Heidi Splete

Dating Violence Link to STDs

Approximately 1 in 3 girls in grades 9–12 who reported sexual activity also reported sexual or physical violence from their dating partners in a study of 1,641 girls, said Michele R. Decker of Harvard School of Public Health, Boston, and her colleagues (Pediatrics 2005;116:e272–6). A similar percentage reported being tested for an STD or HIV. Overall, girls who reported physical and sexual violence or physical violence alone were significantly more likely to be tested for an STD (odds ratio 2.4 or 1.6, respectively) than were girls who did not report any violence. In addition, the odds of a positive diagnosis were significantly higher for girls reporting physical and sexual violence or physical violence alone (odds ratio 2.6 or 2.2, respectively) compared with girls who did not report any violence. The study was limited by several factors, including possible underreporting of testing behaviors, since many adolescents may not know or report their positive results.

Predicting STI Risk in Teens

Teenagers who thought their parents would strongly disapprove of their having sex were less likely to have developed sexually transmitted infections 6 years later, said Carol A. Ford, M.D., of the University of North Carolina at Chapel Hill, and her associates. The study included data on 11,594 adolescents from the National Longitudinal Study of Adolescent Health, a prospective cohort study initiated in 1995 when the participants were in grades 7–12 (Arch. Pediatr. Adolesc. Med. 2005;159:657–64). Approximately half (52.8%) of the subjects were female, and the mean age at follow-up was 22 years. Overall, 5.5% of adolescents who thought that their parents strongly disapproved of sex during adolescence tested positive for Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis, compared with 8.0% and 8.9%, respectively, of those who thought that their parents' disapproval was moderate or low. In a bivariate analysis, factors associated with an increased likelihood of sexually transmitted infections included low grade point average, a perception of looking younger than one's peers, and a higher average daily school attendance rate. However, in a stratified, multivariate analysis, family, school, and individual factors associated with prolonged virginity—such as a high grade point average or attending a parochial school—were not predictive of STI status among boys at follow-up.

Kingella kingae Rising?

In the first reported outbreak of invasive Kingella kingae disease, it affected several toddlers at a day-care center in Minnesota in October 2003, said Karen M. Kiang, M.D., of the Minnesota Department of Health, Minneapolis, and the Centers for Disease Control and Prevention, Atlanta, and her colleagues (Pediatrics 2005;116:206–13). Three cases of osteomyelitis/septic arthritis due to K. kingae occurred: in a 21-month-old boy, a 20-month-old girl, and a 17-month-old boy. The first two cases were confirmed by culture. All three children presented with limping and fevers higher than 100° F, and all three had symptoms of upper respiratory infections prior to or concurrent with the development of their skeletal infections. They were treated with a variety of medications, including intravenous cefazolin and oral amoxicillin. The researchers collected oropharyngeal cultures from 115 of 122 children who attended the day-care center, and 28 of 29 staff members. Overall, 15 (13%) of the children showed K. kingae colonization, but none of the staff members or the 14 children older than 16 months showed colonization. The three infected children had spent time in the same toddler classroom, and the staff and other children in this room received a 2-day prophylactic course of rifampin. By comparison, at a control day center, 45 (38%) of 118 children of similar ages were cultured, and 7 (16%) of them showed K. kingae colonization.

Hepatitis Rates Decline

The incidence of hepatitis dropped from 35% to 19% among children aged 2–18 years between a baseline period of 1990–1997 and 2003, said Annemarie Wasley, Sc.D., of the Centers for Disease Control and Prevention, Atlanta, and her colleagues. The greatest decline occurred among children aged 2–9 years (89%), followed by declines in children aged 10–18 years (83.7%) and children younger than 2 years (79.5%). Overall, 9 of the 10 states with the greatest declines in infection rates were states that had implemented hepatitis vaccination, which became widely available in 1995 (JAMA 2005;294:194–201). In an accompanying editorial, Pierre Van Damme, M.D., and Koen Van Herck, M.D., of the University of Antwerp, Belgium, said that given the proven existence of antibodies more than 10 years after vaccination, and the odds that antibodies will persist for more than 25 years after vaccination, boosters should be unnecessary for healthy people, and childhood vaccination can be reasonable for countries where hepatitis rates are declining (JAMA 2005;294:246–8).

Dating Violence Link to STDs

Approximately 1 in 3 girls in grades 9–12 who reported sexual activity also reported sexual or physical violence from their dating partners in a study of 1,641 girls, said Michele R. Decker of Harvard School of Public Health, Boston, and her colleagues (Pediatrics 2005;116:e272–6). A similar percentage reported being tested for an STD or HIV. Overall, girls who reported physical and sexual violence or physical violence alone were significantly more likely to be tested for an STD (odds ratio 2.4 or 1.6, respectively) than were girls who did not report any violence. In addition, the odds of a positive diagnosis were significantly higher for girls reporting physical and sexual violence or physical violence alone (odds ratio 2.6 or 2.2, respectively) compared with girls who did not report any violence. The study was limited by several factors, including possible underreporting of testing behaviors, since many adolescents may not know or report their positive results.

Predicting STI Risk in Teens

Teenagers who thought their parents would strongly disapprove of their having sex were less likely to have developed sexually transmitted infections 6 years later, said Carol A. Ford, M.D., of the University of North Carolina at Chapel Hill, and her associates. The study included data on 11,594 adolescents from the National Longitudinal Study of Adolescent Health, a prospective cohort study initiated in 1995 when the participants were in grades 7–12 (Arch. Pediatr. Adolesc. Med. 2005;159:657–64). Approximately half (52.8%) of the subjects were female, and the mean age at follow-up was 22 years. Overall, 5.5% of adolescents who thought that their parents strongly disapproved of sex during adolescence tested positive for Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis, compared with 8.0% and 8.9%, respectively, of those who thought that their parents' disapproval was moderate or low. In a bivariate analysis, factors associated with an increased likelihood of sexually transmitted infections included low grade point average, a perception of looking younger than one's peers, and a higher average daily school attendance rate. However, in a stratified, multivariate analysis, family, school, and individual factors associated with prolonged virginity—such as a high grade point average or attending a parochial school—were not predictive of STI status among boys at follow-up.

Kingella kingae Rising?

In the first reported outbreak of invasive Kingella kingae disease, it affected several toddlers at a day-care center in Minnesota in October 2003, said Karen M. Kiang, M.D., of the Minnesota Department of Health, Minneapolis, and the Centers for Disease Control and Prevention, Atlanta, and her colleagues (Pediatrics 2005;116:206–13). Three cases of osteomyelitis/septic arthritis due to K. kingae occurred: in a 21-month-old boy, a 20-month-old girl, and a 17-month-old boy. The first two cases were confirmed by culture. All three children presented with limping and fevers higher than 100° F, and all three had symptoms of upper respiratory infections prior to or concurrent with the development of their skeletal infections. They were treated with a variety of medications, including intravenous cefazolin and oral amoxicillin. The researchers collected oropharyngeal cultures from 115 of 122 children who attended the day-care center, and 28 of 29 staff members. Overall, 15 (13%) of the children showed K. kingae colonization, but none of the staff members or the 14 children older than 16 months showed colonization. The three infected children had spent time in the same toddler classroom, and the staff and other children in this room received a 2-day prophylactic course of rifampin. By comparison, at a control day center, 45 (38%) of 118 children of similar ages were cultured, and 7 (16%) of them showed K. kingae colonization.

Hepatitis Rates Decline

The incidence of hepatitis dropped from 35% to 19% among children aged 2–18 years between a baseline period of 1990–1997 and 2003, said Annemarie Wasley, Sc.D., of the Centers for Disease Control and Prevention, Atlanta, and her colleagues. The greatest decline occurred among children aged 2–9 years (89%), followed by declines in children aged 10–18 years (83.7%) and children younger than 2 years (79.5%). Overall, 9 of the 10 states with the greatest declines in infection rates were states that had implemented hepatitis vaccination, which became widely available in 1995 (JAMA 2005;294:194–201). In an accompanying editorial, Pierre Van Damme, M.D., and Koen Van Herck, M.D., of the University of Antwerp, Belgium, said that given the proven existence of antibodies more than 10 years after vaccination, and the odds that antibodies will persist for more than 25 years after vaccination, boosters should be unnecessary for healthy people, and childhood vaccination can be reasonable for countries where hepatitis rates are declining (JAMA 2005;294:246–8).

Dating Violence Link to STDs

Approximately 1 in 3 girls in grades 9–12 who reported sexual activity also reported sexual or physical violence from their dating partners in a study of 1,641 girls, said Michele R. Decker of Harvard School of Public Health, Boston, and her colleagues (Pediatrics 2005;116:e272–6). A similar percentage reported being tested for an STD or HIV. Overall, girls who reported physical and sexual violence or physical violence alone were significantly more likely to be tested for an STD (odds ratio 2.4 or 1.6, respectively) than were girls who did not report any violence. In addition, the odds of a positive diagnosis were significantly higher for girls reporting physical and sexual violence or physical violence alone (odds ratio 2.6 or 2.2, respectively) compared with girls who did not report any violence. The study was limited by several factors, including possible underreporting of testing behaviors, since many adolescents may not know or report their positive results.

Predicting STI Risk in Teens

Teenagers who thought their parents would strongly disapprove of their having sex were less likely to have developed sexually transmitted infections 6 years later, said Carol A. Ford, M.D., of the University of North Carolina at Chapel Hill, and her associates. The study included data on 11,594 adolescents from the National Longitudinal Study of Adolescent Health, a prospective cohort study initiated in 1995 when the participants were in grades 7–12 (Arch. Pediatr. Adolesc. Med. 2005;159:657–64). Approximately half (52.8%) of the subjects were female, and the mean age at follow-up was 22 years. Overall, 5.5% of adolescents who thought that their parents strongly disapproved of sex during adolescence tested positive for Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis, compared with 8.0% and 8.9%, respectively, of those who thought that their parents' disapproval was moderate or low. In a bivariate analysis, factors associated with an increased likelihood of sexually transmitted infections included low grade point average, a perception of looking younger than one's peers, and a higher average daily school attendance rate. However, in a stratified, multivariate analysis, family, school, and individual factors associated with prolonged virginity—such as a high grade point average or attending a parochial school—were not predictive of STI status among boys at follow-up.

Kingella kingae Rising?

