Any close examination of the epidemiologic trends in childhood suggests 2 fundamental findings. First, pediatrics has been among the most successful specialties in the history of medicine. Second, pediatrics must change. At the heart of this seeming paradox is the recognition that pediatrics has so altered the clinical threats to the well-being ofthe past 50 years that new structures of care will be required. The pride in pediatrics' remarkable record of impact and at the same time defend the status quo. modern children over epidemiology presents a ruthless logic: one cannot take

The challenge to the pediatrics community is to ensure that the changes that will inevitably come are exquisitely focused on meeting the needs of children. We must craft strategies that can protect what remains essential in pediatric practice and yet embrace a historic opportunity to craft requisite reforms. It is in this context that the recent initiatives by the American Board of Pediatrics [Editor's note: also see related supplement titled "Residency Review and Redesign in Pediatrics: New (and Old) Questions" with this issue of Pediatrics.] and the American Academy of Pediatrics to consider new training and practice needs should be welcomed. However, the nature and scale of the challenge will require a new level of direct engagement from pediatricians and a renewed progressive commitment to speak with a stronger and more coherent collective voice.

The American College of Physicians (ACP) developed this guidance statement to present the available evidence on screening for HIV in health care settings. METHODS: This guidance statement is derived from an appraisal of available guidelines on screening for HIV. Authors searched the National Guideline Clearinghouse to identify guidelines on screening for HIV in the United States and used the AGREE (Appraisal of Guidelines Research and Evaluation) instrument to evaluate guidelines from the U.S. Preventive Services Task Force and the Centers for Disease Control and Prevention. GUIDANCE STATEMENT 1: ACP recommends that clinicians adopt routine screening for HIV and encourage patients to be tested. GUIDANCE STATEMENT 2: ACP recommends that clinicians determine the need for repeat screening on an individual basis.

The rising U.S. obesity prevalence has disproportionately affected minority children. Previous studies have reported that among African American U.S.-born participants, those with foreign-born parents were significantly less likely to be obese than individuals with U.S.-born parents. Little is known about the children of Hispanic immigrants from Central and South America, and among 2-5 year olds in particular. The current study examined demographic characteristics of 307 children ages 2-5 year olds who participated in a randomized controlled obesity prevention intervention trial in 8 childcare centers in Miami, Florida. Anthropometric data collected included weight, height, waist circumference and body mass index (BMI). Overweight was defined as > 95th %ile for age and at- risk-for-overweight was defined as > 85th to <95th percentile, based on the Centers for Disease Control and Prevention (CDC) guidelines. Obese children were significantly more likely to be born in the US than another country (P<0.0001). Girls were equally as likely as boys to be overweight; 31% of the sample has a BMI percentile > 85th %ile. Children of Central American immigrants were significantly more likely than their Cuban or Caribbean immigrant parent counterparts to be obese (p< 0.01). Obesity prevention interventions need to target children as young as preschool age and should be tailored to the child’s ethnic background, particularly if the child was born in the US and the parents were not.

ABSTRACT

OBJECTIVE. Despite the success of current newborn screening programs, some critics have argued that in the 1960s hundreds of children with false-positive results for phenylketonuria suffered death or disability from treatment with restrictive diets. Medically adverse outcomes after false-positive results may be a reason to be cautious when expanding current newborn screening programs. We sought to determine if newborn screening programs for phenylketonuria before 1980 led to adverse medical outcomes in children with false-positive results.

PATIENTS AND METHODS. We examined the history of newborn screening programs for phenylketonuria in the United States. We reviewed the historical scholarship, conducted a systematic search for medical adverse outcomes, and interviewed key participants in the history of newborn screening programs.

RESULTS. We found no population-based studies of early screening programs for phenylketonuria. One author reported 2 infants treated with restrictive diets after false-positive results for phenylketonuria who were developmentally delayed, and there is unpublished evidence of 4 additional cases of inappropriate treatment, although adverse outcomes were not documented. There were also 4 published reports of adverse medical outcomes after treating children with phenylketonuria variants, as screening for phenylketonuria revealed infants with intermediate or transiently high levels of phenylalanine.

CONCLUSIONS. We found little evidence of death or disability that resulted from the inappropriate treatment of well children who were falsely identified by early newborn screening programs. Because the first decade of newborn screening typically reveals diagnostic and therapeutic complexity, systematic follow-up of screened populations and rapid dissemination of results may reduce morbidity/mortality rates.

We evaluated the frequency of HIV testing across the Department of Veterans Affairs (VA), the largest provider of HIV care in the United States. An electronic survey was used to determine the volume and location of HIV screening, confirmatory testing, rapid testing and laboratory consent policies in VA medical centers between October 1, 2005, and September 30, 2006. One hundred thirty-five VA laboratories reported that 112,033 HIV screening tests were performed (81% outpatients vs. 19% inpatients, p<.0001). Overall HIV prevalence was 1.49% (1.62% in inpatients vs. 1.46% in outpatients, p=N.S., range=0.2-3.8%). Rapid testing was available in 67% of facilities, 60% of which took place in the clinical laboratory. Sixty-four percent of labs required a copy of the informed consent in order to perform testing. We estimate that fewer than 10% of VA inpatients and fewer than 5% of VA outpatients were tested for HIV during the survey period. Substantial opportunities for increasing routine HIV testing exist in this population.

OBJECTIVES: Narcotic-related adverse drug events are the most common adverse drug events in hospitalized children. Despite multiple published studies describing interventions that decrease adverse drug events from narcotics, large-scale collaborative quality improvement efforts to address narcotic-related adverse drug events in pediatrics have not been described. The purpose of this study was to evaluate collaborative-wide narcotic-related adverse drug event rates after a collection of expert panel-defined best practices was implemented.

