Association of early bilateral middle ear effusion with language at age 5 years.

OBJECTIVE: This study tested the hypothesis that children with early persistent middle ear effusion (MEE) are at risk for later language deficit. METHOD: We recruited 698 newborns and monitored them for MEE every 2 to 4 weeks at home until age 3 years. Language skills were assessed on 294 subjects at age 5, while controlling for 8 demographic and environmental factors. Language outcomes at age 5 years were studied as a function of duration of bilateral MEE from birth to age 3 years. RESULTS: A significant relation was found between duration of bilateral MEE and speech sound sensitivity (Carrow Elicited Language Inventory) and articulation (Goldman-Fristoe Articulation). Children's ability to discriminate speech sounds in a quiet environment (Carrow Auditory Visual Abilities Test) was less affected by early prolonged MEE in homes that provided more cognitive stimulation. CONCLUSIONS: These exploratory results indicate that prolonged early MEE may predispose children to language deficits at age 5 years. The language deficits are of small magnitude and may or may not be clinically significant. Language stimulation at home may protect against some of the effects of prolonged MEE.

Web-based education in family medicine predoctoral programs.

BACKGROUND AND OBJECTIVES: New technologies and widespread Internet access make Web-based education feasible for family medicine predoctoral programs. Offering educational activities and resources through the Web can support community-based education and improve communication. We assessed the status of Web-based education nationally and explored the interest and opportunities for collaboration. METHODS: A survey assessed the inclusion of Web-based educational methods in family medicine predoctoral programs and school-wide programs, the level of national interest in collaborative development, and common obstacles to progress. The survey was mailed to all US family medicine predoctoral directors. RESULTS: The response rate was 61%. Results showed nearly universal use of e-mail and Web pages. The most common educational use of the Internet was posting text information. One third of the responding programs used the Web for evaluation. Barriers to development of Web-based educational programs are faculty time and funding. Most respondents were interested in collaborative Web development and would value a national, Society of Teachers of Family Medicine-based network for this purpose. CONCLUSIONS: Web-based educational activities are commonly offered by family medicine programs. To realize the full potential of Web-based education, collaborative development of new methods and materials will be needed to overcome the limiting factors of faculty time and funding.

Effects of early middle ear effusion on child intelligence at three, five, and seven years of age.

OBJECTIVE: This study tested the hypothesis that children with prolonged middle ear effusion (MEE) during the first 3 years of life are at risk for cognitive delays or deficits. METHOD: A prospective study enrolled 698 children from diverse backgrounds and controlled for eight demographic and environmental factors. Participants were recruited at birth and monitored for ear status frequently in the home; 379 children were assessed for cognition with the Stanford-Binet, 4th ed., at 3 years of age, 294 at 5 years, and 198 at 7 years. RESULTS: Using the SAS General Linear Models (GLM) procedure, we found a significant direct relation between duration of bilateral MEE and Stanford-Binet Composite and Nonverbal Reasoning/Visualization Factor scores at age 3, but not at age 5 or age 7. Statistical clustering analysis revealed four groups with different temporal patterns of MEE: Low MEE, Early MEE (peaking at 0-6 months), Later MEE (peaking at 6-12 months), and High MEE. GLM analyses revealed no direct effects, but several moderated effects, of MEE cluster on cognitive development at 3 years, but none at 5 or 7 years. In general, children in the Later MEE and High MEE groups appeared to be more adversely affected by bilateral MEE at 3 years, but effects were moderated in complex ways by socioeconomic status or home stimulation. Growth curve modeling across the three assessment periods showed no effects of total duration of MEE but did indicate that children in the Later MEE cluster had low scores at age 3 but caught up at ages 5 and 7. CONCLUSIONS: Prolonged MEE, especially between 6 and 12 months, may put children at risk for cognitive delays at 3 years, but the risk effect is not strong and effects are no longer detectable at 5 or 7 years.

Adult smoking in the home environment and children's IQ.

