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The authors respond to a proposal in this issue of Academic Medicine by Ray, Bishop, and Dow, who recommend adopting a free-market approach to the Match in which applicants and programs negotiate directly with each other to find and fill residency positions year-round. This Invited Commentary examines and responds to the reasons Ray and colleagues give for changing the Match and explores their proposal's implications and likelihood of success.The authors question Ray and colleagues' argument that assumptions underlying the National Resident Matching Program algorithm have been violated. The authors suggest there is insufficient evidence for the "July effect" and that the possibility for improvement in physician supply due to the year-round entry of graduates into the workforce ultimately faces the rate-limiting step of caps on residency positions allocated to programs. Most important, competency-based medical education, on which the free-market proposal depends, is not yet sufficiently developed.Nonetheless, the imbalanced ratio of applicants to positions in the Match is contributing to a rise in the numbers of student applications and program interviews. Although the proposed free-market approach might, as Ray and colleagues envision, curtail applications as well as reduce time and financial resources currently expended on the process, it would require significant changes on the part of applicants, residency programs, medical schools, and other stakeholders.Because the proposed free-market approach could reduce some negative effects of the imbalance of applicants and positions, it merits ongoing discussion along with other more immediate practical solutions to issues with the Match.

A program director receives the following complaint from 2 members of the faculty: a postgraduate year (PGY) 3 resident seems argumentative during patient handoffs and is neither receptive to discussions about patient care concerns nor to feedback about their interactions. Under these circumstances, how should the program director approach this problem, which reflects deficiencies in interpersonal and communication skills (ICS) and professionalism competencies? What remediation strategies should be considered and can the milestones guide the remediation? Are there any best practice recommendations that can serve as a template across specialties for professionalism and ICS that program directors can use for their residents? As part of the new accreditation system, the Accreditation Council for Graduate Medical Education developed the Milestone Project, which includes specialty-specific subcompetencies and milestones under each of the 6 competencies. The milestones allow programs to determine the progression of each resident’s knowledge, skills, and attitudes during the course of training. With the understanding that subcompetencies and milestones for competencies, such as patient care and medical knowledge, might vary significantly among specialties, we posed the question as to whether or not those for ICS and professionalism share common content themes. If unifying standards for the house of medicine for these competencies did exist, it should follow that suggested approaches to remediation could be applicable across specialties. It is the authors’ hope that the best practice recommendations to follow will allow a program director to expand his or her toolbox for remediation of these competencies, while also developing a broader understanding of approaches to successful remediation. In addition, a remediation approach using targeted strategies mapped to subcompetency proficiency levels is presented for the authors’ specialty of emergency medicine (provided as online supplemental material).

The global rise in non-communicable disease (NCD) suggests that US-based refugees are increasingly affected by chronic conditions. However, health services have focused on the detection of infectious disease, with relatively limited data on chronic NCDs. Using data from a retrospective medical record review of a refugee health program in the urban Northeast (n = 180), we examined the prevalence of chronic NCDs and NCD risk factors among adult refugees who had recently arrived in the US, with attention to region of origin and family composition. Family composition was included because low-income adults without dependent children are at high risk of becoming uninsured. We found that half of the adult refugees in this sample had at least one chronic NCD (51.1%), and 9.5% had three or more NCDs. Behavioral health diagnoses were most common (15.0%), followed by hypertension (13.3%). Half of adults were overweight or obese (54.6%). Chronic NCDs were somewhat more common among adults from Iraq, but this difference was not significant (56.8 vs. 44.6%). Chronic NCDs were common among adults with and without dependent children (61.4 vs. 44.6%, respectively), and these two groups did not significantly differ in their likelihood of having a chronic NCD after adjustment for age and gender (AOR = 0.78, 95% CI = 0.39, 1.55). This study suggests that chronic NCDs are common among adult refugees in the US, including refugees at high risk for uninsurance. We propose that refugee health services accommodate screening and treatment for chronic NCDs and NCD risk factors, and that insurance outreach and enrollment programs target recently arrived refugees.

Background At our institution, the arterial switch operation for transposition of the great arteries has transitioned from the Gore-Tex patch (W.L. Gore & Associates, Flagstaff, AZ) for pulmonary artery reconstruction to redundant pantaloon pericardial patch (RPPP). The (U-shaped) coronary artery button was used for coronary reimplantation. This study investigates overall mortality and factors for neopulmonary artery, neoaortic, and coronary artery surgical reintervention. Methods We performed a retrospective chart review of all patients who underwent arterial switch between 1983 and 2007. Our surgical database, operative reports, and cardiology clinic charts were reviewed. Time to event was plotted as Kaplan-Meier curves. Predictors of time-to-event were examined using Cox proportional hazard modeling. Results A total of 258 patients underwent arterial switch during the study. Mortality declined from 15% (era I: 1983 to 1990) to 11% (era II: 1991 to 1998) to 7% (era III: 1999 to 2007). Era III had a significantly later time to death compared with era I (hazard ratio [HR] 0.62, p = 0.04). The RPPP had a lower neopulmonary artery reintervention rate compared with Gore-Tex; 9 of 225 (4%) versus 3 of 21 (14%), p = 0.008. Complex anatomy increased risk for neopulmonary reintervention (HR 3.3, p = 0.03). Surgical reintervention rate for coronary arteries was 2%. Complex coronary anatomy (HR 17.9, p = 0.01) predicted coronary reintervention. Predictors of neoaortic reintervention were prior pulmonary artery band (HR 4.3, p = 0.03), complex anatomy (HR 3.5, p = 0.01), and coronary artery anatomy (HR 3.5, p = 0.04). Conclusions Arterial switch operation mortality has decreased. Conversion to RPPP reduced neopulmonary artery reintervention. The (U-shaped) coronary artery button technique is associated with low coronary reintervention rates. Complex coronary anatomy increases coronary and aortic reintervention. Prior pulmonary artery banding and complex anatomy increase aortic reintervention.

