bluuebunny/crossref_metadata_2025_split huggingface dataset:
Is Noncompliance Among Adolescent Renal Transplant Recipients Inevitable?
Authors: Feinstein Sofia , Keich Rami , Becker-Cohen Rachel , Rinat Choni , Schwartz Shepard B. , Frishberg Yaacov 
Published: April 2005

Objective. To evaluate the prevalence of noncompliance and factors that influence poor adherence to immunosuppressive drug regimens among kidney transplant recipients.Methods. We reviewed immunosuppressive drug compliance in 79 posttransplant patients. Patient self-report and low plasma calcineurin inhibitor levels served as indicators of noncompliance.Results. The prevalence of noncompliance was found to be highest in adolescents who were responsible for their own medications and who underwent cadaveric kidney transplantation (CTx; 45.5%) and lower after living related transplantation (28.6%). There were no documented cases of noncompliance among any recipient of living unrelated (commercial) transplantation. Among 13 noncompliant patients, the first indication of “drug holiday” was low plasma calcineurin inhibitor levels in 11 children. Two additional children presented with acute rejection. In 7 patients, repeated episodes of “drug holidays” led to acute rejection later: 21.4 ± 13.2 months after the first decrease in plasma calcineurin inhibitor level had been recorded. All 9 patients who experienced acute rejection subsequently developed chronic rejection. In 4 patients, noncompliance did not influence graft function. Psychosocial factors that were associated with noncompliance included insufficient family support, low self-awareness caused by poor cognitive abilities, and denial.Conclusions. The absence of cases of noncompliance in adolescents who underwent commercial living unrelated kidney transplantation suggests that although noncompliance is prevalent, it is not inevitable. Strategies to decrease noncompliance in young patients with chronic illnesses can be learned from the experience with transplant recipients. The general pediatrician has a central role in identifying and addressing the problem of noncompliance in adolescents with chronic disease.
Yield of Diagnostic Testing in Infants Who Have Had an Apparent Life-Threatening Event
Authors: Brand Donald A. , Altman Robin L. , Purtill Kerry , Edwards Karen S. 
Published: April 2005

Objective. Many infants who have experienced an apparent life-threatening event (ALTE) seem normal by the time they reach the hospital. Nevertheless, they typically undergo an extensive evaluation to rule out serious underlying conditions. The purpose of the present investigation was to determine the yield of different diagnostic tests in helping to identify the cause of the ALTE.Methods. We reviewed test results from a consecutive series of infants who were younger than 12 months and admitted to a tertiary care academic medical center between November 1996 and June 1999 after having experienced a sudden breathing irregularity, color change, or alteration in mental status or muscle tone. For each patient, we noted whether a given test was performed, whether the result was positive, and, if so, whether the test contributed to the diagnosis, that is, suggested or helped establish the cause. We also noted whether the initial history and physical examination contributed information that eventually led to the final diagnosis.Results. A total of 243 patients met the enrollment criteria. Of the 3776 tests ordered, 669 (17.7%) were positive and 224 (5.9%) contributed to the diagnosis. Prompted by findings from the initial clinical assessment, the following tests proved useful in patients who had a contributory history and physical examination: blood counts, chemistries, and cultures; cerebrospinal fluid analysis and cultures; metabolic screening; screening for respiratory pathogens; screening for gastroesophageal reflux; chest radiograph; brain neuroimaging; skeletal survey; electroencephalogram; echocardiogram; and pneumogram. In the remaining patients, who had a noncontributory history and physical examination, only the following tests proved useful: screening for gastroesophageal reflux, urine analysis and culture, brain neuroimaging, chest radiograph, pneumogram, and white blood cell count. Broad evaluations for systemic infections, metabolic diseases, and blood chemistry abnormalities were not productive in these patients.Conclusions. For many tests used in the evaluation of an ALTE, the likelihood of a positive result is low and the likelihood of a contributory result is even lower. Estimates of diagnostic yield derived from the present investigation can help clinicians maximize the productivity and efficiency of their evaluation.
Use of Volume Expansion During Delivery Room Resuscitation in Near-Term and Term Infants
Authors: Wyckoff Myra H. , Perlman Jeffrey M. , Laptook Abbot R. 
Published: April 2005

