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Biomedical subjects

Helen J Binns

Publications and source records attributed to Helen J Binns.

At least 19 recordsLinked to original sources
PubMed2006

Relationships of video assessments of touching and mouthing behaviors during outdoor play in urban residential yards to parental perceptions of child behaviors and blood lead levels.

Childrens' touching and mouthing behaviors during outdoor play in urban residential yards were measured using video observations. Descriptions were made of childrens' outdoor residential play environments. Behaviors assessed were used to examine (1) validity of parental responses to questions on childrens' oral behaviors and outdoor play and (2) relationships of mouthing behaviors to blood lead levels (BLLs). Thirty-seven children aged 1-5 years were recruited for 2 h of video recording in their yard and blood lead measurement. Video assessments included hourly rates of hand touches to ground/walking-level surfaces (cement/stone/steel, porch floor/steps, grass, and bare soil) and oral behaviors. Parental questionnaires assessed their child's outdoor activities, behaviors, and home environment. The children were: mean 39 months; 51% male; 89% Hispanic; and 78% Medicaid or uninsured. Twenty-two children had a blood lead measured (mean 6 microg/dl). During taping, all children had access to cement, 92% to grass, 73% to bare soil, and 59% to an open porch. Children had frequent touching and mouthing behaviors observed (median touches/h: touches to surfaces 81; hand-to-mouth area (with and without food) 26; hand-in-mouth 7; and object-in-mouth 17). Blood lead was directly correlated with log-transformed rates of hand-in-mouth (Pearson's correlation, r=0.564, n=22, P=0.006) and object-in-mouth (Pearson's correlation, r=0.482, n=22, P=0.023) behaviors. Parental questionnaire responses did not accurately reflect childrens' observed oral behaviors, play habits, or play environment. These data confirm the direct relationship between hand-to-mouth activities and BLLs and fail to validate parental perceptions of their child's mouthing behaviors or outdoor play environment.

Child Behavior↗
PubMed2006

Parents' perceptions of their child's weight and health.

OBJECTIVE: This study explored parents' perceptions about their child's appearance and health and evaluated a tool to determine parents' visual perception of their child's weight. METHODS: Parents of children aged 2 to 17 years were surveyed concerning their child's appearance and health and opinions about childhood overweight. They also selected the sketch (from 7 choices) that most closely matched the body image of their child using 1 of 8 gender-and age-range-specific panels of sketches. Children's height and weight were measured. Respondents were grouped by child body mass index (BMI) percentile (<5th, 5-84th, 85-94th [at risk for overweight (AROW)], and > or =95th [overweight]). Those with BMI > or =5th percentile were analyzed. Logistic regression was used to examine factors influencing parental perceptions and levels of worry about their overweight or AROW child. RESULTS: Of the 223 children, 60% were <6 years old, 42% were male, 17% were black, 35% were Hispanic, 42% were white, and 7% were other; 19% were AROW, and 20% were overweight. Few parents (36%) identified their overweight or AROW child as "overweight" or "a little overweight" using words, but more (70%) selected a middle or heavier sketch. Among parents of overweight and AROW children, 18% recalled a doctor's concern and 26% were worried about their child's weight. If the overweight or AROW child was age > or =6 years, parents were more likely to identify their child as "overweight" or "a little overweight" using words, select a middle or heavier sketch, and to be worried. Parents of older children were more likely to be worried if they perceived their child as less active/slower than other children or recalled a doctor's concern. CONCLUSIONS: Few parents of overweight and AROW children recognized their child as overweight or were worried. Recognition of physical activity limitations and physicians' concerns may heighten the parent's level of concern. Sketches may be a useful tool to identify overweight children when measurements are not available.

Adolescent↗
PubMed2004

Lead levels of edibles grown in contaminated residential soils: a field survey.