METHODS: All 42 children's hospitals in the Child Health Corporation of America were invited to participate in the Institute for Healthcare Improvement-style quality improvement collaborative aimed at reducing narcotic-related adverse drug events. A collection of interventions known or suspected to reduce narcotic-related adverse drug events was recommended by an expert panel, with each site implementing >or=1 of these best practices on the basis of local need. Narcotic-related adverse drug event rates were compared between the baseline (December 1, 2004, to March 31, 2005) and postimplementation periods (January 1, 2006, to March 31, 2006) after an a priori-defined intervention ramp-up time (April 1, 2005, and December 31, 2005). Secondary outcome measures included constipation rates and narcotic-related automated drug-dispensing-device override percentages.

RESULTS: Median narcotic-related adverse drug event rates decreased 67% between the baseline and postimplementation time frames across the 14-site collaborative. Constipation rates decreased 68.9%, and automated drug-dispensing-device overrides decreased from 10.18% to 5.91% of all narcotic doses administered.

CONCLUSIONS: Implementation of >or=1 expert panel-recommended interventions at each participating site resulted in a significant decrease in narcotic-related adverse drug events, constipation, and automated drug-dispensing-device overrides in a 12-month, 14-site children's hospital quality collaborative.

STUDY OBJECTIVE: To develop a prioritized list of individual drugs for which future research regarding off-label uses is warranted.

DESIGN: Retrospective, cross-sectional study.

DATA SOURCES: Commercial database that provides ongoing estimates of drug prescribing practices of office-based physicians in the United States and an Internet database of comprehensive evidence-based drug information.

MEASUREMENTS AND MAIN RESULTS: The base analyses incorporated three key factors based on the theory of value of information: volume of off-label use with inadequate evidence, drug safety, and cost and market considerations. Nationally representative prescribing data were used to estimate the number of off-label drug uses by indication from January 1, 2005-June 30, 2007, in the United States, and these indications were then categorized according to the adequacy of scientific support. Black-box warnings and safety alerts, drug cost, date of market entry, and marketing expenditures were also incorporated into the final model to produce a priority score. Sensitivity analyses were conducted by varying key model parameters. Our findings identified a high volume of off-label prescribing in the absence of good evidence for a substantial number of drugs, particularly antidepressants, antipsychotics, and anxiolytic-sedatives. Drugs that consistently ranked high in both our base model and sensitivity analyses were quetiapine, warfarin, escitalopram, risperidone, montelukast, bupropion, sertraline, venlafaxine, celecoxib, lisinopril, duloxetine, trazodone, olanzapine, and epoetin alfa.

CONCLUSION: Future research into off-label drug use should focus on drugs used frequently with inadequate supporting evidence, particularly if further concerns are raised by known safety issues, high drug cost, recent market entry, and extensive marketing. Our quantitative analysis identified particular concerns with the off-label use of antipsychotic and antidepressant drugs. Targeted research and policy activities on our list of prioritized drugs have high potential value.

Our study assesses how work-related monetary and nonmonetary factors affect physicians' job satisfaction at three academic medical centers in Germany and the United States, two countries whose differing health care systems experience similar problems in maintaining their physician workforce. We used descriptive statistics and factor and correlation analyses to evaluate physicians' responses to a self-administered questionnaire. Our study revealed that German physician respondents were less satisfied overall than their U.S. counterparts. In both countries, participation in decision making that may affect physicians' work was an important correlate of satisfaction. In Germany other important factors were opportunities for continuing education, job security, extent of administrative work, collegial relationships, and access to specialized technology. In the U.S. sample, job security, financial incentives, interaction with colleagues, and cooperative working relationships with colleagues and management were important predictors of overall job satisfaction. The implications of these findings for the development of policies and management tactics to increase physician job satisfaction in German and U.S. academic medical centers are discussed.

The American College of Physicians developed this guideline to present the available evidence on the pharmacologic management of the acute, continuation, and maintenance phases of major depressive disorder; dysthymia; subsyndromal depression; and accompanying symptoms, such as anxiety, insomnia, or neurovegetative symptoms, by using second-generation antidepressants.

METHODS: Published literature on this topic was identified by using MEDLINE, EMBASE, PsychLit, the Cochrane Central Register of Controlled Trials, and International Pharmaceutical Abstracts from 1980 to April 2007. Searches were limited to English-language studies in adults older than 19 years of age. Keywords for search included terms for depressive disorders and 12 specific second-generation antidepressants-bupropion, citalopram, duloxetine, escitalopram, fluoxetine, fluvoxamine, mirtazapine, nefazodone, paroxetine, sertraline, trazodone, and venlafaxine-and their specific trade names. This guideline grades the evidence and recommendations by using the American College of Physicians clinical practice guidelines grading system.

RECOMMENDATIONS

1. The American College of Physicians recommends that when clinicians choose pharmacologic therapy to treat patients with acute major depression, they select second-generation antidepressants on the basis of adverse effect profiles, cost, and patient preferences (Grade: strong recommendation; moderate-quality evidence).
2. The American College of Physicians recommends that clinicians assess patient status, therapeutic response, and adverse effects of antidepressant therapy on a regular basis beginning within 1 to 2 weeks of initiation of therapy (Grade: strong recommendation; moderate-quality evidence).
3. The American College of Physicians recommends that clinicians modify treatment if the patient does not have an adequate response to pharmacotherapy within 6 to 8 weeks of the initiation of therapy for major depressive disorder (Grade: strong recommendation; moderate-quality evidence).
4. The American College of Physicians recommends that clinicians continue treatment for 4 to 9 months after a satisfactory response in patients with a first episode of major depressive disorder. For patients who have had 2 or more episodes of depression, an even longer duration of therapy may be beneficial (Grade: strong recommendation; moderate-quality evidence).