In a sample of 3- and 5-yr.-old children, smoking in the home was found to be significantly and inversely related to IQ. Children of normal birth weight and without neurological impairment had been enrolled in a longitudinal study of child development. Analyses were conducted with sex, ethnicity, socioeconomic status, educational stimulation in the home, day care, and mother's intelligence controlled. Significant results were obtained for scores on the Peabody Picture Vocabulary Test-Revised at age three years and on the major Stanford-Binet Fourth Edition scales at ages three and five years. All effects were for the mother, not the father, smoking in the home.

Breast feeding and children's intelligence.

Breast feeding was reported in 1992 by Lucas, et al. to provide advantages for the development of intelligence in children of low birth weight, possibly through nutrients or other biological factors found in human breast milk but not cow's milk. Research on breast feeding and intelligence in children of normal birth weight has yielded mixed results, probably because measurement of environmental influences has not been thorough and the range of intelligence components measured has been limited. Our research with 204 3-year-old children of normal birth weight included control measures for the environment and maternal intelligence (Hollings-head socioeconomic status, Home Observation for the Measured Environment, Shipley) and two measures of childhood intelligence (Stanford-Binet Fourth Edition and Peabody Picture Vocabulary Test-Revised). Controlling for environmental variables and maternal intelligence, initiation of breast feeding predicted scores on intelligence tests at age three. Breast feeding was associated with 4.6-point higher mean in children's intelligence.

The relation of medical risk and maternal stimulation with preterm infants' development of cognitive, language and daily living skills.

High-risk (HR) and low-risk (LR) preterm infants (N = 212) and full-term infants (FT, N = 128) from low socio-economic homes were studied with their mothers in the home at 6 and 12 months of age. Infants' cognitive, language and daily living skills were evaluated in relation to mothers' warm sensitivity, use of strategies which maintained the infants' attention and directiveness. Higher levels of maternal attention-maintaining were positively related to infant development for all groups. During toy play, attention-maintaining was most strongly related to expressive language skills for the HR infants; during toy play and daily activities, this maternal behavior was more strongly related to cognitive and language skills for both preterm groups than for the FT infants.

An asthma self-management program for children, including instruction in peak flow monitoring by school nurses.

A randomized trial of an instructional method was conducted in which school nurses taught children asthma self-management principles and skills, including peak flow monitoring, in 20-min, individual sessions over an 8-week period. Thirty-six children participated. An intervention group of 18 children received the teaching sessions. A control group of 18 children received regular care by the nurses, but no teaching sessions. The sample included 64% boys, 69% African-Americans, and 69% Medicaid recipients. The average age of subjects was 10.2 years. The two groups were demographically similar, but despite random assignment, the control group had a significantly earlier age of onset of asthma and tended to have had more asthma attacks in the preceding year. These factors were statistically controlled in outcome analyses. Results of group comparisons showed no significant differences in the number of postintervention emergency room visits and days absent from school. However, nurses reported that children who practiced breathing exercises had less anxiety during exacerbations, and the nurses' knowledge of the children's baseline peak expiratory flow rates facilitated care of the children. Nurses expressed the opinion that the individual sessions with students might be useful in motivating them to participate effectively in later group sessions. The intervention was well accepted by students, parents, and nurses. We believe that this intervention is promising as a practical, low-cost approach to enhancing children's asthma self-management skills and warrants further testing in a larger sample, with the intervention conducted over a longer period.

Meeting the faculty development needs of generalist physicians in academia.

Development of the academic environments of generalist faculty members is essential if they are to develop the skills to become leaders in medical education and primary care research and effective role models for their students. We conducted a needs assessment that included two-thirds of the generalist faculty members in family medicine, internal medicine, and pediatrics at the University of Texas Medical Branch, Galveston, Texas. The assessment was based on open-ended discussions in small focus groups and on responses to an informal checklist of 24 potential faculty development goals. The participants identified three global needs requiring significant change: (1) better understanding of and rewards for their academic activities, (2) better networking with each other and with nongeneralists, and (3) more control over their time and responsibilities. Individual needs for academic development were diverse but emphasized teaching and career-building skills. Meeting the individual needs of generalist academicians depends on addressing environmental obstacles to their academic development. We recommend building project-oriented teams that collectively develop skills in strategic planning and project management, political negotiation and public relations, and creative use of institutional support systems. Individual faculty development can then be linked to the development of high-priority group projects that stimulate learning and allow opportunities to practice new skills.

