Institutional policies of U.S. medical schools regarding tenure, promotion, and benefits for part-time faculty.

PURPOSE: To collect data on institutional policies regarding tenure, promotions, and benefits for part-time faculty at U.S. medical schools and determine the extent to which part-time work is a feasible or attractive option for academic physicians. METHOD: In July 1996, the authors sent a 29-item questionnaire regarding tenure, promotions, and benefit policies for part-time faculty to respondents identified by the deans' offices of medical schools in the United States and Puerto Rico. Responses were analyzed using descriptive statistics and chi-square analyses. RESULTS: Respondents from 104 of 126 medical schools (83%) completed the questionnaire; 58 responded that their schools had written policies about tenure, promotion, or benefits for part-time faculty. Tenure. Of the 95 medical schools with tenure systems, 25 allowed part-time faculty to get tenure and 76 allowed for extending the time to tenure. Allowable reasons to slow the tenure clock included medical leave (65), maternity leave (65), paternity leave (54), other leave of absence (59). Only 23 allowed part-time status as a reason to slow the tenure clock. Policies written by the dean's office and from schools in the midwest or west were more favorable to part-time faculty's being allowed to get tenure. Promotions. The majority of respondents reported that it was possible for part-time faculty to serve as clinical assistant, assistant, associate, and full professors. Benefits. The majority of schools offered retirement benefits and health, dental, disability, and life insurance to part-time faculty, although in many cases part-time faculty had to buy additional coverage to match that of full-time faculty. CONCLUSIONS: Most medical schools do not have policies that foster tenure for part-time faculty, although many allow for promotion and offer a variety of benefits to part-time faculty.

The development of substance-abuse curricular content by five North Carolina schools.

In 1992, the four medical schools in North Carolina and that state's dental school initiated a four-year project to more thoroughly integrate content about substance abuse into their curricula. The project was based on the premise that medical schools are failing to provide their students with adequate training about substance abuse issues, yet substance abuse is a large and growing source of health problems nationwide. While the authors indicate in broad ways the kinds of curricular content that the project sought, in this article they concentrate on the processes by which key faculty, administrators, and staff members from all the schools worked together in the curriculum development process, with each school tailoring the project's findings to the needs of its own students. Phase I of the project focused on the selection and orientation of the key faculty and members of the working committee at each institution, and garnering institutional support. Phase II focused on the development by key faculty of the project's philosophy, goals, and objectives; conducting needs assessment and curriculum analysis at each school; and identifying the content needed. During Phase III, project participants refined the needed content and integrated it, in individual ways, into each school's curriculum. Some (but not enough) evaluation of these curricular implementations was done. The authors highlight the lessons learned, both positive and negative, in hopes that these will be useful to other educators who wish to design, implement, and institutionalize substance-abuse curricular content.

Invasive group A streptococcal infections in North Carolina: epidemiology, clinical features, and genetic and serotype analysis of causative organisms.

During 1994 and 1995, an increase in the number and severity of group A streptococcal (GAS) infections was noted in North Carolina. Ninety-six patients had GAS recovered from blood and other sterile body fluids, abscesses, and soft tissue. The overall case fatality rate was 11% but was much higher in patients with toxic shock syndrome (55%) and necrotizing fasciitis (58%). Recent invasive GAS isolates were compared with pre-1994 invasive isolates and temporally related pharyngeal isolates by M protein serotyping, pulsed field gel electrophoresis (PFGE), and polymerase chain reaction amplification of the streptococcal pyrogenic exotoxin A gene. Serotypes M1 and M3 accounted for 50% of recent invasive isolates (1994-1995) and 58% of pharyngeal isolates (1994). The latter isolates demonstrated PFGE patterns that were identical to invasive M1 and M3 strains, suggesting that pharyngeal infections may have served as a reservoir for virulent GAS clones.

Pediatrician involvement in breast-feeding promotion: a national study of residents and practitioners.

