bluuebunny/crossref_metadata_2025_split huggingface dataset:
The Effect of Hospital Volume of Pediatric Appendectomies on the Misdiagnosis of Appendicitis in Children
Authors: Smink Douglas S. , Finkelstein Jonathan A. , Kleinman Ken , Fishman Steven J. 
Published: August 2004

Background. Although appendicitis is a common pediatric surgical condition, it is often misdiagnosed. Because higher hospital volume has been associated with improved outcome for many surgical procedures, the current study investigates whether hospital volume of pediatric appendectomies is associated with misdiagnosis of appendicitis in children.Methods. The Kids’ Inpatient Database is a national sample of pediatric discharges from 2521 hospitals in 22 states in 1997. In this study, misdiagnosis was defined as a patient with a principal International Classification of Diseases, Ninth Revision procedure code for nonincidental appendectomy without a corresponding diagnosis code for appendicitis. Hospitals were stratified into 5 groups based on the number of nonincidental appendectomies performed on children in 1997: lowest (&lt;1 per month), low (≥1 per month but &lt;1 per week), medium (1–2 per week), high (2–3 per week), and highest (≥3 per week). Using generalized estimating equations to control for clustering within hospitals, we developed a logistic regression model of the effect of hospital volume on misdiagnosis while adjusting for patient age, gender, race, and insurance status.Results. In the database, 37 109 nonincidental appendectomies were performed on children 1 to 18 years old in 1997. Of those, 3103 (8.4%) were misdiagnosed. Of all appendectomies, 24 655 (66.4%) were performed at lowest- or low-volume hospitals. After adjusting for patient characteristics, lowest- (odds ratio [OR]: 1.5; 95% confidence interval [CI]: 1.0–2.2) and low- (OR: 1.6; 95% CI: 1.1–2.3) volume hospitals had a significantly increased likelihood of misdiagnosis compared with highest-volume hospitals. Misdiagnosis at medium- (OR: 1.5; 95% CI: 1.0–2.2) and high- (OR: 1.4; 95% CI: 0.9–2.2) volume hospitals was similar to misdiagnosis at lower-volume hospitals, although not statistically different from highest-volume hospitals.Conclusions. Almost two thirds of pediatric appendectomies are performed at hospitals performing &lt;1 pediatric appendectomy per week. Lower hospital volume of pediatric appendectomies is associated with a significantly increased likelihood of misdiagnosis of appendicitis in children.
Selective Imaging Strategies for the Diagnosis of Appendicitis in Children
Authors: Garcia Peña Barbara M. , Cook E. Francis , Mandl Kenneth D. 
Published: August 2004

Background. We previously reported an appendiceal imaging protocol in which children with equivocal clinical presentations for acute appendicitis undergo ultrasonography (US) followed by computed tomography (CT). However, risk groups of children who would benefit most from imaging studies have not been established.Objective. To define and test selective imaging guidelines to increase diagnostic accuracy and reduce unnecessary testing for children with suspected appendicitis.Methods. We modeled outcomes under 3 different management guidelines. Patients were risk-stratified by a recursive partitioning analysis of a retrospective cohort. Subjects included children with equivocal presentations of acute appendicitis evaluated between January 1996 and December 1999. By using recursive partitioning, 3 risk groups were identified: low, medium, and high risk for acute appendicitis. Three imaging guidelines were defined. Under the first guideline, representing standard clinical practice at Children’s Hospital Boston at the time of the study, all children with equivocal signs and symptoms for acute appendicitis undergo US first. If the US is positive, the child proceeds to appendectomy. If the US is negative, the child undergoes CT. Under guideline 2, low-risk children undergo US and, if negative, are discharged from the hospital. High-risk children undergo CT, and medium-risk children undergo US followed by CT. Under the third guideline, low-risk children undergo no imaging and are admitted for observation. High-risk children proceed directly to appendectomy without imaging studies. Medium-risk children undergo US followed by CT. Clinical outcomes and the number of imaging studies performed were modeled under current practice and under each guideline.Results. Identified were 1401 cases of equivocal appendicitis; 958 (68.4%) with complete data. The mean age was 11 ± 4.3 years. Of 958 children, 588 (61.4%) had acute appendicitis. One hundred forty-three patients were in the low-risk group, defined as neutrophils ≤67%, bands &lt;5%, and no guarding on abdominal examination. Fifteen (10%) children had appendicitis. Two hundred twenty-five were high-risk for appendicitis defined as neutrophils &gt;67%, white blood cell count &gt;10 000/mm3, guarding, and abdominal pain &gt;13 hours. Of these, 202 (90%) had appendicitis. Under guideline 1, there were 22 negative appendectomies, 35 missed or delayed diagnoses, and 958 USs and 673 CT scans performed. Under guideline 2, there would have been 23 negative appendectomies, 36 missed or delayed diagnoses, and 733 USs and 637 CT scans performed. Under guideline 3, there would have been 36 negative appendectomies, 37 missed or delayed diagnoses, and 590 USs and 412 CT scans performed.Conclusions. Selective imaging guidelines can reduce the number of radiographic studies performed with minimal diminution in accuracy of diagnosis of pediatric appendicitis.
The Diagnosis of Appendicitis in Children: Outcomes of a Strategy Based on Pediatric Surgical Evaluation
Authors: Kosloske Ann M. , Love C. Lance , Rohrer James E. , Goldthorn Jane F. , Lacey Stuart R. 
Published: August 2004

