Robert H. Pantell

Disclosure of illness status to children and adolescents with HIV infection

Many children with human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome are surviving to middle childhood and adolescence. Studies suggest that children who know their HIV status have higher self-esteem than children who are unaware of their status. Parents who have disclosed the status to their children experience less depression than those who do not. This statement addresses our current knowledge and recommendations for disclosure of HIV infection status to children and adolescents.

Urinary tract infection in infants with unexplained fever: a collaborative study.

Nine centers collaborated to determine the rate of urinary tract infection in infants with unexplained fever, to determine whether the rate is higher in febrile infants than in asymptomatic infants, and whether the yield justifies urine cultures in febrile infants. Urine cultures were done in 501 infants 0 to 2 years of age. The rate of confirmed urinary tract infections in the 193 febrile infants was 4.1%. All infections were in girls, with a rate of 7.4%. The rate of confirmed urinary tract infections in the 312 asymptomatic infants was 0.3%; again, all infections were in girls, with a rate of 0.7%. The rate in febrile girls was significantly higher than the rate in asymptomatic girls (P less than 0.01). The data support the advisability of culturing the urine of infant girls with unexplained fever.

Assessment of children's health status: Field test of new approaches.

The assessment of childrens health status presents unique difficulties. These include parent-child differences in reports of functioning, knowledge of what constitutes age-appropriate functioning, obtainment of accurate information for child, and demonstration of the predictivity of health status measures. Recent measures (the Functional Status II-R and instruments from the RAND Health Insurance Experiment) address physical, social, and psychologic domains of childrens health. The authors modified these instruments to develop short (7 and 14 items) questionnaires (RAND, FSQ) to assess child health. Scoring on these questionnaires was compared with traditional measures of illness severity and medical service utilization. The authors also evaluated coding illness-specific and general health limitations (FSQ-S and FSQ-G, respectively). Patients included the parents of 113 children with chronic illness (100 asthmatics). Measure stability was evaluated over a 6-month period in a subset of patients. Internal consistency (Cronbachs alpha) of the seven-item RAND measure was .78, the FSQ-S .78, and the FSQ-G .73 to .89 during repeated samplings over 6 months. The FSQ-S and Rand seven-item measure were moderately correlated (.47, P<.001). The authors observed significant correlations among alternate codings of the FSQ and RAND and between the FSQ-S, FSQ-G, RAND, and severity measure with traditional indices of medical service utilization. Parents were more likely to attribute certain functional status problems (e.g., being tired) to illness than they were other problems (e.g., moodiness or interest in things). The findings demonstrate that these measures have acceptable psychometric properties and provide preliminary evidence of construct validity in a group of young children with asthma. Using general and specific measures will provide differing pictures of a childs functioning. No single measure completely taps the impact of illness as measured by a panel of traditional indicators of illness burden and medical service utilization.

Measuring the impact of medical care on children

To assess the impact of medical care on children we have developed a conceptual model based on both theoretical considerations and empirical research. Child health is viewed as the ability to participate fully in developmentally appropriate activities and requires physical, psychological, and social energy. The medical system influences health through interventions addressing these domains. Many methodologic issues are unique to the measurement of medical care processes and outcomes for children. Problems in measuring the process of medical interviews include developing systems that capture the dynamics of interactions, assess the cognitive appropriateness and metaphorical interpretation of language, and reflect the emotional impact of certain incidents. Issues that confound measurement of childrens views include position bias, acquiescence response bias, and limited understanding of negatively worded items. Further, the concordance between parent and children reports or health constructs varies widely, which suggests the need to include childrens reports to obtain a comprehensive view of their health.

The changing epidemiology of serious bacterial infections in young infants.

Background: Management of febrile young infants suspected of having serious bacterial infections has been a challenge for decades. The impact of changes in prenatal screening for Group B Streptococcus and of infant immunizations has received little attention in population-based studies. Methods: This study analyzed all cultures of blood, urine and cerebrospinal fluid obtained from full-term infants 1 week to 3 months of age, who presented for care at Kaiser Permanente Northern California during a 7-year period utilizing electronic medical records. Results: A total of 224,553 full-term infants were born during the study period. Of 5396 blood cultures, 129 bacteremic infants were identified (2%). Of 4599 urine cultures, 823 episodes of urinary tract infection (UTI) were documented in 778 infants (17%). Of 1796 CSF cultures, 16 infants had bacterial meningitis (0.9%). The incidence rate of serious bacterial infections (bacteremia, UTI and meningitis) and febrile serious bacterial infections was 3.75 and 3.1/1000 full-term births, respectively. Escherichia coli was the leading cause of bacteremia (78), UTI (719) and bacterial meningitis (7). There were 23 infants with Group B Streptococcus bacteremia including 6 cases of meningitis and no cases of Listeria infection. Nine percentage of infants had multiple sites of infection; 10% of UTIs were associated with bacteremia and 52% of bacteremia was associated with UTI. Conclusions: Compared with earlier studies, UTIs now are found significantly more often than bacteremia and meningitis with 92% of occult infections associated with UTIs. These data emphasize the importance of an urinalysis in febrile infants.

