Teaching residents in the neonatal intensive care unit: a non-traditional approach.

Because of the increasing constraints on the amount of time pediatric residents may train in the neonatal intensive care unit (NICU), concerns have been raised about the adequacy of their exposure to acute emergencies in the delivery room and their hands-on experience with sick neonates. Importantly, there are also concerns about the consistency and quality of supervision of PL-1 residents by second- and third-year residents, who themselves may not have had sufficient training in the NICU. To address these concerns, we have instituted an educational plan that links an experienced neonatal nurse practitioner (NNP) one-on-one with a PL-1 resident in a collaborative team. This plan differs from the traditional resident-to-resident supervisory model. An anonymous survey of our residents (n = 14) indicates enthusiastic endorsement of this new educational model. NNPs as first-line teachers in the NICU provide a new approach for residency training programs.

Long-term consequences of adolescent health behaviors: implications for adolescent health services.

The authors discuss the evidence supporting the effectiveness of adolescent preventive services to influence health outcomes, the magnitude of the long-term consequences of adolescent health-compromising behaviors, and their implications for health policies. Particular attention is given to the contribution that behaviors participated in or begun during adolescence have on long-term health, including cancer and heart disease. They postulate the health benefits that might accrue from the widespread implementation of comprehensive adolescent preventive services, assuming a conservative estimate of effectiveness, could be significant.

Toxic shock syndrome in three adolescent males.

Toxic shock syndrome (TSS) is associated with a spectrum of Staphylococcus aureus infections and is not just a disease of menstruating females. We report three cases of TSS in adolescent males. In one case the origin of infection was a cauterized wart that did not appear clinically infected. Two cases were associated with bacteremia and had demonstrable acute phase antibody to toxic shock syndrome toxin-1 (TSST-1). One of these patients died. The S. aureus strain from this patient did not produce TSST-1 but did produce enterotoxin D. The historical and clinical features of TSS are reviewed.

Clinical data used by pediatric residents to assess parenting.

To determine how pediatricians assess parenting at well-child visits, pediatric residents were interviewed following the well-child visit of a child less than 24 months of age. Using a structured format, the residents were interviewed about their judgments concerning the characteristics of the mother just seen and the data used to make these judgments. In addition, ratings were made of the quality of the descriptions of the parents. Fifty interviews, 2 each with 25 residents, were completed. Residents described the parenting abilities of 82% of the mothers in predominantly positive terms and 18% in negative terms. To make these judgments, residents relied on one or more of five categories of data: how mothers used the medical system (98%); observations during the office visit of the mother-child interactions (96%), of the child (74%), and of the mother (68%); and information obtained by interview about the mother's caregiving skills and her feelings toward the child (50%). In 30% of cases the residents' descriptions of the mother contained only minimal information. We conclude that residents rely more on observational data than data acquired during the interview. These findings suggest that residency training programs should sharpen the residents' ability to make behavioral observations and teach more effectively the process of interviewing so that residents will be able to make appropriate assessments of parenting skills.

Diagnostic styles of attending pediatricians, residents, and nurses in evaluating febrile children.

In order to compare the diagnostic styles of attending pediatricians (A), residents (R), and nurses (N) in judging the degree of illness of a febrile child prior to physical examination, we studied the frequency with which they used 139 different history variables and 186 observation variables in evaluating 162 consecutive children less than or equal to 24 months of age with temperature greater than or equal to 38.3 C. Because individual history and observation variables were not used with sufficient frequency, comparison of diagnostic styles based on the individual variables was not possible. The individual history and observation variables were then combined into 25 history and 30 observation categories respectively. One observation category, "Eyes," was used with sufficient frequency to allow comparison of A, R, and N diagnostic styles. In the Eyes category, there were 11 variables describing visual response to stimuli (e.g., looking at the observer) and 10 variables describing appearance of the eyes (e.g., glassy, shiny). Attendings used variables describing visual response to stimuli significantly more frequently than R or N, which may indicate a greater facility in evaluating age-appropriate behavior and/or may be a technique to increase the sensitivity of clinical judgments. These data demonstrate the variety of diagnostic styles of A, R, and N. There is a need to define valid and reliable observation data to identify serious illness in febrile children.