Objective. To characterize use of volume infusion (VI) for infants who are ≥34 weeks' gestational age and receive intensive cardiopulmonary resuscitation (CPR; defined as &gt;1 minute of positive-pressure ventilation and chest compressions, with or without the administration of medications) in the delivery room and are admitted to the NICU.Methods. A retrospective review of a resuscitation registry between January 1999 and June 2001 was conducted.Results. Of 37 972 infants, 23 received CPR, including 13 with VI. Ten of 13 received VI for persistent bradycardia despite CPR, and only 3 of 13 received VI for suspicion of hypovolemia with poor perfusion. More VI versus no VI infants had Apgar scores ≤2 at 5 and 10 minutes. VI versus no VI infants had lower cord arterial pH, had higher arterial partial pressure of carbon dioxide, had larger base deficit, required longer CPR, and required more epinephrine. On admission to the NICU, VI versus no VI infants had lower blood pressure and larger base deficit over the first 2 hours but did not differ in arterial pH, arterial partial pressure of carbon dioxide, heart rate, mortality, or use of additional VI or buffer.Conclusions. VI is rarely given for overt hypovolemia and more often for asphyxiated infants who are slow to respond to intensive CPR. Persistent postnatal hypotension in VI infants suggests that other factors, eg, myocardial dysfunction, may be important contributors to lack of response to CPR.
The Role of Endogenous Opioids in Mediating Pain Reduction by Orally Administered Glucose Among Newborns
Authors: Gradin Maria , Schollin Jens 
Published: April 2005

Objective. It has been demonstrated clearly that sweet-tasting solutions given before a painful intervention can reduce pain among newborns. There is no fully accepted explanation for this effect, but activation of endogenous opioids has been suggested as a possible mechanism. The aim of this study was to obtain deeper knowledge of the underlying mechanism by investigating whether administration of an opioid antagonist would reduce the effect of orally administered glucose at heel stick among term newborns.
Design. A randomized, placebo-controlled, double-blind trial with a validated, neonatal, pain-rating scale.
Participants. The trial included 30 term newborns undergoing heel stick, who were assigned randomly to 1 of 2 groups, ie, group I, with naloxone hydrochloride (opioid antagonist) 0.01 mg/kg administered intravenously before oral administration of 1 mL of 30% glucose, or group II, with a corresponding amount of placebo (saline solution) administered intravenously before oral administration of glucose.
Outcome Measures. Pain-related behavior during blood sampling was measured with the Premature Infants Pain Profile. Crying time and heart rate were also recorded.
Results. The 2 groups did not differ significantly in Premature Infant Pain Profile scores during heel stick. The median crying time during the first 3 minutes was 14 seconds (range: 0–174 seconds) for the naloxone group and 105 seconds (range: 0–175 seconds) for the placebo group. There was no significant difference in heart rate between the 2 groups.
Conclusion. Administration of an opioid antagonist did not decrease the analgesic effect of orally administered glucose given before blood sampling.
Risk Factors for and Outcomes of Bloodstream Infection Caused by Extended-Spectrum β-Lactamase–Producing Escherichia coli and Klebsiella Species in Children
Authors: Zaoutis Theoklis E. , Goyal Monika , Chu Jaclyn H. , Coffin Susan E. , Bell Louis M. , Nachamkin Irving , McGowan Karin L. , Bilker Warren B. , Lautenbach Ebbing 
Published: April 2005

Objective. The increasing prevalence of infections caused by extended-spectrum β-lactamase–producing Escherichia coli and Klebsiella species (ESBL-EK) has become a growing concern in the hospitalized patient population. Previous studies on risk factors for infection with ESBL-EK have mainly focused on adult populations, and these findings may not be relevant among the pediatric population that experiences a unique set of health care exposures and underlying conditions. The objective of this study was to define the risk factors and outcomes associated with ESBL-EK bloodstream infections in children.
Methods. We conducted a nested case-control study using data from the Children's Hospital of Philadelphia from May 1, 1999, to September 30, 2003. Eligible patients were identified from the hospital database of microbiology laboratory records. All patients with ESBL-EK bloodstream infections were compared to a random sample of patients with non–ESBL-EK bloodstream infections. Risk factors analyzed included prior antimicrobial use, comorbid conditions, and demographic characteristics. Pulsed-field gel electrophoresis was performed to determine genetic relatedness of the ESBL-EK isolates.
Results. Thirty-five cases and 105 control subjects were included in the study. The median age among the cases was 2 years (interquartile range: 0–11), compared with 1 year (interquartile range: 0–8) among control subjects. Patients with ESBL-EK infections were 5.8 times (95% confidence interval: 1.9–17.7) more likely to have had exposure to an extended-spectrum cephalosporin in the 30 days before infection than those with non–ESBL-EK infections. Other independent predictors of ESBL-EK infection were being female, infection with a Klebsiella species, and steroid use in the 30 days before infection. All ESBL-EK isolates were susceptible to carbapenem antibiotics. Pulsed-field gel electrophoresis analysis revealed that the ESBL-EK isolates were polyclonal. Although a substantially higher proportion of children with ESBL-EK died (in-hospital mortality: 36% vs 13%), this difference was not statistically significant.
Conclusions. Receipt of extended-spectrum cephalosporins in the 30 days before infection by an Escherichia coli or Klebsiella species is significantly associated with having an ESBL-EK infection in hospitalized children. Curtailed use of cephalosporins among high-risk groups may reduce the occurrence of ESBL-EK infections. Future studies on identifying high-risk children and investigating the impact of curtailed third-generation cephalosporin use to limit additional emergence of ESBL-EK infections should be undertaken.
Variation in Inpatient Diagnostic Testing and Management of Bronchiolitis
Authors: Christakis Dimitri A. , Cowan Charles A. , Garrison Michelle M. , Molteni Richard , Marcuse Edgar , Zerr Danielle M. 
Published: April 2005