In the first reported outbreak of invasive Kingella kingae disease, it affected several toddlers at a day-care center in Minnesota in October 2003, said Karen M. Kiang, M.D., of the Minnesota Department of Health, Minneapolis, and the Centers for Disease Control and Prevention, Atlanta, and her colleagues (Pediatrics 2005;116:206–13). Three cases of osteomyelitis/septic arthritis due to K. kingae occurred: in a 21-month-old boy, a 20-month-old girl, and a 17-month-old boy. The first two cases were confirmed by culture. All three children presented with limping and fevers higher than 100° F, and all three had symptoms of upper respiratory infections prior to or concurrent with the development of their skeletal infections. They were treated with a variety of medications, including intravenous cefazolin and oral amoxicillin. The researchers collected oropharyngeal cultures from 115 of 122 children who attended the day-care center, and 28 of 29 staff members. Overall, 15 (13%) of the children showed K. kingae colonization, but none of the staff members or the 14 children older than 16 months showed colonization. The three infected children had spent time in the same toddler classroom, and the staff and other children in this room received a 2-day prophylactic course of rifampin. By comparison, at a control day center, 45 (38%) of 118 children of similar ages were cultured, and 7 (16%) of them showed K. kingae colonization.

Hepatitis Rates Decline

The incidence of hepatitis dropped from 35% to 19% among children aged 2–18 years between a baseline period of 1990–1997 and 2003, said Annemarie Wasley, Sc.D., of the Centers for Disease Control and Prevention, Atlanta, and her colleagues. The greatest decline occurred among children aged 2–9 years (89%), followed by declines in children aged 10–18 years (83.7%) and children younger than 2 years (79.5%). Overall, 9 of the 10 states with the greatest declines in infection rates were states that had implemented hepatitis vaccination, which became widely available in 1995 (JAMA 2005;294:194–201). In an accompanying editorial, Pierre Van Damme, M.D., and Koen Van Herck, M.D., of the University of Antwerp, Belgium, said that given the proven existence of antibodies more than 10 years after vaccination, and the odds that antibodies will persist for more than 25 years after vaccination, boosters should be unnecessary for healthy people, and childhood vaccination can be reasonable for countries where hepatitis rates are declining (JAMA 2005;294:246–8).

BETHESDA, MD. — Drug resistance poses a problem in treating HIV patients, in part because of the virus's high mutation rate, Roy M. Gulick, M.D., said at an annual conference on antimicrobial resistance sponsored by the National Foundation for Infectious Diseases.

Factors affecting HIV drug resistance include the virus itself, the antiretroviral drugs used, and the characteristics of the individual patient. Drug resistance is one of the main reasons why HIV treatments fail, said Dr. Gulick, director of the Cornell HIV Clinical Trials Unit at Weill Medical College of Cornell University, New York.

The goal of antiretroviral therapy (ART) is to suppress the viral load to as low a level as possible for as long as possible, he noted. Due to the high rate of mutation in the HIV virus, viral diversity is extensive. Failure to suppress viral load levels in the presence of antiretroviral drugs leads to the development of a resistant strain, Dr. Gulick explained.

Patient-related factors that can contribute to the development of resistance include the stage of disease, use of other medications, medication adherence, and side effects.

“We used to follow resistance clinically. If someone was taking their drugs, and their viral load went down, but then rose again, if we were sure that they were taking the medication, we assumed that they had developed resistance,” he said. Today, genotypic tests provide viral sequencing of a patient's viral strain, and phenotypic tests can grow the patient's virus in vitro and assess resistance in the presence of the available antiretroviral drugs.

Are resistance tests clinically valuable? Dr. Gulick cited three studies, including one published in the Lancet, in which several hundred patients who had failed drug therapies were randomized to either genotypic or phenotypic drug-resistance testing or standard care (Lancet 1999;353:2195–9).

Overall, the patients who fared better in terms of viral load reduction on their new regimens were the ones who had the resistance tests.

“Simply put, resistance tests help clinicians choose active drugs for the next regimen,” Dr. Gulick said. Guidelines from the Department of Health and Human Services recommend resistance tests in the clinical setting in cases of virologic failure, suboptimal virologic suppression, and acute HIV infection.

These tests could be considered in cases of HIV infection before starting ART, but they are generally not recommended for patients more than 4 weeks after ART drug use ends, or when viral load levels are less than 1,000 copies per million.

However, studies of the effectiveness of resistance testing are limited by several factors, including problems with the clinical cutoffs—when the drugs lose activity over time—and questions as to whether the studies had enrolled patients who had failed multiple treatments.

Other studies have shown conflicting results regarding the use of resistance tests, especially for highly resistant patients. “The best resistance tests can't help a patient if they have no drug options to go to,” Dr. Gulick said.

Asked whether he recommends genotypic or phenotypic testing for patients who are just starting antiretroviral therapy or who already have resistance, Dr. Gulick commented that although sufficient clinical evidence is lacking, most experts recommend a genotype test for patients who are treatment naive or have failed their first regimen, when it is relatively easy to figure out what the mutations mean. But in patients who have been through multiple regimens, phenotype is easier to interpret.

“Many people say that if cost is not an issue, they would get both tests, because they tell you different things—particularly in the late stages of infection,” he added.

BETHESDA, MD. — Drug resistance poses a problem in treating HIV patients, in part because of the virus's high mutation rate, Roy M. Gulick, M.D., said at an annual conference on antimicrobial resistance sponsored by the National Foundation for Infectious Diseases.

Factors affecting HIV drug resistance include the virus itself, the antiretroviral drugs used, and the characteristics of the individual patient. Drug resistance is one of the main reasons why HIV treatments fail, said Dr. Gulick, director of the Cornell HIV Clinical Trials Unit at Weill Medical College of Cornell University, New York.

The goal of antiretroviral therapy (ART) is to suppress the viral load to as low a level as possible for as long as possible, he noted. Due to the high rate of mutation in the HIV virus, viral diversity is extensive. Failure to suppress viral load levels in the presence of antiretroviral drugs leads to the development of a resistant strain, Dr. Gulick explained.

Patient-related factors that can contribute to the development of resistance include the stage of disease, use of other medications, medication adherence, and side effects.

“We used to follow resistance clinically. If someone was taking their drugs, and their viral load went down, but then rose again, if we were sure that they were taking the medication, we assumed that they had developed resistance,” he said. Today, genotypic tests provide viral sequencing of a patient's viral strain, and phenotypic tests can grow the patient's virus in vitro and assess resistance in the presence of the available antiretroviral drugs.

Are resistance tests clinically valuable? Dr. Gulick cited three studies, including one published in the Lancet, in which several hundred patients who had failed drug therapies were randomized to either genotypic or phenotypic drug-resistance testing or standard care (Lancet 1999;353:2195–9).

Overall, the patients who fared better in terms of viral load reduction on their new regimens were the ones who had the resistance tests.

“Simply put, resistance tests help clinicians choose active drugs for the next regimen,” Dr. Gulick said. Guidelines from the Department of Health and Human Services recommend resistance tests in the clinical setting in cases of virologic failure, suboptimal virologic suppression, and acute HIV infection.

These tests could be considered in cases of HIV infection before starting ART, but they are generally not recommended for patients more than 4 weeks after ART drug use ends, or when viral load levels are less than 1,000 copies per million.

However, studies of the effectiveness of resistance testing are limited by several factors, including problems with the clinical cutoffs—when the drugs lose activity over time—and questions as to whether the studies had enrolled patients who had failed multiple treatments.

Other studies have shown conflicting results regarding the use of resistance tests, especially for highly resistant patients. “The best resistance tests can't help a patient if they have no drug options to go to,” Dr. Gulick said.

Asked whether he recommends genotypic or phenotypic testing for patients who are just starting antiretroviral therapy or who already have resistance, Dr. Gulick commented that although sufficient clinical evidence is lacking, most experts recommend a genotype test for patients who are treatment naive or have failed their first regimen, when it is relatively easy to figure out what the mutations mean. But in patients who have been through multiple regimens, phenotype is easier to interpret.

“Many people say that if cost is not an issue, they would get both tests, because they tell you different things—particularly in the late stages of infection,” he added.

BETHESDA, MD. — Drug resistance poses a problem in treating HIV patients, in part because of the virus's high mutation rate, Roy M. Gulick, M.D., said at an annual conference on antimicrobial resistance sponsored by the National Foundation for Infectious Diseases.

Factors affecting HIV drug resistance include the virus itself, the antiretroviral drugs used, and the characteristics of the individual patient. Drug resistance is one of the main reasons why HIV treatments fail, said Dr. Gulick, director of the Cornell HIV Clinical Trials Unit at Weill Medical College of Cornell University, New York.

The goal of antiretroviral therapy (ART) is to suppress the viral load to as low a level as possible for as long as possible, he noted. Due to the high rate of mutation in the HIV virus, viral diversity is extensive. Failure to suppress viral load levels in the presence of antiretroviral drugs leads to the development of a resistant strain, Dr. Gulick explained.

Patient-related factors that can contribute to the development of resistance include the stage of disease, use of other medications, medication adherence, and side effects.

“We used to follow resistance clinically. If someone was taking their drugs, and their viral load went down, but then rose again, if we were sure that they were taking the medication, we assumed that they had developed resistance,” he said. Today, genotypic tests provide viral sequencing of a patient's viral strain, and phenotypic tests can grow the patient's virus in vitro and assess resistance in the presence of the available antiretroviral drugs.

Are resistance tests clinically valuable? Dr. Gulick cited three studies, including one published in the Lancet, in which several hundred patients who had failed drug therapies were randomized to either genotypic or phenotypic drug-resistance testing or standard care (Lancet 1999;353:2195–9).

Overall, the patients who fared better in terms of viral load reduction on their new regimens were the ones who had the resistance tests.

“Simply put, resistance tests help clinicians choose active drugs for the next regimen,” Dr. Gulick said. Guidelines from the Department of Health and Human Services recommend resistance tests in the clinical setting in cases of virologic failure, suboptimal virologic suppression, and acute HIV infection.

These tests could be considered in cases of HIV infection before starting ART, but they are generally not recommended for patients more than 4 weeks after ART drug use ends, or when viral load levels are less than 1,000 copies per million.

However, studies of the effectiveness of resistance testing are limited by several factors, including problems with the clinical cutoffs—when the drugs lose activity over time—and questions as to whether the studies had enrolled patients who had failed multiple treatments.

Other studies have shown conflicting results regarding the use of resistance tests, especially for highly resistant patients. “The best resistance tests can't help a patient if they have no drug options to go to,” Dr. Gulick said.

Asked whether he recommends genotypic or phenotypic testing for patients who are just starting antiretroviral therapy or who already have resistance, Dr. Gulick commented that although sufficient clinical evidence is lacking, most experts recommend a genotype test for patients who are treatment naive or have failed their first regimen, when it is relatively easy to figure out what the mutations mean. But in patients who have been through multiple regimens, phenotype is easier to interpret.

“Many people say that if cost is not an issue, they would get both tests, because they tell you different things—particularly in the late stages of infection,” he added.

Pregnant women and women who think they might become pregnant should avoid the care and feeding of pet rodents and avoid contact with wild rodents to reduce their risk of contracting the lymphocytic choriomeningitis virus from the animals, the Centers for Disease Control and Prevention has advised.