Plants grown in lead contaminated soils can accumulate lead from the adherence of dust and translocation into the plant tissue. In order to evaluate the potential health hazard due to the consumption of plants grown in residential gardens contaminated by lead, a survey of the lead concentrations in a typical array of edible vegetables, fruits and herbs was conducted. Samples of garden plants harvested from the field were washed with detergent or water alone to remove adhered soil. They were dried, separated into sections including root, shoot and edible fruit, and then analyzed for lead content using inductively coupled plasma-atomic emission spectrometry (ICP-AES). Soil samples, taken in conjunction with the plant harvesting, were analyzed using flame atomic absorbance (FAA). A pattern of lead transference from soil through the root to the stem and leaves of garden crops was found. The majority of the lead was concentrated in the roots (root:soil ranging from 0.02 to 0.51), with some translocation into the shoots (shoot:soil as high as 0.10). This pattern is a concern particularly for crops in which the root, stems, stalks or leaves are edible. The lead concentration in fruiting vegetables was less than the detection limit of 10 ppm (microgram lead/gram dry plant matter). Some edible portions of the leafy vegetables and herbs, however, were found to have lead levels that, if consumed, could contribute to the total body burden of lead. Therefore, urban gardeners should test the lead levels in their soils and develop strategies to ensure safety.

Cities↗
PubMed2004

Evaluation of landscape coverings to reduce soil lead hazards in urban residential yards: The Safer Yards Project.

This study was designed primarily to evaluate the effectiveness of landscape coverings to reduce the potential for exposure to lead-contaminated soil in an urban neighborhood. Residential properties were randomized in to three groups: application of ground coverings/barriers plus placement of a raised garden bed (RB), application of ground coverings/barriers only (no raised bed, NRB), and control. Outcomes evaluated soil lead concentration (employing a weighting method to assess acute hazard soil lead [areas not fully covered] and potential hazard soil lead [all soil surfaces regardless of covering status]), density of landscape coverings (6 = heavy, > 90% covered; 1 = bare, < 10% covered), lead tracked onto carpeted entryway floor mats, and entryway floor dust lead loadings. Over 1 year, the intervention groups had significantly reduced acute hazard soil lead concentration (median change: RB, -478 ppm; NRB, -698 ppm; control, +52 ppm; Kruskal-Wallis, P = 0.02), enhanced landscape coverings (mean change in score: RB, +0.6; NRB, +1.5; control, -0.6; ANOVA, P < 0.001), and a 50% decrease in lead tracked onto the floor mats. The potential hazard soil lead concentration and the entryway floor dust lead loading did not change significantly. Techniques evaluated by this study are feasible for use by property owners but will require continued maintenance. The long-term sustainability of the method needs further examination.

Chicago↗
PubMed2004

Sociodemographic and symptom correlates of fatigue in an adolescent primary care sample.

PURPOSE: To describe the prevalence of prolonged fatigue, chronic fatigue syndrome (CFS)-like illness, and associated symptom patterns in adolescents attending primary care. METHODS: The design was cross-sectional. A questionnaire designed by the authors assessing fatigue and associated symptoms was administered to 901 adolescents (aged 11-18 years) attending 12 primary care clinics in the Chicago area. Prevalence rates for prolonged fatigue and CFS-like illness were calculated. Univariate comparisons involving sociodemographic data and fatigue severity were made between adolescents with and without prolonged fatigue, and sociodemographic and symptom predictors of prolonged fatigue were identified using logistic regression analysis. RESULTS: Prolonged fatigue (> or = 1 month) occurred at a rate of 8.0% and CFS-like illness occurred at a rate of 4.4%. Adolescents with prolonged fatigue were significantly older and also reported greater fatigue severity than those without fatigue. Findings from logistic regression indicated that, in addition to increasing age, headaches, muscle pains, fever, and fatigue made worse by exercise were significantly associated with prolonged fatigue. CONCLUSIONS: Abnormal fatigue is a disabling and prevalent condition in adolescents in primary care. It is associated with a number of additional symptoms, many of which may have viral origins.

Adolescent↗
PubMed2004

Reduction in pediatric hospitalizations for varicella-related invasive group A streptococcal infections in the varicella vaccine era.

