Imaging cytokinesis of Drosophila S2 cells.

Animal cell cytokinesis proceeds through three successive stages: a contractile ring stage, an intercellular bridge stage, and an abscission stage. Many studies have identified a complex network of key proteins required for successful cytokinesis. While each component interacts with, and depends on, several other components, our understanding of how these proteins cooperate in space and time to ensure faithful progression through the stages of cytokinesis remains incomplete. A full understanding of the complexity of the process and its underlying machinery necessitates experimental systems that allow both genetic manipulation and real-time visualization of the various components throughout the successive stages of cytokinesis. Cultured Drosophila S2 cells provide such a system. They are genetically tractable thanks to their exquisite sensitivity to RNA interference mediated by double-stranded RNAs, which can be generated with ease in the laboratory. Furthermore, S2 cells grow well under normal atmospheric conditions, and stable lines expressing fluorescently tagged proteins can be readily generated, making them ideal for long-term live-cell fluorescence microscopy. Here we describe methodology for exploiting S2 cells for the study of cytokinesis, with an emphasis on live-cell imaging. We describe a variety of fluorescent markers available and their utility for highlighting different structures at different stages of cytokinesis. We describe our experimental setup that forms the basis for live-cell analysis of loss-of-function RNAi experiments, rescue experiments, and structure-function analyses of key regulators of cytokinesis. Finally, we describe the types of phenotypes that one can observe at the different stages of Drosophila S2 cell cytokinesis.

Relationship between patient complaints and surgical complications.

BACKGROUND: Patient complaints are associated with increased malpractice risk but it is unclear if complaints might be associated with medical complications. The purpose of this study was to determine whether an association exists between patient complaints and surgical complications. METHODS: A retrospective analysis of 16,713 surgical admissions was conducted over a 54 month period at a single academic medical center. Surgical complications were identified using administrative data. The primary outcome measure was unsolicited patient complaints. RESULTS: During the study period 0.9% of surgical admissions were associated with a patient complaint. 19% of admissions associated with a patient complaint included a postoperative complication compared with 12.5% of admissions without a patient complaint (p = 0.01). After adjusting for surgical specialty, co-morbid illnesses and length of stay, admissions with complications had an odds ratio of 1.74 (95% confidence interval 1.01 to 2.98) of being associated with a complaint compared with admissions without complications. CONCLUSIONS: Admissions with surgical complications are more likely to be associated with a complaint than surgical admissions without complications. Further research is necessary to determine if patient complaints might serve as markers for poor clinical outcomes.

Predictors of influenza virus vaccination status in hospitalized children.

OBJECTIVE: To determine predictors of influenza virus vaccination status in children who are hospitalized during the influenza season. METHODS: A cross-sectional study was conducted among children who were hospitalized with fever between 6 months and 3 years of age or with respiratory symptoms between 6 months and 18 years of age. The 1999 to 2000 influenza vaccination status of hospitalized children and potential factors that influence decisions to vaccinate were obtained from a questionnaire administered to parents/guardians. RESULTS: Influenza vaccination rates for hospitalized children with and without high-risk medical conditions were 31% and 14%, respectively. For both groups of children, the vaccination status was strongly influenced by recommendations from physicians. More than 70% of children were vaccinated if a physician had recommended the influenza vaccine, whereas only 3% were vaccinated if a physician had not. Lack of awareness that children can receive the influenza vaccine was a commonly cited reason for nonvaccination. CONCLUSIONS: A minority of hospitalized children with high-risk conditions had received the influenza vaccine. However, parents' recalling that a clinician had recommended the vaccine had a positive impact on the vaccination status of children.

Corticosteroid prescription filling for children covered by Medicaid following an emergency department visit or a hospitalization for asthma.