Pregnant women who discover wild mice or other rodents in their homes should leave the capture and removal of the animals to a family member or a professional exterminator. They should also avoid spending long periods of time in the same room as a pet rodent and should not clean the cage or feed the animal. Most LCMV infections do not cause serious illness. Symptoms include stiff neck, fever, muscle aches, and nausea.

Although the risk for LCMV infection is fairly low, transmission of infection from mother to fetus has been reported, and infection during the first or second trimester can cause developmental problems in the fetus, according to CDC.

Observing good hygiene practices and environmental modifications can reduce the risk of infection; the virus has been shown to transfer from rodents to humans, but not from person to person (MMWR 2005;54:747–8).

Pregnant women and women who think they might become pregnant should avoid the care and feeding of pet rodents and avoid contact with wild rodents to reduce their risk of contracting the lymphocytic choriomeningitis virus from the animals, the Centers for Disease Control and Prevention has advised.

Pregnant women who discover wild mice or other rodents in their homes should leave the capture and removal of the animals to a family member or a professional exterminator. They should also avoid spending long periods of time in the same room as a pet rodent and should not clean the cage or feed the animal. Most LCMV infections do not cause serious illness. Symptoms include stiff neck, fever, muscle aches, and nausea.

Although the risk for LCMV infection is fairly low, transmission of infection from mother to fetus has been reported, and infection during the first or second trimester can cause developmental problems in the fetus, according to CDC.

Observing good hygiene practices and environmental modifications can reduce the risk of infection; the virus has been shown to transfer from rodents to humans, but not from person to person (MMWR 2005;54:747–8).

Pregnant women and women who think they might become pregnant should avoid the care and feeding of pet rodents and avoid contact with wild rodents to reduce their risk of contracting the lymphocytic choriomeningitis virus from the animals, the Centers for Disease Control and Prevention has advised.

Pregnant women who discover wild mice or other rodents in their homes should leave the capture and removal of the animals to a family member or a professional exterminator. They should also avoid spending long periods of time in the same room as a pet rodent and should not clean the cage or feed the animal. Most LCMV infections do not cause serious illness. Symptoms include stiff neck, fever, muscle aches, and nausea.

Although the risk for LCMV infection is fairly low, transmission of infection from mother to fetus has been reported, and infection during the first or second trimester can cause developmental problems in the fetus, according to CDC.

Observing good hygiene practices and environmental modifications can reduce the risk of infection; the virus has been shown to transfer from rodents to humans, but not from person to person (MMWR 2005;54:747–8).

ORLANDO — Pediatricians become part of the social capital of their communities, Stanley Fisch, M.D., said at a meeting sponsored by the American Academy of Pediatrics.

The concept of “community pediatrics” means a synthesis of clinical practice and public health principles aimed at providing care for each child and promoting the health of all children within family, school, and community settings, said Dr. Fisch of the University of Texas, San Antonio.

Community pediatrics as a discipline has the same elements as other specialties, with knowledge, skills, and attitudes that can be learned and developed, and Dr. Fisch offers several strategies for pediatricians who want to take residents into their practices.

“Medical education has changed rather dramatically in the past several years,” Dr. Fisch said.

There has been a shift from emphasis on inputs to emphasis on outcomes, where “core competencies” are the benchmarks and objectives of achievement. Testing of knowledge and skills has given way to the development and assessment of competencies, he said.

That said, community pediatrics as a discipline can be taught, and taught very well.

For those interested in teaching the next generation, Dr. Fisch offers a 12-step program as a guide to initiating and completing a successful experience with students and medical residents.

Proper preparation makes all the difference. “Sometimes your partners might not want to get involved with teaching, and that's OK,” Dr. Fisch said. But that puts the pressure on you to be organized and to not disrupt the normal routine of your office.

The 12-step program is outlined below:

1. Plan ahead. Where will the learner park his or her car, keep personal items, and have desk or computer space? Don't forget to inform the office staff and introduce them to the learner.

2. Self-orientation. Ask the learner to state three goals for his or her experience in community pediatrics.

3. Orient yourself to the learner. Find out about your resident's background and interests.

4. Site orientation. Have the office manager or a nurse orient the learner to the office environment.

5. Precepting preparation. Look to the next day's schedule and select patients whom the learner can see and topics they can review.

In addition, let them spend some time on the phone answering questions alongside the nurse or whoever answers the phones during the day.

One of the core competencies is systems-based practice, which means that when the doctor needs to attend a credentialing meeting, for example, it is an opportunity for the learner to tag along to see how a practice affects the profession as a whole.

6. Chart review. Of course, finding the “teachable moments” throughout a busy day remains a challenge. Take opportunities as they come.

For example, allow the learner to review a patient's chart, and point out examples of complete vs. poor documentation, as appropriate.

7. Commitment to a plan. Encourage learners to commit to an opinion about a diagnosis, treatment suggestion, or lab result. This opens the door for feedback about clinical skills.

8. Elaborating on the plan. When time permits, ask the learners how they arrived at the conclusions they offered, recognizing that both the process and the outcome are important.

9. Soliciting feedback. Giving feedback can be one of the most difficult aspects of teaching. Asking learners to offer their own assessment of how things are going opens a window for feedback.

This method often helps learners clarify how they are doing and where they should focus more attention.

10. Timing feedback. Setting aside a specific time and place for feedback may make this process easier for the teacher and more helpful for the learner.

Dr. Fisch offers a “recipe” for an effective “feedback sandwich.”

In its simplest form, good feedback reinforces what the learner did right, corrects mistakes, and offers suggestions for improvement. More specifically, effective feedback is:

▸ Detailed, rather than general.

▸ Focused on behavior rather than on personality.

▸ Descriptive, rather than evaluative.

▸ Timely.

▸ Private, if possible.

▸ Prefaced with positive comment.

▸ Focused on suggestions for his or her improvement.

11. Generalizing learning. Encourage learners to improve clinical thinking by asking effective questions, such as “What do you think causes X?” and “How are X and Y similar?”

12. Reflection. Take a few moments at the end of the day and encourage learners to choose some themes or topics to explore on their own.

Community pediatrics begins with knowledge of the community.

To that end, Dr. Fisch recommends a “windshield survey” to provide residents with a sense of the community's social capital, resources, and unique characteristics, such as safety issues, types of schools, and public transportation.

This is an exercise in observation. The resident drives around the community, not getting out of the car or talking to people on the street, but simply making observations and taking notes. When the learner and teacher review the notes, opportunities may arise to discuss observational skills, as well as cultural biases and stereotypes.

The survey works like a scavenger hunt and asks learners to look for public transportation, community centers, types of houses and cars, and ethnic makeup of the community. (See box.)

“We as physicians take pride in what we do, and as we get older, we become interested in who is going to come along after us. It's not a matter of paying back, it's paying forward as well,” Dr. Fisch said.

With a little planning, pediatricians can pay forward through effective teaching in a practice setting.

Components of a Windshield Survey

A “windshield survey” involves approximately half a day with students or residents driving around the area where they are doing their community pediatrics rotation to acquaint themselves with the community and to hone their observational skills.

The survey prompts observations about various community features, including:

▸ Housing and zoning. Age, style, and upkeep of houses.

▸ Transportation. The types of automobiles and the extent of public transportation.

▸ Service centers. Are there community recreation areas, doctors' offices and dentists' offices, alternative medical care? What types of churches?

▸ Race/ethnicity. What are the demographics? Are there signs in languages other than English?

▸ Media. What types of newspapers are available? Are there many satellite dishes?

▸ Open space. How much open space is there, and what is it like? Are there green spaces or rubble-filled lots? Are there well-kept lawns and trees on sidewalks? Is the open space public or private, and who uses it?

▸ Stores. Where do residents of the community shop? Local markets, malls, or large chain stores such as Wal-Mart? Do they travel to their shopping destinations by car or public transportation?

▸ Politics. Are there campaign posters visible? Is there evidence of a predominant party affiliation?

▸ Boundaries. What signs show where neighborhoods begin and end? Are the boundaries natural, such as a change in terrain, or physical, such as a highway?

▸ Commons. Where do people in the community congregate? What groups seem to meet in certain places, such as schools, parks or 24-hour drugstores, at certain times?

▸ Street people. If you are out during the day, who do you see on the street? Mothers with babies? Teenagers? Homeless people? What animals do you see? Strays? Pedigreed pets? Watchdogs?

▸ Signs of decay. Which neighborhoods are on the way up or down? Are there piles of trash? Abandoned buildings? Construction projects?

▸ Health and morbidity. Is there evidence of acute or chronic diseases or conditions in the community? Alcoholism or drug addiction? How far is the nearest hospital from different parts of the community?

Adapted from work by Terry Mizrahi, Ph.D., of Hunter College School of Social Work, New York.

ORLANDO — Pediatricians become part of the social capital of their communities, Stanley Fisch, M.D., said at a meeting sponsored by the American Academy of Pediatrics.

The concept of “community pediatrics” means a synthesis of clinical practice and public health principles aimed at providing care for each child and promoting the health of all children within family, school, and community settings, said Dr. Fisch of the University of Texas, San Antonio.

Community pediatrics as a discipline has the same elements as other specialties, with knowledge, skills, and attitudes that can be learned and developed, and Dr. Fisch offers several strategies for pediatricians who want to take residents into their practices.

“Medical education has changed rather dramatically in the past several years,” Dr. Fisch said.

There has been a shift from emphasis on inputs to emphasis on outcomes, where “core competencies” are the benchmarks and objectives of achievement. Testing of knowledge and skills has given way to the development and assessment of competencies, he said.

That said, community pediatrics as a discipline can be taught, and taught very well.

For those interested in teaching the next generation, Dr. Fisch offers a 12-step program as a guide to initiating and completing a successful experience with students and medical residents.

Proper preparation makes all the difference. “Sometimes your partners might not want to get involved with teaching, and that's OK,” Dr. Fisch said. But that puts the pressure on you to be organized and to not disrupt the normal routine of your office.

The 12-step program is outlined below:

1. Plan ahead. Where will the learner park his or her car, keep personal items, and have desk or computer space? Don't forget to inform the office staff and introduce them to the learner.

2. Self-orientation. Ask the learner to state three goals for his or her experience in community pediatrics.

3. Orient yourself to the learner. Find out about your resident's background and interests.

4. Site orientation. Have the office manager or a nurse orient the learner to the office environment.

5. Precepting preparation. Look to the next day's schedule and select patients whom the learner can see and topics they can review.

In addition, let them spend some time on the phone answering questions alongside the nurse or whoever answers the phones during the day.

One of the core competencies is systems-based practice, which means that when the doctor needs to attend a credentialing meeting, for example, it is an opportunity for the learner to tag along to see how a practice affects the profession as a whole.