Objective. To determine the accuracy of a protocol for diagnosis of appendicitis in children based on clinical evaluation by a pediatric surgeon with selective use of diagnostic imaging studies. We performed this study because 1) current reports in the medical, pediatric, emergency medical, and surgical literature advocate imaging, particularly computed tomography (CT), as the gold standard for diagnosis of appendicitis, and 2) the value of pediatric surgical evaluation early in the management of the child with possible appendicitis has rarely been emphasized.
Methods, Design, Setting, and Participants. Retrospective review of 356 children (mean age: 9.6 years; range: 1–18 years) referred to a regional pediatric surgical center for possible appendicitis from 1999 through 2001.
Interventions. Initial pediatric surgical evaluation consisted of history, physical examination, white blood cell count, differential count, and urinalysis. Children diagnosed with appendicitis underwent appendectomy without additional studies; those with equivocal findings received intravenous fluids, rest, and reevaluation after 4 to 6 hours. Imaging was used selectively by the pediatric surgeon.
Outcome Measures. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the protocol based on final diagnoses; rate of appendiceal perforation; and rate of negative appendectomy.
Results. Of 356 children evaluated for appendicitis, 220 (62%) had an appendectomy. Two-hundred nine (95%) had histologically proven appendicitis, and 11 (5%) had a normal appendix. Of the 209 children with appendicitis, 139 (66%) had acute appendicitis, 34 (16%) had advanced appendicitis without perforation, and 36 (17%) had advanced appendicitis with perforation. Appendectomy was performed after initial evaluation in 195 (89%) of the 220 children and after a period of supportive care and observation in 25 (11%) of 220. One hundred thirty-six children (38%) did not have an appendectomy and were discharged with other diagnoses. The sensitivity of this protocol was 99%, specificity was 92%, positive predictive value was 95%, and negative predictive value was 99%. The accuracy was 97% compared with an accuracy of 82% for ultrasound alone and 90% for CT scan alone.
Conclusions. These data show that a protocol based on clinical evaluation by a pediatric surgeon with selective use of imaging was highly accurate for the diagnosis of appendicitis in children. Low rates of negative appendectomy (5%) and perforation (17%) were achieved without the potential costs and radiation exposure of excess imaging.
Gastric Residuals and Their Relationship to Necrotizing Enterocolitis in Very Low Birth Weight Infants
Authors: Cobb Bridget Arnold , Carlo Waldemar A. , Ambalavanan Namasivayam 
Published: August 2004

