Background:  The Accreditation Council for Graduate Medical Education (ACGME) has recently passed limitations on resident duty hours.  Complying with these regulations poses a dilemma for residency programs where housestaff have post-call, afternoon continuity clinics.  The post-call clinic violates the maximum number of work hours and also may cause sleep-deprivation and fatigue that affect resident performance with their continuity patients.  
Objective:  To evaluate housestaff experience with a pilot program that replaced post-call continuity clinics with evening continuity clinics.
Design/Methods:  In August 2002, we began a pilot of evening continuity clinics at one continuity clinic site for University of California San Francisco (UCSF) pediatric residents.  Instead of post-call clinics, 19 residents had evening continuity clinics added to a regular clinic day when they were neither post-call nor on-call.  In January 2003, we surveyed housestaff satisfaction and experience with the evening clinics, particularly in comparison to post-call clinics.  
Results:  Nineteen of 23 pediatric residents at the pilot site participated in this pilot program.  Four residents who opted to continue their post-call clinics had recently established an obesity clinic.  Nineteen residents completed the survey (3 never had post-call clinic and 4 never had evening clinic).
The percentage of residents who rated overall satisfaction as good/outstanding was 80% for evening clinic and 12.5% for post-call clinic (p <0.01).  All areas of patient care, medical education, and clinic infrastructure were better or equal in evening clinic in comparison to post-call clinic except for continuity of preceptors and access to medical services.  Actual patient show rate for the evening clinic was not statistically different from regular afternoon housestaff continuity clinic (62% versus 69%, p=0.24).
Conclusion:  Post-call afternoon continuity clinics violate the recent ACGME policy on resident work hours.  Housestaff had greater satisfaction and a better clinic experience with evening clinic versus post-call clinic.  Evening housestaff continuity clinic is a viable solution to meeting ACGME guidelines and may provide better patient care and resident education than post-call clinics. 

BACKGROUND:  Maternal depression affects 12 – 48% of mothers, with the highest rates reported among low-income mothers. Maternal depression is associated with inadequate prenatal care and negative parenting behaviors. 
OBJECTIVES: To determine the relationships between maternal depression and maternal use of 1) infant health services, 2) parenting practices, and 3) injury prevention measures.
DESIGN/METHODS: Prospective, community-based survey.  774 mothers to date have been surveyed at 3 time-points pre- and post-partum.  Maternal depressive symptoms were determined by the Center for Epidemiologic Studies Depression Scale (CES-D) at each time-point. Use of infant health services and preventative health practices were measured. ANOVA and Chi-square analyses were performed using STATA 6.0.  Multiple logistic regression analyses were conducted, controlling for maternal race/ethnicity, nativity, education, income, age, employment status, parity, health, housing stability; and infant birth weight, age, and health status. 
RESULTS:  The sample consisted of single (74%), uninsured (63%), young (mean age: 23 + 6 yrs), low-income (mean income: $8,063/year), African American (68%) mothers. Forty-eight percent were depressed at one or two points (sometimes) and 12% at all points (always).  When compared to mothers who were never depressed, always depressed mothers were 2.5 times (adjusted odds ratio [aOR] = 2.5; 95% confidence interval [CI] = 1.4, 4.4) as likely to have their child ever hospitalized, and 1.9 times (aOR = 1.9; 95% CI = 1.1, 3.3) as likely to use corporal punishment.  Always depressed mothers were less likely to have smoke detectors in their home (aOR = 0.3, 95% CI = 0.1, 0.9) or use the back sleep position (aOR = 0.6; 95% CI = 0.3, 0.9) when compared to never depressed mothers. 
CONCLUSIONS:  Maternal depression persisting prepartum to postpartum is associated with an increased risk of infant hospitalization and use of corporal punishment; and a lower likelihood of having a smoke detector or using the back sleep position. Further efforts are needed to reduce maternal depression, which may impact the health and safety of young infants.
 

Background: Routine use of a new conjugated heptavalent pneumococcal vaccine (PCV-7) in children < 2 years could affect the microbiology and reduce overall episodes of acute otitis media (AOM) in vaccinees. In AOM, S. pneumoniae (SP) has been the most common (40-45%) pathogen recovered, and ~1/2 of strains were non-susceptible to penicillin (PNSP).
Setting: Since Summer 2000, > 95% of children in this 7-clinician, sole pediatric practice in rural central Kentucky had received at least 3 doses of PCV-7 by 7 m.o.
Objective: To determine changes in microbiology of AOM after routine implementation of PCV-7.
Methods: Middle ear isolates from a convenience sample of children with severe or refractory AOM were prospectively identified, as our routine for the last 10 years. Among children 7-24 months, we compared 296 AOM isolates from 1992-98 with 81 AOM isolates from Sept. 2000 to Feb. 2003.  
Results:  Children were from all socio-economic classes and 95% white. Comparing each time interval (92-98 vs. 00-03), proportion of sources of isolates differed slightly: tympanocentesis (85% vs. 75%), tympanostomy tube otorrhea (7% vs. 15%) and spontaneous otorrhea (8% vs. 10%) (p=0.054). Rates of SP were 49% vs. 32%; non-typeable H. influenzae 39% vs. 53% [beta-lactamase (+), 56% vs. 58%]; M. catarrhalis 9% vs. 12%; and S. pyogenes 3% vs. 2%. PCV-7 or PCV-7-related serotypes comprised 77% (n=140) and 55% (n=22) (p=0.033), of SP strains pre- and post- PCV-7, respectively. Gram (-) bacteria accounted for 2/3 of AOM isolates post-PCV-7 (p=0.26, O.R.=2.2)    
Discussion:  Overall SP and PCV-7 serotypes in AOM were significantly reduced by routine use of PCV-7 vaccine in our practice. PNSP comprised 30% of AOM isolates in 92-98, whereas all SP comprised only 32% of AOM in 00-03. Gram (-) bacteria may become 2-fold more likely than SP in de novo/refractory AOM in vaccinated young children provided that: 1) high uptake of PCV-7 occurs and 2) PCV-7 supply is adequate.