BACKGROUND The start of transpyloric feedings is often delayed because of challenges in reliably placing tubes blindly at the bedside. OBJECTIVE To determine whether tube placement with the guidance of a noninvasive computerized electromagnetic device shortens the time needed to achieve accurate placement of transpyloric feeding tubes in critically ill children. METHODS In a prospective, randomized trial in a tertiary-care, university-affiliated pediatric intensive care unit, 49 children requiring transpyloric feeding tube placement were randomized to have their tube placed by using conventional blind technique or with the assistance of a noninvasive electromagnetic device. RESULTS Twenty-seven patients were randomized to blind placement, and 22 were randomized to the electromagnetic device group. The time required to place the tubes successfully was significantly longer (P < .03) in the electromagnetic device group (median, 9.5 minutes; 95% confidence interval, 7-13 minutes) compared with the conventional placement group (median, 5 minutes; 95% confidence interval, 4.0-7.0 minutes). CONCLUSIONS Placement of transpyloric feeding tubes with the guidance of a noninvasive electromagnetic device significantly increases the time required for accurate placement. Because placement of transpyloric feeding tubes in critically ill children is common practice in many pediatric intensive care units, technology that delays satisfactory placement may be counterproductive in experienced hands.

The objective of this study was to retrospectively evaluate the utility of serum neopterin as a diagnostic marker of hemophagocytic lymphohistiocytosis (HLH). The medical records of patients diagnosed with HLH (familial and secondary) between January 2000 and May 2009 were reviewed retrospectively, and clinical and laboratory information related to HLH criteria, in addition to neopterin levels, was recorded. A group of 50 patients with active juvenile dermatomyositis (JDM) (who routinely have neopterin levels assessed) served as controls for the assessment of the accuracy, sensitivity, and specificity of neopterin as a diagnostic test for HLH. The Pearson correlation was used to measure the association between serum neopterin levels and established HLH-related laboratory data. Serum neopterin levels were measured using a competitive enzyme immunoassay. During the time frame of the study, 3 patients with familial HLH and 18 patients with secondary HLH were identified as having had serum neopterin measured (all HLH patients were grouped together). The mean neopterin levels were 84.9 nmol/liter (standard deviation [SD], 83.4 nmol/liter) for patients with HLH and 21.5 nmol/liter (SD, 10.13 nmol/liter) for patients with JDM. A cutoff value of 38.9 nmol/liter was 70% sensitive and 95% specific for HLH. For HLH patients, neopterin levels correlated significantly with ferritin levels (r= 0.76,P= 0.0007). In comparison to the level in a control group of JDM patients, elevated serum neopterin was a sensitive and specific marker for HLH. Serum neopterin has value as a diagnostic marker of HLH, and prospective studies are under way to further evaluate its role as a marker for early diagnosis and management of patients.

Correlate adenoid size as determined by lateral neck radiographs and intra-operative mirror exam. Determine if a radiologist's assessment of the lateral neck X-ray correlates with adenoid size. Assess the correlation of endoscopic findings to the degree of adenoid hypertrophy seen on intra-operative mirror exam. To perform a cost analysis of radiographic and endoscopic evaluations of the adenoids.Retrospective study.Patients who underwent adenoidectomy were reviewed. The adenoid size as determined by the adenoid-to-nasopharyngeal (A/N) ratio, radiology report, and flexible nasal endoscopy were compared to the adenoid size as determined by intra-operative mirror nasopharyngeal exam. Compensation rates for each modality were compared.Sixty-one children had pre-operative airway radiography. Ninety-nine patients underwent flexible nasopharyngoscopy. When the A/N ratio was compared to the intra-operative mirror exam, the Pearson Correlation coefficient was 0.64 (p0.0001). The radiology reading was compared to intra-operative mirror exam and the Spearman Correlation coefficient was 0.29 (p=0.0258). When endoscopic nasopharyngoscopy was compared to intra-operative mirror exam, the Pearson Correlation coefficient was 0.62 (p0.0001). The cost of nasal endoscopy was $654. Lateral airway radiography plus radiology interpretation cost $605.Children who undergo lateral radiographs to assess adenoid size are younger than those who undergo awake flexible endoscopic nasopharyngoscopy. Both the A/N ratio and endoscopic nasopharyngoscopy correlate well with the findings of the intra-operative mirror exam. The radiologist interpretations that do not utilize the A/N ratio measurement do not correlate well with intra-operative mirror exam findings. Both modalities are comparable in cost.