OBJECTIVES: To assess changes in hospitalization rates for invasive group A streptococcal (IGAS) and varicella-associated IGAS (VA-IGAS) infections at a pediatric hospital over a period of 9 years, to characterize clinical features of patients with IGAS infections, and to assess frequency of macrolide-resistant IGAS isolates. Study design Medical records of all hospitalized patients with group A streptococcus isolated from a normally sterile site from 1993 to 2001 were reviewed. Data collected included demographics, clinical course, microbiologic features, outcome, and presence of streptococcal toxic shock syndrome (STSS) or necrotizing fasciitis (NF). Annual hospitalization rates for IGAS were determined. RESULTS: There were 144 patients with IGAS infections, including 11 (8%) with STSS or NF. Overall mortality rate was 2% (3/144) but 18% (2/11) among patients with STSS or NF. Preexisting varicella was present in 16% (23/144); 4 of 23 VA-IGAS cases had STSS or NF. Although there was no change in annual hospitalization rates for IGAS infections during the study period, the percentage of VA-IGAS hospitalizations decreased from 27% in the prevaccine era (1993 to 1995), to 16% during vaccine implementation (1996 to 1998) and 2% during widespread vaccine use (1999 to 2001) (linear-by-linear association, P=.001). Macrolide resistance was low in 1993 to 1995 (5%, 1/19) and 1996 to 1998 (0%, 0/42) among tested IGAS isolates and increased significantly in 1999 to 2001 (13%, 5/38) (Fisher exact, P=.035). CONCLUSIONS: A decline in pediatric varicella-related IGAS hospitalizations was temporally associated with utilization of varicella vaccine. These data reinforce the importance of universal varicella vaccination for children. Increasing macrolide resistance among IGAS isolates indicates a need for continued surveillance.

Adolescent↗
PubMed2004

Risk factors for overweight in five- to six-year-old Hispanic-American children: a pilot study.

The objective of this study was to determine the prevalence of and possible risk factors for overweight in a sample of 5- to 6-year-old Hispanic (predominantly Mexican American) children in Chicago, Illinois, to see if overweight is more common in more highly acculturated immigrant families. There were 250 kindergarten students (92% of those eligible) attending two public elementary schools serving primarily Mexican American neighborhoods measured for height and weight. Consenting mothers were interviewed (n = 80) and measured (n = 38). The interview tool covered demography, acculturation, infant and toddler feeding practices, current eating patterns and food preparation habits, physical activity, and psychosocial family characteristics. Overweight was conservatively defined as weight-for-height at or above the National Center for Health Statistics 95th percentile. The data were used to describe the prevalence of overweight. Overweight and nonoverweight children were compared on all survey variables using appropriate statistical tests, with significance set at.05. There were 23% of the total sample of children (n = 250) and 26% of the subsample of children (those whose mothers were interviewed) who were overweight. Analysis limited to children in the subsample explored risk factors. The median score on the Acculturation Scale was 4.0 (range 2.4 - 10.4) on a scale of 2.4 (entirely not acculturated) to 12 (fully acculturated). There was no significant association between overweight and Acculturation Scale score. Overweight children were more likely than those not overweight to watch television for more than 3 hours during weekend days (48% vs. 22%, P =.03). Overweight children were also more likely to consume sweetened beverages (powdered drinks, soda pop, atole) daily (67% vs. 39%, P =.03). There was a trend indicating that free access to food at home increased the risk of overweight (P = 0.06). No other family- or child-level variables were related to overweight. Only 40% of mothers with an overweight child correctly assessed these children as overweight. Approximately one quarter of the children in the study were overweight. Our hypothesis that their obesity was linked to acculturation was not confirmed. Longer hours of child television viewing on weekends and higher levels of sweetened beverage consumption were important behaviors associated with the occurrence of overweight. These data should be considered when designing future studies in this population.

Acculturation↗
PubMed2004

Evaluation of a type 2 diabetes screening protocol in an urban pediatric clinic.

BACKGROUND: In 2000, the American Diabetes Association issued recommendations for type 2 diabetes mellitus screening among children. They recommended testing children > or =10 years of age who have a body mass index (BMI) of >85th percentile for age and at least 2 other risk factors (family history of type 2 diabetes, high-risk race/ethnicity, or evidence of insulin resistance, such as acanthosis nigricans). OBJECTIVE: To describe the application of a type 2 diabetes mellitus screening protocol in an urban pediatric clinic. Design/Methods. Medical records for patients 10 to 18 years of age who were examined in health maintenance visits during a 13-month period were reviewed; 997 subjects were included in the analyses. Data collected included demographic features, medical history, family history, physical examination findings, dietary and physical activity counseling, and results of laboratory tests. BMI percentiles for age were determined from national references. RESULTS: Subjects were 50% male (median age: 13.2 years), 96% Hispanic, and 48% (n = 477) had a >85th percentile BMI (including 26% with a > or=95th percentile BMI). Of the 477 subjects, 100% were in high-risk racial/ethnic groups, 29% had a family history of diabetes, and 20% demonstrated evidence of insulin resistance; 194 (41%) met the criteria for screening. Of those who met the criteria, 38% (n = 73) had screening ordered and 65 of those subjects (89%) completed screening. Acanthosis nigricans was more common among subjects for whom screening was ordered (69%), compared with subjects who were not screened (3%). Three screened subjects exhibited impaired glucose tolerance; none had overt diabetes. Subjects for whom screening was ordered were more likely to have received counseling than were subjects not recognized as qualifying for screening (84% vs 52%). CONCLUSIONS: At this high-risk clinical site, the American Diabetes Association type 2 diabetes screening protocol was inconsistently applied. Acanthosis nigricans was a driving factor in identification and screening. Recognition of the need for screening was associated with a higher rate of documentation of nutritional counseling. Additional evaluation of the effectiveness of screening protocols in the early identification of diabetes and the effects of screening protocols on long-term morbidity is needed.

