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Background: Racial disparities persist in early childhood wheezing and cannot be completely explained by known risk factors., Objective: To evaluate the associations of genetic ancestry and self-identified race with early childhood recurrent wheezing, accounting for socio-economic status (SES) and early life exposures., Methods: We studied 1034 children in an urban, multi-racial, prospective birth cohort. Multivariate logistic regression was used to evaluate the association of genetic ancestry as opposed to self-identified race with recurrent wheezing (>3 episodes). Sequential models accounted for demographic, socio-economic factors and early life risk factors. Genetic ancestry, estimated using 150 ancestry informative markers, was expressed in deciles., Results: Approximately 6.1% of subjects (mean age 3.1 years) experienced recurrent wheezing. After accounting for SES and demographic factors, African ancestry (OR: 1.16, 95% CI: 1.02-1.31) was significantly associated with recurrent wheezing. By self-reported race, hispanic subjects had a borderline decrease in risk of wheeze compared with African Americans (OR: 0.44, 95% CI: 0.19-1.00), whereas white subjects (OR: 0.46, 95% CI: 0.14-1.57) did not have. After further adjustment for known confounders and early life exposures, both African (OR: 1.19, 95% CI: 1.05-1.34) and European ancestry (OR: 0.84, 95% CI: 0.74-0.94) retained a significant association with recurrent wheezing, as compared with self-identified race (OR(whites) : 0.31, 95% CI: 0.09-1.14; OR(hispanic) : 0.47, 95% CI: 0.20-1.08). There were no significant interactions between ancestry and early life factors on recurrent wheezing., Conclusions and Clinical Relevance: In contrast to self-identified race, African ancestry remained a significant, independent predictor of early childhood wheezing after accounting for early life and other known risk factors associated with lung function changes and asthma. Genetic ancestry may be a powerful way to evaluate wheezing disparities and a proxy for differentially distributed genetic and early life risk factors associated with childhood recurrent wheezing., (© 2011 Blackwell Publishing Ltd.)

Objective: To examine the relationship between maternal opioid agonists, methadone, or buprenorphine (BPH), and concurrent psychiatric medication use on length of hospitalization (LOS) among infants with neonatal abstinence syndrome (NAS)., Methods: We reviewed the charts of infants born at Boston Medical Center between 2003 and 2009 with a diagnosis of NAS whose mothers were prescribed methadone or BPH for opiate addiction. Univariate and multivariate linear regression analyses were used to examine associations between maternal opioid substitution concurrent with psychiatric medication use and infant LOS. We also tested whether exposure to BPH was associated with a shorter hospitalization., Results: A total of 273 mother-infant pairs were identified. The average LOS for all infants was 22.9 days (SD: 10.9). In bivariate analyses, maternal use of any psychiatric medication was associated with a longer infant LOS (P < 0.005). Compared with those prescribed methadone alone (n = 158), those also taking benzodiazepines (n = 56) had a 5.88-day longer LOS (95% confidence interval [CI]: 2.15-9.60, P = 0.002). Infants of mothers taking methadone plus an selective serotonin re-uptake inhibitor (n = 51) had a longer LOS (β = 4.47, 95% CI: 1.15-7.79) compared to methadone alone; results remained significant in an initial multivariate model, however the effect was attenuated when additional psychiatric medication use was added to the model. Compared with those exposed to methadone, those exposed to BPH (n = 22) had a significantly shorter LOS (ß = -7.35, CI: -0.18 to -14.52, P = 0.04)., Conclusions: Maternal use of prescribed methadone and benzodiazepines, compared to methadone alone, increased LOS for infants with NAS by 6 days. Maternal use of BPH was associated with a shorter LOS.

Objective: To study when and how an urgent public health message about a boil-water order reached an urban population after the Massachusetts water main break., Methods: In-person surveys were conducted in waiting areas of clinics and emergency departments at a large urban safety net hospital within 1 week of the event., Results: Of 533 respondents, 97% were aware of the order; 34% of those who lived in affected cities or towns were potentially exposed to contaminated water. Among those who were aware, 98% took action. Respondents first received the message through word of mouth (33%), television (25%), cellular telephone calls (20%), landline calls (10%), and other modes of communication (12%). In multivariate analyses, foreign-born respondents and those who lived outside the city of Boston had a higher risk of exposure to contaminated water. New modes (eg, cellular telephones) were used more commonly by females and younger individuals (ages 18 to 34). Individuals who did not speak English at home were more likely to receive the message through their personal networks., Conclusions: Given the increasing prevalence of cellular telephone use, public officials should encourage residents to register landline and cellular telephone for emergency alerts and must develop creative ways to reach immigrants and non-English-speaking groups quickly via personal networks.

