bluuebunny/crossref_metadata_2025 huggingface dataset:
Reimbursement for Pediatric Diabetes Intensive Case Management: A Model for Chronic Diseases?
Authors: Beck Joni K. , Logan Kathy J. , Hamm Robert M. , Sproat Scott M. , Musser Kathleen M. , Everhart Patricia D. , McDermott Harrold M. , Copeland Kenneth C.
Published: August 2004

Objective. Current reimbursement policies serve as potent disincentives for physicians who provide evaluation and management services exclusively. Such policies threaten nationwide availability of care for personnel-intensive services such as pediatric diabetes. This report describes an approach to improving reimbursement for highly specialized, comprehensive pediatric diabetes management through prospective contracting for services. The objective of this study was to determine whether pediatric diabetes intensive case management services are cost-effective to the payer, the patient, and a pediatric diabetes program.

Methods. A contract with a third-party payer was created to reimburse for 3 key pediatric diabetes intensive case management components: specialty education, 24/7 telephone access to an educator (and board-certified pediatric endocrinologist as needed), and quarterly educator assessments of self-management skills. Data were collected and analyzed for 15 months after signing the contract. Within the first 15 months after the contract was signed, 22 hospital admissions for diabetic ketoacidosis (DKA) occurred in 16 different patients. After hospitalizations for DKA, all 16 patients were offered participation in the program. All were followed during the subsequent 1 to 15 months of observation. Ten patients elected to participate, and 6 refused participation. Frequency of rehospitalization, emergency department visits, and costs were compared between the 2 groups.

Results. Among the 10 participating patients, there was only 1 subsequent DKA admission, whereas among the 6 who refused participation, 5 were rehospitalized for DKA on at least 1 occasion. The 10 patients who participated in the program had greater telephone contact with the team compared with those who did not (16 crisis-management calls vs 0). Costs (education, hospitalization, and emergency department visits) per participating patient were approximately $1350 less than those for nonparticipating patients. Differences between participating and nonparticipating groups included age (participants were of younger age), double-parent households (participants were more likely to be from double parent households), and number of medical visits kept (participants kept more follow-up visits). No differences in duration of diabetes, months followed in the program, sex, or ethnicity were observed.

Conclusions. Contracting with third-party payers for pediatric diabetes intensive case management services reduces costs by reducing emergency department and inpatient hospital utilizations, likely a result of intensive education and immediate access to the diabetes health care team for crisis management. Such strategies may prove to be cost saving not only for diabetes management but also for managing other costly and personnel-intensive chronic diseases.
Adenoviral Infections in Children: The Impact of Rapid Diagnosis
Authors: Rocholl Christian , Gerber Kris , Daly Judy , Pavia Andrew T. , Byington Carrie L.
Published: August 2004

Background. Adenovirus (ADV) infections were difficult to diagnose in the past, and many infections were unrecognized. Direct fluorescent assay (DFA) for the rapid diagnosis of ADV infection, as part of a viral respiratory panel, became available at Primary Children’s Medical Center (Salt Lake City, UT) in December 2000.

Objective. To describe children with ADV infection diagnosed by DFA and viral culture and document the impact of rapid ADV testing on patient care.

Methods. DFA testing for respiratory viruses including ADV was performed on nasal wash specimens with parallel viral culture. Chart review was performed for all ADV-positive patients identified from microbiology records between December 2000 and May 2002.

Results. Of 1901 patients positive for respiratory viruses, 143 (7.5%) were ADV-positive by DFA or culture. The mean age of ADV-positive children was 23 months; 90% were ≤60 months old. Eighty percent were previously healthy, and 56% required admission with a mean length of stay of 3.4 days. The most common diagnoses included fever (31%), bronchiolitis (24%), and pneumonia (14%). Other conditions included suspected Kawasaki disease (KD) and hepatitis. Forty-six percent of ADV-positive children were given antibiotics at presentation, but only 2 (1.4%) had documented bacterial infection (one had Escherichia coli urinary tract infection and one had Moraxella catarrhalis bacteremia). Thirty-six percent of children had a change in management based on positive ADV DFA. In children with suspected KD (n = 5), 100% had positive ADV DFA, and immune globulin was withheld in 4. One immunocompetent patient with fulminant liver failure received cidofovir treatment after a positive ADV DFA and recovered before liver transplant.

Conclusions. ADV is a common infection in young children and often results in admission and unnecessary antibiotic therapy. Identifying ADV as the cause of illness can favorably impact care and in some instances may be life-saving. DFA testing for ADV should be considered for infants and children requiring admission for fever, respiratory illness, suspected KD, and hepatitis.
Genital Anatomy in Pregnant Adolescents: “Normal” Does Not Mean “Nothing Happened”
Authors: Kellogg Nancy D. , Menard Shirley W. , Santos Annette
Published: August 2004

Many clinicians expect that a history of penile-vaginal penetration will be associated with examination findings of penetrating trauma. A retrospective case review of 36 pregnant adolescent girls who presented for sexual abuse evaluations was performed to determine the presence or absence of genital findings that indicate penetrating trauma. Historical information and photograph documentation were reviewed. Only 2 of the 36 subjects had definitive findings of penetration. This study may be helpful in assisting clinicians and juries to understand that vaginal penetration generally does not result in observable evidence of healed injury to perihymenal tissues.
Maternal Depressive Symptoms and Adherence to Therapy in Inner-City Children With Asthma
Authors: Bartlett Susan J. , Krishnan Jerry A. , Riekert Kristin A. , Butz Arlene M. , Malveaux Floyd J. , Rand Cynthia S.
Published: August 2004

Context. Little is known about how depressive symptoms in mothers affects illness management in inner-city children with asthma.

