Practice-Based Research: Opportunities and Obstacles

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VOLUME 82 #{149}SEPTEMBER 1988 #{149}NUMBER 3 #{149}PART 2

ARTICLES 399

Pediatrics

PracticeBased

Research:

Opportunities

and

Obstacles

K. K. Christoffel,

MD, MPH,

H. J. Binns,

MD, J. A. Stockman

III, MD,

P. McGuire,

J. Poncher,

MD, S. Unti, MD, B. Typlin,

MD, G. Lasin,

MD,

W. Seigel,

MD, and the Pediatric

Practice

Research

Group*

From the Children’s Memorial Hospital, Chicago

ABSTRACT. Renewed interest in practice-based research

reflects growing realization of the limitations of research

from a hospital perspective. Practice-based pediatric re-search promises to broaden the range and severity of

conditions commonly studied, to enhance the study of

the natural history of disease and of normal development, to provide normal controls and standards, and to

facili-tate recruitment of adequate sample sizes. Cohort, mci-dence, and health services research will be promoted by

the development of patient registries. The Chicago area Pediatric Practice Research Group is a research consor-tium of 81 practitioners in 27 office practices. Formed in

1984, it receives logistic and financial support from Chil-then’s Memorial Hospital, with which it is affiliated. The

Pediatric Practice Research Group has undertaken six

studies, most with outside funding. During these studies, some unifying characteristics of practice-based research

have emerged. These include the need to tailor study protocols to individual practice characteristics and

rou-tines and the critical role of office staff in the conduct of

research. Features can be identified that make specific

studies more or less intrusive into office functioning. It

has proved feasible to obtain data of high quality and

reproducibility despite geographically scattered data col-lection sites. This review of Pediatric Practice Research Group activities and experience is intended to open an exchange of ideas with others interested in practice-based research. Pediatrics 1988;82(pt 2):399-406; practice-based research, primary care.

Practice-based research has become the excep-tion rather than the norm. Biomedical and

epide-Received for publication May 26, 1987; accepted Jan 7, 1988.

* Members of the group are: John Poncher, MD, T. Ludwig,

MD, A. Harrington, MD, J. Miller, MD, Valparaiso, and Portage,

IN; Joel Schwab, MD, Diane DiMaggio, MD, Jody Zylke, MD,

Homewood, and Tinley Park, IL; Howard Rice, MD, Mitchell

Blivaiss, MD, Diane Holmes, MD, Chicago; Florence Winfield,

MD, Elba-Julie Quinones, MD, Lella Jam, MD, Near North

Children’s Health Center, Chicago; Bonnie Typlin, MD, Aleta

Clark, MD, Chicago; Edward Traisman, MD, Howard Traisman,

MD, Ira Chasnoff, MD, Irwin Benuck, MD, Regina Higgins,

MD, Evanston, and Chicago, IL; Diane Fondreist, MD, Sheryl

Stagl, MD, Sheri Rabins, MD, Libertyville, and Barrington, IL;

Wayne Siegel, MD, Nicole Krein, MD, Barbara Levy, MD, Eva Robertson, MD, Michael Reese Health Care, Glenview, IL;

Joseph Terrizzi, MD, William Morrow, MD, William

Tomlin-son, MD, Michael Reese Health Care, Evanston, IL; Tom Riggs,

MD, Brenda Darrah, MD, Jane Kramer, MD, Jeffrey Pomeranz,

MD, Michael Reese Health Care, Schaumburg, IL; Sharon Unti,

MD, Michael Reese Health Care, Chicago; Alma Chandler, MD,

Michael Reese Health Care, Oak Park, IL; Gerald Lasin, MD,

Arthur Lasin, MD, Bernard Pritzker, MD, Allen Krissberg, MD,

A. Rosenson, MD, Karen Burton, MD, Edwin Salter, MD,

Jerome Kaltman, MD, Lake Forest, and Vernon Hills, IL; Marc.

Weissbluth, MD, Chicago; Richard Burnstine, MD, Virginia

DePaul, MD, Bill Mundie, MD, Ira Salafsky, MD, Northbrook,

and Evanston, IL; James Nicklas, MD, Chicago; Garry Gardner,

MD, Thomas Lynch, MD, Kay Lewis, MD, Pamela Huang, MD,

Darien, IL; William Hogan, MD, Joliet, IL; Stephen Brookstein,

MD, Armando Perez, MD, Arlington Heights, IL; Kamala A.

