Design  Longitudinal prospective randomized intervention.

Setting  An urban academic children's hospital.

Patients  A total of 4246 individuals aged 0 to 21 years from each of 4 participating primary care practices recording an index PED visit from April through December 2005.

Intervention  Follow-up phone call from the primary care practice within 72 hours of the initial PED visit to counsel about the availability of after-hours advice and when to access the PED.

Main Outcome Measures  All subsequent visits to primary care practices, PED, pediatric subspecialists, or for inpatient hospitalization during a 365-day follow-up period. Logistic and ordinary least squares regressions estimated unadjusted and adjusted odds ratios of follow-up visits, controlling for covariates.

Results  Of the 2166 intervention subjects, 816 (37.7%) recorded follow-up PED visits compared with 819 (39.4%) of the 2080 control subjects (P = .26, not significant). The adjusted odds of a follow-up visit being to the PED rather than to another venue was significantly less for intervention than for control subjects (odds ratio, 0.88; confidence interval, 0.82-0.94), indicating decreased intensity of PED use.

Conclusion  Follow-up phone calls from primary care practices after PED visits counseling patients on the use of primary care and emergency services can modulate subsequent care-seeking behavior and decrease future PED use.

Design  Cross-sectional study collating information from national, state, and local trauma systems authorities to create a catalog of verified pediatric trauma centers (PTCs) and self-designated "candidate" trauma centers. Access-to-care calculations were estimated using all US block groups and prior validated methods.

Setting  United States.

Patients  Children in the US younger than 15 years.

Main Outcome Measures  The PTC statuses of hospitals in the United States. Percentages of pediatric populations (by state and population density) having access (by ground or air) within 60 minutes to a PTC.

Results  A total of 170 verified PTCs were identified in 41 states (including the District of Columbia). An estimated 71.5% of pediatric patients were within 60 minutes of a verified PTC by air or ground transport, 43% if ground transportation only was considered. An estimated 17.4 million children did not have access to a PTC within 60 minutes. Access ranged from 22.9% of the population in the most rural areas of the United States to 93.5% in the most urban. The addition of 24 candidate centers increased coverage to 77.4% of the pediatric population being within 60 minutes of a PTC.

Conclusions  Current pediatric trauma resources vary greatly by state and population density, with many children, particularly in rural areas, underserved. A thorough standardized catalog of verified PTCs is necessary to accurately assess pediatric trauma needs now and to optimize future trauma system planning for children.

Design  Cross-sectional survey.

Setting  Dana-Farber Cancer Institute and Children's Hospital, Boston, Massachusetts.

Participants  One hundred ninety-four parents of children with cancer (response rate, 70%) in the first year of cancer treatment.

Main Outcome Measure  The Functional Assessment of Chronic Illness Therapy–Spiritual Well-being sense of meaning subscale.

Results  Principal components analysis of Functional Assessment of Chronic Illness Therapy–Spiritual Well-being sense of meaning subscale responses identified 2 distinct constructs, peace of mind (Cronbach  = .83) and sense of purpose (Cronbach  = .71). Scores ranged from 1 to 5, with 5 representing the strongest sense of peace or purpose. One hundred forty-seven of 181 parents (81%) scored 4 or higher for questions related to sense of purpose (mean [SD] score, 4.4 [0.6]). Only 44 of 185 parents (24%) had scores in the same range for peace of mind (mean [SD] score, 3.2 [0.9]) (P < .001). In a multivariable logistic regression model, parents had higher peace of mind scores when they also reported that they trusted the oncologist's judgment (odds ratio [OR] = 6.65; 95% confidence interval [CI], 1.47-30.02), that the oncologist had disclosed detailed prognostic information (OR = 2.05; 95% CI, 1.14-3.70), and that the oncologist had provided high-quality information about the cancer (OR = 2.54; 95% CI, 1.11-5.79). Peace of mind was not associated with prognosis (OR = 0.74; 95% CI, 0.41-1.32) or time since diagnosis (OR = 1.00; 95% CI, 0.995-1.003).

Conclusions  Physicians may be able to facilitate formulation of peace of mind by giving parents high-quality medical information, including prognostic information, and facilitating parents' trust.

Design  Community cross-sectional data obtained using a cluster sample approach.

Setting  From November 5, 2007, through February 5, 2008, we assessed 13 secondary schools in 4 selected health zones in the Ituri district.

Participants  One thousand forty-six adolescents and young adults aged 13 to 21 years completed a self-report questionnaire.

Main Exposures  War-related traumatic events, posttraumatic stress symptoms, and sociodemographic variables.

Main Outcomes Measures  The Adolescent Complex Emergency Exposure Scale, specifically designed for this region, screened for exposure to potentially traumatic events, and the Impact of Event Scale–Revised measured symptoms of posttraumatic stress consistent with Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria.