OBJECTIVE: To identify predictors of corticosteroid prescription filling following an emergency department (ED) visit or a hospitalization for asthma. DESIGN: A retrospective cohort study. PATIENTS: Tennessee children (defined as those aged 2-17 years in this study) covered by Medicaid were included in the cohort if they had an ED visit or a hospitalization for asthma between July 1, 1995, and December 31, 1997. MAIN OUTCOME MEASURES: Prescriptions filled in the child's name for an oral corticosteroid within 7 days of the latest ED visit or hospitalization for asthma. RESULTS: Of 6035 Tennessee children covered by Medicaid with an ED visit for asthma and of 2102 covered by Medicaid with a hospitalization for asthma during the study period, less than half (44.8% following an ED visit and 55.5% following a hospitalization) had prescriptions filled for oral corticosteroids within 7 days. Factors independently predicting a child's not having an oral corticosteroid prescription filled included older age, black race, and residence in rural regions of the state. Conversely, children with oral corticosteroid prescriptions in the previous 6 months were more likely to have oral corticosteroid prescriptions filled following an ED visit for asthma, and children with more than 3 beta-agonist prescriptions in the previous 6 months were more likely to have oral corticosteroid prescriptions filled following a hospitalization for asthma. CONCLUSIONS: Overall, fewer than half of Tennessee children covered by Medicaid had an oral corticosteroid prescription filled following an ED visit or a hospitalization for asthma. Age, race, and county of residence predicted failure to have a prescription filled. Further study is needed to determine whether variations in corticosteroid prescription filling relate to physician practice, family behavior, or both.

Principles of patient safety in pediatrics.

The American Academy of Pediatrics and its members are committed to improving the health care system to provide the best and safest health care for infants, children, adolescents, and young adults. In response to a 1999 Institute of Medicine report on building a safer health system, a set of principles was established to guide the profession in designing a health care system that maximizes quality of care and minimizes medical errors through identification and resolution. This set of principles provides direction on setting up processes to identify and learn from errors, developing performance standards and expectations for safety, and promoting leadership and knowledge.

Quantification of SNARE protein levels in 3T3-L1 adipocytes: implications for insulin-stimulated glucose transport.

Insulin-stimulates glucose transport in peripheral tissues by stimulating the movement ('translocation') of a pool of intracellular vesicles containing the glucose transporter Glut4 to the cell surface. The fusion of these vesicles with the plasma membrane results in a large increase in the numbers of Glut4 molecules at the cell surface and a concomitant enhancement of glucose uptake. It is well established that proteins of the VAMP- (synaptobrevin) and syntaxin-families play a fundamental role in the insulin-stimulated fusion of Glut4-containing vesicles with the plasma membrane. Studies have identified key roles for vesicle associated membrane protein-2 (VAMP2) and syntaxin-4 in this event, and more recently have also implicated SNAP-23 and Munc18c in this process. In this study, we have quantified the absolute levels of expression of these proteins in murine 3T3-L1 adipocytes, with the objective of determining the stoichiometry of these proteins both relative to each other and also in comparison with previous estimates of Glut4 levels within these cells. To achieve this, we performed quantitative immunoblot analysis of these proteins in 3T3-L1 membranes compared to known amounts of purified recombinant proteins. Such analyses suggest that in 3T3-L1 adipocytes there are approximately 374,000 copies of syntaxin 4, 1.15 x 10(6) copies of SNAP23, 495,000 copies of VAMP2, 4.3 x 10(6) copies of cellubrevin and 452,000 copies of Munc18c per cell, compared to previous estimates of 280,000 copies of Glut4. Thus, the main SNARE proteins involved in insulin-stimulated Glut4 exocytosis (syntaxin 4 and VAMP2) are expressed in approximately equimolar amounts in adipocytes, whereas by contrast the endosomal v-SNARE cellubrevin is present at approximately 10-fold higher levels and the t-SNARE SNAP-23 is also present in an approximately 3-fold molar excess. The implications of this quantification for the mechanism of insulin-stimulated Glut4 translocation are discussed.

Adipsin and the glucose transporter GLUT4 traffic to the cell surface via independent pathways in adipocytes.

Insulin increases the exocytosis of many soluble and membrane proteins in adipocytes. This may reflect a general effect of insulin on protein export from the trans Golgi network. To test this hypothesis, we have compared the trafficking of the secreted serine protease adipsin and the integral membrane proteins GLUT4 and transferrin receptors in 3T3-L1 adipocytes. We show that adipsin is secreted from the trans Golgi network to the endosomal system, as ablation of endosomes using transferrin-HRP conjugates strongly inhibited adipsin secretion. Phospholipase D has been implicated in export from the trans Golgi network, and we show that insulin stimulates phospholipase D activity in these cells. Inhibition of phospholipase D action with butan-1-ol blocked adipsin secretion and resulted in accumulation of adipsin in trans Golgi network-derived vesicles. In contrast, butan-1-ol did not affect the insulin-stimulated movement of transferrin receptors to the plasma membrane, whereas this was abrogated following endosome ablation. GLUT4 trafficking to the cell surface does not utilise this pathway, as insulin-stimulated GLUT4 translocation is still observed after endosome ablation or inhibition of phospholipase D activity. Immunolabelling revealed that adipsin and GLUT4 are predominantly localised to distinct intracellular compartments. These data suggest that insulin stimulates the activity of the constitutive secretory pathway in adipocytes possibly by increasing the budding step at the TGN by a phospholipase D-dependent mechanism. This may have relevance for the secretion of other soluble molecules from these cells. This is not the pathway employed to deliver GLUT4 to the plasma membrane, arguing that insulin stimulates multiple pathways to the cell surface in adipocytes.