Ghaey, MD, Chicago; Norman E. Segal, MD, Buffalo Grove, and

Arlington Heights, IL; Naomi Ragins Senser, MD, Walter D.

Campbell, MD, Glenview, IL; William D. Rutenberg, MD,

Rich-ard Pervos, MD, Long Grove, IL; Emalee G. Flaherty, MD,

Chicago; Sophie Levinson, MD, Monte J. Levinson, MD,

Ev-anston, IL; Marvin Cooper, MD, Albert Stein, MD, Sashi

Ku-mar, MD, Chicago; Barry Altshuler, MD, Mark Rosenberg, MD,

Richard Mervis, MD, Merry Collins, MD, Barrington, IL; Peter

I. Liber, MD, Wheaton, IL; Dave Dobkin, MD, Arlington

Heights, IL; Howard Weiss, MD, Pearl Reiffel Gollin, MD,

Benjamin Emanuel, MD, Neil Aronson, MD, Chicago.

Reprint requests to (K.K.C.) Children’s Memorial Hospital, 2300

Children’s Plaza, Chicago, IL 60614.

American Academy of Pediatrics.

at Viet Nam:AAP Sponsored on September 7, 2020

www.aappublications.org/news

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miologic research is now done almost exclusively in

hospitals, medical schools, and related institutions.

It is increasingly clear, however, that work under-taken from the medical center perspective has in-herent problems that may limit its scope and even

its validity. The concentration of research in

refer-ral settings affects not only the research itself but

also medical practice and education. Separation of research from office-based practice may obscure the

role of scientific thinking in the work of all

physi-cians, just as separation of teaching from office

practice obscures the educational value of primary care. Because today it is a rare physician who is capable of excelling concurrently in the roles of caregiver, teacher, and researcher, the means are needed to unite those with strengths in each of

these areas.

Growing awareness of the limits of institutional research has led to a recent reawakening of interest

in practice-based research.’ In pediatrics, the most

visible evidence of this is development of Pediatric

Research in the Office Setting (formerly Collabo-rative Research Practice Network) of the American Academy of Pediatrics. This group is a national network of pediatricians that began its first study

in 1987. Pediatric Research in the Office Setting

builds on the experience in practice-based research

of a network of family practices (ie, the Ambulatory

Sentinel Practice Network) and on the sometimes hidden but long-standing tradition of practice-based research in pediatrics.24#{176}

With increasing numbers of investigators

becom-ing involved in practice based-research, it is

nec-essary to review the opportunities and obstacles

they will encounter.

STRENGTHS OF PRACTICE-BASED RESEARCH

Berkson’s Bias and Related Issues

The fundamental flaw in institutionally based medical/health research is that most people, even when ill, are not seen at an institution. Distortion in study results due to a hospital-based perspective, formally known as Berkson’s bias,4”42 probably af-fects most hospital-based studies. A hospital

per-spective may result in study of only severe

prob-lems. Alternatively, very severe cases may not reach

the hospital, resulting in misleadingly good out-comes. As a result, findings from institutionally

based studies may have dubious generalizability,

particularly to the broad range of patients and

severity of disease seen by office practitioners.

Loss to Follow-up, Small Sample Size, Truncated Range of Conditions, Abnormal Subjects

Another common limitation of hospital- or

insti-tutional-based research is loss of the patient to

follow-up. Patients treated in hospitals for acute or

rare conditions generally stop going to the hospital

specialists after a while. Long-term follow-up is

more likely in a primary care practice, in which

school physicals and acute illnesses bring patients

back. This advantage of the primary care setting

for studying later consequences of disease has its

own problem: a practitioner following-up a single

patient with a rare diagnosis may have difficulty in

determining whether a new finding is related to the

unusual condition. In research linking primary care

practitioners and hospital-based consultants, com-plementary strengths can be linked, thereby im-proving the potential for understanding the natural

history of disease.

Practice-based research can also provide access

to a larger group of more typical children than can

other approaches (eg, newspaper advertisements or signs in schools). Furthermore, study recruitment

can be facilitated when the personal physicians of

potential subjects are enthusiastic coinvestigators.

Practice-based research thus creates the possibility

in real time of large (adequate) samples for research

studies involving growth, development, normative

issues, and common abnormalities.

