EDITORIAL CORRESPONDENCE

Accuracy and reliability of glucose reflectance meters in the high-risk neonate

To the Editor." Glucose reflectance meters have been advocated for determina-

tion of blood glucose concentration in the adult. We previously re- ported that their accuracy and reliability in the neonate is less than optimal when capillary (heel-stick) blood is used for samplingl; cord arterial blood from a separate group of infants was used for comparison with capillary (heel-stick) blood. We questioned whether use of venous blood from the same neonate would affect the accuracy and reliability of using glucose reflectance meters in the neonate.

Samples from 25 neonates whose parents gave permission were evaluated sequentially for accuracy and reliability by using blood obtained from matched capillary (heel-stick) and venous samples. Blood glucose concentration was measured on a YSI glucose ana- lyzer (Yellow Springs Instrument Co., Yellow Springs, Ohio) and on four glucose reflectance meters widely used for blood glucose measurement in the adult: the Glucometer M, Diascan S, Accu- Chek II, and One Touch. All samples were analyzed sequentially

so that no one meter nor the YSI analyzer was used preferentially. Five determinations of capillary (heel-stick) and whole venous blood glucose concentration were performed on each glucose reflectance meter and on the YSI analyzer. Statistical analyses were performed by analysis of variance. Accuracy was determined by the percentage of difference between the means and linear re- gression. Reliability was determined by the percentage of coeffi- cient of variation.

Relative to venous blood, the percentage of difference between the means ranged from -2.9% for the Accu-Chek II to 17.7% for the Diascan S. For capillary (heel-stick) blood, the percentage of different between the means ranged from -7.8% for the Accu-Chek II to 17.7% for Diascan S. A second measure of accuracy, namely linear regression, was also determined. There were significant dif- ferences for all meters relative to the YSI analyzer when both venous blood and capillary (heel-stick) blood were evaluated. The YSI analyzer, which was used as a standard, had a coefficient of variation of 4.5% for venous blood and 3.4% for capillary (heel- stick) blood. For the venous samples the coefficient of variation ranged from 5.4% to 11.6% for the four meters tested. For capil- lary (heel-stick) blood the coefficient of variation ranged from 4.8% to 10%. There were no significant differences relative to reliability between venous blood and capillary (heel-stick) blood for the var- ious glucose meters and the YSI analyzer.

The accuracy and reliability of capillary (heel-stick) versus venous blood glucose concentration in this series and relative to cord blood in the previous series are interpreted to suggest that the site or method of sampling does not affect the evaluation of whole blood glucose concentration determined by glucose reflectance meters. The conclusion of the first study, that the glucose reflec-

tance meters should probably not be used for evaluation of whole blood concentration in the neonate, is reaffirmed.

Richard M. Cowett, MD Lisa Beth D'Amico, R N

Brown University School o f Medicine Department o f Pediatrics

Providence, R I 02905-2401

REFERENCE

1. Lin HC, Maguire C, Oh W, Cowett R. Accuracy and reliabil- ity of glucose reflectance meters in the high-risk neonate. J PEDIATR 1989;115:1000.

Changing face of academic pediatrics

To the Editor:

I read with great interest the excellent special article by Dr. Battaglia (J PEDIATR 1991;119:858-63) on the changing face of academic pediatrics. This article is thought provoking. I agree heartily with most of it.

American pediatrics at the present time is oriented toward tech- nologic prowess but is not fundamentally committed to the welfare of all children. That is why the United States ranks nineteenth in infant mortality rates. Pediatrics lacks a sense of priorities. What Dr. Battaglia describes is a decaying academic system progressively being asphyxiated by bureaucratic and financial struggles.

There are two reasons for this decline. First, physicians in this country have responded to the media-fed public appetite for spec- tacular cures. Such cures are glorious, but they are both expensive and detrimental to the long-term goals of health maintenance. As an example, investing our energy in treating very low birth weight infants is preventing perinatologists from attacking the real culprit in infant death: premature birth.

Academicians doing research are looking for quick fixes to their deteriorating laboratories and have to model themselves as entre- preneurs in the marketplace. To survive academically, they orient their research according to funding sources, not according to their goals, and drop it as the sources run dry, to find other ways to con- tinue academic endeavors. After all, academicians are judged by article production and on the amount of research dollars brought to the department, rather than by their genuine medical contribu- tion.