Objectives. We know little about the variation in diagnosis and management of bronchiolitis. The objectives of this study were (1) to document variations in treatment and diagnostic approaches, lengths of stay (LOSs), and readmission rates and (2) to determine which potentially modifiable process of care measures are associated with longer LOSs and antibiotic usage.
Methods. We used the Pediatric Health Information System, which includes demographic, diagnostic, and detailed patient-level data on 30 large children's hospitals. We examined infants who were younger than 1 year and hospitalized for bronchiolitis (October 2001–September 2003). Multivariate analysis of variance was used to determine whether the variance in the outcomes was hospital related after controlling for other covariates. Linear regression was used to model predictors of increased LOS. Logistic regression was used to model antibiotic usage. Analyses were stratified by age group (&lt;3 months and 3–11 months).
Results. A total of 17397 patients were included in the analysis. The mean LOS was 2.97 days; 72% of patients received chest radiographs, 45% received antibiotics, and 25% received systemic steroids. The mean LOS varied considerably across hospitals (range: 2.40–3.90 days), and hospital remained a significant contributor to LOS variation after controlling for our covariates. Variations in the use of diagnostic tests and medications as well as readmission rates also existed and also remained significant after controlling for covariates. The factors associated with the greatest increases in LOS in the regression analyses included higher severity scores and use of antibiotics, bronchodilators, and corticosteroids. The strongest predictors of antibiotic use in the logistic regression analyses were higher severity scores and receipt of a blood or cerebrospinal fluid culture. Receiving a chest radiograph was a significant predictor of antibiotic use in older but not younger infants.
Conclusions. Considerable, unexplained variation exists in the inpatient management of bronchiolitis. The development of national guidelines and controlled trials of new therapies and different management approaches are indicated.
Prenatal Risk Factors for Severe Retinopathy of Prematurity Among Very Preterm Infants of the Australian and New Zealand Neonatal Network
Authors: Darlow Brian A. , Hutchinson Jolie L. , Henderson-Smart David J. , Donoghue Deborah A. , Simpson Judy M. , Evans Nicholas J. ,   on behalf of the Australian and New Zealand Neonatal Network
Published: April 2005

Objective. To identify prenatal and perinatal risk factors for clinically severe (stage 3 or 4) retinopathy of prematurity (ROP).Methods. Data were collected prospectively as part of the ongoing Australian and New Zealand Neonatal Network audit of high-risk infants (birth weight of &lt;1500 g or gestational age [GA] of &lt;32 weeks) admitted to a level III neonatal unit in Australia or New Zealand. Prenatal and perinatal factors to 1 minute of age were examined for the subset of infants with GA of &lt;29 weeks who survived to 36 weeks’ postmenstrual age and were examined for ROP (n = 2105). The factors significantly associated with stage 3 or 4 ROP were entered into a multivariate logistic regression model.Results. Two-hundred three infants (9.6%) had stage 3 or more ROP. Prematurity was the dominant risk factor, with infants with GA of &lt;25 weeks having 20 times greater odds of severe ROP than infants with GA of 28 weeks. Birth weight for GA also had a “dose-response” effect; the more growth-restricted infants had greater risk, with infants below the 3rd percentile of weight for GA having 4 times greater odds of severe ROP than those between the 25th and 75th percentiles. Male gender was also a significant risk factor (odds ratio: 1.73; 95% confidence interval: 1.25–2.40).Conclusions. These data, for a large, essentially population-based cohort, suggest that factors related to the degree of immaturity, intrauterine growth restriction, and male gender contribute to severe ROP.
Primary and Secondary Nocturnal Enuresis: Similarities in Presentation
Authors: Robson Wm. Lane M. , Leung Alexander K.C. , Van Howe Robert 
Published: April 2005