Objective. Our goal was to determine how maternal depressive symptoms influence child medication adherence, impact of the child’s asthma on the mother, and maternal attitudes and beliefs.

Methods. Baseline and 6-month surveys were administered to 177 mothers of young minority children with asthma in inner-city Baltimore, MD and Washington, DC. Medication adherence, disruptiveness of asthma, and select attitudes toward illness and asthma therapy were measured. Six-month data (N = 158) were used to prospectively evaluate long-term symptom control and emergency department use. Independent variables included asthma morbidity, age, depressive symptoms, and other psychosocial data.

Results. No difference in child asthma morbidity was observed between mothers high and low in depressive symptoms. However, mothers with high depressive symptoms reported significantly more problems with their child using inhalers properly (odds ratio [OR]: 5.0; 95% confidence interval [CI]: 1.3–18.9) and forgetting doses (OR: 4.2; 95% CI: 1.4–12.4). Depressive symptoms were also associated with greater emotional distress and interference with daily activities caused by the child’s asthma, along with less confidence in asthma medications, ability to control asthma symptoms, and self-efficacy to cope with acute asthma episodes. In addition, depressed mothers reported less understanding about their child’s medications and use (OR: 7.7; 95% CI: 1.7–35.9). Baseline asthma morbidity, maternal depression scores, and family income were independently associated with asthma symptoms 6 months later, whereas medication adherence was not predictive of subsequent asthma morbidity or emergency department use.

Conclusions. Maternal depressive symptoms were not associated with child asthma morbidity but were associated with a constellation of beliefs and attitudes that may significantly influence adherence to asthma medications and illness management. Identifying and addressing poor psychological adjustment in mothers is important when developing a child’s asthma treatment and may facilitate parent-provider communication, medication adherence, and asthma management among inner-city children.
Pediatricians’ Use of and Attitudes About Personal Digital Assistants
Authors: Carroll Aaron E. , Christakis Dimitri A.
Published: August 2004

Background. Personal digital assistants (PDAs) are being increasingly used in medical practice. Although they have been touted as having the ability to improve efficiency and safety, little is known about pediatricians’ use of and attitudes about PDAs.

Objective. Our goals were to 1) determine the percentage of pediatricians using PDAs and computers, 2) determine perceived strengths and weaknesses of PDAs, and 3) explore characteristics associated with beliefs and use.

Design/Methods. Pediatricians (2130) were selected randomly from the American Medical Association Physician Masterfile of US-licensed physicians. All participants were mailed a survey along with a prepaid return envelope and a $1 incentive. Up to 3 mailings were sent per participant.

Results. Of eligible participants, 63.2% returned a survey. There were no significant differences between respondents and nonrespondents with respect to sex, type of practice, and present employment. Thirty-five percent of respondents currently use PDAs at work, and 40% currently use PDAs for personal use. Of those using PDAs, the most commonly used applications were for drug reference (80%), personal scheduling (67%), and medical calculations (61%). Few pediatricians are currently using PDAs for prescription writing (8%) or billing (4%). Users of PDAs were more likely to be male (adjusted odds ratio [AOR]: 2.29; 95% confidence interval [CI]: 1.64–3.19), in an urban community (AOR: 1.81; 95% CI: 1.30–2.55), in training (AOR: 2.64; 95% CI: 1.58–4.42), not in private practice (AOR: 1.47; 95% CI: 1.03–2.11), and a more recent graduate of medical school (AOR: 1.04 per year; 95% CI: 1.02–1.06). When controlling for covariates, those using PDAs were more likely to believe that PDAs can decrease medical errors (AOR: 2.22; 95% CI: 1.46–3.38) and increase efficiency (AOR: 2.40; 95% CI: 1.56–3.71). When compared with nonusers, users were less likely to view the small screen size (AOR: 0.53; 95% CI: 0.37–0.77) or system speed (AOR: 0.47; 95% CI: 0.26–0.84) as a problem but were significantly more likely to view memory as an issue (AOR: 3.48; 95% CI: 2.30–5.25).

Conclusions. More than one third of pediatricians are using PDAs in clinical practice. There seems to be a general consensus among users that they have the potential to improve patient safety and streamline care. Future studies should explore means to utilize their potential.
A Bitter Pill: Attempting Change in a Pediatric Morning Report
Authors: Elliott Sean P. , Ellis Susan C.
Published: August 2004

Objective. To assess and address participants’ dissatisfaction with departmental morning report (MR).

Methods. Three consecutive MR sessions were observed, and those data, in combination with findings from the literature, were used to guide creation of a quantitative survey. The survey was administered to all faculty and housestaff. Survey items addressed the educational focus, leadership, and format of MR and the value of specific educational conferences. Subsequently, 2 interventions were developed to increase participants’ level of satisfaction with MR. The interventions’ effect was measured 1 year later using a second survey.