Our objective was to examine clinical/electrocardiogram (ECG) predictors and outcomes of arrhythmias beyond 1 year after pediatric heart transplantation (HTx). We performed a retrospective chart review of 94 1-year HTx survivors, 1988–2006. Clinical records identified patients with arrhythmias occurring >1 year after HTx requiring pharmacotherapy, excluding acute rejection. We reviewed preoperative diagnosis, gender, age at HTx, operative details, transplant coronary artery disease (TCAD), and mortality. We analyzed serial ECGs after HTx for HR, PR, QRS, QT, and QTc intervals. Our results found complete data in 58 patients, 14 (24%) with arrhythmia and 44 controls. Arrhythmias occurred 1.1–17.9 years after HTx (mean = 6.8): 11 focal atrial tachycardia, 1 atrial fibrillation/flutter, 1 atrioventricular node reentry tachycardia; only 1 patient had ventricular tachycardia (VT). Serial ECG intervals were similar between groups, as well as surgical technique, ischemic time, and rejection history. Seven patients (50%) with arrhythmias had death or graft death versus 11% of the controls (P = 0.006). Patients with arrhythmias were more likely to be diagnosed with TCAD (P = 0.007). The patient with VT had no TCAD. In conclusion, supraventricular arrhythmias were frequent (22%) in 1-year survivors of pediatric HTx. These patients were more likely to develop TCAD and/or graft loss/mortality.

The goal of this study was to evaluate tobacco-related documentation in children's medical records.A cross-sectional, consecutive sample of 4216 parents at 13 primary care practices was surveyed on demographics, health habits, and smoking status of household members. The medical records of 2085 children from a subsample of 1149 families (all households with smokers and a sample of nonsmoking households) were reviewed for tobacco-related documentation at the first visit to the practice and visits in the 14 months preceding recruitment. Relationships of documentations with visit type, household smoking status, and use of charting prompts were examined.Most children (93%) hador =1 visit during the reviewed period (77% had a health supervision visit), 23% were agedor =11 years, 52% were Medicaid/uninsured, and 70% lived with smokers; 30.6% of children had family tobacco use status documented at a first visit to the practice and 15.4% had prenatal tobacco use status documented. Among children with a visit in the reviewed period, 39.3% with a health supervision visit and 9.6% without had a tobacco-related notation at a visit (P.001). Overall, 15.2% of children living with a smoker had a visit notation indicating that someone in the household smoked. In households with smokers, documentation of household tobacco use status often disagreed with parent survey. Charting prompts significantly increased rates of identification of family tobacco use history and prenatal tobacco use history.Correct identification of household smoking status was absent for most children living with smokers. Improved documentation systems may facilitate tobacco-related surveillance and counseling.

ADV has emerged as an important pathogen in children undergoing allogeneic HPCT. A prospective study of the epidemiology of ADV infection and preemptive therapy of high risk ADV infections in children undergoing HPCT was undertaken. Cultures of throat, urine, and stool for viral pathogens and plasma for ADV PCR were obtained prior to transplantation, weekly for the first 100 days, and then monthly for one yr. Children developing high-risk ADV infections were treated preemptively with cidofovir 1 mg/kg/day given three times weekly for three wk. A case-controlled study was performed to identify risk factors for high-risk ADV infections. Seven (18%) of the 38 subjects developed high-risk ADV infections usually within 100 days of HPCT and were preemptively treated with i.v. cidofovir at a dose of 1 mg/kg/dose three times weekly for nine doses. High-risk ADV infections resolved in all seven patients without renal toxicity. CMV viremia occurred in two of seven patients during or shortly after therapy with cidofovir. A case-control study did not identify any risk factors that achieved statistical significance. Treatment with a modified dosing regimen of cidofovir was well-tolerated and high-risk ADV infections resolved in all patients.

We hypothesized that transillumination would increase peripheral intravenous (IV) insertion success rates in pediatric emergency department patients. Primary outcome was success in first attempt, and secondary outcome was success within 2 attempts.We evaluated IV insertion by pediatric emergency department physicians and nurses using the Veinlite (TransLite, Sugar Land, Tex). Patients who required nonemergent IV insertion were enrolled if younger than 3 years or aged 3 to 21 years with a history of difficult access. Participants were randomly assigned to transillumination or nontransillumination. Analyses were performed using a mixed-effects logistic regression model adjusting for provider effect.We evaluated 240 patients. After adjusting for significant covariates (safety catheter [P = 0.008], visibility [P = 0.01], and palpability [P = 0.03]) and controlling for provider effect, IV placement was more likely successful in first attempt in transilluminated patients (P = 0.03; odds ratio, 2.1 [95% confidence interval, 1.1-3.9]). After adjusting for significant covariates (safety catheter [P0.001], location [P = 0.005], and palpability [P = 0.05]) and controlling for provider effect, IV placement was more likely successful within 2 attempts in transilluminated patients (P = 0.01; odds ratio, 3.5 [95% confidence interval, 1.4-8.9]). Intracluster correlation for random effect of provider was 10% in first attempt and 16% within 2 attempts.After adjusting for multiple significant covariates and controlling for random effect of provider, our results indicated a benefit in the use of Veinlite transillumination for IV insertion in first attempt and within 2 attempts. This technique seemed to facilitate nonemergent IV placement in pediatric patients compared with standard practice.