6. Chart review. Of course, finding the “teachable moments” throughout a busy day remains a challenge. Take opportunities as they come.

For example, allow the learner to review a patient's chart, and point out examples of complete vs. poor documentation, as appropriate.

7. Commitment to a plan. Encourage learners to commit to an opinion about a diagnosis, treatment suggestion, or lab result. This opens the door for feedback about clinical skills.

8. Elaborating on the plan. When time permits, ask the learners how they arrived at the conclusions they offered, recognizing that both the process and the outcome are important.

9. Soliciting feedback. Giving feedback can be one of the most difficult aspects of teaching. Asking learners to offer their own assessment of how things are going opens a window for feedback.

This method often helps learners clarify how they are doing and where they should focus more attention.

10. Timing feedback. Setting aside a specific time and place for feedback may make this process easier for the teacher and more helpful for the learner.

Dr. Fisch offers a “recipe” for an effective “feedback sandwich.”

In its simplest form, good feedback reinforces what the learner did right, corrects mistakes, and offers suggestions for improvement. More specifically, effective feedback is:

▸ Detailed, rather than general.

▸ Focused on behavior rather than on personality.

▸ Descriptive, rather than evaluative.

▸ Timely.

▸ Private, if possible.

▸ Prefaced with positive comment.

▸ Focused on suggestions for his or her improvement.

11. Generalizing learning. Encourage learners to improve clinical thinking by asking effective questions, such as “What do you think causes X?” and “How are X and Y similar?”

12. Reflection. Take a few moments at the end of the day and encourage learners to choose some themes or topics to explore on their own.

Community pediatrics begins with knowledge of the community.

To that end, Dr. Fisch recommends a “windshield survey” to provide residents with a sense of the community's social capital, resources, and unique characteristics, such as safety issues, types of schools, and public transportation.

This is an exercise in observation. The resident drives around the community, not getting out of the car or talking to people on the street, but simply making observations and taking notes. When the learner and teacher review the notes, opportunities may arise to discuss observational skills, as well as cultural biases and stereotypes.

The survey works like a scavenger hunt and asks learners to look for public transportation, community centers, types of houses and cars, and ethnic makeup of the community. (See box.)

“We as physicians take pride in what we do, and as we get older, we become interested in who is going to come along after us. It's not a matter of paying back, it's paying forward as well,” Dr. Fisch said.

With a little planning, pediatricians can pay forward through effective teaching in a practice setting.

Components of a Windshield Survey

A “windshield survey” involves approximately half a day with students or residents driving around the area where they are doing their community pediatrics rotation to acquaint themselves with the community and to hone their observational skills.

The survey prompts observations about various community features, including:

▸ Housing and zoning. Age, style, and upkeep of houses.

▸ Transportation. The types of automobiles and the extent of public transportation.

▸ Service centers. Are there community recreation areas, doctors' offices and dentists' offices, alternative medical care? What types of churches?

▸ Race/ethnicity. What are the demographics? Are there signs in languages other than English?

▸ Media. What types of newspapers are available? Are there many satellite dishes?

▸ Open space. How much open space is there, and what is it like? Are there green spaces or rubble-filled lots? Are there well-kept lawns and trees on sidewalks? Is the open space public or private, and who uses it?

▸ Stores. Where do residents of the community shop? Local markets, malls, or large chain stores such as Wal-Mart? Do they travel to their shopping destinations by car or public transportation?

▸ Politics. Are there campaign posters visible? Is there evidence of a predominant party affiliation?

▸ Boundaries. What signs show where neighborhoods begin and end? Are the boundaries natural, such as a change in terrain, or physical, such as a highway?

▸ Commons. Where do people in the community congregate? What groups seem to meet in certain places, such as schools, parks or 24-hour drugstores, at certain times?

▸ Street people. If you are out during the day, who do you see on the street? Mothers with babies? Teenagers? Homeless people? What animals do you see? Strays? Pedigreed pets? Watchdogs?

▸ Signs of decay. Which neighborhoods are on the way up or down? Are there piles of trash? Abandoned buildings? Construction projects?

▸ Health and morbidity. Is there evidence of acute or chronic diseases or conditions in the community? Alcoholism or drug addiction? How far is the nearest hospital from different parts of the community?

Adapted from work by Terry Mizrahi, Ph.D., of Hunter College School of Social Work, New York.

ORLANDO — Pediatricians become part of the social capital of their communities, Stanley Fisch, M.D., said at a meeting sponsored by the American Academy of Pediatrics.

The concept of “community pediatrics” means a synthesis of clinical practice and public health principles aimed at providing care for each child and promoting the health of all children within family, school, and community settings, said Dr. Fisch of the University of Texas, San Antonio.

Community pediatrics as a discipline has the same elements as other specialties, with knowledge, skills, and attitudes that can be learned and developed, and Dr. Fisch offers several strategies for pediatricians who want to take residents into their practices.

“Medical education has changed rather dramatically in the past several years,” Dr. Fisch said.

There has been a shift from emphasis on inputs to emphasis on outcomes, where “core competencies” are the benchmarks and objectives of achievement. Testing of knowledge and skills has given way to the development and assessment of competencies, he said.

That said, community pediatrics as a discipline can be taught, and taught very well.

For those interested in teaching the next generation, Dr. Fisch offers a 12-step program as a guide to initiating and completing a successful experience with students and medical residents.

Proper preparation makes all the difference. “Sometimes your partners might not want to get involved with teaching, and that's OK,” Dr. Fisch said. But that puts the pressure on you to be organized and to not disrupt the normal routine of your office.

The 12-step program is outlined below:

1. Plan ahead. Where will the learner park his or her car, keep personal items, and have desk or computer space? Don't forget to inform the office staff and introduce them to the learner.

2. Self-orientation. Ask the learner to state three goals for his or her experience in community pediatrics.

3. Orient yourself to the learner. Find out about your resident's background and interests.

4. Site orientation. Have the office manager or a nurse orient the learner to the office environment.

5. Precepting preparation. Look to the next day's schedule and select patients whom the learner can see and topics they can review.

In addition, let them spend some time on the phone answering questions alongside the nurse or whoever answers the phones during the day.

One of the core competencies is systems-based practice, which means that when the doctor needs to attend a credentialing meeting, for example, it is an opportunity for the learner to tag along to see how a practice affects the profession as a whole.

6. Chart review. Of course, finding the “teachable moments” throughout a busy day remains a challenge. Take opportunities as they come.

For example, allow the learner to review a patient's chart, and point out examples of complete vs. poor documentation, as appropriate.

7. Commitment to a plan. Encourage learners to commit to an opinion about a diagnosis, treatment suggestion, or lab result. This opens the door for feedback about clinical skills.

8. Elaborating on the plan. When time permits, ask the learners how they arrived at the conclusions they offered, recognizing that both the process and the outcome are important.

9. Soliciting feedback. Giving feedback can be one of the most difficult aspects of teaching. Asking learners to offer their own assessment of how things are going opens a window for feedback.

This method often helps learners clarify how they are doing and where they should focus more attention.

10. Timing feedback. Setting aside a specific time and place for feedback may make this process easier for the teacher and more helpful for the learner.

Dr. Fisch offers a “recipe” for an effective “feedback sandwich.”

In its simplest form, good feedback reinforces what the learner did right, corrects mistakes, and offers suggestions for improvement. More specifically, effective feedback is:

▸ Detailed, rather than general.

▸ Focused on behavior rather than on personality.

▸ Descriptive, rather than evaluative.

▸ Timely.

▸ Private, if possible.

▸ Prefaced with positive comment.

▸ Focused on suggestions for his or her improvement.

11. Generalizing learning. Encourage learners to improve clinical thinking by asking effective questions, such as “What do you think causes X?” and “How are X and Y similar?”

12. Reflection. Take a few moments at the end of the day and encourage learners to choose some themes or topics to explore on their own.

Community pediatrics begins with knowledge of the community.

To that end, Dr. Fisch recommends a “windshield survey” to provide residents with a sense of the community's social capital, resources, and unique characteristics, such as safety issues, types of schools, and public transportation.

This is an exercise in observation. The resident drives around the community, not getting out of the car or talking to people on the street, but simply making observations and taking notes. When the learner and teacher review the notes, opportunities may arise to discuss observational skills, as well as cultural biases and stereotypes.

The survey works like a scavenger hunt and asks learners to look for public transportation, community centers, types of houses and cars, and ethnic makeup of the community. (See box.)

“We as physicians take pride in what we do, and as we get older, we become interested in who is going to come along after us. It's not a matter of paying back, it's paying forward as well,” Dr. Fisch said.

With a little planning, pediatricians can pay forward through effective teaching in a practice setting.

Components of a Windshield Survey

A “windshield survey” involves approximately half a day with students or residents driving around the area where they are doing their community pediatrics rotation to acquaint themselves with the community and to hone their observational skills.

The survey prompts observations about various community features, including:

▸ Housing and zoning. Age, style, and upkeep of houses.

▸ Transportation. The types of automobiles and the extent of public transportation.

▸ Service centers. Are there community recreation areas, doctors' offices and dentists' offices, alternative medical care? What types of churches?

▸ Race/ethnicity. What are the demographics? Are there signs in languages other than English?

▸ Media. What types of newspapers are available? Are there many satellite dishes?

▸ Open space. How much open space is there, and what is it like? Are there green spaces or rubble-filled lots? Are there well-kept lawns and trees on sidewalks? Is the open space public or private, and who uses it?

▸ Stores. Where do residents of the community shop? Local markets, malls, or large chain stores such as Wal-Mart? Do they travel to their shopping destinations by car or public transportation?

▸ Politics. Are there campaign posters visible? Is there evidence of a predominant party affiliation?

▸ Boundaries. What signs show where neighborhoods begin and end? Are the boundaries natural, such as a change in terrain, or physical, such as a highway?

▸ Commons. Where do people in the community congregate? What groups seem to meet in certain places, such as schools, parks or 24-hour drugstores, at certain times?

▸ Street people. If you are out during the day, who do you see on the street? Mothers with babies? Teenagers? Homeless people? What animals do you see? Strays? Pedigreed pets? Watchdogs?

▸ Signs of decay. Which neighborhoods are on the way up or down? Are there piles of trash? Abandoned buildings? Construction projects?

▸ Health and morbidity. Is there evidence of acute or chronic diseases or conditions in the community? Alcoholism or drug addiction? How far is the nearest hospital from different parts of the community?

Adapted from work by Terry Mizrahi, Ph.D., of Hunter College School of Social Work, New York.

ORLANDO — Pediatric practices of all sizes, even solo practices, must know their numbers, including their overhead, payroll, patient load, and cost of supplies, in order to survive, Charles A. Scott, M.D., and Herschel R. Lessin, M.D., said in a joint presentation at a meeting sponsored by the American Academy of Pediatrics.