Results. Eighty-two percent of housestaff and 43% of faculty responded to the first survey. Our findings are contrary to those in the literature. For example, respondents rated the presence of all faculty at MR as desirable, and both subspecialty and general pediatric contributions were considered important. Housestaff assigned greater educational value to all teaching conferences than did faculty. Similarly, housestaff believed more strongly than faculty that MR leadership should be changed. A follow-up survey demonstrated a decrease in mean perceived value of MR after our interventions.

Conclusions. Despite aggressive research, we failed to identify the source of participants’ dissatisfaction. Although our interventions were based on research data and reflected participants’ perceptions and concerns related to MR, they were not supported by the faculty. This demonstrates the inherent difficulties in changing an “institution” such as MR. Thus, examination of MR goals and satisfaction by individual training programs should be conducted within the confines of the conference’s preexisting structure, without attempt to apply literature-driven expectations.
Educating the Pediatrician of the 21st Century: Defining and Implementing a Competency-Based System
Authors: Carraccio Carol , Englander Robert , Wolfsthal Susan , Martin Christine , Ferentz Kevin
Published: August 2004

Purpose. The final product of the Accreditation Council for Graduate Medical Education (ACGME) Outcomes Project is to improve health care through ensuring the competence of physicians during their training and beyond. Its success depends on a paradigm shift to a competency-based model of medical education. This article presents an overview of the model and describes the first stages of this multistep transition in a university setting. Our hope is to raise awareness of the impact on the pediatric community at large and provide a foundation on which other educators can continue to build.

Methods. The ACGME established 6 domains of competence as the first step in the paradigm shift. To begin work on the second step of establishing benchmarks for evaluation of competence and thresholds at which they should be achieved, the educational leadership from the primary care departments formed a work group with the support of a Health Resources and Services Administration grant.

Results. Review of the literature led us to embark on a stepwise process for initiating a competency-based system of medical education. We established the benchmarks by a process of individual effort followed by group consensus. These benchmarks, in the aggregate, permit an evaluator to determine whether a given competency has been achieved. The next phases of step 2 required setting thresholds for the demonstration of competence and finally establishing consensus regarding the threshold for competence at each level of training for each specific benchmark. To accomplish the latter, we surveyed the program directors of the 202 accredited pediatric training programs that are members of the Association of Pediatric Program Directors. Eighty-one members (40%) completed our survey. Although some controversy existed for thresholds during the postgraduate-year-1 level, majority consensus was reached for nearly all benchmarks at the upper levels of training. Impact of the shift to competencies for medical students and practicing physicians is also reviewed.

Conclusion. Having defined the benchmarks and thresholds for the 6 ACGME domains of competence, we are well positioned to move to step 3: developing the necessary tools to evaluate competence. The move to competency-based education impacts the entire pediatric community. Lessons learned from our experience may be generalized and thus be of value to the community at large.
How Do Primary Care Physicians Manage Children With Possible Developmental Delays? A National Survey With an Experimental Design
Authors: Sices Laura , Feudtner Chris , McLaughlin John , Drotar Dennis , Williams Michelle
Published: August 2004

Objective. Although early detection and treatment of developmental delays can improve outcome, little is known about factors that influence how primary care physicians manage young children with probable developmental delays. The objective of this study was to describe physician referral practices for children with developmental delays and to test whether the probability of referral is increased by 1) the expression of parental concern; 2) female gender in a child with language delay; 3) disruptive, as opposed to avoidant behaviors; and 4) physician characteristics, including female gender or being a pediatrician.

Methods. A cross-sectional survey was mailed to a national random sample of 800 pediatricians and 800 family practice physicians in primary care practice, using an experimental randomized block design. Recipients randomly received alternative variants of clinical vignettes, which differed only in regard to the variable specific to each of the first 3 hypotheses. Physicians answered questions about the likelihood of referral on a 5-point scale for listed referral options. Hypotheses were tested using multivariable logistic regression modeling. A total of 55% of pediatricians and 43% of family practice physicians returned the survey, for an overall response rate of 49%.

Results. A girl with language delay was 60% more likely to be referred to audiology than a boy (odds ratio: 1.6; 95% confidence interval: 1.1–2.3), and respondents who were female or pediatricians were more likely to refer patients. The expression of parental concern did not increase the probability of referral to diagnostic and treatment services, and avoidant rather than disruptive patient behaviors were associated with an increased probability of referral.

Conclusions. Patient gender and type of behavioral presentation seem to influence referrals to diagnostic and treatment services for young children with probable developmental delays described in clinical vignettes. These findings can guide targeted educational interventions to increase rates of detection and referral for young children with developmental delays.
Gender and Uninsurance Among Young Adults in the United States
Authors: Callahan S. Todd , Cooper William O.
Published: August 2004

Objective. Although one third of young adults in the United States are uninsured, lack of insurance in this age group has been the subject of few published studies. Because opportunities to obtain public and private insurance are likely to differ for men and women, the objective of this study was to describe the gender-specific relationship of sociodemographic variables and lack of insurance among young adults.