We compared the remission of pediatric primary nocturnal enuresis in groups of children who used a physician advised practice plan vs a parent chosen alternative.Between January 2004 and January 2006 there were 119 patients with primary nocturnal enuresis enrolled in this prospective, nonrandomized study. For this study primary nocturnal enuresis was defined as wetting at night during sleep during any 6-month interval without any known causative problem. A total of 76 children received the physician advised treatment plan and used an alarm, oxybutynin, desmopressin, an elimination diet and a bowel program, as indicated. A total of 43 children received a parent chosen alternative treatment plan, which consisted of any single or combination of treatments involving an alarm, oxybutynin, desmopressin and an elimination diet or bowel program. Parents from each group completed an intake survey that measured functional bladder capacity using a 3-day home diary and they identified demographic variables. Followup occurred at 2 weeks and then monthly for 12 weeks to study end.We found that the probability of remission by the end of the study for the physician advised treatment group was significantly higher than that of the parent choice group (88% vs 29%, Kaplan-Meier curve p0.0001).The group of children who followed physician advised treatment for primary nocturnal enuresis showed significantly earlier remission of primary nocturnal enuresis than children who followed the parent choice treatment (25th percentile 2 vs 10 weeks).

Among the myriad of skills required of emergency medicine (EM) physicians, communicating concise and effective transitions in care is one of the most critical for patient safety. EM physicians transition care daily, both within their own department and among other specialties. We will discuss the crucial link between care transitions and patient safety, the processes and challenges in the hand-over exchange, and recommend an approach to improve your current system with transitions in care.

Although in-depth interviewing is well suited to studying the sensitive topic of end-of-life decision making, no reports have been published assessing the effects on parents of participating in interviews regarding end-of-life decision making for critically ill children.To examine the reactions of pediatric intensive care unit (PICU) patients' parents to interviews on end-of-life decision making for their child.We conducted semistructured interviews on end-of-life decision making with PICU patients' parents from two tertiary care PICUs. We approached 117 parents of 102 patients. Seventy-four parents (63%) of 69 patients participated.Forty-three parents (61%) described the interview as "a good experience," 20 (29%) as "a neutral experience," and 1 (1%) as "a bad experience." The parent who judged the interview negatively stated that, "It bothers me a little bit because my son is [out] there having difficulties and I'm in here and not out there." Fifty-four of 59 parents (92%) said they would participate in another similar interview. Most parents (92%) felt the medical community should continue research on end-of-life decision making. Themes identified from the responses included: emotional reaction to the interviews; exposure to end-of-life decision-making issues; impact on parents' views; and impact on future end-of-life decision making. Parents' comments suggested that many perceived the interviews as beneficial.This study demonstrates the willingness of many parents of critically ill children to participate in study interviews regarding end-of-life decision making, a topic that most parents felt was important and warranted more research.

The following paper is a report outlining a significant work pattern change in an acute cardiac ward at a large Brisbane-based private hospital. The nursing staff expressed the desire for more flexible rostering and the opportunity to work 12-hour shifts. After agreement was reached between the hospital, the union and the Industrial Relations Board, guidelines were put in place and a Flexible Rostering System was proposed and trialed An 80% consensus of staff was required both to proceed with the trial and to implement any permanent changes. Initially, the trial was conducted for three months and extended to six months. The shifts trialed were between four and 12 hours in length with varied starting and finishing times. The Flexible Rostering System was evaluated using feedback from staff surveys and the results of a staff vote. In addition, patient feedback, incident reports, financial and managerial evaluation of staff costs, hours per patient day utilised, sick leave, and the use of permanent staff for voluntary extra shifts were also monitored. The outcome of the trial was positive with over 80% of staff voting to implement the Flexible Rostering System permanently. A significant reduction in sick leave of 41 % and improved retention of skilled registered nursing staff was noted. There was no increase in the number of incident reports or patient complaints. Both patients and nurses commented on the improved continuity of care. Salaries and wages were within budget. Staff surveys showed positive feedback such as increased morale, increased flexibility with rosters, decreased fatigue levels, improved patient assessment on night duty and an increase in number of days off. In conclusion, the Flexible Rostering System has been accepted as a positive change for staff and is cost effective for the hospital. In light of nursing shortages, the outcome of this trial cannot be ignored.

Nosocomial transmission of respiratory syncytial virus (RSV) is a serious, preventable cause of RSV infection. Passive RSV prophylaxis became available in 1996. We compared the RSV nosocomial infection rate in our neonatal intensive care unit before and after RSV prophylaxis, using nosocomial rotavirus infections as a comparator. There were no significant differences between nosocomial RSV infection rates before and after institution of prophylaxis.

The practice of emergency medicine (EM) requires proficient and expert skills in multiple high risk procedures. The emergency physician in-training needs a safe and realistic environment in which to practice and perfect the skills necessary to care for patients ranging from the critically ill to the patient with difficult intravenous access. Undergraduate medical, education overall has a need for training that enables students to develop the knowledge, skills and attitudes to practice in a variety of specialties. This article provides an overview of simulation in a three-year emergency medicine residency at Truman Medical Center, in a required final year clerkship for all medical students at the University of Missouri-Kansas City, and discusses national trends for the use of simulation in emergency medicine.