OBJECTIVE: Physician support for breast-feeding mothers has been shown to improve breast-feeding rates, but no evaluation of the adequacy of physicians' breast-feeding-related training has been conducted. This study was designed to assess pediatricians' knowledge, attitudes, training, and activities related to breast-feeding promotion. METHODS: Surveys were mailed to a national random sample of pediatric residents (n = 999) and practitioners (n = 610) who were board certified within the previous 3 to 5 years. RESULTS: Response rates were 74% for residents and 69% for practitioners. Although more than 90% of respondents agreed that pediatricians should be involved in breast-feeding promotion, their clinical knowledge and experience did not suggest a high degree of competency. For example, practitioners were only slightly more aware of breast-feeding's protective effect against otitis media (71% vs 60%), and more than one quarter of both groups did not agree that exclusive breast-feeding is the most beneficial form of infant nutrition. Clinical advice often included inappropriate recommendations for breast-feeding termination or formula supplementation; only 64% of practitioners and 52% of residents knew that supplementing during the first few weeks of life may cause breast-feeding failure. For both groups, prior personal breast-feeding experience (ie, respondent or spouse had breast-fed an infant for 2 or more weeks) was a major determinant of improved clinical knowledge, more frequent activity, and greater self-confidence and perceived effectiveness in the area of breast-feeding promotion. Residents reported that the breast-feeding instruction provided during training was primarily in lecture format, with limited clinical opportunities to practice skills needed to assist breast-feeding mothers. Reflecting on their own training, more than 70% of practitioners recommended that more time be devoted to direct patient interaction and practice of counseling and problem-solving skills. CONCLUSIONS: These results indicate that residency training does not adequately prepare pediatricians for their role in breast-feeding promotion. Improvements in residency training and innovative continuing education programs should be implemented to help pediatricians meet the needs of their breast-feeding patients.

National assessment of physicians' breast-feeding knowledge, attitudes, training, and experience.

OBJECTIVE: Previous reports have demonstrated that physician counseling can improve rates of breast-feeding initiation and duration but suggest that physicians are ill-prepared for this role. It is unclear whether residency training for pediatricians, obstetrician/gynecologists, and family physicians provides the knowledge and skills necessary for effective breast-feeding promotion. DESIGN: Survey. PARTICIPANTS: A national random sample of 3115 residents and 1920 practicing physicians in pediatrics, obstetrics/gynecology, and family medicine. OUTCOMES: Assessment of breast-feeding knowledge, attitudes, training, and experience. RESULTS: Overall response rate was 68%. All groups demonstrated significant deficits in knowledge of breast-feeding benefits and clinical management; for example, less than 50% of residents chose appropriate clinical management for a breast-fed jaundiced infant or a breast abscess. Practicing physicians performed slightly better, but still more than 30% chose incorrect advice for mothers with low milk supply. Residents reported that their breast-feeding instruction consisted mainly of didactic lecture, not patient experience. Only 55% of senior residents recalled even one instance of precepting related to breast-feeding, and less than 20% had demonstrated breast-feeding techniques at least five times during residency. Regarding preparation for breast-feeding counseling, more than 50% of all practicing physicians rated their residency training as inadequate. Overall, physician involvement in breast-feeding promotion was endorsed by 90% of respondents, yet only half rated themselves as effective in counseling breast-feeding patients. The greatest predictor of physician self-confidence was previous personal or spousal breast-feeding experience. CONCLUSIONS: In this national sample of residents and practicing physicians in three specialties, physicians were ill-prepared to counsel breast-feeding mothers. Deliberate efforts must be made to incorporate clinically based breast-feeding training into residency programs and continuing education workshops to better prepare physicians for their role in breast-feeding promotion.

Explanation for false-positive urine cultures obtained by bag technique.