Methods. We examined data for 6884 young adults (aged 19–24 years) who completed the Sample Adult Questionnaire of the National Health Interview Survey for 1998, 1999, and 2000. Gender-stratified multiple logistic regression was used to estimate the odds of being uninsured associated with race/ethnicity, household income, major activity in the previous week, marital status, and pregnancy (women).

Results. Overall, 32% of male participants and 27% of female participants reported being uninsured at the time of the survey. Uninsured men outnumbered insured men in several sociodemographic categories, including Hispanic men (58% uninsured), men not attending high school (85%), and men employed in a workplace that did not offer health insurance (51%). High rates of uninsurance were reported by women not attending high school (65%), Hispanic women (46%), those who were keeping house (41%), and women with a household income between $10 000 and $20 000 (41%). In multiple logistic regression models, many of the sociodemographic variables studied were similarly correlated with health insurance for both men and women. Employment in a workplace where the young adult was not offered health insurance coverage, low household income, low educational attainment, and Hispanic ethnicity were associated with increased odds of being uninsured for both genders. Having attended college, higher household income, and being a student or employed in a workplace that offers health insurance coverage were associated with lower odds of being uninsured for both genders.

Conclusion. This study suggests that additional opportunities for health insurance coverage are needed for young adults—particularly men, Hispanics, and those in low- and middle-income households. Increasing the availability of employment-based health insurance, discouraging attrition from primary and secondary education, and the creation of insurance opportunities for minorities and near-poor and middle-income households are potentially important target areas for programs that seek to reduce the number of uninsured young adults.
Ultrasound Imaging of Milk Ejection in the Breast of Lactating Women
Authors: Ramsay Donna T. , Kent Jacqueline C. , Owens Robyn A. , Hartmann Peter E.
Published: August 2004

Objective. Currently, the methods for assessing milk ejection in women include serial sampling of plasma oxytocin and measurement of intraductal pressure, both of which are invasive and may induce stress. We hypothesized that milk ejection would cause an increase in milk-duct diameter that could be observed noninvasively with ultrasound, and this could be used to investigate the physiology of milk ejection in women.

Methods. One milk duct was scanned in the unsuckled breast in 2 groups of mothers: group BB (n = 21) for the beginning of a breastfeed and group EB (n = 24) for the entire breastfeed. A duct also was monitored for a 5-minute period on 2 separate days in the absence of factors that may induce milk ejection in group EB to provide a baseline duct diameter. Milk intake at a breastfeed was measured by test weighing.

Results. A significant increase in milk-duct diameter was observed when milk ejection was sensed and/or the infant changed its swallowing pattern in both groups. Multiple increases and decreases (mean: 2.5 per breastfeed; standard deviation: 1.5; n = 62) in duct diameter occurred in group EB. Duct diameter remained relatively stable between breastfeeds (coefficient of variation: 1.4%–8.3%). Infant milk intake was positively related to the number of milk ejections (r2 = .365; n = 57).

Conclusions. Ultrasound is an objective, noninvasive technique for detecting milk ejection by observing an increase in milk-duct diameter. However, this technique requires an experienced ultrasonographer, adequate imaging time, and surroundings conducive to breastfeeding. Multiple milk ejections were common during breastfeeding, although they were not sensed by mothers. The number of milk ejections influenced the amount of milk the infant consumed.
Unmet Need for Routine and Specialty Care: Data From the National Survey of Children With Special Health Care Needs
Authors: Mayer Michelle L. , Cockrell Skinner Asheley , Slifkin Rebecca T.
Published: August 2004

Objective. To assess the prevalence of unmet needs for routine and specialty care among children with special health care needs (CSHCN) and to identify factors associated with the likelihood of having unmet need for medical care.

Methods. Data come from the respondents for 38 866 children interviewed for the National Survey of Children With Special Health Care Needs. Bivariate analyses were used to assess differences in unmet need for medical care by various environmental, predisposing, enabling, and need factors. Logit analyses were used to determine independent effects of these variables on the likelihood of having an unmet need for medical care.

Results. Nationally, 74.4% and 51.0% of CSHCN needed routine and subspecialty physician care, respectively. Of those reporting that they needed routine care, 3.2% were unable to obtain these services. Of those reporting a need for specialty care, 7.2% reported not obtaining all needed specialty care. The prevalence of unmet need for specialty care significantly exceeded the prevalence of unmet need for routine care. In logit analyses, African American children and children whose mothers had less than a high-school education faced twice the odds of having an unmet need for routine care. Compared with nonpoor children, children living below the federal poverty level were significantly more likely to have an unmet need for routine (adjusted odds ratio [aOR]: 1.97; 95% confidence interval [CI]: 1.23–3.14) and specialty (aOR: 2.50; 95% CI: 1.49–4.18) care. Near-poor children were also significantly more likely than nonpoor children to have unmet needs for routine and specialty care. Uninsured children were significantly more likely than continuously insured children to report an unmet need for routine (aOR: 7.51; 95% CI: 4.99–11.30) and specialty (aOR: 4.29; 95% CI: 2.99–6.15) care. Our findings also show that higher levels of general pediatrician supply, relative to the pediatric population, are associated with a significantly lower likelihood of having an unmet need for routine care. Likewise, a greater supply of pediatric subspecialists is associated with a decreased likelihood of having an unmet need for specialty care.