The Accreditation Council for Graduate Medical Education requires residency training programs to teach and assess professionalism in residents; however, programs may struggle to successfully remediate residents not meeting professionalism standards. To assist programs with this complex issue, a Professionalism Remediation Task Force was formed by the Council of Emergency Medicine Residency Directors (CORD-EM), which surveyed program directors (PDs) concerning their experiences. The purpose of this study is to report survey results regarding the identification and rating of unprofessional behaviors and challenges in the evaluation and remediation of professionalism.In June 2010, the task force sent an anonymous survey via the CORD-EM listserv to PDs with active EM programs.Fifty percent (77/154) of eligible PDs responded to the survey. Most PDs rated the unprofessional behaviors of interpersonal/communication conflicts, lack of responsibility during patient care, lack of respect of coworkers, and reports of impairment as "critical"; repeated tardiness, incomplete work, poor ability to accept feedback, poor attitude, and repetitive unresponsiveness to aid colleagues were rated as "very serious"; frequent missed deadlines were "serious"; and repetitive failure to complete medical records was rated as "mildly serious." A resident with "less serious" professionalism issues was also felt to be likely to have "serious" or "critical" issues "often" (33.8% of respondents) or "always" (6.5%). The most common methods of assessment were clinical/advisor evaluations. However, existing assessment methods were described as inadequate in identifying serious professionalism issues by 50.7% of responding PDs. Unprofessionalism was most commonly discovered by unofficial faculty complaint (54.5%). Eighty percent report that professionalism is more difficult to remediate than other core competencies. Resident ownership of the problem was reported as most critical to remediation success (84.4%). PDs perceived the greatest challenges in residency remediation to be lack of resident insight or responsibility for the problem (45.2%) and personality/behavioral issues (32.9%).Identification and remediation of professionalism in EM residents is challenging. A future goal is to create a system by which PDs can use standardized pathways as a guide to identify and remediate unprofessional conduct.

Objectives.To characterize handwashing behaviors of children and assess the efficacy of a waiting room-based hand hygiene intervention at improving handwashing ability.Design.Prospective randomized pilot study.Setting.Emergency department waiting room at a freestanding urban pediatric hospital.Participants.Children (8–18 years) and their parent.Intervention.Participants were randomized to glow gel hand washing without hand hygiene education or glow gel hand washing with hand hygiene education. After participants washed with glow gel, “dirty areas” were illuminated using a black light, and hands were scored. A questionnaire about handwashing behavior was administered. All subjects returned 2–4 weeks after intervention to repeat glow gel hand washing and the questionnaire.Results.Sixty pediatric patients and 57 parents were recruited, with 77% of patients returning for follow up. Patients were 50% male, 58% Latino, 28% African American, and 8% Caucasian. At the initial visit, 91% of children reported hand washing after using the bathroom and 78% reported hand washing before dinner. On the basis of objective scoring, all children improved handwashing ability when compared with the initial visit (P = .02) and were more likely to use warm water at follow up (P = .01). Parents did not significantly improve in handwashing ability (P = .73).Conclusion.Glow gel hand washing is an effective method to improve children's handwashing ability. This short-term intervention was effective even in the absence of specific hand hygiene education. This intervention could serve as a valuable public health measure to teach hand washing in healthcare settings.

It has recently been demonstrated that variability in blood phenylalanine levels is inversely correlated with IQ and is a better predictor of IQ in early and continuously treated patients with phenylketonuria (PKU) than mean blood phenylalanine levels. This suggests that stability of blood phenylalanine should be a therapeutic goal in patients with PKU. The purpose of this study was to determine if treatment with sapropterin in patients with BH4-responsive PKU would increase the stability of blood phenylalanine levels. The records of all patients treated with sapropterin in the PKU Clinic at Children's Memorial Hospital in Chicago were examined retrospectively. Patients were included in the study if they were responsive to sapropterin during a 2- to 4-week challenge (reduction of blood phenylalanine level of at least 25% after 2weeks of therapy or, in the case of patients with well-controlled blood phenylalanine at the time of testing, increased dietary phenylalanine tolerance by 4weeks of treatment). A total of 37 subjects were eligible for inclusion (16male; 21 female); the mean age was 12.6years (range, 1.5–32.0). The total number of observations (phenylalanine levels) for all subjects was 1391 with a mean of 39 per subject (range, 13–96). Linear mixed modeling was utilized to estimate variances of the blood phenylalanine before (pre) and after (post) starting sapropterin. Likelihood ratio test was performed using SAS 9.1. Means and standard deviations for phenylalanine as estimated by the model were 6.67mg/dl (4.20) and post 5.16 (3.78). The mean level post-sapropterin was significantly lower ( p =.0002). The within-subject variances (mean and SD) of phenylalanine were: pre 6.897 (2.62) and post 4.799 (2.19). These two variances are significantly different with a p =.0017. We conclude that sapropterin therapy results in increased stability of blood phenylalanine levels. This effect is likely to improve cognitive outcome in BH4-responsive patients with PKU.

The Accreditation Council for Graduate Medical Education requires residency training programs to develop methods to teach and assess communication skills in residents to ensure competence as a practitioner. In response, we piloted a communication curriculum for emergency medicine residents. We describe the curriculum and suggest future directions for development based on the strengths and weaknesses of residents' performance and their reactions to the curriculum.Twenty-six residents in a 3-year program at a university-affiliated county hospital participated. Curriculum components were an introductory session, a single standardized patient encounter using a locally written, unvalidated checklist assessing residents' communication skills, a videotape-facilitated self-assessment, and a private feedback session.Residents demonstrated greatest strengths in basic interpersonal skills and efficient information gathering and greatest weakness in empathy. Residents rated the curriculum favorably.The curriculum as implemented offers an initial foundation for teaching and learning critical care communication. Instruction in empathy requires improvement.