Combining your pediatric practice with another practice can help control costs and manage patient flow, but for any merger to succeed, the advantages must outweigh the disadvantages, said Dr. Scott, a pediatrician in a private group practice in Medford, N.J.

For example, certain legal actions, such as some types of insurance appeals, cannot be taken by groups of unrelated doctors but they can be taken by an integrated group.

Dr. Scott discussed the big picture perspective on what merging practices usually means for the private practice pediatrician.

“It means one taxpayer ID number, commingling [of] money, and working with someone who might have been a competitor,” he said. As with marriage, mergers are about compromise. You must be able to sit in meetings with your partners, cooperate to achieve your goals, and become comfortable with not being the final decision maker.

A merger can be as large as two regions or as small as two doctors.

“Don't expect your overhead to shrink, but your revenue should ultimately go up,” Dr. Scott said.

One advantage of mergers is the ability to get better deals on supplies (especially vaccines) and to get them quickly, which increases the quality of care in any practice.

Mergers can also streamline personnel and cut administrative costs. Merged groups can have centralized billing, with insurance billing specialists who are often on a first-name basis with people at insurance companies.

Large group practices are also more adept at data collection and can more easily stop using insurance companies that don't value their services—or put pressure on such insurance companies to increase payments to a more reasonable and acceptable level. “We have more data about our own practice patterns and utilization than the insurance companies, so we can hold them accountable to some extent,” Dr. Scott said.

An individual doctor can approach an insurance company and suggest that the company consider certain benefits, such as paying for a brand vs. a generic drug. Merged practices, on the other hand, because they are really one practice, have more power because they can threaten to drop the insurance company en masse, he emphasized.

Potential problems with merging practices include the fact that individuals must subvert their egos to accept decisions made by the group and that individual doctors can't choose which insurance plans to accept.

“You also lose some free time, because there are more meetings,” Dr. Scott noted.

Mergers aren't for everyone. However, if forming a group appeals to you, some options include working in multiple locations, combining offices, and inviting subspecialists to join the practice.

“Remember that you need professionals to help you,” Dr. Scott added. “You can't be your own accountant, you can't do your own investing, and you can't be your own lawyer.”

The bottom line is that the advantages of merging practices must far outweigh the disadvantages, because if they don't, it's not worth doing.

“The ego of the doctors is one of the biggest issues; you have to ask yourself whether you can work with your former competition,” Dr. Scott added.

Dr. Lessin, medical director and founding partner of a group practice in Poughkeepsie, N.Y., provided a “micro” perspective on the finer details involved in merging medical practices into a large group.

The total penetration of managed care and the rise of patient accounts have left many private practice pediatricians underpaid and struggling to collect from patients and insurers.

“The health of your practice depends on your knowledge of your practice numbers,” Dr. Lessin said. “You need to know how much it costs to see a patient.”

Essentially, pediatrics is a high-volume business with a low unit cost, and one of the greatest challenges of a large medical group is developing a budget.

“We plan our budget just like a business,” Dr. Lessin said. He and his partners compare their statistics with national statistics, and they determine costs including what they pay for vaccines and for personnel.

On a day-to-day basis, a large group practice can be very efficient because it has the infrastructure to track patients. “We know how many patients we see in a given location, so we can better plan our doctors' schedules,” Dr. Lessin said.

Patient flow varies with the time of day and time of year, and recognition of the busy times helps maximize the doctors' time. Doctors receive their schedules in advance, and they can spend more time seeing patients without getting bogged down so much with administrative details.

Dr. Lessin's group has one large central office and five other offices in the area, so any patient in the region is only about 15 minutes from one of the offices. The central office is open until 8:30 p.m. “We have at least one office open every day of the year,” he said.

Part of the scheduling job involves deciding which doctors will work in the evening or work on weekends. The practice also will have to decide which doctor is on call and who is the backup. A master scheduling coordinator develops job streams that juggle appointments by season, by provider, and by time and creates a template for each doctor.

A partner-level doctor in Dr. Lessin's group sees approximately 43 patients each day and a non-partner-level doctor sees approximately 35 a day. Efficient support and the use of 10-minute slots make it possible, since doctors do “nothing but doctoring,” Dr. Lessin explained.

All of the paperwork and nonphysician tasks are done by nurses and administrative personnel, and referrals are handled by a referral department.

However, flexibility is important as well. “We're always modifying the schedule, because some people work faster than others,” he said. In addition, 10-minute slots can be combined for a more complex visit.

The bottom line is, once you have decided to be part of a practice merger, the group must have goals—business goals, medical goals, and quality goals. For example, Dr. Lessin suggested setting a time frame for where you want to be in the next 5 years and next 10 years, and then executing that plan. “What gets measured gets done,” he said.

A large enough practice can afford the infrastructure to make this kind of system work, Dr. Lessin said. He has 150 employees, which means the practice has high overhead. Although a large payroll raises overhead, the ability to see more patients more effectively will raise revenue as well.

In addition, a group practice has the resources to develop a sophisticated Web site that can serve as a recruiting tool for new doctors and also as a valuable resource for patients who want to make appointments, refill prescriptions, or obtain additional health information.

“The way we are being squeezed in pediatrics, management is very important, regardless of the size of your practice and whether or not you are part of a group,” Dr. Lessin said.

ORLANDO — Pediatric practices of all sizes, even solo practices, must know their numbers, including their overhead, payroll, patient load, and cost of supplies, in order to survive, Charles A. Scott, M.D., and Herschel R. Lessin, M.D., said in a joint presentation at a meeting sponsored by the American Academy of Pediatrics.

Combining your pediatric practice with another practice can help control costs and manage patient flow, but for any merger to succeed, the advantages must outweigh the disadvantages, said Dr. Scott, a pediatrician in a private group practice in Medford, N.J.

For example, certain legal actions, such as some types of insurance appeals, cannot be taken by groups of unrelated doctors but they can be taken by an integrated group.

Dr. Scott discussed the big picture perspective on what merging practices usually means for the private practice pediatrician.

“It means one taxpayer ID number, commingling [of] money, and working with someone who might have been a competitor,” he said. As with marriage, mergers are about compromise. You must be able to sit in meetings with your partners, cooperate to achieve your goals, and become comfortable with not being the final decision maker.

A merger can be as large as two regions or as small as two doctors.

“Don't expect your overhead to shrink, but your revenue should ultimately go up,” Dr. Scott said.

One advantage of mergers is the ability to get better deals on supplies (especially vaccines) and to get them quickly, which increases the quality of care in any practice.

Mergers can also streamline personnel and cut administrative costs. Merged groups can have centralized billing, with insurance billing specialists who are often on a first-name basis with people at insurance companies.

Large group practices are also more adept at data collection and can more easily stop using insurance companies that don't value their services—or put pressure on such insurance companies to increase payments to a more reasonable and acceptable level. “We have more data about our own practice patterns and utilization than the insurance companies, so we can hold them accountable to some extent,” Dr. Scott said.

An individual doctor can approach an insurance company and suggest that the company consider certain benefits, such as paying for a brand vs. a generic drug. Merged practices, on the other hand, because they are really one practice, have more power because they can threaten to drop the insurance company en masse, he emphasized.

Potential problems with merging practices include the fact that individuals must subvert their egos to accept decisions made by the group and that individual doctors can't choose which insurance plans to accept.

“You also lose some free time, because there are more meetings,” Dr. Scott noted.

Mergers aren't for everyone. However, if forming a group appeals to you, some options include working in multiple locations, combining offices, and inviting subspecialists to join the practice.

“Remember that you need professionals to help you,” Dr. Scott added. “You can't be your own accountant, you can't do your own investing, and you can't be your own lawyer.”

The bottom line is that the advantages of merging practices must far outweigh the disadvantages, because if they don't, it's not worth doing.

“The ego of the doctors is one of the biggest issues; you have to ask yourself whether you can work with your former competition,” Dr. Scott added.

Dr. Lessin, medical director and founding partner of a group practice in Poughkeepsie, N.Y., provided a “micro” perspective on the finer details involved in merging medical practices into a large group.

The total penetration of managed care and the rise of patient accounts have left many private practice pediatricians underpaid and struggling to collect from patients and insurers.

“The health of your practice depends on your knowledge of your practice numbers,” Dr. Lessin said. “You need to know how much it costs to see a patient.”

Essentially, pediatrics is a high-volume business with a low unit cost, and one of the greatest challenges of a large medical group is developing a budget.

“We plan our budget just like a business,” Dr. Lessin said. He and his partners compare their statistics with national statistics, and they determine costs including what they pay for vaccines and for personnel.

On a day-to-day basis, a large group practice can be very efficient because it has the infrastructure to track patients. “We know how many patients we see in a given location, so we can better plan our doctors' schedules,” Dr. Lessin said.

Patient flow varies with the time of day and time of year, and recognition of the busy times helps maximize the doctors' time. Doctors receive their schedules in advance, and they can spend more time seeing patients without getting bogged down so much with administrative details.

Dr. Lessin's group has one large central office and five other offices in the area, so any patient in the region is only about 15 minutes from one of the offices. The central office is open until 8:30 p.m. “We have at least one office open every day of the year,” he said.

Part of the scheduling job involves deciding which doctors will work in the evening or work on weekends. The practice also will have to decide which doctor is on call and who is the backup. A master scheduling coordinator develops job streams that juggle appointments by season, by provider, and by time and creates a template for each doctor.

A partner-level doctor in Dr. Lessin's group sees approximately 43 patients each day and a non-partner-level doctor sees approximately 35 a day. Efficient support and the use of 10-minute slots make it possible, since doctors do “nothing but doctoring,” Dr. Lessin explained.

All of the paperwork and nonphysician tasks are done by nurses and administrative personnel, and referrals are handled by a referral department.

However, flexibility is important as well. “We're always modifying the schedule, because some people work faster than others,” he said. In addition, 10-minute slots can be combined for a more complex visit.

The bottom line is, once you have decided to be part of a practice merger, the group must have goals—business goals, medical goals, and quality goals. For example, Dr. Lessin suggested setting a time frame for where you want to be in the next 5 years and next 10 years, and then executing that plan. “What gets measured gets done,” he said.

A large enough practice can afford the infrastructure to make this kind of system work, Dr. Lessin said. He has 150 employees, which means the practice has high overhead. Although a large payroll raises overhead, the ability to see more patients more effectively will raise revenue as well.

In addition, a group practice has the resources to develop a sophisticated Web site that can serve as a recruiting tool for new doctors and also as a valuable resource for patients who want to make appointments, refill prescriptions, or obtain additional health information.

“The way we are being squeezed in pediatrics, management is very important, regardless of the size of your practice and whether or not you are part of a group,” Dr. Lessin said.