Conclusions. Compared with previous reports of the general pediatric population, CSHCN have higher levels of unmet need for medical services. Our regression results emphasize that children vulnerable because of their social circumstances (eg, poverty, etc) have significantly greater odds of having unmet need for routine and specialty physician care. Furthermore, our findings highlight the importance of insurance coverage in ensuring access to needed routine and specialty medical services.
Nonmyeloablative Hematopoietic Stem Cell Transplant for X-Linked Hyper-Immunoglobulin M Syndrome With Cholangiopathy
Authors: Jacobsohn David A. , Emerick Karan M. , Scholl Paul , Melin-Aldana Hector , O’Gorman Maurice , Duerst Reggie , Kletzel Morris
Published: August 2004

Objective. X-linked hyper-immunoglobulin M (X-HIM) syndrome is a rare genetic immunodeficiency syndrome caused by mutations in the gene encoding CD40 ligand (CD40L, CD154). Allogeneic hematopoietic stem cell transplantation (HSCT) offers the prospect of immune reconstitution in X-HIM syndrome. Standard HSCT using high-dose chemoradiotherapy can be followed by serious hepatic problems, including veno-occlusive disease, graft-versus-host disease, and/or drug-induced hepatotoxicity. In patients whose liver function is compromised before HSCT, such as in X-HIM syndrome caused by cholangiopathy and hepatitis related to opportunistic infections, there is a higher likelihood of hepatotoxicity. We explored nonmyeloablative HSCT in 2 patients with X-HIM syndrome. Nonmyeloablative HSCT without liver transplant for X-HIM syndrome, to our knowledge, has not been described previously.

Methods. Two children with X-HIM syndrome and persistent infections had documented cholangiopathy on liver biopsy. Both children underwent nonmyeloablative HSCT from HLA-matched siblings with fludarabine, busulfan, and anti-thymocyte globulin as their preparative regimen. Graft-versus-host disease prophylaxis consisted of cyclosporine.

Results. Both children are >2 years after their HSCT. One remains a mixed chimera, and the other shows 100% donor chimerism. Both children are now free of infections and are no longer dependent on intravenous gammaglobulin. Both show response to immunizations. Both have had resolution of their cholangiopathy.

Conclusions. Nonmyeloablative HSCT from HLA-matched siblings can offer immune reconstitution without hepatotoxicity in patients with X-HIM syndrome and preexisting cholangiopathy. Even with stable mixed chimerism after allogeneic HSCT, patients may be able to enjoy a normal phenotype. Nonmyeloablative HSCT warrants additional study in X-HIM syndrome.
Termination of Life Support After Severe Child Abuse: The Role of a Guardian ad Litem
Authors: Gladsjo Julie Akiko , Breding John , Sine David , Wells Robert , Kalemkiarian Sharon , Oak Joni , Vieira Angela S. , Fallo Friedlander Sheila
Published: August 2004

Discontinuation of life-sustaining interventions often raises ethical concerns. In cases of severe child abuse with poor prognosis for recovery, accused parents may have a conflict of interest regarding medical decision-making for their child, because the outcome of such decisions may impact legal charges filed against them. The recently issued American Academy of Pediatrics guidelines for addressing such cases recommended the appointment of a guardian ad litem for medical decision-making. We present the case of an 8-month-old infant who was abused severely by her father, resulting in a persistent vegetative state. We describe our experience with appointing a guardian ad litem and the ethical issues involved.
Adolescent Twin Sisters With Severe Acute Respiratory Syndrome (SARS)
Authors: Fong N.C. , Kwan Y.W. , Hui Y.W. , Yuen L.K. , Yau E.K.C. , Leung C.W. , Chiu M.C.
Published: August 2004

A novel coronavirus-associated communicable respiratory disease, severe acute respiratory syndrome (SARS), spread worldwide after an outbreak in Guangdong Province of the People’s Republic of China in November 2002. Since late February 2003, there has been an epidemic in Hong Kong involving both adult and pediatric patients. The clinical course, intensive care, and outcome of adolescent twin sisters with SARS are described. Adolescents infected with SARS may develop severe illness as adults, and close monitoring for disease progression in terms of both clinical and radiologic deterioration is warranted.
Ultrafast Magnetic Resonance Imaging of the Neonate in a Magnetic Resonance-Compatible Incubator With a Built-in Coil
Authors: Whitby Elspeth H. , Griffiths Paul D. , Lonneker-Lammers Torsten , Srinivasan Ravi , Connolly Daniel J.A. , Capener David , Paley Martyn N.J.
Published: August 2004

Background. Magnetic resonance (MR) imaging of the neonate is important clinically, because this group of patients often has complex and multiple problems due to prematurity and developmental abnormalities. MR imaging usually involves moving neonates away from their controlled environment to the scanner.

Objective. In this study we present the results of our initial experience with an MR-compatible incubator used on a 1.5-T system.

Methods. Seven neonates were imaged at 1.5 T without sedation or anesthesia. Images were obtained by using single-shot fast spin echo, 3-dimensional Fourier transfer gradient echo, and diffusion-weighted sequences. In 4 cases, time-of-flight angiography was performed.

