Physicians' perspectives on the uncertainties and implications of chromosomal microarray testing of children and families.

Chromosomal microarray analysis (CMA) has improved the diagnostic rate of genomic disorders in pediatric populations, but can produce uncertain and unexpected findings. This article explores clinicians' perspectives and identifies challenges in effectively interpreting results and communicating with families about CMA. Responses to an online survey were obtained from 40 clinicians who had ordered CMA. Content included practice characteristics and perceptions, and queries about a hypothetical case involving uncertain and incidental findings. Data were analyzed using nonparametric statistical tests. Clinicians' comfort levels differed significantly for explaining uncertain, abnormal, and normal CMA results, with lowest levels for uncertain results. Despite clinical guidelines recommending informed consent, many clinicians did not consider it pertinent to discuss the potential for CMA to reveal information concerning biological parentage or predisposition to late-onset disease, in a hypothetical case. Many non-genetics professionals ordering CMA did not feel equipped to interpret the results for patients, and articulated needs for education and access to genetics professionals. This exploratory study highlights key challenges in the practice of genomic medicine, and identifies needs for education, disseminated practice guidelines, and access to genetics professionals, especially when dealing with uncertain or unexpected findings.

Relationship of depressive symptoms to hypertension in a household survey in Harlem.

OBJECTIVE: Two possible explanations for an hypothesized association between depression and hypertension were examined: (1) shared stress-related risk factors are associated with both depression and hypertension and (2) life-style factors associated with depression lead to hypertension. METHODS: A predominantly black sample of 695 adults were interviewed in the Harlem Household Survey. Two measures of hypertension were used and compared-1) self-report and 2) elevated blood pressure (above 140/90 mm Hg)-on the basis of the mean of two blood pressure measures. Depressive symptoms were measured by use of a 24-item scale based on the Diagnostic Interview Schedule. Logistic regression models were used to test associations between hypertension and depressive symptoms, stressors, and life-style factors. RESULTS: Depressive symptoms were associated with self-reported hypertension but not with elevated blood pressure. The association between self-reported hypertension and depressive symptoms was explained partly by shared stress-related risk factors but not by life-style factors. Several stressors and life-style variables were risk factors for elevated blood pressure independently of depressive symptoms. The findings are consistent with studies that have measured hypertension variously by either self-report or blood pressure. Possible explanations were explored (labeling and help-seeking) but were not supported by the data. CONCLUSIONS: An association was found between self-reported hypertension and depressive symptoms, which was explained partly by shared stress-related risk factors. Elevated blood pressure was associated with stressors and life-style factors but not with depressive symptomatology. Research on illness representations and cultural dimensions of health suggest avenues for further investigation.

Illness and treatment perceptions of Ethiopian immigrants and their doctors in Israel.

OBJECTIVES: Patient-provider misunderstandings arising from disparate medical and cultural concepts can impede health care among immigrant populations. This study assessed the extent of disagreement and identified the salient problems of communication between Israeli doctors and Ethiopian immigrant patients. METHODS: Semistructured interviews were conducted with 59 Ethiopian immigrants. Self-reports of health status and effectiveness of treatment were compared with evaluations by the primary care physician and supplemented by qualitative data from descriptions of illness, observations of medical visits, informant interviews, and participant observations conducted by the anthropologist. RESULTS: Health status and effectiveness of treatment were rated significantly higher by the doctor than by the patients. Low doctor-patient agreement occurred mainly for illnesses with stress-related or culture-specific associations. Qualitative data suggested that more long-term immigrants may alter their expectations of treatment but continue to experience symptoms that are culturally, but not biomedically, meaningful. CONCLUSIONS: Misunderstandings between immigrant patients and their doctors emerge from the biomedical system's limitations in addressing stress-related illnesses and from culture-based discrepancies in concepts of illness and healing. Including trained translators in medical teams can reduce medical misunderstandings and increase patient satisfaction among immigrant populations.

Adolescent school failure: failure to thrive in adolescence.

The role of the primary clinician in dealing with school failure can be critical by linking the epidemiological with the clinical and encompassing the pediatric/adolescent life span. It includes components of social and public health advocacy, preventive medicine, evaluation, education, treatment, and referral. The most effective interventions are early and multifaceted. The primary care role includes: community advocacy; counseling about prenatal drug and alcohol abuse; early detection and treatment for attentional disorders, underachievement, and learning disabilities; interviews addressing multiple risk factors, grades, school attitudes, behavior, and friends; anticipatory guidance; education about individual learning style and good "learning hygiene"; early referral and intervention for preadolescent conduct problems and parent-child conflict; early referrals for family distress; and prevention of substance abuse and adolescent pregnancy.