Adolescent↗
PubMed2004

Guidelines help clinicians identify risk factors for overweight in children.

The pediatric office has an important role in national efforts to reverse rising trends in the prevalence of childhood overweight. Overweight may be established at a young age and is difficult to reverse. Lifestyle choices associated with overweight are common and their development may begin in very young children. Therefore, there is a necessity to apply a preventive strategy that addresses all children to promote healthy lifestyle choices from birth onward and to develop an intervention strategy that works by changing family habits so that healthy lifestyle habits are reinforced. It is crucial to develop, evaluate, and apply new systems and practical approaches to aid in this effort in the pediatric practice setting.

Body Mass Index↗
PubMed2003

Aprotinin reduces operative closure time and blood product use after pediatric bypass.

BACKGROUND: The use of aprotinin in children undergoing cardiopulmonary bypass is controversial. We hypothesized that aprotinin would reduce blood product use and operative closure time in selected pediatric patients. METHODS: For a 6-month period starting in October 1999, consecutive cardiopulmonary bypass patients 6 months of age or less (n = 18) or having a repeat sternotomy (n = 18) received aprotinin. Similar consecutive patients from the preceding 6 months served as controls (n = 35 and 41, respectively). Data extracted from medical records included preoperative clinical characteristics, operative and postoperative procedures, and total blood product use. RESULTS: Patients in the aprotinin and control groups were well matched with regard to preoperative and intraoperative variables. Patients 6 months of age or less who received aprotinin required less operative closure time when compared with controls (median, 93 vs 127 minutes, p = 0.004), and trended toward requiring fewer red blood cell unit exposures (median, three vs five exposures, p = 0.07). Patients undergoing repeat sternotomy who received aprotinin required less operative closure time when compared with controls (mean, 126 vs 159 minutes, p = 0.007), fewer red blood cell unit exposures (median three vs four exposures, p = 0.002), and fewer fresh-frozen plasma unit exposures (median, zero vs one exposure, p = 0.007). CONCLUSIONS: Aprotinin reduced operative closure time and blood product exposure in pediatric patients undergoing cardiopulmonary bypass who were 6 months of age or less or underwent a repeat sternotomy.

Aprotinin↗
PubMed2003

A comparison of intravascular ultrasound with coronary angiography for evaluation of transplant coronary disease in pediatric heart transplant recipients.

BACKGROUND: The purpose of this study was to assess the sensitivity of coronary angiography versus intravascular ultrasound for detecting significant transplant coronary artery disease in children. We also examined associations between potential risk factors for transplant coronary artery disease and intravascular ultrasound findings, and evaluated the safety of intravascular ultrasound. METHODS: All pediatric heart transplant patients who had intravascular ultrasound following routine coronary angiography were included. Transplant coronary artery disease was quantified by assigning Stanford classes and calculating intimal indices for intravascular ultrasound images. These findings were compared with qualitative coronary angiography findings. Risk factors for transplant coronary artery disease, cardiac events and complications were recorded. RESULTS: Sixteen patients had 27 intravascular ultrasound procedures during the study period. All patients had evidence of transplant coronary artery disease at their latest intravascular ultrasound study. Of the patients whose most severely afflicted coronary artery underwent both imaging modalities at the latest study, 50% had significant transplant coronary artery disease (Stanford Class >/=II) by intravascular ultrasound and normal coronary angiography. A higher mean first-year biopsy score may be associated with significant transplant coronary artery disease by intravascular ultrasound, but a large number of patients will be required to determine this with statistical certainty. One major complication occurred early in the experience. CONCLUSIONS: In children, intravascular ultrasound is more sensitive for detecting significant transplant coronary artery disease than coronary angiography, but may add cost, time and potential morbidity to screening protocols. Prospective, multicenter studies are needed to best utilize intravascular ultrasound in this patient population.