Results. All 7 neonates were stable throughout the scan time (10–21 minutes). Experienced observers graded the images for quality, and all were graded excellent or good. In no case was the image quality poor.

Conclusion. Neonates can be imaged safely by using an MR-compatible incubator and fast image sequences. This method should allow neonates to be imaged by MR in sites at which a dedicated neonatal MR scanner is not available.
Both Relative Insulin Resistance and Defective Islet β-Cell Processing of Proinsulin Are Responsible for Transient Hyperglycemia in Extremely Preterm Infants
Authors: Mitanchez-Mokhtari Delphine , Lahlou Najiba , Kieffer François , Magny Jean-François , Roger Marc , Voyer Marcel
Published: August 2004

Objective. Many extremely preterm infants develop hyperglycemia in the first week of life during continuous glucose infusion. The objective of this study was to determine whether defective insulin secretion or resistance to insulin was the primary factor involved in transient hyperglycemia of extremely preterm infants.

Methods. A prospective comparative study was conducted in appropriate-for-gestational-age preterm infants <30 weeks of gestational age with the aim specifically to evaluate the serum levels of proinsulin, insulin, and C-peptide secreted during transient hyperglycemia by specific immunoassays. Three groups of infants were investigated hyperglycemic (n = 15) and normoglycemic preterm neonates (n = 12) and normal, term neonates (n = 21). In addition, the changes in β-cell peptide levels were analyzed during and after intravenous insulin infusion in the hyperglycemic group. Data were analyzed using analysis of variance and analysis of variance for repeated measures.

Results. At inclusion, insulin and C-peptide levels did not differ in hyperglycemic subjects and in preterm controls. Proinsulin concentration was significantly higher in the hyperglycemic group (36.5 ± 3.9 vs 23.2 ± 0.9 pmol/L). Compared with term neonates, proinsulin and C-peptide levels were higher in normoglycemic preterm infants (23.2 ± 0.9 vs 18.9 ± 2.71 pmol/L and 1.67 ± 0.3 vs 0.62 ± 0.12 nmol/L, respectively). During and after insulin infusion in hyperglycemic neonates, plasma glucose concentration fell and proinsulin and C-peptide levels were lowered (18.4 ± 7.6 and 20.7 ± 4.5 pmol/L, respectively).

Conclusion. These data suggest that 1) preterm neonates are sensitive to changes in plasma glucose concentration, but proinsulin processing to insulin is partially defective in hyperglycemic preterm neonates; 2) hyperglycemic neonates are relatively resistant to insulin because higher insulin levels are needed to achieve euglycemia in this group compared with normoglycemic neonates. These results also show that insulin infusion is beneficial in extremely preterm infants with transient hyperglycemia.
A Randomized Trial of Early Versus Standard Inhaled Nitric Oxide Therapy in Term and Near-Term Newborn Infants With Hypoxic Respiratory Failure
Authors: Konduri G. Ganesh , Solimano Alfonso , Sokol Gregory M. , Singer Joel , Ehrenkranz Richard A. , Singhal Nalini , Wright Linda L. , Van Meurs Krisa , Stork Eileen , Kirpalani Haresh , Peliowski Abraham ,   for the Neonatal Inhaled Nitric Oxide Study Group
Published: August 2004

Objective. Inhaled nitric oxide (iNO) reduces the use of extracorporeal membrane oxygenation (ECMO)/incidence of death in term and near-term neonates with severe hypoxic respiratory failure. We conducted a randomized, double masked, multicenter trial to determine whether administration of iNO earlier in respiratory failure results in additional reduction in the incidence of these outcomes.

Methods. Neonates who were born at ≥34 weeks’ gestation were enrolled when they required assisted ventilation and had an oxygenation index (OI) ≥15 and <25 on any 2 measurements in a 12-hour interval. Infants were randomized to early iNO or to simulated initiation of iNO (control). Infants who had an increase in OI to 25 or more were given iNO as standard therapy.

Results. The trial enrollment was halted after 75% of target sample size was reached because of decreasing availability of eligible patients. The 150 infants who were given early iNO and 149 control infants had similar baseline characteristics. Arterial oxygen tension increased by >20 mm Hg in 73% of early iNO and 37% of control infants after study gas initiation. Control infants received standard iNO and deteriorated to OI >40 more often than infants who were given early iNO. The incidence of death (early iNO, 6.7% vs control, 9.4%), ECMO (10.7% vs 12.1%), and their combined incidence (16.7% vs 19.5%) were similar in both groups.

Conclusion. iNO improves oxygenation but does not reduce the incidence of ECMO/mortality when initiated at an OI of 15 to 25 compared with initiation at >25 in term and near-term neonates with respiratory failure.
Incidence of Outpatient Visits and Hospitalizations Related to Influenza in Infants and Young Children
Authors: O’Brien Megan A. , Uyeki Timothy M. , Shay David K. , Thompson William W. , Kleinman Ken , McAdam Alexander , Yu Xian-Jie , Platt Richard , Lieu Tracy A.
Published: August 2004

Objective. The Advisory Committee on Immunization Practices currently encourages influenza vaccination for all children aged 6 to 23 months when feasible, based on studies that have demonstrated that young children have high hospitalization rates attributable to influenza. The Advisory Committee on Immunization Practices recently voted to recommend influenza vaccination for all children beginning during the 2004–2005 influenza season; information on the rate of outpatient visits due to influenza is needed to better evaluate the potential health impact and cost-effectiveness of the recommendation. We estimated the incidence of outpatient visits as well as hospitalizations for specific acute respiratory illnesses and for influenza-associated outpatient-visit and hospitalization rates among healthy infants and children in a Massachusetts health maintenance organization.