Texas youth: critical health problems and the need for nontraditional solutions.

Mortality in youthful age groups in the United States is largely violent and increasingly due to homicide involving inner-city dwelling males. The majority of these deaths also involve decreased mental capacity as a result of drug and alcohol abuse. Most of the morbidity of youth is similarly related to high-risk behavior, also correlated with drug and alcohol abuse. Texas is no exception to national trends, as our review of statewide statistics confirms. It is important to recognize that the morbidity and mortality, and the developmental difficulties that lead to them, do not stop with the attainment of a mythical "age of majority," but in fact continue to at least age 25. The "forgotten age group," aged 18 to 25 years, is actually at highest risk, since those not in college have forfeited many of their social and financial supports. Most of these deaths should be preventable, if physicians will take creative leading roles in changing both their office practices and their levels of community involvement to deal with the epidemics of youthful death and dysfunction, and with the poverty and hopelessness of our urban ghettos that overwhelm all other risk factors.

Facilitating faculty development and research through critical review of grant proposals and articles.

BACKGROUND: In 1983 the Department of Pediatrics at the University of Texas Medical Branch at Galveston established a faculty development program to address faculty needs for continuing education and improved resources for research. At first a part-time coordinator was hired; then, in 1985, a full-time, faculty-level science communicator provided help with strategic planning of projects and intensive review of grant proposals and journal articles. Faculty participation in the program was voluntary. METHOD: Pre- and post-intervention data for 1983-1992 included numbers of faculty using the program, faculty evaluations of the program, grant dollars awarded, counts of grant submissions and awards, and numbers of published articles. RESULTS: The review services were used heavily for grant proposals (75% of the department's proposals), but were used lightly for research articles (18% of publications). Grant funding quadrupled from 1983 to 1988; although funding peaked in 1988, it thereafter remained at three to four times the 1983 level. In contrast, the mean number of publications per faculty per year dropped between 1983 and 1990. CONCLUSION: The program provided valuable assistance to the faculty in writing grant proposals, and it helped to generate critically needed resources. However, the program's failure to increase the publication productivity of the faculty suggests that despite financial pressures, similar programs should use their influence and resources to promote a balance between scholarly publication and grant acquisition.

Relation of infant feeding practices, cigarette smoke exposure, and group child care to the onset and duration of otitis media with effusion in the first two years of life.

The relation of infant feeding practices, cigarette smoke exposure, and group child care to the onset and duration of otitis media with effusion (OME) was evaluated in a cohort of 698 healthy infants prospectively monitored by tympanometry in the home every 2 to 4 weeks until 2 years of age. Except for an experimental group of children who were offered early tube placement, the study children received conventional care from their personal physician or clinic. We used LISREL, a structural equation modeling procedure (computer software), to explore associations between environmental variables and OME onset and duration while controlling for interrelations among the variables. Supine feeding position and early initiation of group child care were associated with earlier onset of OME. Shorter duration of breast-feeding, increased packs of cigarettes smoked per day in the home, and increased hours per week in group child care were associated with an increase in the amount of time with OME during one or more of the age blocks studied (birth to 6, 6 to 12, 12 to 18, and 12 to 24 months). For a decrease in the amount of time with OME during the first 2 years of life, prolonged breast-feeding and upright feeding position should be encouraged, and cigarette smoke exposure should be minimized. Limiting early child care in large groups might also be advisable.

Assessment of three-year-olds with the Stanford-Binet Fourth Edition.

The Stanford-Binet, Fourth Edition was normed for children 30 months of age and older, but its usefulness with young children (e.g., 36 months) has received little attention. This study of 121 three-year-old children examined possible administration problems, provided correlations with three environmental measures, and compared scores with those of the Peabody Picture Vocabulary Test--Revised. Problems of administration did arise on some subtests, correlations with environmental measures were moderate, and scores on the Stanford-Binet IV and PPVT-R were moderately correlated. The Stanford-Binet IV is a useful test in assessment of a broad range of intellectual abilities.

Use of videotaping to evaluate pediatric resident performance of health supervision examinations of infants.