What Dr. Battaglia has omitted is the potential influence on academics of health care reform, ready to engulf American med- icine and fueled by economic recession. The reform of health care distribution will influence how, when, and where research will be done. Other countries have already instituted the necessary reforms to maintain public health and protect children. Advice and exam-

1 0 0 2

Volume 120 Edi tor ia l correspondence 1 0 0 3

Number 6

pie from abroad may be necessary to maintain the health of our children in a changing world. Unfortunately, because of mercenary motives, American physicians are still resisting new concepts of

public health care. Academicians need to confront the system to remain productive

and competitive in the next decade. Paul L Toubas, MD

K. C. Sekar, MD Department o f Pediatrics

University of Oklahoma Health Sciences Center Oklahoma City, OK 73104-5066

To the Editors: Dr. Frederick Battaglia (J PEDIATR 1991;119:858-63) has

discussed with clarity the current factors affecting academic life. I suggest an additional factor, specifically that of a new career trend involving teaching and caring for patients while simultaneously accomplishing credible scholarship. In the past 5 years, training in academic general pediatrics in our program has shown a rather re-

markable jump in popularity. Residents in the past found it difficult to give up the excitement

of teaching and patient care for the focus required of an investiga- tive career. Today academic clinical careers focusing on quaiity of care in medical practice, technology assessment, cost-effectiveness, and health policy assessment are in concert with career goals of young physicians. 1 In addition, the field of medical education and its accompanying teacher-educator ladders have opened additional

new opportunities. 2 The public has set a high priority on careful assessment of what

we do in the care of our patients. Increasingly, physicians trained in health care effectiveness research are needed to study quality- of-care issues. Conversion of hospital quality-improvement efforts into scholarly research is an additional opportunity. Study design, epidemiology, and biostatistics have now become the basic science for the majority of hospital-based clinical research.

The biomedical era of the 1960s and 1970s, while effectively emphasizing research, undervalued education. The need for change is now broadly recognized. The new trend of problem-based, fac- ulty-intensive teaching is reinforcing the need for adequate re- wards. 3 Substantially more than 50% of medical schools now have a teacher-educator ladder. Careers of high academic standing are possible by rewarding excellence in teaching and simultaneously

demanding a high level of scholarship. High-level training programs in education and health care

research are greatly needed) Schools of education and offices of educational development are resources for career development. Departmental growth is allowing for differentiation into basic lab- oratory and clinical tracks with accompanying opportunities for clinical investigation. Adequate funding remains a significant challenge. The unleashing of adequate sources of funding from the public and private sectors remains an important task for the future.

Thus I applaud Dr. Battagli~'s list of challenges while suggest- ing new opportunities for academics-bound pediatricians.

Frederick H. Love joy, Jr., MD Associate Physician-in-Chief

Children's Hospital Boston, M A 02115

R E F E R E N C E S

1. Goldman L, Cook EF, Orav J, et at. Research training in clin- ical effectiveness: replacing "in my experience" with rigorous clinical investigation. Clin Res 1990;38:686-93.

2. Bok D. Higher learning. Cambridge, Massachusetts: Harvard University Press, 1986:71-113.

3. Tosteson DC. New pathways in general medical education. N Engl J Med 1990;332:234-8.

To the Editor." Dr. Battaglia (J PEDIATR 1991 ; 119:858-63) laments the fact that

10% of university pediatrics departments manage to receive 75% of available grant monies, but I believe that perhaps this is the way things ought to be. Is it realistic to expect that every university de- partment of pediatrics, much less every faculty member, should be involved in state-of-the-art research? Spreading the grants among a larger number of universities, I fear, would result not in better research but in more mediocre studies. There has been an explosion of publications of scientific papers that have no practical impor- tance and are of dubious scientific value. We do not need more of the same.

One of the most persistent problems of today is lack of access to medical care. Although researchers continue to make new techno- logic advances, a growing proportion of the population cannot af- ford the rising expense that accompanies these marvels of medical

care. I propose that an examination of our own expectations may be

more important than changing the system as it currently stands. The number one priority of medical schools everywhere should continue to be the education of medical care providers.

My second priority would be improving access to medical care, subspecialty care in particular, in the community in which the medical school is located. If subspecialty care is denied by the uni- versity hospital, there is often nowhere else for the indigent patient to turn for help, and helping these patients with problems that can- not be managed in a private office or a hospital emergency depart-

ment should be a moral imperative. At the bottom of my list is research, the third and final priority.

Research efforts should be concentrated at a few selected sites, where scientific minds and resources can achieve the critical mass necessary to make significant contributions to the body of scientific knowledge.

Robert D. Cunningham Jr., MD

Reply To the Editor:

50 Greenway Square Apt. M-31

Dover, DE 19901

Dr. Cunningham asks whether every university department of pediatrics should be doing research. The answer is a resounding yes. Students and residents expect to find some faculty models in clin- ical research in any medical school. Dr. Cunningham's concerns about the quality of publications only support the issues of career development that I raised. Should all faculty do research? The an- swer is certainly no, although I see no danger of such a situation