Design/Methods. Surveillance data were used to identify when influenza viruses, respiratory syncytial viruses, and parainfluenza viruses were circulating in the greater Boston area during 1994–2000. Using computerized medical records, we identified outpatient visits and hospitalizations for selected respiratory illnesses. Outpatient-visit rates and hospitalizations attributed to influenza were calculated by subtracting the rate of visits during the periseasonal period from the rate of visits during the influenza period. Rates were stratified by age and risk for complications from influenza.

Results. Between 1994 and 2000, there were 188 139 outpatient visits and 885 hospitalizations for respiratory illnesses in the study population. Among healthy children aged 6 to 23 months, the rate per 100 person-months for outpatient visits during influenza periods was 14.5 (95% confidence interval [CI]: 13.9 to 15.1), and the excess rate that could be attributed to influenza compared with the periseasonal period was 1.8 (95% CI: 1.1 to 2.4). Among healthy children, the rate of hospitalizations for acute respiratory disease was 10.4 per 10 000 person-months (95% CI: 6.0 to 17.0), and the rate that could be attributed to influenza when compared with the periseasonal baseline period was 3.9 (95% CI: −2.0 to 0.0). Among children who were at high risk for complications from influenza, the rate of outpatient visits per 100 person-months was 28.7 (95% CI: 26.6 to 30.9) during influenza periods. The rate of hospitalizations among high-risk children was 44.6 per 10 000 person-months (95% CI: 19.0 to 17.0).

Conclusion. Influenza season is associated with a substantial increase in outpatient visits by healthy children. These estimates of outpatient visits for influenza will help quantify the potential health benefits and cost savings from influenza vaccination of healthy children aged 6 to 23 months.
Protective Eyewear for Young Athletes
Authors:   Committee on Sports Medicine and Fitness
Published: August 2004

This Policy Statement was retired September 2019.

The American Academy of Pediatrics and American Academy of Ophthalmology strongly recommend protective eyewear for all participants in sports in which there is risk of eye injury. Protective eyewear should be mandatory for athletes who are functionally 1-eyed and for athletes whose ophthalmologists recommend eye protection after eye surgery or trauma.
Role of Pediatric and Internist Rheumatologists in Treating Children With Rheumatic Diseases
Authors: Mayer Michelle L. , Sandborg Christy I. , Mellins Elizabeth D.
Published: August 2004

Objective. To quantify and describe the role of internist and pediatric rheumatologists in the care of children with rheumatic diseases and identify factors associated with internist rheumatologists’ willingness to treat children.

Methods. We surveyed physician members of the American College of Rheumatology who currently practice in California (n = 589). Bivariate and logit analyses were used to examine the effects of training, provider, practice, and distance to the nearest pediatric rheumatologist on the likelihood that an internist rheumatologist treated children.

Results. Our effective response rate was 51%. More than one third of internist rheumatologists who practice in California reported treating pediatric patients. On average, internist rheumatologists who treated children saw 3.1 patients younger than 18 years weekly; half of these patients were 16 and 17 years of age. In logistic regression analysis, internist rheumatologists who treat pediatric patients were significantly more likely to practice in a multispecialty clinic (adjusted odds ratio: 3.5; 95% confidence interval: 1.9–9.7) and to live >50 miles from a pediatric rheumatologists (adjusted odds ratio: 6.8; 95% confidence interval: 2.1–22.7). In aggregate, we estimate that pediatric rheumatologists and internist rheumatologists provide care to 550 and 419 patients younger than 18 years per week, respectively.

Conclusions. A substantial number of California internist rheumatologists are involved in the care of children, especially adolescents. The heavy involvement of internist rheumatologists in the care of children suggests that additional pediatric rheumatologists may be needed in select areas. Our findings have important implications for the size and distribution of the pediatric rheumatology workforce, the content of fellowship training for internist rheumatologists, and future studies of the relative quality of pediatric rheumatology care offered by internist rheumatologists. Furthermore, the role of internist subspecialists in caring for children with other chronic illness should be assessed.
Effectiveness and Safety of Tissue Plasminogen Activator in the Management of Complicated Parapneumonic Effusions
Authors: Weinstein Michael , Restrepo Ricardo , Chait Peter G. , Connolly Bairbre , Temple Michael , Macarthur Colin
Published: August 2004

Objective. The management of parapneumonic effusions in children is controversial. The objective of this study was to evaluate the effectiveness and safety of intrapleural tissue plasminogen activator (tPA) in children who require tube thoracostomy for drainage of a complicated parapneumonic effusion.

Methods. An observational cohort study was used to compare children who were treated with intrapleural tPA (either early or late administration) with children who were treated with thoracostomy tube drainage alone.