STUDY OBJECTIVES: To demonstrate reliability of a method for evaluating pediatric resident performance of health supervision examinations of infants using real patients and to evaluate pediatric resident performance of health supervision examinations of infants before and after an educational intervention consisting of a 6-month ambulatory rotation combined with video-assisted review of resident performance of the examination. DESIGN: Longitudinal cohort study in which all second-year residents were enrolled. Residents' preintervention (baseline) videotapes were compared with postintervention videotapes. Each resident served as his or her own control. SETTING: University hospital pediatric resident continuity clinic. SUBJECTS: Sixteen second-year pediatric residents who were participating in a required 6-month ambulatory rotation. METHOD AND MAIN RESULTS: Reliability study: Using a 51-item instrument derived from the American Academy of Pediatrics Guidelines for Health Supervision, trained raters blind to the sequence and dates of the videotaped health supervision examinations independently rated 44 resident encounters (a minimum of two raters per tape) and achieved good interrater reliability (kappa = 0.80). Intervention study: After a 6-month ambulatory rotation which included resident-faculty reviews of preintervention videotapes, residents showed a 14% mean improvement in performance scores for the examination (P < .05). CONCLUSIONS: The results indicate that videotaped health supervision examinations using real patients can be reliably evaluated by observational techniques in a continuity practice. A 6-month ambulatory block rotation coupled with video-assisted interactive review of examinations is associated with measurable improvement in resident performance on the postintervention test.

Does HOME add to the prediction of child intelligence over and above SES?

The most frequently used measure of the educational stimulation provided by the child's home environment is socioeconomic status (SES). Because SES is a global measure, researchers have developed measures that provide more detailed information. One of these is the Home Observation for Measurement of the Environment (HOME), (Caldwell & Bradley, 1984). Our research examined whether HOME adds to the predictability of child intelligence beyond that provided by SES. Subjects were 121 3-year-olds, Black and White, who were administered the fourth edition of the Stanford-Binet and the Peabody Picture Vocabulary Test-Revised. HOME and Hollingshead SES scores were obtained at age 2. HOME added to the predictability of intelligence over and above that provided by SES for the total group of children and for White children but not for Black children. The predictive utility of HOME also depended on the type of intelligence test being used.

Role of the virology laboratory in diagnosis and management of patients with central nervous system disease.

A number of viruses cause acute central nervous system disease. The two major clinical presentations are aseptic meningitis and the less common meningoencephalitis. Clinical virology laboratories are now more widely available than a decade ago; they can be operated on a modest scale and can be tailored to the needs of the patients they serve. Most laboratories can provide diagnostic information on diseases caused by enteroviruses, herpesviruses, and human immunodeficiency virus. Antiviral therapy for herpes simplex virus is now available. By providing a rapid diagnostic test or isolation of the virus or both, the virology laboratory plays a direct role in guiding antiviral therapy for patients with herpes simplex encephalitis. Although there is no specific drug available for enteroviruses, attention needs to be paid to these viruses since they are the most common cause of nonbacterial meningitis and the most common pathogens causing hospitalization for suspected sepsis in young infants in the United States during the warm months of the year. When the virology laboratory maximizes the speed of viral detection or isolation, it can make a significant impact on management of these patients. Early viral diagnosis benefits patients with enteroviral meningitis, most of whom are hospitalized and treated for bacterial sepsis or meningitis or both; these patients have the advantage of early withdrawal of antibiotics and intravenous therapy, early hospital discharge, and avoidance of the risks and costs of unnecessary tests and treatment. Enteroviral infection in young infants also is a risk factor for possible long-term sequelae. For compromised patients, the diagnostic information helps in selecting specific immunoglobulin therapy. Good communication between the physician and the laboratory will result in the most benefit to patients with central nervous system viral infection.

Immunity to leptospirosis: bacterins in dogs and hamsters.

Resistance to clinical and renal leptospirosis in dogs vaccinated with a bacterin containing Leptospira interrogans serotype canicola and Leptospira interrogans serotype icterohaemorrhagiae was demonstrated. The relationship between resistance induced in vaccinated dogs and that induced in vaccinated hamsters was also demonstrated, using criteria of leptospiremia, renal infection, leptospiruria, and clinical signs of disease in dogs and death in hamsters.