Objective. To determine the characteristics of gastric residuals in very low birth weight (VLBW; ≤1500 g birth weight) infants with and without necrotizing enterocolitis (NEC).
Methods. Case-control study compared 51 VLBW infants who had proven NEC (pneumatosis intestinalis, portal venous gas, and/or perforation; excluding spontaneous gastrointestinal perforations) with 102 control subjects (without suspected or proven NEC) who were matched for birth weight, gestational age, race, and sex and were born January 1996 to December 2001. The age in days at diagnosis of NEC was identified in infants with NEC, and feeding characteristics were recorded for the previous 6 days. Feeding characteristics were recorded for control subjects for the corresponding time period.
Results. The median birth weight was 822 g and median gestational age was 26 weeks in both groups. Feeds were started on the fifth day, with a planned increase to full feeds over 10 days (median) in both groups. Median time to full feeds was 13 days in both groups. Median age of onset of NEC was day 24. The total residuals as a percentage of total feed volume (the primary outcome), maximum residual in the previous 6 days, maximum residual as a percentage of the feed, maximum residuals over the 6 days, and the percentage of feeds with residuals were higher in the NEC group. The maximum residual (median [25th–75th centiles]) was as follows: control subjects: 2 mL per feed (0.5–3.5) or 14% of a feed (4–33); NEC group: 4.5 mL per feed (1.5–9.8) or 40% of a feed (24–61). The total residuals as percentage of feeds and the average of maximum residuals increased in the NEC group from the first 3 days to the 3 days before diagnosis of NEC, but a similar increase was not noted for control subjects.
Conclusions. VLBW infants who developed NEC had more gastric residuals. However, there was overlap with the normal control subjects. Of the gastric residual data, the maximum residual seems to be the best predictor for NEC in the subsequent days.
Computerized Physician Order Entry and Medication Errors in a Pediatric Critical Care Unit
Authors: Potts Amy L. , Barr Frederick E. , Gregory David F. , Wright Lorianne , Patel Neal R. 
Published: August 2004

Objective. Medication errors are a major concern of health care professionals and medical institutions, especially errors involving children. Studies in adults have shown that computerized physician order entry (CPOE) systems reduce medication errors and adverse drug events (ADEs). The effect of CPOE implementation in a pediatric population has not been reported. The objective of this study was to evaluate the impact of CPOE on the frequency of errors in the medication ordering process in a pediatric critical care unit (PCCU).
Methods. A prospective trial was conducted of 514 pediatric patients who were admitted to a 20-bed PCCU in a tertiary-care children’s hospital before and after implementation of CPOE. Medication errors were identified after review of all orders during the study period and then further classified as potential ADEs, medication prescribing errors (MPE), and rule violations (RV).
Results. A total of 13 828 medication orders were reviewed. Before implementation, potential ADEs occurred at a rate of 2.2 per 100 orders, MPEs at a rate of 30.1 per 100 orders, and RVs at a rate of 6.8 per 100 orders. After implementation, the rate of potential ADEs was reduced to 1.3 per 100 orders, MPEs to 0.2 per 100 orders, and RVs to 0.1 per 100 orders. The overall error reduction was 95.9%. Potential ADEs were reduced by 40.9%, and MPEs and RVs were reduced by 99.4% and 97.9%, respectively.
Conclusions. The implementation of CPOE resulted in almost a complete elimination of MPEs and RVs and a significant but less dramatic effect on potential ADEs.
An Evaluation of Information-Seeking Behaviors of General Pediatricians
Authors: D’Alessandro Donna M. , Kreiter Clarence D. , Peterson Michael W. 
Published: August 2004

Objective. Usage of computer resources at the point of care has a positive effect on physician decision making. Pediatricians’ information-seeking behaviors are not well characterized. The goal of this study was to characterize quantitatively the information-seeking behaviors of general pediatricians and specifically compare their use of computers, including digital libraries, before and after an educational intervention.
Methods. General pediatric residents and faculty at a US Midwest children’s hospital participated. A control (year 1) versus intervention group (year 2) research design was implemented. Eligible pediatrician pools overlapped, such that some participated first in the control group and later as part of the intervention. The intervention group received a 10-minute individual training session and handout on how to use a pediatric digital library to answer professional questions. A general medical digital library was also available. Pediatricians in both the control and the intervention groups were surveyed using the critical incident technique during 2 6-month time periods. Both groups were telephoned for 1- to 2-minute interviews and were asked, “What pediatric question(s) did you have that you needed additional information to answer?” The main outcome measures were the differences between the proportion of pediatricians who use computers and digital libraries and a comparison of the number of times that pediatricians use these resources before and after intervention.
Results. A total of 58 pediatricians were eligible, and 52 participated (89.6%). Participant demographics between control (N = 41; 89.1%) and intervention (N = 31; 70.4%) were not statistically different. Twenty pediatricians were in both groups. Pediatricians were slightly less likely to pursue answers after the intervention (94.7% vs 89.2%); the primary reason cited for both groups was a lack of time. The pediatricians were as successful in finding answers in each group (95.7% vs 92.7%), but the intervention group took significantly less time (8.3 minutes vs 19.6 minutes). After the intervention, pediatricians used computers and digital libraries more to answer their questions and spent less time using them.
Conclusion. This study showed higher rates of physician questions pursued and answered and higher rates of computer use at baseline and after intervention compared with previous studies. Pediatricians who seek answers at the point of care therefore should begin to shift their information-seeking behaviors toward computer resources, as they are as effective but more time-efficient.
Safety, Pharmacokinetics, and Pharmacodynamics of Drotrecogin Alfa (Activated) in Children With Severe Sepsis
Authors: Barton Phil , Kalil Andre C. , Nadel Simon , Goldstein Brahm , Okhuysen-Cawley Regina , Brilli Richard J. , Takano Jeanne S. , Martin Lynn D. , Quint Peter , Yeh Timothy S. , Dalton Heidi J. , Gessouron Morris R. , Brown Kellie E. , Betts Helen , Levin Michael , Macias William L. , Small David S. , Wyss Virginia L. , Bates Becky M. , Utterback Barbara G. , Giroir Brett P. 
Published: August 2004