OBJECTIVE: To test whether a urine bag technique, previously shown in circumcised male infants 1 month to 1 year of age to yield no false-positive cultures, would give similar results in newborns (females and circumcised and uncircumcised males). DESIGN: Prospective study in which periurethral and urine specimens were obtained from healthy newborns. After the periurethral specimen was obtained, the perineum was washed and a urine bag applied. The urine bag was removed immediately after voiding and the urine was cultured. SETTING: Normal newborn nursery and pediatric hospital. SUBJECTS: Ninety-eight healthy full-term newborns (49 female and 49 male) admitted to the normal nursery during a 4-month period. MAIN RESULTS: Isolation of a pathogen from the bag urine reflected periurethral flora. In 20 (95%) of the 21 urine specimens from which a pathogen was isolated, the same pathogen was detected on the periurethra. Sixteen of the 21 urine cultures were falsely positive (> 10(4) colony-forming units of pathogen per milliliter). In 50 (98%) of the 52 urine samples that yielded no growth, the periurethral culture was also negative. In the remaining 25 urine samples in which nonpathogens were detected, the periurethra yielded nonpathogens or no growth. Thus, if a pathogen was isolated from a bag urine sample, the same pathogen was detected on the periurethra 95% of the time. Conversely, if the bag urine sample was negative for a pathogen, the periurethral culture was negative 100% of the time. The presence of a pathogen on the periurethra was more common in female than male neonates (16 of 49 vs four of 49; P = .004), and none of the 14 circumcised male neonates had a pathogen detected on their periurethra or in their urine. CONCLUSION: This study explains the finding of false-positive cultures with the bag technique. Pathogens detected in bag urine samples reflected pathogens on the periurethra. Until a bag collection technique that avoids contamination by periurethral flora can be developed, urethral catheterization and suprapubic aspiration remain the methods of choice for obtaining a urine specimen in female and uncircumcised male neonates.

Hospital-acquired urinary tract infections in the pediatric patient: a prospective study.

To determine through a prospective study the characteristics of hospital-acquired urinary tract infections (HAUTI) in children, 525 children subjected to bladder catheterization during a hospital admission were identified through surveillance of 12,316 admissions during a 24-month period. Urine culture results were available for 296 (56.4%) of the catheterized patients. In addition 12 noncatheterized children with a documented HAUTI were identified. The clinical courses of all patients with a HAUTI were followed for at least 6 months after their last HAUTI during the study period. Forty-four patients, 1 week to 17 years of age, with 1 or more HAUTI during a hospital unit admission were identified. A total of 51 HAUTI occurred. Thirty-nine (76.5%) of the infections occurred in patients subjected to catheterization. Thirty-two (10.8%) of 296 catheterized patients developed a HAUTI. Forty-three (84.3%) of the 51 infections were single organism infections. One HAUTI was associated with a wound infection with the same organism and one with a concurrent bacteremia with the same organism. Relapses were seen after 4 HAUTI. One reinfection was identified. There were no deaths directly associated with a HAUTI. Hospitalized children subjected to urinary tract catheterization are at significant risk for HAUTI. Complications are infrequent and not life-threatening.

Frequency and correlates of bacteriuria among children with neurogenic bladder.

Bacteriuria is a common clinical problem among children with neurogenic bladder due to meningomyelocele or traumatic spinal cord injury. To determine the frequency of bacteriuria among affected children at our institution, we obtained 257 urine specimens from 105 children being seen as outpatients for routine care over a 2-year study period. Specimens were obtained via catheterization. Almost half of these specimens (110/257 or 43%) yielded positive results when tested for urinary pathogens. To assess whether any characteristics of these children were related to the likelihood of bacteriuria, we analyzed further a subgroup of 46 children with normal renal ultrasonography from whom two to five specimens were obtained. There were no statistically significant associations between the likelihood of bacteriuria and the following characteristics: age, gender, socioeconomic status, level of spinal cord lesion, voiding technique, and use of prophylactic antibiotics. Children with neurogenic bladder are at high risk for bacteriuria. The pathogenesis of this bacteriuria, its part in deterioration of the urinary tract, and the possible means of its prevention in this special population all deserve further study.

Effect of periurethral colonization on the risk of urinary tract infection in healthy girls after their first urinary tract infection.

We examined whether periurethral colonization with bacterial pathogens predicts recurrent urinary tract infection (UTI) in girls at risk for infection. Periurethral and urine cultures were obtained weekly from each of seven healthy toilet-trained girls (3 to 6 years of age, normal urinary tract) during the 6 months after their first UTI, when the risk of UTI is 35%. Periurethral and urine isolates of Escherichia coli were grouped into electrophoretic types (ETs) by multilocus enzyme electrophoresis. Fifty-three (43%) of the 122 periurethral cultures were positive for a pathogen (median, 6 positive cultures/patient). Two patients each experienced 2 UTI. Positive periurethral cultures were as common in the five uninfected patients as in the two infected patients (9 of 32 vs. 44 of 90, P = 0.06). In only 1 of the 4 UTI was the infecting organism detected on the periurethra in the 2 weeks prior. Multilocus enzyme electrophoresis of the 104 periurethral and urine E. coli isolates from the 7 patients revealed 22 ETs. Such a diversity of ETs suggests that the flora of the periurethral region is colonized by multiple E. coli strains and is constantly changing in clonal composition. Five E. coli strains (ETs) associated with the initial UTI were detected again on the periurethra of 3 patients during surveillance but did not ascend to cause infection. Thus the mere presence of a pathogen on the periurethra is not by itself a risk factor for UTI.