Results. Over a 6-year period, 12 children received early tPA (within 24 hours of diagnosis), 18 children received late tPA (>24 hours after diagnosis), and 23 children received thoracostomy tube drainage alone for the management of a complicated parapneumonic effusion. Total pleural fluid drainage was highest for the late tPA group (691 mL vs 360 mL in the control group); however, the rate of pleural fluid drainage was highest for the early tPA group (7 mL/h vs 3 mL/h in the control group). The duration of chest tube placement was 84 hours for the early tPA group, 209 hours for the late tPA group, and 130 hours for the control group. There was a significant difference in duration of chest tube placement between the early and late tPA groups. No child who was treated with tPA developed local or systemic bleeding.

Conclusions. Early administration of intrapleural tPA seems to be a safe and potentially effective treatment in children with complicated parapneumonic effusions. Randomized controlled trial evidence is needed to confirm this finding.
Can We Predict Which Children With Clinically Suspected Pneumonia Will Have the Presence of Focal Infiltrates on Chest Radiographs?
Authors: Lynch Tim , Platt Robert , Gouin Serge , Larson Charles , Patenaude Yves
Published: August 2004

Objective. To determine predictive factors for the presence of focal infiltrates in children with clinically suspected pneumonia in a pediatric emergency department.

Methods. Children (1–16 years) with clinically suspected pneumonia were studied prospectively. The presenting features were compared between the children with and without focal infiltrates using χ2 analysis, t test, and odds ratio with 95% confidence intervals. A multivariate prediction rule was developed using logistic regression.

Results. A total of 570 were studied. Risk factors (odds ratio; 95% confidence interval) for the presence of focal infiltrates included history of fever (3.1; 1.7–5.3), decreased breath sounds (1.4; 1.0–2.0), crackles (2.0; 1.4–2.9), retractions (2.8; 1.0–7.6), grunting (7.3; 1.1–48.1), fever (1.5; 1.2–1.9), tachypnea (1.8; 1.3–2.5), and tachycardia (1.3; 1.0–1.6). We then used logistic regression to develop a candidate prediction rule for the variables of fever, decreased breath sounds, crackles, and tachypnea, which had an area under the receiver operating curve of 0.668. This rule had excellent sensitivity (93.1%–98%) yet poor specificity (5.7%–19.4%).

Conclusions. Multiple predictive factors for children with suspected pneumonia have been identified. Patients with focal infiltrates were more likely in our study to have a history of fever, tachypnea, increased heart rate, retractions, grunting, crackles, or decreased breath sounds. A multivariate prediction rule shows promise for the accurate prediction of pneumonia in children. However, the prospective evaluation of this multivariate prediction rule in a clinical setting is still required.
A Comparison of Buffered Lidocaine Versus ELA-Max Before Peripheral Intravenous Catheter Insertions in Children
Authors: Luhmann Janet , Hurt Sarah , Shootman Mario , Kennedy Robert
Published: August 2004

Background. Peripheral intravenous catheter (PIV) insertion is a common, painful experience for many children in the pediatric emergency department. Although local anesthetics such as injected buffered lidocaine have been shown to be effective at reducing pain and anxiety associated with PIV insertion, they are not routinely used. ELA-Max, a topical local anesthetic, has the advantage of needle-free administration but has not been compared with buffered lidocaine for PIV insertion.

Objective. To compare the reduction of pain and anxiety during PIV insertion provided by subcutaneous buffered 1% lidocaine or topical ELA-Max in children.

Methods. A randomized trial in children 4 to 17 years old undergoing PIV insertion with 22-gauge catheters was conducted. Children received either buffered lidocaine or ELA-Max. Buffered lidocaine was administered by using 30-gauge needles to inject 0.1 to 0.2 mL subcutaneously just before PIV insertion. ELA-Max was applied to the skin and occluded with Tegaderm 30 minutes before PIV insertion. Self-reported Visual Analog Scale (VAS) questionnaires (rating on a scale of 1–10; 1 = no pain, anxiety) were completed by patients and their parents before PIV insertion to assess baseline perceptions about pain and anxiety associated with PIV insertion and immediately after PIV insertion to assess pain and anxiety associated with the experience. After PIV insertion, the nurse who inserted the PIV also completed a VAS questionnaire assessing technical difficulty and satisfaction with the local anesthesia. A blinded observer also completed a VAS questionnaire to assess pain and anxiety associated with the PIV insertion. Data were analyzed by using χ2 and t tests.

Results. Sixty-nine subjects were enrolled, and questionnaires were competed by all (mean age: 12.1 ± 4.5 years; 61% female). There were no differences for buffered lidocaine and ELA-Max groups in age, gender, race, prior IV experience, or baseline pain and anxiety. There were no significant differences between buffered lidocaine and ELA-Max in mean pain and anxiety after PIV insertion by patient, parent, and blinded observer ratings. Nurse ratings of technical difficulty, number of PIV-insertion attempts, and satisfaction with local anesthesia also were not significantly different for buffered lidocaine and ELA-Max groups.

Conclusions. ELA-Max provided similar pain and anxiety reduction during PIV insertion in children compared with injected buffered lidocaine. Technical difficulty and satisfaction by nurses inserting the PIV also were similar.