Ambulatory Child Health最新文献

Objective  To evaluate the effect of a quality improvement initiative which utilized educational interventions combined with a phone follow-up program on the rate of return for tuberculin skin test (TST) interpretation.

Design Before and after trial with analysis of practice records for all TSTs placed.

Setting/Sample  The study was conducted in a resident and attending primary care practice in an urban children's hospital. All children (n = 1315) who had TSTs placed during August and October of 1995 and August and October of 1996 were included in the study.

Intervention  Medical staff were re-educated regarding TST screening. Patients families were given written information about tuberculosis. Physicians and nursing staff discussed TST screening with the patients' families prior to TST placement. All patients received a series of three reminder telephone calls on three consecutive days to remind them to return for TST interpretation followed by a letter if necessary. The following data were collected: date of birth, age, zip code, type of provider, transit time from the hospital, type of health insurance, number of telephone calls made, and return status for TST interpretation. Return rates were compared pre- and post-intervention.

Results  A total of 1315 TSTs were placed during the pre- (n = 611) and post-(n = 704) intervention periods. Return rates increased from 6.2 to 61.5%. Attendings' patients and those with private insurance were more likely to return. There was no relationship to season, age or distance from the practice.

Conclusions  Targeted screening programs utilizing more effective methods for TST interpretation should be considered.

Background The standard recommendation for treatment of young, febrile children with urinary tract infection has been hospitalization for intravenous antimicrobials. The availability of potent, oral, third-generation cephalosporins, as well as interest in cost containment and avoidance of nosocomial risks prompted evaluation of the safety and efficacy of outpatient therapy.

Methods In a multicentre, randomized clinical trial, the investigators evaluated the efficacy of oral versus initial intravenous therapy in 306 children 1 to 24 months old with fever and urinary tract infection, in terms of short-term clinical outcomes (sterilization of the urine and defervescence) and long-term morbidity (incidence of reinfection and incidence and extent of renal scarring documented at 6 months by ^99mTc-dimercaptosuccinic acid renal scans). Children received either oral cefixime for 14 days (double dose on day 1) or initial intravenous cefotaxime for 3 days followed by oral cefixime for 11 days. Costs were estimated using charge-data.

Results Treatment groups were comparable regarding demographic, clinical, and laboratory characteristics. Of the short-term outcomes: (1) repeat urine cultures were sterile within 24 h in all 306 children, and (2) mean time to defervescence was 25 and 24 h for children treated orally and intravenously, respectively. Of the long-term outcomes: (1) symptomatic re-infections occurred in 4.6% of children treated orally and 7.2% of children treated intravenously; (2) renal scarring at 6 months was noted in 9.8% of children treated orally versus 7.2% of children treated intravenously; and (3) mean extent of scarring was ~8% in both treatment groups. Mean costs were at least twofold higher for children treated intravenously ($3577 versus $1473) compared with those treated orally.

Conclusions Oral cefixime can be recommended as a safe and effective treatment for children with fever and urinary tract infection. Use of cefixime will result in substantial reductions of health care expenditures.

Objective A randomised controlled trial to investigate whether parents of asthmatic children would stop smoking or alter their smoking habits to protect their children from environmental tobacco smoke.

Participants 501 families with an asthmatic child aged 2–12 years living with a parent who smoked.

Intervention Parents were told about the impact of passive smoking on asthma and advised to stop or change their smoking habits to protect their child’s health.

Main outcome measures Salivary cotinine concentrations in children, and changes in reported smoking habits of the parents 1 year after the intervention.

Results One year after the baseline visit, a small decrease in salivary cotinine concentrations was found in both groups of children, but there was no significant difference between the groups. Overall, 98% of parents in both groups still smoked at follow-up. However, there was a nonsignificant tendency for parents in the intervention group to report smoking more at follow-up and to having a reduced desire to stop smoking.

Conclusions A brief intervention to advise parents of asthmatic children about the risks from passive smoking was ineffective in reducing their children’s exposure to environmental tobacco smoke. If a clinician believes that a child’s health is being affected by parental smoking, the parent’s smoking needs to be addressed as a separate issue from the child’s health.