PTSD symptoms and comorbid mental disorders in Israeli war veterans.

BACKGROUND: The purpose of this study was to investigate patterns of mental disorders co-morbid with PTSD symptoms in young Israeli men exposed to combat. METHOD: Six hundred and seventeen subjects were selected via a general population sample and evaluated in a two-phase case-identification procedure, culminating in a modified SADS-L interview, administered by psychiatrists. RESULTS: Major depressive disorder (OR = 3.2), substance use disorders (OR = 1.9) and personality disorders (OR = 3.0) occurred more frequently in men reporting symptoms of PTSD than in men who had been under fire who did not report symptoms. With the possible exception of personality disorders, comorbid disorders did not constitute risk factors for PTSD. Comorbid PTSD and RDC disorders were associated with increased help-seeking. CONCLUSIONS: The results suggest similar rates and types of PTSD comorbidity in Israeli war veterans as in veterans in the US assessed in general population studies, and are consistent with shared risk factors for PTSD and comorbid disorders.

Measuring the savings from managed care: experience at Citibank.

In a leap of faith, Citibank in 1989 designed a point-of-service plan aimed at containing health care costs in the long term without sacrificing quality of care. In 1994 a study was undertaken to empirically evaluate whether these goals had been achieved. The study supported Citibank's overall managed care strategy, providing objective, quantifiable data that can lead to greater efficiencies.

[Prevalence of anti-HCV (C100-3) antibodies in 20.373 blood donors]. / Prévalence de l'anticorps anti-HCV (C100-3) chez 20,373 donneurs de sang.

The anti-HCV antibody (C100-3) is present in the serum of 70-90% of patients that are carriers of posttransfusion non-A non-B hepatitis. This marker appears to be associated with a viral replication and infectiousness state. Since 1st August 1990 the Swiss Red Cross Transfusion Service has operated a systematic search for anti-HCV antibodies for every blood donation. The aim of the study was to establish the prevalence of anti-HCV antibodies in a donor population, look for the risk factors in the anti-HCV positive group, look for biological symptoms and signs of chronic hepatitis, and compare the data with that from an anti-HCV negative control group. From August to March 1991, 20,373 donors were tested by EIA (Ortho). The presence of anti-HCV antibody was confirmed by a neutralization test (Abbott). The donors in which both tests were positive formed the group studied (55 subjects). Their data was compared with that of a control group of anti-HCV negative donors. The prevalence of anti-HCV antibody in the group of 20,373 donors was 0.29%. Possible parenteral exposure to hepatitis C virus was found in 47% of anti-HCV positive subjects (30% blood transfusion, 9% i.v. drug addiction, 8% tattooing). 42% of the anti-HCV positive donors had no risk factor presently known for hepatitis C. 27% of anti-HCV positive donors had elevated transaminase levels. Until more effective screening tests are introduced it appears necessary to stress the previous history of future blood donors in order to search for hepatitis C risk factors.(ABSTRACT TRUNCATED AT 250 WORDS)

Hospital influences on early infant-feeding practices.

Newborn nursery nursing staff members were surveyed to determine their attitudes and teaching practices regarding breast- and bottle-feeding. Concurrently, mothers using this nursery responded to a structured interview concerning their infant-feeding practices at 14 to 21 days postpartum and possible hospital influences on these practices. The nursing staff strongly advocated breast-feeding and did not favor specific bottle-feeding practices or products. Nursing staff counseling was generally interpreted by mothers as supporting breast-feeding, but this did not deter a large proportion of mothers who stated an initial preference for breast-feeding from introducing formula as a supplementary or exclusive form of infant feeding during the short study period. Almost all mothers doing any amount of bottle-feeding at the time of their interview were using the same formula brand and a ready-to-feed preparation used during their hospital stay. Other influences on mother's infant-feeding patterns are discussed. It is concluded that the hospital staff and routines exerted a stronger influence on mothers' infant-feeding practices by nonverbal teaching (the hospital "modeling" of infant formula products) than by verbal teaching (counseling supporting breast-feeding). Future studies might explore new ways of supporting mothers who desire to breast-feed by designing innovative hospital routines to model breast-feeding rather than feeding by infant formula.

Variability in the management of the febrile infant under 2 months of age.