Changes in continuity of enrollment among high-risk children following implementation of TennCare.

BACKGROUND: TennCare, Tennessee's Medicaid managed care program, was introduced in 1994 with the goals of controlling spending and of improving access to health care. OBJECTIVE: To assess changes in the continuity of enrollment following the implementation of TennCare for 2 groups: infants in the first year of life (defined as persons aged 0-12 months in this study) and children hospitalized with a chronic health condition (defined as persons aged 0-18 years in this study). DESIGN: Retrospective cohort analysis. SETTING AND POPULATION: Infants born during 1992 or 1995 to women enrolled in Medicaid or TennCare and 0- to 18-year-old children enrolled in Medicaid or TennCare who were discharged from a hospital during 1992 or 1995 with a chronic health condition. MAIN OUTCOME MEASURES: For infants, failure to enroll an infant in the first 30 days of life or subsequent gaps in enrollment for 7 days or longer during the first year of life. For children hospitalized with a chronic health condition, any gap in enrollment lasting 7 days or longer by 1 year after discharge from a hospital. RESULTS: There was a reduction in the proportion of infants without continuous enrollment in the first year of life following TennCare (19.4% after vs 25.1% before TennCare; odds ratio, 0.69; 95% confidence interval, 0.67-0.72). Improvements in continuity of enrollment for infants occurred despite an increase in the proportion of infants who were not enrolled in TennCare in the first 30 days of life, even though their mother was enrolled at delivery (14.0% after vs 8.0% before TennCare; odds ratio, 1.86; 95% confidence interval, 1.78-1.96). There was a decrease in the proportion of children hospitalized with a chronic health condition who had subsequent gaps in enrollment by 1 year following discharge from a hospital (14.3% after vs 23.3% before TennCare; odds ratio, 0.52; 95% confidence interval, 0.46-0.59). CONCLUSION: For infants in the first year of life and for children hospitalized with a chronic health condition, implementation of TennCare improved continuity of coverage.

Differential regulation of secretory compartments containing the insulin-responsive glucose transporter 4 in 3T3-L1 adipocytes.

Insulin and guanosine-5'-O-(3-thiotriphosphate) (GTPgammaS) both stimulate glucose transport and translocation of the insulin-responsive glucose transporter 4 (GLUT4) to the plasma membrane in adipocytes. Previous studies suggest that these effects may be mediated by different mechanisms. In this study we have tested the hypothesis that these agonists recruit GLUT4 by distinct trafficking mechanisms, possibly involving mobilization of distinct intracellular compartments. We show that ablation of the endosomal system using transferrin-HRP causes a modest inhibition ( approximately 30%) of insulin-stimulated GLUT4 translocation. In contrast, the GTPgammaS response was significantly attenuated ( approximately 85%) under the same conditions. Introduction of a GST fusion protein encompassing the cytosolic tail of the v-SNARE cellubrevin inhibited GTPgammaS-stimulated GLUT4 translocation by approximately 40% but had no effect on the insulin response. Conversely, a fusion protein encompassing the cytosolic tail of vesicle-associated membrane protein-2 had no significant effect on GTPgammaS-stimulated GLUT4 translocation but inhibited the insulin response by approximately 40%. GTPgammaS- and insulin-stimulated GLUT1 translocation were both partially inhibited by GST-cellubrevin ( approximately 50%) but not by GST-vesicle-associated membrane protein-2. Incubation of streptolysin O-permeabilized 3T3-L1 adipocytes with GTPgammaS caused a marked accumulation of Rab4 and Rab5 at the cell surface, whereas other Rab proteins (Rab7 and Rab11) were unaffected. These data are consistent with the localization of GLUT4 to two distinct intracellular compartments from which it can move to the cell surface independently using distinct sets of trafficking molecules.