Development of Left Occipito-Temporal Systems for Skilled Reading Following a Phonologically Based Intervention in Children

B. A. Shaywitz, S. E. Shaywitz, B. Blachman, K. R. Pugh, R. K. Fulbright, P. Skudlarski, W. E. Mencl, R. T. Constable, J. M. Holahan, K. E. Marchione, J. M. Fletcher, G. R. Lyon and J. C. Gore. 

Reading disability (developmental dyslexia) is one of the most common neurobehavioral problems affecting children and adults. There is now a strong consensus that the central difficulty in dyslexia reflects a deficit within the language system, and more particularly, in a lower level component, phonology, which has to do with the ability to access the underlying sound structure of words.  In young school-age children a deficit in phonology represents the most reliable and specific correlate of dyslexia.  Such findings form the basis for the most successful and evidence-based interventions designed to improve reading.  According to recent findings, provision of an evidence-based intervention at an early stage of reading instruction leads to the development of fluent reading (“the ability to read a text quickly, accurately and with proper expression”), the hallmark of skilled reading. Recent neurobiological findings implicate left hemisphere posterior brain systems in reading and, especially the left occipito-temporal “word form” area, as critical in skilled reading and that these posterior systems fail to function properly in dyslexic children and adults.  This dysfunction in left hemisphere posterior reading circuits is already present in dyslexic children and cannot be ascribed simply to a lifetime of poor reading. Such evidence of a disruption in the normal reading pathways provides a neurobiological target for reading interventions.  We used functional magnetic resonance imaging to study the effects of a phonologically based reading intervention on brain organization and reading fluency in 57 children ages 6.1-9.4 years; children comprised three experimental groups: Experimental intervention (n=37); community intervention (n=12) and community controls (n=28).  Immediately after the year-long intervention, children taught with the experimental intervention had made significant gains in reading fluency and demonstrated increased activation in left hemisphere regions including the inferior frontal gyrus and the middle temporal gyrus and one year after the experimental intervention had ended these children were activating bilateral inferior frontal gyri and left superior temporal and occipito-temporal regions.  These data indicate that teaching matters and that use of an evidence-based reading intervention can facilitate the development of those fast-paced neural systems that underlie skilled reading.

BACKGROUND: The benefit of treating children with moderate to severe croup with dexamethasone (DEX) is well established.  However, many children with croup have mild symptoms, and these children may not derive the same degree of benefit from treatment as those with more severe disease.  
OBJECTIVES: To determine if the treatment of children who present to an emergency department (ED) with mild croup with a single dose of oral DEX: 1) reduces the rate of return to a health care provider for persistent croup symptoms within 7 days of treatment, and 2) reduces croup symptoms in the first 3 days following treatment as measured by the Telephone Out Patient (TOP) Score (a validated tool for assessing croup severity).  
DESIGN/METHODS: Children (3 mos.-9 yrs.) with mild croup (Westley Croup Score < 2) evaluated at 4 pediatric EDs in 4 Canadian cities who met enrollment criteria and whose parents gave written informed consent were randomized to receive either a single oral dose of DEX (0.6mg/kg) or placebo (PLAC).  All patients were initially discharged home and their primary caretaker was contacted by telephone 1,2,3, 7, and 21 days later. To enhance the accuracy of phone assessment, one trained study investigator utilizing a standardized questionnaire incorporating recordings of a barky cough and stridor conducted all 4 interviews with the same parent. Statistical methods included Fisher’s exact test for the difference in proportion of children per group returning for care by day 7, and proportional odds model for ordinal logistic regression for difference in the TOP scores on days 1,2, and 3.  
RESULTS: Between Sept 2000 & Feb 2003, 720 patients were enrolled (359 DEX). 26/352 (7.4%)  & 53/352 (15.1%) of those patients treated with DEX and PLAC, respectively, returned to a health care provider because of persistent symptoms (P=0.002, 95%CI for Difference 3.0 - 12.3%).  Children treated with DEX had significantly lower TOP scores than those treated with PLAC (P=0.001).
CONCLUSIONS: Children with mild croup treated with a single oral dose of DEX, as compared with placebo, had substantially fewer croup symptoms and, as a result, markedly fewer return visits to a health care provider in the week following treatment.  
Funded by Can. Institutes of Health Research

