Pediatrics
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Very low birth weight (VLBW)infants (those with birth weights <1500 g) account for only 1.2% of births but 46% of infant deaths. Large improvements in neonatal technology in the last 2 decades have significantly improved survival prospects for infants with low birth weights, but at a high cost. Due largely to a lack of data, the costs of medical care during the period in which infant mortality is measured (the first year of life), as well as the cost-effectiveness of that care for VLBW infants, have not been quantified. Despite this fact, public policies both toward providing insurance coverage for their care, as well as denying payment for their treatment, have either been proposed or implemented on cost-effectiveness grounds. ⋯ Public policies aimed at improving birth outcomes by providing insurance coverage for pregnant women and children, such as the recent Medicaid expansions, can potentially be very cost-effective. Although maternal interventions such as prenatal care are relatively inexpensive, each normal birth that results instead in a VLBW birth saves $59 700 in first year medical expenses. However, cost savings attributable to increased birth weights depend on where in the birth weight distribution the increase occurs as well as the size of the birth weight increase. For infants with birth weights >750 g, significant gains can accrue from even a small shift in the birth weight distribution. A shift of 250 g at birth saves an average of $12 000 to $16 000 in first year medical costs and a shift of 500 g generates $28 000 in savings. However, there is a threshold effect on birth weight. For infants <750 g, increases in birth weight may increase medical expenditures. For instance, a shift in birth weight to the 750 to 999 g range increases costs by $29 000.
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Biography Historical Article
The psychotherapeutic role of the pediatrician, by Milton J. E. Senn, MD, Pediatrics, 1948;2:147-152.
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The combined effects of recent changes in health care financing and training priorities have compelled academic medical centers to develop innovative structures to maintain service commitments yet conform to health care marketplace demands. In 1992, a municipal hospital in the Bronx, New York, affiliated with a major academic medical center reorganized its pediatric service into a vertically integrated system of four interdependent practice teams that provided comprehensive care in the ambulatory as well as inpatient settings. One of the goals of the new system was to conserve inpatient resources. ⋯ We conclude that vertical integration of a pediatric service at an inner-city municipal hospital is achievable; conveys advantages of improved continuity of care, enhanced opportunities for primary care training, and increased participation of senior clinicians; and has the potential to conserve significant amounts of inpatient resources.
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To determine the effects of increased physician training and a structured clinical form on physician documentation of child physical abuse. ⋯ Little improvement in physician documentation of child physical abuse was noted between 1980 and 1995 despite increased efforts to educate housestaff in the evaluation of child abuse during this time period. Although a structured form prompted physicians to document dates and times and to illustrate physical injuries on the diagram provided, it did not significantly improve documentation of other items.
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To compare historical features, physical examination findings, and testicular color Doppler ultrasound in pediatric patients with epididymitis, testicular torsion, and torsion of appendix testis. ⋯ The physical examination is helpful in distinguishing among epididymitis, testicular torsion, and torsion of appendix testis. Patients presenting with a tender testicle and an absent cremasteric reflex were more likely to have a testicular torsion rather than epididymitis or torsion of appendix testis. An absent cremasteric reflex was the most sensitive physical finding for diagnosing testicular torsion. Color Doppler ultrasound is a useful adjunct in the evaluation of the acute scrotum when physical findings are equivocal.