Controls

Similar considerations make it apparent that

of-fice practice is a better setting than the hospital for

recruiting the “normal controls” needed by

inves-tigators. As compared with hospital well-child

din-ics, pediatric practices contain handicapped,

chron-ically ill, and well children in proportions that more

closely approximate community prevalence. The

skew of specific practice panels (in terms of race,

socioeconomic status, etc) can be identified and balanced in study designs by including

complemen-tary practices. Although PPRG members are a

biased (research oriented) sample of area pediatric

practitioners, the patients seen by the member

practices are presumed not to be similarly biased;

ie, they probably select their sources of pediatric

care based on the usual geographic and socioeco-nomic considerations.

Population, Incidence, and Health Services, Research

Practice-based research has the potential to be population-based research. If the children and

fam-ilies in participating practices could be enumerated,

characterized (eg, with reference to birth date, race, sex, and social status), and tracked, it would become

possible to study disease incidence and health

serv-ices utilization patterns. Such research is

impossi-ble from a hospital or specialist (numerator)

per-spective. Comparison of parallel cohorts in a variety

of practice types and locales could clarify regional

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IPI’RG Steering Committee

(5private practitioners,

Department Chairman, PPGR Office Staff)

Figure. Pediatric Practice Research Group (PPRG)

or-ganizational structure. Lines indicate flow of

responsibil-ity. Steering committee is responsible to both

member-ship and PPRG office (and hence to hospital, university,

and funders). CMH, Children’s Memorial Hospital; FTE,

full-time equivalent.

differences (eg, in health care practice and disease

incidence) and provide clues concerning both

dis-ease causation and the relative merits of various

child health planning options.

MOTIVATION FOR PPRG PARTICIPATION

The organizational structure of the PPRG is shown in the Figure. The PPRG has many

cate-gories of participants: the practitioners, their office

staff, the parents and patients who participate in

the studies, the hospital with which the research is affiliated (and which helps to support the PPRG),

the hospital staff pediatric faculty, and outside

funding sources.

Practitioner Attitudes and Practice Factors

The characteristics of the practices in the PPRG are shown in Table 1. The practitioners involved in the PPRG have expressed several sources of

satis-faction. The research group and its work provide a

means to continue scientific inquiry, a pursuit that

many physicians turned from with ambivalence when they entered practice. In addition, the scm-tiny of office routines that accompanies study par-ticipation can reveal interesting information about pediatric practice and may improve care. Unex-pected findings during the PPRG’s Infant Growth

Study were these: during the first year of life, 10%

to 20% of infants left the practices in which they

were first seen, and many families initiated solid

feedings of their infants earlier than their doctors

suggested. In several Infant Growth Study

prac-tices, the use of measuring boards for infant length measurements became an office routine that

per-sisted after termination of the study protocol. For

some physicians in small practices, meetings

pro-vide a context for colleagueal discussion that is

otherwise elusive.

Practitioner priorities and cooperation are criti-cal to practice-based research. This is the reverse

of the usual research situation, in which the

spe-cialist investigator sets the agenda and “takes” the

patients. The PPRG explicitly acknowledges that high quality research cannot proceed without prac-titioner cooperation and leadership. The group places much ofthe responsibility for both the choice and implementation of studies in the hands of the practitioners and their office staffs. This

appropri-ately ascendant position in the advancement of

pediatric knowledge is refreshing for physicians

TABLE 1. Pediatric Practice Research Group*

Characteristics No. No. No. (%) of

(%) of (%) of Practitioners

Practices Offices (n = 81)

(n =29) (n = 37)

Practice type

HMOt 1 (4) 5 (14) 13 (16)

Solos 8 (20) 9 (24) 8 (10)

Group

Small (2-4 physicians) 15 (55) 17 (46) 40 (50)

Large (5 physicians) 3 (11) 6 (16) 20 (24)

Office locations

City 10 (34) 11 (30) 20 (25)

Suburb 17 (59) 23 (62) 57 (70)

Semirural 2 (7) 3 (8) 4 (5)

* Nine practices are also members of the American Academy of Pediatrics’ Pediatric

Research in the Office Setting.

t Five offices within the umbrella of a single HMO. In these practices, some private

patients are also seen on a fee-for-service basis.