Objective. In a phase 3 trial, recombinant human activated protein C (drotrecogin alfa [activated]) significantly reduced mortality in adult patients with severe sepsis. We have now performed a preliminary analysis of the safety, pharmacokinetics, and pharmacodynamics of drotrecogin alfa (activated) in pediatric patients with severe sepsis.Design and Setting. Open-label, nonrandomized, sequential, 2-part study conducted in 11 medical centers in the United States and United Kingdom.Patients. Eighty-three pediatric patients with severe sepsis aged term newborn (≥38 weeks’ gestation) to &lt;18 years old.Intervention. In part 1, drotrecogin alfa (activated) was administered as escalating doses of 6, 12, 24, and 36 μg/kg per hour for 6 hours for each patient (n = 21). In part 2, drotrecogin alfa (activated) was infused at a rate of 24 μg/kg per hour for 96 hours in 62 patients.Main Outcome Measures. Plasma clearance, plasma concentration, D-dimer, protein C, and antithrombin levels were measured, and adverse events were monitored.Results. The trial enrolled 83 pediatric patients with severe sepsis, aged term newborn (≥38 weeks’ gestation) to &lt;18 years. In part 1, a dose of 24 μg/kg per hour produced steady-state plasma concentrations of activated protein C similar to those attained in equivalently dosed adult severe sepsis patients. For all pediatric patients dosed at 24 μg/kg per hour, the median weight-normalized clearance was 0.45 L/hour/kg and the median steady-state concentration was 51.3 ng/mL. The mean plasma half-life was 30 minutes. Weight-normalized clearance in pediatric and adult patients did not differ significantly with age or weight. D-dimer levels decreased 26% from baseline to end of infusion. Baseline levels of protein C and antithrombin increased 79% and 24%, respectively, over the 96-hour treatment period in part 2. The incidence of serious bleeding during infusion and during the entire study period was 2.4% and 4.8%, respectively.Conclusions. Pediatric patients with severe sepsis manifest sepsis-induced coagulopathy including protein C deficiency comparable to that seen in adults with severe sepsis. The pharmacokinetics, pharmacodynamic effects, and safety profile of drotrecogin alfa (activated) in pediatric patients are similar to those previously published for adult patients. A large, phase 3, randomized, placebo-controlled study is ongoing to confirm these results and formally assess the safety and efficacy of drotrecogin alfa (activated) in children.
An Evaluation of Two Procedures for Training Skills to Prevent Gun Play in Children
Authors: Himle Michael B. , Miltenberger Raymond G. , Gatheridge Brian J. , Flessner Christopher A. 
Published: August 2004