Fever in the First Six Months of Life Risks of Underlying Serious Infection

The age-specific rate of elevated temperature over 37.8 C was evaluated in all infants less than 6 months of age (n = 1341) seen from July 1, 1974 to June 30, 1978 in a family practice clinic. Mild elevations (37.8 C-38.3 C) were common even in the first few months of life, and accounted for 20.7 per cent of infant visits. Temperatures greater than 38.3 C are uncommon in the first months of life but are seen more frequently with each succeeding month. Temperature elevation over 38.3 C was associated with a significantly higher rate of meningi tis (p < .01), otitis media (p < .001) and lower respiratory infection (p < .05). Significantly higher laboratory usage was documented in infants less than 3 months and for infants with temperature more than 38.3 C. The high rate of mild temperature elevations in young infants suggests that a selective diag nostic strategy directed at high-risk infants is important. Infants less than three months of age with a fever exceeding 38.3 C are calculated to have 21.5 times the risk of a serious underlying infection as infants older than three months with a similar temperature elevation. Clinical evaluation must remain an important tool in determining which febrile infants should be evaluated by further laboratory and diagnostic tests.

Office-based treatment and outcomes for febrile infants with clinically diagnosed bronchiolitis.

OBJECTIVES. The goals were to describe the (1) frequency of sepsis evaluation and empiric antibiotic treatment, (2) clinical predictors of management, and (3) serious bacterial illness frequency for febrile infants with clinically diagnosed bronchiolitis seen in office settings. METHODS. The Pediatric Research in Office Settings network conducted a prospective cohort study of 3066 febrile infants (<3 months of age with temperatures ≥38°C) in 219 practices in 44 states. We compared the frequency of sepsis evaluation, parenteral antibiotic treatment, and serious bacterial illness in infants with and without clinically diagnosed bronchiolitis. We identified predictors of sepsis evaluation and parenteral antibiotic treatment in infants with bronchiolitis by using logistic regression models. RESULTS. Practitioners were less likely to perform a complete sepsis evaluation, urine testing, and cerebrospinal fluid culture and to administer parenteral antibiotic treatment for infants with bronchiolitis, compared with those without bronchiolitis. Significant predictors of sepsis evaluation in infants with bronchiolitis included younger age, higher maximal temperature, and respiratory syncytial virus testing. Predictors of parenteral antibiotic use included initial ill appearance, age of <30 days, higher maximal temperature, and general signs of infant distress. Among infants with bronchiolitis (N = 218), none had serious bacterial illness and those with respiratory distress signs were less likely to receive parenteral antibiotic treatment. Diagnoses among 2848 febrile infants without bronchiolitis included bacterial meningitis (n = 14), bacteremia (n = 49), and urinary tract infection (n = 167). CONCLUSIONS. In office settings, serious bacterial illness in young febrile infants with clinically diagnosed bronchiolitis is uncommon. Limited testing for bacterial infections seems to be an appropriate management strategy.

Screening sexually active adolescents for Chlamydia trachomatis: what about the boys?

OBJECTIVES We sought to determine the effectiveness of a systems-based intervention designed to increase Chlamydia trachomatis (CT) screening among adolescent boys. METHODS An intervention aimed at increasing CT screening among adolescent girls was extended to adolescent boys (14-18 years). Ten pediatric clinics in a health maintenance organization with an ethnically diverse population were randomized. Experimental clinics participated in a clinical practice improvement intervention; control clinics received traditional information on screening. RESULTS The intervention significantly increased CT screening at the experimental sites from 0% (baseline) to 60% (18-month posttest); control sites evidenced a change only from 0% to 5%. The overall prevalence of CT was 4%. CONCLUSIONS Although routine CT screening is currently recommended only for young sexually active women, the present results show that screening interventions can be successful in the case of adolescent boys, among whom CT is a moderate problem.

Management and Outcomes of Previously Healthy, Full-Term, Febrile Infants Ages 7 to 90 Days.

BACKGROUND: There is considerable variation in the approach to infants presenting to the emergency department and outpatient clinics with fever without a source. We set out to describe the current clinical practice regarding culture acquisition on febrile young infants and review the outcomes of infants with and without cultures obtained. METHODS: This study analyzed Kaiser Permanente Northern California’s electronic medical record to identify all febrile, full term, previously healthy infants born between July 1, 2010, and June 30, 2013, presenting for care between 7 and 90 days of age. RESULTS: During this 3-year study, 96 156 full-term infants were born at Kaiser Permanente Northern California. A total of 1380 infants presented for care with a fever with an incidence rate of 14.4 (95% confidence interval: 13.6–15.1) per 1000 full term births. Fifty-nine percent of infants 7 to 28 days old had a full evaluation compared with 25% of infants 29 to 60 days old and 5% of infants 61 to 90 days old. Older infants with lower febrile temperatures presenting to an office setting were less likely to have a culture. In the 30 days after fevers, 1% of infants returned with a urinary tract infection. No infants returned with bacteremia or meningitis. CONCLUSIONS: Fever in a medical setting occurred in 1.4% of infants in this large cohort. Forty-one percent of febrile infants did not have any cultures including 24% less than 28 days. One percent returned in the following month with a urinary tract infection. There was no delayed identification of bacteremia or meningitis.

Cost-effectiveness of pharyngitis management and prevention of rheumatic fever.

Excerpt Sore throat is the fourth most common symptom seen in medical practice (1). New management recommendations, such as those suggested by Tompkins, Burnes, and Cable in this issue (p. 481), as...