:1:One solo practice has two offices, and two practices have offices in both city and suburbs. § Within 75 miles of city center.

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who have too often endured and resented being the

“private medical doctor” or “local medical doctor.”

It has been difficult for office-based PPRG

mem-bers to lead in the writing of proposals or research

papers, but their critical review of and comments

on documents in evolution have contributed

mark-edly to writing efforts. As agreed at the first PPRG

meeting, practitioner participation in research will

be acknowledged by coauthorship. Those involved

in design and writing are listed as authors and

others participating in the study are listed as PPRG

members (as in the present article).

The role of coinvestigator can improve

commu-nication with hospital-based specialists, both

con-cerning specific patients and concerning recent

de-velopments in various specialty areas. Results of

better communication include the enhancement of advice given, of care provided, and of provider

sat-isfaction with both.

The financial costs of PPRG participation to

practices have not been determined. The largest

costs include variable (but generally modest)

num-bers of hours spent by office staff for study-related

tasks and time spent by physicians with meetings,

proposal reviews, and related matters. In general,

these costs have been readily absorbed by individual

practices and have been seen by some as the

ac-ceptable price ofthe benefits of PPRG involvement. On occasion, when greater amounts of time have been needed (eg, to check data in office files), the PPRG has paid willing office staff on a per hour

basis. At other times, PPRG staff have been

we!-comed into offices to do this work.

Patients and Their Families

Studies may increase the complexity of a

pedi-atric visit. Members have reported that many of

their patients’ families approve of their physicians’

being involved in research, however. At times,

fam-ilies benefit directly from particular studies (eg, by

learning that a child has high cholesterol level). The need for informed consent is addressed in every

study protocol; some studies have required it,

whereas others have not. To assure patient

confi-dentiality, personal identifiers are routinely deleted

at the data entry stage.

Office Staff

For office staff, participation in PPRG studies is a mixed blessing. The sense of pride in scientific endeavor is at least partially, and at times entirely, offset by the additional complexity the studies

cause in patient flow and office operations. In

real-ity, many studies are performed entirely by the

office staff, with little impact on the practitioners’

days. As a result, staff enthusiasm and

encourage-ment are critical to successful research in the office

setting. Particularly when studies demand a high

level of attention and commitment from office staff,

periodic feedback is essential to maintaining good will and participation. Practitioners and office staff

like and deserve to know how the study is

proceed-ing, whether their input is satisfactory, and how

their results compare with those of other practices.

Timely practice-specific information (both

enroll-ment rates and study findings) have been of

ex-treme interest to participating practices.

Recogni-tion of staff effort by means of verbal and written

communications and of tokens of thanks have a

high priority in practice-based research.

The Hospital

For the hospital, the principal virtue in

practice-based research is that it is a means of strengthening

ties with the practitioners who refer patients. The

hospital research foundation also recognizes the

scientific merit of the PPRG’s work and is

inter-ested in the potential impact of study findings on

the effectiveness and efficiency of care provided by

the hospital and its medical staff. The hospital

maintains an oversight role in PPRG research,

because all proposals are reviewed by the hospital’s

research and ethics committees.

Full-time Faculty

For hospital-based faculty, collaboration with the PPRG has focused on common conditions (eg, strep

throat, noncompliant behavior), normal controls,

and treatment of rare conditions (eg, Kawasaki

disease). Interest in performing research with the

PPRG continues to grow, as evidenced by regular

inquiries from hospital-based investigators

con-cerning possible collaboration either with the

PPRG as an organization or with individual

mem-bers.

STUDIES UNDERWAY AND THEIR INTRUSIVENESS INTO PRACTICE

Brief descriptions of the studies that the PPRG

has undertaken are shown in Table 2. From the

point of view of participating practices, the most

important differences among them concern the

manner and extent to which they interfere with the

flow of patients and records in the office.

High Intrusiveness

The Infant Growth Study43’44 was extremely

in-trusive because it enrolled all healthy full-term

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pediatric practice. Receptionists and nursing staff

had to track hundreds of enrollees in order to

administer questionnaires and obtain standardized

measurements at all well-child visits during the first

year of life. For offices that did not use length

measuring boards routinely, a special, simple piece

of equipment had to be taken out, used, and

re-placed to measure each study patient. New office

staff had to be oriented to study procedures during

the 2 years in which the study took place (1 year of

enrollment, follow-up of each subject to 1 year of

age). Data forms had to be stored and then mailed

to the PPRG office. Missing (or obviously

incor-rect) data had to be obtained (or checked). As

enrollment increased, so did interference with

pa-tient flow. It became clear that most offices could

handle only one such intrusive study at a time, and

that some offices found this level of intrusiveness

only barely feasible when volume was highest (at

full enrollment and before many enrolled infants

had graduated from the study on their first

birth-day).

