M. Douglas Jones

Failure of association of premature rupture of membranes with respiratory-distress syndrome.

Abstract Records on 16,458 consecutive births were examined to determine associations between the respiratory-distress syndrome of the newborn and cesarean section, maternal diabetes, ante-partum hemorrhage, toxemia of pregnancy, low one-minute Apgar scores and prolonged rupture of fetal membranes. Groups of infants were compared by four-week gestational age blocks. One-minute Apgar scores of less than 5 and of less than 8 were associated with a significant (p < 0.05) increase in the incidence of respiratory-distress syndrome at gestational ages beyond 30 weeks. Cesarean section was associated with a significant increase after 34 weeks of gestation. There was no association between the syndrome and toxemia of pregnancy, ante-partum hemorrhage or prolonged rupture of fetal membranes. These data do not support the hypothesis that there is a lower incidence of the respiratory-distress syndrome in infants born after prolonged rupture of fetal membranes. (N Engl J Med 292:1253–1257, 1975)

Perspective: Competencies, outcomes, and controversy--linking professional activities to competencies to improve resident education and practice.

Regulatory organizations have recently emphasized the importance of structuring graduate medical education around mastery of core competencies. The difficulty is that core competencies attempt to distill a range of professional behaviors into arguable abstractions. As such, competencies can be difficult to grasp for trainees and faculty, who see them as unrelated to the intricacies of daily patient care. In this article, the authors describe how two initiatives are converging in a way that should make competencies tangible and relevant. One initiative is based on the idea that competencies will be more meaningful if trainees understand specifically how they relate to important professional activities in their own specialty. The authors suggest that there is a dyadic relationship between competencies and major professional activities in pediatric medicine. They also suggest that these relationships should be discussed as part of the process by which trainees are entrusted to perform clinical activities without direct supervision. The other initiative proposes to construct narrative milestones that provide a picture of what progression toward mastery of core competencies might look like. Together, the authors argue, these two initiatives should illuminate the core competencies by providing relevant clinical context and valuable educational substance.

Utilization and Costs for Children Who Have Special Health Care Needs and Are Enrolled in a Hospital-Based Comprehensive Primary Care Clinic

Objective. When deciding how much hospital resources should be allocated to comprehensive primary care clinics for children with multisystem disorders, it is important to consider all of the non-primary care revenue streams associated with these children as well as the effects of a comprehensive primary care program on access and quality. The objectives of this study were, first, to determine costs as well as the payments associated with hospital ambulatory and inpatient services for children with multisystem disorders followed by a comprehensive primary care clinic; and, second, to determine the effect of enrollment in a hospital-based comprehensive primary care clinic on ambulatory and inpatient utilization patterns and expenditures for children with multisystem disorders. Methods. The study population for the payment analysis consisted of 1012 children of all ages who were seen in the Special Primary Care Clinic (SPCC) in 2001. For these children, outcomes included direct costs, total (direct plus allocated overhead) costs, and payments per patient per 365 days after their first SPCC visit in 2001. A total of 175 of these patients were 4 years of age or older and had no SPCC visit before their first visit in 2001. We compared utilization and expenditures for the 175 children during the year before enrollment in SPCC with those in the year after enrollment. The Childrens Hospital administrative database was used to document direct costs, total costs, and payments by type of service for 365 days after an index visit. Ambulatory services included medical and surgical ambulatory, inpatient, emergency department (ED), and ancillary services. We determined the proportion of children who had visits; the visit rates per 100 child-years; and the average total and direct costs per visit, per child with a visit, and per child-year. Inpatient services data included non-intensive care and intensive care hospitalization rates per 100 child-years; the proportion of children hospitalized; their average length of stay; and the average total and direct costs per hospitalization, per patient hospitalized, and per child-year of total patients in the cohort. Results. For 1012 children who were seen in SPCC in 2001, the hospital overall loss per child-year was

Recently Trained General Pediatricians: Perspectives on Residency Training and Scope of Practice

956. The loss per child-year for outpatient services was

General Pediatrics Resident Perspectives on Training Decisions and Career Choice

1554. This loss was partially offset by a gain from inpatient services of

Oxygen Free Radicals and the Cerebral Arteriolar Response to Group B Streptococci

598. For the 175 patients for whom data were available to compare costs before and after enrollment in the SPCC, there were no significant differences in hospitalization or in direct costs per patient for patients who were hospitalized. The average length of non-intensive care stay was lower after enrollment (4.8 vs 11.7). In the surgical specialty analysis, children were more likely to see a surgeon after enrollment (41% vs 21%) and had a higher rate of visits per 100 child-years (102.3 vs 51.4). Differences in medical subspecialty, ancillary, and ED services did not achieve statistical significance. Conclusion. This study suggests that children with multisystem disorders are medically fragile and require frequent hospitalizations and ED visits even with improved primary care. Enrollment in a comprehensive primary care program was associated with a decreased length of stay for non-intensive care hospitalizations and with increased use of surgical services.

Insulin effect on fetal glucose utilization.