Comparison of perinatal outcomes among TennCare managed care organizations.

OBJECTIVE: To compare perinatal outcomes among the managed care organizations (MCOs) providing care to beneficiaries enrolled in TennCare, Tennessee's capitated Medicaid managed care program. DESIGN: Retrospective cohort analysis. SUBJECTS: Infants born in Tennessee during 1995 to women enrolled in TennCare. PRIMARY OUTCOME MEASURES: Prenatal care use, birth weight (BW), death in the first 60 days of life, and delivery of extremely low BW (<1000 g) infants in hospitals without level 3 neonatal intensive care units. RESULTS: During 1995, 34 402 infants were born to mothers enrolled in TennCare. The MCOs differed widely in the demographic characteristics of their enrollees. In addition, there were small differences in prenatal care utilization, but no differences in BW outcomes among the MCOs. In multivariate analysis, however, infants born to women enrolled in 1 MCO were 2.8 times more likely to die in the first 60 days of life than were infants born to women enrolled in the largest MCO (OR: 2.81; 95% CI: 1.31-6.03). Women enrolled in this same MCO seemed to have a higher proportion of extremely low BW (<1000 g) infants delivering in a hospital lacking a level 3 neonatal intensive care unit (38% vs 20% in the largest MCO). CONCLUSION: The differences among MCOs in early infant death and in the delivery of high-risk infants in hospitals lacking appropriate neonatal facilities suggest that monitoring of care delivery to vulnerable children should include assessment of appropriate use of specialized services.

Early childhood mortality from community-acquired infections.

In this study, the authors identified maternal and child characteristics that were independent predictors of death from infectious diseases acquired in the community and determined if these factors could be used to identify groups of children with excess risk of mortality from infection. A historical cohort study was conducted of children less than 5 years of age between 1985 and 1994 (the study period), who were born in Tennessee, and had complete information on their birth certificates. The primary outcome was death from infection identified from death certificates and confirmed through medical record review. Among the 1,014,976 children less than 5 years of age, who contributed 3,351,568 child-years of follow-up, there were 247 deaths from infections (7.4 deaths from infections per 100,000 child-years). Respiratory infections accounted for approximately one half of the deaths. Children having three or more older siblings or birth weight of less than 1,500 g had a 3-fold and 10-fold increased risk of death from infection, respectively, while children with both characteristics had a nearly 20-fold increased risk that persisted beyond the first year of life. Interventions should be focused on prevention of these infections in vulnerable children. At-risk children should be targeted for careful follow-up and early hospitalization when signs of infection develop.

Sociodemographic factors identify US infants at high risk of injury mortality.

OBJECTIVES: To identify sociodemographic predictors of infant injury mortality and to compare trends in injury mortality rates for high- and low-risk US infants from 1985 to 1991. DESIGN: Historical cohort. SETTING/STUDY PARTICIPANTS: The National Center for Health Statistics linked US infants (<1 year) born from 1985 to 1991 with death certificates. MAIN OUTCOME MEASURES: Multivariate regression was used to identify sociodemographic factors associated with injury mortality. The adjusted relative risks (RRs) of maternal age, education, marital status, number of other children, and infant birth weight were used to categorize infants into risk groups. We compared trends in injury rates for the highest and lowest risk groups. RESULTS: There were 5963 injury deaths and 18.6 million infant years or 32.1 injury deaths per 100 000 infant years. Highest risk infants were born to mothers who were younger than 20 years compared with older than 30 years (RR, 3.25; 95% CI, 2.92-3.63), had less than a high school education compared with a college education (RR, 2.22; 95% CI, 1.95-2.53), had more than 2 other children compared with no other children (RR, 3.15; 95% CI, 2.88-3.45), were unmarried (RR, 1.67; 95% CI, 1.57-1.78), or had birth weights 2500 g (RR, 3.36; 95% CI, 2.94-3.84). Infants in the highest risk group (21.0% of the population) had a >10-fold increased risk of injury mortality compared with the lowest risk group (18.1% of the population) and there was no evidence that this disparity was narrowing. CONCLUSIONS: Sociodemographic predictors of infant injury mortality include maternal age, education, number of other children, marital status, and infant birth weight. Based on these factors, 1 in 5 infants in the United States can be identified at birth as having a >10-fold increased risk of injury mortality compared with infants in lowest risk group. Programs to reduce injuries in these high-risk groups are urgently needed.