Experience with the Infant Growth Study

sug-gests two guidelines for practice-based research: (1)

to minimize intrusiveness, study protocols must be

adapted to fit the rhythms of each office; (2) To

preserve long-term involvement in research,

partic-ipating practices must have an interval between

intrusive studies.

Low Intrusiveness

The Foreign Body Study, in contrast to the In-fant Growth Study, involved relatively few patients and interfered little with patient flow. The initial data collection forms were completed quickly by

physician or office staff (parents were not required

to receive or complete any forms) and were designed

as self-mailers. Telephone follow-up was done by a

hospital-based investigator with patients referred

to the practitioners for needed care.

Treatment studies (eg, treatment of strep throat

carriers) are similarly easy for practices to handle

if protocol implementation is coordinated outside

of the practice and frequent communication is

maintained between hospital-based investigators and primary care providers.

Surprising Intrusiveness

The Hazard Survey proved to be more intrusive

than expected. The concept that the survey tool

could provide parents with something to do while

waiting to be seen was well received by families but

has not been easy for office staff to incorporate into

patient registration routines. The desired record

keeping-concerning patients who decline

enroll-ment-was burdensome for already busy

reception-ists. Intermittent questionnaire administration did

not promote cooperation with the study, as

in-tended, but rather confused office staff.

The Cholesterol Screening Study ran for a short

time, but involved many patients, required

metic-ulous record keeping concerning who was and who

was not enrolled, and involved coordination of

lab-oratory determinations among widely scattered

of-fices. The study differed from other PPRG studies

in a number of ways: it required blood drawing,

identified “abnormal” values in otherwise normal

children, and required calling back children with

high screening values for retesting. Because of these

features, extremely close communication among

of-fices was needed. The study therefore proved to be

a more intrusive study than its initial 2 months of

screening suggested.

MEASUREMENT

STANDARDIZATION

AND DATA

QUALITY

ASSESSMENT

Most pediatric practitioners and office staff are unaccustomed to perceiving their offices as research

laboratories. Measurement practices, screening

procedures, and other aspects of routine care may not be administered in the precise manner neces-sary for data gathering. The ability to collect infor-mation regarding relatively unbiased samples of patients is of no benefit if the information collected

is of poor (or variable) quality. Data obtained in

diverse offices are potentially unreliable because of

interobserver and equipment variability within and

between offices. Invalid methods and misrecording

may endanger any data set.

Because of these considerations, current practice-based research must take care to assess data quality and to provide documentation that data are valid, accurate, and reliable. In the Infant Growth Study and the Formula Reformulation Evaluation, the PPRG used several methods to assess growth meas-urement quality during periodic visits to

participat-ing offices. Scales were checked with standard

weights, each study infant was measured by

multi-ple individuals, and the spread of the observations was calculated (maximum measurement to mini-mum measurement). In the Infant Growth Study,

these evaluations indicated a small average

meas-urement spread: 28 g for weight, 1.25 cm for length, and 0.5 cm. for head circumference. In the

Choles-terol Screening Study, fasting lipid measurements

were centralized in one laboratory, in which meas-urement validity was assessed by use of standards provided by the Centers for Disease Control.

Assessing and interpreting data resulting from

common procedures may have clinical as well as methodologic importance. For example, in

evalu-ating the best means of standardizing cholesterol

measurements, it became apparent that

(7)

was being done without sound information about

the reliability of such decentralized testing.

ONGOING

CHALLENGES

Patient Registry

Many studies can be done without a patient

registry, including treatment trials, some cohort

studies, and nonrandom surveys. The full potential

of practice-based research can only be realized with

a registry, however. Creation of a centralized

regis-try requires that offices have a handwritten or

computerized record-keeping system that can gen-erate patient listings. Both approaches are ex-tremely demanding of resources-time and/or money-at the outset. In its exploration of this problem, the PPRG’s current strategy is to identify a computerized office management system that will meet the needs of member practices and also pro-vide patient entries for a hospital-based file (by list,

disk, or modem).