ORLANDO — Pediatric practices of all sizes, even solo practices, must know their numbers, including their overhead, payroll, patient load, and cost of supplies, in order to survive, Charles A. Scott, M.D., and Herschel R. Lessin, M.D., said in a joint presentation at a meeting sponsored by the American Academy of Pediatrics.

Combining your pediatric practice with another practice can help control costs and manage patient flow, but for any merger to succeed, the advantages must outweigh the disadvantages, said Dr. Scott, a pediatrician in a private group practice in Medford, N.J.

For example, certain legal actions, such as some types of insurance appeals, cannot be taken by groups of unrelated doctors but they can be taken by an integrated group.

Dr. Scott discussed the big picture perspective on what merging practices usually means for the private practice pediatrician.

“It means one taxpayer ID number, commingling [of] money, and working with someone who might have been a competitor,” he said. As with marriage, mergers are about compromise. You must be able to sit in meetings with your partners, cooperate to achieve your goals, and become comfortable with not being the final decision maker.

A merger can be as large as two regions or as small as two doctors.

“Don't expect your overhead to shrink, but your revenue should ultimately go up,” Dr. Scott said.

One advantage of mergers is the ability to get better deals on supplies (especially vaccines) and to get them quickly, which increases the quality of care in any practice.

Mergers can also streamline personnel and cut administrative costs. Merged groups can have centralized billing, with insurance billing specialists who are often on a first-name basis with people at insurance companies.

Large group practices are also more adept at data collection and can more easily stop using insurance companies that don't value their services—or put pressure on such insurance companies to increase payments to a more reasonable and acceptable level. “We have more data about our own practice patterns and utilization than the insurance companies, so we can hold them accountable to some extent,” Dr. Scott said.

An individual doctor can approach an insurance company and suggest that the company consider certain benefits, such as paying for a brand vs. a generic drug. Merged practices, on the other hand, because they are really one practice, have more power because they can threaten to drop the insurance company en masse, he emphasized.

Potential problems with merging practices include the fact that individuals must subvert their egos to accept decisions made by the group and that individual doctors can't choose which insurance plans to accept.

“You also lose some free time, because there are more meetings,” Dr. Scott noted.

Mergers aren't for everyone. However, if forming a group appeals to you, some options include working in multiple locations, combining offices, and inviting subspecialists to join the practice.

“Remember that you need professionals to help you,” Dr. Scott added. “You can't be your own accountant, you can't do your own investing, and you can't be your own lawyer.”

The bottom line is that the advantages of merging practices must far outweigh the disadvantages, because if they don't, it's not worth doing.

“The ego of the doctors is one of the biggest issues; you have to ask yourself whether you can work with your former competition,” Dr. Scott added.

Dr. Lessin, medical director and founding partner of a group practice in Poughkeepsie, N.Y., provided a “micro” perspective on the finer details involved in merging medical practices into a large group.

The total penetration of managed care and the rise of patient accounts have left many private practice pediatricians underpaid and struggling to collect from patients and insurers.

“The health of your practice depends on your knowledge of your practice numbers,” Dr. Lessin said. “You need to know how much it costs to see a patient.”

Essentially, pediatrics is a high-volume business with a low unit cost, and one of the greatest challenges of a large medical group is developing a budget.

“We plan our budget just like a business,” Dr. Lessin said. He and his partners compare their statistics with national statistics, and they determine costs including what they pay for vaccines and for personnel.

On a day-to-day basis, a large group practice can be very efficient because it has the infrastructure to track patients. “We know how many patients we see in a given location, so we can better plan our doctors' schedules,” Dr. Lessin said.

Patient flow varies with the time of day and time of year, and recognition of the busy times helps maximize the doctors' time. Doctors receive their schedules in advance, and they can spend more time seeing patients without getting bogged down so much with administrative details.

Dr. Lessin's group has one large central office and five other offices in the area, so any patient in the region is only about 15 minutes from one of the offices. The central office is open until 8:30 p.m. “We have at least one office open every day of the year,” he said.

Part of the scheduling job involves deciding which doctors will work in the evening or work on weekends. The practice also will have to decide which doctor is on call and who is the backup. A master scheduling coordinator develops job streams that juggle appointments by season, by provider, and by time and creates a template for each doctor.

A partner-level doctor in Dr. Lessin's group sees approximately 43 patients each day and a non-partner-level doctor sees approximately 35 a day. Efficient support and the use of 10-minute slots make it possible, since doctors do “nothing but doctoring,” Dr. Lessin explained.

All of the paperwork and nonphysician tasks are done by nurses and administrative personnel, and referrals are handled by a referral department.

However, flexibility is important as well. “We're always modifying the schedule, because some people work faster than others,” he said. In addition, 10-minute slots can be combined for a more complex visit.

The bottom line is, once you have decided to be part of a practice merger, the group must have goals—business goals, medical goals, and quality goals. For example, Dr. Lessin suggested setting a time frame for where you want to be in the next 5 years and next 10 years, and then executing that plan. “What gets measured gets done,” he said.

A large enough practice can afford the infrastructure to make this kind of system work, Dr. Lessin said. He has 150 employees, which means the practice has high overhead. Although a large payroll raises overhead, the ability to see more patients more effectively will raise revenue as well.

In addition, a group practice has the resources to develop a sophisticated Web site that can serve as a recruiting tool for new doctors and also as a valuable resource for patients who want to make appointments, refill prescriptions, or obtain additional health information.

“The way we are being squeezed in pediatrics, management is very important, regardless of the size of your practice and whether or not you are part of a group,” Dr. Lessin said.

In the event of an influenza vaccine shortage during the 2005–2006 season, the Centers for Disease Control and Prevention has advised physicians to prioritize people age 65 years and older with comorbid conditions if their local vaccine supplies are extremely limited.

A three-tiered chart, developed by the CDC and the Advisory Committee on Immunization Practices, stratifies priority groups based on the likelihood of flu-related deaths and hospitalizations (MMWR 2005;54:749–50).

If a vaccine shortage occurs, but local supplies are not extremely limited, all people in the first tier should be given equal priority. The first tier, ranked as follows, includes people aged 65 years and older with comorbid conditions, long-term-care facility residents, people aged 2–64 years with comorbid conditions, people aged 65 years and older without comorbid conditions, children aged 6–23 months, pregnant women, health care workers, and any caregivers and household contacts of children younger than 6 months of age.

If additional inactivated vaccine doses become available during a shortage, vaccinations could be offered to people in tiers 2 and 3, which include household contacts of children or adults at increased risk for flu-related complications, healthy people aged 50–64 years, and healthy people aged 2–49 years, according to the CDC.

In the event of an influenza vaccine shortage during the 2005–2006 season, the Centers for Disease Control and Prevention has advised physicians to prioritize people age 65 years and older with comorbid conditions if their local vaccine supplies are extremely limited.

A three-tiered chart, developed by the CDC and the Advisory Committee on Immunization Practices, stratifies priority groups based on the likelihood of flu-related deaths and hospitalizations (MMWR 2005;54:749–50).

If a vaccine shortage occurs, but local supplies are not extremely limited, all people in the first tier should be given equal priority. The first tier, ranked as follows, includes people aged 65 years and older with comorbid conditions, long-term-care facility residents, people aged 2–64 years with comorbid conditions, people aged 65 years and older without comorbid conditions, children aged 6–23 months, pregnant women, health care workers, and any caregivers and household contacts of children younger than 6 months of age.

If additional inactivated vaccine doses become available during a shortage, vaccinations could be offered to people in tiers 2 and 3, which include household contacts of children or adults at increased risk for flu-related complications, healthy people aged 50–64 years, and healthy people aged 2–49 years, according to the CDC.

In the event of an influenza vaccine shortage during the 2005–2006 season, the Centers for Disease Control and Prevention has advised physicians to prioritize people age 65 years and older with comorbid conditions if their local vaccine supplies are extremely limited.

A three-tiered chart, developed by the CDC and the Advisory Committee on Immunization Practices, stratifies priority groups based on the likelihood of flu-related deaths and hospitalizations (MMWR 2005;54:749–50).

If a vaccine shortage occurs, but local supplies are not extremely limited, all people in the first tier should be given equal priority. The first tier, ranked as follows, includes people aged 65 years and older with comorbid conditions, long-term-care facility residents, people aged 2–64 years with comorbid conditions, people aged 65 years and older without comorbid conditions, children aged 6–23 months, pregnant women, health care workers, and any caregivers and household contacts of children younger than 6 months of age.

If additional inactivated vaccine doses become available during a shortage, vaccinations could be offered to people in tiers 2 and 3, which include household contacts of children or adults at increased risk for flu-related complications, healthy people aged 50–64 years, and healthy people aged 2–49 years, according to the CDC.

No significant relationship was found between routine childhood vaccines and hospitalizations for nontargeted infections in a population-based study of 805,206 children younger than 5 years, said Anders Hviid, M.Sc., and colleagues at the Statens Serum Institut in Copenhagen.

The complex nature of current routine vaccinations has prompted concern that children who receive multiple antigen vaccines might suffer immune dysfunction and become vulnerable to diseases not targeted by the vaccines (JAMA 2005;294:699–705). The population-based study examined six vaccines and seven infectious disease categories for a total of 42 possible associations.

There was one adverse association during 2,900,463 person-years of follow-up that occurred between the Haemophilus influenzae type b vaccine and acute upper respiratory tract infections, with an incident rate ratio of 1.05.

There also was one adverse association of the incident rate ratios for vaccinated children within the 14-day lag period relative to unvaccinated children that occurred between the MMR vaccine and acute upper respiratory tract infections, with an incident rate ratio of 1.10; this was not significant. None of the incident rate ratios increased by more than 10% between vaccinated and unvaccinated children during the lag period.

The increase in the incident rate of hospitalizations per dose of vaccine was calculated, and yielded an incident rate ratio of 0.94 for viral pneumonia, 0.96 for bacterial pneumonia, 0.98 for septicemia, 0.99 for viral CNS infections, 0.99 for diarrhea, 0.99 for acute upper respiratory tract infections, and 1.00 for bacterial meningitis.

The other four vaccines studied were diphtheria-tetanus-inactivated poliovirus, diphtheria-tetanus-acellular pertussis-inactivated poliovirus, whole-cell pertussis, and oral poliovirus.

No significant relationship was found between routine childhood vaccines and hospitalizations for nontargeted infections in a population-based study of 805,206 children younger than 5 years, said Anders Hviid, M.Sc., and colleagues at the Statens Serum Institut in Copenhagen.

The complex nature of current routine vaccinations has prompted concern that children who receive multiple antigen vaccines might suffer immune dysfunction and become vulnerable to diseases not targeted by the vaccines (JAMA 2005;294:699–705). The population-based study examined six vaccines and seven infectious disease categories for a total of 42 possible associations.