Objective To broaden existing knowledge of pediatric end-of-life decision making by exploring factors described by parents of patients in the pediatric intensive care unit (PICU) as important/influential if they were to consider withdrawing life-sustaining therapies. Design Quantitative and qualitative analysis of semi-structured one-on-one interviews. Setting The PICUs at 2 tertiary care hospitals. Participants English- or Spanish-speaking parents who were older than 17 years and whose child was admitted to the PICU for more than 24 hours to up to 1 week. Intervention Semi-structured one-on-one interviews. Results Forty of 70 parents (57%) interviewed said they could imagine a situation in which they would consider withdrawing life-sustaining therapies. When asked if specific factors might influence their decision making, 64% of parents said they would consider withdrawing life-sustaining therapies if their child were suffering; 51% would make such a decision based on quality-of-life considerations; 43% acknowledged the influence of physician-estimated prognosis in their decision; and 7% said financial burden would affect their consideration. Qualitative analysis of their subsequent comments identified 9 factors influential to parents when considering withdrawing life-sustaining therapies: quality of life, suffering, ineffective treatments, faith, time, financial considerations, general rejection of withdrawing life-sustaining therapies, mistrust/doubt toward physicians, and reliance on self/intuition. Conclusion Parents describe a broad range of views regarding possible consideration of withdrawing life-sustaining therapies for their children and what factors might influence such a decision.

To examine risk factors for lack of immunization, we tested the impact of maternal, paternal, and household variables on child immunization status in childrenor =1 year in a rural area of Ethiopia. Data collected by face-to-face interview on maternal, paternal, household and child variables from cross-sectional random sample community-based study on health and well-being in rural Ethiopia was used to test hypotheses on immunization status of children (n = 924). Bivariate and multivariate logistic regression models were used for two immunization outcomes: record of at least one vaccination, and record of DPT3, indicating completion of the DPT series. Complete data were available for 924 childrenor =1 year of which 79% had at least one vaccination. Of those, 64% had DPT3/Polio3; below recommended coverage level. Children were more likely to be vaccinated if the mother reported antenatal care (ANC), and less likely to be vaccinated if the mother had a history of stillbirth, and no opinion of health center. Children were more likely to have DPT3 if: mother hador =1 year of education, mother reported ANC, or older paternal age. Children were less likely to have DPT3 in households with food insecurity and no maternal opinion of health center. The study had three findings with implications for immunization programming: (1) Mothers completing the recommended ANC visits is strongly associated with receiving at least one vaccination and with completing a vaccination series; (2) Maternal education is associated with a completed vaccination series; (3) Paternal characteristics may affect vaccination series completion.

Hispanic ethnicity is an independent risk factor for increased morbidity and mortality in cystic fibrosis (CF) patients. In order to compare the prevalence of risk factors for morbidity and mortality between the Hispanic CF population and the non-Hispanic CF population, we performed a cross-sectional study of patients in the 2004 Cystic Fibrosis Foundation Patient Registry. Among 22,714 CF patients, 1,511 were identified as ethnic Hispanic. Hispanic patients were diagnosed earlier (2.8 vs. 3.3 years, P = 0.005) and acquired Pseudomonas aeruginosa at a younger age (6.6 years vs. 10 years, P0.001). FEV(1) was lower for Hispanic patients (81.5% vs. 87% predicted for those under 18 years old [P0.001] and 2.1 L vs. 2.3 L for those 18 years and older [P = 0.01]). Hispanic patients had similar or better nutritional status. Hispanic patients were more likely to be diagnosed with liver disease (OR 1.31 [1.1, 1.56]) but less likely to be diagnosed with depression (OR 0.53 [0.39, 0.68]), bone and joint disease (OR 0.55 [0.41, 0.71]), or CF-related diabetes (OR 0.53 [0.43, 0.62]). Hispanic patients had lower median income by zip code ($41,930 vs. $47,341; P0.001), a higher rate of government insurance (55.2% vs. 32.0%; P0.001), and greater percentage of mothers with less than a high school education (26.7% vs. 6.5%; P0.001). We conclude that there is an increased prevalence of important risk factors for morbidity and mortality in the Hispanic CF population.

Approximately 10% to 50% of competitive athletes experience asthma symptoms with exercise, due to either chronic asthma or exercise-induced bronchospasm. Early recognition and management of asthma symptoms may improve athletic performance and quality of life for athletes with asthma or exercise-induced bronchospasm. Athletic trainers may have frequent opportunities to identify asthma symptoms and assist athletes with management.To survey athletic trainers about their experience and comfort with evaluation and management of asthma symptoms in athletes and identify athletic trainer characteristics associated with higher comfort levels.A 2005 cross-sectional survey of National Athletic Trainers' Association and Illinois Athletic Trainers Association members.A total of 304 athletic trainers.Respondents completed a Web-based survey reporting years of experience, competitive level of athletes supervised, satisfaction with asthma education, experience evaluating asthma symptoms, and comfort managing asthma.Response rate was 13.9% (304 of 2,175). At least 23% of respondents evaluated asthma symptoms five or more times the previous year. Respondents working exclusively with junior high and/or high school athletes evaluated asthma symptoms more frequently than those working exclusively with college and/or professional athletes. Fifty-eight percent of respondents were unsatisfied with their asthma education. Only 25.3% were "very" comfortable managing asthma. Respondents with higher comfort levels evaluated asthma symptoms more frequently (p0.01, r = 0.18) and were more likely to be satisfied with their asthma education (p0.001). Over 95% of respondents endorsed more asthma education in athletic training curricula.Results of this pilot study indicate that athletic trainers have opportunities to help athletes manage asthma symptoms that can compromise athletic performance or limit sports participation. However, few athletic trainers are very comfortable managing asthma, and most are unsatisfied with their asthma education. Further study is needed to determine the effect of enhanced asthma education on athletic trainers' comfort and skills with asthma evaluation and management.