Objective. To determine the differences or similarities in the clinical presentation between patients with primary and secondary nocturnal enuresis.Methods. A total of 170 patients with nocturnal enuresis were assessed at a busy tertiary care pediatric voiding dysfunction clinic at the University of Oklahoma Health Sciences Center. Patients with primary nocturnal enuresis (PNE) were compared with patients with secondary nocturnal enuresis (SNE) for a variety of clinical features, including gender, age when first voiding on their own, age on presentation, infrequent voiding, frequent voiding, urgency, daytime wetting, nocturia, urinary tract infection, constipation, vesicoureteral reflux, attention-deficit/hyperactivity disorder, uroflow results, and ultrasound evidence of a postvoid residual.Results. The only significant difference between the patients with PNE and those with SNE was in the prevalence of constipation. Constipation was significantly associated with PNE (74.59% vs 57.54%; odds ratio: 2.17; 95% confidence interval: 1.07–4.41). When adjusted for a history of constipation, the age at which a child began to void on his or her own became statistically significant. Patients with SNE started to void on their own at 2.13 years (SD: 0.61), an average of 0.22 years earlier than those with PNE, who started to void on their own at 2.35 years.Conclusions. PNE and SNE likely share a common pathogenesis. Symptoms of daytime voiding dysfunction are common in patients with PNE and SNE. Daytime voiding habits might influence how the central nervous system responds at night to a full or contracting bladder.
Lengths of Stay and Costs Associated With Children's Hospitals
Authors: Merenstein Dan , Egleston Brian , Diener-West Marie 
Published: April 2005

Objective. Because of the unique mission of freestanding children's hospitals, higher costs have generally been accepted; however, increasing health care costs and the impetus for outcomes data demand more accountability. For common diagnoses, with respect to quality care indicators, length of stay (LOS), and total charges, we propose to compare freestanding children's hospitals and other hospitals. Our hypothesis is that, for similar diagnoses, freestanding children hospitals will have longer LOSs and higher costs than other hospitals.Methods. Data were analyzed from the Healthcare Cost and Utilization Project Kids' Inpatient Database 2000. Encounters qualified for evaluation when 1 of the top 3 discharge codes was consistent with pneumonia, gastroenteritis, respiratory syncytial virus, dehydration, or asthma. Our outcomes were LOS and total charges per hospital admission; hospitals were categorized as children's hospitals and nonchildren's hospitals. We adjusted for the following potential confounders: number of diagnoses, insurance information, patient age in years, race of patient, admission source, procedures, teaching status of hospital, and hospital location. Because of the right skew of the outcomes, our primary analyses consisted of robust median regression; to support our final models, we also performed sensitivity analyses.Results. Of 252262 total inpatient encounters, 24322 met the inclusion criteria. There were 3408 encounters from 23 different freestanding children's hospitals and 20914 encounters from 1749 nonchildren's hospitals. Freestanding children's hospitals provided care to a higher risk population with more children transferred from other hospitals, a higher percentage of minorities, increased number of co-diagnoses, and a higher percentage on Medicaid. There was no statistically significant difference in LOS by hospital type. However, there was a significant difference in total costs, with the median cost of an admission at freestanding children's hospitals $1294 more per hospitalization than at nonchildren's hospitals, after adjusting for confounders.Conclusion. We found no significant difference in median LOS among freestanding children's hospitals and nonchildren's hospitals, but freestanding children's hospitals had higher total charges per admission, even after adjusting for differences in population characteristics. Additional studies are needed to elucidate whether these increased costs result in better health outcomes or are simply attributable to other characteristics of children's hospitals, in which not all patients may benefit.
Estimated Impact of Competing Policy Recommendations for Age of First Dental Visit
Authors: Jones Kari , Tomar Scott L. 
Published: April 2005

Objective. To compare levels of dental utilization and untreated dental decay among children aged 1 to 3 years that are likely to occur under 2 potential guidance policies: (1) pediatricians refer all toddlers to dentists for screening (consistent with American Academy of Pediatric Dentistry and the American Dental Association recommendations; DENT), and (2) pediatricians receive training in caries risk assessment, screen toddlers, and refer at-risk children to dentists (consistent with American Academy of Pediatrics recommendations; PED).Methods. Using decision analysis, we estimated the impact of PED and DENT assuming alternately unlimited dental capacity for Medicaid-insured patients and fixed Medicaid dental capacity.Results With unlimited capacity, if DENT were implemented, then dental utilization is estimated to increase from 27% under the status quo to 65% and untreated decay to decrease from a mean of 0.60 surfaces to 0.52 surfaces per child. If PED were implemented, then dental utilization and untreated decay would decrease from status quo levels to an estimated 11% and 0.47 surfaces, respectively, assuming that diagnostic sensitivity and specificity both equaled 1; they would decrease to 13% and 0.53 surfaces, respectively, if sensitivity equaled 0.76 and specificity equaled 0.95. With fixed capacity, under DENT, untreated decay is estimated to increase to 0.63 surfaces because low-risk private-pay patients would crowd out at-risk Medicaid-insured children, whereas under PED, untreated decay would still be less than under the status quo.Conclusions. Implementing PED will decrease untreated decay under most plausible scenarios, whereas switching to DENT will increase the burden of disease if Medicaid dental capacity is limited.