BACKGROUND/OBJECTIVES: Canadian guidelines reserve RSV prophylaxis for infants born <33 weeks GA with BPD.  The impact of RSV associated hospitalization on subsequent use of hospital services and mortality in healthy preterm infants born 32-35 weeks GA is assessed. Pre-term infants are at increased risk for several conditions some of which may be presentable including RSV infections and hospitalizations.  The purpose of the current study was to assess the impact of RSV infections on subsequent health care resource utilization in pre-term infants.
METHODS: Case control study using Canadian Institute of Health Information Discharge Abstract and Morbidity databases. Cases are healthy infants, born between 32-35 week gestation between 1998 and 2001 and hospitalized for proven, or probable RSV. Controls were matched to cases with respect to gestational age, gender and province.  Infants with congenital abnormalities and BPD were excluded.  Mean follow up was 1.66 years (Range: 1.4-3.0)
RESULTS: 2,415 cases of RSV associated hospitalizations were identified and matched to 20,254 controls.  The mean (SD) age at the index admission was 0.65(0.44) years and 46% of the total study sample was male.  Subsequent hospital services, excluding the index event, for cases and controls respectively were:  Hospitalization: 2.96(2.81) vs. 1.28(1.42); Special Care Unit Visits: 0.67(1.70) vs. 0.40(0.33); Respiratory Therapy Visits: 0:31(0.70) vs. 0.13 (0.37); MD Consults: 3.61(4.54) vs. 0.89(1.12); In-hospital Procedures: 1.05(4.02) vs. 0.81(1.51); Out Patient Visits: 18.4(10.58) vs. 7.54(4.31); Total inpatient days: 14.71(18.69) vs. 5.04(7.09).  All of these estimates were statistically significantly higher for the cases (p=0.001). Subsequent diagnoses for cases and controls respectively were:  Respiratory conditions (64% vs. 13%); Fever (2.7% vs. 0.7%); Anorexia (2.2% vs. 0.6%); Lack of Normal Physiological Development (2.8% vs. 1.1%) (P<0.05); The rate of sudden death was 6.1% in the cases versus 0.3 % in the controls (p<0.05).  
CONCLUSION: The results of this study show that RSV hospitalization in healthy premature infants is associated with a significant increase in subsequent health care resource utilization and mortality.   These results support prophylaxis of premature infants against RSV hospitalization.
Funded by MedImmune, Inc.    

BACKGROUND: Pulmonary exacerbations (PE) have been shown to negatively impact the health-related quality of life (HRQOL) of patients with cystic fibrosis (CF), but little is known about factors related to change in HRQOL after PE. Our objective therefore was to investigate the impact of PE on the HRQOL of patients with CF and to elucidate factors that are associated with changes post-PE.
METHODS: Patients with CF completed the questionnaires at 3 points in time: 1) at baseline, 2) at the beginning of the PE and 3) at follow-up after treatment. To measure HRQOL, we used the Child Health Questionnaire-Parent Form for patients < 18 years, and the SF-36 for patients ≥ 18 years. We examined the following predictor variables for association with change in Physical Summary (PHS) and Psychosocial Summary (PSS) HRQOL after PE: demographics, disease severity - % of predicted forced expiratory volume in 1 second  (FEV₁), hospitalization, duration of antibiotic therapy, mode of antibiotic therapy, duration of nebulized therapy, presence or absence of pseudomonas colonization, weight change, and time between PE and follow-up. We used parametric and non-parametric univariate statistical analyses, and linear regression for multivariable analyses.
RESULTS: We collected data from 52 PE in 48 subjects. Their mean (SD) age at the time of PE was 15.8 (8.4) years; 27 (56.3%) were female; their mean (SD) baseline FEV₁ was 60.5% (27.9%); their mean (SD) standardized PHS score was 41.7 (12.9); their mean (SD) PSS score was 50.8 (9.3); and their mean (SD) time between the beginning of the PE (time 2) and followup (time 3) was 2.7 (2.0) months.  In univariate analyses, PE were associated with a significant (p<0.05) decrease in    FEV₁ (-10.5%) and PHS scores (-3.9 points). PSS scores did not significantly change with PE (-0.9 points). In multivariable analyses examining change in PHS and PSS from the beginning  (time 2) of the PE to follow-up (time 3), no variables were significantly associated with change in PHS scores, but hospitalization was associated with relative improvement in PSS scores. When examining change from baseline (time 1) to follow-up (time 3), greater duration of antibiotic therapy and being hospitalized were associated with relative worsening in PHS scores, and hospitalization and being older were associated with relative improvement in PSS scores.
CONCLUSION: PE impact physical health more than psychosocial health in children and adults with CF. Being hospitalized was associated with relative improvement in PSS scores following PE but with relative worsening of PHS scores.