Results  Among the 477 girls (45.6%) and 569 boys (54.4%) in the study, 95.0% reported at least 1 traumatic event. On average, adolescents were exposed to 4.71 traumatic events, with higher exposure rates reported in boys, older groups, rural and urban areas, and respondents whose mother or father was dead. Of 990 respondents, 52.2% met symptom criteria for posttraumatic stress disorder. Symptom scores were strongly related to cumulative trauma exposure; however, the strength of this relationship differed slightly across living area groups for girls.

Conclusion  Adolescents in the eastern Democratic Republic of Congo are highly exposed to political violence, putting them at a considerable risk—mediated by living area and sex—to develop posttraumatic stress symptoms.

Design  Cross-sectional study.

Setting  Lower Manhattan, New York, New York.

Participants  One hundred two preschool child-mother dyads directly exposed to the World Trade Center attacks.

Exposures  Maternal disorders: 2 (posttraumatic stress disorder [PTSD] and depression), 1 (depression or PTSD), or none.

Main Outcome Measures  Maternal depression and PTSD were self-reported. Child behavioral problems were rated by mothers and teachers using a standardized behavioral checklist. For each informant, we created separate dichotomous variables that indicated whether the child's behavioral problems were severe enough to be clinically significant. We then used an analytic technique (generalized estimating equations) that integrates the child behavioral problem ratings by the mother and teachers to derive a more reliable indicator of clinically significant child behavioral problems.

Results  The rate of clinically significant child behavioral problems increased linearly relative to the number of maternal psychopathologies. The number of maternal psychopathologies was associated with a linear increase in functional impairment. Compared with children of mothers without psychopathologies, children of mothers with depression and PTSD were at greater risk for several clinically significant problems, notably, aggressive behavior (relative risk, 13.0), emotionally reactive behavior (11.2), and somatic complaints (10.5). Boys were more likely to have clinically significant behavior problems than were girls.

Conclusion  Concurrent maternal depression and PTSD was associated with dramatic increases in the rate of clinically significant behavioral problems in preschool children, particularly boys, 3 years after the World Trade Center attacks.

Design  Transmission disequilibrium testing in case mothers and maternal grandparents.

Setting  Previous studies have consistently shown increased frequency of HLA-DR4 in probands with autism and their mothers, but not their fathers. However, this has been documented only in case-control studies and not by a more direct study design to determine whether HLA-DR4 acts in mothers during pregnancy to contribute to autism in their affected offspring.

Participants  We genotyped for HLA-DR alleles in members of 31 families with parents and maternal grandparents. Probands with autism were tested using the Autism Diagnostic Observation Schedule–Western Psychological Services and Autism Diagnostic Interview, Revised. There was 80% power to detect an odds ratio of 3.6. Participants were all families from New Jersey and were similar in number to earlier studies of autism and HLA-DR4.

Outcome Measures  Analysis was by standard transmission disequilibrium testing. As a secondary test we examined the possibility of maternal imprinting.

Results  Significant transmission disequilibrium for HLA-DR4 was seen (odds ratio, 4.67; 95% confidence interval, 1.34-16.24; P = .008) for transmissions from maternal grandparents to mothers of probands, supporting a role for HLA-DR4 as an autism risk factor acting in mothers during pregnancy. Transmission disequilibrium was not seen for HLA-DR4 transmissions from parents to probands or from mothers to probands.

Conclusions  The HLA-DR4 gene may act in mothers of children with autism during pregnancy to contribute to autism in their offspring. Further studies are required to confirm these findings.

Design  Longitudinal cohort study.

Participants  Children retained in kindergarten or first (K/1) grade and third grade, presumably for academic reasons, were followed up through fifth grade.

Main Outcome Measure  Presence or absence of an IEP.

Results  A total of 300 children retained in K/1 and 80 retained in third grade were included in the study. Of the K/1 retainees, 68.9% never received an IEP during the subsequent 4 to 5 years; of the third-grade retainees, 72.3% never received an IEP. Kindergarten/first-grade retainees in the highest quintile for socioeconomic status and those with suburban residence were less likely to receive an IEP than retained children in all other socioeconomic status quintiles (adjusted odds ratio, 0.17; 95% confidence interval, 0.05-0.62) and in rural communities (0.16; 0.06-0.44). Among K/1 retainees with persistently low academic achievement in math and reading, as assessed by standardized testing, 38.2% and 29.7%, respectively, never received an IEP.

Conclusions  Most children retained in K/1 or third grade for academic reasons, including many of those who demonstrated sustained academic difficulties, never received an IEP during elementary school. Further studies are important to elucidate whether retained elementary schoolchildren are being denied their rights to special education services. In the meantime, early-grade retention may provide an opportunity for pediatricians to help families advocate for appropriate special education evaluations for children experiencing school difficulties.