Adolescent↗
PubMed2002

Persistence and emergence of anemia in children during participation in the Special Supplemental Nutrition Program for Women, Infants, and Children.

CONTEXT: The prevalence of iron-deficiency anemia in children has decreased owing to the provision of iron-containing infant formula and cereal and food vouchers to children enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). OBJECTIVE: To determine the prevalence of anemia and changes in anemia status in children receiving WIC supplementation. DESIGN: Retrospective cross-sectional and longitudinal analysis of information on WIC participants. Two definitions of anemia were considered separately: Anemia1 and Anemia2, the latter using a more stringent definition of anemia to avoid misclassification. PARTICIPANTS: Consecutive cohort of 7053 infants and children aged 6 to 59 months. MAIN OUTCOME MEASURES: Prevalence of anemia by age and race or ethnicity and relationship between anemia and sex, birth weight, and weight-for-height z score. RESULTS: Infants aged 6 to 8 months were 3.3 times more likely to be anemic than children aged 36 to 59 months. There was no association between anemia and race, birth weight, sex, or weight-for-height z score. Anemia rates were approximately halved in the more stringently defined Anemia2 group. Among children seen for at least 3 visits (n = 2926), 8.5% developed anemia and 19.1% of initially anemic children remained anemic; an additional 6.6% developed anemia at a third visit after having had 2 normal hemoglobin measurements. CONCLUSIONS: Anemia was common in WIC participants, with infants at highest risk. The diagnosis of anemia in black children depends on the cutoff value used. Despite ongoing receipt of WIC benefits, many children develop anemia or remain anemic. Implementation of mandatory follow-up of all anemic infants by WIC or health care providers may be warranted.

Adult↗
PubMed2002

Lead poisoning and asthma: an examination of comorbidity.

OBJECTIVES: To determine the comorbidity of lead poisoning and asthma in urban children, and to examine associated clinical factors. METHODS: One-hundred-one patients at an inner-city clinic with blood lead levels (BLLs) of 25 microg/dL or higher (> or =1.2 micromol/L) (BLL25 group) were randomly selected from a tracking lead database and matched on age, sex, and primary language to 101 randomly selected patients with a first BLL recorded in the database of lower than 5 microg/dL (<0.2 micromol/L) (BLL5 group) and no subsequent BLLs of 10 microg/dL or higher (> or =0.5 micromol/L). Medical records were reviewed to determine diagnosis or symptoms of asthma or wheezing at any visit, immunization status, and number of visits. Analyses for matched pairs were conducted. RESULTS: The BLL25 and BLL5 groups did not differ on age at diagnostic BLL (26.6 months vs 24.2 months), sex (54% male), or language (12% Spanish). The BLL25 and BLL5 groups had a similar number of subjects with a diagnosis of asthma (6% vs 11%; odds ratio, 0.5; 95% confidence interval, 0.2-1.6); 26% of BLL25 and 34% of BLL5 subjects had either a diagnosis or symptoms of asthma or wheezing (odds ratio, 0.7; 95% confidence interval, 0.4-1.3). Subjects with BLL25 were more likely to have delayed immunization and a first clinic visit when older than subjects with BLL5. CONCLUSIONS: There was no increased likelihood of asthma diagnosis or symptoms among young children with lead poisoning. Children with lead poisoning also had delayed medical care. These data may help guide interventions aimed at preventing or reducing the impact of lead poisoning and asthma.

Asthma↗
PubMedDate not supplied

Retrospective assessment of subacute or chronic osteomyelitis in children and young adults.