Objective. Unintentional firearm injuries threaten the safety of children in the United States. Despite the occurrence of these injuries, few studies have evaluated the effectiveness of child-based programs designed to teach children gun-safety skills. This study compared 2 programs that were designed to reduce gun play in preschool children.Methods. A between-groups no-treatment control design was used. Children were randomly assigned to either 1 of 2 firearm-injury prevention programs or a no-treatment control condition. Participant recruitment, training, and data collection occurred in preschools and children’s homes located in a midwestern city with a population of approximately 80 000. Thirty-one 4- and 5-year-old children participated in the study. The effectiveness of the National Rifle Association’s Eddie Eagle GunSafe Program and a behavioral skills training program using instruction, modeling, rehearsal, and feedback was evaluated. Children were issued 0 to 3 ratings on the basis of their ability to say correctly the safety message and similar ratings on the basis of observations of their ability to perform correctly the skills in the classroom and when placed in a realistic simulation.Results. Both programs were effective for teaching children to reproduce verbally the gun-safety message. The behavioral skills training program but not the Eddie Eagle GunSafe Program was effective for teaching children to perform gun-safety skills during a supervised role play, but the skills were not used when the children were assessed via real-life (in situ) assessments.Conclusions. Existing programs are insufficient for teaching gun-safety skills to children. Programs that use active learning strategies (modeling, rehearsal, and feedback) are more effective for teaching gun-safety skills as assessed by supervised role plays but still failed to teach the children to use the skills outside the context of the training session. More research is needed to determine the most effective way to promote the use of the skills outside the training session.
Pediatrician Self-Efficacy for Counseling Parents of Asthmatic Children to Quit Smoking
Authors: Cabana Michael D. , Rand Cynthia , Slish Kathryn , Nan Bin , Davis Matthew M. , Clark Noreen 
Published: August 2004

Background. Although environmental tobacco smoke is a common trigger for asthma exacerbations in children, pediatricians infrequently counsel parents who smoke to quit. High physician self-efficacy, or self-confidence, in the ability to counsel parents about smoking cessation is associated with increased physician screening and counseling on this topic. However, it is not clear which factors are associated with high physician self-efficacy for counseling, such as previous training in smoking-cessation counseling or number of years in pediatric practice.
Objective. To identify factors associated with high levels of physician self-efficacy for 4 skills associated with smoking-cessation counseling.
Design. Cross-sectional survey.
Participants. A national random sample of 829 primary care pediatricians.
Results. The response rate was 55% (457 of 829). The percentage of physicians with high levels of self-efficacy for screening parents and screening patients to identify smokers was 87% and 84%, respectively. The percentage of physicians with high levels of self-efficacy for counseling parents and patients was 59% for both groups. The presence of previous training in smoking-cessation counseling was associated with high levels of self-efficacy for all 4 skills including inquiring about an asthma patient’s smoking status (odds ratio [OR]: 3.91; 95% confidence interval [CI]: 1.63, 9.37); inquiring about a parent’s smoking status (OR: 2.51; 95% CI: 1.09, 5.75); counseling a patient to quit smoking (OR: 5.30; 95% CI: 3.02, 9.31); and counseling a parent to quit (OR: 4.96; 95% CI: 2.85, 8.61). Years since completion of residency were not associated with high self-efficacy.
Conclusions. These findings suggest that formal training in smoking cessation has a significant impact on physician self-efficacy related to smoking cessation throughout a physician’s career.
Girls at Five Are Intrinsically More Insulin Resistant Than Boys: The Programming Hypotheses Revisited—The EarlyBird Study (EarlyBird 6)
Authors: Murphy Michael J. , Metcalf Brad S. , Voss Linda D. , Jeffery Alison N. , Kirkby Joanne , Mallam Katie M. , Wilkin Terence J. 
Published: August 2004

Objective. Recent studies of type 2 diabetes in young populations consistently show a predominance of affected girls over boys. Girls are more insulin resistant than boys. We aimed in the present report to establish how much of the sex difference in insulin resistance is intrinsic.
Methods. EarlyBird is a community-based, nonintervention cohort study of 307 healthy children from school entry at age 5 years. It asks the question: which children are insulin resistant and why? Anthropometric measures, physical activity, resting energy expenditure, and insulin resistance and its metabolic correlates were measured.
Results. At 5 years, insulin resistance was 35% higher in girls than in boys. Girls carried 26% more subcutaneous fat despite similar body weights. However, after correcting for anthropometric variables and physical activity, girls remained 33% more insulin resistant than boys. Triglycerides were significantly higher in girls, and high-density lipoprotein cholesterol and sex hormone-binding globulin were significantly lower.
Conclusions. Sex-linked genes may account for the intrinsic sex difference observed. These genes may have an important impact on the development of insulin resistance and the metabolic syndrome and may help to explain the female preponderance of type 2 diabetes in children. Their identification may also help in understanding the pathogenesis of insulin resistance.