Identifying medical center units with disproportionate shares of patient complaints.

BACKGROUND: A pilot study was conducted to learn whether an academic medical center's database of patient complaints would reveal particular service units (or clinics) with disproportionate shares of patient complaints, the types of complaints patients have about those units, and the types of personnel about whom the complaints were made. RESULTS: During the seven-year (December 1991-November 1998) study period, Office of Patient Affairs staff recorded 6,419 reports containing 15,631 individual complaints. More than 40% of the reports contained a single complaint. One-third of the reports contained three or more complaints. Complaints were associated with negative perceptions of care and treatment (29%), communication (22%), billing and payment (20%), humaneness of staff (13%), access to staff (9%), and cleanliness or safety of the environment (7%). Complaints were not evenly distributed across the medical center's various units, even when the data were corrected for numbers of patient visits to clinics or bed days in the hospital. The greatest proportion of complaints were associated with physicians. DISCUSSION: Complaint-based report cards may be used in interventions in which peers share the data with unit managers and seek to learn the nature of the problems, if any, that underlie the complaints. Such interventions should influence behavioral and systems changes in some units. SUMMARY AND CONCLUSIONS: Further experience should indicate how different types of complaints lead to different kinds of interventions and improvements in care. Tests of the system are also currently under way in several nonacademic community medical centers.

Evidence for a role for ADP-ribosylation factor 6 in insulin-stimulated glucose transporter-4 (GLUT4) trafficking in 3T3-L1 adipocytes.

ADP-ribosylation factors (ARFs) play important roles in both constitutive and regulated membrane trafficking to the plasma membrane in other cells. Here we have examined their role in insulin-stimulated GLUT4 translocation in 3T3-L1 adipocytes. These cells express ARF5 and ARF6. ARF5 was identified in the soluble protein and intracellular membranes; in response to insulin some ARF5 was observed to re-locate to the plasma membrane. In contrast, ARF6 was predominantly localized to the plasma membrane and did not redistribute in response to insulin. We employed myristoylated peptides corresponding to the NH2 termini of ARF5 and ARF6 to investigate the function of these proteins. Myr-ARF6 peptide inhibited insulin-stimulated glucose transport and GLUT4 translocation by approximately 50% in permeabilized adipocytes. In contrast, myr-ARF1 and myr-ARF5 peptides were without effect. Myr-ARF5 peptide also inhibited the insulin stimulated increase in cell surface levels of GLUT1 and transferrin receptors. Myr-ARF6 peptide significantly decreased cell surface levels of these proteins in both basal and insulin-stimulated states, but did not inhibit the fold increase in response to insulin. These data suggest an important role for ARF6 in regulating cell surface levels of GLUT4 in adipocytes, and argue for a role for both ARF5 and ARF6 in the regulation of membrane trafficking to the plasma membrane.

Compensation for birth-related injury: no-fault programs compared with tort system.

OBJECTIVE: To compare compensation systems for birth-related injuries. DESIGN: Retrospective cohort study. SETTING: Florida. PARTICIPANTS: Parents of children with birth-related injuries who filed claims that closed before August 1, 1995, with Florida's no-fault program (Neurological Injury Compensation Act [NICA]) or who filed tort claims that closed from January 1, 1986, to August 1, 1995. MAIN OUTCOME MEASURES: Compensation for medical and income losses due to birth-related injuries. RESULTS: Families who received tort settlements were overcompensated for the injury, considering all sources of compensation. By contrast, NICA recipients broke even. Those who did not receive tort or NICA compensation lost nearly $75000 in the first 5 years following the birth. In the subsample of families of children with cerebral palsy, overcompensation by tort claim was even greater, whereas NICA recipients were undercompensated. The cost of care for cerebral palsy in both groups was the same. The difference between tort and NICA compensation levels was attributable to payment for income loss. Overall, NICA recipients were satisfied with compensation received. CONCLUSIONS: Medical expenses were adequately covered under NICA, but not income loss. A universal health insurance program for children would not cover income losses. Similar costs incurred in NICA and tort systems suggests no rationing of care by NICA. Finally, absent some sort of targeted compensation, the losses experienced by families of children with birth-related injuries were substantial.

The influence of obstetric no-fault compensation on obstetricians' practice patterns.