Background: The Pediatric Residency Review Committee requires programs to provide a curriculum that advances residents' knowledge of the basic principles of research. In July 2002, the Boston Combined Residency Program instituted a 3-month career-development block (CDB) rotation. During the rotation residents pursue an academic or clinical project under mentorship by a faculty member., Objective: Our objective for this study was to evaluate the outcome of the CDB rotation since it was implemented., Methods: A survey was administered to 165 residents who completed the CDB rotation., Results: Of 165 residents, 136 (82%) responded to the survey. Of 122 residents who reported the type of project they conducted, 59 (48%) completed a clinical/health services project, 24 (20%) completed a project in education or curriculum development, and 7 (6%) worked in basic science. Thirty-five residents (27%) received funding to support their work. Thirty-five residents (26%) presented at national meetings such as the Pediatric Academic Societies Meeting. Fifteen (11%) residents have had manuscripts accepted for publication, and 22 (16%) additional residents have submitted manuscripts for publication. Factors associated with successful publication included having received funding (odds ratio: 3.37 [95% confidence interval: 1.34-8.42]) and the nature of the research project (odds ratio: 3.55 [95% confidence interval: 1.40-9.04]). The majority of residents (84%) stated that the CDB rotation enhanced residency training., Conclusions: A dedicated academic rotation that includes protected time, senior faculty mentorship, and program funding, can lead to productive research accomplishments by pediatric residents. Support of academic work during residency training may encourage engagement in a variety of academically oriented activities.

Objective: To describe the quantity and type of school health services provided by nurses in Boston Public Schools., Setting: In 2001, the 63 024 students enrolled predominantly belonged to minority groups (48% black, 28% Hispanic, and 9% Asian) and were eligible for a free or reduced-price lunch (71%)., Main Outcome Measure: Analysis of the 2001-2002 Boston Public Schools Health Services database., Results: A total of 63 024 students generated 721 291 individual encounters with 93.5 full-time equivalent school nurses, including episodic care (57.8%), medication administration (31.5%), procedures (6.2%), and screening (5.1%). A total of 2420 students had an individual health care plan for the administration of medications and procedures during the school day. Students with individual health care plans averaged 117.9 encounters per year with school nurses, and students without averaged 7.2 encounters per year. Outcomes of encounters included school dismissal (3.0%); verbal communication with parents (10.6%), school staff (3.9%), and community agencies or health care providers (1.1%); and referral to a primary care provider (4.6%) or emergency services (<0.1%)., Conclusions: Some school-age children receive a large amount of health care from school nurses in Boston Public Schools. We estimate that these children are 8 times more likely to see a school nurse than a pediatric health care provider. These school nurses were involved in the care of children with mental health and chronic health care needs. Despite the extensive amount of care, little is known about the efficacy of the care provided or the effect of these services on health care use.

Objectives: To assess the utility of radiographs taken immediately after the application of a cast in the management of pediatric torus (or buckle) fractures and to determine the need for serial radiographs taken at follow-up visits., Design: Retrospective medical record review; survey questionnaire of a panel of experts., Setting: The pediatric emergency department (PED) and the pediatric orthopedic clinic at an urban, tertiary care hospital., Patients: All children with torus fractures referred to the pediatric orthopedic clinic for follow-up visits between February 1995 and February 1997., Main Outcome Measures: The number of patients whose postcast studies was obtained in the PED; number of follow-up visits and studies conducted at the pediatric orthopedic clinic; usual regional practices as extracted from a panel of experts by survey questionnaire., Results: Of 70 patients, 46 (66%) were evaluated by a single, precast study in the PED, and 24 (34%) were evaluated by both precast and postcast studies in the PED. The time range of the first follow-up study was the first to fifth week after the patient's injury. The range of the number of follow-up studies for each patient was 0 to 5. Our cohort's total radiology charges for 70 patients were $27251. Regional directors of pediatric orthopedic surgery unanimously agreed that postcast studies in the PED are unnecessary. The range of the number of follow-up studies they obtained is 0 to 3 per patient., Conclusions: Postcast studies of torus fractures are unnecessary. Multiple radiographs taken during follow-up visits, especially early in the healing process, do not change fracture management. Relying on the clinical examination, perhaps combined with a single follow-up study, is a more appropriate regimen for the management of pediatric torus fractures and translates into a cost savings of over $ 10000 for our 70 patients.