Making a presumptive diagnosis of urinary tract infection by using a urinalysis performed in an on-site laboratory.

The purpose of our study was to characterize the utility of certain elements of urinalysis, singly or in combination, in identifying children with urinary tract infections (i.e., positive findings on urine culture). Laboratory results for urine specimens subjected to both urinalysis and culture in an on-site outpatient clinic (office) laboratory during a 36-month period were reviewed. All specimens were collected by one of three methods (the midstream void technique, urethral catheterization, or suprapubic aspiration of urine) from children with symptoms to assist in documenting a possible urinary tract infection. Specimen processing by certified technologists was initiated within 10 minutes of collection. Sensitivity, specificity, and positive and negative predictive values were determined for each test or combination of tests. Of 689 specimens, 102 (14.8%) had positive culture results. The combination of dipstick analysis (leukocyte esterase and nitrite tests) and of microscopic examination for bacteria had a sensitivity of 100% and a negative predictive value of 100%. The nitrite test had a specificity of 100% and a positive predictive value of 100%. We conclude that, when properly collected specimens are evaluated promptly by certified technologists, the rate of accuracy in detecting or ruling out a urinary tract infection (i.e., positive findings on urine culture) with certain elements of the urinalysis is high.

Antibacterial activity of the bladder mucosa.

Antibacterial activity of bladder mucosa is believed to be a host defense against infection. In this study we examined the antibacterial activity of the bladder mucosa without the effect of voiding. In addition we examined whether the property of adherence was advantageous for the organism in contact with the bladder mucosa. For this, three adhering and three nonadhering strains of E. coli were placed in contact with the bladder mucosa for 4 h in an in vivo rabbit model. E. coli grown in broth and applied to 32 bladders increased in titer by 1 log. E. coli grown in rabbit urine and applied to seven bladders increased in titer by 1.2 log. In contrast E. coli inoculated into control vials containing broth increased in titer by 2.3 log (P = 0.01). There was no significant difference in the titer between adhering and nonadhering strains of E. coli after 4 h of contact with the bladder mucosa. Bladder mucosa may have an inhibitory effect on bacterial growth (regardless of adherence characteristics) and with urine flow serves to prevent infection of the bladder urine.

Paecilomyces lilacinus infection in a child with chronic granulomatous disease.

Chronic granulomatous disease (CGD) is a rare inherited disorder in which neutrophils do not appropriately generate cytotoxic superoxide anion, the respiratory burst, in response to invading bacteria or fungi as a part of normal host defence. We report the case of a child with CGD who had two abdominal wall abscesses caused by Paecilomyces lilacinus, an organism not previously known to cause infections in patients with CGD. The abdominal wall is a location that is rarely associated with Paecilomyces infections. Parenteral amphotericin B eradicated the infection in an immunocompromised child whereas this regimen has heretofore largely been unsuccessful in the treatment of this infection. Paecilomyces species and other fungi from immunocompromised hosts and thought to be laboratory contaminants, need to be carefully investigated for they may become pathogens in this clinical setting.

Periurethral colonization and urinary leukocytes as markers for bacteriuria in children with neurogenic bladder.

Bacteriuria and associated renal damage is common in children with a neurogenic bladder, but the pathogenesis of urinary tract infection (UTI) is undefined. We examined the association between periurethral bacterial colonization and the presence of urinary leukocytes in 76 catheter urine specimens from children with neurogenic bladders. Although all the children were asymptomatic, 38/76 (50%) of the urine cultures were positive. Periurethral colonization was significantly more common with positive than with negative urine cultures, suggesting a pathogenetic role for periurethral bacteria in infection of the neurogenic bladder. Urinary leukocytes were present in 24/38 (63%) with positive cultures, as against none (0/38) of those with negative urine cultures, and their presence represents a host response to bladder bacteriuria.