Design  Prospective, population-based observational study.

Setting  Community.

Participants  Three hundred twenty-nine 2- to 48-month-old children.

Main Exposures  Audible television. Children wore a digital recorder on random days for up to 24 months. A software program incorporating automatic speech-identification technology processed the recorded file to analyze the sounds the children were exposed to and the sounds they made. Conditional linear regression was used to determine the association between audible television and the outcomes of interest.

Outcome Measures  Adult word counts, child vocalizations, and child conversational turns.

Results  Each hour of audible television was associated with significant reductions in age-adjusted z scores for child vocalizations (linear regression coefficient, –0.26; 95% confidence interval [CI], –0.29 to –0.22), vocalization duration (linear regression coefficient, –0.24; 95% CI, –0.27 to –0.20), and conversational turns (linear regression coefficient, –0.22; 95% CI, –0.25 to –0.19). There were also significant reductions in adult female (linear regression coefficient, –636; 95% CI, –812 to –460) and adult male (linear regression coefficient, –134; 95% CI, –263 to –5) word count.

Conclusions  Audible television is associated with decreased exposure to discernible human adult speech and decreased child vocalizations. These results may explain the association between infant television exposure and delayed language development.

Design  Ten pediatric clinics were randomly assigned to an intervention (5 clinics) or control group (5 clinics). The proportion of sexually active girls screened for CT was estimated over 18 months (April 2005-September 2006).

Setting  Large health maintenance organization in northern California.

Participants  Pediatric clinics providing urgent care services for adolescent girls aged 14 to 18 years.

Intervention  In the intervention clinics, a team of providers and clinic staff met monthly to redesign their clinic system to improve CT screening during urgent care. Controls received an informational lecture on CT screening.

Main Outcome Measures  Clinic-specific proportions of sexually active adolescent girls screened for CT.

Results  The change over time in clinic-specific CT screening rates in urgent care was significantly greater in the intervention group than in the control group (likelihood ratio, ²₁ = 18.7; P < .001). Between baseline and the fifth intervention period, the proportions of girls screened for CT increased by 15.93% in the intervention group and decreased by 2.13% in the comparison clinics.

Conclusions  The intervention significantly improved the proportion of adolescent girls screened for CT during urgent care. Despite this success, substantial barriers to screen for CT in urgent care remain. Innovative strategies to provide basic information about CT, other sexually transmitted infections, and pregnancy are greatly needed since many teens are never seen for preventive care in a given year.

Design  School survey.

Setting  Postmandatory schools.

Participants  A total of 6790 students (3275 females) aged 16 to 20 years, grouped as adolescents with CHCs (355 females, 354 males) and control peers (2920 females, 3161 males).

Main Exposure  Chronic health condition was defined using a noncategorical approach including adolescents with a chronic disease and/or a physical handicap.

Main Outcome Measures  Sports practice, barriers to sports practice among individuals not practicing any sports, and biological, psychological, socioeducative, and physical activity characteristics.

Results  Males with CHCs were less likely than control males to practice sports, whereas no significant difference was observed for females. Chronically ill youth were significantly more likely to report having a CHC as a barrier for not practicing sports. However, the most frequently reported barrier was preference for other activities for males with CHCs and lack of time for control males and for females with and without CHCs.

Conclusions  Having a CHC seems to influence sports practice among males but not females. We recommend that practitioners dealing with adolescents remember to take into account sports practice as part of the care of young patients with CHCs.

Data Sources  Cochrane Effective Practice and Organisation of Care Group database (January 1966 to April 2006), MEDLINE (January 1966 to April 2006), Cochrane Consumers and Communication Group database (January 1966 to May 2006), and bibliographies of retrieved articles.

Study Selection  Randomized controlled trials, controlled before-after trials, or interrupted time series trials of English-language QI evaluations.

Interventions  Must have included 1 or more QI strategies for the outpatient management of children with asthma.

Main Outcome Measures  Clinical status (eg, spirometric measures); functional status (eg, days lost from school); and health services use (eg, hospital admissions).

Results  Seventy-nine studies met inclusion criteria: 69 included at least some component of patient education, self-monitoring, or self-management; 13 included some component of organizational change; and 7 included provider education. Self-management interventions increased symptom-free days by approximately 10 days/y (P = .02) and reduced school absenteeism by about 0.1 day/mo (P = .03). Interventions of provider education and those that incorporated organizational changes were likely to report improvements in medication use. Quality improvement interventions that provided multiple educational sessions, had longer durations, and used combinations of instructional modalities were more likely to result in improvements for patients than interventions lacking these characteristics.

Conclusions  A variety of QI interventions improve the outcomes and processes of care for children with asthma. Use of similar outcome measures and thorough descriptions of interventions would advance the study of QI for pediatric asthma care.