There was one adverse association during 2,900,463 person-years of follow-up that occurred between the Haemophilus influenzae type b vaccine and acute upper respiratory tract infections, with an incident rate ratio of 1.05.

There also was one adverse association of the incident rate ratios for vaccinated children within the 14-day lag period relative to unvaccinated children that occurred between the MMR vaccine and acute upper respiratory tract infections, with an incident rate ratio of 1.10; this was not significant. None of the incident rate ratios increased by more than 10% between vaccinated and unvaccinated children during the lag period.

The increase in the incident rate of hospitalizations per dose of vaccine was calculated, and yielded an incident rate ratio of 0.94 for viral pneumonia, 0.96 for bacterial pneumonia, 0.98 for septicemia, 0.99 for viral CNS infections, 0.99 for diarrhea, 0.99 for acute upper respiratory tract infections, and 1.00 for bacterial meningitis.

The other four vaccines studied were diphtheria-tetanus-inactivated poliovirus, diphtheria-tetanus-acellular pertussis-inactivated poliovirus, whole-cell pertussis, and oral poliovirus.

No significant relationship was found between routine childhood vaccines and hospitalizations for nontargeted infections in a population-based study of 805,206 children younger than 5 years, said Anders Hviid, M.Sc., and colleagues at the Statens Serum Institut in Copenhagen.

The complex nature of current routine vaccinations has prompted concern that children who receive multiple antigen vaccines might suffer immune dysfunction and become vulnerable to diseases not targeted by the vaccines (JAMA 2005;294:699–705). The population-based study examined six vaccines and seven infectious disease categories for a total of 42 possible associations.

There was one adverse association during 2,900,463 person-years of follow-up that occurred between the Haemophilus influenzae type b vaccine and acute upper respiratory tract infections, with an incident rate ratio of 1.05.

There also was one adverse association of the incident rate ratios for vaccinated children within the 14-day lag period relative to unvaccinated children that occurred between the MMR vaccine and acute upper respiratory tract infections, with an incident rate ratio of 1.10; this was not significant. None of the incident rate ratios increased by more than 10% between vaccinated and unvaccinated children during the lag period.

The increase in the incident rate of hospitalizations per dose of vaccine was calculated, and yielded an incident rate ratio of 0.94 for viral pneumonia, 0.96 for bacterial pneumonia, 0.98 for septicemia, 0.99 for viral CNS infections, 0.99 for diarrhea, 0.99 for acute upper respiratory tract infections, and 1.00 for bacterial meningitis.

The other four vaccines studied were diphtheria-tetanus-inactivated poliovirus, diphtheria-tetanus-acellular pertussis-inactivated poliovirus, whole-cell pertussis, and oral poliovirus.

An amoxicillin/clavulanate combination was significantly more effective than azithromycin in eliminating bacterial acute otitis media, including penicillin-resistant strains, reported Alejandro Hoberman, M.D., of the Children's Hospital of Pittsburgh, and his colleagues.

In a randomized, investigator-blinded study sponsored in part by GlaxoSmith-Kline, 730 children aged 6–30 months were randomized to receive either a 90-mg amoxicillin and a 6.4-mg clavulanate/kg combination daily in 2 divided doses for 10 days, or a 10-mg/kg dose of azithromycin once daily for 1 day, followed by 5 mg/kg once daily for 4 days.

The study was conducted at 34 centers worldwide, including Bulgaria, Chile, the Dominican Republic, Guatemala, Israel, Peru, Romania, Latvia, Mexico, and the United States from April 2001 to November 2002.

The increasing evolution of antimicrobial resistance among the pathogens that cause acute otitis media (AOM) and the approval of a large-dose pediatric formulation of amoxicillin/clavulanate prompted the study.

At baseline, 494 (67.7%) of the children had at least one protocol-defined pathogen; 249 in the amoxicillin/clavulanate group and 245 in the azithromycin group. Of these, 19 (7.6%) children in the amoxicillin/clavulanate group and 38 (15.5%) in the azithromycin group had more than one pathogen at baseline (Pediatr. Infect. Dis. J. 2005:24:525–32). The children without discernible pathogens at baseline (118 in each group) were included in the safety analysis.

In addition, of the 229 total Streptococcus pneumoniae isolates (111 children in the amoxicillin/clavulanate group and 118 children in the azithromycin group), 48.5%, 11.4%, and 20.5% were not susceptible to penicillin, amoxicillin, and azithromycin, respectively.

Overall, clinical success rates among children with baseline AOM pathogens were significantly greater in the amoxicillin/clavulanate group (90.5%), compared with the azithromycin group (80.9%).

Clinical success was defined as the lessening or complete resolution of acute ear infection and inflammation, with or without middle-ear effusion, to the extent that no additional antibiotics were needed. Clinical response at 12–14 days after the start of therapy served as the primary end point of the study.

Bacteriologic success was defined as the eradication of the initial AOM pathogen with or without a new pathogen, based on a lack of middle-ear fluid.

Bacteriologic success at an “on-therapy” visit 4–6 days after the start of treatment was associated with clinical success at the end of therapy in 96 of 105 children (91.4%) in the amoxicillin/clavulanate group and 80 of 89 (89.9%) in the azithromycin group.

Amoxicillin/clavulanate was significantly more effective than azithromycin against both S. pneumoniae, (96.0% vs. 80.4%) and Haemophilus influenzae, (96.7% vs. 52.9%). The distribution of pathogens was similar between the two groups. H. influenzae was the more common, found in 48.6% of the amoxicillin/clavulanate group and 50.6% of the azithromycin group.

In the subset of 101 amoxicillin/clavulanate patients and 82 azithromycin patients who demonstrated bacteriologic responses after 4–6 days, amoxicillin/clavulanate was significantly more effective than azithromycin against penicillin-resistant S. pneumoniae, with eradication in 23 of 25 cases (92.0%) vs. 12 of 22 cases (54.5%), respectively.

Although significantly more children in the amoxicillin/clavulanate group withdrew from the study due to an adverse event, compared with the azithromycin group (21 vs. 7), the total number of adverse events was not significantly different between the two groups (139 vs. 128).

An amoxicillin/clavulanate combination was significantly more effective than azithromycin in eliminating bacterial acute otitis media, including penicillin-resistant strains, reported Alejandro Hoberman, M.D., of the Children's Hospital of Pittsburgh, and his colleagues.

In a randomized, investigator-blinded study sponsored in part by GlaxoSmith-Kline, 730 children aged 6–30 months were randomized to receive either a 90-mg amoxicillin and a 6.4-mg clavulanate/kg combination daily in 2 divided doses for 10 days, or a 10-mg/kg dose of azithromycin once daily for 1 day, followed by 5 mg/kg once daily for 4 days.

The study was conducted at 34 centers worldwide, including Bulgaria, Chile, the Dominican Republic, Guatemala, Israel, Peru, Romania, Latvia, Mexico, and the United States from April 2001 to November 2002.

The increasing evolution of antimicrobial resistance among the pathogens that cause acute otitis media (AOM) and the approval of a large-dose pediatric formulation of amoxicillin/clavulanate prompted the study.

At baseline, 494 (67.7%) of the children had at least one protocol-defined pathogen; 249 in the amoxicillin/clavulanate group and 245 in the azithromycin group. Of these, 19 (7.6%) children in the amoxicillin/clavulanate group and 38 (15.5%) in the azithromycin group had more than one pathogen at baseline (Pediatr. Infect. Dis. J. 2005:24:525–32). The children without discernible pathogens at baseline (118 in each group) were included in the safety analysis.

In addition, of the 229 total Streptococcus pneumoniae isolates (111 children in the amoxicillin/clavulanate group and 118 children in the azithromycin group), 48.5%, 11.4%, and 20.5% were not susceptible to penicillin, amoxicillin, and azithromycin, respectively.

Overall, clinical success rates among children with baseline AOM pathogens were significantly greater in the amoxicillin/clavulanate group (90.5%), compared with the azithromycin group (80.9%).

Clinical success was defined as the lessening or complete resolution of acute ear infection and inflammation, with or without middle-ear effusion, to the extent that no additional antibiotics were needed. Clinical response at 12–14 days after the start of therapy served as the primary end point of the study.

Bacteriologic success was defined as the eradication of the initial AOM pathogen with or without a new pathogen, based on a lack of middle-ear fluid.

Bacteriologic success at an “on-therapy” visit 4–6 days after the start of treatment was associated with clinical success at the end of therapy in 96 of 105 children (91.4%) in the amoxicillin/clavulanate group and 80 of 89 (89.9%) in the azithromycin group.

Amoxicillin/clavulanate was significantly more effective than azithromycin against both S. pneumoniae, (96.0% vs. 80.4%) and Haemophilus influenzae, (96.7% vs. 52.9%). The distribution of pathogens was similar between the two groups. H. influenzae was the more common, found in 48.6% of the amoxicillin/clavulanate group and 50.6% of the azithromycin group.

In the subset of 101 amoxicillin/clavulanate patients and 82 azithromycin patients who demonstrated bacteriologic responses after 4–6 days, amoxicillin/clavulanate was significantly more effective than azithromycin against penicillin-resistant S. pneumoniae, with eradication in 23 of 25 cases (92.0%) vs. 12 of 22 cases (54.5%), respectively.

Although significantly more children in the amoxicillin/clavulanate group withdrew from the study due to an adverse event, compared with the azithromycin group (21 vs. 7), the total number of adverse events was not significantly different between the two groups (139 vs. 128).

An amoxicillin/clavulanate combination was significantly more effective than azithromycin in eliminating bacterial acute otitis media, including penicillin-resistant strains, reported Alejandro Hoberman, M.D., of the Children's Hospital of Pittsburgh, and his colleagues.

In a randomized, investigator-blinded study sponsored in part by GlaxoSmith-Kline, 730 children aged 6–30 months were randomized to receive either a 90-mg amoxicillin and a 6.4-mg clavulanate/kg combination daily in 2 divided doses for 10 days, or a 10-mg/kg dose of azithromycin once daily for 1 day, followed by 5 mg/kg once daily for 4 days.

The study was conducted at 34 centers worldwide, including Bulgaria, Chile, the Dominican Republic, Guatemala, Israel, Peru, Romania, Latvia, Mexico, and the United States from April 2001 to November 2002.

The increasing evolution of antimicrobial resistance among the pathogens that cause acute otitis media (AOM) and the approval of a large-dose pediatric formulation of amoxicillin/clavulanate prompted the study.

At baseline, 494 (67.7%) of the children had at least one protocol-defined pathogen; 249 in the amoxicillin/clavulanate group and 245 in the azithromycin group. Of these, 19 (7.6%) children in the amoxicillin/clavulanate group and 38 (15.5%) in the azithromycin group had more than one pathogen at baseline (Pediatr. Infect. Dis. J. 2005:24:525–32). The children without discernible pathogens at baseline (118 in each group) were included in the safety analysis.

