The chest roentgenograms of 128 consecutive ambulatory children with radiologic pneumonia were read independently and without clinical information by a faculty general pediatrician (Ped), a pediatric radiologist (R-P) and a general radiologist (R-G). The films were classified as normal, indicative of a viral or bacterial process, or indeterminate. Readings were compared with results of viral titers and bacterial cultures. Agreement between any two observers in classifying films, measured by unweighted Kappa, while statistically significant (p less than 0.001) for any pair, was low. There was no significant difference between the agreement scores of Ped/R-P, Ped/R-G, and R-P/R-G. Twenty-one patients had fourfold viral titer increases (N = 16) or positive bacterial cultures of blood or pulmonary aspirate (N = 5). The sensitivity of viral readings for titers increases varied from 19% to 68% depending on observer type; the sensitivity of bacterial readings for positive bacterial cultures varied from 60% to 80%. The three observers agreed on a correct reading in only three children with viral and three with bacterial pneumonia. Because of poor observer agreement and appreciable false-negative errors when viral and bacterial readings were compared to titer increases and positive bacterial cultures, respectively, we conclude that radiographic findings are poor indicators of etiology diagnosis in ambulatory childhood pneumonias and, of themselves, are an insufficient data base for making therapeutic decisions.
Because of the increasing constraints on the amount of time pediatric residents may train in the neonatal intensive care unit (NICU), concerns have been raised about the adequacy of their exposure to acute emergencies in the delivery room and their hands-on experience with sick neonates. Importantly, there are also concerns about the consistency and quality of supervision of PL-1 residents by second- and third-year residents, who themselves may not have had sufficient training in the NICU. To address these concerns, we have instituted an educational plan that links an experienced neonatal nurse practitioner (NNP) one-on-one with a PL-1 resident in a collaborative team. This plan differs from the traditional resident-to-resident supervisory model. An anonymous survey of our residents (n = 14) indicates enthusiastic endorsement of this new educational model. NNPs as first-line teachers in the NICU provide a new approach for residency training programs.
Large variations in inpatient illness severity and diagnostic diversity were seen across programs, but program size was found to be a poor indicator of inpatient learning opportunities.
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