Radiographic findings and etiologic diagnosis in ambulatory childhood pneumonias.

The chest roentgenograms of 128 consecutive ambulatory children with radiologic pneumonia were read independently and without clinical information by a faculty general pediatrician (Ped), a pediatric radiologist (R-P) and a general radiologist (R-G). The films were classified as normal, indicative of a viral or bacterial process, or indeterminate. Readings were compared with results of viral titers and bacterial cultures. Agreement between any two observers in classifying films, measured by unweighted Kappa, while statistically significant (p less than 0.001) for any pair, was low. There was no significant difference between the agreement scores of Ped/R-P, Ped/R-G, and R-P/R-G. Twenty-one patients had fourfold viral titer increases (N = 16) or positive bacterial cultures of blood or pulmonary aspirate (N = 5). The sensitivity of viral readings for titers increases varied from 19% to 68% depending on observer type; the sensitivity of bacterial readings for positive bacterial cultures varied from 60% to 80%. The three observers agreed on a correct reading in only three children with viral and three with bacterial pneumonia. Because of poor observer agreement and appreciable false-negative errors when viral and bacterial readings were compared to titer increases and positive bacterial cultures, respectively, we conclude that radiographic findings are poor indicators of etiology diagnosis in ambulatory childhood pneumonias and, of themselves, are an insufficient data base for making therapeutic decisions.

Further definition of history and observation variables in assessing febrile children.

The experienced clinician makes a judgment (hereafter called overall assessment [OA]) about the degree of illness of a febrile child prior to physical examination. In order to define the history and observation variables on which OA is based, 262 febrile children less than or equal to 24 months of age were evaluated simultaneously by multiple observers including attending pediatricians, practicing pediatricians, pediatric house officers, and nurses. The observer listed history and observation variables he/she thought most important in making an OA on a blank, lined form and then scored those variables and OA as normal, or mildly, moderately, or severely impaired. Scoring for observation rather than history variables was better correlated with scoring for OA and serious illness. The observation variables most frequently mentioned by all observers were the child's "looking at the observer" and "looking around the room." There were 20 observation variables frequently mentioned, the scoring of which significantly correlated with scoring for OA; four of these 20 variables related to eye function. The child's response to a stimulus was noted in 105/186 different observation variables listed; both the attending pediatrician and the house officer scored these stimulus-response variables significantly different in children with, vs those without, serious illnesses. For attending pediatricians, house officers, and nurses, serious illness was five to seven times as likely if an OA of moderate or severe impairment was made than if it were not made. OA is a key skill in evaluating febrile children; these data identify variables on which OA is based, document the importance of assessing eye function in young, febrile children, and demonstrate that eye function is one key type of stimulus-response behavior on which the pediatrician as clinician and developmentalist relies to make judgments about febrile children.

History and observation variables in assessing febrile children.

Attending pediatricians listed five history and eight observation variables on which they base their "instinctive" judgment (prior to performing a physical examination) of overall degree of illness of febrile children. Attending pediatricians and house staff observer pairs independently scored these variables in an overall assessment on 219 young, febrile children. The observation variable playfulness had the strongest correlation with overall assessment. Observer agreement in scoring the variables and overall assessment, while statistically significant, was only fair. When an attending pediatrician judged a child as moderately or severely ill on overall assessment, serious illnesses were four times as likely as when such a judgment was not made. When a house officer judged a child as moderately or severely ill, serious illnesses were less than twice as likely as when such a judgment was not made. However, only 57% of children with serious illnesses were judged by the attending pediatrician as moderately or severely ill on overall assessment. These data demonstrate the importance and limitations of "instinctive" clinical judgments about young, febrile children; the association between observation of complex behavioral patterns, especially playfulness, and overall assessment; and the need for further study of these complex behavioral patterns in order to define a reliable clinical approach to febrile children.