The management in the emergency department of febrile infants less than 2 months of age is influenced by the standard of practice in the community. We sought to determine if uniform practices existed across the United States. Individual academically based faculty from 154 (61%) United States pediatric residency programs responding to a questionnaire on the emergency department management of febrile infants less than 2 months of age showed great variability. Twenty-nine respondents reported written policies and 103 reported informal but defined guidelines for the evaluation and management of infants seen at their institutions. There was little consensus among the respondents as to the definition of fever in this age group. Those at institutions with formal policies reported using more laboratory tests in the evaluation. Respondents differed on the number and types of tests used and on antibiotic administration. University affiliation, type of population served, or presence of advanced training programs in ambulatory pediatrics were not related to the type of policy. The care of the young febrile infant varies greatly.

Phototherapy in full-term infants with hemolytic disease secondary to ABO incompatibility.

Current guidelines for treatment of hemolytic disease of the newborn make no differentiation between ABO and Rh incompatibility. A protocol that prolonged the observation period in full-term, ABO-incompatible infants with positive Coombs' tests who were otherwise healthy was tested. Postponement of treatment made it possible to determine more accurately which infants needed phototherapy. This dramatically decreased the number of infants treated without increasing their risk of requiring exchange transfusion.

Jaundice in the full-term neonate.

Hyperbilirubinemia is the most common problem experienced by the full-term infant in the immediate neonatal period. The development of jaundice was prospectively investigated in 866 newborns. Significant correlations were found between the serum bilirubin level and the method of birth, perinatal complications, blood group incompatibilities, birth weight, and method of feeding. Breast-feeding was highly related to the development of exaggerated jaundice. The most common occurrence of jaundice requiring phototherapy was in breast-feeding infants in whom no cause for the jaundice could be determined. Study findings were most compatible with a theory of relative caloric deprivation as an explanation of the increased incidence of hyperbilirubinemia found in breast-fed newborns.

Teaching well child care.

Despite recommendations that the emphasis of the well child visit be on behavior and development, some studies indicate that pediatricians continue to spend a relatively small percentage of each well baby visit on these subjects. One factor contributing to the discrepancy between current recommendations and practice may be the way we teach residents to perform this task. In this study, we investigated and evaluated current methods for teaching well child care. Our data indicate that the content of well child care is being taught, but that problems with teaching setting, methods and frequency of supervision, and lack of formal evaluation may be among the factors which contribute to our continued inability to change the focus of well child visits.

Clinical estimation of liver size in newborn infants.

Liver size was measured in 100 healthy newborn infants of gestational ages 35 to 44 weeks. A mean liver span of 5.9 +/- 0.8 cm was determined in these infants by measuring the distance between the percussed upper and palpated lower liver borders along the midclavicular line. This value correlated well with measurements derived from percussing both borders (r = .8) and correlated poorly with measurements of liver projection below the costal margin (r = .55). The practice of reporting liver projection below the costal margin as a single indicator of liver size should be discouraged.

Educational priorities in the newborn nursery.

The newborn nursery provides an ideal setting for introducing basic concepts in primary care. The incorporation of the new born (low risk) nursery as a component of a division of ambulatory and community pediatrics presents an opportunity to address many of these issues and provides a focus for mother-child and family-institution bonding. In the University of California, Irvine, Medical Center nursery, management plans of residents and medical students are reviewed by a multidisciplinary team. The team considers the many physiologic adjustment a newborn infant must undergo to adapt successfully to its environment and discusses the impact of psychosocial stress, economic conditions, citizenship status, and environmental concerns on the ability of the parents to provide a supportive environment for their infant. Supervision of direct patient care and administrative responsibility for medical decisions in the nursery are the duties of the child health associate assigned to the nursery and his supervising physician.

Supervision of pediatric trainees in biosocial pediatrics. A survey of graduate programs.

To assess the current state of supervisory methods in biosocial pediatrics, fellowship programs in ambulatory pediatrics (AP), adolescent medicine (AM), and behavioral pediatrics/child development (BP/CD) were surveyed. Fifty-eight responses (98%) were analyzed. Forty-five percent of programs dealt extensively with behavioral pediatric problems. The AM and BP/CD fellowships were more psychosocially oriented than the AP programs. Ninety-two percent of AM and 82% of BP/CD programs used a formal supervisory style, but 48% of AP programs relied solely on unscheduled supervision. Direct observation or audiovisual tapes were used by only 57% of the programs. Significantly fewer AP programs used such objective methods. Supervision of biosocial pediatric programs should be formalized and include direct observation or audiovisual tapes.