Medical students need to learn how to recognize and manage critically ill patients; to communicate in critical situations with patients, families, and the healthcare team; and finally, to integrate technical knowledge with communication skills in caring for these patients. Meeting their needs will help prepare them to demonstrate, as physicians, the ability to synthesize information while simultaneously caring for patients, that the American Medical Association recently characterized as vital.Responding to these needs, we developed and implemented a curriculum to enable students in a required emergency medicine clerkship to recognize, manage, and simultaneously communicate with critically ill patients.The curriculum consisted of lectures and exercises on caring for the critically ill including: an introduction to the systematic approach; an interactive lecture on comprehensive communication; observation and discussion of real patients in the emergency department; participation in a single standardized patient encounter while peers and a faculty member observed them; assessment of students' own videotaped performance of the examination by using critical care and communication/interpersonal skills checklists; and receipt of private feedback based on the checklists from the faculty and the standardized patient. Students evaluated the curriculum at the end of the clerkship.Complete performance data for 46 students and curriculum evaluation data from 42 students were available. According to faculty assessment, students as a group performed 79.6% (SD 0.15) of the critical care and 70.9% (SD 11.5%) of the communication skills. Students most often demonstrated Basic Interpersonal Skills (97.9%, SD 0.056) and least often demonstrated Empathy skills (41.7%, SD 0.235). Students rated the curriculum positively.It is feasible to integrate the teaching of communication skills with the recognition and management of critically ill patients. The next step will be to revise the curriculum to address student deficiencies and to evaluate its effectiveness more rigorously.

Successful mentoring programs for new graduate nurses are designed to provide professional supports to ease the transition of these newcomers from student to practicing nurse. In the financially constrained health care environment, a resource-intensive program can be sustained only by leaders who see quantitative evidence of organizational impact over time. A descriptive study was undertaken at a pediatric academic medical center to compare the job satisfaction and retention rates of two cohorts of new graduate nurses: one before and one after the implementation of a Pediatric RN Internship Program. In this study overall job satisfaction was significantly higher in the post-internship group as compared to the pre-internship group. Improved job satisfaction was also reflected in a lower turnover rate (12% vs. 20% in the pre-internship group) that was sustained during the 2-year post-intervention study period. By lowering turnover rates, organizations avoid costs associated with recruitment, orientation, and temporary labor coverage for vacant RN positions.

The aim of this study was to compare functional gait differences between patients with myelomeningocele (MM) who have a ventriculoperitoneal shunt (VPS) with those who do not. Our analyses were adjusted for confounding by age, lesion level, orthotic use, and assistive device use. The Functional Mobility Scale (FMS) was used to compare the shunted group (n=98; 60 males, 38 females; mean age 10y 2mo [SD 3y 11mo]; 73 sacral/19 low lumber/six high lumbar lesion level) with the non-shunted group (n=63; 32 males, 31 females; mean age 9y 11mo [SD 3y 11mo]; 45 sacral/12 low lumber/six high lumbar lesion level). Participants with a shunt had lower FMS 500 and FMS 50 scores compared with participants without a shunt; hence the participants without a shunt were more independent in their ambulation at medium and longer distances. For a subset of participants who underwent a three-dimensional gait analysis, we also collected temporal-spatial gait parameters (velocity, cadence, and stride length). Our results show that participants with MM and no shunt who underwent gait analysis(11 males, 10 females; mean age 9y 6mo [SD 4y]; 15 sacral/6 low lumber/0 high lumbar lesion level) tend to walk at a significantly greater velocity and stride length as compared with those with a shunt (33 males, 18 females; mean age 10y [SD 4y]; 38 sacral/13 low lumber/zero high lumbar lesion level). These data allow the treatment team to present more specific information regarding functional ambulatory expectations to patients with MM and their families.

The purpose of this study was to evaluate the safety and efficacy of pressure-limited power injection of contrast medium through central lines for pediatric body CT examinations.All patients with a central line who were referred for body CT examinations requiring an i.v. contrast agent were prospectively evaluated. The power injector was pressure limited to 25 psi (172 kPa). A standard dose of 2 mL/kg of iodinated contrast medium was power-injected through the central line. Two pediatric radiologists scored all examinations on a scale of 1 (poor) to 5 (superior) for adequacy of contrast enhancement. Regression and receiver operating characteristic analyses were performed.The subjects were 63 patients 0.3-22 years old. Nineteen of these patients had tunneled lines, 18 had ports, and 26 had peripherally inserted central catheters. There were no complications related to power injection. Regression analysis showed a significant association between patient weight and contrast enhancement adequacy score (p0.001), higher patient weights yielding lower contrast enhancement adequacy scores. Receiver operating characteristic analysis showed a weight cutoff of 30 kg as a reasonable predictor of adequacy of contrast enhancement. For patients weighing 30 kg or more, the average contrast enhancement score was 2.4 (suboptimal to adequate). For patients weighing less than 30 kg, the average contrast enhancement score was 3.4 (adequate to good).Pressure-limited power injection through central lines in children is safe. The contrast enhancement obtained with 25 psi (172 kPa) pressure-limited injection is acceptable only for patients who weigh less than 30 kg.