OBJECTIVES: The objectives were to determine level of satisfaction among obstetricians with the no-fault insurance programs in Florida and Virginia and to study any reported practice patterns attributable to implementation of no-fault compensation. STUDY DESIGN: Structured surveys were conducted with 119 obstetricians in Florida and Virginia. RESULTS: More than 90% of obstetricians were enrolled in no-fault insurance programs, but only 13% reported having had a patient compensated by a no-fault program. Only 14% knew of a colleague with a patient who had been compensated. Despite no-fault compensation, threat of lawsuits was a factor in 39% of cases of physicians who quit practicing obstetrics. The no-fault programs did not cause obstetricians to report increases in their obstetric caseloads or in their fraction of patients at high risk. Overall, obstetricians were far more satisfied with the no-fault system than with the tort system. Still, more than half of the respondents expressed dissatisfaction with premiums assessed by no-fault insurance. CONCLUSION: Obstetricians who knew about the no-fault programs were generally satisfied with their performance. However, the no-fault programs have not built a constituency with physicians, and the programs are relatively small in their scope of coverage. No-fault compensation thus has had minor impact on reported obstetric practice. To be effective in improving patient access, no-fault compensation must be broader in scope.

What health professionals can do to identify and resolve patient dissatisfaction.

BACKGROUND: Patient satisfaction affects consistency of self-care, health outcomes, level of service utilization, choice of health professionals, and decisions to sue in the face of adverse outcomes. Understanding patients' specific dissatisfactions may help health professionals and administrators identify and rectify organizational deficiencies before they become costly. COMMON CAUSES OF COMPLAINTS: As part of a series of research projects, more than 12,000 patient/family complaint narratives were examined in which patients or patients' family members told interviewers or patient advocates about the care they received from their health professionals in both inpatient and outpatient settings. Complaints may be categorized as involving issues of care and treatment, communication, humaneness, access and availability, environment, and billing/payment. STRATEGIES FOR RESOLVING COMPLAINTS: Even though caregivers may not have control over all the factors that lead to dissatisfaction, they can often hear and address complaints. As a result, they may not only contribute to quality of care but improve the systems in which they practice. The challenges are how to prevent dissatisfaction in the first place, and, if it does occur, to identify and if possible rectify patient concerns. Three case studies are provided. CONCLUSION: All health professionals must be involved in efforts to resolve problems that compromise patient care. Some problems could be prevented if administrators and leaders used complaint data to recommend new policies and procedures or to identify and counsel with health care team members who generate disproportionate numbers of complaints. If all are involved in both prevention and problem solving, resources devoted to uncovering, understanding, and resolving patient complaints are likely to prove cost-effective.

Predictors of mortality from fires in young children.

BACKGROUND: In the United States in 1994, fires claimed 3.75 lives per 100 000 child years and accounted for 17.3% of all injury deaths in children <5 years of age. OBJECTIVES: To conduct a historical cohort study that uses maternal demographic characteristics to identify young children at high risk of fire-related deaths, thus defining appropriate targets for prevention programs. METHODS: The cohort consisted of children born to mothers who resided in the state of Tennessee between 1980 and 1995. Information was obtained by linking birth certificates, 1990 census data, and death certificates. Children were eligible for the study if they were <5 years of age at any time within the study period and if key study variables were present (99.2% of births). Birth certificates provided information on maternal characteristics including age, race, education, previous live births, use of prenatal care, and residence (in standard metropolitan statistical area). Child characteristics included gender, gestational age, and birth type (singleton/multiple gestation). Neighborhood income was estimated by linking the mother's address at the time of birth to the 1990 census (block group mean per capita income). The study outcome was a fire resulting in at least one fatality (fatal fire event) during the study period, identified from death certificates (coded E880 through E889 in the International Classification of Diseases, 9th rev). We calculated the fatal fire event rate corresponding to each stratum of maternal/child characteristics. We assessed the independent association between each characteristic and the risk of a fatal fire event from a Poisson regression multivariate analysis. RESULTS: During the study period, 1 428 694 children contributed 5 415 213 child years to the cohort: there were 270 deaths from fire (4.99 deaths per 100 000 child years) and 231 fatal fire events. In the multivariate analysis, factors associated with greater than a threefold increase in fatal fire events included maternal education, age, and number of other children. Compared with children whose mothers had a college education, children whose mothers had less than a high school education had 19.4 times (95% confidence interval [CI], 2.6-142.4) an increased risk of a fatal fire event. Children whose mothers had more than two other children had 6.1 times (95% CI, 3.8-9.8) an increased risk of a fatal fire event compared with children whose mothers had no other children. Children of mothers <20 years of age had 3.9 times (95% CI, 2.2-7.1) increased risk of a fatal fire event compared with children whose mothers were >/=30 years old. Although both maternal neighborhood income and race were associated strongly with increased rates of fatal fire events in the univariate analysis, this association did not persist in the multivariate analysis. Other factors that were associated with increased risk of fatal fire events in the multivariate analysis were male gender and having a mother who was unmarried or who had delayed prenatal care. The three factors associated most strongly with fire mortality were combined to create a risk score based on maternal education (>/=16 years, 0 points; 13 to 15 years, 1 point; 12 years, 2 points; <12 years, 3 points); age (>/=30 years, 0 points; 25 to 29 years, 1 point; 20 to 24 years, 2 points; <20 years, 3 points); and number of other children (none, 0 points; one, 1 point; two, 2 points; three or more, 3 points). The lowest-risk group (score <3) included 19% of the population and had 0.19 fatal fire events per 100 000 child years. In contrast, highest-risk children (score >7) comprised 1.5% of the population and had 28.6 fatal fire events per 100 000 child years, 150 times higher than low-risk children. Children with risk scores >5 contributed 26% of child years but experienced 68% of all fatal fire events. If the fatal fire event rate for all children had been equal to that of the low-risk group (risk score <3), then 95% of deaths from

