar for a 28-day period was completed hy a random sample of 512 families in a typical upstate New York community. The 71,316 personday descriptions yielded information on life events unaccessible by retrospective interviews, such as everyday medical complaints, well-being, taking of medications and “things going wrong.” Events accessible by interview, such as doctor visits, could be measured more accurately by the health calendar. Relatively rare events like hospitalizations or major stress, such as death in a family, are not efficiently assessed by health diaries. It is argued that a combination of calendar and interview adds new dimensions for the study of health and illness behavior. The health calendar proved to be efficient and reliable for recording a wide range of everyday events. It automatically provides time series data for the study of short-term processes in a family context and, in combination with interview data, promises greater theoretical return from morbidity and utilization surveys. The considerably higher cost involved in the field work and the computer analysis, compared with retrospective interviews only, is in our view justified by the greater quantity of data collected and the larger potentialities for complex analysis.

Sexual behavior, contraception, and risk among college students

PURPOSE To characterize the differences and similarities among college freshmen, sophomores, juniors, and seniors regarding their sexual behavior including contraception choices and human immunodeficiency virus (HIV) risk. METHODS A 41-item sexual behavior questionnaire designed for this study was administered to a convenience sample (N = 797) of a college population. RESULTS Levels of sexual activity were found to be comparable to other college-based surveys. Notable trends included an increased level of oral contraceptive use among partners reported by seniors, as compared to freshmen, without a corresponding increase in condom use; an increased reliance among seniors, as compared to freshmen, on women to provide contraception; and a low level of self or partner HIV testing either before or after initiating sexual intercourse. Gender differences also revealed greater partner relationship duration, intensity, and communication prior to initiating sexual intercourse among women versus men (p < or = .001). CONCLUSIONS Sexual behavior among college students differs across the 4 years with regard to rates of intercourse, contraception choice, and responsibility, as well as HIV testing and partner trust. University- and college-based health care programs should address sexual behavior with an awareness of the differences that exist in the four cohorts of students.

Sibling adaptation to childhood cancer collaborative study: prevalence of sibling distress and definition of adaptation levels

A multisite collaborative study assessed the frequency and intensity of emotional/behavioral distress in siblings of children with cancer. A sample of 254 siblings, aged 4 to 18 years, and their parents completed interviews and self-report measures 6 to 42 (average 22.5) months after diagnosis of cancer in a brother or sister. Matched controls were obtained from respondents to the Child Health Supplement of the National Health Interview Survey administered in 1988 (CHS88). Before diagnosis, the prevalence of parent-reported emotional/behavioral problems among siblings was similar to that in the general population (7.7% vs 6.3%; p = not significant). After diagnosis, prevalence rose to 18% among siblings. When siblings were grouped according to the presence or absence of problems exacerbated by and/or arising after diagnosis, four levels of adaptation, consistent with scores on the Behavior Problem Scales from the CHS88, emerged. This differentiation may help explain inconsistencies in sibling response reported previously and provides a framework for investigating factors that enhance adaptation. J Dev Behav Pediatr 15:353–366, 1994. Index terms: chronic illness, childhood cancer, siblings, adaptation, coping, psychosocial stress.