OBJECTIVES. The goals were to determine whether primary care provider identification of children as overweight was associated with additional screening or referrals and whether the types and numbers of visits to primary care differed for overweight and nonoverweight children. METHODS. Sequential parents/guardians at 13 diverse pediatric practices completed an in-office survey addressing health habits and demographic features. Medical records of each child from a sample of families were reviewed. Data were abstracted from the first visit and from all visits in the 14-month period before study enrollment. Analyses were limited to children ≥2 years of age for whom BMI percentile could be calculated. RESULTS. The analytic sample included 1216 children (mean age: 7.9 years; 51% male) from 777 families (parents were 43% white, 18% black, 34% Hispanic, and 5% other; 49% of families had a child receiving Medicaid/uninsured). Among overweight children (BMI of ≥95th percentile; n = 248), 28% had been identified as such in the record. Screening or referral for evaluation of comorbidities was more likely among overweight children who were identified in the record (54%) than among overweight children who were not identified (17%). Among children at risk of overweight (BMI of 85th to 94th percentile; n = 186), 5% had been identified as such in the record and overall 15% were screened/referred. In logistic regression modeling, the children identified as overweight/at risk of overweight had 6 times greater odds of receiving any management for overweight. CONCLUSIONS. Low rates of identification of overweight status and evaluation or referrals for comorbidities were found. Identification of overweight status was associated with a greatly increased rate of screening for comorbidities.

Pseudomonas aeruginosa is a frequent cause of respiratory exacerbations in individuals with cystic fibrosis. An important virulence determinant of this pathogen is its type III protein secretion system. In this study, the type III secretion properties of 435 P. aeruginosa respiratory isolates from 56 chronically infected individuals with cystic fibrosis were investigated. Although it had been previously reported that 75 to 90% of P. aeruginosa isolates from patients with hospital-acquired pneumonia secreted type III proteins, only 12% of isolates from cystic fibrosis patients did so, with nearly all of these isolates secreting ExoS and ExoT but not ExoU. Despite the low overall prevalence of type III protein-secreting isolates, at least one secreting isolate was cultured from one-third of cystic fibrosis patients. Interestingly, the fraction of cystic fibrosis patient isolates capable of secreting type III proteins decreased with duration of infection. Although 90% of isolates from the environment, the presumed reservoir for the majority of P. aeruginosa strains that infect patients with cystic fibrosis, secreted type III proteins, only 49% of isolates from newly infected children, 18% of isolates from chronically infected children, and 4% of isolates from chronically infected adults with cystic fibrosis secreted these proteins. Within individual patients, isolates of clonal origin differed in their secretion phenotypes, indicating that as strains persisted in cystic fibrosis patient airways, their type III protein secretion properties changed. Together, these findings indicate that following infection of cystic fibrosis patient airways, P. aeruginosa strains gradually change from a type III protein secretion-positive phenotype to a secretion-negative phenotype.

Objective: Length of time elapsed between recurrent laryngeal nerve (RLN) injury and surgery may affect voice result. The purpose of this study was to compare voice outcome after thyroplasty in patients with short- and long-term vocal fold immobility. Methods: Thirty-five patients with longstanding vocal fold immobility (8.3 years) and 35 patients more acutely denervated (10 months) underwent type I thyroplasty. Trained listeners before and after surgery rated perceptual judgments of voice. Acoustic and aerodynamic data were analyzed. Results: Voice outcome did not differentiate the two groups with respect to objective measures. Perceptual ratings of post-operative voice quality favored the short-term patients, with the long-term group having a mildly ‘constricted’ quality. Conclusion: Thyroplasty yields a functional voice result even when substantial time has elapsed. Patients with chronic immobility may be unable to release longstanding hyperfunctional voicing behaviors even after surgery has afforded them an improved mechanism. In five of 35 long-term patients, therapy enhanced voice quality.

A 24-item tool, using a Likert attitudinal scale, was developed to measure labor and delivery nurses' attitudes toward fetal monitoring and was administered to 124 nurses. For each of the 24 attitude statements, cumulative responses were over 50% positive at least. Fifty-two percent of the nurses felt that routine continuous monitoring of all labor patients would be ideal, and 88% felt that the fetal surveillance achieved by monitoring cannot be matched by intermittent auscultation.

A new instrument for harvesting craniotome bone dust is described. This has been designed with the contours of the skull in mind and the ideal bone fragment size for satisfactory graft take.

Nager's syndrome, which has the facial features of Treacher Collins syndrome, preaxial upper limb defects, short stature, and frequently subnormal intelligence, is very rare. Five new cases have been collected. In four, there was virtually total absence of the soft palate. This has been described in two patients in the past. Differing methods of correcting this are presented.

Prenatal education should be initiated as soon as any pregnancy is suspected. This article describes the development and improvement of a program of early prenatal education for a large obstetrical population initiated prior to the completion of the first trimester.