To identify factors associated with and to describe treatment outcomes of pediatric subacute or chronic osteomyelitis (S/CO), we retrospectively identified 52 patients with S/CO from January 1994 to November 1999 seen at a large pediatric hospital infectious disease clinic. S/CO was defined by the following: >10 days of clinical symptoms; radiographic, surgical, or pathologic changes consistent with S/CO; or relapse of prior osteomyelitis. Of these patients 63% were male, median age 9 years. Bones involved included vertebra (19% of subjects), femur (17%), finger (12%), humerus (10%), and tibia (8%). Sixty-five percent had at least 1 risk factor (most commonly hardware, neurologic disease or preceding trauma, sepsis, or surgery). Blood, bone, or wound aspirate cultures were positive in 67%, most commonly for Staphylococcus aureus. Erythrocyte sedimentation rate (ESR) was elevated in 88% of 41 patients at the time of diagnosis. Intravenous antibiotics were given for a median of 6 weeks and oral antibiotics for a median of 4.5 months. One child had a complication. In conclusion, consideration of S/CO should be high when predisposing factors are present. ESR may be useful for determining effectiveness and duration of therapy. With prolonged antibiotic therapy nearly all patients demonstrated resolution of disease.

Adolescent↗
PubMedDate not supplied

Assessment of suspicion of abuse in the primary care setting.

OBJECTIVES: To describe the primary care practitioner's assessment of the likelihood that an injury was caused by physical abuse. The hypotheses were 1) practitioners face great uncertainty as to the possibility that an injury may have been caused by abuse; a measure that assigns variable degrees of suspicion to childhood injuries can be developed that will reveal this uncertainty; and 2) practitioner factors and patient factors influence this suspicion. METHODS: Primary care practitioners in a regional practice-based research network prospectively collected information about each consecutive office encounter during a 4-week study period. For injury-related visits, the practitioner described injury type, reported cause and severity, and the practitioner's assessment of the cause of injury. Practitioners also used a 5-point Suspicion Scale to identify their level of suspicion that the injury was caused by abuse, with 1 equating to impossible and 5 equating to virtually certain. A subset of practitioners gave information about child and family risk factors. The practitioner's reporting activity was not studied. RESULTS: Participating practitioners (n = 85) in 17 practices collected information about 12 510 office encounters, including 659 injuries. Although the practitioners assessed no injuries as "caused by abuse," they rated 21% of the injuries as having "some suspicion" of abuse. Practitioners were more likely to have "some suspicion" of abuse for those children who were Hispanic or African-American (vs. White) (P =.001, chi(2)) and for those children whose mothers had no college education (P =.018, chi(2)). In multivariate logistic regression modeling, "some suspicion" of abuse was associated with higher injury severity (odds ratio [OR] 3.4, 95% confidence interval [CI] 1.7, 7.0), age <6 years (OR 2.9, 95% CI 1.5, 5.6), Medicaid or self-pay health care (OR 1.4, 95% CI 1.4, 5.3), practitioner identification of family risk factors (OR 4.8, 95% CI 1.6, 14.6), and more recent practitioner education about child abuse (OR 2.9, 95% CI 1.4, 5.8). CONCLUSION: Primary care practitioners reported some degree of suspicion that 21% of injuries they evaluated were caused by abuse. Patient factors and practitioner factors influenced their suspicion.

Adolescent↗
PubMedDate not supplied

Evaluating computer capabilities in a primary care practice-based research network.

PURPOSE: We wanted to assess computer capabilities in a primary care practice-based research network and to understand how receptive the practices were to new ideas for automation of practice activities and research. METHOD: This study was conducted among members of the Pediatric Practice Research Group (PPRG). A survey to assess computer capabilities was developed to explore hardware types, software programs, Internet connectivity and data transmission; views on privacy and security; and receptivity to future electronic data collection approaches. RESULTS: Of the 40 PPRG practices participating in the study during the autumn of 2001, all used IBM-compatible systems. Of these, 45% used stand-alone desktops, 40% had networked desktops, and approximately 15% used laptops and minicomputers. A variety of software packages were used, with most practices (82%) having software for some aspect of patient care documentation, patient accounting (90%), business support (60%), and management reports and analysis (97%). The main obstacles to expanding use of computers in patient care were insufficient staff training (63%) and privacy concerns (82%). If provided with training and support, most practices indicated they were willing to consider an array of electronic data collection options for practice-based research activities. CONCLUSIONS: There is wide variability in hardware and software use in the pediatric practice setting. Implementing electronic data collection in the PPRG would require a substantial start-up effort and ongoing training and support at the practice site.

Ambulatory Care Information Systems↗