Maintaining

Practitioner

Involvement

All of the several hundred pediatricians with staff

privileges at Children’s Memorial Hospital have

been invited to join the PPRG, and other Chicago area pediatricians with nonhospital-based practices have been invited to join. Visible leadership by the

university and hospital Chairman of Pediatrics

(J.A.S.) has helped to provide authority and pres-tige to the organization.

At 3 years of age, the PPRG faces the challenge

of maintaining physician involvement. Of all PPRG

members, only a minority have attended business meetings and fewer still attend regularly. In 1987, biannual evening meetings at local restaurants were initiated to facilitate attendance by members who cannot attend daytime meetings. When meetings involve ten to 15 people, they are most reinforcing and productive; meetings of four or five people still get work done. Of the 27 PPRG practices, 21 have been involved in at least one study, and members reported that they feel involved even when they cannot attend meetings. Communication with

members who do not attend meetings has been

maintained by means of an eight- to ten-page news-letter that appears every 2 to 3 months. It includes

summaries and discussions of the progress (and

problems) of individual studies; a research bulletin board in which hospital-based investigations

seek-ing enrollees are listed; abstracts of proposals and

papers submitted; news; and a feedback page for

comments. A staff page with photographs of and

comments by practice staff is planned for 1988.

Communication is probably facilitated most by office visits (by the PPRG coordinator and/or one

of the hospital-based physicians) to deliver

sup-plies, retrieve data, explain forms, standardize measurements, and distribute tokens of thanks.

These office visits have been invaluable for

clan-fying strengths and identifying difficulties in

mdi-vidual projects and offices. Contact with office staff has also provided the interpersonal contact that is

essential to cooperation in patient follow-up and

enrollment.

Funding

Coordination of multipractice studies requires personnel time, travel, equipment, and supplies. The PPRG’s first step toward obtaining funding (for an unproven group of would-be practitioner-researchers) was the undertaking of an important and feasible study (the Infant Growth Study) that could be initiated on a shoestring. When it had begun, we were able to gain support from the hos-pita!. Gradually, the activities and possibilities of the PPRG have led to funder interest, and this has been maintained by the continuing momentum of the PPRG research effort. With actual patients enrolled, data analyses in hand, and papers

pre-sented,43’ it became possible to join forces with

The Department of Community Health and Pre-ventive Medicine of Northwestern University

Med-ical School to compete successfully for funding in a

national multicenter hypercholesterolemia treat-ment study. Personal and institutional contacts have facilitated corporate and local charitable

fund-ing. American Academy of Pediatrics support for

practitioner research was sought and obtained by one steering committee member (J.P.) for his work on the Infant Growth Study.

Involvement of two hospital-based physicians (approximately a one-half full-time equivalent in all) is supported by grant monies and the Depart-ment of Pediatrics. The PPRG office is staffed by a full-time research coordinator and a half-time data entry clerk/typist. The office is essential to ongoing success and is supported by grant monies. Maintaining funding remains a high priority and

commands much time.

THE NEXT PHASE

In the next few years, the primary challenges facing the PPRG will be maintenance of funding and active practitioner participation, and develop-ment of a registry and methods to streamline fol-low-up of enrolled patients. In years to come, we hope the primary challenge will be coordination of a research effort that continues to grow as the

possibilities of practice-based research continued to

expand.

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ACKNOWLEDGMENTS

The work of the PPRG has been supported by the

Children’s Memorial Institute for Education and

Re-search, the Chicago Community Trust Narcissa Niblack

Thorne Fund, Wyeth Laboratories, the American

Acad-emy of Pediatrics, and the National Heart, Lung, and

Blood Institute (via subcontract from Northwestern Uni-versity).

Drs AT. Davis, D. Jaffe, R. Tanz, and E. Zieserl of the

Division of General and Emergency Pediatrics at

Chil-then’s Memorial Hospital provided helpful suggestions

during the preparation ofthis manuscript. Debi Bednarek

provided secretarial assistance.

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Pediatrics

Typlin, G. Lasin and W. Seigel

K. K. Christoffel, H. J. Binns, J. A. Stockman III, P. McGuire, J. Poncher, S. Unti, B.