Effects of pediatrician characteristics on management decisions in simulated cases involving apparent life-threatening events.

OBJECTIVES: To study variations in the way pediatricians would evaluate and manage an infant with an apparent life-threatening event. SUBJECTS AND METHODS: A survey was mailed to the chief residents of all pediatric residency training programs in the United States in which respondents were presented with a simulated case and asked how they would manage an infant who had experienced an apparent life-threatening event that did not require resuscitation. The survey also explored each physician's tolerance of uncertainty, knowledge of apparent life-threatening events, experience, fear of litigation, responsiveness to parental demands, and propensity to order tests. MAIN OUTCOME MEASURES: Presumed decisions to prescribe antibiotics and/or order home apnea monitoring in a simulated case of an infant who had experienced an apparent life-threatening event not requiring resuscitation. RESULTS: Logistic regression analysis revealed 2 characteristics that made significant and independent contributions to respondents' presumed decision to prescribe antibiotics: (1) experience with an adverse outcome, and (2) propensity to order diagnostic tests. Presumed decisions to order a home apnea monitor were notably affected by fear of litigation. CONCLUSIONS: These findings suggest that differences in pediatricians' characteristics contribute to variations in care. Efforts to make management more uniform must consider that decisions are influenced by a host of different characteristics and experiences.

No-fault system of compensation for obstetric injury: winners and losers.

OBJECTIVE: To determine whether Florida's implementation of a no-fault system for birth-related neurologic injuries reduced lawsuits and total spending associated with such injuries, and whether no-fault was more efficient than tort in distributing compensation. METHODS: We compared claims and payments before and after implementation of a no-fault system in 1989. Data came from the Department of Insurance's medical malpractice closed claim files and no-fault records. Descriptive statistics were compiled for tort claims before 1989 and for tort and no-fault claims for 1989-1991. We developed two projection approaches to estimate claims and payments after 1989, with and without no-fault. We assessed the program's performance on the basis of comparisons of actual and projected values for 1989-1991. RESULTS: The number of tort claims for permanent labor-delivery injury and death fell 16-32%. However, when no-fault claims were added to tort claims, total claims frequency rose by 11-38%. Annually, an estimated 479 children suffered birth-related injuries; however, only 13 were compensated under no-fault. Total combined payments to patients and all lawyers did not decrease, but of the total, a much larger portion went to patients. Compensation of patients after plaintiff lawyers' fees rose 4% or 44%, depending on the projection method used. Less than 3% of total payments went to lawyers under no-fault versus 39% under tort. CONCLUSION: Some claimants with birth-related injuries were winners, taking home a larger percentage of their awards than their tort counterparts. Lawyers clearly lost under no-fault. Because of the narrow statutory definition, many children with birth-related neurologic injuries did not qualify for coverage.