Objective: Underimmunized children are less frequently screened for anemia and elevated lead levels than those who are up-to-date (UTD). However, the association between underimmunization and actual disease (hemoglobin [Hgb] <11 g/dL or blood lead level [PbB] >/=10 microg/dL) has not been reported. The objective of this study was to evaluate the association between underimmunization, anemia, and elevated lead levels among children attending an inner-city clinic., Study Design: Data from a computer-based immunization tracking system were integrated with primary care-based laboratory data. Cross-sectional data for immunization coverage, anemia, and elevated lead levels were evaluated for children who were 1, 2, 3, and 4 years of age. The first Hgb or PbB values obtained within 6 months of the child's birthday were used., Setting: An inner-city hospital-affiliated pediatric primary care center., Patients: A child was considered to be a pediatric primary care center patient if he/she had at least 3 immunizations in the immunization tracking system and at least 1 Hgb or PbB screening test during February 1993 through February 1996., Results: A total of 4045 Hgb tests from 2672 children were available for analysis (1198, 1102, 945, and 800 at 1, 2, 3, and 4 years of age, respectively). Anemia was common during the first 4 years of life (21.2%, 15.8%, 11.0%, and 10.3% at 1, 2, 3, and 4 years of age, respectively). At 2 and 3 years of age, underimmunized children were significantly more likely to be anemic compared with UTD children (relative risk [RR] = 1.49, 95% confidence interval [CI] = 1.24-1.79 at 2 years of age; RR = 1.43, 95% CI = 1.12-1.83 at 3 years of age). Underimmunized children with anemia at 1 year of age were less likely than UTD children to resolve their anemia by 2 years of age (52.5% vs 20.8%, RR = 2.39; 95% CI = 1.47-3.87). Underimmunized children were also significantly more likely to have elevated lead levels at 2 years of age (RR = 1. 24; 95% CI = 1.03-1.5)., Conclusion: Underimmunized children in the inner city are at especially high risk for anemia and elevated lead levels. These children need routine preventive health services, as well as immunization. Integrating laboratory screening data with immunization tracking systems would be an important step toward improving the health of inner-city children.

Objective: To describe parents' opinions and concerns about antibiotics and to contrast these opinions with those of pediatricians., Design: Parents were surveyed using an interviewer-administered questionnaire and pediatricians were mailed a self-administered questionnaire., Results: Parents from two private practices (N = 300) were largely white (84%) and had completed college (81%). The parents from a community health center (N = 100) were mostly black (80%) and had not completed college (91%). Twenty-nine percent of parents were worried that their children were receiving too many antibiotics. Eighty-five percent believed there were problems with receiving too many antibiotics, with 55% mentioning resistance or immunity as concerns. Eighteen percent of parents had given their child an antibiotic at home before consulting a physician. Parents believed that antibiotics were always or sometimes required for ear infections (93%), throat infections (83%), colds (32%), cough (58%), and fever (58%). Fourteen percent of parents believed that their child had required an antibiotic when the doctor did not prescribe one, with clinic parents significantly more likely to report this issue (22%) than private practice parents (12%). Nine percent believed that their doctor had prescribed an antibiotic unnecessarily (private practice = 12%, community health center = 3%). Parents from the private practices were also more likely to report requesting a specific antibiotic (34%) in comparison with 19% of clinic parents. Sixty-one percent of the physician surveys were returned after two mailings and a follow-up phone call. The pediatricians had been in practice for a median of 12 years, seeing a median of 110 patients per week. Fifty-eight percent of pediatricians reported that some, many, or most of the parents in their practices were worried that their children were receiving too many antibiotics. Seventy-one percent indicated that four or more times during the previous month, a parent had requested an antibiotic when the physician believed it was unnecessary, and 35% said that at least occasionally they went along with these requests. Sixty-one percent reported that parents requested a different antibiotic from the one they were going to prescribe at least four times in the previous month, and 30% of pediatricians said that they agreed to parents' requests often or most of the time., Conclusions: Both the parent and the physician surveys suggest that parents are concerned about the overuse of antibiotics, but often request them when their physicians believe they are unnecessary. Parents often administer antibiotics without physician knowledge, and many parents have misconceptions about which illnesses warrant antibiotic therapy. Understanding parents' concerns and beliefs about antibiotics and the range of physician practice styles with respect to antibiotics may direct the development of intervention strategies to reduce the inappropriate use of oral antibiotics.

The concern that there are too few generalist physicians and too many specialists is part of the ongoing health care debate. Medical educators have been challenged at the graduate and undergraduate levels to educate more generalists. While some question the actual effect of medical education on the choice of a generalist career, others strongly express the view that a generalist curriculum influences graduates to pursue a career in primary care. Residency training programs are largely based in hospitals, and pediatric practice is largely community based. The terms educational malpractice, educational mismatch, and, most recently, educational dysjunction have been used to describe the difference between the educational and practice experience.

Cocaine use during pregnancy was assessed by interviews and urine assays obtained prenatally and immediately postpartum from 679 urban women enrolled in prenatal care. Of these, 17% were found to have used cocaine at least once during pregnancy. Eight percent had urine assays positive for cocaine metabolites using the enzyme-mediated immunoassay technique with a cut-off of 300 ng/mL of benzoylecgonine. Of the cocaine users, 24% denied use at the time of the interview and were identified solely by urine assay. Cocaine users were significantly (P less than .01) less likely than nonusers to be married, Hispanic, or black born outside of the United States and were less well nourished. Users reported significantly (P less than .01) more sexually transmitted diseases, prior low birth weight infants, spontaneous and elective abortions, and greater use of alcohol, cigarettes, marijuana, opiates, and other illicit drugs during pregnancy. Because cocaine use is correlated with many potential risk factors, large sample sizes and multivariate statistical techniques are needed to determine whether cocaine use during pregnancy poses an independent risk for adverse neonatal outcomes.