OBJECTIVE. Because of the increase in both the prevalence and complexity of chronic diseases in children, there is heightened awareness of the need for general pediatricians to be prepared to comanage their patients with chronic disorders with subspecialists. It is not known currently how well prepared general pediatricians believe themselves to be for these roles after residency training. This study was conducted to determine the perspectives of recently trained general pediatricians in practice regarding their decisions on residency choice, career choice, and adequacy of training. METHODS. A random sample of 600 generalists whose initial application for general pediatric certification occurred between 2002 and 2003 (4–5 years out of training) and 600 generalists who applied for board certification between 2005 and 2006 and who were not currently enrolled in or had completed subspecialty training (1–2 years out of training) received a structured questionnaire by mail. The survey focused on decision-making in selection of residency programs, strength of residency training in preparation for clinical care, and scope of practice. RESULTS. The overall response rate was 76%. The majority of generalists reported that their residency training was adequate in most subspecialty areas. However, a large proportion of generalists indicated that they could have used additional training in mental health (62% [n = 424]), sports medicine (51% [n = 345]), oral health (52% [n = 356]), and developmental/behavioral pediatrics (48% [n = 326]). Most generalist respondents reported that they are comfortable comanaging cases requiring subspecialty care with a subspecialist. However, generalist respondents without local access to subspecialists were more likely to report that they are comfortable managing patients who require subspecialty care. CONCLUSIONS. The training of general pediatricians, and the needs for their adequate preparation to care for patients, should be a dynamic process. As the nature and epidemiology of pediatric care change, our educational system must change as well.

Pediatric Fellows: Perspectives on Training and Future Scope of Practice

OBJECTIVE. Little is known regarding at what point during the training period residents in pediatrics make decisions on their future career choices. As part of a dedicated process of reexamining the structure of residency training in pediatrics, the American Board of Pediatrics sought information to better understand the influences, process, and sequencing of both residency program selection and career decision-making among residents. METHODS. All pediatrics resident physicians in all training programs in the United States and Canada (N = 8290) received the survey as part of the general pediatrics in-training examination. The survey focused on exploring how and when pediatrics residents make career choices and assessed perceived flexibility of their individual pediatrics residency program. RESULTS. The response rate was 95%. Location was the most important factor in selecting a residency program for 42% of all residents. Almost half of the pediatrics residents planned to pursue fellowship training after residency, a proportion that changed little across the 3 training years (level 1: 47%; level 2: 49%; level 3: 47%). Those who planned to pursue a general pediatrics career (either with or without inpatient care) were more likely than those who intended to pursue fellowship training to report that lifestyle was the most important factor in their career choice (63% vs 21%). CONCLUSIONS. Not surprisingly, different priorities motivate pediatricians to pursue specific programs for training and specific career options. The finding that those with the highest priority regarding lifestyle are more likely to pursue generalist training has implications for the generalist workforce, because those persons may also be more likely to seek part-time employment. Lifestyle concerns may need to be addressed in subspecialty training and subsequent subspecialty careers to ensure a continued flow of residents into fellowship training.

Comparison of Cerebrovascular Response to Hypoxic and Carbon Monoxide Hypoxia in Newborn and Adult Sheep

ABSTRACTS: We used a cranial window preparation to observe the effects of direct application of group B streptococci to the surface of the brain in the adult rat. Continuous exposure to group B streptococci at concentrations of 103 and 105 organisms/mL caused progressive dilation of surface (pial) cerebral arterioles that became statistically significant (p < 0.05) after 2.5 h. These results were reproduced with heat-killed organisms at the same concentration, but not with a bacteria-free filtrate of the growth medium. In separate studies, we found that infusion of alkaline cerebrospinal fluid (pH = 7.8) into the window did not reverse vasodilation, suggesting that it was not due to progressive cerebrospinal fluid acidosis. A solution of nitroblue tetrazolium infused into the window at the end of a 3-h exposure to the organism was promptly reduced, suggesting the presence of oxygen free radicals. Treatment with i.v. polyethylene glycol-superoxide dismutase and polyethylene glycol-catalase in doses of 10 000 and 20 000 U/ kg, respectively, was itself without effect on pial arterioles, but treatment with these compounds before exposure to group B streptococci eliminated the vasodilation. These data support a role for oxygen free radicals in the pathogenesis of pial arteriolar dysfunction induced by exposure to group B streptococci.

Recently Trained Pediatric Subspecialists: Perspectives on Training and Scope of Practice

Summary: Insulin infused into a sheep fetus over a 3-hr period at the rate of ∼0.24 U·kg-1·h-1 increased fetal glucose uptake (utilization) from 4.4 ± 0.7 mg·min-1·kg-1 to 6.9 ± 0.9 mg·min-1·kg-1 as compared to a noninsulin control period. Insulin administration did not alter fetal oxygen consumption (8.6 ± 0.7 ml·min-1·kg-1 vs. 7.7 ± 0.7 ml·min-1·kg-1), umbilical blood flow (220 ± 1 ml·min-1·kg-1 vs. 209 ± 16 ml·min-1·kg-1), or the placental clearances of antipyrine (114 ± 7 ml·min-1·kg-1 vs. 109 ± 8ml·min-1·kg-1) and urea (24.5 ± 2.2 ml·min-1·kg-1 vs. 25.0 ± 2.1 ml·min-1·kg-1). Fetal plasma glucose concentration fell significantly (0.22 ± 0.01 mg·ml-1 to 0.16 ± 0.01 mg·ml-1) during insulin infusion. The insulin effect on fetal glucose uptake occurred over a range of maternal glucose concentrations (0.32 → 0.78 mg·ml-1), which were not altered by the infusion of insulin in the fetal compartment.Insulin has a specific effect on increasing fetal glucose uptake and utilization.Speculation: The effect of insulin on increasing transplacental fetal glucose uptake is consistent with a growth-promoting role for insulin in the fetus. This action of insulin might be due to a direct effect of insulin on the mechanisms of placental glucose transport, to an alteration of placental glucose catabolism, or simply to the effect of insulin on the transplacental gradient of glucose.