In addition, of the 229 total Streptococcus pneumoniae isolates (111 children in the amoxicillin/clavulanate group and 118 children in the azithromycin group), 48.5%, 11.4%, and 20.5% were not susceptible to penicillin, amoxicillin, and azithromycin, respectively.

Overall, clinical success rates among children with baseline AOM pathogens were significantly greater in the amoxicillin/clavulanate group (90.5%), compared with the azithromycin group (80.9%).

Clinical success was defined as the lessening or complete resolution of acute ear infection and inflammation, with or without middle-ear effusion, to the extent that no additional antibiotics were needed. Clinical response at 12–14 days after the start of therapy served as the primary end point of the study.

Bacteriologic success was defined as the eradication of the initial AOM pathogen with or without a new pathogen, based on a lack of middle-ear fluid.

Bacteriologic success at an “on-therapy” visit 4–6 days after the start of treatment was associated with clinical success at the end of therapy in 96 of 105 children (91.4%) in the amoxicillin/clavulanate group and 80 of 89 (89.9%) in the azithromycin group.

Amoxicillin/clavulanate was significantly more effective than azithromycin against both S. pneumoniae, (96.0% vs. 80.4%) and Haemophilus influenzae, (96.7% vs. 52.9%). The distribution of pathogens was similar between the two groups. H. influenzae was the more common, found in 48.6% of the amoxicillin/clavulanate group and 50.6% of the azithromycin group.

In the subset of 101 amoxicillin/clavulanate patients and 82 azithromycin patients who demonstrated bacteriologic responses after 4–6 days, amoxicillin/clavulanate was significantly more effective than azithromycin against penicillin-resistant S. pneumoniae, with eradication in 23 of 25 cases (92.0%) vs. 12 of 22 cases (54.5%), respectively.

Although significantly more children in the amoxicillin/clavulanate group withdrew from the study due to an adverse event, compared with the azithromycin group (21 vs. 7), the total number of adverse events was not significantly different between the two groups (139 vs. 128).

A case of bubonic plague was confirmed in a teenaged boy in New Mexico this summer, according to the New Mexico Department of Health.

The boy was the first known human case of plague in New Mexico this year; no cases occurred in 2004, and one case occurred in an adult in 2003.

At press time, the teenager was expected to return home after several days in the hospital. He was treated with gentamicin and should recover fully without complications, according to Paul Ettestad, D.V.M., New Mexico's state public health veterinarian.

Dr. Ettestad and colleagues investigated the area near the boy's semirural home, where they found rodent burrows and the bodies of several rock squirrels who had apparently died of plague.

“Rock squirrels and their fleas are the number one source of plague in New Mexico,” Dr. Ettestad said in an interview.

Although plague is primarily a bacterial disease of rodents, it can jump to humans by way of bites from infected fleas or by direct contact with infected animals, including pets and wildlife.

Symptoms include fever, chills, and painful, swollen lymph nodes in the neck, armpit, or groin. Some patients also have headaches, vomiting, and diarrhea.

The disease can be fatal in both people and pets if not treated promptly.

The New Mexico Department of Health recommends several precautions to prevent plague, including avoiding sick or dead rodents, teaching children to stay away from rodent nests or burrows, and cleaning areas near the house where rodents could nest. In addition, pets should be treated with flea control products and not allowed to roam or hunt. Sick pets should be taken to a veterinarian as soon as possible.

A case of bubonic plague was confirmed in a teenaged boy in New Mexico this summer, according to the New Mexico Department of Health.

The boy was the first known human case of plague in New Mexico this year; no cases occurred in 2004, and one case occurred in an adult in 2003.

At press time, the teenager was expected to return home after several days in the hospital. He was treated with gentamicin and should recover fully without complications, according to Paul Ettestad, D.V.M., New Mexico's state public health veterinarian.

Dr. Ettestad and colleagues investigated the area near the boy's semirural home, where they found rodent burrows and the bodies of several rock squirrels who had apparently died of plague.

“Rock squirrels and their fleas are the number one source of plague in New Mexico,” Dr. Ettestad said in an interview.

Although plague is primarily a bacterial disease of rodents, it can jump to humans by way of bites from infected fleas or by direct contact with infected animals, including pets and wildlife.

Symptoms include fever, chills, and painful, swollen lymph nodes in the neck, armpit, or groin. Some patients also have headaches, vomiting, and diarrhea.

The disease can be fatal in both people and pets if not treated promptly.

The New Mexico Department of Health recommends several precautions to prevent plague, including avoiding sick or dead rodents, teaching children to stay away from rodent nests or burrows, and cleaning areas near the house where rodents could nest. In addition, pets should be treated with flea control products and not allowed to roam or hunt. Sick pets should be taken to a veterinarian as soon as possible.

A case of bubonic plague was confirmed in a teenaged boy in New Mexico this summer, according to the New Mexico Department of Health.

The boy was the first known human case of plague in New Mexico this year; no cases occurred in 2004, and one case occurred in an adult in 2003.

At press time, the teenager was expected to return home after several days in the hospital. He was treated with gentamicin and should recover fully without complications, according to Paul Ettestad, D.V.M., New Mexico's state public health veterinarian.

Dr. Ettestad and colleagues investigated the area near the boy's semirural home, where they found rodent burrows and the bodies of several rock squirrels who had apparently died of plague.

“Rock squirrels and their fleas are the number one source of plague in New Mexico,” Dr. Ettestad said in an interview.

Although plague is primarily a bacterial disease of rodents, it can jump to humans by way of bites from infected fleas or by direct contact with infected animals, including pets and wildlife.

Symptoms include fever, chills, and painful, swollen lymph nodes in the neck, armpit, or groin. Some patients also have headaches, vomiting, and diarrhea.

The disease can be fatal in both people and pets if not treated promptly.

The New Mexico Department of Health recommends several precautions to prevent plague, including avoiding sick or dead rodents, teaching children to stay away from rodent nests or burrows, and cleaning areas near the house where rodents could nest. In addition, pets should be treated with flea control products and not allowed to roam or hunt. Sick pets should be taken to a veterinarian as soon as possible.

CHICAGO — The quality of healed wounds treated with bilayered cell therapy equaled that of wounds treated with a standard dressing in a randomized, multicenter study of 172 patients, Vincent Falanga, M.D., reported at the annual meeting of the Wound Healing Society.

Apligraf, a wound dressing based on bilayered cell therapy (BLCT), is approved by the Food and Drug Administration for the treatment of both venous leg ulcers and diabetic foot ulcers, and has been associated with fewer amputations and osteomyelitis in ulcer patients. These results suggest it is appropriate for excisional wounds as well as ulcers, said Dr. Falanga, professor of dermatology and biochemistry at Boston University.

The patients, aged 18–85 years, underwent either Mohs or excisional surgery for skin cancer.

The BLCT patients received an application of BLCT mesh, followed by a tie-over, a semiocclusive dressing, and a conforming bandage, while the control group received a similar dressing and bandage without the mesh. A total of 84 patients were treated with BLCT, and 88 were treated with standard dressings.

Wound quality was assessed using the Vancouver Burn Scar Assessment Scale, in which the investigator and an independent observer rate the wound on a scale of 0 (no scar) to 15 (worst scar). Overall, 57 of the 84 BLCT patients received scores of 4 or less from both the investigator and the observer. By comparison, 60 and 54 of the 88 control patients were assigned scores of 4 or less by the investigator and the observer, respectively. No significant difference in healing times was seen between patients treated with BLCT and controls.

Dr. Falanga has received grant support from and consulted for Novartis Pharmaceuticals Corp. and Organogenesis Inc.

CHICAGO — The quality of healed wounds treated with bilayered cell therapy equaled that of wounds treated with a standard dressing in a randomized, multicenter study of 172 patients, Vincent Falanga, M.D., reported at the annual meeting of the Wound Healing Society.

Apligraf, a wound dressing based on bilayered cell therapy (BLCT), is approved by the Food and Drug Administration for the treatment of both venous leg ulcers and diabetic foot ulcers, and has been associated with fewer amputations and osteomyelitis in ulcer patients. These results suggest it is appropriate for excisional wounds as well as ulcers, said Dr. Falanga, professor of dermatology and biochemistry at Boston University.

The patients, aged 18–85 years, underwent either Mohs or excisional surgery for skin cancer.

The BLCT patients received an application of BLCT mesh, followed by a tie-over, a semiocclusive dressing, and a conforming bandage, while the control group received a similar dressing and bandage without the mesh. A total of 84 patients were treated with BLCT, and 88 were treated with standard dressings.

Wound quality was assessed using the Vancouver Burn Scar Assessment Scale, in which the investigator and an independent observer rate the wound on a scale of 0 (no scar) to 15 (worst scar). Overall, 57 of the 84 BLCT patients received scores of 4 or less from both the investigator and the observer. By comparison, 60 and 54 of the 88 control patients were assigned scores of 4 or less by the investigator and the observer, respectively. No significant difference in healing times was seen between patients treated with BLCT and controls.

Dr. Falanga has received grant support from and consulted for Novartis Pharmaceuticals Corp. and Organogenesis Inc.

CHICAGO — The quality of healed wounds treated with bilayered cell therapy equaled that of wounds treated with a standard dressing in a randomized, multicenter study of 172 patients, Vincent Falanga, M.D., reported at the annual meeting of the Wound Healing Society.

Apligraf, a wound dressing based on bilayered cell therapy (BLCT), is approved by the Food and Drug Administration for the treatment of both venous leg ulcers and diabetic foot ulcers, and has been associated with fewer amputations and osteomyelitis in ulcer patients. These results suggest it is appropriate for excisional wounds as well as ulcers, said Dr. Falanga, professor of dermatology and biochemistry at Boston University.

The patients, aged 18–85 years, underwent either Mohs or excisional surgery for skin cancer.

The BLCT patients received an application of BLCT mesh, followed by a tie-over, a semiocclusive dressing, and a conforming bandage, while the control group received a similar dressing and bandage without the mesh. A total of 84 patients were treated with BLCT, and 88 were treated with standard dressings.

Wound quality was assessed using the Vancouver Burn Scar Assessment Scale, in which the investigator and an independent observer rate the wound on a scale of 0 (no scar) to 15 (worst scar). Overall, 57 of the 84 BLCT patients received scores of 4 or less from both the investigator and the observer. By comparison, 60 and 54 of the 88 control patients were assigned scores of 4 or less by the investigator and the observer, respectively. No significant difference in healing times was seen between patients treated with BLCT and controls.

Dr. Falanga has received grant support from and consulted for Novartis Pharmaceuticals Corp. and Organogenesis Inc.